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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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14 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 co { o = . _ m 1.5 Oh j 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.