Globalisation is good for your health, mostly
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7311.504 (Published 01 September 2001) Cite this as: BMJ 2001;323:504
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Sir,
Feachem 1 argues that the position of contemporary anti-globalisation
protesters is undermined by three flaws – they ignore the evidence that
globalisation brings significant economic benefits, they ignore its wider
social and political benefits, and they fail to propound a “counter
proposal” against globalisation.
Feachem’s central proposition is that “…globalisation, economic
growth and improvements in health go hand in hand”. Yet he underplays
curiously the measured conclusions of the contributors to the Bulletin of
the WHO series which he oversaw on this very subject. 2-4 With differing
emphasis, all these authors identify a common theme: globalisation,
openness to trade, and economic growth all have great potential to improve
health - but only when i) effective domestic and international policies
exist to prevent or mitigate adverse impacts, ii) states and international
bodies are capable of developing and implementing credible health
policies, and iii) states and international authorities intervene actively
in the market to ensure that the poor and vulnerable receive some share of
its benefits.
Feachem also ignores the core political argument against contemporary
“globalisation”. This is that the current incarnation of global
capitalism has actively undermined the authority of democratically
accountable governments in the face of the rising power of unaccountable
multinational business and capital, and hence has eroded democracy in its
very heartlands. 5 This argument notes that politicians in both
developed and developing countries have frequently appeared helpless in
the face of corporate threats, and appear to be unwilling to pull out of a
global “race to the bottom” or to challenge overt and egregious corporate
misbehaviour.
Despite Feachem’s assertion that the protesters have no counter-
proposal to the status quo, a myriad alternatives exist the moment that
crudely economistic dogma is dropped. Differing balances of regulation,
intervention and social protection can achieve a huge number of different
outcomes, to be judged on their ability to improve social welfare – which
must itself be conceived of through multiple criteria. If, however,
Feachem requires that a genuine “alternative” must be an all encompassing,
full-blooded ideological competitor to contemporary capitalism, then one
is forced to enjoin him to take care in what he wishes for. No-one can
quantify the true costs of the ideological conflicts that scarred the
world from 1917 – but we have enough experience to say that insistence on
doctrinal purity carries an unacceptably high price. Now is surely the
time for ideology to give way to quiet pragmatism.
1. Feachem RGA. Globalisation is good for your health, mostly. BMJ
2001;323:504-6.
2. Dollar D. Is globalization good for your health? Bulletin of the
World Health Organization 2001;79:827-833.
3. Cornia GA. Globalization and health: results and options. Bulletin of
the World Health Organization 2001;79:834-841.
4. Woodward D, Drager N, Beaglehole R, Lipson D. Globalization and
health: a framework for analysis and action. Bulletin of the World Health
Organization 2001;79:875-881.
5. Hertz N. The silent takeover. London, William Heinemann. 2001. p197
-212.
Competing Interests:
I am currently employed by the European Union’s Public Health Sectoral
Support Programme. I have previously undertaken paid consultancy
assignments for the World Bank, the World Health Organisation, DFID and
the IMF / World Bank / WHO Commission on Macroeconomics and Health. I
have benefited enormously from being the privileged child of a capitalist
society, and am keen to ensure that my children receive even better.
Competing interests: No competing interests
Dear Sir,
In his recent article praising the positive health effects of
globalization, Richard Feacham1 espouses a view shared by few researchers
concerned about the negative effects of “globalization-as-we-know-it” on
the health of poor countries. There are demonstrated harmful effects of
the debt crises, structural adjustment, and privatization of health
services on the overall health of poor countries, yet Feacham does not
address these.2
Feacham follows the lead of other proponents of undemocratic,
corporate-controlled globalization. He does not answer the critics’
charges, but rather creates straw-man arguments and then knocks them down.
Opponents of “globalization” are not isolationists. Who in the world, save
for a few dictatorial countries, is not open to greater communication
between peoples and cultural exchange? He conveniently sidesteps
addressing the documented damaging effects of what globalization is known
as around the world, namely neoliberal economics: privatization, cuts in
government social spending, imposition of user fees, export promotion over
the promotion of domestic production, higher interest rates, and currency
devaluation.
