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2
·
The Globalization of Health:
Common Problems, Common Needs
The health needs of diverse countries are converging as the factors that affect
health increasingly transcend national borders. Among those factors are the
globalization of the economy, demographic change, and the rapidly rising costs
of health care in all countries. In a world where nations and economies are
increasingly interdependent, ill health in any population affects all peoples, rich
and poor. As global needs change, the responses of the international health
agencies are also being critically reexamined a process that will in turn have
consequences for health policies worldwide.
This chapter shows that the world's nations the United States included-
now have too much in common to consider health as merely a national issue.
Instead, a new concept of"global health" is required to deal with health
problems that transcend national boundaries, that may be influenced by
circumstances or experiences in other countries, and that are best addressed by
cooperative actions and solutions. The chapter sets the scene by discussing some
key problems and showing how they are bringing nations' health needs closer
together.
ECONOMIC GLOBALIZATION AND TlIE TRANSFER OF RISKS
The liberalization of international trade has greatly increased the exchange
of goods and people across borders. This increased movement of people and
goods, occurring in a context of growing political instability, means that risks are
being transferred too: for example, opportunities for the transmission of
emerging and resurging infectious diseases have increased, and more people than
ever before are exposed to substances from other countries that potentially affect
their health, from food to tobacco and from weapons to banned drugs
There are at least four routes for the international transfer or acquisition of
health risks: (1) the movement of people; (2) the international exchange of both
legal and illegal potentially toxic products and contaminated foodstuffs; (3) the
variance in environmental and occupational health and safety standards; and (4) the
indiscriminate spread of medical technologies.
Since 1990, the number of refugees and persons displaced within their own
countries by war, environmental crisis, or economic collapse has increased by over
60 percent, from approximately 30 million to 48 million (Toole, 19959. A reported
11
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12
AMERICA 'S VITAL INTERESTIN GLOBAL HEALTH
1 million people travel between the developing and the industrial worlds each
week.* This increased movement contributes to the spread of infection (Finkelman,
1992; Garrett, 19969.
More people than ever before are exposed to substances
from other countries that potentially affect their health,
from food to tobacco and from weapons to banned drugs.
Even though the majority of people affected by infectious diseases are in the
developing world, all nations, even the richest, are susceptible to the scourges of
infection. In the past two decades dozens of new diseases or new forms of old
diseases have been identified (see Table 2-1 for some examples). HIV, estimated to
infect some 23 million people worldwide (WHO, 1996c), is by far the most
important of the new infections, both globally and in the United States. Older
diseases including tuberculosis, dengue, malaria, and cholera-that had been
partially controlled are resurging, considerably increasing the burden of disease,
and exacerbated in some cases by the spread of drug-resistant strains. The
emergence and reemergence of infectious diseases in the United States and abroad
pose serious challenges to our detection and surveillance systems.
As people travel and international trade and telecommunications increase,
toxic products, both legal and illegal, reach wider markets. Tobacco and alcohol
use are promoted by worldwide marketing campaigns, which frequently originate
in the United States. Every minute, 6 people die from smoking-related diseases.
Annual tobacco-related deaths currently exceed 2 million and are projected to
approach 10 million by the year 2025, the majority of them in developing regions
(Bosanquet and Trigg, 1993~. Alcohol, meanwhile, is now estimated to be the
fourth most important cause of disability worldwide (Murray and Lopez, 1996~.
The use of baImed drugs has also increased in recent decades.
The variance between the developed and the developing worlds in
environmental and occupational health arid safety standards, as well as standards
for such items as foods, drugs, vaccines, and medical devices, creates serious heals
risks for everyone. The variance encourages multinational corporations to site their
hazardous production facilities in developing nations that lack or do not enforce
strict regulations. In this way, corporations avoid the stringent environmental and
occupational regulations of the developed world. This practice places the
*Developing country: this designation includes all countries that are not classified as
industrial. The developing countries can further be divided into subgroups such as the
poorest developing countries (46 nations) and the heavily indebted poor countries (15
countries). Developed countries: a classification that has evolved over time to include 23
countries: Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany,
Greece, Iceland, Italy, Japan, Luxembourg, the Netherlands, New Zealand, Norway,
Portugal, Spain, Sweden, Switzerland, the United Kingdom, and the United States.
