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Globalization and Health - Issue Papers
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Globalization and Health
Gill Walt
People's Health Assembly - Issue Paper
Paper presented at the Medact Meeting on 13 May, 2000
This document in
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Introduction
Globalization is a confusing concept. For some it conjures up images of electronic communications: an email sent from a remote part of the world
triumphing in an Arsenal win, watched a thousand miles away on the global media, the ubiquity of mobile phones. For others it is about trade: the ability to buy coca-cola in
rural villages in Africa, or to shop in Sainsburys in Cairo. For yet others -the Reith lecturer - Vandana Shiva - it is about misappropriation and greed: the suicide of Indian
peasant farmers, ruined by agri-business and genetically modified seeds. In this paper I start by defining globalization, and then go on to consider five different characteristics
of globalization.
What is globalization?
‘Globalization is the flow of information, goods, capital
and people across political and economic boundaries’ (Daulaire 1999; 22). As that
definition implies, it is not new: people have always carried information, goods and
capital across countries. Indeed the globalization of disease is usually said to have
begun in 1492 when the Europeans discovered the Americas, and inflicted one of the
earliest examples of genocide on the American peoples through the importation of smallpox,
measles and yellow fever, as well, of course, as the use of force and firearms. Not all
this early globalization was negative, however, as ideas and cultures, spices and cashew
nut trees. What is new is its scale and pace. Kelley Lee (2000) has defined globalization
as ‘the process of closer interaction of human activity across a range of spheres,
including the economic, social, political and cultural, experienced along three
dimensions: spatial, temporal and cognitive’
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Our perceptions of physical space have changed - the ‘death of distance’ has
made the world feel smaller - more people travel, and more often (in 1950 there were 2
million international airline passengers a year; today 1.4 billion)
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Our perceptions of time have changed - the communications revolution has heightened our
expectations of quick turnarounds - anyone who has experience of email knows that answers
are expected immediately as we no longer rely on postal systems; even remote
‘backpacker’ beaches in Thailand are on the internet.
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The spread of ideas, cultures and values covers not simply worldwide availability of
Japanese cameras, Finnish mobile phones (Nokia), Asian clothes, Colombian coffee, but also
the transfer of culture through films and other media, and of political ideas - the
neo-liberalism of the 1980s, which in turn fostered the health systems reform movement.
Globalization can be characterised by five, often conflicting, themes. While separated here conceptually, they are clearly inter-dependent:
1) Economic transformation: financial volatility,
marginalization, labour insecurity
The world economy has grown hugely - the average value of foreign exchange transactions grew from $215 billion in 1973 to £1.2 trillion in 1995 (Sutherland
1998). With de-regulation this has led to financial volatility - as affected Mexico and SE
Asia, and created unemployment and hardship; marginalization - many low income countries
are hardly part of the global economy (unless they are repaying debts); and labour
insecurity, with the political authority of the state corresponding less and less to the
geography of markets. All these factors are creating greater inequalities between groups,
both within and between countries, which are then reflected in health experience. In the
health sector direct influences have come with deregulation of trade:
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There is increasingly fluid investment across borders. For example, foreign investment
in hospital management has increased, as businesses have looked for opportunities in other
countries to open private clinics and hospitals. Although these are often joint ventures
(ie local partners are mandatory) a significant characteristic of commercial presence in
hospital operation and management is the involvement of companies whose traditional
business lies outside health care services, such as pharmaceutical companies. The way they
measure outcomes may differ from traditional health sectors.
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Another technique for penetrating foreign markets is through ‘managed care’
services, which combine management and insurance. Here foreign commercial presence has
grown, as it has in the insurance sector. For example, within a year of Brazil opening its
market to private insurance companies in 1996, four multinational companies had
established themselves in the country, mainly creating joint-ventures with local
companies. While perceived to have had beneficial results - with better choice for
consumers - there may be longer term dangers for the public health system
(Zarrilli 1998).
Such investments carry the danger of establishing two-tier health systems, movement of
health professionals from the public sector, inequitable access to health care, and
undermining of national health systems.
2) New trade regimes: winners and losers
Trade is now probably the most highly contested international
arena, and while it could be argued that international relations are far too dependent on
trade as the main negotiating force between nations, several points cannot be ignored
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The World Trade Organisation - perceived as unaccountable and secretive - is widely
perceived to be advancing corporatist interests, creating what Vandana Shiva called, in
relation to agri-business, a ‘monoculture of the mind’. However, protests such
as those in Seattle have forced some re-thinking of the way the WTO operates, to admit
that it needs to become more open and less bureaucratic, and even ‘to lose its power
- easily open to abuse - to authorise retaliatory trade sanctions against recalcitrant
countries’ (Legrain 2000). But there is a long way to go.
