Economic globalisation and its effect on health

According to World Bank figures Tanzania ranks as one of the world’s poorest countries,¹ yet its commercial centre, Dar es Salaam, is one of the most expensive cities in the world in which to live²—because expatriates on developed world salaries have helped to fuel living costs. An even greater irony is that for Tanzania and many developing nations net flows of wealth remain, as in colonial days, from poor to rich.³ Far more is spent on servicing national debt than on services such as health or education.⁴ These are perhaps some of the less expected features of globalisation of the world economy.

At the eighth congress of the World Federation of Public Health Associations last October in Arusha, Tanzania, a recurring theme was the advance of globalisation and its adverse effects on health.⁵ Professor Kris Heggenhougen of Harvard Medical School argued that the continual search for cheaper labour by multinational companies promotes widening income differentials, and in their search for new markets companies sell damaging products to developing countries.

Delegates heard that the basketball player Michael Jordan is paid more by Nike in one year for advertising training shoes than the combined annual wages of the 30 000 Indonesians who make them. While tobacco companies are being prosecuted in the United States they are ruthlessly expanding their markets in low income countries such as Tanzania.⁶,⁷ With the demise of the cold war Western arms companies seek to support their profits through selling more arms to low income countries. Since 1945 the vast majority of the deaths directly or indirectly due to armed conflict have been among the world’s poor.⁸ Efforts within low income countries to implement rational drug policies through lists of essential drugs have met with resistance from multinational pharmaceutical companies. These companies continue to focus most of their efforts in the developing world on the promotion of “non-essential” drugs⁹ and on occasions have undermined the efforts of governments to implement national drugs policies.¹⁰

These are of course selected examples of economic globalisation. An unfair selection? Perhaps. Economic orthodoxy asserts that globalisation is both inevitable and desirable: interfering with the free movement of capital hinders the very processes that will bring better standards of living and health for all. A counterargument is that what we are seeing at the moment is very far from “free trade,” but a world economy increasingly dominated by a small number of multinational giants able to dictate the conditions of trade.

Whatever your point of view, the past 20 years has undoubtedly seen an increase in the gap between the world’s rich and poor.³,⁴ At the Arusha congress Gro Bruntland, former prime minister of Norway and nominated as the next director of the World Health Organisation, noted that many countries continue to struggle with diseases that could be eradicated for the cost of “a couple of fighter planes.”

By its very size and momentum economic globalisation presents formidable challenges to the promotion of health. Global problems demand global responses. Coordinated, forthright, and determined advocacy by health workers and their associations at national and international levels could and should play a much greater role in mobilising public and political opinion and in bringing pressure to bear on multinational companies and international economic bodies. Their advocacy should include the promotion of “essential public health functions”—a basic package of services that should be available to all populations. It should also include the promotion of a health research agenda led by the health and policy needs of countries who bear the brunt of the world’s ill health: currently much research in poor countries is determined by the rich.

Like it or not, the signs are that economic globalisation will continue apace. Where should we look for the leadership to match this? The World Health Organisation, perhaps the most obvious place, has been much maligned recently for being ineffectual in the face of international economic pressure. Let’s hope this will now change under its new leadership. The onus is also on other international organisations with an interest in public health, such as the World Federation of Public Health Associations, to play a more forthright role. Individual healthcare professionals can play their part by lobbying their national organisations to become effective international partners in this fight.

Letters p 1456