Intended for healthcare professionals

Letters

Globalisation and health

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7328.44 (Published 05 January 2002) Cite this as: BMJ 2002;324:44

Informed and open debate on globalisation and health is needed

  1. Kelley Lee, senior lecturer (kelley.lee{at}lshtm.ac.uk),
  2. David Bradley, professor,
  3. Mike Ahern, research assistant,
  4. McMichael, professor,
  5. Colin Butler, PhD student
  1. Centre on Globalisation, Environmental Change and Health, London School of Hygiene and Tropical Medicine, London WC1E 7HTTony
  2. National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory 0200, Australia
  3. School of Public Health, La Trobe University, Melbourne 3057, Australia
  4. Gorway Lodge, Walsall WS1 3BB
  5. Institute for Global Health, University of California, 74 New Montgomery Street, Suite 508, San Francisco, CA 94105, USA
  6. 53C Darnley Road, Hackney, London E9 6QH
  7. William Harvey Hospital, Ashford, Kent TN24 0LZ
  8. Agencia Regional di Sanità Toscana (Regional Health Agency of the Tuscany Region), Via Vittorio Emanuele II 64, I-50134 Florence, Italy
  9. Health Systems and Policy Department, School of Public Health, Free University of Brussels, CP597 Route de Lennik 808, B-1070 Brussels, Belgium

    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.”1 An informed, inclusive discussion of globalisation's merits and demerits, including its impacts on human health, is needed, given the increasingly polarised nature of this debate. The mass demonstrations of anti-capitalist protesters at major international meetings, most recently at the G8 summit in Genoa, Italy, communicate the angst felt by many for the human, social, and environmental consequences of the kind of globalisation we are experiencing today. But the violence that has accompanied 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.2 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 in which 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, sex, 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.3 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.4 The claim that globalisation will ultimately bring greater wealth, and thus better health, is open to challenge. What is needed 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.5 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.

    References

    1. 1.
    2. 2.
    3. 3.
    4. 4.
    5. 5.

    Challenges of globalisation deserve better than simplistic polemics

    1. David Legge, associate professor
    1. Centre on Globalisation, Environmental Change and Health, London School of Hygiene and Tropical Medicine, London WC1E 7HTTony
    2. National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory 0200, Australia
    3. School of Public Health, La Trobe University, Melbourne 3057, Australia
    4. Gorway Lodge, Walsall WS1 3BB
    5. Institute for Global Health, University of California, 74 New Montgomery Street, Suite 508, San Francisco, CA 94105, USA
    6. 53C Darnley Road, Hackney, London E9 6QH
    7. William Harvey Hospital, Ashford, Kent TN24 0LZ
    8. Agencia Regional di Sanità Toscana (Regional Health Agency of the Tuscany Region), Via Vittorio Emanuele II 64, I-50134 Florence, Italy
    9. Health Systems and Policy Department, School of Public Health, Free University of Brussels, CP597 Route de Lennik 808, B-1070 Brussels, Belgium

      EDITOR—Feachem argues that globalisation facilitates economic growth and creates benefits, and that the protesters have no alternative policies.1 His argument is weak in logic, selective in its evidence, unbalanced in its coverage, sweeping in its generalisation, and egregious in misrepresenting the people whom Feachem describes as opposed to globalisation. Polemical sneering is no more constructive than breaking shop windows.

      Industry and trade are the sectors where wealth is produced and where the distribution of wealth is determined. To narrow the income gap and the health gap must entail creating the conditions for productive industry and mutually beneficial trade. But the structures and rules that currently determine the production and distribution of wealth are biased in favour of the rich strata of the rich countries.

      The global economy faces a continuing threat of crisis because of the overhang of accelerating productivity over constrained demand. Increasingly efficient production for increasingly global markets reduces aggregate employment and therefore demand. Corporations see sluggish demand growth as a threat to profits and respond by cost cutting and expanding market share. Both reduce the buying power of the labour force and further threaten profits and reinforce the need for strategies of cost cutting and market share.

      Meanwhile, levels of consumption are maintained through:

      • Increasing household debt in the developed world (as corporate profit is diverted from new investment, parked in the financial sector, and available for consumer credit)

      • Bubble consumption among small shareholders (as a result of overly optimistic income expectations associated with inflated asset values)

      • Increasing consumption by the new global middle class, including wealthy minorities in low and middle income countries

      • Flow of funds from the economies of the developing world to the banks of the developed world through national debt repayment

      • Flow of value from the developing countries to the developed countries through unfair trading relations

      • Conversion of environmental assets into current income flows.

