Health Policy in a Globalising World

Rating:
Summary: An important contribution to the literature on health policy
Review: I reviewed this book for the Yale Journal of Health Policy, Law and Ethics, 2003, 3:2, 417-424. The text below is from a draft of that review -- for the final version see the reference above. (warning -- this is a little bit long!)

As I write this review, the United States has taken on the role of global "enforcer" -- we have gone to war with Iraq to effect "regime change", largely without the support of our traditional European allies - dismissively termed "old Europe". This war sets a frightening precedent - the first time the United States has gone to war without having been attacked first. The president who has declared this war presides over the sole remaining superpower and thus, is arguably the most powerful American president in history. Coincidentally, and very sadly, among recent presidents he also stands out as one with little interest in, and experience of the rest of the world. Of the Congressmen and Senators he has to work with (and who serve as an important check on his power), only about 30% actually hold a current US passport. This war is the culmination of a unilateralist trend which began with his presidency - walking away from numerous international treaty obligations and promises on global climate change, the international court, landmines, and so many other issues. But the seeds of this trend were visible earlier: the US has become the most powerful and most influential nation, and the "driver" of globalization in so many ways, and yet we remain a nation which is largely unconcerned with the impact of its actions and policies, and those of its citizens and corporations, on the rest of the world.

That is where this book comes in. Lee, Buse and Fustukian have brought together an excellent collection of essays on a wide range of aspects of the health impact of globalization. Anyone who wants to take the time to understand the wider implications of this phenomenon will find much of value in this collection. Students of health policy and of international health would also do extremely well with this collection, and teachers of those subjects will find this a very useful contribution to the literature on this recent and evolving issue.

What do these authors understand by globalization? The authors use a definition of globalization as "processes that are changing the nature of human interaction across a wide range of spheres including the sociocultural, political, economic, technological, and ecological."(from Lee, 2001) As a consequence, boundaries whether they are "spatial, temporal, or cognitive" are changing and in some ways becoming far less important than they were previously. The authors also distinguish between "international health" and "global health", with international health relating essentially to matters between states or regions, and global health dealing with issues which are "transborder in cause or effect" and not confined to any country or group of countries.

The fourteen chapters of this book cover a wide range of issues, from an introduction to global health policy; the implications of the multilateral trade agreements; the growing enthusiasm for public/private partnerships; regulation; health care financing reform; cost-effectiveness and priority-setting; violence against women and reproductive health; the globalization of the DOTS approach to treatment of tuberculosis; aging and health policy; worker's health and safety; and finally globalization, conflict, and the humanitarian response. Some of the chapters are more directly related to the issue of globalization than others. I confess I read the introductory chapter but then moved directly to the chapter which seemed to promise the most relevance to the current world situation - chapter 13, "Globalisation, conflict, and the humanitarian response" by Anthony Zwi, Suzanne Fustukian, and Dinesh Sethi. I was not disappointed. The authors make several important observations. First, that insufficient attention has been paid in recent conflicts to "prevent or mitigate significant human rights abuses...(and) to the links between external and internal non-state actors, such as private companies and diaspora communities, that can play a major role in supporting violence..." A second key observation is that ethnic identity is playing a growing role in conflict; they quote Lipschutz and Crawford (1999) that "so-called ethnic conflicts are reflections of failing social contracts between different groups as global economic forces place governments under immense pressure to promote greater economic efficiencies and exploitation of local resources." Conflicts have winners and losers; and typically the losers are the already poor and marginalized, while those who benefit are in a position to manipulate markets or seize assets - and thus have an interest in perpetuating conflict.

