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Interrogating globalization, health and development: Towards a comprehensive framework for research, policy and political action

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Critical Public Health
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Health researchers recognize the need to better understand the ways in which contemporary globalization can lead to improved health for all, especially for the poor. This requires expanding the global health research agenda beyond a disease-specific focus to one that also examines the social, environmental and economic contexts that partly determine the incidence and persistence of many diseases, and to understand how these contexts shape health opportunities and behaviours at different levels. Organizing extant findings for policy purposes and to generate new studies capable of embodying such complexity is rendered more feasible if guided by reasonably comprehensive frameworks identifying the differing levels and pathways by which globalization phenomena can influence health. This article presents such a framework, illustrating it with evidence of health effects of globalization presently known though often disputed. Its value lies in its ability to shape future research allowing detailed and rigorous study of certain of the relationships it maps to be located within a broader research-informed policy context.
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Interrogating globalization, health and development:
Towards a comprehensive framework for research,
policy and political action
RONALD LABONTE
1
& RENEE TORGERSON
2
1
University of Ottawa, Canada and
2
University of Saskatchewan, Canada
Abstract
Health researchers recognize the need to better understand the ways in which contemporary globali-
zation can lead to improved health for all, especially for the poor. This requires expanding the
global health research agenda beyond a disease-specific focus to one that also examines the social,
environmental and economic contexts that partly determine the incidence and persistence of many
diseases, and to understand how these contexts shape health opportunities and behaviours at different
levels. Organizing extant findings for policy purposes and to generate new studies capable of embody-
ing such complexity is rendered more feasible if guided by reasonably comprehensive frameworks
identifying the differing levels and pathways by which globalization phenomena can influence
health. This article presents such a framework, illustrating it with evidence of health effects of
globalization presently known though often disputed. Its value lies in its ability to shape future
research allowing detailed and rigorous study of certain of the relationships it maps to be located
within a broader research-informed policy context.
Introduction
Although globalization is not new, interest in its potential health impacts is relatively recent.
Understanding how globalization affects health is not easy; the concept itself is multifa-
ceted, and the breadth and depth of the pathways by which it influences health almost
defies study of causal relations. Any explanation for how globalization affects health
(for better or for worse) becomes an evidence-based argument, in which evidence
necessarily derives from multiple studies examining differing aspects of globalization
(what this article calls ‘processes’ or ‘drivers’) for their impact on theoretical or empirically
established causal chains. The evidence is built up link by link; the problematic becomes
one of organizing the evidence into a coherent story.
Correspondence: Professor Ron Labonte, Canada Research Chair, Globalization/Health Equity,
Institute of Population Health, University of Ottawa, 1 Stewart Street, Ottawa, Ontario, Canada, K1N 6N5.
E-mail: rlabonte@uottawa.ca
ISSN 0958-1596 print/ISSN 1469-3682 online ß2005 Taylor & Francis Group Ltd
DOI: 10.1080/09581590500186117
Critical Public Health, June 2005; 15(2): 157–179
In this article we provide an analytical framework for developing such a story, and proffer
its usefulness as a heuristic for organizing both past and future research and policy studies.
We begin by defining ‘globalization’, and what the rudiments of a critical approach to its
health study imply. We then differentiate ‘global health’ from its older kin of ‘international
health’, and critique briefly the dominant neo-liberal discourse on globalization and health.
This leads us to an elaboration of our analytical framework and a presentation of some of
the extant findings of globalization’s impacts on important pathways to health. We conclude
with an instance of how the framework is being used, an example of how it might be applied,
and a commentary on how researchers can approach globalization/health study from a more
‘critical’ perspective.
Defining globalization
Globalization, at its simplest, describes a constellation of processes by which nations,
businesses and people are becoming more connected and interdependent via increased
economic integration and communication exchange, cultural diffusion (especially of
Western culture) and travel. By emphasizing processes we draw attention to the means
by which this interdependence and connectivity is occurring and how these processes are
embedded within current political and economic differentials within and between countries.
We differ from others in this respect (e.g. Lee, 2002) who consider globalization more
broadly as a function of technology, culture and economics leading to a compression of
time (everything is faster), space (geographic boundaries begin to blur) and cognition
(awareness of the world as a whole). This is undoubtedly true but, as others have
argued, ‘economic globalization has been the driving force behind the overall process of
globalization over the last two decades’ (Woodward, Drager, Beaglehole, & Lipson,
2001, p. 876). As such, and from a health vantage, the globalization processes that require
intense scrutiny are those pertaining to the economy.
Even considered in this narrower cast, globalization is not a new phenomenon; the history
of humankind—or at least of Western civilizations—has been one of continuous pushing
against borders, exploring, trading, expanding, conquering and assimilating, generally
driven by an economic pursuit of resources or wealth (Diamond, 1997). Nor is this
the first time in more recent history that capital, and capitalists, have had greater interest
in foreign markets than in those in their home jurisdictions. The period of rapidly increased
integration of global markets that began in the 1980s continues a longer historical
trajectory. The percentage of global economic output accounted for by international
trade has only recently returned to the levels characteristic of the late nineteenth and early
twentieth century (Cameron & Stein, 2000). But contemporary globalization also differs
from previous eras in significant ways, including the speed and scale of capital flows,
the existence of enforceable trade and investment liberalization agreements and the size
of transnational corporations, many of which are economically larger than most of the
world’s countries. These new global phenomena carry (some) health benefits and (many)
health risks that demand critical appraisal, an undertaking that is still in its infancy
(Drager & Beaglehole, 2001). We use ‘critical’ here in the sense described in an earlier
article in this series (Labonte, Polanyi, Muhajarine, McIntosh, & Williams, 2005), with
three key tenets: (1) health is seen as embedded in social relations of power and historically
inscribed contexts; (2) research questions to ‘unpack’ the policy- and program-relevant
aspects of health determinants are shaped by the interests of those who face the greatest
burden of disease; and (3), where applicable, research methods aim to be empowering
and health-enhancing in their own right.
158 R. Labonte & R. Torgerson
The first critical step: From international to global health
Until recently, researchers, development agencies and non-governmental organizations
(NGOs) mobilized around ‘international health’ issues: the greater burden of disease
faced by poor groups in poor countries. More critical elements, the ‘new internationalists’,
pointed to the role of powerful First World nations and corporations in undermining the
efforts of many postcolonial Third World countries to create Western-style democracies
and social policies to improve the health, education and economic well-being of their
least well-off. International health remained essentially an extension of national health,
the ‘global’ component being the rich world’s modest efforts, whether official or funnelled
through NGOs, to aid in the development of countries lagging behind, or a critique of their
role in creating the lag in the first place.
Four world events changed the landscapes of these international relations irrevocably.
The first was the 1970s recession in the industrialized world, compounded by the
‘oil crisis’ and domestic monetary policies that dramatically increased interest rates.
These events led many developing countries to default on international loans, and reshaped
the International Monetary Fund (IMF) and World Bank into ‘watchdog[s] for developing
countries, to keep them on a policy track that would help them repay most of their
debts and to open their markets for international investors’ (Junne, 2001, p. 206). The
policy track of ‘structural adjustment’, which we discuss later, embodied the neo-liberal
economic orthodoxy and conservative politics of the wealthier countries that dominate
decisions in both institutions. The second event, the fall of the Berlin Wall, established
the United States as the world’s only superpower and created a normative vacuum for
alternative models of development that could no longer experiment with ‘third way’
blends of state centralism and market capitalism The birth of the World Trade
Organization (WTO) in 1995, with its first set of agreements tilted steeply in favour of
transnational corporations based in wealthier nations, followed only a few years later.