      The structured unfairness of the current regulatory régime is necessary to defer the crisis by maintaining the net flow of value from south to north. Continuing poverty, displacement, violence, and wide inequalities are the costs of maintaining these stabilising flows. We should be building positive discrimination into the regulation of global trade in favour of the poorer countries rather than the reverse.

      References

      1. 1.

      Globalisation should be supported

      1. Jammi N Rao, public health physician
      1. Centre on Globalisation, Environmental Change and Health, London School of Hygiene and Tropical Medicine, London WC1E 7HTTony
      2. National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory 0200, Australia
      3. School of Public Health, La Trobe University, Melbourne 3057, Australia
      4. Gorway Lodge, Walsall WS1 3BB
      5. Institute for Global Health, University of California, 74 New Montgomery Street, Suite 508, San Francisco, CA 94105, USA
      6. 53C Darnley Road, Hackney, London E9 6QH
      7. William Harvey Hospital, Ashford, Kent TN24 0LZ
      8. Agencia Regional di Sanità Toscana (Regional Health Agency of the Tuscany Region), Via Vittorio Emanuele II 64, I-50134 Florence, Italy
      9. Health Systems and Policy Department, School of Public Health, Free University of Brussels, CP597 Route de Lennik 808, B-1070 Brussels, Belgium

        EDITOR—The electronic responses to Feachem's paper confirm the belief prevailing in public health circles that globalisation can only be bad for public health.1 Some facts might help.2 International trade has been going on for hundreds of years. It has grown in the past few decades because of easier, cheaper, and more efficient transport and near instantaneous communications. Trade even between unequal partners is better for everyone than no trade at all, since it is not a zero sum game. Most trade occurs among countries at a similar stage of development, and most economic activity is still locally determined and regulated.

        Governments constantly have to choose between promoting the interests of consumers and protecting those of producers and workers. In general they should think of consumers first. International trade has in the past been exploitative, as illustrated by slavery. It has become less so with international institutions such as the World Trade Organisation trying (albeit with limited success) to set the rules.

        The power of multinational corporations and their brands has been exaggerated. They come and go, and nimble footed upstarts constantly threaten them. Free trade, like technological development, creates a few losers but many more winners. Globalised trade has on the whole created far more winners than losers.2 The anti-globalisation movement has become a convenient forum for people with diverse interests and agendas to pursue their selfish goals: trade unionists want to protect jobs, and anarchists need a target. The public health lobby has unquestioningly got caught up in the fashionable rhetoric of the moment.

        Globalisation has become a convenient scapegoat for the failings of governments to prevent monopoly power. To blame any rise in inequality on global trade as opposed to fiscal and other policies pursued by governments is simplistic and xenophobic. Worse, it is potentially damaging to the prospects of poorer countries to improve their lot sooner rather than later.3 The fact is that trade is the only way for poorer countries rapidly to catch up with the rich world. We need more, not less, trade. Rather than reject globalisation the public health lobby should fight for a world trading system based on the principles of freedom and liberty and oppose the tendencies of vested interests in rich countries to use it as a vehicle for trade protectionism on spurious environmental or human welfare grounds.

        References

        1. 1.
        2. 2.
        3. 3.

        Author's reply

        1. Richard G A Feachem, professor
        1. Centre on Globalisation, Environmental Change and Health, London School of Hygiene and Tropical Medicine, London WC1E 7HTTony
        2. National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory 0200, Australia
        3. School of Public Health, La Trobe University, Melbourne 3057, Australia
        4. Gorway Lodge, Walsall WS1 3BB
        5. Institute for Global Health, University of California, 74 New Montgomery Street, Suite 508, San Francisco, CA 94105, USA
        6. 53C Darnley Road, Hackney, London E9 6QH
        7. William Harvey Hospital, Ashford, Kent TN24 0LZ
        8. Agencia Regional di Sanità Toscana (Regional Health Agency of the Tuscany Region), Via Vittorio Emanuele II 64, I-50134 Florence, Italy
        9. Health Systems and Policy Department, School of Public Health, Free University of Brussels, CP597 Route de Lennik 808, B-1070 Brussels, Belgium

          EDITOR—As I say in my paper and as the September issue of the bulletin of the World Health Organization elaborates, globalisation encompasses events and processes that 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 the World Health Organization and with considerable support from the World Bank. Other risks and consequences of globalisation remain to be adequately addressed, especially in the areas of infection and the environment.

