Public Health Policy Forum

The Globalization of Public Health, I: Threats and Opportunities

Derek Yach, MPH, MBChB, and Douglas Bettchet; MD, PhD, MSc
A wxeb of trade, investment, diplomacy, grassroots action and telecommunications is forging a global village from xNhich our sense of commitment to the other half is

strengthened.'
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The double face of globalization, one promising and the other threatening, is a fact of life as humanity is being catapulted into a more interdependent future and a new millennium. Globalization not only refers to economic processes or the development of global institutions but also describes the interconnection between "individual life" and "global futures."3 More specifically, globalization is defined as the process of increasing economic, political, and social interdependence and global integration that takes place as capital, traded goods, persons, concepts, images, ideas, and values diffuse across state boundaries.4 The roots of globalization can be traced back to the industrial revolution and the laissez-faire economic policies of the 19th century. However, the globalization of the late 20th century is assuming a magnitude and taking on pattems unprecedented in world history.6 It not only embraces the liberalization of financial markets and trade but encompasses transboundary problems such as destruction of the ozone layer. The link between the lives of individuals and the global context of development is evident in another face of globalization, an often forgotten one: global health futures are directly or indirectly associated with the transnational economic, social, and technological changes taking place in the world. As a result, the domestic and intemational spheres of public health policy are becoming more intertwined and inseparable.

Since the achievement and maintenance of the health of populations is an integral part of sustainable development, the health impacts of globilization, both positive and negative, are key policy issues. Health development in the 21st century must take advantage of the opportunities afforded by global change and, at the same time, minimize the risks and threats associated with globalization so that the dramatic improvements in the health of the world's population achieved in this century can be maintained and advanced in the next one. The main theme of this paper is that the challenges posed by globalization make collective action imperative and mutually beneficial.

The Globalization of Public Health

The health benefits to developing countries of increased trade, diffusion of appropriate technologies, and acceptance of human rights throughout the world were emphasized by Roemer and Roemer in 1990.6 According to the Roemers' analysis, cross-national exchanges have facilitated the diffusion of technological innovations such as effective methods of contraception, techniques for obtaining safe drinking water, low-cost refrigeration, efficient transport and communication technologies, and new therapeutic agents that can effectively treat leprosy, schistosomiasis, trachoma, onchocerciasis (river blindness), and many other diseases. Nevertheless, the Roemers also recognized

The authors are Nvith the VNsorld Health Organization, Geneva, Sxxitzerland. Requests for reprints should be senit to Derek Yach, WXorld Health Organization. 20 Axve Appia. Geneva 27 CH- 121 1, Swxitzerland.

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American Journal of Public Health 735

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some of the negative aspects of trade liberalization for health, such as the US threat of trade sanctions against 4 Asian countries in the 1980s if American cigarette companies were not given free access.8 The perception of the world has shifted a great deal in the few years since the Roemers' important commentary. The end of the Cold War and of a world characterized by 2 competing social/political systems has unleashed massive global changes. With these changes, our health development paradigm-in other words, our road map for seeing the world-must also shift. This transformed world is characterized by increased competition for market share, liberalization of trade and finance, and global communications. In the health sector, for example, the liberalization of health services under the provisions of the General Agreement on Trade in Services has the potential to blur the boundaries between national and "globalized" health sectors. (The General Agreement on Trade in Services is the first set of multilateral rules governing fair and nondiscriminatory trade in services. It was one of the major components of the Uruguay Round package.) Transformations such as these are generating "powerful transnational dynamics" and suggest that we are on the verge of a "global health village" in which some health problems primarily concern particular countries, while others are of common concern.9 Moreover, national health systems are becoming transnationalized: the ease and rapidity of communications have facilitated the diffusion of ideas, ideologies, and policy concerns relating to health care (as well as diseases), thereby fostering a global culture of reform.10 The domain of globalization includes many interconnected phenomena and risks that affect the sustainability of health systems and the well-being of the populations of both developing and industrialized countries. Although not intended to be a complete list, the transnationalization of health risks and disease is depicted in Table 1. (Refer to a recent article by John Last" that evaluates the quality of evidence for various health-related features of global

