Globalization and public health: a new challenge for WHO?

24 World Health • 51 st Year, No. 2, March-April 1998 Globalization and public health: a new challenge for WHO? Communication technology con be harnessed in mony woys to the fight against diseases and the improvement of health. Photo Keystone© l arge claims are made these days about globalization and how it is changing the entire structure of the world. As the World Health Organization reaches its 50th year, many analysts argue that globaliza- tion and global change are major challenges for the Organization in the 21st century. What are these international public health chal- lenges? Is the world really so differ- ent from what it was 50 years ago? Is globalization a fact, or just jargon? Globalization means different things to different people. On the one hand, it can simply refer to increasing financial and trade inter- dependence between countries. On the other, it suggests a much broader and more complex process of eco- nomic, political, social and cultural integration which takes place as capital, traded goods, persons, ideas, images, values, environmental toxins , and even microorganisms move across state boundaries. The concept of the globalization of public health takes this broader view, and refers to the threats and opportunities for health which transcend national boundaries. Advocates of this model argue that many health issues cannot be re- solved by national policies alone since such issues do not respect the geographical confines of sovereign states. The most commonly cited exam- ple of a transnational health threat is that of infectious disease spreading between countries. This is not a new problem. In mediaeval times the expansion of trade routes between Europe and East Asia was accompa- nied by epidemics: for example, plague spread across Asia and reached Italy in 1347. The threat of epidemics prompted European states to convene the first International Sanitary Conference in 1851 as a collective response to infectious diseases. In the late 20th century the risk of infectious disease trans- mission has been magnified by the increased volume and speed of travel. In the past 200 years the average distances travelled and the speed of travel have increased by a thousandfold. The massive volume of international traffic, with over one million persons crossing national boundaries each day, facilitates the "globalization" of infectious agents. With the emergence of new infec- tious diseases such as the Ebola virus and HIV I AIDS, and the re- emergence of old diseases such as tuberculosis, the transnational threat of communicable disease should not be underestimated. Global trade liberalization is also associated with transnational public health risks . Although the roots of globalized trade can be traced back to the industrial revolution and laissez-faire economic policies of the 19th century, the marketing and promotion of commodities have been enhanced by modem technol- ogy and by global trade agreements such as those reached by the World Health • SlstYeor, No. 2, Morch-April 1998 The gl~balization of information is bringing precious knowledge about health within the reach of those most in need. Photo Still Pictures/) Schytte © Uruguay Round of multilateral negotiations. Increased trade liber- alization has facilitated multina- tional food production, processing and distribution. The value of food trade, US$ 266 OOO million in 1994, was more than 300% greater than it was 20 years ago and continues to grow rapidly. The mass production and extensive distribution systems in the food industry favour the spread of infectious diseases across wide areas. The cross-border trade in psy- choactive drugs, tobacco, and alco- hol also poses a major threat to health in the 21 st century. For in- stance, the liberalization of world trade has accelerated the spread of tobacco products globally. The growth in tobacco consumption has been magnified by the aggressive advertising methods of multinational tobacco conglomerates which have targeted women, adolescents, and developing economies. If present trends continue there will be 10 million tobacco-related deaths in 2020, as compared with about 3 million deaths a year in the early 1990s. Global communication links have the power to enhance the pro- motion of harmful lifestyles. Trade in health services is an- other transnational health concern, although data on the extent of such trade are incomplete. In particular, the brain-drain of health profession- als from developing economies to industrialized ones threatens the quality of care in many countries. Although the negative effects of labour migration are partially offset by the foreign currency sent back to home countries, this does not com- pensate for the lower quality health services there. Structural adjustment policies, which have played a major role in liberalizing finance and trade, have important implications for public health. Structural adjustment pro- grammes aim to reduce the role of state institutions in national economies, and to open up these economies to international competi- tion by the reduction of trade barri- ers, and market deregulation. The globalization of adjustment policies in the health sector has resulted in a global culture of reform within health systems. Though the empiri- cal evidence is not conclusive, several studies have correlated adjustment policies with an increased burden on the health of vulnerable groups such as children, and a deterioration in the welfare of the poor in rural and urban areas. In many countries, economic adjustment is also associated with the deregulation of labour markets in favour of competition, resulting in erosion of basic labour rights and health and safety regulations, as well as access to services such as child care and maternity leave. The evolu- tion of flexible labour markets is linked to new employment and production patterns. For example, 25 employment in the "Maquila indus- tries" in the Americas and the "ex- port processing zones" in other parts of the world is characterized by low pay, poor working conditions, short- term tenure, and a primarily female workforce. Protection of employee well-being under these circum- stances is a matter of public health concern. It is important to note, however, that the implications of globalization for public health are not all nega- tive. The diffusion of modern tech- nologies and ideas between countries presents promising oppor- tunities for improving global health in the future. Recent advances in telecommunications technology, for example, have resulted in global communications links which are unprecedented in world history. Communications technology can be exploited for health purposes, which include: telemedicine, interactive health networks, disease surveil- lance systems, communication links between health workers, human resource development and continu- ing education, and distance learning. In summary, a strong case can be made that the globalization of public health represents an important trend for the 21st century. Although some transnational health problems have historical precedents, many new issues are emerging which are unique to our time. The 1997 Kyoto conference on climate change under- scored the fragility of the world's ecosystem, and showed how interde- pendent the health of all of humanity has become. Shared global prob- lems transcending state borders call into question conventional para- digms which divide countries into North and South, or developed and developing. The WHO Constitution of 1948 provides a rationale for global ac- tion. The cross-border issues con- fronting the world in 1998 can only be resolved by global cooperation. Transnational health threats and opportunities call for collective action. WHO could play a pivotal role in facilitating such action on transnational policy issues in the 21 st century. •