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The other area where global contestation is occurring and will continue is over trade
related aspects of intellectual property - TRIPs. TRIPS obliges all WTO members to provide
a minimum of 20 years patent protection on drugs. Compulsory licensing, which is
consistent with TRIPS allows countries, for reasons of public interest, to grant a
licence, without permission from the patent holder (who nevertheless gets some
remuneration). This means that a particular drug can be produced much more cheaply
(‘t Hoen 1999; 89). South Africa has blazed the trail on this one - having come under
huge pressure to repeal its draft medicines law which would allow compulsory licensing and
parallel import of AIDS related drugs, although its latest policies on AIDS have caused
worldwide concern (Lancet 2000a). In the meantime of course, poor people are losing out
because of lack of access to, or high price of, essential drugs that could alleviate
suffering or even prevent death.
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I hardly need draw the attention of this audience to the deregulation of trade that has
escalated the intensity of environmental deterioration. Robin Stott’s (2000) naming
of ‘Carson’s syndrome’ has brilliantly drawn attention to the
non-accidental injuries being perpetrated on the planet), which will have both short term
effects on respiratory disorders, but much longer term effects on the ecosystem
(McMichael
& Haines 1997).
3) A growing poverty gap: rising health inequalities
The basic facts are known: 20% of the world’s population
live in absolute poverty, with an income of less than $1 per day. Surviving on less than
$2 a day is a reality for almost half the people on the planet (Brundtland 1999). The
resulting inequalities in health outcomes are stark. Those living in absolute poverty are
five times more likely to die before reaching five years of age than those in higher
income groups. Life expectancy gains from the 1950s on are falling in some countries - due
to AIDS and growth in poverty. In Botswana life expectancy has fallen from 70 to around 50
years. Even in rich nations socio-economic inequalities in health have grown in the last
20 years.
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In many countries of the world health systems have deteriorated: access is poor, quality
is poor, drugs are not available. In some low income countries over 70% of the health
budget is coming from external sources.
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As public health systems have broken down, so has the spread of infectious diseases
become increasingly labile - hitting the poor disproportionately. Attention on
emerging
and re-emerging infectious diseases has risen over the past decade, partly because of
growing drug resistance, partly because of new diseases such as AIDS, and partly because
of self-interest: tuberculosis, for example, was described as ‘conquered’ in the
industrialized world in the 1950s, but has re-emerged in the late 1980s. (There were also
unexpected outbreaks of cholera, dengue, ebola, E.coli, diphtheria - even the dreaded
plague - just to mention a few in 1997). While the response in the rich world is often
couched in terms of a new threat to the health of their populations, it has drawn
attention to problems which were never absent from low income and some middle income
countries: TB and malaria for example, and, with a change in leadership at WHO, have led
to concerted action around these diseases, as evidenced by some public-private
partnerships and by campaigns such as Roll Back Malaria. Nevertheless, the balance is far
from redressed.
4) The electronic revolution: the knows and the know nots
Electronic communications offer extraordinary opportunities, and
even in very remote parts of the world it is possible to connect to the internet; but to
take advantage of this opportunity people need to have access to regular electricity,
computers, training and education. Those who do not have, run the risk of further
marginalization.
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However, the benefits may be undermined by harms. We hardly know the extent to which
electronic communications will change commerce: e-commerce such as the sale of
pharmaceuticals through the internet has implications of loss of revenue for governments
as well as to all those selling to the public, creating further disadvantages for those
unable to access cheaper medicines; but it also raises huge questions about regulation -
regarding drug resistance, drug abuse, and so on.
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In the same way, telemedicine - ‘the practice of medical care using interactive
audio, visual and data communications, includes medical care delivery, consultations,
diagnosis and treatment, as well as education and the transfer of medical data’
(Mandil 1998; 87) is another area likely to grow with improved communications. It is still
relatively limited, but there are already a few commercial enterprises providing services
across a number of industrialised countries, and increasingly, in low income countries.
For example, a private sector development is reported to have set up a 50-bed telemedicine
centre in India, equipped with facilities such as an operating theatre, a CT scanner,
x-ray facilities, and an integrated laboratory. Using special software and hardware
doctors at the telemedicine centre can scan, convert and send data images several hundred
kilometres away to speciality hospitals, and it is planned to extend this cover to 125
primary health centres, 25 district hospitals and three tertiary centres in five states
(Lancet, 2000b). However, such projects raise a number of ethical and regulatory issues:
privacy of the patient, recognition of qualifications of providers, legal liabilities, as
well as questions about who will be able to pay for such services.
5) New forms of governance: the proliferation of non-state actors
Finally, where once we looked to the state to provide the rules
and framework of engagement, increasingly the role of the state is being transformed, and
transnational social and political movements are becoming more and more important.
The entry of the corporate sector into health reminds us how far the health landscape has
changed. Until the late 1970s there was minimal collaboration between private and public
sectors, and relationships were often abrasive or downright hostile. Today there is huge
convergence - and a great deal of discussion about partnerships between the private and
public sectors - at the national level - where governments are making deals or contracting
private sector companies to undertake tasks which used to be the responsibility of the
public sector - in this country the PFI is an example (Pollock et al 1999). In many
developing countries Ministries of Health have contracted out various hospital services
such as laundry or cleaning; or contracted private hospitals and clinics to provide
particular services. We have hardly begun to understand how these changes will impact on
inequalities in health and health services.
