Emily C Zielinski Gutiérrez & Carl Kendall. Handbook of Social Studies in Health and Medicine. Editor: Gary L Albrecht, Ray Fitzpatrick, Susan C Scrimshaw. Sage Publications, 2000.
‘Globalization’ is a diffuse construct used to denote the growing perceived spread of a capitalist world system and its integration with systems of trade, communication, transportation, patterns of urbanization, cultural influence, and migration throughout the world. Kearney defines globalization as the movement of people, ‘…information, symbols, capital and commodities in global and transnational spaces’ (Kearney 1995: 547). Quoting Giddens, Kearney notes that globalization in his usage is ‘… the intensification of worldwide social relations which link distant localities in such a way that local happenings are shaped by events occurring many miles away and vice versa’ (Giddens 1990).
There is nothing particularly new about these phenomena. However, authors who use the construct argue that there is something different about the velocity of these changes that has created a qualitatively new set of economic and social forces. Some authors use the construct as a portmanteau that encompasses any economic, cultural, or social phenomena with extra-national links, while others argue for appreciating the synergistic integration of finance, trade, economics, politics, and culture that they mean by globalization.
These multiple meanings, and the enormous range of phenomena glossed, make a review of the globalization construct difficult if not impossible. Although there is no denying the sense of ‘connectedness’—both psychological and physical—that permeates the contemporary world, the consequences of this for politics, economics, society, and culture, let alone for health and disease, are difficult to predict and sometimes even to trace.
In the case of the globalization of disease, the reviewer must appreciate both the globalization of disease in terms of epidemiology, and the impact of globalization on disease. A complete account of these two topics is not attempted here. What is attempted is an exploration of recent literature on health and globalization, including the roles of economic linkages, transportation and systems of communication, and the impacts of environmental change and urbanization on health. This chapter will review exemplary global health problems, several social processes that are embedded in globalization, and finally, medical and public health responses in a world where health must be ‘globally’ considered. Without committing to either the argument that the world is qualitatively or only incrementally different, the construct of globalization can be worthwhile to explore as an example of new public health thinking (Yach and Bettcher, 1998: 735 ff). Identifying social constructs that help to explain patterns of disease is an increasingly important goal for a public health community that is seeking a broad-based understanding of the current health transition and how to influence it.
The ‘globalization of disease’ functions as a deliberately provocative term, in both the health and economic sectors. Jonathan Mann states that, ‘the world has rapidly become much more vulnerable to the eruption and, most critically, to the widespread and even global spread of both new and old infectious diseases’. (Mann in Garrett 1994: xv). This vulnerability means that infectious diseases are no longer isolable in dangerous tropical locales, and this fact has been used to regenerate interest—sometimes approaching panic—in infectious diseases in economically advantaged countries. However, what is less well reported is how the economic and social processes associated with globalization (often originating within these ‘more developed’ countries) visit diseases on the developing world.
Convergence and Divergence: Health in a Connected World
Examining the globalization of disease often involves appreciating patterns of convergence made clearer by advances in measurement. Murray and Lopez (1996) draw on their research in the Global Burden of Disease (GBD) study, and the derived composite measure of disability-adjusted life years (DALYs: ‘the sum of years of life lost becaue of premature mortality and years of life lived with disability, adjusted for severity of disability’) (Murray and Lopez 1996: 740) to project global mortality and disability burdens between the years 1990 and 2020. Their baseline projection anticipates ischemic heart disease, unipolar major depression, road traffic accidents, and cerebrovascular disease becoming the top four causes of mortality and disability, positions currently (1990) occupied by lower respiratory infections, diarrheal disease, and perinatal conditions. Demographic shifts and trends (many attributable to the increased use of tobacco) are cited as the main causes for these changes (Murray and Lopez 1996). In these projections we see the rising proportional effects of noninfectious disease, with increasing numbers of persons in both higher income and ‘developing’ nations being affected by noncommunicable conditions. Murray and Lopez cite that nearly 9 per cent of the GBD in 2020 may be due to tobacco-related mortality and disability; global marketing, transportation, and communication are all implicated in tobacco’s spread. Additionally, as strides are made against infectious diseases, these survivors in lowerincome regions will become candidates for chronic conditions.
There are also important dynamics of divergence in the impacts stemming from globalization. The above projections do not mean that communicable diseases cease to be a problem. Murray and Lopez note, ‘there is a dramatic difference in the distribution of deaths between established market economies (EMEs) and the formerly socialist economies of Europe and the developing regions’ (Murray and Lopez 1996: 741). Communicable diseases, maternal and perinatal causes, and nutritional deficiencies accounted for 65 per cent of deaths in subsanaran Africa, and they were implicated in just over 15 per cent of deaths in EMEs (Murray and Lopez 1996: 741). It is the relative burden of disease that is anticipated to shift, more than a large-scale reduction in the absolute number of people affected by infectious disease. In Murray and Lopez’s baseline projection, HIV would rise from twenty-eighth to tenth in its share of the GBD, and tuberculosis would retain its current rank, although increasing its share of DALYs, from 2.8 to 3.1 per cent. While the maxim holds true that anyone can be infected, the reality is that the toll is higher among the poor in all regions.
Globalization has led, in some respects, to more awe and fear of the microbial world—and its human and animal hosts—than during preceding generations of medicine and public health. After all, with the advent of modern technology a sense of security overcame native caution (Lappé 1995). The complex interweaving of the health effects of globalization and the responses to it can be demonstrated when examining malaria as a long-known infectious disease that still defies control.
Although heading toward control in the 1960s, malaria has reemerged as a first-order health problem in the tropical regions of the globe. Approximately 300-500 million people are infected with malaria each year, making it the fifth most common cause of ill health worldwide and the cause of an estimated 1.5-2.7 million deaths per year. Nearly one million of these deaths are among children under 5 years old, some of whom succumb to malaria in combination with nutritional deficiencies and respiratory disease (WHO 1998a).
