Interrogating globalization, health and development: Towards a comprehensive framework for research, policy and political action

Abstract

Health researchers recognize the need to better understand the ways in which contemporary globalization can lead to improved health for all, especially for the poor. This requires expanding the global health research agenda beyond a disease-specific focus to one that also examines the social, environmental and economic contexts that partly determine the incidence and persistence of many diseases, and to understand how these contexts shape health opportunities and behaviours at different levels. Organizing extant findings for policy purposes and to generate new studies capable of embodying such complexity is rendered more feasible if guided by reasonably comprehensive frameworks identifying the differing levels and pathways by which globalization phenomena can influence health. This article presents such a framework, illustrating it with evidence of health effects of globalization presently known though often disputed. Its value lies in its ability to shape future research allowing detailed and rigorous study of certain of the relationships it maps to be located within a broader research-informed policy context.

Acknowledgements

Some of the work reported herein was undertaken with support from the Globalization, Trade and Health Group, World Health Organization, and the Institute of Population and Public Health, Canadian Institutes of Health Research. All opinions expressed in this paper are those of the authors. Thanks are offered to Ted Schrecker, Senior Policy Researcher, Institute of Population Health, University of Ottawa, for contributions to this article, to SPHERU research faculty for helpful comments on earlier drafts, and to two anonymous reviewers.

Notes

 Monbiot (2003), in an essay on creating a global democracy to countervail the abuses of unfettered global capitalism, makes the point that international or multilateral approaches based on today's institutions are inadequate. If all countries did decide to re-confine capital within their borders, internationalism might work. But poor countries want foreign capital and the elite financial and export interests in rich countries have no desire to be re-nationalized. These interests dominate most political parties, while all of our current international institutions, from the United Nations to the IMF and World Bank, routinely defer to the United States. Only new global responses and structures will be able to correct these international inequalities in power.

 Even the recent report of the UN Millennium Project, which calculates the domestic and international aid resources required to meet the Millennium Development Goals (see Table 2), and which takes into account aid, trade, debt cancellation and economic growth factors, is rather anodyne with regard to the impacts of economic globalization (UN Millennium Project, 2005). It calls for increased developing country public spending on health and education through better tax measures even as it urges tax holidays to attract foreign direct investment and proposes regressive value-added taxes as the principal domestic revenue generator. It sees no conflict (real or potential) between the interests of the private (corporate) sectors, the public sector and civil society organizations, particularly in the delivery of essential health and water/sanitation services. It claims a human rights-based approach to development is powerfully linked to economic growth but is silent on the human rights abuses in China, the developing country demonstrating the greatest (albeit disputed) growth and poverty reduction data. It costs out a comprehensive ‘scaling up’ of HIV/AIDS intervention programs, but is largely silent on the historic global context that abetted the pandemic. While harsh on rich world agricultural subsidies, it proposes deeper liberalization for poor countries upon which its scaled up assistance package may be conditional, essentially imposing a rich world economic model on all other countries. It assumes that, with suitable investments in environmental technologies, rapid global growth will not imperil the planet's remaining stock of natural capital. Thus, while more indicative of what we call a ‘global health’ approach, the project stops substantially short of being ‘critical’ in its analyses.

 There are sharp debates about the impacts of globalization on poverty and economic growth. A much cited World Bank claim that globalization has reduced the number of people in extreme poverty (< $1/day) by over 200 million since 1980, due largely to economic growth in China and India (Dollar, 2002), rests on unreliable data and has been challenged on methodological grounds (Wade, 2002). There are fewer disputes about the rise in income inequality. Whether income inequality is the root of disease inequality, however, remains contentious (Deaton, 2001). Poverty, which is higher in high income-inequality countries, may the bigger problem. But the greater the income inequality the harder it becomes for the economic growth presumed to follow trade liberalization to actually lift people out of poverty. Moreover, income inequality is associated with declines in social cohesion, social solidarity and public support for strong states with strong redistributive income, health and education policies that have been shown to buffer liberalization's un-equalizing effects (Deaton, 2001; Global Social Policy Forum, 2001; Gough, 2001). Income inequality is also associated with higher rates of homicide, suicide and generalized conflict. Dollar (2001), in his ‘health defence’ of globalization, argues that liberalization does not cause inequality because there is no consistent pattern between the two. However, those market-liberalizing developing countries experiencing the greatest economic growth (China, Vietnam and India) are also the ones experiencing the sharpest increases in income inequality. The liberalizing countries where income distribution became more equal were those that failed to grow, i.e. everyone remained poor. Moreover, Dollar (2002) acknowledges that, assuming continued trade liberalization, global income inequalities will increase steeply by 2015.

