Globalisation and its Impact on Public Health
We now live in an increasingly interconnected and interdependent world. If industrialization and urbanization constituted the principle propellants of economic growth as well as health transition in the 19th and 20th Centuries, globalization constituted the tailwind that accelerated health transition towards the end of the 20th Century. This we have seen in the way non-communicable diseases have now become a global phenomenon. We have also seen how knowledge as well as technologies have been used to better control infectious diseases across the world. So globalization offers us advantages as well as disadvantages.
So naturally we find enthusiastic supporters as well as very strong skeptics. We need to critically look at how the advantages of globalization can be amplified while curtailing some of the absolute disadvantages that it has brought to global health.
Globalization has been defined as a process of greater integration within the world economy, through movements of goods and services, capital, technology, labor, all of which lead increasingly to economic decisions being influenced by global conditions. We see that the world economy now is increasingly being dominated by the forces of globalization, whether it is the spread of infectious diseases through rapid movement of people, or even the global contagion of economic crisis which affected the banking system in the first decade of the 21st Century. In such an environment you can have the forces of growth fueling production and employment in other parts of the world, but you can also have an increasing vulnerability where financial systems are actually either unstable or inequitable. Globalization affects health in several pathways.
Firstly, in terms of a direct impact on health systems as well as a direct impact on health policies. There is also an increasing exposure to hazards like infections, tobacco and other marketed products. But it also affects indirectly through the impact on national economies. For example, health sector affects the public health expenditure on health in terms of globalization influencing some of the policies related to allocation of resources, both through the health sector overall as well as within health itself, resetting of priorities for expenditure. We also recognize that there can be increasing effects on population risks. For example, on the kind of diets that people now start eating as a result of the global marketing forces and that has an impact on nutrition. And in turn, on health. Living conditions are also substantially altered by the forces of globalization. And all of this cumulatively can decide on whether the impact of globalization on health is positive or negative. For example, we see in the case of Central America the import of snacks from the United States has markedly increased as a result of trade between 1989 and 2006. And we see overweight and obesity rapidly rising in that region of the world, especially in Mexico. And also in other Central American countries. We recognize that we can also have the market liberalization bringing in healthy foods. Like in the case of Poland, where the opening up of the markets brought in much more vegetable oils which were healthier than the animal fats that were being traditionally consumed. And also a greater amount of fruit and vegetables.
And that resulted in a fairly rapid decline of cardiovascular mortality in the mid-1990s in Poland. So globalization in terms of nutrition can be a double-edged sword, depending upon which type of products are being marketed and are being consumed. At the same time we also recognize that trade impacts access to medicines. While this is going to be elaborated much more in a future lecture, we must recognize that lifesaving medicines can now be exported or imported worldwide. But there are barriers which sometimes prevent access to medicines because trade often prioritizes intellectual property over the social contract of making medicines available to everybody who needs them. And therefore trade is a very important area for us to look at when we see the impact of globalization on health, particularly through access to medicines. The whole area of trade liberalization was also accompanied by prescriptions for structural adjustments in the economy. And that had an impact on the way public funds were being utilized for health. During a transition to a market economy in the early 1990s, in Russia, there was a drastic fall in life expectancy, especially of the Russian males, which hit a point which was lower, lowest in a century. About 1.4 to 1.6 million premature deaths occurred during 1990 to 1995. A great proportion of these were among working age men. And there were several factors that were cited as being responsible for this effect.
Firstly the import of a large number of unhealthy foods into the Russian market exacerbated some of the poor diets that they were already having. But one of the most important factors was the deregulation of alcohol consumption which hugely increased alcohol consumption and binge drinking became a norm. And that resulted not only in increased cardiovascular disease, especially sudden cardiac death, but also a huge surge in accidents and injuries. This was also accompanied by reduced public spending on healthcare. And even some of the infectious diseases that were previously very well controlled now started springing up again.