affordable to developing countries, the potential benefits are extensive: the uses of modern information technology in health include telemedicine, interactive health networks, communication services between health workers, human resource development and continuing education, and distance learning.'2 However, making these technologies available in the poorest communities of the world may require special government incentives, including incentives that could be at odds with nonns governing liberalization of trade and removal of special subsidies.'3 Adoption of proactive policies that protect essential health system functions from downsizing and privatization would ensure that core components of national health systems are protected as a matter of public safety. Another positive intervention would involve the global media, which could play a major role in health promotion in terms of preventing a portion of the estimated 10 million deaths per year (70% in developing countries) that are expected to occur from smoking-related diseases in year 2020.14 The global media could also help to reverse the disastrous effects that smoking-related deaths will have on the health and economies of both developing and industrialized countries.

policies will need to be reexamined; traditional concepts of national security based on the ability to resist armed aggression are being supplemented by notions of "shared human security."'6 For instance, the control and surveillance of communicable diseases has become a matter of preventive diplomacy.'7 In a similar vein, World Health Organization Director-General Hiroshi Nakajima notes that
foreign policies based on narrow interests of isolationism and protectionism will reduce the creative spirit of international scientific investigation. . The global [health] development strategies needed to address these complex and inter-related problems will require innovative, intersectoral interventions, involving a high degree of intemational cooperation and political will. 18

Policy Implications
The policy implications of globalization and transnational trends were one of the major themes of last year's Denver Summit of the Eight (G-8). The leaders of the major industrialized countries observed the following:
The process of globalization, a major factor underlying the growth of world prosperity in the last fifty years, is now advancing rapidly and broadly. More openness and integration across the global economy create opportunities for increased prosperity.... At the same time, globalization may create new challenges. The increasing openness and interdependence of our economies, with deep trade linkages and ever greater flows of private capital, means that problems in one country can spill over more easily to affect the rest.15

change.)
At the same time, it should not be assumed that the implications of globalization for public health are all negative. Seriously addressing the risks and negative aspects of increasing global interdependence could help to sustain the process of economic and political globalization. Many of the risks cited in Table 1 could be turned into opportunities for improving our global health future. For instance, if modem information technologies are accessible and
736 American Journal of Public Health

The G-8 summit stressed that countries must collaborate in confronting shared problems such as climate changes, environmental health issues, the spread of infectious diseases, trafficking in illicit drugs, and ethical

issues surrounding technological developments such as cloning. Unilateral efforts will not be successful. As the world becomes more interdependent, the objectives of national foreign

As part of renewing the health-for-all policy for the 21st century, the World Health Organization proposes that governments will need to work together to develop a broader base for international relations and collaborative strategies that will place greater emphasis on international health security. A draft of a new policy being developed by the organization emphasizes that addressing the threats to health security should include the health consequences of trade in commodities harmfil to health, violations of human rights, transnational disease threats, environmental degradation, migration and population growth, and inequities between and within countries.19 These shared areas of foreign policy concern must be translated into welldefined strategies. The following are needed to deal with the major transnational health issues6'19: * Global intersectoral action through transnational cooperation and partnerships, for example, between the health sector and trade/finance sectors both within countries and at the international level. * An enhanced role for international legal instruments, standard setting, and global norms. * More comprehensive forms of global vigilance, research, monitoring, and assessment. Information on health status and the global determinants of health is vital for defining future actions in a rapidly changing policy environment. * Global research programs that concentrate on developing cost-effective technologies to improve the status of the poor. * Human resource development in certain underdeveloped areas (e.g., public health law). * Ongoing comparative assessments and cross fertilization of experiences regarding health system reform. May 1998, Vol. 88, No. 5

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TABLE 1-Health and Global Change