Feachem claims that countries who have increased trade and reduced
tariffs have grown much faster than other developing countries. One might
question how that growth is measured and how well it correlates with
improved health measures and human rights standards.3 In fact, inequality
within and between countries has actually worsened over the past 20
years.4 Even using the imperfect measure of per capita income,
globalization’s effects are mixed. From 1960 to 1980, per-capita income in
Latin America grew by 73%, whereas from 1980 to 2000 growth was only 6%.
In Africa incomes rose 34% between 1960 and 1980 and fell 23% between 1980
and 2000.5 Growth was no greater in countries that followed World
Bank/IMF policy than those who did not.
We agree that globalization of previously codified human rights
standards is good for global health. However, to assume that one must put
up with if not welcome “the eyesore of the McDonald’s outlet in
Hyderabad,” in order to achieve equity and parity in human rights and
health stretches credibility. Many countries have made advances in health
and human rights standards without inviting in Western corporate fast food
chains.
Feacham acts as if no one calling attention to the abuses of
globalization has put forth a viable alternative. No thoughtful health
professional is opposed to economic growth and the advancement of human
development as long as those two goals are considered equally. Human
development is all too often considered secondary in global economic
policy decisions. Our viable alternative is a democratic development
strategy that is both equitable and beneficial to the poorest sectors of
the global economy, that takes into consideration the full spectrum of
human rights, including health, environment and labor rights. Proposals
that continue to ignore the health of the poorest sectors will be doomed
to perpetuate economic inequality and poor health for us all.
Timothy H. Holtz, MD, MPH,
Vice President
tholtz@igc.org
Wendy Johnson, MD,
Secretary
wendyj@igc.org
Doctors for Global Health,
PO Box 1761,
Decatur, GA 30031
1. Feacham RGA. Globalisation is good for your health, mostly.
British Medical Journal 2001;323:504-6.
2. Kim JY, Millen JV, Irwin A, Gershman J, editors. Dying for Growth:
Global Inequality and the Health of the Poor. Monroe, Maine: Common
Courage Press, 2000.
3. Sen A. Health in development. Bulletin of the World Health Organization
1999;77(8):619-623.
4. UNDP. Human Development Report 1998. New York, NY: United Nations
Development Program, 1998.
5. Weisbrot M, Baker D, Kraev E, Chen J. The Scorecard on Globalization,
1980-2000: Twenty Years of Diminished Progress. Washington, D.C.: Center
for Economic and Policy Research, 2001.
Competing interests: No competing interests
Most of the points that struck me as I read Richard Feachem's article
have already been raised, but I was interested to see his reply. My main
concern was never that the article had been published but that a blatant
conflict of interest had been ignored. And with an evident antipathy to
protestors and dissenting opinion throughout, and some somewhat
tendentious views (where did that stuff about East Timor and the brave San
Suu Kyi come from?) the whole article veers dangerously close to
propoganda. Should have gone into Personal View or similar because that is
what it is.
For the record I'm glad someone has finally pointed out that violence
from the protestors was greatly overshadowed by that of the state. Let's
not forget the vast majority of those there were peaceful, there were
rumours of of police infiltration, a protestor was killed by an
inexperienced recruit given a gun and there was a despicable raid on a
community centre where people were beaten in their sleeping bags and
arrested on charges that with one exception were instantly thrown out of
court. Consular assisstance was witheld by our own government.
And if I have gone on about this - and there is more I wish to say -
yes I am happy to reveal I am active in local politics (Socialist
Alliance) and remember the vivid eye-witness accounts. I don't always
agree with what protestors have to say but they have a right to do so
peacefully, and without fear. I know I was irritated by the tone of the
article, neglecting the real source of violence at Genoa, and feel
strongly a more neutral voice would have been better received.