Several waves of control strategies have been attempted, none achieving definitive success: environmental alteration, prophylactic use of antimalarials, vector control with insecticides, and, since the early 1980s, vaccine development (NIAID, 1998). Treatment has, in fact, played a role in the new threat that malaria poses (Oaks et al. 1991: 67). In many places, mass chemoprophylaxis led to the presumptive treatment of all fevers with chloroquine, the biological effect of which has likely played a great role in the doubly deleterious effect of promoting resistance to chloroquine and reducing naturally gained immunity in populations. Population movement further enhanced this process. Many villagers have learned to use chloroquine as a universal fever remedy. Helitzer-Allen et al. (1994) and others have demonstrated that a broad range of illnesses is now popularly associated with malaria. As the term ‘malaria’ replaces local language terms for ‘fever,’ this heightens the difficulty of using fever as a signal for mothers to bring young infants and children to clinics for other treatment. If fever = malaria, then treatment = chloroquine in the local lexicon. Thus, not only is chloroquine being used inappropriately for malaria, but also to treat other diseases. Part of the globalization of disease is the diffusion of biomedical nosology, even if it remains incomplete.
Financial crisis in malaria-endemic countries impedes the utility of many scientific advancements against the parasite. Second-line drugs are beyond the economic reach of most residents in chloroquine-resistant areas. Although reliable rapid diagnostic tests for malaria exist (Makler et al. 1998), at their present cost the expense of one test outspends many countries’ per person yearly health allocation (Verle et al. 1996). Without means of delivery, medical breakthroughs cannot reach those in severest need.
While much credit for historical malaria control successes has been attributed to the use of DDT, malaria was also successfully controlled with environmental interventions and rural development initiatives in many parts of Southern Europe, Latin America, and Asia (Brown 1984; Kere et al. 1996; Litsios 1997). Recent research in Kenya, the Gambia, Ghana, and Burkina Faso suggests that bed nets may be more successful in preventing deaths from malaria than current candidate vaccines (Economist 1998a). In combination with new discoveries about the role of vitamin A and zinc in promoting the body’s own immune response, community-based interventions may be more feasible (Economist 1998b).
Community-based interventions that demonstrate the need for an integrated approach to health appear to offer great promise. Such programs, however, require close collaboration across health, economic, and social sectors, and broad population adherence achieved through significant participation and education. Such ‘development-focused’ and fine-tuned interventions are less predictable, more laborious, and do not lend themselves to the development of commercial products. As a result, they become less likely to be promoted in this global environment.
‘A Web of Interconnectedness?’
There can be no denial that the benefits of global trade are distributed unevenly, while the economic and social costs associated with rapid change fall more heavily on poorer countries. Developing regions of the world provide raw materials, cheap labor, and vast new markets, and there are no social safety nets to protect vulnerable populations of women, children, and adolescents. This lack of balance in global costs and benefits is also true in terms of health systems and technology. Although some authors argue that globalization promises a more equitable development of the health sector in the future, one can also speculate that these economic changes will only further polarize wealthier and poorer countries.
While this convergence of economic interests has been well noted, the effects of such integration on local health have not always been so clearly in focus. Globalization has fueled the mobilization of groups—from US and European factory workers to indigenous groups in rural Mexico and mass uprisings in Indonesia. People recognize that they are not sharing equitably in the benefits of a global economy (Navarro 1998). Economic growth affects numerous physical exposures to risk factors, but additionally it determines access to resources and investment in infrastructure within a country. These factors have clear implications for current health conditions, and for the emerging patterns of disease. As Navarro states, ‘One consequence of public policies that benefit globalization has been an unprecedented growth of inequalities in today’s world’ (Navarro 1998: 742).
Yach and Bettcher (1998), in a notably positive review, state that expectations regarding globalization have been mixed. Optimists have written of ‘a web of… [interconnectedness]… from which our sense of commitment to the other half is strengthened’ (Yach and Bettcher 1998). Yet who are the other half spoken of here? If it is the poor, there are several points of error. First, the proportions are not even so well divided, and second, the response to the appreciation of poverty is not necessarily to correct the condition. In fact, awareness without identification can make the poor seem more, not less, remote. As a justifying ideology for globalization, this theory falls short.
Globalization has primarily been the project of just a few countries in Europe and North America during the twentieth century: although they have been fueled by capitalism and technological development, they are inextricably linked to cultural baggage, such as an ethic of ‘acquisitive individualism’ and growth without limit (Lasch 1991: 15). The popular recognition that growth and expansion can have negative as well as positive consequences has come as a relatively recent revelation to the developed world. Other countries have felt the impact of incipient globalization and pandemics of imported disease since the sixteenth century, and have had diverse, but often negative, reactions to it (Diamond 1997; Wolf 1982).
Ironically, globalization is a process in which national boundaries—the construction of which appears to have been the work of nineteenth and twentieth century capitalism—recede in importance (Kalekin-Fishman 1996). While ‘internationalization’ heightens the degree of cooperation among states, globalization refers to processes that act in a separate arena, thereby ‘undermining or eroding sovereignty’ (Fidler 1996: 77). This process is repeated at many other institutional levels, and can result in an intensification of personal relationships at the expense of social, political, and economic institutional ties. As a result, any individual’s life-course appears more contingent on personal networks than on any institutional features. ‘Personhood,’ or the valorization of the individual social and biological personae, is also a Eurocentric project, and illness, identifying as it does the individual sufferer, grows in importance in this scheme.
The most common meaning associated with globalization is economic, especially the ‘internationalization of finance’ (Navarro 1998). Global factors play an increasing role in local economies, as is manifest in the huge volume of goods and services that move across national borders each day. Production facilities in the developing world take advantage of low local wages, gender inequity, and other social, political, and cultural differences to produce cheap goods for distant markets. International investment can move toward the maximization of profits largely heedless of national borders, with currency and market speculation at times blamed for significant trauma to local economies. This financial globalization takes advantage of the relative absence of social, political, and cultural globalization.
The Institute of Medicine has characterized the result of economic globalization as a transfer of risks due to the ‘movement of people,’ ‘exchange of toxic products’ (both intentional and unintentional), ‘variance in environmental and occupational safety standards,’ and ‘the indiscriminate spread of medical technology,’ (Institute of Medicine 1997). The United Nations Development Fund, in its 1998 World Development Report, frames ‘underconsumption’ as a major constraint to better health and livelihood conditions in the developing world. The need to increase the availability, and equitable distribution, of goods and services conforms well to a model of global propagation of consumption and economic expansion. Solutions under such a paradigm are clearly placed within the hands of producers rather than the public sector (United Nations 1998a).