Third, the 1992 United Nations Conference on Environment and Development (United
Nations, 1992) fostered a ‘global environmental consciousness’ with special emphasis on
the developing world’s need both for economic growth and for environmental protection.
The fourth event, harder to date, has been the diffusion of convergent information and
communications technologies (ICTs) that transformed the nature of global capitalism.
The instantaneous global information systems enabled by technology, of course, also
increase the speed and scale with which civil society can analyze and mobilize responses
to its economic abuses.
In this new landscape, a shift is needed in how global health is conceptualized. An
international concern with poorer countries’ greater burden of disease needs to give way
to a more critical recognition that both the determinants and the consequences of their
excess disease are inextricably linked to processes of globalization. Labonte and Spiegel
(2002, 2003) use the concept of Inherently Global Health Issues (IGHIs) to describe
health-determining phenomena that transcend national borders and political jurisdictions
(Table I), and urge greater research and policy attention to the linkages between
these issues, and to their economic and political ‘drivers’ or what we call globalization
processes.
1
The first (international) conceptualization predominates in global health discourse,
from the new global fund ‘partnerships’ (e.g. the Global Fund to Fight AIDS,
Tuberculosis and Malaria, and the Global Alliance for Vaccines and Immunization)
to the US Administration’s 2002 commitment to increase bilateral AIDS funding to
developing countries. It is exemplified by the recent list of ‘top 10 biotechnologies’
Interrogating globalization, health and development 159
to improve health in developing countries (Daar et al., 2002) that range from better diag-
nostic devices and recombinant vaccines against HIV/AIDS to simpler vaccine devices
replacing needle injections. The pursuit of such technologies also lies at the heart of
the Gates Foundation ‘Grand Challenges in Global Health’ initiative, which promises
to help fund new breakthroughs in treating ‘neglected diseases’ in poor countries.
These approaches confine their analyses of disease aetiology and intervention to individual
or, at best, community levels. Little or no attention is paid to inadequate public health
systems (and how they came to be so) or to the shifting social and economic conditions
that underpin many of the developing world’s persisting pandemics. The African
HIV/AIDS pandemic, for example, has roots in global macroeconomic changes as much
as in the failures of African states and donor nations to confront the problem. ‘The top
epidemiological predictor for HIV infection around the world’, Basu (2003) notes,
‘is not ‘‘risk behaviour’’ but rather a low income level’. The pathways linking poverty
(low income) to HIV infection are multiple but, in sum, ‘the background for increasing
HIV transmission is a background of neo-liberalism—a context where the movement
of capital is privileged above the ability of persons to secure their own livelihoods’
(Basu, 2003).
2
Questioning globalization’s dominant discourse
Debates over globalization tend to be polarized. Proponents claim, in ‘history-ending’
fashion, that it represents the logical triumph of liberal capitalism, a humanizing
victory that should be propelled more quickly through rapid liberalization and global
market integration. Opponents counter, in ‘anti-globalization’ rhetoric, that it represents
less a humanizing victory than one of corporate and elite group interests based largely
in a few high-income countries. More nuanced perspectives argue that globalization
is neither good nor bad. Its momentum may be unstoppable, but its shape is not
ineluctably determined (the notion that ‘there is no alternative’ is a specious
simplification) and its human impacts are readily malleable to human-made policies and
regulations.
Table I. Inherently global health issues.
Environmental global degradation 1. Greenhouse gas emissions (climate change)
2. Biodiversity loss
3. Water shortage
4. Decline in fisheries
5. Deforestation
Social/economic 6. Increasing poverty
7. Financial instability (capital markets)
8. Digital divide
9. Taxation (tax havens, transfer pricing)
Cross-cutting 10. Food (In)security
11. Trade in health-damaging products
(tobacco, arms, toxic waste)
12. Governance
13. War and conflict
Source: Labonte and Spiegel (2003). This table omits two other inherently global health
issues: Tourism and human migration (voluntary or forced). We thank one of our
reviewers for this insight.
160 R. Labonte & R. Torgerson
Contrasting discourses similarly accompany discussion of the health impacts of
globalization. The diffusion of new knowledge and technology through trade and
investment, it is argued, can aid in disease surveillance, treatment and prevention
(Lee, 2001). Information communication technologies (ICTs) can enable more rapid
scientific discovery, create virtual communities of support, increase knowledge about
human rights and strengthen diasporic communities. Globalization has had positive effects
on gender rights and empowerment (Sen, 1999; Chinkin, 2000; Harcourt, 2000),
largely through increasing employment opportunities. The dominant health pro-
globalization discourse, however, rests principally on the rationale put forward by
pro-liberalization economists and trade ministers. Liberalization (the removal of border
barriers, such as tariffs, on the flow of goods and capital), proponents claim,
increases trade. This increases economic growth, which decreases poverty; and any
decline in poverty is good for people’s health (Dollar & Kraay, 2000; Dollar, 2001).
Growth also provides revenue for investments in healthcare, education, women’s
empowerment programs and so on. Improved health, particularly amongst the
world’s poorer countries, also increases economic growth (Savedoff & Schultz,
2000; WHO, 2001) and so the pro-globalization, pro-health circle virtuously closes
upon itself.
This virtuous circle, however, has some vicious undertows. These include the more
rapid spread of infectious diseases, some of which are becoming resistant to treatment,
and the increased adoption of unhealthy ‘Western’ lifestyles by larger numbers of
people (Lee, 2001), ‘globalizing’ new pandemics of tobacco-related diseases, obesity
and diabetes. Diffusion of new health technologies to developing countries usually
benefits the wealthy, often at the expense of already under-funded and fraying public
healthcare systems for the poor. And there are important gender relational and power
implications. Trade openness might increase women’s share of paid employment, an
important element of gender empowerment (UNDP, 1999). Such work, however, is fre-
quently in Export Processing Zones that often pay below market wages, have poor health
and safety standards and suppress union organizing (Durano, 2002; ICFTU, 2003).
Public support for the care of young children has been declining in many trade-opened
countries, portending future health inequalities. In an emerging global ‘hierarchy of care’,
women from developing nations employed as domestic workers in wealthy countries
send much valued foreign currency back home to their families. Some of this is used to
employ poorer rural women in their home countries to look after the children they have
left behind. These rural women, in turn, leave their eldest daughter (often still quite
young and ill-educated) to work full-time caring for the family they left behind in the village
(Hochschild, 2000).
More fundamentally, trade and financial liberalization does not inevitably lead to
increased trade or economic growth (Rodrik, 1999; Rodriguez & Rodrik, 2000). When it
does, such growth does not inevitably reduce health-damaging poverty, and almost
always leads to health-damaging inequality (UNDP, 2000; Cornia, 2001; Weisbrot,
Baker, Kraev, & Chen, 2001).
3
Much depends upon pre-existing social, economic and
environmental conditions within countries; and upon specific national programs and
policies that enhance the capacities of citizens, such as health, education and social welfare
programs (UNDP, 1999, 2000). Yet such programs and policies are often cut back radically
as part of structural adjustment, whether undertaken at the behest of international financial
institutions or independently by governments seeking to attract investors with low taxes
and an expanding pool of low cost labour.
Interrogating globalization, health and development 161
Of devils and the details: A framework for critically assessing globalization’s
impacts on health
Sufficient evidence now exists to support a profound scepticism about the dominant ‘story’
that links globalization, growth, development and health. Two recent reviews comparing
economic, health and social development indicators in the ‘pre-globalization’ era (roughly
1960–80) with those following structural adjustment and trade liberalization indicate that
the net beneficiary was the group of wealthy countries (Weisbrot et al., 2001; Milanovic,
2003), what Milanovic calls the WENAO (Western Europe, North America and Oceania).