Competing interests: No competing interests
Richard Feachem declares no conflict of interest when he says
‘Globalisation is good for your health, mostly’ (BMJ 2001;323:504-6). One
could argue that he does have one- he simply wants a system that keeps him
and his ‘civilised’ world rich and comfortable to continue. Simply being
wealthy appears to make not just people but whole countries feel that they
can announce what is good for the rest of the world! And I suppose it
makes them also want to stay wealthy.
Restricting one’s argument to health- a state of physical, mental and
social well being (WHO 1996), and I think the definitions linking health
to expectations are even more apt- it could be said that even if a
minority of individuals greatly benefited from the advances in health
care, humanity as a whole has not. Man has simply had some 30 years added
to the end of his lifespan which is where he would not have wanted it! The
personal, social, economic and moral consequences of this are evident only
to those who suffer them or those who deal with the resulting problems.
Globalisation, which funnily enough does not encompass globalising of
wealth, appears to make the poor countries even more dependent on the rich
countries- it simply ensures the continued well being of the rich
countries. What is the use of having Coca-cola available in a place where
clean drinking water is not available to millions? It is better not to
know about it.
What Feachem does not realize is that globalisation makes people in
the poorer countries aspire to things that they can only get through crime
or corruption; and that thousands of San Suu Kyi continue to be eliminated
by the pseudo-democracies of most poor countries. This is no different to
what happens in the ‘uncivilised’ world and the ‘civilised’ world will cry
only when there is money or strategic positioning in it or if there are no
news items about sexual exploits of their rich and famous for their media.
No, globalisation is no good for any country that cannot feed,
clothe, shelter, educate and protect their whole population
satisfactorily. Any health benefit it can bring is worthwhile only once
this condition is satisfied.
Competing interests: No competing interests
EDITOR - We live in extraordinary times, but not for the reasons that Feachem
celebrates in his eulogy on globalisation as mostly "good for your
health". An informed, inclusive discussion of globalisation’s merits and
demerits, including its impacts on human health is needed, given the
increasingly polarized nature of this debate. The mass demonstrations of
"anti-capitalist" protesters at major international meetings, most
recently at the Group of Eight (G8) Summit in Genoa, communicate the angst
felt by many for the human, social and environmental consequences of the
kind of globalisation we are experiencing today. However, the violence
that has piggybacked on these demonstrations has undermined and confused
the protestors’ message.
For the health community, a fuller review of the evidence begins with
a disentangling of globalisation as a complex web of cause and effect.
Both sides of the debate have abused the term as a catch-all to explain
many natural and human-induced changes. Defining globalisation as
"openness" does not capture the multiple, often contradictory, forces at
play. Globalisation can also be defined as processes that are changing
the ways people interact across boundaries, notably physical (such as the
nation-state), temporal (such as instantaneous communication via email),
and cognitive (such as cultural identity). The result is a redefining
of human societies across many spheres - economic, political, cultural,
technological and so on. As such, globalisation affects the health of
different people in very different ways. How "good" or "bad"
globalisation happens to be for you will be influenced by socioeconomic
status, gender, education, age, geographical location and other factors.
We are only beginning to understand these interconnections but
existing evidence about the adverse health impacts of globalisation cannot
be readily dismissed. The role of global environmental change on diseases
such as malaria, dengue fever and cholera has been well-documented. The
alarming rise of tobacco-related diseases has followed recent global
economic policies. The claim that globalisation will ultimately bring
greater wealth, and thus better health, is open to challenge. What is
needed, in short, is a comprehensive examination of the data bearing on
each of the many components of globalisation, an assessment of the risks
and benefits of each component, and innovative policy responses enabling
us to act appropriately when choices are possible, and to adapt to changes
that are inevitable. To do otherwise will reinforce a simplistic debate
that is not only widely divided already, but will ultimately fail to
benefit the health of all people.
