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G LO B A L H E A LT H
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RU T H M AC K L I N
HEALTH is a primary good for individuals. ‘Primary goods’ are things that every rational person would want because they are needed to carry out a personal life plan (Rawls 1971). Since populations are the sum of individuals in a country, it follows that health is also a primary good for populations. Public health is a public good, and in today’s world public health is global health. If governments have any obligations that go beyond their national boundaries, they have obligations to promote global public health. An assumption of this chapter is that governments do have obligations that go beyond their own borders, and, consequently, they have obligations to help prevent the spread of disease, to provide financial or technical assistance to countries too poor to afford medical care and treatment for their own populations, and to adopt policies that preserve and promote health throughout the world.
But what is the source of obligations to protect and promote public health throughout the world? Is it a global obligation of beneficence, to maximize health benefits and minimize harms to health wherever those benefits and harms may exist? Is it an obligation based on a principle of justice that calls for helping the least advantaged populations, those too impoverished or lacking the knowledge or technical capacity to help themselves? Is it simply a matter of enlightened self-interest, an obligation to the population in one’s own country to ensure that the developing world is not a reservoir for deadly infectious diseases or instability stemming from the devastating effects of ill health in large numbers of the population? Do obligations flow from human rights as specified in such
This chapter includes excerpts from my book Double Standards in Medical Research in Developing Countries (Cambridge: Cambridge University Press, 2004).
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documents as the Declaration of Human Rights, the International Covenant on Economic, Cultural, and Social Rights, and customary international law?
In addressing these questions, this chapter deals with four topics in global health: (1) the accelerating rate of spread of communicable diseases throughout the globe; (2) the inequities among industrialized and developing countries in their populations’ access to medical treatments; (3) the role of the World Trade Organization (WTO) and industrialized countries in maintaining barriers to poor countries’ access to drugs; and (4) the relation between global health and human rights. What ties these topics together is the phenomenon of globalization in the broadest sense of that term.
Intercontinental transportation makes it possible for microbes as well as airline passengers to travel farther and more quickly than at any time in history. Tuberculosis and HIV/AIDS affect populations on every continent, but only a small minority of the world’s population has access to effective treatments for these and other diseases. The vast increase in growth and power of transnational companies continues to produce increasingly worrisome environmental consequences, as well as occupational health hazards that affect populations in poor countries. Most such countries have neither the means (or desire) to resist giant industries nor the regulatory structure to protect the health of their own populations. The major multinational pharmaceutical companies, bolstered by the wealthy countries in which they are based, have successfully resisted weakening of patent protections in order that their profits remain as high as possible.
This chapter focuses on access of people in developing countries to medications and medical services that are readily available to inhabitants of industrialized countries. There are, of course, other critical dimensions of public health that require action on a global scale. These include relief for large numbers of people who are starving or living at nearly subsistence levels; provision of a supply of clean, potable water for populations deprived of that essential resource; and the consequences for local agricultural production in countries in which globalization has led to deforestation of vast portions of the land. The focus here on access to health services and needed medications is not intended to minimize the importance of these other areas of global health.
WHAT IS GLOBALIZAT ION?
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Whatever globalization is, it has its strong proponents and opponents. Most people associate globalization with economics, world trade, and especially the establishment by huge international corporations of outposts in developing countries where labor in factories and agriculture is cheap. The fierce opposition to globalization is never
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more apparent than at the annual meetings of the WTO, where protesters gather to disrupt the travel of delegates as well as the proceedings of the meetings.
According to one definition, ‘globalization’ means ‘openness to trade, to ideas, to investment, to people, and to culture’ (Feachem 2001). This definition, with its positive connotation, seems overly broad. If that is all it means, it is hard to see why the phenomenon would give rise to such fierce opposition. Besides, it implies that globalization is nothing new; it has been around for a long time. A somewhat narrower definition takes globalization to be ‘the trend of growing economic integration among nations’ (Ricupero 2001: 3). Yet even that narrower definition does not describe anything new or, in the view of one commentator, particularly radical: ‘Historians have traced its origins as far back as the great sea voyages of Renaissance Europe, and a small academic industry has been built around comparisons of the process of global economic integration today and in the decades before the First World War’ (Ricupero 2001: 3).