While most attention to economy has focused on the role of capital, at times as a rather disembodied element acting in financial markets, the 1998 Nobel Prize for Economics marked a change when it was awarded to Amartya Sen (Sachs 1998). Sen’s focus on welfare economics and redefinition of poverty not by income but according to one’s welfare and capability moves toward the realization that measurement must adjust to the local reality (Sen 1997).
Globalization, of course, has institutional features beyond the movement of capital. Giddens refers to a ‘time-space grid’ that is laid over the planet as one characterization of globalization (Giddens 1990). While the accomplishment of such a linkage is honored, its effect, as mentioned above, can be to dismember local institutions and to devalue local meanings. Globalization results in the confrontation of the local and global; global forces, be they economic, political, technological, or biological, penetrate local environments at such a pace and intensity that ‘local’ ceases to have a clear referent. Although Redfield was quick to critique his own notion of the small-scale, isolated community in the sociology of the 1930s, this model made sense to many, as both descriptor and goal (Redfield 1989).
It is precisely this quality of overpowering the local context that tempers enthusiasm for globalizing tendencies as a positive force. The local community—Bhopal, India, for example—is not equipped to respond to global forces that manifest as a ‘local’ health event. Catastrophes constitute only a small part of the potentially dangerous situations that are a result of the spread of technology to new social and cultural environments. Mundane objects out of context can prove dangerous; for example, the recycling of insecticide and herbicide sacks for the storing of food and seed grains in rural Central America has grave consequences for health. The changes in local economies due to international market influences, a redefinition of local medicine according to cosmopolitan medical standards, and the influx of new risks—social, behavioral, and biological—appear to have overwhelmed the local ability to adapt and cope.
At the same time, at the global level, the conceptual tools used to capture information about health and changes in health have not kept pace with the accelerating effects of globalization. The next section reviews several key concepts—epidemiological transition, epidemiological polarization, and health transition—and examines their relevance in the light of globalization’s influence.
Globalization and the Epidemiological Transition
The transformation of health conditions, including the decline of infectious childhood diseases, first in the developed world at the beginning of this century and then accelerating throughout the world in the latter half of this century, has been termed the epidemiological transition. Under this paradigm, societies, responding to improvements in health and agricultural technologies, pass from conditions of high infectious disease mortality in children to concern about chronic diseases of aging, such as coronary heart disease. This apparent transition led to a naive and simplistic belief in the power of health technologies: ‘… as nations moved out of poverty and basic food and housing needs were met, scientists could use the pharmaceutical and chemical tools at hand to wipe out parasites, bacteria and viruses. [Leaving]… the slower chronic diseases that primarily struck in old age’ (Garrett 1994: 32). This supports the argument for the convergence of health problems discussed earlier.
Although medical and technological advances have tempted belief in the linear and irreversible character of health development, no society has made this transition completely. At the end of the twentieth century, one-third of all deaths in the United States are due to infectious disease, and infectious diseases are still the leading cause of death in the developing world. Even some of the so-called chronic diseases of aging or ‘lifestyle induced’ health problems are linked to infectious causes, such as the role found for the infectious agent Helicobactor pylori in producing ulcers.
The concept of epidemiologic polarization (Mosley et al. 1993) is key to understanding the divergent effects of globalization. This concept describes a dual dynamic of increasing chronic disease and entrenchment of infectious disease among lower-income populations in both developed and developing countries. Some mechanisms of globalization, such as the diffusion of new technologies, allow rapid ‘development’ within subsectors of a population and subsequent improvements in health indicators. However, the dilemma is not only that a restricted enclave is benefiting from this technology, but rather that other economic dislocations accompany these processes, creating a marginalization and impoverishment that contributes to disease, either through new exposures to pathogens, the creation of new disease-enhancing environments, dislocations of land tenure and traditional food supplies, or several other effects.
While the epidemiological transition focuses solely on changing patterns of morbidity and mortality, the health transition embeds the demographic and epidemiological transition in a construct that refers simultaneously to the social and economic factors that produce them (Caldwell 1990). The health transition, as elaborated in the work of Caldwell, Frenk, Bobadilla, and others (q.v. Jamison et al. 1993), is deliberately self-conscious of the complex interaction between health and interacting forces that propel social change. Conflating the epidemiological and the health transition produces a difficulty—while the epidemiological transition can be understood through exploration of fairly proximate disease variables (Mosley and Chen 1984), the health transition recognizes that its effects are produced through changes in social, economic, and political factors such as globalization. The construct of the health transition to date, however, provides few clues in understanding the multiple pathways that interconnect these sectors, predicting the impact of changes in one sector on another, or directly influencing health in the future.
A Shrinking World: Our Physical and Electronic Connections
The mechanical connection between the globalization of certain diseases and advances in travel and the transportation of people and goods is clear. During 1994, more than 97 million passengers traveled by air between the United States and other countries (United States Department of Transportation 1998). A commentator noted, ‘The protective effect of clipper ship travel is long gone’ (Ginzburg 1996), although certainly the slow speed of transport did not prevent the devastation of the New World either. The volume and accessibility of air travel literally means that, at least as far as the microbes are concerned, the global village is here. Policy makers, as well as the public, have seized on transportation as an explanation of a world at risk. This is evidenced by stories about a ‘patient-zero,’ a widely traveled, ‘promiscuous’ airline steward who is cited as the origin of the worldwide AIDS epidemic. It is hard to imagine a more perfectly crafted social parable to support discrimination and the erection of community barriers. There is an easily imagined fear of an undiagnosed hemorrhagic fever patient arriving from Africa to a major North American or European transportation hub, the vividness of which is as likely to be responsible for prompting attention and funding for disease surveillance and reporting as countless carefully considered scientific reports (Hamilton 1995; Institute of Medicine 1992).