Kelley Lee, Senior Lecturer and Co-Director
David Bradley, Professor and Co-Director
Mike Ahern, Research Assistant
Centre on Globalisation, Environmental Change and Health
London School of Hygiene & Tropical Medicine, Keppel Street, London
WC1E 7HT
Tony McMichael, Professor and Director
Colin Butler, PhD student
National Centre for Epidemiology and Population Health,
Australian National University,
Canberra, ACT 0200, AUSTRALIA
References
Feachem R. Globalisation is good for your health, mostly. BMJ 2001; 323:
504-506.
Lee K. Globalisation and Health: An introduction. London:
Palgrave, forthcoming.
Intergovernmental Panel on Climate Change, Third Assessment Report.
Cambridge: Cambridge University Press, 2001.
Yach D and Bettcher D. Globalisation of tobacco industry influence
and new global responses. Tobacco Control 2000; 9: 206-16.
Weisbrot M., Naiman R. and Kim J, "The Emperor Has No Growth:
Declining Economic Growth Rates in the Era of Globalization," CEPR
Briefing Paper, Center for Economic and Policy Research, Washington DC,
May 2001.
Competing interests: No competing interests
EDITOR
Globalisation is good for your health, mostly.
- Presumably Feachem's article1 was not meant to be taken personally
by those reading the BMJ if they were a patient in a rural hospital in
central Africa where staffing shortages and a falling life expectancy are
major issues.
The globalisation of the labour market means that the NHS is
advertising in a number of countries and planning to entice doctors and
nurses to travel to the UK and fill vacant posts here. It is simplistic
to suggest that "globalisation, economic growth and health improvements go
hand in hand." Staffing shortages in Africa as a result of such labour
movements will bring no short term health benefits to developing countries
- however big the remittances that such expatriates might send home to
their families. Some developing countries have invested heavily in
training health staff and cannot afford to loose them to the Northern
Hemisphere. A country with limited resources cannot develop health
services in the face of such an expensive skill drain. The morals of such
advertising are debatable.
The pressures on many sub-Saharan health staff are immense. An
experienced staff nurse may be paid only £20.00 per month while a check
out assistant in a local store earns £30.00. Globalisation may bring
improved economic opportunities for some but they may not be rolled out
through the community.
Partly as a result of HIV/AIDS, life expectancy is falling. For
subsistence farmers in central Africa a year of poor rain means that there
is little or precarious food security. Agricultural free trade undoubtedly
does bring some benefits for larger scale producers but for those who are
subsistence farmers, monopolistic seed suppliers selling sterile seed or
plants that are heavily fertiliser dependent are not welcome in the market
place.
From my conversations with colleagues in one of the world's poorest
countries, the tenuous statement that "it may still be the case that …poor
households are getting richer" is not a reality.
Feachem's article has indeed generated debate but it needs to be
interpreted in the reality of rural poverty and should have had the sub
title - "A silver lining for a thundercloud?" Globalisation is neither
the fundamental cause nor the total cure for the gross inequalities in
health and economic status today. Whether it is "good for your health"
depends whether you are under the silver lining or the thundercloud.
John Dorward
General Practitioner
The Health Centre,
Houndlaw Park
Eyemouth, Berwickshire.
TD14 5DA
Competing Interest - Medical worker in Malawi 1986-91
1 Feachem RGA. Globalisation is good for your health, mostly. BMJ
2001;323:504-506.
Competing interests: No competing interests
Dear Sir,
The exchange of views in your columns on globalization is certainly
lively. I will make just a few points at this time.
First, as my paper states and as the September issue of the Bulletin
of WHO (vol. 79, no. 9, 2001) elaborates, globalization encompasses events
and processes which undoubtedly threaten public health and the interests
of poorer people in poorer countries. These dangers and adverse
consequences require serious research and action. Some are now receiving
a heightened response; for example tobacco, under the leadership of WHO
and with considerable support from the World Bank. Other risks and
consequences remain to be adequately addressed, especially in the areas of
infection and the environment.
Second, globalization is in no way a panacea. Many national and
international policies and actions are also necessary to ensure sustained
growth and poverty alleviation. In addition, some problems remain
intractable and the solutions elusive. This is nowhere more apparent than
in the desperate situation of some African countries, now tragically
worsened by the HIV/AIDS pandemic.
