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Chapter 2
Macrosocial Determinants
of Population Health in the Context
of Globalization
Lia S. Florey, Sandro Galea, and Mark L. Wilson
15
1. Introduction
We live in an increasingly interconnected world, as some like to say, a “global vil-
lage.” As in any village, social, economic and biophysical environments shape
individual action and interaction, which, in turn, influence the quality of life and
the health of inhabitants. Technology, information, media, food, goods and serv-
ices, as well as environmental pollution and diseases are shared among villages,
cities, countries and continents. Not only are these exchanges great in scope, but
the magnitude and speed of interaction among individuals and populations is also
increasing. For example, international trade grew 8.6% per year during the
decade 1990–1999 (World Trade Organization, 2000a, b), with an estimated
US$1.7 trillion in daily global trading (Lee, 2000). An estimated 760 million
people traveled to international destinations in 2004 (World Trade Organization,
2005), and circumnavigation of the globe is now possible in a mere 36 hours
(Smolinski, Hamburg, & Lederberg, 2003). Immigration contributes to global
exchanges, with an estimated 175 million individuals spending at least one
year in another country (United Nations, 2002). Additionally, approximately
17 million refugees and internally displaced persons migrate from their homes
every year (United Nations High Commissioner for Refugees, 2004). These
trends of growing interactions on the global scale shape the environments in
which we live and which influence our well-being and our health.
The term globalization is used to denote these global trends in exchanges and
interactions. Historically, globalization has been defined in economic terms as
“the removal of tariff and non-tariff barriers to trade” (Weisbrot, Baker, Kraev, &
Chen, 2002) or “the process whereby national and international policy-makers
promote domestic deregulation and external liberalization” (Cornia, 2001). We
argue, as have many before us, that globalization is comprised of much more
than fiscal trends and policies. For the purposes of this review we use an expan-
sive definition for which globalization consists of the “processes contributing to
intensified human interaction in a wide range of spheres (that is, economic,
political, social, environmental) and across three types of boundaries—spatial,
temporal and cognitive—that have hitherto separated individuals and societies”
16 Florey et al.
(Bettcher & Lee, 2002). Implicit in this definition is the ubiquity of globalization
processes and the pervasiveness with which these processes affect human lives.
Although the existence of global influences on individuals and populations is
clear, the effect of globalization on individual well-being and population health is
not well established. Empirical evidence suggests both positive and negative
effects of globalization on health, but there is no simple equation that can encap-
sulate how globalization may improve, or harm, population health. Instead it is
likely that myriad processes comprise globalization, and each may influence the
health of populations through multiple pathways. The challenge lies in elucidat-
ing the mechanisms by which globalization affects health. An understanding of
these mechanisms will inform the decision-making process and enable imple-
mentation of policies that will mitigate the negative consequences of globaliza-
tion and enhance its potential positive influences.
This chapter addresses an important gap in knowledge on the global context of
population health by providing a conceptual framework from an epidemiologic
perspective. The aim of this framework is to facilitate understanding of the com-
plex relationships among globalization, macro-level determinants of health, and
population health. The relationships between each component of the framework
and population health will be briefly discussed followed by a presentation of
potential mechanisms that may explain these associations. This chapter integrates
current knowledge pertaining to the relationships of interest, generates hypothe-
ses about mechanisms where current knowledge is scarce, and presents a brief
discussion of methodological issues pertaining to epidemiologic studies of glob-
alization and population health. We acknowledge that we approach this chapter as
epidemiologists, building explicitly on epidemiologic multilevel thinking. We
suspect that other disciplinary perspectives may approach the issue of globaliza-
tion differently. We hope that our approach is illuminating, regardless of the
reader’s disciplinary orientation, and may engender discussion and debate that
can bring about cross-disciplinary synthesis.
1.1. Framework
Globalization is characterized by a plethora of components that may influence
health at the population level. We propose a framework that summarizes a few key
characteristics of the global, national and community level environments that are
associated with population health. This framework builds on previously published
conceptual models (Huynen, Martens, & Hilderink, 2005; Labonte et al., 2002;
Spiegel, Labonte, & Ostry, 2004; Woodward, Drager, Beaglehole, & Lipson,
2001) and on the broader literature examining the effects of contextual determi-
nants on health (Galea, Freudenberg, & Vlahov, 2005; Galea, Rudenstine, &
Vlahov, 2005; Kaplan, 1999; Link & Phelan, 1995).
Our framework (Figure 2.1) builds upon the emerging thinking about multiple
“levels” of determination of population health (Kaplan, 1999) and suggests that
three levels of variables may be considered central to the role played by global-
ization in population health. Global-level factors (including global trade, income
distribution, population movement, global governance and communications) are
conceptualized to shape national-level factors (infrastructural resources, employ-
ment, income growth, population density, and national governance). The
national-level factors influence community-level factors (resource allocations,
social services, physical environmental, social environment, and population het-
erogeneity). In turn, each of these elements are affected by global distributions
and dynamics of power, as well as by underlying conditions such as history, cli-
mate, and geography that are represented by the horizontal rows at the top and the
bottom of the model. Although this framework is designed to be hierarchical,
with global-level factors influencing population health through the national and
community-level factors, we recognize that there will be some direct effects
between elements at any level of organization and health. Similarly, we consider
that these associations could be bidirectional (a national-level factor may directly
influence a global-level factor) as well as vertical (interrelationships among sev-
eral components at the global level). The aim of this conceptual model, however,
is to present the integral role of global-level processes in influencing population
health as part of a multivariate, multilevel framework. This simplification of what
is undoubtedly a far more complex web of associations is intended to clarify the
current state of knowledge and help guide future research.
Although an unconventional approach, we begin by exploring the proximal
relationships between community level factors and population health before
approaching the more distal national-level and global-level factors (moving from
right to left in Figure 2.1). This strategy allows clearer and more explicit develop-
ment of the pathways through which globalization exerts influence on health and
is compatible with clinical and epidemiologic approaches to health research.
2. Macrosocial Determinants of Population Health 17
FIGURE 2.1. Conceptual framework summarizing how characteristics of the global, national
and community-level environments may influence population health
2. Community-Level Processes
Despite extensive public health research focusing on the “community,” a defini-
tion of this concept remains elusive. Considerable recent investigations have
addressed “neighborhoods,” while others have grouped people into census tracts
or other administrative units. Such groupings may be convenient, affordable or
otherwise useful for spatial analyses; however, they do not always carry social
meaning for individuals. For purposes of this review, communities are defined as
any sub-national aggregation that is socially meaningful to local residents.
As many scholars have noted, diverse aspects of community life that we char-
acterized in Figure 2.1 play an enormous role in forming the health profiles of
populations. These are the most proximal of the macro-level health determinants
that are addressed in this chapter and should therefore affect population health
indicators through the most direct pathways. Yet we recognize that multiple ele-
ments of communities may interact to shape health indicators through more com-
plex, indirect pathways. The brief descriptions and examples presented below are
not meant to be exhaustive, but rather to illustrate a few specific mechanisms
whereby population health is affected by the environmental, social and political
realities of communities.