          Globalisation is not a panacea. Many national and international policies and actions are also necessary to ensure sustained growth, alleviation of poverty, and health gain. 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 worsened by the HIV/AIDS pandemic.

          The multicountry econometric analyses (some of which I cite), however, 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 poor people is good for their health. I pointed out in my paper that these relations do not apply everywhere and always, and this is a matter of grave concern requiring careful analysis and strenuous action. Globalisation also brings social and political benefits, especially to poor and oppressed people, which are typically overlooked in the literature on globalisation and health.

          There is a mainstream view on globalisation and development, which is generally correct and supported by the evidence. 1 2 Then there is the common view in the health community, which is notably more negative. It is this presumption of guilt that leads respectable medical journals to publish statements to the effect that globalisation has increased poverty or health inequity without citation or with only circular citation to earlier unsupported assertions. As I in my paper and Rao in his letter point out, the matter is far more complex and there is good evidence that globalisation reduces poverty and inequity.

          An extreme and ideological response to globalisation negates the real benefits of globalisation to the poor and therefore undermines their interests. It also weakens the important messages concerning the adverse health consequences of globalisation and the need for action to ameliorate them. Only when the health community joins the mainstream of the debate will we have the influence that we deserve and the ability to protect and improve the health of people everywhere.

          References

          1. 1.
          2. 2.

          Struggle for public health and against economic globalisation go hand in hand

          1. James Woodcock, member, Globalise Resistance
          1. Centre on Globalisation, Environmental Change and Health, London School of Hygiene and Tropical Medicine, London WC1E 7HTTony
          2. National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory 0200, Australia
          3. School of Public Health, La Trobe University, Melbourne 3057, Australia
          4. Gorway Lodge, Walsall WS1 3BB
          5. Institute for Global Health, University of California, 74 New Montgomery Street, Suite 508, San Francisco, CA 94105, USA
          6. 53C Darnley Road, Hackney, London E9 6QH
          7. William Harvey Hospital, Ashford, Kent TN24 0LZ
          8. Agencia Regional di Sanità Toscana (Regional Health Agency of the Tuscany Region), Via Vittorio Emanuele II 64, I-50134 Florence, Italy
          9. Health Systems and Policy Department, School of Public Health, Free University of Brussels, CP597 Route de Lennik 808, B-1070 Brussels, Belgium

            EDITOR—Feachem's article misses the point of the anti-globalisation protests.1 To him, globalisation is openness to trade, ideas, investment, people, and culture. What he does not answer is whose culture, what terms of trade, which people, and who controls the investment.

            Perhaps he should consider why the largest British group of demonstrators in Genoa marched under the name Globalise Resistance. In the report of the World Health Organization, which Feachem edits, Cornia comes closest to articulating those aspects of globalisation contested on the streets of Genoa—principally deregulation, trade liberalism, privatisation, and freedom for capital movement.2 That is economic neoliberalism. On that definition, he argues that there is no evidence that globalisation has improved economic growth and that with slow growth and frequent rises in inequality health improvements during the era of deregulation and globalisation decelerated perceptibly. The worst case was in the former Soviet Union where, he says, the excess mortality in Belarus, Ukraine, and the Russian Federation was an estimated 4 million between 1990 and 2000.2 The effects of economic globalisation primarily occur through increased instability, inequality, and charges for essential services.

            Feacham's claim that globalisation increases the income of the poor relies on cross country comparisons.1 He merely reiterates the unsurprising correlation between trade, inward investment, and growth. He forgets that often the poorest countries are not able (because of sanctions, lack of tradeable goods, or war) rather than not willing to increase trade and attract investment.

            Perhaps the most unlikely claim Feachem makes is that economic globalisation promotes democracy and human rights. For this he cites East Timor and Indonesia, forgetting that in Indonesia openness to multinationals, free trade in weapons, and support from developed countries went together with mass murder. Repeatedly, economic liberalisation has proved compatible with increased barriers to human migration.

            To provide an evidence based approach to globalisation and health it is necessary to analyse the impact of specific policies. Feachem does not even attempt to analyse the existing literature. One example is the World Trade Organisation's proposals to make it compulsory to open up all sectors of the economy that already contain some competitive element.3 In Britain this will almost certainly mean the NHS, as part privatisation is already being introduced through the private finance initiative. This has consistently meant fewer beds, fewer staff, and higher costs.4 Therefore, the struggle for public health and against economic globalisation go hand in hand.