However, the multi-country econometric analyses (some of which I
cite), and the documented experience of individual countries, make clear
that participation in the global economy promotes economic growth and that
economic growth, on average, increases the incomes of the poor. What is
good for the incomes of the poor is good for the health of the poor. The
fact that these relationships do not apply everywhere and always is
explicitly pointed out in my paper and is a matter of grave concern
requiring careful analysis and strenuous action.
Some respondents have expressed interest in my employment history.
This is a matter of public record. For those who may be interested, I
have worked for Voluntary Service Overseas (1 year), the University of New
South Wales (3 years), the University of Birmingham (2 years), the London
School of Hygiene and Tropical Medicine (19 years), the World Health
Organization (1 year), the World Bank (5 years), and for the University of
California (2 years and counting). I have also held appointments at Johns
Hopkins and George Washington Universities. I have sat on several
charitable boards and advised a number of public and not-for-profit
organizations. I speak for none of these bodies. As with my numerous
other publications, my views are my own, based on a lifetime of work in
international health and extensive time living in and visiting developing
countries, including 3 years of residence in extremely poor and remote
villages in Melanesia.
Finally, some commentators have implied that it is somehow
inappropriate for the BMJ to publish this material. Why? Serious
journals and academic presses publish evidence and opinions of this kind
regularly. It would seem to be desirable that the medical and public
health communities are also exposed to this stream of evidence and
opinion, especially where the focus of the paper, and of the author, is on
globalization and health.
Richard G A Feachem
Competing interests: No competing interests
Richard Feachem’s article on globalisation cannot be left
unchallenged. It perpetuates the broad brush approach of macroeconomists
tied to western and northern economic approaches to the problems of the
south.Globalisation is indeed regarded by many as a threat to the poor and
underprivileged, as well as to ecosystems and the wider environment, and
with good reason.It is also regarded by many as a direct threat to
democracy itself by tending to homogenise politics into a narrow band,
supportive of the status quo, and bought and paid for by powerful
economic interests.In quoting the economic benefits of globalisation
Feachem relies heavily on conventional short term economic accounting
which ignores the value lost as biodiversity is reduced, the environment
degraded, and social support networks broken down. An oil spill for
example may result in increased spending and income within a nation,
temporarily raising GDP and becoming an “economic good” in this way.
Cutting down a rainforest may earn valuable short term currency in timber
exports, and boost GDP, but few sensible observers would argue that this
is in the long term interests of local people, or indeed the wider world.
The same apply to many huge dams, new roads, irrigation schemes and other
grandiose schemes unless a thorough and credible environmental and social
assessment is carried out.His espousement of the “trickle down” theory of
wealth distribution would be challenged by many economists, and his
equation of human rights with globalisation is laughable when many workers
live in conditions akin to slavery at home in the Export Processing Zones
of various poor countries and where protests against corporate activity
has been met with human rights abuses.
His argument that no alternative has been profounded is false. The
fair trade movement has shown what is possible. New rules enforcing decent
and thorough social and environmental assessment can lead to beneficial
and sustainable development, as with the new criteria for assessment of
dams, however imperfect these may turn out to be. Action at the micro
level such as small scale loan schemes, clean water provision,
agricultural support, anti-erosion schemes and renewable energy have been
shown to improve the lot of the poor, without displacing them and leaving
them landless to drift into the Metropolis and shantytowns.Many charities
do sterling work in this area but sadly western government aid is often
dominated by the promotion of corporate interests at home, rather than a
true desire to help the poor abroad. The new concepts of localisation are
gaining support in a UK which has been devastated by BSE and foot and
mouth, both worsened by modern globalised agricultural systems.
Finally, as for the comment that the meetings disrupted by the
protesters in Genoa and elsewhere discussed matters of great concern to
the south, this has been widely challenged. The AIDS package was small
scale, and a diversion of resources from other areas already earmarked for
spending, not new money.No significant deal was achieved on debt
forgiveness, despite massive levels of indebtedness in sub-saharan Africa.