2.1. Resource Allocation
Community allocation of resources affects population health through direct and
indirect pathways. Directly, certain basic resources are necessary for the mainte-
nance of body functions. Access to a sufficient quantity and quality of food is
essential for proper nutrition. Malnutrition and undernutrition have severe conse-
quences for growth and development of children (de Onis, Monteiro, Akre, &
Glugston, 1993; Stevenson, Latham, & Ottesen, 2000; Weinreb et al., 2002), as
well as for the functioning of the immune system and prevention of disease
(Cunningham-Rundles, McNeeley, & Moon, 2005). Adequate nutrition requires
either enough arable land for local food production or access to markets with
imported food and income with which to purchase the food. Not only are the
absolute quantities and costs of these resources in a community important, but the
distribution of these resources also contributes to shaping health outcomes. For
example, the availability and cost of fresh fruits and vegetables and the spatial
patterns of supermarkets are strongly linked to the income and racial characteris-
tics of neighborhoods in Detroit (Zenk et al., 2005; Zenk et al., 2006)
Similarly, the quantity and quality of a community’s water supply is an important
determinant of people’s health (United Nations, 2005). Insufficient water sources
may lead to insufficient food supplies due to lack of irrigation of crops. The
economies of developing countries are highly dependent on agriculture, which gen-
erates 80% of export earnings; however, this important source of income requires
almost 70% of the world’s freshwater use (United Nations, 2005). In communities
where potable water sources are far from residences, considerable time and energy
is expended supplying households with water (Cosgrove & Rijsberman, 1998).
18 Florey et al.
It has been estimated that 40 billion working hours are lost in Africa each year due
to time spent transporting water, with the burden falling most heavily on women
and children (United Nations, 2005). Poor quality water in conjunction with poor
sanitation and hygiene is responsible for 1.6 million deaths per year due to diseases
such as cholera, typhoid fever, trachoma, and schistosomiasis, to name a few
(World Health Organization, 2004). Water can also be a source of toxicity. The well
water consumed by 28–35 million Bangladeshi (United Nations, 2005) contains
high levels of arsenic, causing skin lesions and various cancers (Smith, Lingas, &
Rahman, 2000).
Shelter from the elements is another essential resource influenced by community-
level factors. Good quality construction (Konradsen et al., 2003; Yé et al., 2006), and
screened windows and doors (Lindsay, Emerson, & Charlwood, 2002) prevent
spread of vector-born diseases such as malaria. Quality housing protects inhabitants
from climate extremes (heat, cold, wet), which contribute to disease and mortality
(Evans, Hyndman, Stewart-Brown, Smith, & Petersen, 2000; Gemmell, 2001; The
Eurowinter Group, 1997). Insufficient physical space in a community may lead to
overcrowded housing, which facilitates the spread of communicable diseases such as
tuberculosis (Antunes & Waldman, 2001) and helminth infections (Carneiro,
Cifuentes, Tellez-Rojo, & Romieu, 2002). Indoor air quality is another important
characteristic of housing that can influence the risk of respiratory diseases (Bruce,
Perez-Padilla, & Albalak, 2000).
In a similar manner, medications also are essential community resources.
Insufficient or unreliable supplies of medications have serious health repercus-
sions by contributing directly to morbidity and mortality as well as to drug resist-
ance (Draper, Brubaker, Geser, Kilimali, & Wernsdorfer, 1985).
Aside from essential resources, communities also have differential access to
goods that may be deleterious to health, such as tobacco, alcohol and nar-
cotics. For example, neighborhoods in Baltimore, Maryland, comprised pre-
dominantly of African Americans have a higher density of alcohol distributing
outlets than neighborhoods with different racial demographics (LaVeist &
Wallace, 2000). Many other such directly detrimental social impacts exist at
the community level.
Indirectly, the distribution, volatility, and cost of these resources in the com-
munity are likely to have effects on social interactions and behaviors which may
shape population health (Gopalan, 2001). Food insecurity causes psychosocial
stresses that are harmful to mental health and can increase susceptibility to other
acute and chronic diseases (Weinreb et al., 2002). Residential crowding, result-
ing from limited access to housing or from prohibitory housing costs, also
contributes to psychosocial stress in a community (Krieger & Higgins, 2002).
Unequal access to basic resources such as food, water, housing and medical sup-
plies may have repercussions for the entire community by decreasing social
cohesion (Wakefield & Poland, 2005). Social cohesion and collective efficacy
help to defend a community against crime and vandalism (Kawachi, Kennedy,
Lochner, & Prothrow-Stith, 1997) and provide social resources that buffer the
negative health effects of being resource deprived (Sampson, Raudenbush, &
Earls, 1997) (see Section 2.4).
2. Macrosocial Determinants of Population Health 19
2.2. Social Services
Communities with local access to health care, emergency and security services,
good educational opportunities and social support systems such as welfare and
social security are more likely to have good health (Cheadle et al., 1991). Access
to these social services increases opportunities to obtain necessary resources (dis-
cussed above) and provides a buffer against volatile economic situations.
Important issues include presence of these services, physical proximity to com-
munities, cost and distribution.
Mechanisms by which social services affect community health include the
provision of basic human needs (e.g. food, shelter, medications) or the means by
which people meet those needs (e.g. employment or supplementary income). For
example, communities that lack access to good quality health services may have
higher burdens of disease because sick individuals will delay seeking care or will
turn to alternative options, such as traditional healers or self-treatment (Chen
et al., 2004; Meerman et al., 2005). Delayed treatment can have serious health
consequences. For example, Gambian children presenting with severe malaria
were significantly more likely to have delayed seeking treatment by more than
four days than were those presenting with mild malaria (Meerman et al., 2005).
Furthermore, self-medication may encourage drug resistance, as has been
observed with malaria (Evans et al., 2005). Because poor or nonexistent welfare
services can lead to increased poverty, malnutrition, homelessness, and starvation
(Marmot, 2002) as well as reduced access to good education, such services have
long been considered a “fundamental” determinant of health (Adler & Newman,
2002; Adler & Ostrove, 1999; Link & Phelan, 1995). Education also may affect
health by increasing knowledge of healthy behaviors and by increasing employ-
ment opportunities that provide income to meet basic health needs (Ross & Wu,
1995). Individuals with better education live longer and suffer less morbidity than
do their more poorly educated counterparts (Bobak, Hertzman, Skodova, &
Marmot, 1999; Hemingway, Shipley, Macfarlane, & Marmot, 2000; Lynch,
Kaplan, Salonen, Cohen, & Salonen, 1995). Research by Winkleby and others
(1992) revealed that even after controlling for the effects of income and occupa-
tion, education reduced risk of cardiovascular disease. Emergency services pro-
vide urgent care, which can lessen population morbidity and mortality. Security
services such as fire fighting and policing help to deter crime and violence, which
have serious implications for health. For example, the 1975 fiscal crisis in New
York City led to a 20% reduction in the number of city police employees, which
likely contributed to the homicide epidemic of the 1980s (Freudenberg, Fahs,
Galea, & Greenberg, 2006).
