Globalization how healthy?
As the street protests that swirled around the recent G8 summit in Genoa clearly showed, globalization is not everybody's cup of tea. If for many world leaders and economists it is a panacea for a faltering world economy, for a growing number of critics it heralds the destruction of cherished traditional cultures. As Michael Hagmann discovered, in the public health community the contrasts tend to be less stark.
"I see globalization as a morally neutral but nonetheless inevitable force that poses both opportunities and threats," says Dr Nils Daulaire, president of the Global Health Council, an umbrella organization for health care professionals and public health organizations. "Those who judge it to be bad might as well try to hold back the tide. It's just like electricity. If you put your finger in a socket, it's bad. But if you use it to plug in things that improve your well-being, it's wonderful." Dr David Heymann, who heads WHO's communicable disease activities, agrees. "There are certainly good and bad sides to globalization. It is a challenge for us all to make sure it all moves in the right direction."
One positive outcome of globalization for health advocates is that it has given global health a far more prominent place on the political agenda. "Ten years ago health wasn't so central to meetings like the G8," says Dr Kelley Lee from the Centre on Globalisation, Environmental Change and Health at the London School of Hygiene and Tropical Medicine. But that seems to be changing. Says Daulaire: "Public health is the fastest rising topic these days, and it's going to be one of the central issues in the future. Nongovernmental organizations involved in public health have begun to realize that it does no good to complain about globalization but that we have to learn how to harness its forces for the benefit of the needy." A case in point is the US$ 1 billion commitment, announced by G8 leaders in Genoa, for UN secretary-general Kofi Annan's Global Health Fund.
A powerful message
One reason for the increased political awareness of health stems from a negative consequence of globalization: the unprecedented speed with which infectious diseases can now spread around the globe. "The globalization process has brought the world to understand that an infectious disease in one country may represent a very real health threat for the rest of the world. This is a very powerful message and a great incentive to help mobilize partnerships for public health," says WHO's Heymann.
AIDS, malaria, dengue, yellow fever, West Nile virus, Ebola, mad cow disease to name but a few are painful reminders that the 21st century's global village poses serious threats to public health. Or, as WHO director-general Dr Gro Harlem Brundtland puts it, that "in a globalized world, we all swim in a single microbial sea". Adding to the public health challenge are noncommunicable diseases (NCDs) such as cardiovascular diseases, diabetes or smoking-related disorders, once considered afflictions of the affluent, which have begun in earnest to afflict developing countries as well.
The Black Death
Travel is a prime culprit in the global spread of disease. Indeed, the link between infectious diseases and international travel was the catalyst for the First International Sanitary Conference held in Paris in 1851 and a precursor to global health institutions like WHO. And as far back as the 14th century the plague, or Black Death, followed the trading routes of the time. In the last century, however, international travel, and with it the risk of pandemics, skyrocketed. Today, according to Daulaire, more than 700 million people cross international borders each year, and with them any infections they may be harbouring.
Travellers are also penetrating deeper into uncharted ecosystems, such as tropical forests, where they may encounter previously unknown infectious organisms. Since the 1970s more than two dozen new infectious agents or diseases have been recognized, including Ebola virus, Hanta virus, prions and, of course, HIV. And old scourges, like tuberculosis, cholera and malaria, long thought to be all but wiped out, are staging a comeback on a global scale, partly as a consequence of international travel. What's more, misuse of antibiotics has fuelled the spread of drug-resistant microbial strains, which can cause disease that is particularly difficult and expensive to treat.
The spread of infectious diseases is, however, only one effect of globalization. Harmful products and lifestyles that travel with ease across an increasingly global market can contribute to the increasing incidence of NCDs such as cancer, heart disease or diabetes. According to WHO's noncommunicable diseases and mental health unit these major killers in industrialized countries are now also on the rise in developing countries. "In India and Brazil, the rate of obesity, around 3040% among adults of high socioeconomic status, is now comparable to the US, resulting in associated problems such as heart disease, hypertension, and diabetes", says Lee. Due to a shift from traditional foods like fish and vegetables to a "westernized" diet higher in fat, sugar, and salt, hypertension rates and diabetes in some indigenous African populations are increasing, says Dr Derek Yach, head of noncommunicable diseases and mental health at WHO. The same is true for obesity in the Eastern Mediterranean. And WHO projections indicate that stroke deaths will double in incidence in the developing world over the next 20 years. "In China alone one million people are dying of stroke each year, and that is mainly due to a salt intake that lies above what we consider healthy levels. Reducing salt intake could probably save several tens of thousands lives each year," says Yach.