            Footnotes

            • JW is a member of the campaigning organisation Globalise Resistance, which aims to bring together groups and individuals opposed to the global growth of corporate power.

            References

            1. 1.
            2. 2.
            3. 3.
            4. 4.

            Globalisation is not good for your health

            1. Andrew Porter, consultant paediatrician (grampsyp{at}hotmail.com)
            1. Centre on Globalisation, Environmental Change and Health, London School of Hygiene and Tropical Medicine, London WC1E 7HTTony
            2. National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory 0200, Australia
            3. School of Public Health, La Trobe University, Melbourne 3057, Australia
            4. Gorway Lodge, Walsall WS1 3BB
            5. Institute for Global Health, University of California, 74 New Montgomery Street, Suite 508, San Francisco, CA 94105, USA
            6. 53C Darnley Road, Hackney, London E9 6QH
            7. William Harvey Hospital, Ashford, Kent TN24 0LZ
            8. Agencia Regional di Sanità Toscana (Regional Health Agency of the Tuscany Region), Via Vittorio Emanuele II 64, I-50134 Florence, Italy
            9. Health Systems and Policy Department, School of Public Health, Free University of Brussels, CP597 Route de Lennik 808, B-1070 Brussels, Belgium

              EDITOR—Feachem's article expresses complacency, beginning with the statement that globalisation—defined as openness to trade, ideas, people, and culture—brings benefits today as it has for centuries.1 This is true, but benefits to whom? The slave trade brought great benefits to the American plantation owners but not to the millions of Africans unwillingly globalised or their descendants. Similarly today, access to world markets brings ever increasing benefits to the large multinational companies and their stockholders, who are overwhelmingly based in the richest countries, but, in my experience, not to poor people in the countries being opened.

              In Hyderabad, India, a city that Feachem would probably hail as a triumph of globalisation, there are motorways, palatial residential areas and hotels, and increasing numbers of sophisticated private hospitals. But the public Nilufar Children's Hospital, once the pride of the region, is run down and dilapidated, although it still attempts to deal with the bulk of childhood disease in the city.

              Feachem does not mention trickle down, but that discredited theory seems to lie behind his faith in the benign effects of economic growth on health. He cites in evidence the World Bank, whose enforcement of structural adjustment in the 1980s and 1990s has been strongly linked to worsening health indices during that time. Economic growth, if linked to enlightened government, can bring health and social benefits, as it did in the years after the second world war in the United Kingdom—but the globalisers by and large do not mix with the poor and too readily assume that economic growth brings benefits to all sectors of society. Even in the United States this is patently not the case.

              Feachem complains that those opposed to globalisation have no alternative to offer. I would point to the thousands of small initiatives to encourage local self sufficiency and income generation that have transformed lives among the poorest in many countries where they have been encouraged (and not flattened by competition from multinationals): on a larger scale, the example of Cuba shows what marked health benefits can accrue even in a poor country when the right priorities are adopted.

              Openness is fine as long as it is mutually beneficial. The American and European globalisers expect countries to be open to their products, but the capital flow still tends to be one way. Is this globalism or neo-colonialism? I need much more evidence of health benefits to be convinced.

              References

              1. 1.

              More openness is needed before more trade

              1. Rodolfo Saracci, chairman,
              2. Marina Cuttini, senior epidemiologist (marina.cuttini{at}arsanita.toscana.it)
              1. Centre on Globalisation, Environmental Change and Health, London School of Hygiene and Tropical Medicine, London WC1E 7HTTony
              2. National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory 0200, Australia
              3. School of Public Health, La Trobe University, Melbourne 3057, Australia
              4. Gorway Lodge, Walsall WS1 3BB
              5. Institute for Global Health, University of California, 74 New Montgomery Street, Suite 508, San Francisco, CA 94105, USA
              6. 53C Darnley Road, Hackney, London E9 6QH
              7. William Harvey Hospital, Ashford, Kent TN24 0LZ
              8. Agencia Regional di Sanità Toscana (Regional Health Agency of the Tuscany Region), Via Vittorio Emanuele II 64, I-50134 Florence, Italy
              9. Health Systems and Policy Department, School of Public Health, Free University of Brussels, CP597 Route de Lennik 808, B-1070 Brussels, Belgium