In language notably blunt for a (now former) World Bank economist, Milanovic argues,
‘maintaining that globalization as we know it is the way to go and that, if [its] ...policies
have not borne fruit so far, they will surely do so in the future, is to replace empiricism
with ideology’ (2003, p. 679). How, then, can one harness research to a more critical
interrogation of globalization’s health impacts? The impacts of globalization on health
cannot be inferred from one or two independent variables, such as trade liberalization
or levels of inward foreign direct investment (FDI); there are simply too many historical
and contingent confounders. The range of health outcome measures (the dependent
variables) is vast and the reliability of the historic data in many countries is poor. An
especially important point is that national-level comparisons provide little useful infor-
mation about how health gains or risks are distributed sub-nationally or by different
population groups. Locally oriented research, especially when it gives much needed voice
to marginalized groups, can partly address this problem.
The task of identifying health impacts that are a direct consequence of globalization
processes is complicated by the interactions of such processes with domestic political and
economic opportunity structures. For example, the anticipation of conditionalities attached
to lending by the IMF or World Bank can lead countries to adopt domestic social and
economic policies in the absence of overt intervention by lenders. Cheru quotes a finance
minister from one of the heavily indebted poor countries: ‘We do not want to second-
guess the Fund [IMF]. We prefer to pre-empt them by giving them what they want
before they start lecturing us about this and that. By so doing, we send a clear message
that we know what we are doing, i.e. we believe in structural adjustment’ (2001, p. 12).
4
Methodologically, there are lag-time problems: are present health gains the result of a
national economy’s recent embrace of globalization (liberalization), or of previous periods
of domestically oriented economic policy? There are also lead-time problems: How may
today’s embrace of globalization lead to health-related environmental damage from rapid
urbanization, increased resource depletion, or industrial pollution?
Our own approach to this complexity was to undertake a reasonably comprehensive review
of analytical frameworks to create a ‘map’ of the linkages between globalization and health
(Labonte & Torgerson, 2003), using as a reference point the work of David Woodward
and colleagues at the WHO (Woodward et al., 2001). We defined ‘frameworks’ as graphic,
visual representations of concepts, contexts and pathways that link globalization to health,
whether these pathways are defined in terms of arithmetical relationships or qualitative
descriptions of causal relations. Most frameworks identified in our literature review were
partial, reflecting the disciplinary or sectoral interests of their creators, e.g. physical environ-
ment, social environment, economic growth, healthcare services. We found that many frame-
works failed to define, much less operationalize, their key constructs. Few frameworks
incorporated people as social actors able to influence public policies, social norms or
macroeconomic contexts. Interestingly, those that did, identifying community organizations
or civil society groups as mediators between globalization and its impacts, were developed
162 R. Labonte & R. Torgerson
by non-governmental organizations. The frequent absence of social actors relates to another
common omission: Analysis of social power relations, by class, gender or ethno-racial back-
ground (notable exceptions are Rico, 1998; Woodward et al., 2001). Such analysis, we argue,
is basic to a critical approach to understanding health determinants.
While the many analytical frameworks we encountered generated partial answers to
some questions about globalization and health, the absence of more comprehensive frame-
works makes it difficult to identify the full range of both positive and negative effects. We
present below our own composite and more comprehensive framework, which incorporates
Political Systems and Processes Pre-Existing Endowments
SUPER-
ORDINATE
CATEGORIES
GLOBAL
CONTEXTS
Macroeconomic Policies
Trade Agreements and Flows
Intermediary Global Public Goods
Official Development Assistance
DOMESTIC
CONTEXTS
Domestic Policy Space/Policy Capacity
Domestic Policies
(e.g. economics, labour, food security, public
provision, environmental protection)
COMMUNITY
CONTEXTS
Local Government Policy Space/Policy
Capacity
Civil Society Organizations
Service and Program Access
Geographic Disparities
Community Capacities
Urbanization
HOUSEHOLD
CONTEXTS
Current Household Income/Distribution
Health Behaviours
Health, Education, Social Expenditures
HEALTH OUTCOMES
Environmental Pathways
GLOBALIZATION AND HEALTH: SELECTED PATHWAYS AND ELEMENTS
Figure 1. Globalization and health: Basic framework.
Interrogating globalization, health and development 163
elements that we found from our review to be theoretically and/or empirically ‘rich’
(substantiated).
5
It is organized as a simple hierarchy. What follows is a brief discussion
of the framework’s different levels, and their implications for assessing globalization’s
impacts on health.
Health outcomes
Our concern is with greater equity (fairness) in health within and between nations.
But reliance on health measures such as mortality, morbidity or disability rates as
1. Political Systems and Processes
* public policy formation
* social sratification
* political, economic and civil society traditions
2. Pre-Existing Endowments
* economic development level
* environmental resources
* human and social capital
* demographic structure
SUPER-
ORDINATE
CATEGORIES
GLOBAL
CONTEXTS
3. Macroeconomic
Policies
* structural adjustment
programs
* poverty reduction
strategy papers
4. Trade Agreements
and Flows
* WTO, regional,
bilateral
* commodity flows
* investment flows
5. Intermediary
Global Public Goods
6. Official
Development
Assistance and Debt
Relief
* levels/trends
* conditionalities
DOMESTIC
CONTEXTS
7. Policy Space/Policy Capacity
* regulatory space (multilateral encroachment)
* spending space
* public sector capacity
8. Macro-
economic
Policies
9. Migration/
Refugee
Policies
10. Labour
Policies
11. Food
Security
Policies
12. Public
Provision
Policies
13. Political
Power
Policies
14. Environmental
Protection
Policies
COMMUNITY
CONTEXTS
15. Policy Space/Policy Capacity
* local government openness
* civil society organizations
* local resources/endowments/opportunities
16. Service and
Program Access
* supplyside variables
17. Geographic
(Regional, Local)
Disparities
18. Community
Capacities 19. Urbanization
HOUSEHOLD
CONTEXTS
20. Current
Household Income/
Distribution
21. Subsistence
Production
22. Health
Behaviours
23. Health, Educ.,
Social Expenditures
* demand side
variables
25. HEALTH OUTCOMES
24. Environmental Pathways
resource base * sink function * wastes * amenities * biodiversity * aggregate (inherently global)
GLOBALIZATION AND HEALTH: SELECTED PATHWAYS AND ELEMENTS
Figure 2. Globalization and health: More complex framework. Note: Health systems, and other public
infrastructures essential to better health outcomes, are subsumed under the categories of ‘Public Provision
Policies’ and ‘Services and Program Access’.
164 R. Labonte & R. Torgerson
indicators in studies of the health impacts of globalization is insufficient for the lead-
and lag-time reasons already mentioned. The HIV/AIDS pandemic, national or regional
conflicts and environmental catastrophes, while associated with globalization processes,
nonetheless are ‘wildcards’ that render suspect any direct cross-national comparative
analyses using measures of globalization and of health outcomes alone. The value of
analytical frameworks linking globalization to health is that the effects of such wildcards,
and the sundry ways in which globalization phenomena influence health by affecting
known social and environmental determinants of health, can be assessed by individual
studies detailing partial relationships that are then collected and assembled against a
framework of the whole. Gaps in the pathways can be identified for future research,
while reasoned and fairly comprehensive conclusions about globalization’s complex
impacts on health, via its more direct impacts on multiple pathways, can be tentatively
reached. At the same time, it is helpful to have a delimited set of health outcomes for
cross-national comparisons, supported by detailed longitudinal case studies. An obvious
shortlist, particularly for developing countries, is provided by the health targets associ-
ated with the first seven of the Millennium Development Goals (Table II), which are
the focus of the United Nations Development Programme’s 2003 Human Development
Report (UNDP, 2003) and a recently released five-year review of progress (UN
Millennium Project, 2005). Some caution is still in order because the MDGs are
stated in aggregate terms. Improvements in health status and in the determinants of
health sufficient to meet the MDG targets when measured at the national level only
may not reflect improvements in the situation of the poorest or least healthy (Gwatkin,
2002). A country could conceivably reach the MDG targets by increasing health
inequalities between high- and low-income groups within its borders. Careful monitor-
ing of the incidence of such improvements using national-level equity stratifiers is
needed.