Despite the important role of increased air travel, other trajectories of movement are even more vital in determining disease. Massive migration takes place in response to political, military, and social unrest. The factors surrounding large-scale migration are often associated with the inability of local authorities or communities to control violence or provide adequate means for subsistence. Such massive migration sets the stage for epidemic infectious disease. The exodus of millions from Rwanda in 1994 gave witness to one of the most devastating and deadly cholera epidemics in recent history (Kristof 1997). A quick review of the rising numbers of refugees and internally displaced persons, especially on the African continent, reveals the gravity of the situation. In 1997, figures for Africa note 4.3 million refugees, 1.7 million ‘returnees,’ and 16 million internally displaced persons (United Nations 1998b). If change and instability are the footholds for disease, these numbers speak volumes about the entrenchment of disease on the globe’s largest continent. Worldwide, the number of refugees, returnees, and internally displaced persons has increased more than four-fold, from 5.4 million in 1980 to 22.7 million in 1997 (United Nations 1998b).
Migration is important in less dramatic circumstances as well, contributing, for example, to the introduction of multiple dengue serotypes in new regions, a factor implicated in the development of dengue hemorrhagic fever. Migrant workers can suffer from their lack of immunity to diseases such as malaria when they travel looking for work. Economic migration has played a key role in the spread of HIV (Lurie et al. 1995). While the decision to migrate and resultant disease are local manifestations, they are often in response to distant factors.
Threats to health can also move directly in trade. Adopting the use of hazardous products such as tobacco and alcohol is discussed in depth below, but concern also centers on the unintentional export of health-threatening materials. Numerous incidents, such as the discovery BSE (bovine spongiform encephalopathy)-infected beef and cyclospora-infected raspberries, verify the urgency of cooperation between governments to adapt to the global trade in food produced by consumer-driven markets fed by multinational agroindustry.
Although global transportation has been transformed, the sweep of communication technology and content has even broader implications for health. Our capabilities in communication epitomize the ever-shrinking world evoked by the term ‘globalization.’ Global cash and culture transfer ride on the ‘time-space grid’ of communication technologies. Communication does not carry the same readily apparent threat of disease that is present in travel and transportation; digital information is (organic) virus free. Yet, for many in the developing world, communication technology brings disembodied contact with patterns of living that must stand in surreal contrast to local realities. A vivid anecdote from one of the authors is a late afternoon visit to a rural pulpería (store) in Honduras in 1985. Rather than lounging outdoors after a long day’s work, men crowded inside a dark house. The rubber-booted and straw-hatted farmers, machetes dangling from their hands, stared at a 12-inch black and white TV powered by an automobile battery. In a country with a GNP per capita of less than $500, these grindingly poor farmers were watching the Mexican telenovela, Los ricos también lloran (The Rich Cry Too). In response to the question ‘what’s going on here?’ the author got a plot synopsis.
Global mass media and other forms of communication lead to a transnationalization of culture. Certainly there is greater recognition, and celebration, of the rich cultural legacy of many parts of the world and an internationalization of many major metropolitan areas. The effects on health, though, come from less benign messages and stem more from growing effects of sedentar-ism and consumerism. Murray predicts that 8.4 million deaths in the year 2020 will be attributed to tobacco (Murray and Lopez 1996). The effects of dietary change, increased access to alcohol, tobacco, and other drugs, and violence will take a high toll even in countries with the infrastructure to treat them. The effects can be devastating in areas still struggling under high burdens of infectious disease, low disposable income, and high levels of malnutrition.
A few countries may deflect the satellite-borne images that waft the globe and discourage viewing in a thoroughly futile attempt to restrict access, but the effect of communication is not necessarily negative. The presence of electronic devices and materials in even the most inaccessible locales demonstrates the power available through communication for improved health and education, and, of course, disease surveillance. Failure to invest in information technology and the supporting infrastructure can only widen the disparity between industrialized and nonindustrialized countries. Communication creates new agendas for health, and produces social and cultural construction of health, as evidenced by the worldwide prioritization of child health. Although there are clear ethical reasons for reducing disparities in the use of technology for surveillance and health, it is also in the best interests of the developed world to truly ‘globalize’ communication. The most sophisticated technical surveillance abilities in industrialized countries can be rendered useless by the weakest communications links in developing countries.
One example of the promising use of technology is provided by Pro-MED, an Internet-based newsgroup begun by the Federation of American Scientists, which gathers worldwide reports of human, plant, and animal disease outbreaks (http://www.healthnet.org/programs/promed.html). Moderated to maintain the quality of submissions, this system bypasses traditional academic journals, opening a communication channel through which more voices can be heard and can communicate with one another with unprecedented rapidity. Clinicians and public health professionals are able to poll their global peers for insight and instruction through this technology, demonstrating how knowledge is truly able to serve a global public. Although limited to those lucky enough to have access to a computer and an Internet connection, it is step in the right direction.
Although an untapped potential exists to harness technology and incorporate it into health programs, global communication continues to deliver less benign messages. Widely disseminated messages have enormous ramifications for health. Advertising for tobacco and alcohol products in developing countries, as well as in low-income US neighborhoods (Hackbarth et al. 1995; Moore et al. 1996), aids in the penetration and promotion of these goods in vulnerable areas. At the same time, new, biomedically defined diseases and lifestyles relatively free from infectious diseases have become better known through the media, challenging local constructs. Coupled to this is the spread of commercial pharmaceuticals, which are both more expensive than their local counterpart and often inappropriately used. This phenomena affects conceptions of health throughout the world.
At the same time, the evolution of the concept of emerging diseases provides an example of how alliances can be formed between science and the public through communication. However, the reader should bear in mind that visions of the ‘other’ are easily distorted through the media. Messages are not transmitted as pure ‘information,’ but rather act as packets of cultural knowledge that are squirted around the world. Recognizing the cultural content of messages is as important for understanding communication (or the lack of it) as the scientific content.
Global Environment Impact
A major area of current and potential convergence of risk is connected to environmental change. These processes are clearly independent of national boundaries, yet attempts to control the factors influencing environmental change and degradation remain bound to national politics and policies despite numerous attempts to bridge such differences through multinational negotiation. John Last, in his text Public Health and Human Ecology, notes numerous phenomena encompassed by the term ‘global change,’ including global warming, stratospheric ozone depletion, environmental pollution, species extinction, reductions in biodiversity, and desertification; all of which represent a ‘new scale of human impact on the world…’ (Last 1998: 395).
The unfolding of globalization has changed the basic relationship of communities to the environment, with an impact that is impossible to fully quantify or predict. Forces such as migration and expanding production can carry negative consequences, especially when production is not restricted to the service of local needs and may not be managed according to local wishes. Expanding economies and populations also have an impact on the earth that is impossible to fully quantify or to predict. Much of the ongoing debate regarding global climate change acknowledges that our human history of record keeping, and even the predictions interpreted from other natural sources, can mean little in the light of long-term trends. In the long term, environmental degradation may come to play the largest role in determining global health.