The health impact of conflict includes the high mortality due to the conflict itself, and due to displacement both internally and across borders; and the mental health impact of trauma, torture and stress is enormous. Often the conflict results in damage to the health services themselves, whether through actual destruction to infrastructure including human resources, or diversion of funds away from health purposes to the military. How has globalization contributed to conflict? Globalization involves a shift in power both from states to markets, and from weak states to strong states. Within countries, the pressure brought about by the World Bank and IMF's program of Structural Adjustment Programs, or SAPs, has produced a "residual state" unable to contain or curtail violence within its borders, or worse, based on "structural violence" which involves unequal and unfair distribution of resources and services. And the World Bank continues to insist on economic policies consistent with a "globalized world economy" wherein the state is no longer a "provider" but rather a "facilitator and regulator". Truly weak states are not in a position to either facilitate or regulate. And the authors point out that income and wealth disparities have grown substantially over the past several decades. The UNDP estimated in 1999 that the assets of the three wealthiest individuals in the world are more than the combined GNP of all the least developed countries and their 600 million people. The top three in recent years have all been Americans.

Many readers will find chapter 2, on "The public health implications of multilateral trade agreements," particularly useful. This chapter focuses in particular on the World Trade Organization, or WTO. The chapter begins with the WTO's basic premise, that "human welfare will increase through economic growth based on trade liberalization....From a public health perspective, this desirable goal requires linking the benefits of the global trading system to sound social policies."(Drager, 1999). That key link, as the chapter demonstrates, not only has not been made, but attempts to make it have been opposed by a number of strong states and actors.

One of the more interesting discussions is in chapter 6, by Lee and Goodman, in which they describe the policy discussion around health care financing reform, and the formation of a "transnational policy elite" with two hubs, in Washington and London. (This book is largely the work of researchers with ties to, or based at, the London School of Hygiene & Tropical Medicine, and in the interest of full disclosure, this reviewer spent 10 years as a faculty member there and obtained her PhD from that institution.) They describe an "early transatlantic divide" between the Washington hub which had links to the World Bank and USAID, and the London hub, largely based at the London School of Hygiene & Tropical Medicine, with funding from the UK government and links to colleagues at the Liverpool School of Tropical Medicine, WHO and UNICEF. The main issue on which they divided was user fees, with the Washington hub being a strong proponent, and the London hub raising equity concerns. They trace this to "differences in the underlying values and principles that shape the US and European health care systems", with the Europeans viewing health care as a "social good" which should be available to all regardless of ability to pay, whereas in the US health care continues to be viewed as primarily the responsibility of the individual, and a private consumption good.

Chapter 8 by Kumaranayake and Walker, on the applications of cost-effectiveness analysis (CEA) presents a thoughtful commentary on the use of especially the Disability-adjusted life year, or DALY, which will be of interest not just to economists but to anyone who has wrestled with the use of CEA for health priority setting. They review the use of this tool to attempt to determine global priorities, with all its limitations of poor local data and difficulties of application of those data to different settings. They sensibly conclude that "we must be aware of not expecting too much from the tool... rather than aiming for precision, which both the data and tool are not designed for." And further, that CEA "does not take the politics out of decision-making...but is an element in the process of overall-priority setting, rather than a mechanistic way to select alternatives."(p. 155)

In chapter 9, on violence against women and reproductive health, Mayhew and Watts review the global attempts to reduce the horrific levels of different forms of violence against women. They cite figures which indicate that around the world, between 20 and 50% of women report having been assaulted or raped by a male partner at least once in their lives. They point out that "partner violence occurs in all countries, and transcends socio-economic and cultural boundaries." But violence against women includes not only rape and sexual assault by partners, but trafficking in women, forced prostitution, and violence and rape which is "perpetrated or condoned by the state, such as rape in war." Curiously this definition, adopted by the UN, does not appear to cover the selective abortion or infanticide of female fetuses and babies which results in the "missing females" - over 50 million female infants were missing in India and China at the beginning of the 90s according to Coale, and Nobel prizewinner Amartya Sen believes the number is closer to 100 million.(Gray, 2001) Their discussion of the global debate around this issue is valuable and focused, and they point out that the Reagan administration's "hard right-wing line on population" forced the groups of women who otherwise would have focused on violence against women to align with those promoting family planning, so as to prevent further restrictions on availability. It seems that the same phenomenon is repeating itself - the threat of limiting access to family planning and contraception, including abortion, diverts attention from the wider issue of violence against women in all settings.

