BMJ 2001;323 ( 28 July )

Editor's choice

Social exclusion: old problem, new name

In 1842 the BMJ published an editorial deploring that "a professional man, a gentleman, or the family of such living in Bath" could expect to live into their 50s, whereas labourers and their families in Liverpool could expect no more than 15 years of life. In 1865 the Lancet set up a special commission to inquire into London workhouse infirmaries. The commission was instigated by Ernest Hart, who later became the greatest editor of the BMJ. He helped to start the Association for the Improvement of Workhouse Infirmaries, which included Charles Dickens and John Stuart Mill as members. The principal feature of the BMJ during the three decades of Hart's editorship was its emphasis on social medicine.

More than a century later the BMJ is concerned with the same issues, but we seem to lack the vision, vigour, and optimism of Hart. This is not a theme issue that we planned a year ago. This issue has arisen because we noticed that we had accepted for publication many studies that related to social exclusion. Rather than scatter the studies through several issues we decided to bring them together. Why are there so many studies? One answer is the huge increase in social inequity that occurred in Britain in the 1980s. The number of children living in poverty tripled during the '80s, "catapaulting the UK to the highest rates of any country in the European Union" (p 175). These increases were partly the result of global forces and partly the result of political choices. Then came a change of government, with a new emphasis on social exclusion. Among other initiatives, it funded research into social exclusion.

Social exclusion is defined as "the inability of our society to keep all groups and individuals within reach of what we expect as a society and the tendency to push vulnerable and difficult individuals into the least popular places." The result is that children living in poverty may enter a cycle of poor educational achievement, unmanageable behaviour, drug misuse, unemployment, teenage pregnancy, homelessness, crime, and suicide. This is hugely expensive for society, not only in human but also in economic terms (p 191). It can also lead to a society that is unpleasant for all. These problems are not uniquely Britishand some studies (p 207) and commentaries (p 197) are from outside Britainbut Britain leads the world in this research, because it has both severe problems and a long history of studying them.

What might depress Hart if he were to return would not be so much the continuation of the problems, but the failure of a great social experimentthe NHSto make important inroads into them (pp 177 and 179).

Footnotes

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