Industrial country: one of the developed countries. The newly industrializing Asian
economies (Hong Kong; Korea; Singapore; and Taiwan, China) are still designated as
developing economies.
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THE GLOBALIZATION OF HEALTH
13
developing nations at risk of becoming dumping grounds for hazardous
manufacturing plants, and it puts manufacturers who do comply with environmental
and occupational health and safety standards at a competitive disadvantage.
Nonuniform standards and enforcement ultimately threaten to degrade
environmental and occupational health in all countries (McGuinness, 1994~.
Although many health technologies are highly beneficial, some create adverse
health effects and require unnecessary financial expenditures (IOM, 1992b). Yet
the regulation of imported technology at the national level is usually fragmented,
ineffective, and focused primarily on pharmaceutical products. There have been
efforts over the years either to develop common international standards for the
regulation of health technologies or to bring the various national standards into
closer alignment, both in the pharmaceuticals industry and in medical devices
and technologies.
DEMOGRAPHIC CHANGE AND THE EPIDEMIOLOGIC TRANSITION
While the globalization of the economy and the transfer of risks have made all
nations more vulnerable to infection and other cross-border hazards, another trend
is causing a different-and in some ways, more profound kind of convergence in
the health needs of populations. This is the global demographic transition, marked
by declining fertility and the aging of populations. As populations age, the relative
burdens of health problems that predominate among adults such as depression,
heart disease, and cancers-gradually increase, as the burdens of those that
predominate among children gradually decrease. While the developed regions
experienced this "health transition" earlier this century, it is now well under way in
developing countries. Within the next 25 years, therefore, it is expected that the
dominant health problems of the majority of the world's population will rapidly
come to resemble those of the industrialized nations today.
Heart disease and depression are set to become the hNO
most important causes of disease burden worldwide by
2020.
.
A recent assessment of global health trends suggested that by 2020, ischemic
heart disease is likely to replace respiratory infections as the world's leading cause
of ill health, followed by depression and road traffic accidents (see Table 2-2~.
The idea that noncommunicable diseases are linked to affluence is thus rapidly
losing credibility: the dominant diseases of Latin America or the nations of China
and India are increasingly like those ofthe United States.
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AMERICA 'S VITAL INTERESTIN GLOBAL HEALTH
TABLE 2-1 Examples of Pathogenic Microbes and the Diseases They Cause,
Identified in the Past 25 Years
Microbe Type Disease Caused
1973 Rotavirus Virus Infantile diarrhea
1977 Ebola virus Virus Acute hemorrhagic fever
1977 Legionella pneumophila Bacterium Legionnaires' disease
1980 Humar~ T-lymphotropic Virus T-cell lymphoma/leukemia
virus I (HTLV 1)
1981 Toxin-producing Bacterium Toxic shock syndrome
Staphylococcus aureus (tampon use)
1982 Escherichia cold 0157:H7 Bacterium Hemorrhagic colitis; hemolytic
uremic syndrome
1982 Borrelia burgdorferi Bacterium Lyme disease
1983 Human immunodeficiency Virus Acquired immunodef~ciency
virus (HIV) syndrome (AIDS)
1983 Helicobacter pylori Bacterium Peptic ulcer disease
1989 Hepatitis C Virus Parenterally transmitted non-A'
non-B liver infection
1992
Vibrio cholerae 0139
Hantavirus
Bacterium
1994 CIypotospiridium Protozoa
1995 Ehrlichiosis Bacterium
New strain associated with
epidemic cholera
Adult respiratory distress
syndrome
Enteric disease
Severe arthritis?
SOURCE: Adapted from CISET, 1995.