Table II. The first seven millennium development goals.
Goal 1 : Eradicate extreme poverty and hunger
Target 1 : Halve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day
Target 2 : Halve, between 1990 and 2015, the proportion of people who suffer from hunger
Goal 2 : Achieve universal primary education
Target 3 : Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course
of primary education
Goal 3 : Promote gender equality and empower women
Target 4 : Eliminate gender disparity in primary and secondary education preferably by 2005 and to all levels of
education no later than 2015
Goal 4 : Reduce child mortality
Target 5 : Reduce by two-thirds, between 1990 and 2015, the under-5 mortality rate
Goal 5 : Improve maternal health
Target 6 : Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio
Goal 6 : Combat HIV/AIDS, malaria and other diseases
Target 7 : Have halted by 2015, and begun to reverse, the spread of HIV/AIDS
Target 8 : Have halted by 2015, and begun to reverse, the incidence of malaria and other major diseases
Goal 7 : Ensure environmental sustainability
Target 9 : Integrate the principles of sustainable development into country policies and programs and reverse
the loss of environmental resources
Target 10 : Halve, by 2015, the proportion of people without sustainable access to safe drinking water
Target 11 : By 2020, to have achieved a significant improvement in the lives of at least 100 million slum dwellers
Source: Devarajan, Miller and Swanson (2002, pp. 34–35).
Interrogating globalization, health and development 165
Superordinate categories
Governments’ decisions to contribute to, negotiate or abide by globalization’s key economic
drivers, and their capacities to mitigate any health-damaging or otherwise undesired social
and environmental impacts, are conditioned by their national histories—a point
that has been made with special force in the case of Africa (Mkadawire & Soludo, 1999,
pp. 1–20). We identify two categories of elements (many are still too broadly stated to be
considered variables) that reflect this: Pre-existing endowments and political systems and
processes.
Pre-existing endowments
Crude measures of pre-existing economic endowments include per capita income or wealth,
currency reserves and other monetary measures. Natural resources also constitute a pre-
existing endowment. Countries facing deficits in water, arable land, fibre (forests), energy
and other natural resources will experience the impacts of globalization more harshly
than those with a surfeit of natural capital. Human capital (traditional knowledge,
new knowledge, education attainment, individual and collective skills or abilities) and
social capital (social networks predicated on trust and reciprocity) are other pre-existing
endowments. A country’s demographic profile can also be considered another important
facet of its pre-existing endowments, particularly with regard to its impact on environmental
resources use/depletion (Leach & Mearns, 1991).
Political systems and processes
Political institutions and processes similarly shape the range of possible policy responses.
In a case study of post-apartheid South Africa, McIntyre and Gilson (2001) argue that
the influence of global contexts on domestic (national) policy space and capacity has
been mediated by acceptance of discrimination (on the basis of race, ethnicity or
gender), definition of public need and attitudes towards privatization, determination of
public policy (degree of civil society participation), level of unionization and accountability
of public administration. Some of these influences (notably the second, third and fourth)
have been found in other cross-national studies (Global Social Policy Forum, 2001;
Gough, 2001), particularly those contrasting the social and labour market impacts
of global market integration between different forms of rich world capitalism (i.e. the
Nordic social democratic, European corporatist and Anglo-American liberal models; see
Esping-Anderson, 1990).
6
Related to these points is the discounting of the political nature of globalization.
‘Making globalization work for the poor’—the language of the Communique
´issued at
the conclusion of the 2001 G8 Summit (ô3)—becomes an exercise in adjudicating
fine details of particular trade agreements or domestic ‘regulatory frameworks’ that might
help to mitigate the ‘no alternative’ juggernaut of increased global economic integration.
Lost in the technical discussions is the extent to which global capitalism, however
technically buffered, is substantially shifting power away from public governing structures
and towards private economic organizations, the power of which is defined by national
and supra-national structures of property rights. Conflict and political instability are
other aspects of political systems and processes that can effectively determine the
acceptance of, or compliance with, macroeconomic policies and trade regimes. The
extent of prior social status systems within countries, whether stratified by gender, class,
166 R. Labonte & R. Torgerson
caste, ethnic or wealth-based criteria, is also posited as an important prior condition
influencing how macroeconomic policies are selected, implemented and ultimately shape
health outcomes (Diderichsen, Evans, & Whitehead, 2001). Countries with unequal
power distribution are more likely to support global macroeconomic policies that retain
elite group privileges than are those with a broad middle-class, gender equity and strong
civil society groups and labour unions. We emphasize that our use of the term ‘pre-existing’
refers only to how a country’s current endowments affect its ability to respond to future
challenges. In fact, most ‘pre-existing’ endowments are reflections of past historical
processes; the current endowments of many developing countries are directly traceable to
their colonial past.
Global policy and economic contexts
A focus of much of our work to date concerns the health impacts of four key elements of the
global context, each of which is primarily under control of the rich, industrialized countries
and the holders of transnationally enforceable property rights: domestic macroeconomic
policies, trade agreements (global, regional or bilateral), official development assistance
and debt relief (for elaboration see Labonte, Schrecker, Sanders, & Reeus, 2004). To
this list can be added the movement of peoples (over 175 million people lived outside
their country of birth in 2000) and the flow of remittances to developing countries, some
US$80 billion in 2002, more than double the amount in 1990, and an important source
of foreign currency for many poorer countries) (Kapur & McHale, 2003).
7
Macroeconomic policies
The most commonly examined macroeconomic policies are those embodied in the
conditionalities imposed by the IMF and World Bank on indebted countries in return
for loans, grants or partial debt relief, collectively known as structural adjustment programs,
or SAPs (Mohan, Brown, Milward, & Zack-Williams, 2000). Funds were made available
only if the debtor country agreed to a relatively standard package of macroeconomic policies
including reduced subsidies for basic items of consumption, the reduction or elimination of
tariffs and controls on capital flows, privatization of state-owned productive assets, currency
devaluations to increase the competitiveness of exports, and domestic austerity measures
such as reduced government spending on education and health and the introduction of
cost recovery through user fees (Milward, 2000). SAPs are associated with the erosion
of labour market institutions (full employment policies, decreased minimum wage and
reduction in public sector employment), shifts in taxation policies (less progressive) and
reduced public spending (e.g. on education, health, environmental protection) (Cornia &
Court, 2001).
While SAPs have disappeared in name, many of their macroeconomic elements are
still found in the conditionalities associated with the Heavily-Indebted Poor Countries
(HIPC) initiative launched in 1996 to provide partial debt relief for some of the world’s
most desperate countries.
8
A key element of eligibility for HIPC is the preparation of
a national Poverty Reduction Strategy Paper (PRSP) as the basis for domestic social and
economic policy. Key PRSP elements include commitments to poverty reduction, broad
public participation and local government ownership. However, the lenders who assess
PRSPs operate on the presumption that poverty reduction is best achieved through
neo-liberal prescriptions for privatization, deregulation and rapid integration into the
global economy, PRSPs sometimes requiring more rapid liberalization than that mandated
Interrogating globalization, health and development 167
under World Trade Organization agreements, all of which is likely to exacerbate
existing inequalities (UNDP, 2001; SAPRIN, 2002; Brock & McGee, 2004). The World
Health Organization (2001) identifies several serious health-related shortcomings in
existing PRSPs: negative effects of cost recovery for healthcare services and the failure of
fee-exemption programs for the poor; lack of clear government commitments to increase
resources for health and education; and failure to consider health as an outcome, rather
than simply a means, of development.