Still another account, similar but taking the meaning beyond economic integration — ‘the increasing interconnectedness of people and nations through economic integration, communication and cultural diffusion’ — also claims it is nothing new (Labonte 2003: 1). Noting that ‘the history of most humankind has been one of pushing against borders, expanding, conquering, and assimilating’, this account proceeds to specify a series of health risks that arise as a result of today’s version of globalization. These include the harms resulting from resource depletion and pollution, increased transportation-based fossil-fuel emissions, and decreasing amounts of safe water, among others.
A comprehensive definition that is perhaps the most authoritative is provided by Joseph Stiglitz, winner of the 2001 Nobel Prize for Economics: ‘Fundamentally, it is the closer integration of the countries and peoples of the world which has been brought about by the enormous reduction of costs of transportation and communication, and the breaking down of artificial barriers to the flow of goods, services, capital, knowledge, and (to a lesser extent) people across borders’ (Stiglitz 2002: 9). Stiglitz argues that globalization has had global impacts, and to deal with those, global collective action is required. He cites global environmental issues as an example of such needed action, and the spread of diseases like AIDS, which respect no boundaries, as another. Stiglitz emphasizes the importance of ‘global public goods’ as values that transcend a country’s own national interests. This contrasts starkly with the view expressed by George W. Bush: ‘We will not do anything that harms our economy, because first things first are the people who live in America’ (Singer 2002: 1 – 2).
In his book on the ethics of globalization, Peter Singer provides a more nuanced meaning of the term: ‘implicit in the term ‘‘globalization’’ rather than the older ‘‘internationalization’’ is the idea that we are moving beyond the era of growing ties between nations and are beginning to contemplate something beyond the existing conception of the nation-state’ (Singer 2002: 8). Whatever that ‘something’ is, it has
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implications for how nation-states do — and perhaps should — interact with one another. It raises the question whether, in a globalized world, nations have moral obligations that go beyond their own economic self-interest.
Factors other than the growth in power and wealth of transnational companies are at play in globalization. The role of the World Bank and the International Monetary Fund (IMF) in imposing a variety of economic reforms in developing countries has been a significant factor only indirectly related to world trade, if at all. The Bank and the IMF have required various forms of privatization and imposed ‘structural adjustment’ policies on poor countries as conditions of lessening or forgiving debts those countries are unable to repay. Stiglitz identifies the World Bank, the IMF, and the WTO as the main institutions that govern globalization.
Is globalization good or bad for human health? There are evidence and arguments on both sides of this debate. One view takes the unequivocal position that globalization is good for health:
The evidence that openness to trade and investment is good for economic growth is compelling and goes back several centuries. . . . Because gross national product per capita correlates so strongly with national health status, we can conclude that, in general, openness to trade improves national health status.
And further:
Globalisation, economic growth, and improvements in health go hand in hand. Economic growth is good for the incomes of the poor, and what is good for the incomes of the poor is good for the health of the poor. Globalisation is a key component of economic growth. (Feachem 2001)
The author of these remarks was the Director of Health, Nutrition, and Population at the World Bank from 1995 to April 1999. Given the role of the Bank in fostering globalization, this statement may be viewed as antecedently biased in its favorable assessment of the consequences.
While not denying that globalisation has had some positive influence on the health of poor people in developing countries, another commentator nevertheless provides evidence for the view that globalization can be bad for health. Globalization’s negative impacts produce health risks in at least the following areas:
•Poverty and inequality — poverty being the single greatest determinant of disease.
•The environment — the disease perils of over-consumption, pollution and climate change are well known.
•The capacities of national governments — binding trade rules and multi-lateral institutions like the World Trade Organization . . . undercut institutions that support public health and social well-being.
(Labonte 2003: 1)
The promotion by the United States of a market model for delivery of health care has had negative consequences for developing countries that formerly had more
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robust public health systems. One article notes that ‘a policy that promotes ‘‘market models’’ for the delivery of health care in less developed countries is an example of political, administrative globalisation rather than the global reach of for-profit health-care companies’ (Pappas et al. 2003: 100). The increasing privatization of health in middle-income developing countries, such as Argentina and Brazil, has led to increasing costs for poorer segments of the population, as well as a wider gap in the quality of health care between the public and private sectors. In addition, there is evidence that the global economic policies of the World Bank, the WTO, and the IMF have contributed to chronic and severe malnutrition in many developing countries (Pappas et al. 2003).
