Social vaccines to resist and change unhealthy social and economic structures: a useful metaphor for health promotion
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Social vaccines to resist and change unhealthy social
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SDA-RF-AT-3.2
M <Health Promotion International. Vol. 24 No. 4
doi:10.1093/ltcapro/dap026
Advance Access published 23 July, 2009
I
I'he Author (2009). Published by Oxford University Press. All rights reserved.
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DEBATE
Social vaccines to resist and change unhealthy social
and economic structures: a useful metaphor
for health promotion
I RAN BAUM1’2*, RAVI NARAYAN13, DAVID SANDERS1’4,
VIKRAM PATEL5 and ARTURO QUIZHPE1’6
'Global Steering Council, People’s Health Movement, 2Southgate Institute for Health, Society and
Equity, Flinders University, GPO Box 2100, Adelaide 5001, Australia, 3Centre for Public Health and
Equity, 367, Srinivasa Nilaya, .1akkasandra, 1st Main, 1st Block, Koramangala, Bangalore 560 034, India,
'School of Public Health, University of the Western Cape, Private Bag XI7, Bellville 7535 Cape, South
Africa, >London School of Hygiene & Tropical Medicine, Sangath Centre, Allo Porvorim, Goa 403521,
India and bDepartment of Paediatrics Faculty of Medical Sciences, University of Cuenca, Ecuador
^Corresponding author. E-mail: fran.haum@fiinders.edu.au
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SUMMARY
The term ‘social vaccine' is designed to encourage the
hioniedically orientated health sector to recognize the
legitimacy of action on the distal social and economic
determinants of health. It is proposed as a term to assist
the health promotion movement in arguing for a social
view of health which is so often counter to medical and
popular conceptions of health. The idea of a social
vaccine builds on a long tradition in social medicine as
well as on a biomedical tradition of preventing illness
through vaccines that protect against disease. Social vac
cines would be promoted as a means to encourage
popular mobilization and advocacy to change the social
and economic structural conditions that render people
and communities vulnerable to disease. They would
&
facilitate social and political processes that develop
popular and political will to protect and promote health
through action (especially governments prepared to inter
vene and regulate to protect community health) on the
social ami economic determinants. Examples provided
for the effects of social vaccines are: restoring land owner
ship to Indigenous peoples, regulating the advertising of
harmful products and progressive taxation for universal
social protection. Social vaccines require more research
to improve understanding of social and political
processes that are likely to improve health equity
worldwide. The vaccine metaphor should be helpful in
arguing for increased action on the social determinants of
health.
Key words', social vaccine; social determinants; community participation; health promotion
INTRODUCTION
There is a long tradition in public health that
has recognized and called for interventions on
the social and economic determinants of health,
going back to at least the work of the
nineteenth-century Silesian physician Virchow
(Waitzkin, 2006). This tradition is reflected in
the World Health Organisation's 1978 Alma
Ala Declaration on Primary Health Care
(WHO, 1978). and the Ottawa Charter for
Health Promotion (WHO, 1986). The People’s
Health Movement (PHM, 2008) has been a
strong advocate for tackling the economic,
social, political and environmental determinants
of health since its formation in 2000, especially
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Social vaccines a metaphor for health promotion
evident in the People’s Charier for Health. The
work of the Commission on Macroeconomics
and Health (CMH, 2001) and of the
Commission on the Social Determinants of
Health (CSDH, 2008) also provide strong evi
dence of the importance of structural determi
nants of health. In particular, the CSDH has
argued for a concerted action to close the
health equity gap in a generation. Doing this
will require a shift in the thinking of many
working within the dominant medical paradigm.
This paper proposes the application of a vaccine
metaphor to social determinants. A social
vaccine would have at its heart the need for
social movements advocating for health equity
to move governments to adopt socially justice,
regulatory policies for health and health equity.