Several current examples can be provided. The introduction of vector and rodent species into new areas is linked to habitat destruction and weakened regional biodiversity. Accounts that relate disease to shifts in local land use are legion. Lyme disease in the northeastern United States was a reaction to changed housing patterns and forest incursion that enhanced human exposure to deer-borne ticks (Institute of Medicine 1992). Outbreaks of Lassa fever in Africa, hantavirus in the southwestern United States, and Bolivian hemorrhagic fever were linked to increased rodent-human interaction (Garrett 1994; Ryan 1997). These ‘emerging’ threats are, at least in part, responses to human activity.
As global climate change occurs, the spread of vectors beyond current tropical areas is likely. The presence of a vector alone, of course, does not predict the spread of disease. Epidemiologic modeling involves the reproductive rate of a vector-borne disease (‘number of new cases of the disease that will arise from one current case given an entirely susceptible population’) which is produced by a number of factors including rainfall and temperature. A high reproductive rate among a disease-naive population could bring epidemic spread of disease (Rogers and Packer 1993).
Border Economics, Environment, and Health
Economic policies that are at odds with local control of resources interact with environmental issues to heighten health problems. An example lies in the privatization of government-held land previously used by ‘ejidos’ (organized groups of farmers and peasants) and individual farmers in Mexico. Partly, this was a response to the need for investment in irrigation and new agricultural technology in a desiccating environment. The sale of land reinforced rural-to-urban migration. This trend provided abundant low-wage employees to the thriving maquiladora industry (foreign-owned factories at the heart of Mexico’s 1965 ‘Border Industrialization Program’). On one hand, the dynamics of migration and plant employment undermine family, community, and economic structures in both urban and rural areas and bring their own consequences. On the other hand, urban land resources are taxed with vast colonias (shantytowns) that spring up to accommodate urban migrants with no local identification, opening up new ecologies for disease. The sheer scale of industrial development and agricultural runoff from both sides of the border have, at times, turned the Rio Grande into one of the most polluted waterways in North America, and ineffective environmental protection has raised deep concern over the dumping of toxic waste.
While such change may be inevitable and necessary under the operating economic paradigm, the rapidity of change outpaces local ability to adapt, threatening the environment and traditional lifestyles as well as health. There is great reluctance among national políticos and legislatures to confront issues that may present boundaries to economic development. While decisions to migrate are made locally, they are responses to global forces that converge to determine the choices of action available on the local level (see DeWalt et al. 1994; Interhemispheric Research Center 1998a, 1998b).
Urbanization: A Confluence of Migration and Economic Change
Urbanization as a social process exemplifies the simultaneously physical and cultural phenomenon that is globalization. This discussion posits urbanization as a major by-product of globalization. Economic development and investment fuels the growth of cities, which draw increasingly larger populations. Population growth, however, outpaces investment in infrastructure and overwhelms the local capacity to accommodate new urban dwellers. These large populations become proletarianized, threatening both the state and the economy if their needs are not met, as events in Jakarta during 1998 demonstrated.
This century has seen an explosion of ‘mega-cities’: urban centers with populations greater than 10 million, the vast majority of which are in developing countries. Such cities include Bangkok, Beijing, Bombay, Buenos Aires, Cairo, Calcutta, Delhi, Jakarta, Karachi, Lagos, London, Los Angeles, Manila, Mexico City, Moscow, Paris, Rio de Janeiro, Sao Paulo, and Tokyo. Never before in history have people gathered with such density; as a species prone to ‘herd’ diseases, the implicit danger is clear, yet the effects of urbanization on health are complex.
The history of health in cities provides a mixed picture. In England in the nineteenth century the infant and child mortality rates of the rural poor were lower than those rates among the urban poor and even the middle class. Data from England as recently as 1910-1912 indicate that mortality from several of the most common diseases of the time was lower among farm laborers than among better-paid urban professional and salaried workers (Collins 1926). Yet the twentieth century, especially post-World War II, did demonstrate improved health in urban centers. Poor access to health and educational services and the lack in variety and quantity of foods available in rural areas enhanced infant and child health.
Despite their modern conveniences, urban centers are once again creating greater risk: air, water and environmental pollution, high population densities with consequent opportunities for infectious disease spread, and lifestyle changes in sexuality, diet, and exercise that are conducive to disease (United Nations 1996a). Cities have been called ‘the dynamo driving infection’ (Horton 1996). Today, in both developed and developing countries, the urban poor have the highest health risks (WHO 1995). Urbanization appears to be driven by two highly interrelated factors: inadequate distribution of infrastructure, resources, and opportunities in rural areas, and the concentration of industrial activity within megacities, factors certainly not divorced from other patterns considered in this chapter and intimately related to the project of globalization.
Urban dwellers may have remarkably different patterns of risk. While the wealthy and middle classes have better access to tertiary care, the poorest groups have little or no access to such services. Rapidly growing squatter and shanty settlements usually have no services of any kind, and residents may be barred or discouraged from using those in nearby neighborhoods. Even emergency services, which are generally in town centers, may not be readily available to the many who live in settlements on the outskirts.
Urban settings serve as laboratories for examining how poverty differentials determine health. In Porto Allegre, Brazil, the infant mortality rate (IMR) in squatter settlements is three times that of nonsquatter areas, more than 75 deaths per thousand live births (Fischmann and Guimaraes 1986), with further evidence of the association of low income and childhood mortality provided by Victora et al. (1992). In Quito, Ecuador, in the early 1980s, the IMR in upper-class districts was 5 per 1000 live births, comparable to the most developed countries today. At that same time, manual workers in Quito’s squatter settlements saw their children die at a rate of 129 per 1000 live births, a rate slightly below the global average at that time for the least developed countries. Similarly, large differentials have been observed in the Philippines, Sri Lanka, England, Wales, and elsewhere.