Public-private partnerships are also apparent at the global level, and indeed, are
beginning to be recognised as potentially new systems of global governance. No longer is
WHO the main health player at the international level: the corporate sector - especially
the pharmaceutical industry is increasingly a major player; as too, are the ‘new
philanthropists’ who have made large profits from the communications and global media
business. Ted Turner and Bill Gates for example have become important players in global
health: at the end of 1999 the Melinda and Bill Gates Foundation pledged $6 billion for
vaccines (WHO’s annual budget is less than U$1 billion).
Dozens of public-private partnerships between UN agencies, governments, industry and both
new and old foundations, have sprung up over the past few years (Buse and Walt 2000a).
Some of these are donation programmes - where pharmaceutical companies have donated doses
of a particular drug to help eliminate a particular disease: the best known, and longest
established being the Mectizan Donation Programme, where Merck have donated ivermectin for
as long as necessary to rid many African countries of onchocerchiasis - river blindness.
Other companies have in the last few years, followed Merck’s example: Glaxo-Wellcome
are giving Malarone as a second-line treatment against malaria in Kenya; Pfizer have
donated zithromax to tackle trachoma, SmithKline Beecham have donated albendazole to help
eliminate lymphatic filariasis. Other partnerships are looking for, or testing drugs: one
of the largest is the International AIDS Vaccine Initiative.
While all these partnerships are hugely welcomed because they are, to some extent,
beginning to address issues such as orphan diseases and the shortfall in research and
development for new vaccines (of over 1200 new chemical entities developed between 1975
and 1995, only 11 were for tropical diseases), they also raise questions about
representation and accountability (Buse & Walt 2000b). UN organisations such as WHO
derive their legitimacy from near universal membership in their governing bodies. Liberal
democratic governments are responsible, in the final analysis to their electorates. Global
public private partnerships cannot claim such representation, and indeed, often developing
country recipients of programmes, are not included in governing boards or even necessarily
involved in early planning. Accountability is also problematic in public-private
partnerships. Although both sectors have well-established mechanisms of accountability -
being held responsible for their actions - there is a huge distance between global
partners and beneficiaries. They also raise questions about who is setting the global
health agenda.
Conclusion
Globalization is both an opportunity and a threat. We need to
examine both aspects and decide what we can do. I conclude with two observations:
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We should take heart from successful actions. There have been many - from the AIDS
activists who have persuaded some pharmaceutical companies to decrease their prices for
AIDS drugs, to those environmentalists who dug up fields, or consumers, NGOs, and others
who lobbied governments and supermarkets, or even individuals such as the current
president of the Rockefeller Foundation - all of whom helped to change Monsanto’s
mind about their so-called terminator seeds. The battle isn’t won - only small steps
have been made - but they have been made because people acted. ·
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Globalization may feel inexorable, but I do not subscribe to the view that there is
nothing we can do about it. The shape and form of globalization is contestable, and open
to local and global political challenge. We can be, and should be, researching,
discussing, and acting on the threats to health, and taking advantage of the
opportunities.
References
Brundtland G 1999
Poverty and Health Report by the Director General, WHO:
Geneva 14 December, EB105/5
Buse K & Walt G 2000 Global public-private partnerships: part 1 - a new development in
health? Bulletin of the World Health Organisation, June forthcoming
Buse K & Walt G 2000 2000 Global public-private partnerships: part II - what are the
issues for global governance? Bulletin of the World Health Organisation, July forthcoming
Daulaire N 1999 Globalization and health Development 42: 4; 22 - 24
Lancet 2000a Politicisation of debate on HIV care in South Africa April 29; 355; 1473
Lancet 2000b Remote Indian villages to benefit from telemedicine project, April 29; 355;
1529
Lee K 2000 Globalization and health policy: a review of the literature and proposed
research and policy agenda In: Health Development in the New Global Economy
PAHO:
Washington
Legrain P 2000 Against Globaphobia Prospect May 30 - 35
Mandil S 1998 Telehealth: what is it? Will it propel cross-border trade in health
services? In: Zarrilli S (ed) 1998 International trade in health services: a development
perspective United Nations & WHO: Geneva
McMichael J & Haines A 1997 Global climate change : the potential effects on health
British Medical Journal 315 ; 805 - 09
Pollock A 1999 PFI and the WTO Lancet 27 November
Stott R 2000 Carson’s Syndrome Medicine Conflict and Survival 16:1; 94 - 103
Sutherland P 1998 Answering Globalization’s Challenges ODC Viewpoint October, 1-2
‘t Hoen E 1999 Access to essential drugs and globalization Development 42: 4; 87 - 91
Zarrilli S (ed) 1998 International trade in health services: a development perspective
United Nations & WHO: Geneva
Biodata summary
Gill Walt
Reader in Health Policy,
London School of Hygiene and Tropical Medicine,
Keppel Street, London WC1E 7HT
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