Social vaccines to resist and change unhealthy social and economic structures: why we need them and how they would work

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Title: Social vaccines to resist and change unhealthy social and economic
structures: why we need them and how they would work
extracted text: SDA-RF-AT-3.4

Social vaccines to resist and change unhealthy social and economic
structures: why we need them and how they would work
Fran Baum1. Dave McCoy2. Ravi Narayan'. David Sanders4, Vikram Patel5 and Arturo Quizhpe'6
1. Chair, Global Steering Committee, People's Health Movement & Professor and
Health of Department of Public Health. Flinders University, GPO Box 2100
Adelaide 5001 Australia.
2. Health Care and Evaluation Group. Department of Epidemiology and Public
Health, University College , London, 1-19, Torrington Place, London WC1E 6BT,
UK
3. Member Steering Committee People’s Health Movement & Community Health
Advisor, Community Health Cell. 367, Srinivasa Nilaya, Jakkasandra, 1st Main.
1st Block. Koramangala. Bangalore - 560 034, India
4. Convenor, People's Health Movement Research Circle & Director. School of
Public Health, University of the Western Cape. Private Bag XI7, Bellville, 7535,
Cape. South Africa
5. Reader in International Mental Health & Wellcome Trust Senior Clinical
Research Fellow in Tropical Medicine. London School of Hygiene & Tropical
Medicine, Address: Sangath Centre. Porvorim, Goa, India 403521
6. Professor of Paediatrics Faculty of Medical Sciences, University of Cuenca.
Ecuador
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Summary points
• The term “social vaccine" is designed to encourage the bio-medically orientated
health sector to recognize and lake action on the distal social and economic
determinants of health
• This concept 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 vaccines would be designed to change the social and economic structural
conditions that make people and communities vulnerable to disease and to
develop their ability to protect their health
• Examples of social vaccines provided are restoring land ownership to Indigenous
peoples, regulating the advertising of harmful products, and providing for
progressive taxation to fund education, social and health interventions

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Introduction

There is a long tradition in public health that has recognised 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. This tradition is
reflected in the World Health Organisation's 1978 Alma Ata Declaration on Primary
Health Care, and the Ottawa Charter for Health Promotion. The People's Health
Movementiv has been a strong advocate for tackling the economic, social, political
and environmental determinants of health since its formation in 2000. especially
evident in the People's Charter for Health. The work of the Commission on
Macroeconomics and Health and of the Commission on the Social Determinants of
Health also provide strong evidence of the importance of structural determinants on
health.
The accumulating evidence was summed up by Rose's 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 significant body of evidence
documents how such distal determinants as the structure of the political economy, the
nature of the labour market and the nature of social life have an impact on health.
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 proximal behavioural and biological determinants of health. This is true in rich
and poor countries.
This paper explores the value of adopting a metaphor from medicine, the vaccine, as a
mechanism to promote the recognition of the importance of action on the economic
and social determinants of health. It does this by introducing and defining the concept
of social vaccines, including a discussion of different types of social vaccine and by
providing three examples of how social vaccines might be constructed and
implemented. It concludes by arguing that the concept is worthy of further discussion,
research and testing with policy makers.
What is a social vaccine?
The metaphor is designed to shill the dominant biomedical orientation of the health
sector towards the underlying distal factors that cause disease and suffering. The
value of vaccines to protect people from diseases by causing an immunological
response is widely accepted and understood. Few question their value as a costeffective intervention. The use of the vaccine metaphor is designed to promote the
implementation of social and economic interventions that can (just as medical
vaccines do) help to protect people from disease and illness through measures, often
universal, applied across populations.
The term has been used previously. For example, the UN’s International Labour
Organisationxiii and Narayan el al xiv. as part of the battle against HIV/AIDS, have
advocated for a social vaccine in the form of social inclusion, and income and job
security for people living with HIV/AIDS.

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At the most recent Global Forum on Health Research the People ’s Health Movement
hosted a session at which the concept of social vaccines was explored in detail.
Concern was expressed that the use of the term vaccine may result in an unwarranted
medicalisation ol social factors. It may give the impression that social and economic
interventions can be constructed in technological terms when in fact they often entail
complex political and cultural dimensions. While this risk has to be guarded against,
employing the social vaccine metaphor to engage policy makers and practitioners who
are comfortable with the biomedical paradigm was regarded as beneficial. The session
concluded that the notion ol social vaccines could be helpful provided that such
"vaccines" were designed to truly offer comprehensive approaches to tackling the
underlying determinants of health and were not seen as “magic bullets ”, nor as social
intervention imposed on communities from outside and without their involvement.
Thus we propose the following definition:
A social vaccine is an intervention or set of interventions,
often universally applied, aimed at mitigating the
structural social and economic conditions that make
people and communities vulnerable to disease, illness and
trauma. While medical vaccines help develop immunity
against disease, social vaccines develop the ability of
communities to resist and change social and economic
structures and processes (hat have a negative impact on
health.

fable 1 provides a list of types of social vaccines with some examples. Each of these
types of social vaccine is aimed at intervening along the chain of causation that results
in ill health and health inequities social vaccines work to protect the whole
population. This chain of causation is summarised in the framework developed by the
Commission on the Social Determinants of Healthxvi which sees ill-health (and
unequal health outcomes) as being produced, in part, by the underlying social
stratification. At each point of the chain social vaccines can contribute to reducing
inequity and poor population health outcomes by:
1. Decreasing social stratification (e.g. taxes on wealth)
2. Decreasing exposure to factors that threaten health (e.g. legislation to control
tobacco and alcohol sales and the arms trade).
3. Reducing the vulnerability of people to health damaging conditions &
strengthening the community and individual level factors which promote
resilience (e.g. anti-discrimination legislation).
4. Providing accessible, equitable and effective health care (e.g. universal public
health system).
Practical examples of social vaccines
Hie definition of social vaccine we have offered places prime importance on
interventions that affect the structures within which people live and work and which,
over time, have significant effects on health outcomes and their distribution in the
population. We provide three examples of how social vaccines could work in practice.