So we saw the destabilization of the Russian health system during this period of economic transition. Again, marketization of health systems became an important feature of the prescription provided by multilateral institutions like the World Bank and the International Monetary Fund, during the late ’80s and early ’90s. And these traditionally worsened public spending on health by reinforcing the market driven approach to healthcare provision. And we are seeing how their emphasis on user fee became counter-productive. Evidence from Kenya, Burkina Faso, Papua New Guinea, all of them showed a clear decline in the utilization of health services with the introduction of user fee. One of the most dramatic impacts was seen in China, where despite the huge advantage that China had derived earlier from wise investments in nutrition, in public health, for water and sanitation, and in general, spending on provisional basic health services to the Chinese people, the introduction of market reforms saw considerable disinvestment of public finance in the health system. The percentage of women with insurance coverage for prenatal delivery, uh, prenatal and delivery services fell from 58.3% in 1989 to 34.7% in 1997. And the overall access to insurance coverage already available to just one in four Chinese in 1989 continued to decline slowly through the 1990s. This led China to review and revise its policy and introduce substantial reforms with infusion of public finance and an increase in the coverage of the insurance system through three programs to more than 95% of the population The fact that market prescriptions may have been unwise has also been acknowledged by the president of the World Bank, Jim Yong Kim, who referred to some of the prescriptions that the World Bank had made to Thailand against some of the reforms that Thailand wanted to undertake in order to launch universal health coverage. He said, “let me acknowledge that Thailand launched its universal coverage program against concerns over fiscal sustainability initially raised by my own institution. Thailand’s health leaders were determined to act boldly and provide access for their whole population. Today the world learns from Thailand’s example.” This confession that the World Bank prescription of the ’90s was incorrect came when Jim Kim addressed the World Health assembly in 2013. But the fact remains that many countries did follow the World Bank in name of prescriptions in the ’90s and that may have affected the way health equity grew among those countries. The World Bank has now formally changed its goal to fighting no longer just for the eradication of poverty, but also for shared prosperity, recognizing that mere growth itself is not a guarantor of good health, but you ought to reduce income disparities within countries if you want to gain from growth to the maximum extent. So that again is an important revision of the overall economic philosophy of the World Bank. And that may influence how globalization is perceived in the future.
When we come to the other impacts of globalization and health, we must also consider brain drain of health professionals. More than 20% of physicians working in Australia, Canada and the United States of America come from other countries. WHO estimates that there is a global shortage of about 4.3 million physicians, midwives, nurses and support workers worldwide, and the export of health workers to other countries from countries most in need of them for their own under-resourced health systems adversely affects global health. And this is a problem that we must address. And the WHO has provided a code on human migration of health workers which can offset some of these problems. But we must recognize again, that if there is a global shortage of health workers, we need a global response which provides those resources to all countries, but does not divert them from the less developed countries to the more developed countries. We also must recognize that global funding is now sometimes skewing the priorities both for health research and health programs within countries. While the infusion of a lot of private funding from philanthropic foundations and from the private sector is indeed welcome in terms of raising the overall pie of funds that is available for the health sector, if priorities are principally going to be decided by what the donors choose, then you may actually land up with priorities which are misaligned to the needs of countries as well as that of global health. So we need to build in a greater accountability into the whole system of global funding from nongovernmental sources and say that these are the kind of priorities that have to be determined by countries and by consensus among countries, and any private funding should not distort those priorities. At the same time we see the increased global movement of humans and goods can increase the risk of infectious disease spread. We have seen that for Ebola. We have seen that for SARS. So we need to be very careful about how we actually ensure the movement of people and goods during a period…during an era of accelerated globalization does not cause more of infectious disease spread, resulting in pandemics.