Trade agreements, flows and institutions
Trade liberalization is a sub-set of macroeconomic policy. The aim of contemporary trade
agreements is to facilitate the reorganization of production or commodity chains across
national borders in order to maximize profitability. Considerable disagreement surrounds
the question of whether trade liberalization per se will improve or worsen health and
health-determining social contexts (Kirkpatrick & Lee, 1999; Cornia, 2001; Cornia &
Court, 2001; Dollar, 2001; Labonte, 2001). Trade liberalization by definition reduces
tariffs. This can shrink the amount of revenue governments have to spend on health,
education and environmental protection. Tariff reduction has been particularly hard on
developing countries, which used to get much of their revenue from tariffs. Few countries
experiencing sharp post-liberalization declines in tariffs have been able to generate other
forms of compensatory taxation (Hilary, 2001). This severely reduces their ‘spending
capacity’—the amount available for key health-promoting investments such as public
healthcare, education, water/sanitation and gender empowerment programs, or to enforce
occupational, environmental or labour rights and standards.
9
Trade policy may have perverse effects on health in two further ways. First, development
policy observers who disagree on many other points agree that meaningful improvements
in market access for the products of the world’s poorest countries would result in dramatic
increases in income and, therefore, in opportunities to improve health. A recent Oxfam
report on making trade work for the poor, for example, notes that: ‘If developing countries
increased their share of world exports by just five per cent, this would generate
$350bn—seven times as much as they receive in aid’ (Watkins, 2002, p. 8). Despite the
free-trade rhetoric of the industrialized countries, and their demands that developing
world markets be opened up to imports, they protect their own domestic markets in various
ways, ranging from high tariffs on products of special importance to developing countries to
trade-distorting subsidies to agricultural producers (Figure 3). Indeed, the industrialized
world can be seen as giving with one hand (in the form of limited debt relief and develop-
ment assistance) and taking away much more aggressively (in the form of trade protection
and agricultural subsidies) with the other. The collapse of the WTO trade talks in Cancun
in September 2003 can be read as a simultaneous success and failure in this regard. The
success is the increased strength of organized developing countries; the failure lies in the
apparent commitment of wealthier countries, particularly the US, to focus now on bilateral
and regional trade agreements where its economic might can overwhelm a more diluted
developing world opposition.
10
Second, an additional and increasingly scrutinized aspect of trade agreements involves
the loss of domestic ‘regulatory space’ (Rao, 1999; Labonte, 2001) (Table III). This loss
can have positive health consequences, if it prevents governments from providing subsidies
to domestic companies that lead to resource depletion or environmentally destructive activ-
ities (for example, in agriculture or fisheries). But its impact is negative ‘when the ability of
governments to enact and implement appropriate environmental regulations is undermined
168 R. Labonte & R. Torgerson
by the provisions of trade and investment agreements’ (OECD, 2001, p. 54). Most of
the environmental frameworks reviewed in our study, using empirically based modelling
experiments or case studies, concluded that increased global trade will create negative
environmental externalities through accelerated resource depletion, trade-related energy
consumption and greenhouse gas emissions (Labonte & Torgerson, 2003), the health
implications of which are profound.
Domestic regulatory space is further, if indirectly, encroached by the costs of implement-
ing WTO agreements, which are estimated as far exceeding the total development
budgets of the least developed countries (Finger & Schuler, 2001); and by the level of
public sector employment, which is often severely curtailed as a consequence of austerity
measures undertaken in response to pressure from lenders (Milward, 2000; Cornia &
Court, 2001).
Official development assistance
Official development assistance (ODA) is rarely considered in globalization frameworks,
perhaps because of the stagnation and subsequent decline of ODA spending by most
industrialized countries during the 1980s and 1990s. (The recent attention given to
the Millennium Development Goals, and the importance of massively increased levels of
development assistance to achieve them, is beginning to focus more media and public
attention on ODA.) Figure 4 shows a precipitous drop in ODA from the ‘Group of 7’
(G7) richest countries, over the very decade in which these countries experienced global
trend-setting wealth creation. Only a few European countries ever achieved the inter-
nationally agreed target of 0.7% of GDP for official development assistance. Several
donor countries have pledged recently to reach this target by 2015, including the UK
and France, but excluding the US, Germany, Japan and Canada (UN Millennium
Project, 2005, p. 252).
0 500 1000 1500
US dollars
Japan annual dairy subsidy, per cow
EU annual dairy subsidy, per cow
Per capita annual income, sub-Saharan Africa
Per capita cost of package of essential health interventions
Per capita annual health expenditure, 63 low income countries
2000 2500 3000
Figure 3. Rich world agricultural subsidies in perspective. Source: Commission on Macroeconomics and
Health (2001), United Nations Development Programme (2003) and World Bank (2002).
Interrogating globalization, health and development 169
Although ODA remains an essential element in many national government budgets
amongst the world’s least developed countries, a number of problems (aside from its insuf-
ficient value) must be considered. Targeting of countries for assistance is inconsistent,
making it difficult for countries to plan sustainable infrastructures and program expen-
ditures. Much of the aid is tied (requiring purchases from the donor country) or in the
form of technical cooperation (requiring employment of donor country nationals).
Reflecting an overall pattern of government expenditure in many developing countries,
much aid, especially in health and education, does not go to ‘basic’ services benefiting
Table III. WTO agreements and health-damaging loss of domestic regulatory space.
Agreement
Health impacts from loss of
domestic regulatory space
Agreement on Trade Related
Intellectual Property Rights
Extends patent protection rights, limiting governments’
abilities to provide essential medicines at affordable costs
Higher cost of drugs with extended patent protection
drains money useful for primary health care
Case example: Access to antiretroviral drugs
Agreement on Sanitary and
Phytosanitary Measures
Requires scientific risk assessments even when foreign goods
are treated no differently than domestic goods (i.e. even
when there is no discrimination between a domestic and
a foreign supplier of the good)
Such assessments are costly, and are imperfect in assessing
the many potential health risks associated with
environmental and manufactured products
Case example: The successful challenge to the European
Union’s ban on the use of artificial hormones in
raising beef
Technical Barriers to Trade Agreement Requires that any regulatory barrier to the free flow of
goods be ‘least trade restrictive as possible’
Many trade disputes over domestic health and safety
regulations have invoked this agreement
The only WTO dispute where the health exception, allowing
countries to abrogate from trade agreement rules for
purposes of protecting human, animal and environmental
health, was in favour of France’s ban on the import of
Canadian asbestos products
This occurred under appeal, and followed widespread negative
reaction to the initial WTO ruling in favour of Canada
Agreement on Trade Related
Investment Measures
Limits countries’ abilities to direct investment where it would
do most good for domestic economic development and
employment equity, both of which are important to
improving population health
Agreement on Government Procurement Limits governments’ abilities to give priority to domestic
firms bidding on its contracts, or to require purchases of
goods from local companies, both of which can promote
employment opportunities and regional equity, which in
turn have strong links to better population health
This is currently an ‘optional’ agreement to which few
developing countries have ‘signed on’
Agreement on Agriculture Continuing export and producer subsidies by the US, EU,
Japan and Canada depress world prices and cost
developing countries hundreds of millions of dollars in
lost revenue which could be used to fund health,
education and other health-promoting services
Subsidized food imports from wealthy countries undermine
domestic growers’ livelihoods
Market barriers to food products from developing countries
persist and deny poorer countries trade-related earnings
170 R. Labonte & R. Torgerson
the least well off, but to technically advanced services benefiting a smaller number
of the privileged (World Bank, 2000, pp. 80–85). Finally, high debt and ODA insufficiency
are conjoined twins. The problem is ‘fungibility’, meaning that development dollars
that are not already tied go indirectly but no less certainly into the pockets of
First World bankers, investors, government marketing boards, the IMF and other
creditors—many of whom could be held at least partly responsible for these debts in
the first place (Stiglitz, 2003). In 1995, for all developing countries, debt service
costs amounted to 3.6 times the value of ODA receipts. By 2000, the ratio had risen to
over 7 : 1 (Pettifor & Greenhill, 2002).