2.3. Physical Environment
Environments have long been recognized to play an important role in population
health, from the ancient Greek’s association of malaria with swamps to the miasma
theorists purporting that squalid living conditions caused illness. With the advent
20 Florey et al.
of germ theory and the advancement of modern epidemiologic methods and statis-
tical tools, our understanding of relationships between environmental conditions
and health outcomes has deepened. We now recognize that forces at many levels
shape environments and associated diseases. Global climate patterns influence
temperature, precipitation, and extreme weather events; accumulating evidence
suggests that human behaviors, such as the expanding use of fossil fuels, are caus-
ing rapid changes in climate (Vitousek, Mooney, Lubchenco, & Melillo, 1997).
Similarly, air and water pollution are affecting the quality of local, national and
global environments and are shaped by human behaviors at each of these
spatial/political scales. At the community level, environments are defined in part
by physical conditions, which are affected by local, state or federal policies, such
as zoning laws (Schilling & Linton, 2005), as well as by human behaviors and
actions such as vandalism (Ross & Wu, 1995). The range of health indicators
influenced by the built environment is vast and includes mental health (Weich
et al., 2002), sexually transmitted infections (Cohen et al., 2000; Cohen, Mason
et al., 2003), crime and violence (Newman, 1986; Sampson et al., 1997), substance
abuse (Galea, Rudenstine et al., 2005), cardiovascular disease (Diez Roux, 2003)
and physical activity (Frumkin, 2002), to name a few. Local environments, includ-
ing homes and workplaces, may be sources of exposures to toxic substances, aller-
gens or poor air quality (Bruce et al., 2000). Aspects of the outdoor environment
are recognized as contributors to increased injury (Moore, Teixeira, & Shiell,
2006) or breeding of disease spreading vectors (McMichael et al., 1999; Moore,
Gould, & Keary, 2002).
Community-level environmental characteristics and their potential health
effects range in complexity and diversity. Climatic factors recently have drawn the
attention of epidemiologists as measurement and analytic tools have improved.
Greater climate extremes and global climate changes create or destroy microhabi-
tats for many organisms that affect people’s daily lives. Some changes may be ben-
eficial, but most are expected to challenge efforts to improve health, particularly in
developing countries. For example, insects that serve as vectors for various infec-
tious diseases may become more abundant or widespread with global warming.
One example is the possible increased range of malaria into previously uninfected
highland regions (Bouma, Dye, & Van der Kaay, 1996; Loevinsohn, 1994;
Zhou, Minakawa, Githeko, & Yan, 2004). Climate change, including extreme
events, has been associated with other infectious diseases as well, such as cholera
(Pascual, Rodo, Ellner, Colwell, & Bouma, 2000), cryptosporidiosis (Atherholt,
LeChevallier, Norton, & Rosen, 1998), and other water-borne diseases (Curriero,
Patz, Rose, & Lele, 2001).
Similarly, changes in precipitation and temperature may affect local agricultural
yields, thereby affecting food availability with all of the accompanying health
implications (Fischer, Shah , Tubiello, & van Velhuizen, 2005). As another exam-
ple, temperature extremes may have direct effects on mortality, especially for poor,
elderly or otherwise disadvantaged individuals. A heatwave in Chicago in July of
1995 resulted in 460 excess deaths that disproportionately affected African
Americans and bed-ridden individuals (Semenza et al., 1996). In southern Chile,
2. Macrosocial Determinants of Population Health 21
exposure to UV-B radiation due to the proximity to the Antarctic ozone hole has
been linked to increased sunburn and photosensitivity (Abarca, Casiccia, &
Zamorano, 2002), and increases in skin cancer rates have been predicted (Jones,
1987). Limiting outdoor activities might protect against these health risks, yet this
may cause other morbidities, such as obesity and diabetes, due to decreased phys-
ical activity (Gracey, 2002; McMichael, 2000). Many health effects of the built
environment are certainly mediated by forces of the social environment.
2.4. Social Environment
Environments are not only physical but are also social. Social environments shape
our interactions, our beliefs and our behaviors, all of which have health effects. To
complicate matters, social environments likely interact with physical environ-
ments in their relationships with population health.
Aspects of the social environment that are likely to influence human health
include social disorganization, social resources (including support and capital),
social contagion, spatial segregation and inequality. The theory of neighborhood
social disorganization, arising from sociological research of urban Chicago in the
1940s, posits that social disorder is conducive to deviant behavior and crime
(Shaw & McKay, 1942). This theory hypothesizes that social disorder originates
from lack of social control, low density friendship networks, and lack of partici-
pation in local organizations (Sampson & Groves, 1989). More recent research
has shown that communities with high social disorganization are more likely to
suffer from violence, victimization and homicide (Sampson et al., 1997), as well
as coronary heart disease (Sundquist et al., 2006). Social disorganization may
arise from inequalities in levels of deprivation and lead to anomie, defined as
strain caused by disparate levels of attainment within a community (Kawachi,
Kennedy, & Wilkinson, 1999). Social strain not only encourages deviant behavior
and crime (Agnew, 1992), but also has been shown to be associated with
increased homicide and cardiovascular mortality (Cohen, Farley, & Mason,
2003). Social strain may also cause physiological stress responses, which have
well established links with mental and physical health (Elliott, 2000; Latkin &
Curry, 2003; Ross & Mirowsky, 2001).
Social resources, including social support and social capital, are recognized to
provide better coping mechanisms for difficult situations and are therefore associated
with better health (Kawachi & Berkman, 2001; McLeod & Kessler, 1990). Social
capital is also likely to help buffer negative health effects of social disorder by pro-
viding economic and social support (Sampson et al., 1997). Negative associations
have been found between social capital and mortality (Kawachi et al., 1997;
Skrabski, Kopp, & Kawachi, 2004) and violent crime (Kennedy, Kawachi,
Prothrow-Stith, Lochner, & Gupta, 1998) and positive associations between social
capital and self-reported health (Subramanian, Kim, & Kawachi, 2002).
Social contagion, or social influence, is thought to affect health by the sharing
of behaviors and attitudes among members of social networks, which can have
both positive and negative health effects. These social norms are important in the
22 Florey et al.
transmission of infectious diseases, such as sexually-transmitted infections (STIs)
and HIV (Pick & Obermeyer, 1996; Wellington, Ndowa, & Mbengeranwa, 1997),
as well as in the spread of behaviors such as suicide (Phillips & Carstcnsen, 1986)
and criminality (Jones & Jones, 1995).