An intermediate view is that globalization is a mixed blessing from a public health perspective. On the positive side are economic growth and technological advances that have improved the health status of populations in developing countries. On the negative side is the accelerated rate at which a decline in public health and the spread of disease can occur in those same countries. Among the public health consequences of globalization is the role of multinational tobacco companies, which are mostly based in the United States, the United Kingdom, and Japan. The tobacco industry has focused marketing campaigns on developing countries, chiefly in Asia and Africa. The World Health Organization (WHO) estimates that by about 2020 deaths due to tobacco will reach 10 million and 70 per cent of these deaths will be in developing countries (Ram 2001). This is occurring at the same time that antismoking campaigns and restrictive anti-smoking laws have resulted in a decline in the number of smokers in the United States and some other industrialized countries. In recognition of the toll tobacco has increasingly taken in developing countries, Gro Harlem Brundtland, the former Director-General of WHO, launched a major anti-tobacco initiative during her tenure at the organization.
WHO is the leading public health organization seeking to improve conditions in developing countries through both disease prevention and treatment programs. Stiglitz (2002) notes that globalization has led to renewed attention to this and other long-established intergovernmental organizations, which have generally been a force for good in the world. In this connection one could also add international nongovernmental agencies that do humanitarian work related to diseases and disasters, such as the International Red Cross and Medecins´ sans Frontieres` (MSF).
GLO BAL SPREAD OF COMMUN ICABLE
DISEASES
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Several factors contribute to the current situation in which diseases that emerge in one part of the world spread — slowly or rapidly, but almost inevitably — to all parts
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of the globe. The best single example of that today is HIV/AIDS, which is believed to have begun in Africa when a simian (chimpanzee) strain of the virus jumped to humans. In a matter of years, a communicable disease that took root in Africa and spread with increasing rapidity in several countries on that continent came to affect millions of people throughout the world. By the end of 2003, an estimated 40 million people were living with HIV/AIDS and more than 3 million died in that year alone.
Early in the epidemic, epidemiologists confirmed the role of international travel as contributing to the speed with which the AIDS virus spread when they tracked down a single individual who became known as ‘patient zero’. This individual was a Canadian flight attendant whose occupation called for worldwide travel. Researchers who analyzed a number of early cases of HIV/AIDS found that the Canadian flight attendant was either directly or indirectly involved in sexual contacts that spread the infection to these other persons.
It is not only HIV/AIDS, but also other communicable diseases that can spread rapidly by similar means. According to one report:
Infectious diseases are a global hazard that puts every nation and every person at risk. The recent SARS outbreak is a prime example. Knowing neither geographic nor political borders, often arriving silently and lethally, microbial pathogens constitute a grave threat to the health of humans. Indeed, a majority of countries recently identified the spread of infectious disease as the greatest global problem they confront. (Institute of Medicine 2003)
However, HIV/AIDS, SARS (Severe Acute Respiratory Syndrome), avian influenza, and other current examples are not the first known instance of worldwide spread of diseases. One third of the population of Europe died in the Black Death epidemic of 1347, which was a direct result of international trade. When European explorers and colonial powers went to the Americas from about 1500 and through the next two centuries, they brought smallpox and other infectious diseases that decimated entire native populations. The influenza pandemic of 1918 – 19 killed between 40 and 50 million people in a single winter, and this was before the scale of modern transportation in today’s world. With the constant movement of immigrants, refugees, military personnel, and travelers for business and tourism, the prospect of rapid global spread of diseases is greatly enhanced.
Among the recent examples is West Nile virus, which experts say is unlikely to be eradicated now it has reached the shores of North America, but at best can only be contained by vigilance and other methods. In the first three years after the virus first appeared in New York City, it spread to thirty-nine states in the United States, infecting thousands of people and killing several hundred (Institute of Medicine 2003). Avian influenza, or bird flu, is at the time of writing still confined to transmission from chickens and birds to humans in several countries in Asia. But public health and infectious disease experts are worried that if people become infected with both bird flu and other forms of influenza that people pass on to other