The impression given is one of a rich man’s club carving up the world,
impervious to the democratic process,dominated by corporate interests and
deaf to civilised peaceful protest, where sleeping protestors are dragged
from their beds at night and beaten unconscious by the local police force.
Unless a mechanism is developed to make institutions accountable,
democratic and ethical I’m afraid the situation both in the south and with
protests will continue to worsen, as will the modern day problems of
asylum seekers and violent protest.
Competing interests: No competing interests
Dear Sir,
When Feachem sites the many economic and social advantages of
globalisation (1st September) he misses the point completely. Few would
argue that economic development is not beneficial to the poor living in
the third world. Most of us are not angry about globalisation per se. We
are angry because despite the worlds massive technological advances and
our ease of access to the poorest people in the world, we are using
globalisation to make profits from the disadvantaged, not to help them.
Globalisation is an inevitable product of development and has the
potential to produce great benefits for the third world. Surely the
system that enabled people to walk on the moon must be able to work
wonders for those who have become our neighbours in the global village.
Sorting out universal water supplies can’t be so difficult when we can
send e-mails from a laptop in the desert? However, instead of using
globalisation for the benefit of those who are struggling, the
multinational companies have used it to make greater profits for their
companies (and for us, the shareholders). Following the industrial
revolution it took 100 years to produce any kind of dignity for factory
workers in the UK. But having achieved that, what happens? The companies
turn their attention to those places where there is less regulation and
where profits can be obtained unhindered by the need for compassion for
the workforce. The result is the sweatshops of the Far East.
But who is responsible? Those who work in the sweat shops are
compelled to by the lack of any alternative and the managers want to keep
their jobs. Those who run these companies must keep their shareholders
happy, as must the fund managers who control the flow of investment. And
the shopper innocently looking for a Christmas bargain in a clean,
brightly lit store can hardly be held responsible.
So to whom can we turn to protest? We turn to those with real power
– the leaders of the most powerful countries in the world. They have the
only real power to start regulating the system. And the truth is that
direct action has had far more effect than would any letter writing
campaign. Would there have been an article in the BMJ if it were not for
the Genoa protests?
Economic progress is good for your health. Globalisation too should
be good for your health, but whilst it is being led by powerful,
unregulated institutions for whom profit comes before compassion, it will
come about only as a by-product, if at all. Multinationals must take the
responsibilities that come with their arrival into the third world. And
the leaders of the most powerful nations should use the opportunities that
globalisation has provided to ensure that our poorer neighbours in the
global village achieve at least basic healthcare and living standards.
Yours sincerely,
Andrew Weeks
Competing interests: No competing interests
Globalism versus Globalisation
The remarkable facts about the article of RGA Feachem "Globalisation
is good for your health, mostly" are that neither the question of power
and its distribution in world society nor the question of human dignity
and how we want to live has been raised. Nobody,including the protesters
against the G8 summit in Genoa, is against globalisation as a process of
social integration, which the protesters have demonstrated by their
demonstration. Social including economic integration is an ongoing process
since human
beings have appeared on the stage of earth. Instead the critique of many
people is raised against another universal scientific ideology applicable
to all countries and all aspects of human life which we had hoped to leave
behind in the last century. This I prefer to call globalism instead of
globalisation.
In this ideology economic growth becomes an axiom which is not
questioned as in above article. The discussion of power and its
distribution becomes a taboo and is therefore not
even mentioned in the article.
According to Feachem the protests against globalisation can be
summarised in the phrase: "Increasing global economic and social
integration is a conspiracy by the rich and powerful to exploit the poor
and underprivileged".
I prefer to rephrase the central theme of the protest against
globalism: "Increasing global social and ecological exploitation is an
economic game by the rich to satisfy their addiction to power with
destructive consequences for our common global heritage which is of
concern to poor and rich alike".
Dr. R. Huss
Competing interests: No competing interests