Domestic public policy contexts
11
A longer and more robust history exists of mapping pathways that link national (as distinct
from global) policies to health outcomes, particularly in high-income countries. There is
a premise that public policies determine the ultimate allocation of opportunities and
resources within a political jurisdiction. We describe these as domestic, rather than national,
policies, since most countries have a complex layering of policy-making rights from national
to community levels. The ones identified in our framework are those with the strongest
relationship to health outcomes.
Community contexts
Elements from higher-order categorizations recur within community contexts. First, there
is the issue of how national resources are allocated to geographic areas, and the nature of
local-level endowments capable of generating the means of livelihood and savings within
communities. Second, there are aspects of local government itself (i.e. openness) and of
civil society strength, both of which can enhance citizen participation in policy, program
and resource decisions. But this participation, in turn, and particularly for poorer groups,
is often confined by a deficit in certain ‘capacities’ identified by the international and
community development practice literature (e.g. leadership, resource mobilization, assess-
ment and analysis skills, organizational skills); hence an emphasis here on strategies that
build such community capacities (Labonte & Laverack, 2001). Key vehicles for this purpose
reside in various publicly provided services; and here disparities in regional or community
reflect responses to a macroeconomic policy context that is determined at national and
international levels. Not only might there be geographic or regional disparity; many
poorer countries have significantly unequal allocations of public programming and service
resources within the same geographic community. A critical juncture between globalization
processes and community contexts is the impact of economic restructuring (via SAPs
and free trade agreements) on accelerated urbanization, creating massive ‘slums’ in poor
countries with sanitation, crowding and poverty problems rivalling the worst of the
European urban slums during the early period of nineteenth-century industrialization
(World Resources Institute, 1996, pp. 14–55).
Household contexts
All of the analytical frameworks we reviewed that incorporated a household level describe
and analyse gender roles—a perspective the importance of which was noted earlier.
McCulloch, Winter and Ciera (2001) argue that the effects of poverty fall ‘disproportio-
nately on women, children and the elderly’ (p. 69). They discuss this in terms of ‘gender
Interrogating globalization, health and development 171
power within the household’, and how trade-related lowered family wage and a rise of
female labour, without compensational help with household duties, may decrease
women’s welfare and compromise any increased household power their income-earning
potential might have accrued them. Greater female control of household income, in turn,
is associated with better health and educational outcomes for children.
Conclusion: Towards an empowering methodology
The utility of any analytical framework in population health research depends on its ability
to identify (or allow identification of) causal relations in ways that support and inform policy
interventions, on scales ranging from the community to the transnational. Many of the
links between the pathways inherent in our framework elements (e.g. trade liberalization
and biodiversity, macroeconomic adjustment policies and health services) have already
been studied empirically. Additional research can further explore subsets of framework
linkages. The most useful information, particularly from a policy vantage, would be
comparative case studies where as many as possible of the potential linkages could be
assessed within one country, using secondary data, existing partial studies and new research
as required; with comparisons made ex post between different countries displaying different
superordinate and macroeconomic patterns. What is important is that such studies incorpo-
rate elements of each of the framework’s different levels.
One example of where the framework has been applied is an ongoing study of health and
development commitments made by the G8 countries (Canada, France, Germany, Italy,
Japan, Russia, the UK and the US), in which commitments were assessed for compliance,
adequacy and coherence (Labonte et al., 2004). The framework guided the selection of
research studies and multilateral reports used in the assessment exercise; this article essen-
tially extends the discussion of the framework contained in the book-length presentation
of the first tranche of findings, Fatal Indifference: The G8,Africa and Global Health
(Labonte et al., 2004).
We have also proposed use of the framework in future research studies, using as an
example studies of the impacts of debt cancellation on health outcomes. For any partic-
ular country, analyses could be undertaken to study the relationship between the
0.7
1984–85 (average)
2000
2001
0.6
0.5
0.4
0.3
0.2
0.1
0
Canada
France
Germany
Italy
Japan
UK
US
G7 average
Figure 4. Total ODA as percentage of gross national income (GNI), 1984–85 (average), 2000 and 2001,
G7 countries. Note: 1984–85 average is for bilateral aid only; data allowing for calculation of multilateral
contributions for 1984–85 are not available. ODA contributions increased for some, but not all, G7 countries
in 2002; data for 2003 have not been released at time of writing. Source: OECD (2002, Table 4); OECD
(2003, Table 4). Estimates of 2000 and 2001 multilateral contributions made by authors.
172 R. Labonte & R. Torgerson
following variables (numbers on the left refer to particular boxes in Figure 2, for ease of
cross-referencing):
4. debt service as percentage of exports of goods and services;
6. debt relief committed to case study country (amount/year);
debt relief committed under HIPC Initiative (US$);
cost-recovery conditionalities attached to debt relief (this cross-refers to 3.
Macroeconomic Policies, and would include inter alia assessment of conditions related
to tariff reduction and its impact on public revenues and, thence, on indicators in
categories 11, 17, 20, 21 and 23, noted below);
7. ratio of pre- to post-HIPC public expenditures on health, education, water, sanitation
(in absolute terms and as a percentage of GDP);
11. changes in prices of basic foods, nationally and regionally;
12. trends in cost of essential drugs;
13. debt service as percentage of public expenditures in health, education, water, sanitation;
17. trends in public expenditures in health, education, water, sanitation by geographic
regions or neighborhoods, organized by income level, gender or other social stratifiers,
before and after HIPC or other forms of debt relief (i.e. regional-level changes in access
to health, education, water, sanitation);
20. impact of public expenditures in health, education, water, sanitation on household
income level, gender distribution or other social stratifiers;
21. impact of public expenditures in health, education, water, sanitation on health
behaviors, by household income level, gender distribution or other social stratifiers;
23. impact of public expenditures in health, education, water, sanitation on private health
expenditures for these services, by household income level, gender distribution or other
social stratifiers (i.e. household level changes in access to health, education, water,
sanitation);
25. as annual data accumulate, analyses of debt relief on health-specific indicators for the
Millennium Development Goals.
These two examples bring us to the important issue of how globalization/health research
itself might adopt some of the tenets of a critical population health that we identified earlier.
This issue is particularly acute when the research questions concern power differentials
between the world’s wealthiest and poorest citizens. Normal criteria of ‘community partici-
pation’ is not possible in any direct sense if that community includes researchers in
high-income countries and, as an example, residents of black townships in South Africa.
It is complicated by national research-granting bodies that fund (in our case) Canadian
researchers, but not necessarily their partners in developing countries. This granting
policy, however, is changing, partly through the efforts of a newly established Canadian
Coalition for Global Health Research and a Memorandum of Agreement between
Canada’s federal health ministry, health research institutes and development agencies to
increase funding for such research. Several broadly stated principles for conducting
global health research have been proposed (Labonte & Spiegel, 2001):
.Give priority to research on inherently global health issues that will reduce the burden
of disease.
.Give priority to research on the burden of disease that includes study of inherently global
health determinants.
.Within both, give priority to research that represents Southern-defined concerns or
questions.
Interrogating globalization, health and development 173
.Within such research, give priority to proposals that will increase equity in health
outcomes between groups within nations.
.Within such research, give priority to proposals that have solid civil society engagement.