Globalization has also been recognized as one of the drivers of change in ecosystems. For example, agricultural production itself is greatly skewed to meet international demand created by market pressures rather than by addressing local needs. And not even in terms of looking at global health goals or national health goals, but purely looking at the commercial profit line of the crop production that has often resulted in reduced crop diversity with a much greater emphasis on some of the cash crops than even on staples or protein sources or providing the kind of diversity that’s required for healthy diets. For example we see tobacco, meat, soya and palm oil dominating the agricultural system which are not always to the advantage of good health. Global meat production for example is now going up substantially and is likely to rise from about 310 millions of tons in 2013 to about 518 millions of tons in 2050. While we do require protein sources, this level of meat consumption is not good for health and certainly not good for the environment because of the high level of methane emissions as well as the huge amount of deforestation that is required to produce the grain that goes into feed the animals.
So we must recognize that agricultural systems which are being driven by forces of global commercial compulsions are now sometimes acting to the detriment of good health as well as the environment. And the environmental degradation in turn affects health. We also recognize that shifting of production to low and middle income countries with poor environmental and safety regulations negatively affects the environment in some ways because of increased air pollution levels, because of a number of factories which belch out a lot of carbon dioxide and other greenhouse gases, or contamination of water bodies because of poor environmental regulation. Drainage of water because of soft drink companies draining away a lot of needed water for production of their beverages in the low and middle income countries.
Or even poor living conditions whether it is the garment factory workers in Bangladesh who suffer because of fires breaking out in very poorly regulated conditions of work, or when you’re looking at people working in South African vineyards or people working the tobacco factories of India, we find that while the production forces are now investing much more in low and middle income countries,they’re not ensuring the health and safety of the low paid employees. And this is again, a distortion of globalization that we ought to correct. It has been said that globalization itself is a wonderful opportunity for equalization of opportunity across the world. And by spurring on economic growth, it’ll not only foster better health but also reduce health inequities. Angus Deaton differs and points out that economic growth by itself will not be enough to improve population health, at least in any acceptable time. Clearly we need growth, but we also need inclusive growth in which health inequities which accompany economic inequities are reduced. And Angus Deaton says that as far as health is concerned the market by itself is not a substitute for collective action. So the imperative of globalization is collective action, not just abandoning everything to the forces of the market. Therefore, we need to recognize that market interventions are required for protecting health. Even in the national context, we have recognized that asymmetry of information and decision-making power doesn’t make health a perfect market. In fact, it’s a very imperfect market. And the same thing applies even at the global level when trade and other market compulsions often negate the need for policies which are conducive to good health at the global level. Therefore, recognizing that the market is here with us and is something that we have to reckon with, we need to mold the market by adopting a number of other forces which are favorable to public health.
Firstly, we must raise consumer consciousness so that the demand for healthier products steers the industry towards them. We must also offer the industry incentives for producing healthier products by pointing out the health dividend that comes from a health society which is much more productive, which stable labor and consumer markets for a variety of goods. We need to see that public-private partnerships are much more responsible and are responsive to health concerns and produce healthier products for the global market.