Although official poverty levels used in national studies are suspect, even these studies estimate that half of urban inhabitants in developing countries are living in poverty (Hamid and Fouad 1993). In 1990 ‘at least 600 million urban dwellers in Africa, Asia, and Latin America live in “life and health-threatening” homes and neighborhoods because of the very poor housing and living conditions and the inadequate provision for safe and sufficient water supplies and for sanitation, drainage, the removal of garbage, and health care’ (Satterthwaite 1995).
The impact of crowding, poor access to care, and high population densities can be seen in a number of diseases. Tuberculosis is responsible for approximately 3 million deaths per year, and ‘is the single largest cause of adult death in the world’ (WHO, 1998b). Acute respiratory infections take the lives of 4-5 million infants and children annually. These diseases tend to be more prevalent in urban areas, with the highest incidence seen in the poorest, most-crowded areas. Air quality deteriorates as well. Mexico City and Sao Paulo, for example, are afflicted with excessive levels of carbon monoxide, ozone, and particulates that lead to increases in respiratory and cardiovascular diseases (UN 1996b).
Urban environments provide epicenters for the transmission of multiple-drug-resistant tuberculosis, allowing for interactions between various risk populations. Predictably, high rates of tuberculosis often correlate with high AIDS prevalence in an area, with the additional twist that TB is the one AIDS-related opportunistic infection that can impact the general population (WHO 1998c).
Cholera, long absent from Latin America, has reestablished itself due to poor sanitation and hygiene, failure to protect water sources and food supplies, and global trade and travel (WHO 1998d). Urban environments, particularly sections without adequate water, sanitation, and solid waste services, and where many people handle food before it reaches the consumer, provide ideal circumstances for transmission. A host of other diseases abound, such as dengue fever, which can thrive in trash-strewn urban landscapes (Gubler and Clark 1996). Parasitic diseases such as Chagas fever is transmitted to humans by the T. cruzi-Mected triato-mine bug, which has now adapted to life in the housing that typifies the sprawling periurban shanty towns of Latin America (Coura et al. 1995; Walsh et al. 1993). This disease is controllable when discovered early, but is difficult to diagnose and has seriously debilitated many sufferers, particularly in Brazil. In general, malaria is less common in urban areas, but in South Asia the vector mosquitoes have adapted to urban life (Hati 1997). The future may see further emergence of malaria proximate to urban areas and the rapid spread of drug-resistant strains of the parasite, helped by increased contact between urban and rural populations and travel between countries (Moore et al. 1994).
The intense social dynamics created by urbanization contribute to rising disease rates, as demonstrated by HIV. HIV/AIDS thrives in urban settings, which initially demonstrated the highest levels of HIV incidence in both developed and developing countries. Urban areas ereate new opportunities for mixing populations and spreading the risk of sexually transmitted disease (STD) and HIV infection. The groups at highest risk, particularly in the earliest stages of the epidemic, are present in disproportionate numbers in urban populations. Even small groups of people who engage in high-risk sexual behaviors in urban centers—such as intravenous drug use, commercial sex work, and transport workers, and their sexual contacts—may suffice to fuel successive waves of the infection into the population at large (Way and Stanecki 1995). STDs, including HIV, account for more than 10 per cent of the disease burden for both men and women worldwide (United Nations 1996). The World Health Organization (WHO) recognizes that STDs are most frequent in sexually active young people aged 15-24 years, with the peak age of infection lower in girls than in boys. Young women are among those most at risk for HIV and STDs, often being taken as desirable sexual partners by older male members of high-risk groups. It is estimated that half of all HIV infections in developing countries have been contracted by people younger than 25 years of age. Up to 65 per cent of infections in females are believed to occur by age 20 (WHO 1995). The reasons for this are many. Traditional barriers to early sexual activity and limiting sexual partners are more likely to have broken down in urban settings. At the same time, wide disparities in income are created, prompting resort to desperate income-generating activities such as prostitution. In sub-Saharan African samples, estimates suggest that as many as half of all female migrants are involved in prostitution at one time or another. In Thailand, there is a large proportion of urban migrants who are young women participating in prostitution, either voluntary or coerced. While this activity has been historically tolerated, attitudes appear to be changing rapidly (Hanenberg and Rojanapithayakorn 1998).
The social, political, and economic links tied to HIV stretch across the globe. Migratory patterns connected to global trade, urbanization, and the movement of labor and goods help explain the trajectory of this epidemic. Structural adjustment policies in Africa intended to encourage free-market economic development and the consequent decline of government-provided health services (Lurie et al. 1995) created an ideal environment for the transmission of STDs (Felman 1990). The basic circumstances are not improving, ‘thus deepening the social crisis in which HIV breeds’ (Epstein 1992).
In addition to ‘conventional’ disease threats, huge urban populations are vulnerable to natural disasters that are, to all intents and purposes, inevitable. It is, in fact, unknown whether large megacity populations can be sustained within finite areas. Events that killed hundreds in centuries past may kill thousands in the future due to the economic and social forces that create these megacities. Paradoxically, globalization spreads linkages widely over the globe but contributes to the dynamics of local urban concentration. The continuing demands of economic growth, and the desires of people to access education and the limited infrastructure, will doubtless sustain patterns of urbanization.
The Future of Global Response to Health and Disease
The growth and hegemony of biomedicine have characterized health policy and intervention during the twentieth century. Lappé states, ‘the superficial success of modern medicine has created an illusion of human supremacy over the natural world’ (Lappé 1995: ix). Advances in biochemistry imply a knowledge and manipulation of cellular mechanisms, with a promise to change the basis of prevention and therapy and to improve the clinical control of disease in the twenty-first century. Vast areas of the world, particularly Africa, were once off-limit to globalizing processes due to disease. Vaccines, anti-malarials, and other treatments have opened many of these regions to an influx of expatriates and tourists (while the benefits from these advances have not been available to local residents to the same extent). Yet many successful disease control interventions were not the products of laboratory research, but of epidemiological investigation, and the interventions were revolutions in the organization and management of health programs more than new technical ‘fixes.’