.Within such research, give priority to proposals that will increase equity in knowledge
capacities between the North and South.
Our own efforts to act on these principles include new research work on the ‘brain drain’
of health professionals from southern African countries to Canada, the UK and Australia.
The impetus for this research came from research/civil society networks in southern Africa,
who are examining how globalization processes (from trade agreements to macroeconomic
policies to aid/debt trends) affect the supply of health workers in already under-resourced
nations. It has an explicit advocacy plan and time frame; indeed, it is the advocacy plan’s
need for the research that is driving the collaboration.
Globalization, though not an entirely new phenomenon, is a fairly new construct.
Its impacts on health are potentially enormous, for better and for worse. Reaching some
consensus on how globalization might maximize the former and minimize the latter
depends, albeit only partly, on assembling evidence and undertaking new research that, as
Starfield (2001) argues, is best based on a delimited range of frameworks. A more funda-
mental question, and one that for the moment remains unresolved, is that of whether
responses can really be ‘evidence based’, or whether they will be shaped by the interests
of the world’s rich minority. The challenge this poses for critical population health research
is the degree to which researchers are committed to the political nature of the project in
which they engage.
Acknowledgements
Some of the work reported herein was undertaken with support from the Globalization,
Trade and Health Group, World Health Organization, and the Institute of Population
and Public Health, Canadian Institutes of Health Research. All opinions expressed in
this paper are those of the authors. Thanks are offered to Ted Schrecker, Senior Policy
Researcher, Institute of Population Health, University of Ottawa, for contributions to
this article, to SPHERU research faculty for helpful comments on earlier drafts, and to
two anonymous reviewers.
Notes
1. Monbiot (2003), in an essay on creating a global democracy to countervail the abuses of unfettered global capit-
alism, makes the point that international or multilateral approaches based on today’s institutions are inadequate.
If all countries did decide to re-confine capital within their borders, internationalism might work. But poor
countries want foreign capital and the elite financial and export interests in rich countries have no desire to
be re-nationalized. These interests dominate most political parties, while all of our current international institu-
tions, from the United Nations to the IMF and World Bank, routinely defer to the United States. Only new
global responses and structures will be able to correct these international inequalities in power.
2. Even the recent report of the UN Millennium Project, which calculates the domestic and international aid
resources required to meet the Millennium Development Goals (see Table 2), and which takes into account
aid, trade, debt cancellation and economic growth factors, is rather anodyne with regard to the impacts of eco-
nomic globalization (UN Millennium Project, 2005). It calls for increased developing country public spending
on health and education through better tax measures even as it urges tax holidays to attract foreign direct invest-
ment and proposes regressive value-added taxes as the principal domestic revenue generator. It sees no conflict
(real or potential) between the interests of the private (corporate) sectors, the public sector and civil society orga-
nizations, particularly in the delivery of essential health and water/sanitation services. It claims a human rights-
based approach to development is powerfully linked to economic growth but is silent on the human rights abuses
in China, the developing country demonstrating the greatest (albeit disputed) growth and poverty reduction
174 R. Labonte & R. Torgerson
data. It costs out a comprehensive ‘scaling up’ of HIV/AIDS intervention programs, but is largely silent on the
historic global context that abetted the pandemic. While harsh on rich world agricultural subsidies, it proposes
deeper liberalization for poor countries upon which its scaled up assistance package may be conditional, essen-
tially imposing a rich world economic model on all other countries. It assumes that, with suitable investments in
environmental technologies, rapid global growth will not imperil the planet’s remaining stock of natural capital.
Thus, while more indicative of what we call a ‘global health’ approach, the project stops substantially short of
being ‘critical’ in its analyses.
3. There are sharp debates about the impacts of globalization on poverty and economic growth. A much cited
World Bank claim that globalization has reduced the number of people in extreme poverty (< $1/day) by
over 200 million since 1980, due largely to economic growth in China and India (Dollar, 2002), rests on unreli-
able data and has been challenged on methodological grounds (Wade, 2002). There are fewer disputes about the
rise in income inequality. Whether income inequality is the root of disease inequality, however, remains conten-
tious (Deaton, 2001). Poverty, which is higher in high income-inequality countries, may the bigger problem. But
the greater the income inequality the harder it becomes for the economic growth presumed to follow trade lib-
eralization to actually lift people out of poverty. Moreover, income inequality is associated with declines in social
cohesion, social solidarity and public support for strong states with strong redistributive income, health and edu-
cation policies that have been shown to buffer liberalization’s un-equalizing effects (Deaton, 2001; Global Social
Policy Forum, 2001; Gough, 2001). Income inequality is also associated with higher rates of homicide, suicide
and generalized conflict. Dollar (2001), in his ‘health defence’ of globalization, argues that liberalization does
not cause inequality because there is no consistent pattern between the two. However, those market-liberalizing
developing countries experiencing the greatest economic growth (China, Vietnam and India) are also the ones
experiencing the sharpest increases in income inequality. The liberalizing countries where income distribution
became more equal were those that failed to grow, i.e. everyone remained poor. Moreover, Dollar (2002)
acknowledges that, assuming continued trade liberalization, global income inequalities will increase steeply by
2015.
4. See McIntyre, Thomas and Cleary (2004) for an important case study of post-apartheid South Africa. The
newly elected ANC government voluntarily adopted neoliberal policies of liberalization and constraints on
public sector spending (including health, at a time when the HIV/AIDS pandemic was rising both in prevalence
and attention) in order to attract foreign direct investment and signal ‘fiscal probity’ to global markets. One
might rightly see this choice as coerced, however subtly, by the broader globalization context; it also underscores
the care that must be taken in determining the direct and indirect influences of globalization’s processes on
health-determining pathways.
5. Figure 1 ‘overviews’ the framework and allows the reader to grasp its broad shape. Figure 2 unpacks its levels
in more detail. We provide both versions in this article since Figure 2 is often difficult to grasp without first
seeing its simpler contours. The boxes in Figure 2 are numbered, and are referred to by number in an example
provided in our concluding section.
6. The loss of domestic regulatory capacity and space that this article documents as consequent to contemporary
globalization has tempted some to announce the death of the nation-state as an important political actor. This
is not the case. First, nations have created and agreed to the new global economic rules that subsequently
diminished their own policy flexibility. Once created, these rules become a path-dependent force making it
difficult, although not impossible, to alter the rules in the future. Moreover, considerable variation in domestic
policies has persisted over the past two decades of global market integration. The Nordic countries continue
to have high-tax, high-welfare, low-poverty capitalist regimes that also perform better, economically, than do
most of the Anglo-American low-tax, low-welfare, high-poverty capitalist regimes. More at issue, and the
reason why ongoing study of globalization’s health impacts is important, are the effects of new global eco-
nomic rules on developing countries to achieve the type of welfare capitalism still enduring in much of
Northern Europe.
7. Intermediary Global Public Goods (IGPGs) comprise another element in our list of globalization processes.
IGPGs refer to the agencies and regulatory structures for ‘global public goods’, or GPGs. The GPG concept
is a new expansion of the classical economic construct of public goods. At issue for a critical population
health approach is that the GPG concept is beset by definitional disputes. Some claim that free trade agreements
are GPGs on the assumption that they promote economic growth, which, by definition, is a public good. Others
argue that such agreements are global public ‘bads’ by virtue of the inequities in wealth distribution they exacer-
bate and the environmental pollution and resource depletion that usually accompanies rapid growth. Detailing
the debates over GPGs is beyond the scope of this article; for further discussion, see Blouin, Foster and Labonte
(2004); Kaul, Grunberg and Stern (1999); and Woodward and Smith (2003).