                EDITOR—At the level of generalities, Feachem's observation that, in general, openness to trade improves national health does not match the accuracy of Keynes's famous statement “in the end we will all be dead.”1 At a more specific level, and going back several centuries, histories of national economics show inconstant associations of free trade with economic growth. With the exception of Great Britain, most other large developed countries became industrialised and experienced economic growth under the shield of long periods of protectionism, most extended for the United States.2 Between 1950 and 1998 world exports have increased along an exponential-like curve by 20 times whereas the world's gross domestic product has grown in a linear curve by six times, which indicates, if anything, decreasing returns of trade on growth.3

                The key difference between “neo-global” people, raising critical questions on current globalisation, and supporters of the all purpose answer “more trade” is that the former advocate independent analyses of specific issues whereas the latter rely on the postulate, verging on irrational faith, that unlimited trade of any kind (in food and guns, speculative capitals and productive investments, or polluting and ecology friendly industries) is able to produce unlimited growth, personal wealth, health, and—why not?—happiness.

                Feachem's definition of globalisation as openness, with which one could concur, clashes with globalisation as currently observable. Openness implies a view opened to all citizens on who controls and regulates what, as well as explicit mechanisms of democratic checks. This is remote, in substance and form, from the secretive development of the (aborted) first version of the multilateral agreement on investments; from the coexistence in the World Trade Organisation—against the basic principle of separation of powers—of legislative and judiciary functions; and from the opaque daily conduct of huge speculative transactions heavily conditioning all economic activities. Immanuel Kant said that all actions concerning the rights of others that are incompatible with publicity are unjust.4 Before being asked to take a stance on future negotiations in the World Trade Organisation, health professionals must be fully informed of what exactly is being negotiated and what its foreseeable consequences on health in different countries are going to be.

                Globalisation can be beneficial, not only in respect of health, provided that the great national movements for democracy, liberty, and social justice that took place in the 18th and early 19th centuries in nation states are now reproduced globally. Nothing less will do—certainly not more trade per se.5

                References

                1. 1.
                2. 2.
                3. 3.
                4. 4.
                5. 5.

                Globalisation of information could decrease effectiveness of healthcare provision

                1. Jean Macq, researcher (jmacq{at}ulb.ac.be)
                1. Centre on Globalisation, Environmental Change and Health, London School of Hygiene and Tropical Medicine, London WC1E 7HTTony
                2. National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory 0200, Australia
                3. School of Public Health, La Trobe University, Melbourne 3057, Australia
                4. Gorway Lodge, Walsall WS1 3BB
                5. Institute for Global Health, University of California, 74 New Montgomery Street, Suite 508, San Francisco, CA 94105, USA
                6. 53C Darnley Road, Hackney, London E9 6QH
                7. William Harvey Hospital, Ashford, Kent TN24 0LZ
                8. Agencia Regional di Sanità Toscana (Regional Health Agency of the Tuscany Region), Via Vittorio Emanuele II 64, I-50134 Florence, Italy
                9. Health Systems and Policy Department, School of Public Health, Free University of Brussels, CP597 Route de Lennik 808, B-1070 Brussels, Belgium

                  EDITOR—Feachem in his paper praises globalisation.1 I challenge his opinion when he presents globalisation as openness to ideas, people, and culture. Let's take the case of health services. According to Feachem, globalisation should make health services more open to local needs, demands of the people, and their culture. Furthermore, it should greatly improve the management and delivery of healthcare services.

                  Our fear is that things could go the other way. Nowadays, the provision of public health services in low income countries, behind the justification of evidence based medicine and cost effectiveness, are provided in the same way in Zimbabwe, Sierra Leone, and Nicaragua. They offer standardised care to mothers, children, and for specific diseases (tuberculosis, malaria, AIDS, and a few others), leaving behind the rest. All is decided during technocrats' meetings in Geneva, Washington, or Brussels and translated into standardised guidelines. It becomes politically incorrect to challenge these new guidelines openly.

                  Direct observation of treatment for tuberculosis is one of these examples. It is a worldwide standardised strategy born in the era of globalisation that has been hard to challenge. It has made the provision of care more rigid and less adapted to patients' demands and cultures. The consequence has been that patients with tuberculosis, as seen in Vietnam and Nicaragua, have used private care, incurring useless expenses and receiving care of doubtful quality (J Macq et al, unpublished data).2 This has probably decreased the effectiveness of healthcare services in various contexts.

                  With regard to the dominant trends in international intervention in the health sector, it is unlikely that globalisation will promote openness to ideas, people, and culture. We should fear that it will impose worldwide uniformity in public healthcare provision, disconnecting health services from people and their culture, and decreasing their effectiveness.

                  References

                  1. 1.
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