Global Transnational Factor
Macroeconomic prescriptions Structural adjustment policies and downsizing Structural and chronic unemployment2' Trade Tobacco, alcohol, and psychoactive drugs Dumping of unsafe or ineffective pharmaceuticals Trade of contaminated foodstuffs/feed Travel More than 1 million persons crossing borders/day Migration and demographic Increased refugee populations and rapid population growth Food security Increased demand for food in rapidly growing economies, for example, countries in Asia Increase in global food trade continuing to outstrip increases in food production, and food aid continuing to decline21 Environmental degradation and unsustainable consumption patterns Resource depletion, especially access to fresh water Water and air pollution Ozone depletion and increases in ultraviolet radiation Accumulation of greenhouse gases and global warming

Consequences and Probable Impact on Health Status

Marginalization, poverty, inadequate decreased social safety netsa Higher morbidity and mortality ratesb

Increased marketing, availability, and useb Ineffective or harmful therapyb Spread of infectious diseases across bordersb

Infectious disease transmission and export of harmful lifestyles (e.g., high-risk sexual behavior)c
Ethnic and civil conflict and environmental degradationc

Structural food shortages as less food aid is available and the poorest countries of the world are unable to pay hard currency" Food shortages in marginalized areas of the world; increased migration and civil unrest a Global and local environmental health impact" Epidemics and potential violence within and between countries (water wars) Introduction of toxins into human food chain and respiratory disorders Immunosuppression, skin cancers, and cataracts22 Major shifts in infectious disease patterns and vector distribution (e.g., malaria), death from heat waves, increased trauma due to floods and storms, and worsening food shortages and malnutrition in many regions of the world22
Benefits of new technologies developed in the global market are unaffordable to the poorc
Active promotion of health-damaging practices"b Threat to multilateralism and global cooperation required to address shared transnational health concernsc

Technology Patent protection of new technologies under the traderelated aspects of intellectual property rights agreement Communications and media Global marketing of harmful commodities such as tobacco Foreign policies based on national self-interest, xenophobia, and protectionism

aPossible short-term problem that could reverse in time. bLong-term negative impact. cGreat uncertainty.

In conclusion, national health systems are increasingly being influenced by global factors that transcend state borders. These trends call for cross-national comparisons of health systems; this will allow for the sharing of infonnation and the development of a transnational research agenda. Moreover, the globalization of public health will act as a strong impetus for global actions to address these areas of shared concern. L]

ment Agency, Canadian Public Health Association, and Health Canada) for their support of the International Meeting on Intersectoral Action for Health (April 1997), which served as a forum for discussing the general conceptual framework ofthis paper.

References
1. Speth JG. Europe provides a guide to shrinking the world's rich-poor gap. International Herald Tribune. February 3, 1997:6. 2. Corea G. Globalization-the opportunities and dangers for Sri Lanka. Daily News (Colombo, Sri Lanka). December 11, 1996:8. 3. Giddens A. Anthony Giddens on globalization. UNRISD News. 1997;15 :4-5. 4. Hurrell A, Woods N. Globalization and inequality. Millennium J Int Stud. 1995;24(3): 447-470. 5. Ruggie R. At home abroad, abroad at homeinternational liberalization and domestic stability in the new world economy. Millennium JInt Stud. 1995;24(3):507-526.

Acknowledgments
We wish to thank Dr F. S. Antezana, Deputy Director-General AI, World Health Organization, for his intellectual input and support of this work; Milton I. Roemer and Ruth Roemer for their comments on an earlier version of this paper; the Rockefeller Foundation for hosting a meeting in Bellagio (March 1997) at which an earlier version was presented; and the Canadian donors (Canadian International Develop-

6. Bettcher D. Think and Act Globally and Intersectorally to Protect National Health. Geneva, Switzerland: World Health Organization; 1997. WHO document PPE/PAC/97.2. 7. Bonvin J. Globalization and linkages: challenges for development policy. Development. 1997;20(2):39-42. 8. Roemer M, Roemer R. Global health, national development, and the role of government. Am JPublic Health. 1990;80:1 188-1192. 9. Chen L, Bell D, Bates L. World health and institutional change. In: Pocantico Retreat, Enhancing the Performance of International Health Institutions. New York, NY: Rockefeller Foundation; 1996:9-21. 10. Altenstetter C, Bjorkman JW. Globalized concepts and localized practice: convergence and divergence in national health policy reforms. In: Altenstetter C, Bjorkman JW, eds. Health Policy Reform, National Variations and Globalization. London, England: Macmillan; 1997:1-16.