 See McIntyre, Thomas and Cleary (2004) for an important case study of post-apartheid South Africa. The newly elected ANC government voluntarily adopted neoliberal policies of liberalization and constraints on public sector spending (including health, at a time when the HIV/AIDS pandemic was rising both in prevalence and attention) in order to attract foreign direct investment and signal ‘fiscal probity’ to global markets. One might rightly see this choice as coerced, however subtly, by the broader globalization context; it also underscores the care that must be taken in determining the direct and indirect influences of globalization's processes on health-determining pathways.

 Figure 1 ‘overviews’ the framework and allows the reader to grasp its broad shape. Figure 2 unpacks its levels in more detail. We provide both versions in this article since Figure 2 is often difficult to grasp without first seeing its simpler contours. The boxes in Figure 2 are numbered, and are referred to by number in an example provided in our concluding section.

 The loss of domestic regulatory capacity and space that this article documents as consequent to contemporary globalization has tempted some to announce the death of the nation-state as an important political actor. This is not the case. First, nations have created and agreed to the new global economic rules that subsequently diminished their own policy flexibility. Once created, these rules become a path-dependent force making it difficult, although not impossible, to alter the rules in the future. Moreover, considerable variation in domestic policies has persisted over the past two decades of global market integration. The Nordic countries continue to have high-tax, high-welfare, low-poverty capitalist regimes that also perform better, economically, than do most of the Anglo-American low-tax, low-welfare, high-poverty capitalist regimes. More at issue, and the reason why ongoing study of globalization's health impacts is important, are the effects of new global economic rules on developing countries to achieve the type of welfare capitalism still enduring in much of Northern Europe.

 Intermediary Global Public Goods (IGPGs) comprise another element in our list of globalization processes. IGPGs refer to the agencies and regulatory structures for ‘global public goods’, or GPGs. The GPG concept is a new expansion of the classical economic construct of public goods. At issue for a critical population health approach is that the GPG concept is beset by definitional disputes. Some claim that free trade agreements are GPGs on the assumption that they promote economic growth, which, by definition, is a public good. Others argue that such agreements are global public ‘bads’ by virtue of the inequities in wealth distribution they exacerbate and the environmental pollution and resource depletion that usually accompanies rapid growth. Detailing the debates over GPGs is beyond the scope of this article; for further discussion, see Blouin, Foster and Labonte (2004); Kaul, Grunberg and Stern (1999); and Woodward and Smith (2003).

 The ‘debt overhang’ is considered to be a major factor in the inability of least developed countries to sustain or benefit from economic growth (UNCTAD, 1999). It is also a major impediment to their ability to invest in health, education, water, sanitation and other essential human development infrastructures. For example, scheduled debt service in Zambia and Tanzania exceeds 40% of their governments’ budgetary resources (AFRODAD, 2002). African countries are currently paying over $15 billion annually in debt servicing charges to rich country creditors, an amount that equals the total aid they receive (OECD, 2002, p. 258). The advocacy of debt cancellation organizations, such as Jubilee Research and the 2005 ‘Make Poverty History’ campaign, has intersected with research findings that many low-income countries will be unable to make progress on MDG targets unless their debts are written off (UN Millennium Project, 2005). The speed with which the US mobilized massive debt cancellation for (otherwise oil-rich) Iraq also engendered a growing awareness amongst wealthy creditor nations that it was politically unwise not to consider deeper and more widespread debt write-offs for the world's poorest countries, especially those struggling with HIV/AIDS and other disease pandemics. Despite growing support for such debt cancellations, and some unilateral action such as the UK's pledge to pay a portion of poor country debt owed to the World and African Development Banks, no multilateral commitments for debt cancellation have been made at time of writing (January 2005).

 Cornia (2001) and Cornia and Court (2001), amongst others, argue that liberalization in capital markets has had far more negative health effects than liberalization of trade in goods, including the increased vulnerability of national economies to capital flight and currency collapse. In each country affected by such currency collapses, the result has been increased poverty and inequality, and decreased health and social spending (O’Brien, 2002).

 A 2004 WTO agreement on a ‘framework’ for the gradual removal of rich country agricultural subsidies resolves little; the details of what, when and how the subsidies will be removed are still subject to ongoing WTO negotiations.

 For reasons of space, discussion of the remainder of the framework is necessarily truncated. A longer elaboration can be found in Labonte & Torgerson (2003).