2.5. Population Heterogeneity
The spatial distribution of racial and ethnic groups or groups of different socio-
economic status may contribute to the determination of population health. From an
economic viewpoint, segregation leads to homogeneity of resources, where those
with low socio-economic position cannot access the resources that benefit more
affluent individuals. Segregation by socio-demographic characteristics is known to
accompany differential exposure to poor quality environments, including toxins,
crime, violence, poverty and infectious diseases (Cohen, Mason et al., 2003). Poor,
segregated populations have restricted access to health care services, shortages
of health care providers and many under- or un-insured individuals (Mayberry,
Mili, & Ofili, 2000). Finally, segregation and income inequality can cause both
perceived and actual inequity, which erodes social trust and diminishes social cap-
ital with the resulting health effects as discussed above. This process may be
enhanced by spatial proximity of the rich and the poor (Kaplan, Pamuk, Lynch,
Cohen, & Balfour, 1996; Kawachi et al., 1997; Mayberry et al., 2000).
In contrast, spatial heterogeneity of socio-economic groups encourages diver-
sity and allows an opportunity for resource sharing. Wealthier individuals may be
encouraged to use their money and power to improve the access and distribution of
resources needed for good health. This heterogeneity may also provide access to
broader social networks, including positive role models and salubrious social
norms. For example, unequal distribution of education in communities in New
York City has been shown to have salutary effects for all residents, suggesting ben-
efits of actions of highly educated individuals (Galea & Ahern, 2005). However,
heterogeneous social environments may encourage social strain by providing
images of unachievable aspirations to those with poor access to resources and few
opportunities for advancement (Kawachi et al., 1999; Sampson & Groves, 1989).
3. National-Level Processes
A substantial amount of epidemiologic research has examined the role of global-
ization in shaping population health at the national level. Cross-national compar-
isons of health indicators have investigated the effects of national income (Dollar,
2001; Lynch, Smith, Kaplan, & House, 2000; Weisbrot et al., 2002), mode of
governance (Navarro & Shi, 2001), and average educational attainment
(Williamson & Boehmer, 1997), among others. We add to this body of literature
by explicitly hypothesizing mechanisms through which aspects of nations may
influence health and the extent to which this is mediated by the community-level
determinants of health discussed above.
2. Macrosocial Determinants of Population Health 23
3.1. Infrastructural Resources
Availability of national resources and the distribution of those resources have
great potential to influence population health. To the extent that money can
finance infrastructural development, overall national income becomes an
important element in this equation. National incomes are based on myriad fac-
tors, including exploitable natural resources, position in the global economy,
import tax policies, and domestic tax policies. Income alone, however, does not
equal infrastructure. National governments make choices about how income
will be spent.
Explicit pathways through which national infrastructural resources may affect
population health are many, making a thorough cataloguing beyond the scope of
this chapter. We present a few examples for illustrative purposes.
Underinvestment in national health services can be manifest through scarce
health clinics, hospitals or health providers, inadequate accessibility, or poor
quality of available health services (Chen et al., 2004). Low salaries and unpleas-
ant work conditions lead health providers in some low-income nations to migrate
to better opportunities (Brown & Connell, 2004). Such “brain drain” compounds
the negative health effects of underinvestment in health services by reducing the
number of health providers, as well as the quality of available care (Brown &
Connell, 2004; Chanda, 2001; World Health Organization, 2006). Some evidence
exists that perceived poor quality of health services leads to underutilization of
these services and increased use of alternative resources (Haddad & Fournier,
1995; Segall, 2000). Alternatives include traditional healers or self-medication,
which may increase chances of inappropriate or insufficient treatment, possibly
also encouraging drug resistance for certain pathogens (Evans et al., 2005).
Underinvestment in social resources at the national level is also an important pre-
dictor of population health (Davey Smith, 1996; Wagstaff, Bustreo, Bryce, &
Claeson, 2004). Societies with a large proportion of uninsured or underinsured indi-
viduals who cannot afford health care costs are at risk for sustained transmission of
communicable diseases as well as high burdens of disability due to untreated
chronic diseases (Hadley, 2003; Institute of Medicine, 2002). A lack of support for
people who are unemployed, unable to work, or underpaid increases poverty levels.
Poverty is recognized as an important determinant of population health through a
vast array of mechanisms, including increased susceptibility to disease due to poor
nutrition (Wagstaff et al., 2004) and incomplete vaccination (Klevens & Luman,
2001), increased contact with disease-causing agents due to unhealthy environ-
ments and crowding, and prolonged duration of disease due to lack of appropriate
treatment (Wagstaff et al., 2004).
Finally, underinvestment in environmental infrastructure, including roads, the
built environment, water and sewage systems, and electricity, also holds great
potential to reduce population health. For example, unpaved roads on a Native
American reservation in New Mexico were shown to discourage timely access to
health services in children with meningitis (Williams, 1987). Lack of potable
water and sewage and waste disposal facilitates the spread of infectious diseases
24 Florey et al.
(World Health Organization, 2004) and increases the stress and physical strain for
families (especially women and children) who must transport water long distances to
their homes (Cosgrove & Rijsberman, 1998; United Nations, 2005). Additionally,
poor water quality and inadequate sewage infrastructure may create breeding sites
for vectors that transport infectious disease agents (Keating et al., 2003).
3.2. Employment
The availability and nature of employment opportunities at the national level
have been shown to affect population health, especially overall mortality
(Gerdtham & Johannesson, 2005) and suicides (Dooley, Fielding, & Levi, 1996).
National employment trends may be examined by several characteristics. Most
commonly, unemployment rates are reported as an indication of the percentage
of a nation’s population that is unwillingly jobless. Another important element
of employment is salary, with information coming from both minimum wages
mandated by national law and the range and distribution of salaries in the coun-
try. Additionally, the permanence or reliability of employment and the type of
job and associated work conditions are national employment trends that shape
population health.
Unemployment, underemployment and nonstandard employment affect popu-
lation health through several mechanisms. First, joblessness usually accompanies
loss of income, which limits the purchase or attainment of necessary resources.
Unemployment or part-time or seasonal employment may lead to loss of medical
insurance to cover disease prevention and treatment (Ostry & Spiegel, 2004).