A double burden
An even greater culprit, says Yach, is tobacco. Multinational tobacco companies are trying to make up for their losses in industrialized countries by increasingly targeting developing country markets with aggressive marketing strategies. The developing world "faces a double burden of infectious diseases and NCDs," says Yach. By 2020, WHO estimates, about 70% of the predicted 8 million smoking-related deaths in the world will occur in developing countries. A recent study sponsored jointly by the World Bank and WHO showed that the dropping of trade barriers through recent world trade agreements has led to a significant increase in cigarette consumption, especially in low-income countries where there is little or no health education about the negative impacts of smoking. In a global world, says Yach, a shared culture is emerging where tobacco consumption patterns are more or less similar around the world, especially in the "global teen" population, one of the main targets of tobacco advertising.
But globalization itself is giving public health leaders new opportunities in their struggle against diseases and needless deaths. To try and counter the tobacco marketing offensive, for example, WHO started negotiations last October on a global scale on a Framework Convention on Tobacco Control (FCTC), scheduled to be up and running by 2003, which should regulate, among other things, tobacco advertising and promotion, taxes and subsidies throughout the world.
Reporting of epidemics
What's more, in its quest to curb the spread of infectious diseases, WHO is currently revising the 30-year-old International Health Regulations (IHR), the only internationally binding legislation on the reporting of epidemics. In 1995 the World Health Assembly, WHO's governing body, called for a revision of the IHR. The original version of the regulations calls for mandatory reporting of three infectious diseases: cholera, plague, and yellow fever. Negotiations over a revised version started in 1999. "They are likely to include any major public health risk due to infectious agents rather than be limited to specific diseases," says Heymann, who expects the updated version to be submitted to the World Health Assembly for approval by 2004.
And then there's Kofi Annan's global "war chest" to finance the fight against AIDS, tuberculosis and malaria, an initiative made possible by the new "globalized" perspective on health. The leaders of the world's richest countries have committed themselves to provide more than US$ 1 billion for the Global Health Fund to develop vaccines, treatments and prevention programmes. The fund will be governed by an independent board representing the various stakeholders, including the UN, WHO, national governments from both donor and developing countries, and nongovernmental organizations. The Global Council's Daulaire expects the fund to be operational by the end of the year. "This is the first time real money is being committed. I think this year will be seen as a watershed," he enthuses.
Another positive outcome of globalization, the revolution in information technology, is increasingly being used to mitigate epidemic threats to global public health. The Global Outbreak Alert and Response Network is a "network of networks" initiated by WHO in April 2000 as a technical partnership to mobilize and connect global resources to control outbreaks which threaten national and global health security.
The Global Outbreak Alert and Response Network builds on existing initiatives such as the influenza surveillance network (FluNet), disease-specific networks such as the Cholera Task Force, and regional initiatives such as PACNET in the Pacific and the EU Surveillance Network in Europe. At the same time, it strengthens partnerships with technical institutions such as the Institut Pasteur in France, the Centers for Disease Control and Prevention in the USA, and national institutes for public health and infectious disease control in Japan, the UK and other countries, as well as international humanitarian organizations like the Red Cross, Médecins sans Frontières and the International Rescue Committee. Part of this network is the Global Public Health Information Network (GPHIN), an internet-based "early warning" application, developed in partnership with WHO and Health Canada. It continuously explores key web sites, media wires and specialized discussion groups, seeking information related to epidemic threats. It then passes these reports to WHO for rapid verification of outbreaks of potential international importance by WHO's country offices.
And in July, a "Health InterNetwork" was launched that will provide researchers and doctors in developing countries with free or almost-free Internet access to medical journals and with more hi-tech goodies, such as computers, software programs and the like. For Yach, this is a "wonderful example" of how information technology can be harnessed to offset some of the downsides of globalization.
Kelley Lee at the London School agrees but notes that there remains a lot to be done. "The challenges are enormous," she says. "If public health is going to be improved in a globalized world, we in the public health community have to get our act together. We need better information, concrete policy ideas, and the political assertiveness to push public health even higher on the globalization agenda."