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EDITORIALS: Richard Smith A time for global health BMJ 2002; 325: 54-55 [Full text]

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Globalisation on trial

David G Legge   (14 July 2002)

Western gangsters

Ian G Roberts   (15 July 2002)

September 11 - shock therapy for addressing global health inequalities

Niyi Awofeso, N/A   (17 July 2002)

Globalisation on trial 14 July 2002
David G Legge, Associate Professor School of Public Health, La Trobe University, Bundoora, Victoria, 3086, Australia Send response to journal: Re: Globalisation on trial	Why would a report on Macroeconomics and Health (WHO, 2001) fail to address the structured economic discrimination which is built into the regulation of global investment, production and trade? The dynamics of the global economy continue to drive a net flow of resources from the South to the North thereby contributing to poverty and ill-health in the developing world. Surely this would rate a mention in a report on macroeconomics and health? Have the issues canvassed in the WHO's 1992 report on the health dimensions of economic reform (WHO, 1992) all been addressed? The commissioners recognise that in some respects 'globalisation' might not be so good for people's health. They cite the brain drain from the Third World; increasing ease of international transmission of disease and the undercutting of local cultural patterns (eg with respect to food) (page 76). In these respects they are using 'globalisation' simply to denote increased international movement of information, people and goods. They also cite the international 'pressure' to reduce taxes (although do not analyse where this pressure comes from). This could reflect the second or third meanings. However, the construction 'globalisation is on trial', appears to reflect an implicit acceptance by the Commission of a third usage. What is 'on trial' is the current regime of global economic governance and regulation. In speaking explicitly of a 'regime' of global economic governance and regulation I am including the rules articulated through the World Trade Organisation, the disciplines imposed by the IMF and the World Bank (on developing countries) and through the financial markets and ratings agencies. The 'regime' includes also the various forums (official and private) where leaders of governments, banks and corporations meet. It includes the mass media, led by the financial press. It includes the US Defence Department and its supporters in Whitehall and other capitals. The prevailing theology through which the workings of this regime are given some semblance of rationality is neo-liberal economics and more particularly the Washington Consensus. A High Level Advisory Group, advising the Group of 77 developing countries (2001), comments: "The development needs and interests of developing countries are only marginally reflected in global economic and multilateral rules and institutions. A consequence of this practice is that there are international mechanisms by which rules can be implemented for the weak countries but not for the strong and the agenda for new multilateral rules and standards is largely shaped by the interests of a few powerful industrialised countries." It is disappointing that a Commission dominated by economists, when asked to comment upon "the place of health in economic development", should have steered so carefully away from any explicit discussion of the ways in which the current orthodoxy regarding development policy is creating the conditions for health stagnation for poor people in the poorer countries. However, despite its failure to explicate its analysis, the Commission concludes clearly that the current regime of global economic governance is not generating sufficient resources in the hands of consumers and governments in poor countries to enable them to meet their basic health needs. This is clearly an acknowledgment of the failure of this regime. It is not yielding the economic growth and wealth creation in the poor countries that would be necessary for the most basic health care. The Commission does not even pretend that at any time in the foreseeable future the current regime will allow these countries to achieve basic health care through national economic development. Rather, the Commissioners conclude that the rich world governments, the banks and the pharmaceutical giants must provide the necessary development assistance, debt relief and drug discounts to allow a very basic set of health programs to be put in place. In fact official development assistance (ODA) has been progressively declining over the last decade or more. It is moot whether this report will be able to arrest this decline. More significant is the relative insignificance of ODA as a channel for redistributing buying power from rich to poor. Real economic growth through sustainable production and fair trade is a far more sustainable mechanism for wealth creation. However, there is no analysis in this report of the systematic discriminations against the poor countries that are built into the current global regime of governance of trade, intellectual property, investment, communications and the ways in which these discriminations create the conditions for poor health. Rather than discuss the kinds of economic relationships and regulatory frameworks which might enable poor countries to produce and trade themselves out of poverty and towards better health the Commission develops, in some detail, the virtuous cycle hypothesis: 'better health creates economic growth creates better health'. According to this hypothesis: "Health is the basis for job productivity ... [G]ood population health is a critical input into poverty reduction, economic growth and long term economic development at the scale of whole societies. [...] Conversely, several of the great "takeoffs" in economic history - such as the rapid growth of Britain during the Industrial Revolution; the takeoff of the US South in the early 20th century [...] were supported by important breakthroughs in public health, disease control and improved improved nutritional intake ..." (page 32) This story may apply to certain industries in certain places and times. But it is not so simple. In many countries, industries and periods industrial growth has been achieved at the cost of destroying the health and lives of workers. Capital accumulation during the Industrial Revolution in Britain was in part based on using up workers' health as an input to production rather than as a capital asset. The mines of apartheid -era South Africa exemplify industries across the contemporary Third World where workers' health is consumed in creating capital, rather than treated as an asset. It is simplistic to argue that there are no contradictions between the policies directed at industrialisation and capital accumulation on the one hand and creating the conditions for population health. Companies recruiting cheap unskilled labour in poor countries with high unemployment, who choose not to invest in occupational health and safety and who refuse to contribute through taxation to education, housing and health care, may be expressing a judgement that workers' health is a consumable input rather than a capital asset. The reverse may be true in relation to high skill scarce labour. There are contradictions between health and production and they need to be named and the process explicitly regulated either to avoid such contradictions or to find the best compromise. Morrow (2002) is too kind when he suggests that the Commission has oversimplified the relationships between economic growth and health status improvement. A conceptual edifice based on partial truths such the virtual cycle hypothesis (of 'health-growth-health') is irrelevant to real policy making. However, it may be important in the rhetorical domain. We need to look beyond flawed reasoning to explore the possible rhetorical purposes of this document. In this respect I agree with Richard Smith's conclusion (Smith, 2002) that the final message of the Commission's report is that globalisation is on trial. "It may mean the rich continuing to neglect and exploit the poor, spending huge amounts on their own defences to keep out the poor, and allowing deterioration in global health and further environmental degradation. In that case, riots will continue at the meetings of global leaders, and the world may become steadily more unpleasant for all of us, rich and poor. Alternatively, globalisation through increasing openness and recognition of interdependence could lead to dramatic reductions in poverty and improvements in health. Finding political commitment to use the best of modern science and technology and the huge wealth of the rich world to improve health would, says the commission, inspire and unite peoples all over the world." The logic of this 'globalisation on trial' interpretation might be spelled out in detail along the following lines: WHO has been superseded by the World Bank as the premier global health policy authority. The World Bank is now the dominant development assistance donor globally. Confrontation with the Bretton Woods family (over the impact on health of economic policy prescriptions) jeopardises rich country funding of the WHO and invites lobbying to appoint a more compliant Director General. A non-confrontational approach to the Bretton Woods family may be more effective, seeking to persuade them of the importance of health using arguments that they will respond to, in particular, advocating the instrumental value of health as an input to economic growth; and endorsing the role of the World Bank through structural adjustment lending as the disburser and coordinator of development assistance (including health sector assistance). How likely that such a strategy would achieve significant improvements in health? Clearly a big injection of resources would make a difference but what grounds are there for expecting that such increases in official development assistance would be forthcoming? The ascendancy of neoliberalism in the industrialised countries has been such that ODA commands very little policy support. Perhaps this might be reversed if the policy community centred on the Bretton Woods family and the G8 started to see increased ODA as in their interest! So the message of the Report is essentially "Pay up to reduce the risk of instability and delegitimation of the prevailing global economic regime". This raises the possibility that the warnings about the threats to globalisation are more than scene-setting but are part of the substantive message of the report. According to this (more speculative) scenario this report represents the WHO and its economic advisers telling the World Bank and G8 that the Washington Consensus is under attack as never before; that the cause of this fraying legitimacy is the failure of the Washington Consensus to deliver economic growth and the conditions for health development; that unless the governors of the regime find the resources to at least ameliorate the worst of the health problems of the developing countries (perhaps by more ODA, perhaps by re-thinking the Procrustean brutality of the Washington Consensus) the stability of the regime globally will be jeopardised because of the crisis of legitimacy. The report of the Commission on Macroeconomics and Health is an important document. It may prove to be quite influential. Debates around its contents and significance could also provide important opportunities for new thinking and the strengthening of alternative movements. (A more extended discussion of the arguments presented in this response can be found at <http://users.bigpond.net.au/sanguileggi/PrelimAnalCMHReport.html>.) Smith, R. (2002). A time for global health. BMJ 325: 54-55 Morrow RH. Macroeconomics and health. BMJ 2002; 325: 53-54 World Health Organization. Macroeconomics and health: investing in health for economic development. Report of the commission on macroeconomics and health. Geneva: WHO, 2001. High-level Advisory Group of Eminent Personalities and Intellectuals (2001). Report on Globalization and its Impact on Developing Countries. http://www.socwatch.org.uy/2000/eng/updates/financing/g77_HLAG_report_sept.htm (current at: 5 Jan 2002) World Health Organisation (1992). Health dimensions of economic reform. Geneva.