Another important mechanism by which unemployment affects health is by ele-
vating acute stress or creating situations of chronic stress. A large body of litera-
ture on the health effects of threatened job loss in factory workers reveals many
negative outcomes, such as elevated blood pressure, increased depression and
anxiety (Cobb & Kasl, 1977; Ostry & Spiegel, 2004), or diminished mental health
and increased stress (Hamilton, Broman, Hoffman, & Renner, 1990). A Danish
study conducted on bus drivers with restructured and contracted out jobs (less sta-
bility) found high levels of urinary cortisol and elevated blood pressure
(Netterstrom & Hansen, 2000). Non-standard work (part-time, contingent) may
also increase risk of stress and workplace injury (Quinlan, Mayhew, & Bohle,
2001). A complete review of the health effects of stress is beyond the scope of this
paper, but it includes reduced immunity to infectious diseases (Cohen, Tyrrell, &
Smith, 1991; Takkouche, Regueira, & Gestal-Otero, 2001), increased adoption of
unhealthy behaviors (smoking, drinking, etc.) (Adler & Newman, 2002) and
increased susceptibility to inflammatory diseases (Korte, Koolhaas, Wingfield, &
McEwen, 2005; McEwen & Seeman, 1999).
Even reliable employment with livable wages may affect population health
through the nature of the work and the work environment. Poor work environ-
ments place workers at risk for injury, respiratory disease, exposure to toxins and
infectious agents (Loewenson, 2001). For example, in African countries annual
injury rates for occupations such as mining, forestry and transport all exceed
2. Macrosocial Determinants of Population Health 25
30 injuries per 1000 workers (Loewenson, 1998). The risk for such negative
health outcomes at the national level depends greatly on the nature of available
jobs. Current global trends concentrate the risks of poor quality work environ-
ments and insecure, low paying, low quality jobs in less industrialized countries
(Loewenson, 2001). Women are disproportionately affected by these trends,
which compound the health affects of the social and economic marginalization
that they experience. A clear example is female employment in export processing
zones. These jobs provide low wages, exposure to toxic chemicals and sub-
stances, long work hours, physical brutality and psychological stress (Hippert,
2002; Loewenson, 2001). The health effects of child labor are also important. An
estimated 211 million children under the age of 14 and 352 million under the age
of 17 are part of the worldwide workforce, most in developing countries
(Habenicht, 1994; International Program on the Elimination of Child Labor,
2002). Child labor detracts from the benefits of education and has been shown to
be associated with stunting and wasting (Hawamdeh & Spencer, 2003).
3.3. Income Growth
National income growth is generally assumed to be beneficial for population
health (Marmot, 2002). More income means more resources that can be used to
meet the health needs of the population. In reality, the association between
national income growth and health is much more complex and depends on a wide
array of contextual factors. The important factors likely include fiscal and regula-
tory policies, level of dependence on imports and exports, level of indebtedness
and loan stipulations, and baseline income level as well as the distribution of the
income (Ayala-Carcedo & Gonzalez-Barros, 2005). Considerable economic liter-
ature on globalization argues that opening economies to the global market stimu-
lates economic growth, which, in turn, reduces poverty (Dollar & Kraay, 2002;
Frankel & Romer, 1999). Assuming that poverty reduction is good for health, it
logically follows that opening national economies will lead to healthier nations.
There are several problems with this argument. First, it is controversial whether
opening economies to the global market promotes national income growth
(Cornia, 2001). Support for this hypothesis is informed by Dollar and Kraay’s
(2002) findings. Their work relies heavily on data from India and China, presum-
ably because those countries represent such a large percentage of the world’s pop-
ulation; however, the experiences of Indian and Chinese economies post-trade
liberalization are not necessarily representative of all nations. Second, population
health indicators seem to be more sensitive to changes in national incomes with
lower baselines (Marmot & Wilkinson, 2001). Globalization’s effect on income
inequalities at both the global and national levels has been hotly debated (Lynch
et al., 2004; Subramanian & Kawachi, 2004; Wilkinson & Pickett, 2006) as has
the relative importance of income inequality versus income growth on health out-
comes (Lynch et al., 2000; Ross & Mirowsky, 2001). While readers can draw
their own conclusions in this debate, we present several mechanisms by which
national income growth may influence population health.
26 Florey et al.
Income growth provides government revenues and other societal resources
needed to supply goods and services (Dodgson, Lee, & Drager, 2002; Diaz-
Bonilla, Babinard, & Pinstrup-Andersen, 2002). Income growth may stimulate
national labor markets, thereby providing more jobs for the population.
Dependable employment with livable wages provides means for people to pur-
chase necessary resources such as food and health care (Collins, 2003). Being
securely employed also encourages feelings of self-worth and increases social
cohesion (Sen, 1997). However, if national income growth is based on volatile
economies, employment may be insecure and layoffs unexpected (Sen, 1997).
Various potential health effects of job insecurity were described in Section 3.2.
Another result of volatile income growth is sudden unexpected reductions in
household wealth, which may result in children leaving school to join the work-
force and sometimes engaging in high risk jobs such as prostitution (Cornia,
2001). Sudden decline in wealth may also compromise health by reducing quan-
tity and quality of nutrition (Cornia, 2001).
3.4. Population Density
Population density has long been associated with population health. Historic
studies of environmental determinants of disease in urban settings during the era
of industrialization in Europe comprise the backbone of modern social epidemio-
logic science. Conditions during that era, including rapid industrial development,
the breakdown of traditional social and ideological structures, and urban blight
followed by suburban flight of the wealthy, led to concentrated poverty, crowding,
death and disease in many urban settings (McMichael, 2000; Szreter, 1997).
Although these trends may be less relevant for societies in Western Europe and
other developed nations today, they are reality for nations in the developing
world. Population density is rising in many parts of the world due to rural-to-
urban migration (urbanization) and population growth (McMichael, 2000).
People searching for economic opportunities, employment and a better standard
of living, combined with destruction of habitats in rural areas, are among
the plethora of reasons for migration to cities in the developing world (see
Section 4.3). By 2007 it is estimated that over half of the world’s population
will live in urban settings, contrasted with only 5% at the beginning of the
19th century (United Nations Department of Economic and Social Affairs, 2003).
The proportion of urban dwellers is expected to grow to 60% by 2030 (United
Nations Department of Economic and Social Affairs, 2003). Additionally, the
size of urban populations is continuing to expand. From 1940 to the present,
the number of “megacities” with more than 10 million inhabitants rose from one
(New York City) to fifteen (Satterthwaite, 2000).
Among urban residents, crowding may occur due to poverty or lack of
habitable physical space. Evidence suggests that population density may
predict many health effects, including infectious diseases such as tuberculosis
(Antunes & Waldman, 2001) and acute respiratory infection (Lee, Jordan,
Sanchez, & Gaydos, 2005), chronic diseases such as stomach cancer (Barker,
2. Macrosocial Determinants of Population Health 27
Coggon, Osmond, & Wickham, 1990), and poor mental health (Lepore, Evans, &
Palsane, 1991). In addition, people living in dense populations experience higher
rates of violent death (Wallace & Wallace, 1998) and injury (LaScala, Gerber, &
Gruenewald, 2000) than do less dense populations.