The accumulating evidence was summed up by
Rose [(Rose, 1992), p. 29] conclusion, based on
decades of epidemiological work: 'the primary
determinants of disease are mainly economic and
social and therefore its remedies must also be
economic and social. Medicine and politics
cannot and should not be kept apart'. A signifi
cant body of evidence (Marmot and Wilkinson,
1999) documents how distal determinants such as
the structure of the political economy (Doyal,
1979; Navarro, 2002), the nature of the labour
market (Heymann, 2006) and the nature of social
life have an impact on health (Berkman and
Kawachi, 2000). These same determinants also
explain the persistence of health inequalities
according to class, gender and race. Despite this
evidence, much of the effort and resources
devoted to preventing disease and promoting
health focuses on the more immediate and proxi
mal behavioural and biological determinants of
health. This is true in rich and poor countries.
Evidence suggests that when action on the social
and economic determinants of health is taken, it
is often the result of long-term mobilization by
civil society groups whose work acts to protect
populations by building resilience against
unhealthy policies through a process of political
empowerment (Szreter, 1988).
This paper explores the value for the health
promotion movement of adopting a metaphor
from medicine, the vaccine, as a mechanism to
promote the recognition of the importance of
popular mobilization in forcing the hand of gov
ernment and other institutions to regulate and
intervene through social and economic policies
in favour of the public good and community
health. It does this by introducing and defining
429
the concept of social vaccines and by providing
three examples of the application and effects of
social vaccines. It concludes by arguing that the
concept is worthy of further research.
WHAT IS A SOCIAL VACCINE?
The metaphor is designed to shift the dominant
biomedical orientation of the health sector
towards the underlying distal factors that cause
disease and suffering. The value of vaccines in
protecting people from diseases by causing an
immunological response is widely accepted and
understood. Despite the theoretical danger of
‘medicalizing’ social processes, we believe that
on balance such a metaphor can be useful in
engaging the medical community and possibly a
broader public which is so inculcated with a
medical model.
The term has been used previously. For
example, the UN’s International Labour
Organisation (ILO. 2006) and Narayan et al.
(Narayan et al., 2006) and at the 2006 Global
Forum on Health Research (GFHR, 2006). On
the basis of previous thinking, we propose the
following definition:
A social vaccine is a process of social and political
mobilisation which leads to increased government and
other institutions' willingness to intervene with inter
ventions, applied to populations rather than individ
uals, aimed al mitigating the structural social and
economic conditions that make people and commu
nities vulnerable to disease, illness and trauma. While
medical vaccines help develop immunity against
disease, social vaccines develop the ability of commu
nities to resist and change social and economic struc
tures and processes that have a negative impact on
health and force governments to intervene and regulate
in the interests of community health.