At the same time, we ought to adopt national policy frameworks with political, economic, and social motivators that reduce some of the distortions brought about by globalization, whether it is nutrition which has to have incentives for healthy foods in form of subsidies, or disincentives for unhealthy foods in terms of increased import tariffs. We also need global agreements for example by way of the framework convention on tobacco control or agreements to ban advertising of junk foods and soft drinks to children. So there are a large number of global agreements also which can bring about some degree of balance in the market forces that dictate global health. As Nancy Birdsall, the director of the Center for Global Development remarked, globalization as we know today is fundamentally asymmetric. In its benefits and its risks, it works less well for the currently poor countries and for poor households within developing countries. In a very famous phrase, Thomas Friedman described the world as being flat; basically pointing out globalization has brought in a number of opportunities across the world reducing the asymmetries that existed prior to that. But even what appears to be superficially a very flat surface sometimes can be very tilted. And that is the asymmetry of power, even in a globalized world. With multilateral institutions like the World Bank, the IMF, the World Trade Organization, the distribution of power is unequal. The G-8 nations account for nearly half of the global economy and trade. They hold four of the five U.N. Permanent Security Council seats and have a major shareholder control over the International Monetary Fund and the World Bank. So even in the era of globalization, which offers considerable opportunity for other countries in the world to benefit from an integrated global economy, it is this asymmetry of both economic and political power that brings in distortions. So we need to insure that those are corrected if we are really pursuing the goals of global health and health equity. So for globalization and health what needs to be done is to make more resources available for health systems by expanding and improving the overseas development assistance, improving debt relief. That’s very critical because countries which are actually in the poverty trap because of huge, unaffordable debt need to be provided support so that they can escape the poverty trap and invest much more in their own health systems. We need to reform the international trade regime, bringing in health front and center as a consideration. And ensure that the WTO regulations do not undermine what the WHO is trying to do or what countries are trying to do. We need to consider health as a human right because unless we do that, we’ll not be able to set right some other distortions that have occurred because of globalization. We need to protect national governments policy space for addressing the social determinants of health in light of the unpredictable nature of financial capital. We can’t leave everything to globalization which brings in investment because we know how fickle financial capital is. At the earliest sign of risk, capital flees, leaving the countries high and dry. And that can have a detrimental effect on their own investments in the health sector as well as in the social determinants of health. So we ought to be able to insulate some of the fundamental things like water, sanitation, nutrition, environment and basic health services against some of the imbalances that occur because of the imperfections in the financial markets. But having looked at some of the flip side of globalization, we must also recognize that globalization has several advantages to offer. Firstly, there is globalization of knowledge. Globalization of knowledge in terms of science, in terms of technologies, all of these can be highly beneficial to humanity if they’re shared. And we recognize whether it is the causation of disease or interventions to prevent disease or reduce the impact of disease, this knowledge has been transformational over the 20th Century, can be even more so in the 21st Century. So we need to build bridges by which knowledge can rapidly diffuse across the world and act in favor of good health.
At the same time, in terms of reverse innovation, there is a lot happening in the low and middle income countries where because of some of the challenges faced by the health systems they’re coming up with absolutely brilliant innovations which are problem-solving and low cost. And some of these innovations can now become portable even to the high income countries and they can benefit from some of this new knowledge that’s being created. In terms of global financing of health, we now recognize that there can be increased funds flowing into the health sector to a variety of poor resources. Countries need not be all the time essentially living on uncertain charity. Pre-committed funds as the part of global programs for health are going to be very important for supporting some of the health system innovations in low and middle income countries and helping them to overcome their own health inequities. In terms of globalization of health norms we now recognize that communications have now transported role models across the world through the media which is now globally shared. Whereas people were looking at unhealthy foods as one of the norms, now they’re looking at healthier foods, physically active living habits as the desirable social norms. Nothing illustrates this more than tobacco-free public spaces. Now in many parts of the world to smoke in public is not only legally taboo, but socially frowned upon. And these are changes in health norms that have actually come from some of the developed countries and are now rapidly moving for adoption in the low and middle income countries.
So globalization of health norms can be very effective too. And again, this can be didirectional because some of the traditional cultural norms and traditional health norms of the low and middle income countries can also be adopted by the high income countries. Globally shared goals are important. We’ve seen the tremendous impact of the millennium development goals and that has been an important area of global cooperation, where a shared vision enabled different countries to work together to reduce maternal mortality, child mortality, under-nutrition and poverty. But for all of this to happen, we need globalization of solidarity. You cannot have narrow, self-serving sectoral interests driving the forces of globalization.
You need a common commitment to global good as the unifying force of globalization where we are looking at economic inequities being reduced, we are looking at health inequities being reduced and we recognize human welfare as something that we’re all concerned about as a common human family. So if we can actually make that as the unifying platform of globalization, then we will be able to eliminate or substantially minimize the distortions of globalization on global health and really build upon that solidarity for advancing global health to levels that we have never seen before and reducing health inequities to the lowest possible. Go back to start of transcript.