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11. Last JM. Human health in a changing world. In: Public Health and Human Ecology. 2nd ed. Stamford, Conn: Appleton & Lange; 1998: 395-425. 12. Health Informatics and Telemedicine. Geneva, Switzerland: World Health Organization; 1997. WHO document EB99/INF.DOC./9. 13. Adams 0. International Trade in Health Services: Some Key Issues. Geneva, Switzerland: World Health Organization; 1997. 14. Tobacco Alert: The Tobacco Epidemic, a Global Public Health Emergency. Geneva, Switzerland: World Health Organization; 1996.
15. Final Communique of the Denver Summit of the Eight. Denver, Colo: Group of Eight Countries; 1997. 16. Alleyne G. Health and national security. Bull Pan Am Health Organ. 1996;30:158-163. 17. O'Brien E. The diplomatic implications of emerging diseases. In: Cahill KM, ed. Preventive Diplomacy. New York, NY: Basic Books; 1996:244-268. 18. Nakajima H. Global health threats and foreign policy. Brown J WorldAff 1997;IV:319-332. 19. Health for All in the 21st Century. Geneva, Switzerland: World Health Organization; 1998. WHO document EB101/8. 20. Martikainen P, Valkonen T. Excess mortality of unemployed men and women during a period of increasing unemployment. Lancet. 1996;348:909-912. 21. Food Security Assessment. Rome, Italy: Food and Agricultural Organization; 1996. FAO document WFS 96/TECH/7. 22. McMichael AJ, Haines A, Sloof R, Kovats S, eds. Climate Change and Human Health-An Assessment Prepared by a Task Group on Behalf ofthe WHO, WMO, and UNEP. Geneva, Switzerland: World Health Organization; 1996.

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The Globalization of Public Health, II: The Convergence of Self-Interest and Altruism
Derek Yach, MPH, MBChB, and Douglas Bettcher, MD, PhD, MSc

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Introduction
The globalization of public health means that global awareness, analysis, and action must be improved in the coming century. It also means that charting a different course of development for the coming century is an ethical imperative, for this and future generations. Addressing future health challenges will require coordinated responses at many levels: individual, family, community, national, and global.' The development of transnational actions will need to be supported by a strengthened educational and research capacity extending to schools of public health, health sciences faculties, and research bodies. At the global level, influential nations such as the United States should use their strengths to build partnerships for health for the 21st century in key areas of global concem. This will require that countries and communities go beyond narrow self-interests in order to address the problems and take advantage of the opportunities of globalization. Although national action remains vital, transnational action needs to complement "domestic" initiatives. However, this will not happen if states cloak themselves in policies that attempt to insulate and shield them from transnational threats.

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ease") to cattle herds in many European countries in exported feedstuffs and the risk that this agent may pass through the food chain to humans provide an important lesson of what may happen when international vigilance, cooperation, and action fail. When international vigilance and action break down, as in the case of BSE, governments may find themselves in a de facto quarantine.2 Moreover, the BSE experience demonstrates that in an interdependent world, international strategies are needed for promoting health. The following analysis maps out a global strategy for avoiding such unfortunate errors. Awareness
There is a need for all health professionals and the general public to receive information regularly about the health consequences (both positive and negative) of globalization in order to promote awareness of the transnational dimensions of health. This information should be based on sound empirical analysis. Particular attention needs to be given to understanding the consequences of national policies and actions for health in "far-off' lands. Koop's3 statement concerning the United States' use of Section 301 of the 1974 trade act provides a good example of such action at a distance:
The authors are with the World Health Organization, Geneva, Switzerland. Requests for reprints should be sent to Derek Yach, World Health Organization, 20 Ave Appia, Geneva 27 CH- 121 1, Switzerland.

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The Needfor Global Awareness, Analysis, and Action

The spread of bovine spongiform encephalopathy (BSE, or "mad cow dis-

May 1998, Vol. 88, No. 5