Illuminating the mechanisms through which increased population density
may affect population health is more challenging than showing an association
exists. Perhaps the most intuitive relationship to discuss is that between popula-
tion density and risk of infectious disease. High population density means that
individuals will have a greater number of contacts with others. Contact rates are
an essential parameter in the risk of infectious disease transmission, particularly
for those diseases with person-to-person modes of transmission (Anderson &
May, 1991). A higher contact rate generally corresponds to more transmission,
all other factors being equal. Therefore, areas with high population densities are
more conducive to disease spread. In addition, populations living in crowded
conditions are also often those with the fewest resources (Baum, Garofalo, &
Yali, 1999). Crowding in situations of poor sanitation increases the spread of
infectious disease through increased risk of exposure to infectious agents in the
environment (Krieger & Higgins, 2002). These factors contribute to the ongo-
ing cholera pandemic, especially, for example, in areas such as the peri-urban
slums of Brazil (Nations & Monte, 1996). Similar concerns appear in other
parts of the world, such as Russia, where overcrowded prisons and insufficient
public health measures contribute to multi-drug resistant tuberculosis (TB)
(Holden, 1999). In Saudi Arabia, Muslim pilgrims gather annually during the
Hajj, increasing risks of meningococcal outbreaks, hemorrhagic fever and even
SARS (Ahmed, Arabi, & Memish, 2006), and in Palestinian refugee camps in
the Gaza strip, crowding and poor sanitation contribute to intestinal parasites
and diarrheal diseases (Abu Morad, 2004). Where dense populations coexist in
poverty and inadequate infrastructure, environments may also increase the risk
of vector-borne diseases by increasing contact with vector breeding sites
(Afrane et al., 2004; McMichael, 2000).
Urban settings have been linked to high rates of certain chronic diseases,
including cardiovascular disease and type II diabetes (Diez Roux, 2003;
McMichael, 2000). These associations might be explained in part by aspects of
the built environment that allow easier access to energy-dense foods and a
decline in physical activity (Handy, Boarnet, Ewing, & Killingsworth, 2002).
Concentration of cars, trucks, and buses in densely populated areas elevates
noxious emissions exposure. Urban traffic is therefore linked to increased risk of
respiratory disease (McMichael, 2000), not to mention the risk of transportation
related accidents (LaScala et al., 2000). Furthermore, dense populations tend to
have higher rates of suicides, violent crimes, drug use and mental diseases due to
social tension, competition for resources, lack of social cohesion or psychosocial
stress (Galea & Vlahov, 2005). Stress is also a risk factor for many chronic condi-
tions such as atherosclerosis and depression (McEwen, 2004) and is associated
with lowered immune response, making it a risk factor for infectious disease as
well (McEwen & Seeman, 1999).
28 Florey et al.
3.5. Governance and Policies
National policies may include health policies as well as other legislation affecting
the social and environmental domains of society. National health policies dictate
to what extent national governments have control over and responsibility for pro-
viding health services to the population. Some countries support a nationalized
system of health care whereby the government both pays for and provides health
services. Other nations have privatized health care such that individuals are
responsible for meeting their health care needs through the private market. Even
nations with privatized health care usually subsidize the costs of such services for
certain members of the population (the elderly or poor) as in the Medicare and
Medicaid programs of the US.
Other aspects of health policy important for population health include eco-
nomic decisions about resource allocation. Governments may decide to invest in
the development of primary care and disease prevention services to maximize
cost-benefit indices, or tertiary care and treatment may be prioritized for fund dis-
tribution. Judgments must also be made about investment in research and devel-
opment of medications, technologies and vaccines. Resource allocation decisions
about health services relative to other national services are necessary. These deci-
sions are political and vary greatly by nation and ideologies (Coburn, 2004). They
are likely to influence health by determining what kinds of services are available,
how accessible and affordable they are and what sectors of the population have
access (Mehrotra, 2006). National policies regarding other domains of public life,
including welfare, education, social security, subsidized housing, and employ-
ment, are also likely to play an important role in determining both quality of pop-
ulation health, as well as distribution of health outcomes in the population
(Marmot, 2002). Finally, political ideologies at the national level have been
hypothesized to influence health by differential support of welfare policies and
recognition of and attention to the needs of the population (Franco, Alvarez-
Dardet, & Ruiz, 2004). For example, a recent study found a link among good gov-
ernance measured by accountability, political stability, absence of violence,
government effectiveness, regulatory quality, rule of law and the control of cor-
ruption and national HIV prevalence (Menon-Johansson, 2005; Widdus, 2005)
Economic decisions regarding resource allocation and distribution are likely to
influence population health through various pathways with resounding health
effects. For example, Freudenberg and colleagues (2006) describe the impact of
city, state and federal budget cuts on a TB/HIV/homicide combined epidemic in
New York City during the 1980s and 1990s, which they term a “syndemic”. These
authors argue that budget cuts undermined the ability of city health and social
service infrastructures to respond to health emergencies and emerging health
threats; reduced education, policing and drug treatment services; and amplified
social trends. These factors then contributed to increased risk of violence and dis-
ease in the population. Other authors have posited that national policies influence
health through the mechanisms of social capital, empowerment and access to
information, which are differentially accorded to populations living under different
2. Macrosocial Determinants of Population Health 29
political economic systems (Franco et al., 2004). Perhaps most relevant to global-
ization and health are arguments delineating relationships between government
policies shaped by capitalist ideology and health outcomes mediated by increas-
ing income inequalities and lowered social cohesion (Coburn, 2000; Muntaner &
Lynch, 1999). National governance therefore affects population health both
through national-level and community-level pathways.
4. Global-Level Processes
Epidemiologic research on the health effects of global-level factors is inadequate.
We consider global-level factors to involve the processes of globalization that
extend beyond national borders (outlined in Section 1.1). Understanding the dif-
ferential effects of national-level factors on health in the global system will
enhance opportunities for effective health interventions through a focus on
global-level structural changes to achieve sustainable improvements in health.
4.1. Global Trade
One important component of globalization is increased trade in goods and serv-
ices both between and within nations. Exchanges of goods and services shape
nations’ economies through imports and exports and levied taxes. In effect, trade
serves to redistribute commodities and wealth throughout the world, and it is the
patterning of this redistribution and its associations with health that interests us.
Some global health researchers seek to determine whether trade and increased
access to material resources leads to more equitable redistribution of wealth or to
a concentration of wealth in the hands of a few.
The nature of the dynamic global exchange of resources is likely to be affected
by enduring conditions such as geographical location, location of exploitable natu-
ral resources, and history of past interactions in the global market (Gallup, Sachs, &
Mellinger, 1999; Moore et al., 2006). For example, Moore et al. (2006) found that
tropical and landlocked countries were more likely to have higher infant mortality
rates than were other countries even after adjusting for the position of the country in
the world system. Increasingly, nations are becoming dependent on the global econ-
omy and on trade with others for the well being and survival of their citizens.
