Special Theme Globalization
Globalization: changing the public health landscape
Nick Drager1 & Robert Beaglehole2
In June of this year trade negotiators from developing and industrialized countries met at the World Trade Organization to discuss intellectual property rights and access to essential medicines for the poor. Several delegations included ministry of health officials, and others had been briefed by public health experts. At about the same time, at the World Health Organization, governments, businesses and nongovernmental organizations were discussing plans for a global health fund, launched earlier this year by Kofi Annan, Secretary-General of the United Nations. This fund may become the basis of a new collective approach to controlling diseases of the poor, particularly AIDS, malaria and tuberculosis.
These two examples from a growing number of initiatives reflect widespread awareness of the need for domestic action within the health sector to be complemented by cross-sector and cross-border action. Only with complementary strategies of this kind will it be possible to protect and promote the health of poor populations. In a world of increasing interconnection and interdependence there is an urgent need to scale up combined activities to improve the health of those who have been left behind. It requires a new kind public health workforce with the knowledge and skills to maximize the beneficial effects of globalization on population health status, and minimize the adverse ones.
This special issue of the Bulletin is another step towards informing public health professionals about the implications of globalization for their work. The articles cover a wide spectrum of points of view, from international to local, from cheerful to gloomy, from broadly generalizing to highly specific. The major unanswered public health question in this field, despite the firm views held by interested parties, is the health consequences of the economic growth engendered by the current phase of globalization. Two contrasting views appear in this issue. Dollar of the World Bank (pp. 827 833) presents evidence that economic globalization has raised the incomes of poor countries, and that this has generally benefited poor people. Cornia of the University of Florence (pp. 834841), on the other hand, while appreciating the economic growth- promoting potential of globalization, suggests that the benefits have been restricted to a small number of countries. Importantly, he stresses that where there have been successes they have resulted from a combination of outward orientation and strong domestic regulation. He challenges the view that the impact of globalization on income distribution has been neutral.
Two local case studies, on Kerala by Thankappan (pp. 892893) and Thailand by Sitthi-amorn et al. (pp. 889890), discuss some specific impacts of various aspects of globalization on health, and in a third, Wyn-Owen (pp. 890891) illustrates the role of an influential nongovernmental organization in putting the issue of globalization and health high on the political agenda. Again at the local level, Evans et al. (pp. 856862) find that cost considerations are more important than nutritional knowledge, or even personal preferences, when people shop for food.
There is agreement that changes to the international architecture are required to ensure that globalization is beneficial to the poor. Kaul & Faust (pp. 869874), on the basis of an examination of infectious disease control, emphasize the need to reconsider notions of public and private interests. These authors make a case for viewing international cooperation in health not just as an aid issue, but as a concern about global public goods, to be financed at least in part from national health sector budgets.
Many of the benefits of globalization are based on the impressive and unprecedented developments in information and communication technologies. However, as Chandrasekhar & Ghosh point out (pp. 850855), the Indian experience is not all encouraging; they stress the need to focus on education as a prerequisite for reducing the impact of the digital divide.
None of the main papers in this issue deal with a fundamental public health challenge that has been exacerbated by the current phase of economic globalization. This is the overriding need for economic sustainability if our ecosphere is not to be further threatened. This is touched on, however, in an interview with John Last (pp. 896897) and in two book reviews (pp. 898899).
Public health scientists are still in the early stages of gathering concrete evidence on the effects of globalization on population health. This evidence is required to inform policies and actions to protect and promote the heath of the poor. The productivity of this research would be improved if there was an agreed framework for considering the various mechanisms by which economic globalization affects population health status. Woodward et al. (pp. 875881) present such a framework for discussion. It is already evident, however, that policy measures are required to rectify the adverse effects of globalization on health and strengthen the positive ones. Policy should be guided by the following principles: (i) growth needs to be inclusive, equitable and sustainable, and this requires policy coherence between economic, social and environment sectors; (ii) opening up of borders should be gradual and preceded by appropriate protective conditions; (iii) international rules and institutions should promote the production of global public goods and the control of global public "bads"; (iv) special attention is needed to increase the transfer of financial and technical resources to those left behind in the development process; (v) strong national health policies, institutions, regulations and programmes are essential; (vi) the public health workforce must be equipped with the knowledge and skills to engage with partners across sectors and across borders to achieve health and other social goals.
This issue of the Bulletin reflects the significance of globalization, especially its economic aspects, for population health status. The challenge is to find ways to measure its impact and formulate evidence- based national and international policy responses.
1Coordinator, Globalization, Cross-Sectoral Policies and Human Rights, Department of Health and Development, World Health Organization, 1211 Geneva 27, Switzerland. Correspondence should be addressed to this author.
2Public Health Adviser, Department of Health and Development, World Health Organization.
Ref. No. 01-1488