A time for global health
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7355.54 (Published 13 July 2002) Cite this as: BMJ 2002;325:54All rapid responses
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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.
Competing interests: No competing interests
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_se...
(current at: 5 Jan 2002)
World Health Organisation (1992). Health dimensions of economic
reform. Geneva.
Competing interests: No competing interests
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
Competing interests: No competing interests