Table 1 provides a comparison of social and
medical vaccines. This shows that the equivalent
to the administration of a vaccine are processes
that raise the consciousness of a community and
the individuals within it which leads to resist
ance to unhealthy policies and practices through
political action. This process needs to spread
through a population, so that governments and
other institutions adopt health promoting social
and economic policies and achieve population
coverage (like a medical vaccine) in order to be
effective. There is no formula for this social and
political mobilization and subsequent political
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430
F. Baum et al.
Table 1: Comparison of medical and social vaccine
Medical vaccine
Administration of vaccine
Raises immunity in
individuals —immunity
spreads across
population resulting in
Herd effect
Necessity to ensure
immunity across a high
percentage of the
population in order to
prevent outbreaks
Social vaccine
Raising consciousness about
causes of unhealthy
conditions and
strengthening social
mobilization leads to
resistance
Resilience raised
Popular mobilization leads
to government action to
regulate unhealthy
practices and intervene in
the interests of
community health
Spread across population
Need to create and maintain
sufficient popular
mobilization and
‘resistance’ to unhealthy
policies and practices
Popular mobilization builds
empowerment, and a
resultant political
accountability and will to
take action to promote
health
The political will for change
leads to governments
adopting progressive
social and economic
policies and regulatory
mechanism that promote
health equitably
uptake of popular demands. Il is a dynamic
process that reflects and influences the context
within which it happens. However, there are
some constants. Empowerment is both a per
sonal and a group process which builds collec
tive self-confidence. The process should lead to
people shedding feelings of powerlessness and
resignation which result, at least in part, from
the lack of skills and confidence required to
change their condition (Werner and Sanders,
1997). Frequently, this confidence is forged in a
common struggle —whether it be against gender
or ethnic oppression, economic exploitation,
political repression or foreign intervention. As a
result of the social vaccine, a population is able
to resist unhealthy policies and practices and
mobilize and take action to stop threats to
health, usually through influencing the develop
ment of ‘political will’ which results in health
promoting policies and laws. These threats may
be from the socio-economic context (e.g. unfair
taxation or labour laws), from social structures
(such as race or gender discrimination)
unhealthy living and working conditions
(inadequate housing, food insecurity; poor
transport and a polluted living environment) or
the need for accessible, equitable and effective
health care (e.g. universal public health system)
(Irwin and Scali, 2005; Baum, 2008). We recog
nize that, unlike medical vaccines, social vac
cines are often bi-directional and there is often
a dialectic between popular pressure, political
will and eventual regulation and intervention.
PRACTICAL EXAMPLES OF SOCIAL
VACCINES
Our definition of social vaccine places prime
importance on mobilization that results in
political commitment to interventions that affect
the structures and circumstances within which
people live and work and which, over time, have
significant effects on health outcomes and their
distribution in populations. We provide three
examples of instances where popular mobiliz
ation followed by political commitment to action
on social or economic determinants of health has
or has had the potential to improve health.
Land rights and subsistence
In many countries around the world, the
Indigenous owners of land have had that land
removed through the processes of colonization
and industrialization. They have been dispos
sessed and forced to change from collective pat
terns of land ownership, which built social
capital and minimized inequities, towards pat
terns of land ownership that are unequal and
based on private and individualized forms of
ownership. Across the world, the loss of control
over land has had a devastating impact on the
health of Indigenous peoples. In the words of
an Australian Aboriginal leader:
Our identity as human beings remains tied to our
land, to our cultural practices, our systems of auth
ority and social control, our intellectual traditions,
our concepts of spirituality, and to our systems
of resource ownership and exchange. Destroy
this relationship and you damage—sometimes
irrevocably —individual human beings and their
health (Anderson, 1996).
Combining such perspectives with the insights
of the work of Marmot (2004) (concerning the
importance to health of control over one’s life
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Social vaccines a metaphor for health promotion
trajectory), makes the centrality of land reform
evident. Australian Aboriginal people living on
their land and with a continuous relationship to
it appear to have better physical and mental
health (McDermott et al., 1998). Land rights
movements have been evident around the world
and act to empower Indigenous peoples
(Burgess and Morrison, 2007) and act as a
social vaccine to construct land restitution as an
intervention to promote and protect the health
of Indigenous peoples.
In many countries, unequal land distribution
is aggravated further by changes in farming
practice (Chopra, 2005). For example, in India,
recently the large numbers of suicides among
farmers in India has been linked to unfair
agricultural development policies that support
cash crops over food crops (Patel, 2001; Suri,
2006). In Kenya, thousands of dairy farmers
have been bankrupted as a result of cheap
imports of milk products from Europe, result
ing from massive subsidies to the European
dairy industry, combined with reduced import
tariffs necessitated by ‘free trade’ agreements
(Madeley, 2003). Strengthening of farmers'
protest movements supported by consumers
around the world could create a social vaccine
that ultimately could result in political will to
ensure agricultural policies aimed primarily at
sustaining local livelihoods (rather than produ
cing cash crops through large commercial
farming enterprises), the removal of unfair
agricultural subsidies to industrial farmers in
the North and the use of trade protection
measures to protect small farmers in poor
countries.