What is billed as the single greatest public health achievement of this century, the eradication of smallpox, is often misinterpreted. Disease eradication is usually regarded as the epitome of technological intervention. Smallpox eradication, however, was not the product of new technology (although a new, more heat-stable vaccine was made available, a vaccine for smallpox has been available for 200 years), but rather the combination of the disease’s special epidemiological characteristics, a new, vertical strategy that focused on enhanced surveillance and disease outbreaks (rather than overall immunization coverage) and skillful international management (Baxby 1995; Hopkins 1983: 305). Enhanced surveillance and communication recognized outbreaks while there was still time to do something about them. Taking advantage of improved transportation, the program could arrive with enough vaccine to surround and arrest the outbreak. Fear of smallpox and the prestige, political support, and promise of the program drove even skeptical communities and individuals to be immunized. The eradication effort demonstrated the accomplishments possible with the new global tools.
While certain other diseases such as polio and measles may be susceptible to eradication, the vast majority of diseases are not (CDC 1993; Olive et al. 1997). The model of focus on disease, epidemiological prioritization, and enhanced delivery strategies has been the model for other selective primary health-care interventions as well. How relevant is this model today? Smallpox eradication occurred at a particular historical moment: fueled by Cold War dollars, the program operated through the World Health Organization and national ministries of health. It led to the epidemiological mapping of the world. We currently retain a fairly detailed picture of global disease control priorities that permits the recognition of the role of major childhood diseases such as diarrheal disease, acute respiratory infection (ARI), and malaria in the quest for global health.
However, the response to the identification of this global burden of disease has not been straightforward. The primary health care (PHC) declaration ‘health for all by the year 2000’ was to be a response to the health infrastructure and disease control needs for the developing world. These health programs were intended to function with very limited resources, promote prevention and the use of appropriate technology, and rely on health education and community participation. Health was seen as inextricable from development, and was recognized as being tied to the ability of the population to sustain itself and as a reflection of the total ‘health’ of a community. However, these communities were identified as distant and foreign-not part of the developed world’s community—and even this program was soon deemed too ambitious.
A more targeted, ‘selective’ primary health care (SPHC) approach was devised that biomedicalized ‘prescriptions’ for the most severe diseases affecting large numbers of people. The focus was on diseases that were more amenable to discreet interventions and were the most attractive to international donors. Medical and technological treatments—immunizations, oral rehydration therapy, pesticide application, and access to antimalarials—are measurable and often highly effective means to intervene rapidly in disease. They lend themselves to vertical, targeted, and limited programs that may or may not ultimately enhance the capacity of that village or community to deal with continuing threats to its overall health.
These types of programs have only been sustainable with large external inputs. At the same time, they provide interventions that are at odds with tertiary solutions available in the private sector and in hospitals, but rather illustrate the fact that these medical interventions demonstrate the contradictions inherent in considering globalization as a unified and beneficial phenomenon. Tools from the same global surveillance kit demonstrate both the health needs and the economic shortfall in realizing health for all, transforming the question ‘How much health is enough?’ (not an economic question, but a global one) into ‘How much health care can be bought for x dollars?’ misses the point, puts economics before health, and produces very different answers in different parts of the world.
What does it Mean if Health is a Commodity?
Under an economic paradigm, decisions are made to maximize economic benefit. As the world is brought into a more coordinated economic system, it is valuable to examine how the decisions that affect health are made, and who is affected. To the extent that the global economic system mirrors processes in advanced capitalist countries, the American experience may be instructive. The commodification of health influences the debate over health costs, and leads to a confusion between ‘health’ and ‘health care.’ If ‘health’ is a good that can be purchased by an individual consumer, then the model for decision making is the marketplace. Yet, this perspective is clearly inadequate. Children must be vaccinated regardless of their wishes and the wishes, or ability, of their parents’ to pay. The public is forced to pay, both financially and in terms of disease, when others choose less healthy lifestyles, or are forced to go without adequate health care. Even if consumers could purchase health, the cost of new technology puts it out of the reach of all but a handful of individuals. Standing astride this debate, medicine finds that professional autonomy and high-quality health care is difficult to achieve within the institutions that have been developed to awkwardly bridge consumer needs and population health needs.
To translate this template to the global market is certainly a recipe for disaster (see Navarro 1993). Decisions have already been made about the levels of health that may be achieved in different countries. Often without the benefit of formal economic analysis, policy makers in both the health and other sectors often presumptively exclude programs and investments in health. Contamination of drinking water in Peru due to the failure to expand and maintain water systems in Lima, Callao, and Trujillo, for example, factored into the reintroduction of cholera in the Americas (Swerdlow et al. 1992). Declining environmental surveillance and the failure to control trade in tires containing mosquito eggs led to the introduction of Aedes albo-pictus in the United States and contributed to concerns about the transmission of encephalitis and imported dengue fever (Francy et al. 1990). Trade in used tires from the United States played a major role in the reintroduction of Aedes aegypti to Latin America in the 1960s.
How should governments and international organizations consider the trade-off among investments in health and investment in other sectors? At both national and international levels, health is distilled into quantifiable indicators of success or failure, but these figures are difficult to interpret and often fail to influence policy. Current health may be attributable to investments made long ago or to temporary economic success. At the same time, short-term political influences may demand investment for disasters or emergencies that far outpace development assistance. The pattern of continuing crises creates an unending series of demands for programs that leave little behind for the next crisis.
The commodification of health has contributed to the widespread availability of antibiotics, which are often seen as an inexpensive and easily dispensed remedy, and they are substantially misused. Although the widespread use of antibiotics has contributed to better health in the past 40 years, these drugs have been increasingly abused. Patterns of adherence are poor, and patients stop taking the expensive drugs when symptoms disappear or when side effects, such as gastric disturbance, begin. In addition, these drugs are often self-prescribed and one or two may be taken at a time. Parents, accustomed to some ‘tangible’ health treatment, may insist on antibiotics for a child’s treatment, and overworked, harried physicians may concede to the demands, despite the knowledge that the infection could be viral or not require medication. The culture of medicine in which antibiotics represent ‘purchasable health’ has contributed to the rapid evolution of drug-resistant strains of infections (Demissie et al. 1997; Rapkin 1997).
Finally, in considering commodification, it must be recognized that biomedicine is a huge industry. Potential profits and eager markets drive drug development. While developing countries represent huge markets, the relative returns are low due to the use of generic drugs and poor populations that are unable to pay high prices regardless of the utility offered by a drug (Trouiller 1996). Research for malaria treatment—one of the most important causes of infectious mortality in the world—must be covered under Orphan drug’ protection, with little commercial support for development. The global diffusion of biomedicine is displacing local knowledge of remedies that could have enormously enhanced the pharmaceutical armamentarium. While some local remedies may be nonefficacious, their use constitutes a coping strategy for dealing with misfortune. Now, deaths from pneumonia, diarrhea, malaria, and even AIDS are reduced to ‘outside’ social, economic, and political explanations. Although locally meaningful remedies have existed, they are simply no longer being provided.