Adults in developing regions are already suffering a heavy burden of
noncommunicable diseases, even though this has traditionally been overlooked.
In the developing regions as a whole, almost one-tenth of the total burden of
disease is contributed by mental health problems such as depression,
schizophrenia, epilepsy, and suicide. Alcohol-related problems are estimated to
affect between 5 and 10 percent of the world's population. Alcohol and illicit
substances tend to be associated with increased violence, itself a major cause of
death and disability.
Developing nations are struggling to meet the challenges that these diseases
pose for their health systems, even as they continue to grapple with an unfinished
agenda of deadly infections, malnutrition, and poor reproductive health (Frenk et
al., 1989; IOM, 1996b; World Bank, 1993; WHO, 1996b). The added burden on
their already stretched health systems is likely to create further strains on their
economies, with possible consequences for their growth and for international trade.
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THE GLOBALIZATION OF HEALTH
TABLE 2-2 Projected Change in the Rank Order of Disease Burden for
15 Leading Causes, Worldwide 1990-2020
1990 Rank
Disease or injury Order
15
2020
Disease or injury
Lower respirator infections 1
Diarrheal diseases 2
Conditions arising during perinatal 3
period
Unipolar major depression
Ischemic heart disease
Cerebrovascular disease
Tuberculosis
Measles
Road traffic accidents
Congenital anomalies
Malaria
Chronic obstructive pulmonary
disease
Falls
Iron-deficiency anemia
Protein-energy malnutrition
Ischemic heart disease
Unipolar major depression
Road traffic accidents
Cerebrovascular disease
Chronic obstructive pulmonary
disease
Lower respiratory infections
Tuberculosis
War
Diarrheal diseases
HIV
Conditions arising during perinatal
period
Violence
13 Congenital anomalies
14 Self-inflicted injuries
15 Cancers of trachea, lung, and
bronchus
NOTE: Disease burden is measured in disability-adjusted life years (DALYs), a measure
that combines the impact on health of years lost due to premature death and years lived with
a disability. One DALY is equivalent to one lost year of healthy life.
12
SOURCE: Murray arid Lopez, 1996.
POVERTY AND HEALTH
Poverty has been shown to be of overwhelming importance as both a direct
and an indirect cause of poor health, and, in turn, ill health makes people poor.
Studies have shown, for example, that the cost of an average case of malaria in
Sub-Saharan Africa is equivalent to about 12 days of productive output; the total
cost of malaria in 1995 for the region was estimated at 1 percent of gross domestic
product (WHO, 1996b). Increasingly in a global economy, one region's poverty is
another region's loss. The United States is the poorer for the poverty of the rest of
the world.
More than one-fifth ofthe world's population lives in extreme poverty. Almost
a third of all children are undernourished, and up to 2.5 billion people lack regular
access to essential drugs (UNDP, 1991~. In addition, the gap between rich and poor
is increasing. In 1960, the income of the richest 20 percent of the world's
population was 30 times greater than that of the poorest 20 percent; by the early
l990s it was more than 60 times greater (WHO, 1994~.
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16
AMERICA 'S VITAL INTE=STIN GLOBAL HEALTH
Despite unprecedented progress in world health this century, and an increase
in life expectancy of more than 25 years in most countries, the world's poorest
people still suffer a heavy burden of largely avoidable disease and death. Much of
this can be blamed on poverty. Infant mortality rates in the developing countries,
though falling, are still on average almost 10 times greater than in the industrialized
countries (WHO, 1996b). And, every year, 7 million adults around the world die of
conditions that could be inexpensively prevented or cured; tuberculosis alone
causes 2 million ofthese deaths (WHO, 1996a).
Women in the poorest countries and communities continue to suffer the health
consequences of poor reproductive health and a lack of access to methods for
limiting and spacing their families. International survey data demonstrate that
between 100 and 200 million women who would like to space or limit
childbearing are not using modern contraceptives (IOM, 1996d). In developing
regions, 500 women die as a result of pregnancy and childbirth for every
100,000 births, compared with just 7 maternal deaths for every 100,000 births in
the rich countries. Some 50 million or more pregnancies end in abortion, and
about 20 million of these procedures are carried out illegally and unsafely.