8. The ‘debt overhang’ is considered to be a major factor in the inability of least developed countries to sustain
or benefit from economic growth (UNCTAD, 1999). It is also a major impediment to their ability to invest
in health, education, water, sanitation and other essential human development infrastructures. For example,
scheduled debt service in Zambia and Tanzania exceeds 40% of their governments’ budgetary resources
(AFRODAD, 2002). African countries are currently paying over $15 billion annually in debt servicing
charges to rich country creditors, an amount that equals the total aid they receive (OECD, 2002, p. 258).
The advocacy of debt cancellation organizations, such as Jubilee Research and the 2005 ‘Make Poverty
History’ campaign, has intersected with research findings that many low-income countries will be unable
to make progress on MDG targets unless their debts are written off (UN Millennium Project, 2005).
Interrogating globalization, health and development 175
The speed with which the US mobilized massive debt cancellation for (otherwise oil-rich) Iraq also
engendered a growing awareness amongst wealthy creditor nations that it was politically unwise not to con-
sider deeper and more widespread debt write-offs for the world’s poorest countries, especially those strug-
gling with HIV/AIDS and other disease pandemics. Despite growing support for such debt cancellations,
and some unilateral action such as the UK’s pledge to pay a portion of poor country debt owed to the
World and African Development Banks, no multilateral commitments for debt cancellation have been
made at time of writing (January 2005).
9. Cornia (2001) and Cornia and Court (2001), amongst others, argue that liberalization in capital markets has
had far more negative health effects than liberalization of trade in goods, including the increased vulnerabi-
lity of national economies to capital flight and currency collapse. In each country affected by such currency
collapses, the result has been increased poverty and inequality, and decreased health and social spending
(O’Brien, 2002).
10. A 2004 WTO agreement on a ‘framework’ for the gradual removal of rich country agricultural subsidies
resolves little; the details of what, when and how the subsidies will be removed are still subject to ongoing
WTO negotiations.
11. For reasons of space, discussion of the remainder of the framework is necessarily truncated. A longer elabora-
tion can be found in Labonte & Torgerson (2003).
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Interrogating globalization, health and development 179
... My second example focuses on transformation. It is grounded in the global health model developed by Labonte and Torgerson (2005 ). As shown in Figure 1, the model acknowledges bidirectional connections between policy and action at multiple levels, which run from individual to superordinate categories. ...
... Based on the Labonte and Torgerson (2005 ) model, the interactions between levels of power start to become evident. The top-down funder expected results from the evaluation that reflected their normative understanding of value, merits, and worth. ...
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... But still, it fosters economic growth, and the more globalised countries witness higher economic growth (Dreher, 2006;Missoni, 2013). Improvements in health status, healthcare services, and health systems of countries (such as China, Vietnam, and India) can be attributed to deregulation in the domestic market and abolition of barriers to international trade (Cornia, 2001;Labonte & Torgerson, 2005). ...
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... It is clear today that, left to their own devices, health systems do not naturally tend to move in the direction of the objectives of health for all, thus deviating more and more from providing care primary healthcare articulated in the Alma-Ata Declaration. Indeed, today´s health systems are developing in directions that do little to contribute to equity and social justice, and fail to derive the best health outcomes from their investments [5,6]. ...
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... It is clear today that, left to their own devices, health systems do not naturally tend to move in the direction of the objectives of health for all, thus deviating more and more from providing care primary healthcare articulated in the Alma-Ata Declaration. Indeed, today´s health systems are developing in directions that do little to contribute to equity and social justice, and fail to derive the best health outcomes from their investments [5,6]. ...
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This article attempts to analyze the problem of the modernity of primary healthcare, as well as the reforms to be implemented in a new context characterized by COVID-19. This article offers another vision to follow, to build a modern primary healthcare system. It is a descriptive and analytical study, which addresses the failure of the health system in general, as it proposes the reforms necessary to provide equitable, efficient and modern primary healthcare. The results clearly show that we can no longer act unilaterally; multi-sector efforts at the national level should be encouraged: we must act, in a preventive way, on the causes of the disease; international agreements on the environment, prices of basic foods and medicines, etc. are much needed to improve the health status of middle and low income countries, the case of the majority of African countries. So, different solutions can be conveyed by primary healthcare, in order to improve the whole health system.
... De igual forma se valoran otros estudios del turismo en que se utiliza esta aproximación cualitativa participativa (Freitag 1996;Stonich 2000;Taylor 1993). Énfasis particular se confiere a resultados relacionados con la salud y el desarrollo del turismo (Frechtling 1997;Richter 2003) sostenible en regiones insulares (Apostolopoulos and Sonmez 2002;González 2006), reconociendo las implicaciones para las comunidades anfitrionas (Cohen 1984;Joseph and Kavoori 2001) y los efectos de la globalización sobre el desarrollo local y la salud (Cameron 2000;Labonte and Torgerson 2005;McMurray 2004). ...
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Ergotherapeutische Modelle strukturieren unser Denken und unsere Arbeit. Sobald wir mit Klienten aus einem anderen Kulturraum arbeiten, stoßen wir jedoch an unsere Grenzen. Das ist wenig verwunderlich, da viele unserer Modelle, Theorien und Forschungsarbeiten in der westlichen Kultur entwickelt wurden – meist von gesunden weißen Frauen.
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This collection of papers offers a new rationale and framework for international development cooperation. Its main argument is that in actual practice development cooperation has already moved beyond aid. In the name of aid (i.e., assistance to poor countries), we are today dealing with issues such as the ozone hole, global climate change, HIV, drug trafficking, and financial volatility. All of these issues are not really poverty related. Rather, they concern global housekeeping: ensuring an adequate provision of global public goods. Many important lessons could be drawn by first recognizing this fact – revealing innovative reforms toward more effective international policy making in the twenty‐first century.
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Do countries with lower policy-induced barriers to international trade grow faster, once other relevant country characteristics are controlled for? There exists a large empirical literature providing an affirmative answer to this question. We argue that methodological problems with the empirical strategies employed in this literature leave the results open to diverse interpretations. In many cases, the indicators of "openness" used by researchers are poor measures of trade barriers or are highly correlated with other sources of bad economic performance. In other cases, the methods used to ascertain the link between trade policy and growth have serious shortcomings. Papers that we review include Dollar (1992), Ben-David (1993), Sachs and Warner (1995), and Edwards (1998). We find little evidence that open trade policies--in the sense of lower tariff and non-tariff barriers to trade--are significantly associated with economic growth.
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The process of global economic integration has sharply altered the context in which most governments are thinking about policies for economic development. The world economy and the 'dictates' of international economic integration loom much larger than ever before. Indeed, in many 'emerging' economies traditional developmental concerns relating to industrialization and poverty have been crowded out by the pursuit of 'international competitiveness'. Openness to the world economy can be a source of many economic benefits. The importantion of investment and intermediate goods that may not be available domestically at comparable cost, the transfer of ideas and technology from more developed nations, and access to foreign savings can help poor nations circumvent some of the traditional obstacles to rapid growth. But these are only potential benefits, to be realized in full only when the complementary policies and institutions are in place domestically. The claims made by the boosters of international economic integration are frequently inflated or downright false. Countries that have done well in the postwar period are those that have been able to formulate a domestic investment strategy to kick-start growth and those that have had the appropriate institutions to handle adverse external shocks, not those that have relied on reduced barriers to trade and capital flows. The evidence from the experience of the last two decades is quite clear: the countries that have grown most rapidly since the mid-1970s are those that have invested a high share of GDP and maintained macroeconomic stability. The relationship between growth rates and indicators of openness - levels of tariff and non-tariff barriers or controls on capital flows - is weak at best. Policymakers therefore have to focus on the fundamentals of economic growth - investment, macroeconomic stability, human resources, and good governance - and not let international economic integration dominate their thinking on development.