There are, however, far-sighted companies, such as Merck and Smith Kline, which have found ways to support drugs for orphan diseases. The free distribution of Merck’s Ivermectin for onchocerciasis control in Africa and Latin America is subsidized by its sale for veterinary use in the United States. The partnership between WHO’s Tropical Diseases Research Program, these companies, and the country disease programs is a model of enlightened corporate multinationalism (TDR 1998).
This examination of globalization reminds us that, whether or not one believes in an inevitable drive toward a more unified economic, social, and technological world, there are terrific costs being paid, both in human and environmental terms, in the current world system. International health and medicine must play an active role in considering these issues and structuring responses as we lurch towards the millennium.
While both human population growth and the development of medical technology in the twentieth century have been staggering, ill health still plagues much of mankind. The very young, children and adolescents, women, the elderly, and the poor of all ages are still vulnerable. The ability of pathogens to adapt and new pathogens to develop must challenge our faith in uniquely technological solutions. To fully accept the concept of the globalization of disease demands that we view our expansion as a social, cultural, and ecological project as well as an economic one.
The Institute of Medicine’s 1992 report on emerging infections acknowledges that the ‘factors in emergence’ of emerging infectious disease are inherently social in nature. Members of the panel identified six sets of factors, specifically focusing on human demographics and behavior, technology and industry, economic development and land use, international travel and commerce, the breakdown of public health measures, and microbial adaptation and change. These social factors also work in describing the patterns that are tied to globalization dynamics and the spread of disease, both infectious and chronic.
Popular questions concerning the globalization of disease ask whether a new, lethal, worldwide epidemic is likely. The argument of this chapter is that such considerations are only a small part of the globalization and health picture. Without large-scale change beyond the health sector, infectious and chronic disease burdens will continue to grow among those who are most vulnerable. Under a system where the numbers of people in poverty and poor health greatly outweigh the number of people with high incomes, the challenges seem clearly laid out. There is no indication of a reversal in these trends.
This chapter would be incomplete without an effort to address potential solutions to the issues outlined above. The patterns of the global economy, mobility, communication, and urbanization provide opportunities as well as problems. Although these comments will seem Utopian, the reader must realize that they are perceived as goals, a Utopian realism, as Giddens (1991) would put it.
- Health must remain, and become more of, a public/private partnership. Funding of public investments in health must recognize the role that the global economy, including consumerism, trade, and transport, plays in disease. Although a variety of medical services will be increasingly available throughout the world, and rising economic circumstances will continue to improve health in many parts of the world, the cost for this expansion should not be borne solely by public investments in health infrastructure. Part of the cost of this must be shouldered by the institutions of global economic expansion.
- Differences in the cost of labor and goods fuel global expansion; however, the ethics of this expansion demand more equitable levels of investment in health. Initial global economic penetration fuels rapid urbanization and taxes existing infrastructure. The argument that certain areas of the world need to ‘accept’ certain levels of disease on the road to development when these risks are well known is unethical and simply acquiesces to current practice. At the very least, these decisions need to be debated in the open and involve the populations concerned. The enhanced expectations explicit in global growth, communication, and urbanization are as real as the economic facts. These expectations and priorities in development need to be negotiated in a multisector forum where health as well as economic development is considered an outcome.
- Globalization offers opportunities to build systems of disease surveillance. An effective system of surveillance for disease can and should be constructed, linking sentinel national institutions where available, and providing direct assistance for the construction and support of sentinel sites in areas that do not yet, or no longer, have the infrastructure for effective surveillance of disease. Remote sensing technology is able to provide enormous detail about large areas of the world. We have the technology to develop a significant global network, and we have institutions, such as the WHO, available to implement and coordinate these functions. This surveillance should include not only traditional disease categories, but also substance abuse and violence, human rights violations, and violation of environmental laws.
- Multilateral institutions have not prospered in the global expansion. The mandate of these institutions, such as the United Nations, the World Health Organization, and the lending institutions needs to be changed to meet new priorities or, if unable to adapt, new institutions should be designed in their place. A new reorganization of the WHO demonstrates the recognition of these needs and promises new innovative approaches. However, to fully address these needs will require implementation, as well as coordination, which will require expanded budgets and authority.
- International, ‘global’ institutions should not be created at the expense of national institutions, many of which have suffered as a result of economic restructuring. A mechanism is required not only to sustain but also to encourage local training and research. Developed country institutions should be encouraged to build real partnerships with their counterpart institutions, and provide the long-term support and mutual benefit that are essential for careers in research programs.
- The Global Burden of Disease study and Sen’s approaches to defining poverty provide models for improving the science of health, disease, and welfare measurement. Challenges to conventional notions of determining risk must continue in order to provide data that are useful in weighing intervention options.
- A tremendous global communication industry exists. This infrastructure should be put to use for educational as well as commercial purposes. The newly created urban environments create great need for education about health risks and appropriate treatment. The learning deficits on both sides of the equation are large.
- Global authority is required to control travel during epidemics. This requires the active participation of the transportation sector and a truly global authority with the ability to take forceful action when necessary. Such global authorities might also be mandated to participate in the control of biological weapons and weapons of mass destruction and to assist in complex emergencies.
What the ‘globalization of disease’ best offers is an enhanced paradigm for understanding health. The health transition consists of social processes such as globalization that directly affect health and investment in the health sector. Globalization demands attention to changing vulnerabilities and recognition of the multi-faceted outcomes of ‘development’ and technological advances. Surveillance and intervention, both preventive and curative, require a rethinking of institutions and strategies. The patterns of economic and social change outlined here are only going to intensify. Automation, global communication, and a focus on production have allowed many societies to reach the future that they have been defining, but the byproducts of these same mechanisms can further entrench the health problems that we once thought were surmountable through technology. Certainly technical solutions, health communication, and policy dialogue are needed. However, the new challenge is to use the promises and realties of globalization, not just to respond to crises, but to take responsibility for and shape our future.