Poverty is also a cause off rapid population growth and environmental
degradation, phenomena that in themselves create new risks to health. By the year
2000, world population will reach about 6.2 billion. Poverty forces many millions
of urban dwellers to live in overcrowded and unhygienic conditions, where lack of
clean water and sanitation provide breeding grounds for emerging and resurgent
infectious diseases. The threat of these diseases is not self-contained. As Linden
(1996) notes, "The health of cities in the developed world depends in some
measure on developing nations' efforts to control new diseases and drug-resistant
strains of old ones incubating in their slums. The developed world ignores at its
peril the problems of Third World cities."
RISING COSTS OF HEALTH CARE AND THE NEED FOR
HEALTH SYSTEM REFORM
In 1990, public and private expenditures on health care worldwide reached
$1,700 billion, or 8 percent of world economic output (World Bank, 1993). The
costs of increasingly complex services continue to rise in all countries.
Nevertheless, large proportions of the world's population have limited or
inadequate access to effective and affordable health services. The United States is
no stranger to the problems of financing equitable and efficient health care.
In 1990, public and private expenditures on health care
worldwide reached $1,700 billion, or 8 percent of world
economic output.
-
Most countries around the world are curreIltly attempting to reform their health
systems. The reforms tend to have common aims, including (a) separating the basic
functions of the health system regulation, financing, and delivery-to establish
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THE GLOBALIZATION OF HEALTH
17
incentives that will promote competition, efficiency, and quality of care; (b)
assuring universal access to essential health services; (c) establishing permanent
mechanisms to evaluate the cost and effectiveness of new health interventions; (d)
developing programs that guarantee the continuous monitoring of health care
quality; (e) creating mechanisms that encourage the rational use of health
technologies; and (f) promoting public participation in the development and
implementation of health care policy (Frenk, 1995; Frenk and Gomez-Dantes,
1995~. Surprisingly, despite the common aims of reform, there is relatively little
exchange of information and experience among countries.
CHANGES IN INTERNATIONAL HEALTH AGENCIES
As global health needs and opportunities change, the international health
agencies and in particular those of the UN system are being forced to review
their roles to identify how they can best respond within their resource constraints.
Since global health policy is likely to be strongly influenced by the shape these
organizations take in the future, all countries have a direct interest in their
development.
The international health institutions include the UN agencies, programs, and
funds; the development banks; and the multilateral development agencies. Another
important group is represented by the development assistance agencies of
developed countries. Among the notable nonprofit private organizations
participating in the world health system are international foundations, professional
bodies, health and medical assistance groups, and consulting agencies. The private
sector the producers of both medical products and health services is also a key
player.
The lead UN agency in health is the World Health Organization (WHO),
which was created in 1948 with the objective of guaranteeing "the attainment by
all people of the highest possible level of health" (WHO, 1992~. The
international health agencies have developed a unique set of human resources,
organizational abilities, and knowledge that has enabled them to reach such
ambitious goals as the eradication of smallpox and the near-eradication of polio.
Over the years, however, the world health system has grown in capacity, in the
number of participants in the field of international health, and in the complexity
of programs (Frenk, 19959. In particular, the World Bank has taken and
increasingly influential role (see Figure 2-19.
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18
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m 1.5
Oh
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3.0
2.5
2.0
1.0
0.5
o
AMERICA 'S VITAL INTERESTIN GLOBAL HEALTH
World Bank Loans for Health
~-
~ ~0-- }-~-~-'[~!
_~-{t
~-~
WHO Total Budget
1 1 1 1 1 1 1 1
1984 1986 1988 1990 1992
Year
1994 1996 1998
FIGURE 2-1 The growing role of the World Bank in health. SOURCE: Adapted from
Brown, 1997.
Representative terms from entire chapter:
international health