Restriction and regulation of corporate
advertising
Many behaviours that result in poor health
arise, in part, from unhealthy and unethical
advertising campaigns. Cigarette smoking and
the displacement of breast milk by infant
feeding substitutes are two examples where
advertising and marketing have actively encour
aged people to adopt unhealthy practices. In
both cases, widespread social mobilization
(Chapman, 1994; Chapman and Wakefield,
2001) has led to the regulation of advertising
through international codes which have helped
to protect people from unhealthy practices.
Considerable concern is being expressed in
high- and low-income countries about the rising
431
rates of obesity and the increase in chronic
disease such as diabetes, cardiovascular disease
and joint problems (Gardner and Halweil,
2000). In rich countries, the rising prevalence of
obesity in children is of particular concern.
Food manufacturers spend massive amounts on
advertising food that is often high in fat and
sugar. In the UK, for instance, one soft drink
manufacturer spent £23 million on advertising
in 2002, which is about 10 times the entire
national budget for nutritional health pro
motion (Caraher et al., 2005). The advertise
ments are generally designed to appeal to
children, often featuring promotional free toys.
Political awareness of this threat and social
mobilization against it is increasing, and calls
for regulation of the corporate food sector are
growing (CFAC, 2008). This is to protect chil
dren from this unhealthy marketing by, for
example, insisting on correct nutritional mess
ages or banning the advertising of unhealthy
food on television when children are most likely
to be watching.
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Progressive taxation for social security
Poverty and extremely unequal distribution of
wealth and income remain the biggest under
lying causes of premature morbidity and mor
tality. They are strongly associated with
malnutrition and increased exposure and vul
nerability to disease, illness and trauma, and
deny billions of people access to health care. In
much of the rich world, one of the most signifi
cant advances made in promoting good health
was the introduction of social protection, often
funded through progressive taxation (Navarro
et al., 2006). These measures came about
because of pressure from social movements,
especially trade unions, which created a political
demand for them. This process of mobilization
leading to political will and subsequent taxation
reform was an effective social vaccine for
those in social democracies (Szreter, 1988).
Most low-income countries lack any real pro
spect of raising adequate public revenue to fund
essential social protection. Therefore, a social
movement advocating for universal social pro
tection—as recommended by the Commission
on the Social Determinant of Health (2008)—
could be the first step in developing a social
vaccine to secure the political will to implement
a global treaty to ensure social protection for all
citizens.
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F. Baum et al.
CALL FOR RESEARCH INVESTMENT
ON SOCIAL VACCINES
We conclude this paper by making a call for
more research relevant to social vaccines.
Compared with the resources invested in
researching vaccines for just a single disease,
the investment in research relevant to providing
evidence for and testing social vaccines has
been minimal (McCoy et al., 2004). Yet there is
an urgent need to understand what social and
political arrangements promote an empowered
and resilient population, who are able to recog
nize threats to health and take action to protect
themselves from the threat, and force govern
ments to regulate and intervene. The causal
links between structural determinants and
health outcomes are complex and embedded in
a web of political, economic, environmental and
social factors which require research designs
that can accommodate this complexity (CSDH,
2008). Research leading to improved under
standing of these social and political processes
is likely to improve health equity worldwide.
CONCLUSION
This paper has argued that action on the social
and economic determinants of health can be
advanced by adopting a ‘social vaccine' metaphor,
which applies the logic of traditional medical vac
cines to processes of popular mobilization and the
resultant political will that leads to interventions
and regulations that protect populations from the
structural causes of illness and health inequities.
This metaphor has value for the health promotion
movement in arguing more effectively to those
imbued in the biomedical model for a social
determinants perspective on health promotion.
FUNDING
F.B. is supported by an Australian Research
Council Federation Fellowship and V.P. by a
Wellcome Trust Senior Clinical Research
Fellowship.
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