So much has happened in the past few years - September 11, the war on Iraq and worldwide protests against that war, to name a few - that some will forget that the last time large numbers of people took to the streets was to protest the WTO, in particular its impact on workers and worker health. The chapter on "Workers' health and safety in a globalizing world" by Fustukian, Sethi and Zwi is one of the most useful in the book and is packed with information - a survey of this important issue in 20 pages. The chapter begins with a review of the data on workers' health around the world and catalogues the reasons why this is so - the lack of health and safety standards; the concentration of poor migrants in the most dangerous jobs, where they are vulnerable to exploitation; and the transfer of often-dangerous technologies to areas where there is little awareness of the dangers they pose, or where enforcement of existing standards is minimal. The use of female and child labor in the workforce, particularly the even less regulated informal sector, puts them beyond the reach of international organizational efforts which usually target the formal, export industries. Workers in developing countries are often particularly vulnerable to the practices of multinational and transnational countries which are deliberately targeting countries with a large labor force and poor regulation; they cite the notorious Union Carbide disaster in Bhopal, India in 1984, as an example of this: double standards in terms of design, equipment and maintenance, as well as deficiencies in operational practices, meant that the workers and surrounding population were put at significant risk. However, as the subsequent investigation showed, the Indian authorities were complicit in the low standards maintained by this subsidiary of a large multinational company. The authors describe how most low and middle income countries are content to leave labor standards issues up to the largely toothless ILO, rather than an organization such as the WTO which has genuine "teeth". In this they are joined, somewhat surprisingly, by the multinational companies themselves - and the reason is that they fear losing the industry altogether in a world where the multinationals are able to quickly shift their operations from one country to a more "welcoming" environment elsewhere. What then is to prevent this from happening more regularly? This brings us back to the protests in Seattle and elsewhere in the world in 2000 and 2001, where the interests of industrialized countries' consumers and their unionized workers coincided to bring pressure on such companies as Nike to improve their "sweatshop" practices. Voluntary codes of practice are being adopted in response to demands from civil society - or were before the economic downturn post-September 11.

There are several areas which I would have liked to see covered in such a book. Using the definition set out by the authors in the first chapter, of global health being affected by processes which are changing the way humans interact, I would have liked to see more explicit consideration of several important global health issues. For example, an examination of the attempts to agree on measures to improve the environment and slow global climate change, the politics around the Kyoto protocol in particular would have been welcome as would have been a review of the attempts to set up a tribunal to hear accusations of war crimes and on the effort to agree on a global ban on landmines. I would also have expected more on the changing roles of other UN agencies such as the UNFPA and the influence of US domestic politics on reproductive health; on the UN Security Council and the UNDP, and UNHCR. A chapter devoted to the controversies around pharmaceutical distribution, pricing, and access would have been timely, although the issue of patent protection and the impact of the WTO's Trade related aspects of intellectual property rights, or TRIPS, is nicely covered in the chapter on regulation by Kumaranayake and Lake. Other issues which are closely linked with globalization, but which are not covered in any depth are the global trade in illegal drugs, trafficking in women, and international attempts to control the distribution and marketing of tobacco products. According to WHO, by 2020 tobacco use will cause over 12% of all deaths globally, and tobacco will cause more deaths worldwide than HIV, tuberculosis, maternal mortality, motor vehicle accidents, suicide and homicide combined. It seems a significant omission from this important book. And finally there is no chapter devoted to the biggest health issue of our time -- the HIV/AIDS pandemic. These last two are huge omissions from a volume on international health and globalization.

But what is here is a very useful and thoughtful collection of work on many of the most pressing global health issues of the day, with a policy framework to tie them together. It should be of much interest to both those interested in health policy and international relations and international policy specialists who want to know more about how globalization affects health.