Increased trade provides an opportunity for the exchange of both essential, salu-
brious resources and those that may be deleterious for health. Commerce in essen-
tial goods, such as food, improves access to good nutrition in areas of the world
with poor quality agricultural land or short growing seasons (Hawkes, 2006; Shetty,
2006). Trade in medicinal products such as vaccines and pharmaceuticals helps to
protect the quality and duration of life in areas of the world without the technologi-
cal or industrial capabilities to produce their own supplies (World Health
Organization, 2004; Widdus, 2005). Exchanges in services such as health care and
education also provide opportunities to improve population health in disadvantaged
nations (Bettcher, Yach, & Guindon, 2000; Widdus, 2005). However, expanding
30 Florey et al.
markets have also provided a venue for the dissemination of goods that are deleteri-
ous to health such as tobacco, illegal drugs and weapons (Huynen et al., 2005;
McMichael & Beaglehole, 2000; Yach & Bettcher, 2000). In addition, global trade
creates an opportunity for contaminated products or infectious agents to cause
widespread illness, facilitating the speed and distance of disease outbreaks. For
example, the transportation of Aedes aegypti mosquito eggs in used tires being
shipped across the oceans led to the rapid expansion of dengue virus infections
worldwide (McMichael, 2000). Indeed, a multitude of food-borne pathogens are
transported globally each year; for example, Cyclospora cayetanensis in raspberries
imported to the US caused an outbreak of diarrheal disease in 1996 (Centers for
Disease Control and Prevention (CDC), 1996).
The dynamics of global trade are complex and influence health at the same
time that they are influenced by national-level and community-level factors. For
example, increased global trade does not ensure even distribution of commerce
throughout the world (Subramanian, Belli, & Kawachi, 2002). Some countries
may be denied access to the world market due to national-level factors such as
governance, lack of marketable products or lack of income with which to pur-
chase commodities (Ayala-Carcedo & Gonzalez-Barros, 2005). These countries
are unlikely to experience the health benefits of increased global trade. Minimal
access to the global market may also affect population health by restricting
the growth of national economies, which in turn limits funds available for infra-
structure development and health services at the community level. Limited
national funds for health workers salaries also contributes to poor population
health as doctors, nurses, teachers, and other skilled workers emigrate in search of
better opportunities, thereby depriving communities of quality health services
(Brown & Connell, 2004; World Health Organization, 2006). Even countries
experiencing positive income growth due to trade activities on the global market
may experience poor population health outcomes if the money is not used to pro-
vide necessary social services or infrastructure development. Additionally,
unequal distribution of resources at the community level may contribute to deteri-
oration of the physical and social environments, which has deleterious health
effects as previously discussed (see Sections 2.3 and 2.4).
4.2. Income Distribution
Unequal distribution of goods and services contributes to unbalanced global trade
as well as to income inequalities among nations. Why do we care about the distri-
bution of wealth? We know that on an individual level rising income leads to bet-
ter nutrition, lower child mortality, and better maternal health (Filmer & Pritchett,
1999; Pritchett & Summers, 1996). Whether this relationship between income
and health holds at the population level is less clear. Some economists argue that
nations with more open trade policies experience more rapid income growth,
which leads directly to better population health (Dollar, 2001; Dollar & Kraay,
2002). Others provide evidence that increased global integration leads to increas-
ing inequality both in wealth and in health and both within and between nations
2. Macrosocial Determinants of Population Health 31
(Coburn, 2000; Lynch et al., 2004; Wilkinson & Pickett, 2006). The debate on
income inequality and its potential health effects is multifaceted. Does globaliza-
tion encourage increasing income inequality, and if so, is this inequality within
nations, between nations or both? Is income inequality bad for population health?
What are the mediating factors of the income inequality-population health
relationship?
Global income distribution may shape population health through its influence
on global, national, and community level factors. At the global level, rising
income inequality encourages migration and fosters conflict (Wade, 2004).
Coburn (2000) hypothesizes that neo-liberal economic policies affect health by
encouraging intra-national income inequality and decreased social cohesion. At
the national level, unequal global income distribution provides differential access
to necessary goods and services (Baum, 2001). These goods and services help to
determine national income which affects community-level access to resources
necessary for good health through providing the means for infrastructural devel-
opment, provision of social services, and provision of employment opportunities.
Differential global income distribution therefore affects the local distribution of
health resources. Sizeable income inequality also suppresses income growth at
the national level (Cornia, 2001) and reduces the rate of poverty alleviation
(Ravillion, 2001).
The health effects of global income inequality may be moderated or mediated
by national-level characteristics, such as national policies and type of governance.
For example, Navarro and Shi (2001) found that countries with predominantly
social democratic government traditions between 1945 and 1980 experienced
more economic growth, lower levels of income inequality and unemployment,
and lower infant mortality rates than did countries with liberal or fascist govern-
ment traditions. Community-level characteristics may act as mediators of the
health effects of income distribution as well. For example, poor communities in
nations with high income inequality may experience reduced social cohesion and
the associated health effects due to a lack of employment opportunities and higher
poverty (Wade, 2004).
4.3. Population Movement
Population movement is another important component of globalization with sig-
nificant health implications. Improvements in transportation technology in the
past century have drastically amplified the speed and distance of human travel
(Smolinski et al., 2003). Ease of travel, both domestically and internationally, has
lead to an unprecedented magnitude of travelers both for business and for tourism
(World Trade Organization, 2005). Yet any economic benefits must be evaluated
in the context of increased transport and transmission of infectious diseases
(Wilson, 2003). Migration is another reason for international and domestic travel.
Motivations for migration are diverse and include search for better economic
situations, flight from violent conflict or repressive government, and pursuance
of educational opportunities, to name a few. Rural to urban migration, also
32 Florey et al.
known as urbanization, is an increasingly important phenomenon in the consider-
ation of determinants of population health (Galea, Freudenberg et al., 2005;
McMichael, 2000). The driving factors behind trends in population movement
also change population demographics. For example, in developing countries,
rural villages are aging due to the rural-urban migration of youth looking for
work in the cities (Stloukal, 2001). In many villages in Southern Africa, men
leave to work in the mines (Quinn, 1994), altering the male to female ratio in the
communities. In Mexico and Asia it is women who leave the home to work in the
export processing zones (Hippert, 2002).
Mobility of human populations has the potential to affect health through a variety
of mechanisms. At the global level, population movement facilitates spread of cul-
ture and technology, which can be beneficial for population health by expanding
health knowledge and encouraging healthy behaviors (Frenk, 2005). However, the
globalization of culture has been seen as “Westernization” or “Americanization”,
which threatens other ways of life and can sometimes lead to conflict (Frenk,
Sepulveda, Gomez-Dantes, McGuinness, & Knaul, 1997; Holton, 2000).