Western gangsters 15 July 2002
Ian G Roberts, Professor of Epidemiology and Public Health London School of Hygiene and Tropical Medicine WC!B 3DP Send response to journal: Re: Western gangsters	In his editorial on global health, Richard Smith states that “many of the world’s poorest countries are run by gangsters who care little for their people, particularly women and children.” (1) There is increasing evidence that the same situation holds in the world’s richest countries. The World Health Organisation estimates that the economic sanctions imposed on Iraq by western gangsters that include the President of the United States and the British Prime Minister have resulted in a doubling the death rate among children, adding another half a million deaths. (2) The bombing of Afghanistan, one of the world’s poorest countries, would certainly have added to the death toll. Nor must we forget that many of the gangsters in low income countries were installed, to the detriment of the people of those countries, by gangsters in the west. (3) References 1. Smith R. A time for global health. BMJ 2002;325:54-5. 2. Delamothe T. Some talk of genocide. BMJ 2000;320:722. 3. Pilger J. The New Rulers of the World. Verso, London 2002.
September 11 - shock therapy for addressing global health inequalities 17 July 2002
Niyi Awofeso, Public Health Officer (Surveillance), New South Wales Corrections Health Service Long Bay Correctional Complex, P. O. Box 150, Matraville, NSW 2036, N/A Send response to journal: Re: September 11 - shock therapy for addressing global health inequalities	Sir, September 11 - shock therapy for addressing global health inequalities? I read Editor Richard Smith’s piece, titled “A time for global health” with great interest. I however differ in my interpretation of the main reason for increased concern for global health inequalities, as described in the editorial. He suggests that, primarily, factual analysis of health problems in poorer countries (such as by the WHO commission on Macroeconomics and Health) and how lives could be saved in the Third World made global health inequalities more fashionable than it was decades earlier. Although he mentioned the link between global health concerns and global security in the third paragraph of this editorial, I believe this point was understated. Human Development Reports have been published for decades. These reports detail global disparities and provide country profiles. For example, the 1997 Human Development Report, commenting on the impact of globalisation on health, stated that “… globalisation has its winners and losers … poor countries lose out because the rules of the game are biased against them."1 Unfortunately, no significant reaction to advancing equitable global health could be documented to result from these seminal Reports. In my view, global health inequalities are more fashionable today than they were as recently as this time last year primarily because of the September 11 terrorist attacks. This deplorable act sensitised world leaders to issues like bio-terrorism, and what threats poor, lawless countries may be transformed into by terrorists. He mentioned the UN and G8 interest in HIV/AIDS and communicable disease issue. I believe these groups’ interest came a bit too late, and should be placed in the September 11 (‘9/11’) context. For example, compare the conduct of the (pre 9/11) 2000 World AIDS Conference, where President Thabo Mbeki was vilified for daring to suggest that South Africa was too poor to afford anti-HIV drugs2, and the (post 9/11) 2002 AIDS conference, where American delegates were vilified for contributing too little, too late, to AIDS control efforts in poor countries. World leaders have always been aware of global health inequities, but they have hitherto erroneously assumed that they could “live with it” as long as their nationals are insulated from such inequities. For instance, President Bill Clinton’s policy response to HIV/AIDS in April 2000 was to declare this disease a national security threat, thus focussing efforts on preventing HIV-infected individuals from entering the United States.2 This approach typified the extent of world leaders concern to global health disparities prior to the unfortunate events of September 11. Now, there is consensus, but less action, that efforts to improve the public’s health globally must address the problem of poverty and poor health right across the globe. The most recent G-8 Summit, where the entire continent of Africa was given 10% of its request for development/health assistance, while Russia was given over thrice Africa’s aid package specifically to destroy/improve the safety of her nuclear arsenals underscores the priorities of world leaders. We are surely far from the stage where world leaders exhibit sincerity of purpose with regards to global health inequalities, but the September 11 attacks represented a sad but important milestone in changing the attitudes of world leaders towards its complex ramifications. References 1) United Nations Development Program. Human Development Report 1997, Oxford University Press, 1997. 2) Awofeso N., Degeling P., Ritchie J., Winters M. Thabo Mbeki and the AIDS ‘jury’, Aust. Health Rev. 2001; 24(3): 74-9. Author: Dr Niyi Awofeso, MBChB, MPH