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Land rights and subsistence

In many countries around the world the Indigenous owners of land have had that land
removed through the processes of colonisation and industrialisation. They have been
dispossessed and forced to change from collective patterns of land ownership, which
built social capital and minimized inequities, towards patterns of land ownership that
are unequal and based on private and individualised forms of ownership. Across the
world report (hat 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 authority 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.*'"
concerning
Combine such perspectives with the insights of the work of Marmot
the importance to health of control over one’s life trajectory, and then the centrality of
land reform becomes evident. Australian Aboriginal people living on their land and
with a continuous relationship appear to have better physical and mental health*1*. A
social vaccine would 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 practicexx. 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**1. In Kenya thousands of dairy farmers have been
bankrupted as a result of cheap imports of milk products from Europe, resulting from
massive subsidies to the European dairy industry combined with reduced import
tariffs necessitated by “free trade" agreements**". A social vaccine would construct
agricultural policies aimed primarily at sustaining local livelihoods (rather than
producing 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 as key interventions.
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 substitution of breast milk with
infant feeding substitutes are two examples where advertising and marketing have
actively encouraged people to adopt unhealthy practices. In both cases, the regulation
of advertising through international codes has helped to protect people from unhealthy
practices demonstrating the use of regulation as a potent form of 'social vaccine’.
Today, considerable concern is being expressed in high and low income countries
about the rising rates of obesity and the increase in chronic disease such as diabetes
and cardiovascular disease and joint problems** 1". 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

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instance, one soft drink manufacturer spent £23 million on advertising in 2002. which
is about ten times the entire national budget for nutritional health promotion'' 1'. The
advertisements are generally designed to appeal to children, often featuring
promotional free toys. A social vaccine would regulate the corporate food industry so
as to protect children from this unhealthy marketing by, for example, insisting on
correct nutritional messages or banning the advertising of food on television when
children are most likely to be watching.

Progressive taxation for social security
Poverty and extremely unequal distribution of wealth and income remain the biggest
underlying causes of premature morbidity and mortality. They cause malnutrition and
increased exposure and vulnerability to disease, illness and trauma, and deny billions
of people access to health care. In much of the developed world, one of the most
significant advances made in promoting good health was the introduction of social
security nets, often funded through progressive taxation. Social security and the use of
tax to fund are a form of social vaccine that protects the poor from the various
diseases of poverty.
In a world where most low income countries lack any real prospect of raising
adequate public revenue to fund essential social security nets, greater consideration
needs to be given to the generation of public finance at the global level. The World
Commission on the Social Dimensions of Globalization"' saw that taxation could be
a powerful tool by which to make globalisation fairer and suggested a tax on
international financial transactions and taxes on the use of natural resources,
especially those that impinge upon the global commons such as the planet's carbon
sinks. They also recommended exploring the means of establishing a framework for
global taxation, the revenue from which could be used to make the outcomes of
globalisation fairer.
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 vaccines by calling for interventions that will protect populations
from the structural causes of illness and health inequities.
Compared to 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 minimalxxvi . Hence we conclude this paper by making a call for
more research relevant to social vaccines. This is especially required because the
causal links between most structural determinants and health outcomes are complex
and embedded in a web of political, economic, environmental and social factors.
Research designs are required that can accommodate this complexity. An improved
understanding of the ways in which actions to alter its underlying determinants can
lead to improvement in health is likely to improve health equity worldwide.

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Table 1: Types of Social Vaccines

Types of'social vaccine' _______________ Examples____________________________
Taxation and other forms of progressive •
Progressive income tax, wealth taxes
financing to allow for the universal
and death duties at the national level
provision of essential health, education •
New forms of innovative taxation at
and social services.
the global level to create global
finance
e.g.
currency
public
transaction taxes___________________
Social sector policies and social security • Universal social welfare benefits
interventions aimed at eradicating the ill • Conditional cash transfers
health of poverty
• Free essential health care
• Free public education______________
Regulation to protect people from:
• Framework Convention for Tobacco
Control
• the harms associated with commercial
advertising such as promotion of • International Code on the Marketing
of Breastmilk Substitutes
tobacco, breast milk substitutes.
unhealthy food
• Social, health and environmental
• the negative externalities caused by
impact assessments
private / corporate activity such as • Legal instruments and an effective
pollution or depletion of natural
judicial system to allow class-action
resources
suits against corporate malfeasance
Economic protection for poor country • Tariffs aimed at preventing the
economics, small business, small hold
dumping of cheap, subsidized
farmers etc from unfair competition
agricultural produce from rich
countries onto developing country
markets __________________________
Anti-discrimination legislation / legal • Land rights
rights
• Housing tenure security
• Anti-gender and race discrimination
legislation ________________
Systems of political accountability
• Democratic media
• Strong civil society / watchdogs /
voice for the poor
• Research and evaluation on social
vaccines especially social sciences
and social epidemiology.
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IV The People's Health Movement is a network of progressive health non-government
organizations which subscribe to the philosophy detailed in the People's Health
Charter (available on line at www.plimovement.org accessed 8th February 2007)

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