The effects of global population movement on population health may be medi-
ated by national factors. Take, for example, the enhanced spread of infectious dis-
eases facilitated by novel patterns of human to human contact, as well as by
changing eco-social environments (McMichael, 2000). The magnitude of mor-
bidity and mortality due to increased infectious disease spread is likely to depend
on national capacity to respond to disease outbreaks, which is a function of
income, infrastructure and health knowledge and resources. The recent SARS
pandemic provides an appropriate opportunity for comparison of population
health outcomes for affected nations with different mediating characteristics. We
might compare the SARS mortality rates in Canada, China and Singapore as a
function of national infrastructure or of per capita income. Community-level
effects of the spread of infectious diseases due to increased population movement
are demonstrated by the SARS outbreak in Toronto, Canada. The social environ-
ment of the city was affected by the psychosocial effects of fear and local
resources were disrupted by the economic effects of isolation and quarantine
(Gupta, Moyer, & Stern, 2005; Hawryluck et al., 2002).
Another example of population health effects of human mobility involves the
dynamics of population flows. At the global level, population movement is increas-
ing, but this movement is not uniform among nations or regions of the world. The
classic example is that of “brain drain”, in which highly educated or skilled individ-
uals from poor countries are recruited for employment in more wealthy nations.
This differential migration exacerbates national and community-level problems of
poor education, poor access to health services, and poor quality health services
in the neediest regions of the world (Brown & Connell, 2004; World Health
Organization, 2006). At the national level, changing demographics associated
with mobile populations include rapid urbanization, especially in the developing
world (Galea & Vlahov, 2005; McMichael, 2000; Moore et al., 2006). This phe-
nomenon, coupled with high fertility rates, threatens population health by increas-
ing pressures on limited national and community resources (McMichael, 2000).
2. Macrosocial Determinants of Population Health 33
At the community level, the physical environment is affected; poor urban infra-
structure fails to provide potable water and sewage facilities to these burgeoning
populations, resulting in increased disease burdens (McMichael, 2000). Local con-
flicts may also arise from competition over limited food or arable land.
Psychosocial stress resulting from high population densities and difficult living
conditions may also seriously influence community health outcomes (McEwen &
Seeman, 1999).
4.4. Global Governance
All the aforementioned components of globalization are affected, to some
extent, by the nature and extent of global governance. Governance is defined by
Dodgson et al. (2002) as “the actions and means adopted by a society to promote
collective action and deliver collective solutions in pursuit of common goals,”
and has typically been conceptualized at local and national levels. As trends of
globalization change our delineation of societies, the concept of governance
must take on a new dimension: Increasingly globalized societies need gover-
nance on a global scale.
Pursuit of global governance is challenging due to the historical precedent of
national sovereignty, the right of each nation to govern its citizens. Reorganizing
governmental hierarchies and establishing common goals for the entirety of the
world’s people is not an easy task. Some forms of governance do exist on a global
scale, however. The World Trade Organization (WTO) has developed trade agree-
ments that guide exchanges in goods and services among nations (Kinnon, 1998).
Two examples include the Agreement on Trade-Related Aspects of Intellectual
Property Rights (TRIPS) and the General Agreement on Trade in Services
(GATS). TRIPS establishes minimum standards of protection of intellectual prop-
erty, thereby safeguarding industrially applicable inventions, such as pharmaceu-
ticals, under patent laws. GATS regulates trade in health services. The World
Health Organization (WHO) also governs global health through the legally bind-
ing International Health Regulations. These regulations aim to reduce global dis-
ease spread with minimal trade interference.
Before discussing the mechanisms through which global governance affects
population health, we must mention one key caveat. It is questionable to what
extent governance has truly globalized despite the existence of international
organizations such as the WTO and the WHO. These organizations are charged
with defending the trade interests and health interests, respectively, of member
states. However, not all nations are members of these organizations despite the
fact that all nations share trans-border health risks. Additionally, member
states do not all have equal representation in these organizations. Many poor
countries cannot pay the fees needed to send representatives to meetings
(Bowman, 2004).
Mechanisms by which trends in global governance affect population health are
many and varied. At the global level, international policies regulate trade in
goods. As this partially predicts income distribution, governance, trade, and
34 Florey et al.
income are closely intertwined. At the national level, income mediates the effect
of global governance on population health. A classic example is the debate over
generic pharmaceutical production in developing countries that arose over the
need for antiretroviral (ARV) medication for HIV. Under the TRIPS agreement
created by the WTO, the production of patented medications was prohibited at the
global level. The result was that national access to expensive medications was
determined by national income; rich countries could afford to buy life-saving
medication for their populations and poor countries could not. To pursue this
example to the community level, countries with enough income to purchase lim-
ited supplies of ARVs might offer better health outcomes to high income commu-
nities that could afford the high prices. Alternatively, these nations might choose
other distribution criteria, offering the medications to government employees or
to those seeking care at a certain health facility. It is easy to understand how, in a
community with high HIV prevalence, differential access to ARVs might erode
social cohesion and trust (Bennett & Chanfreau, 2005). High medication prices
may also divert resources from other necessities, such as food and school fees,
producing resounding population health effects.
Two other potential mechanisms are worth noting. An addition of a global
dimension to governance of health issues may be counterproductive, undermining
the authority and the ability of national governments to protect the health of their
citizens (Collins, 2003). This argument can similarly be made for all neo-liberal
trade policies in that the tenets of economic globalization, including decentraliza-
tion, may lead to disempowered national governments (Coburn, 2000; Navarro &
Shi, 2001). Finally, in the current era of globalization, an increasing number of
non-state actors (e.g., NGOs, private corporations, religious organizations) may
influence health governance, thereby eroding national resources for addressing
health issues (Dodgson et al., 2002). Despite the increasing influences of these
non-state actors in health decisions, the WHO focuses its efforts on working with
Ministries of Health of sovereign member states. Neglecting to bring NGOs and
private sector actors into negotiations results in a lost opportunity for valuable
input (Dodgson et al., 2002).
4.5. Communications and Technology
Global communications include radio, telephone, television, and media in gen-
eral, as well as the internet. The scope of global communications is enormous; in
2004 over 30 minutes per person were spent on international telephone calls
worldwide, and 69% of the world’s population was covered by mobile telephony
(World Bank, 2006). In addition, the number of global internet users increased by
189% from 2000 to 2005, with more than one billion people now having access
(Internet World Stats, 2006).
Enhanced global communications affects population health through the
dispersion of ideas, information, knowledge and technologies. Telephone networks
provide avenues for emergency communications and foster social connections
between friends and families (Berkman, Glass, Brissette, & Seeman, 2000).
2. Macrosocial Determinants of Population Health 35
The internet provides opportunities for education and information sharing,
which can lead to healthier behaviors and, perhaps, more informed and effec-
tive health interventions (Frenk, 2005). Nations and communities can use the
internet to store and communicate health data and statistics, allowing more tar-
geted and efficient use of resources (Frenk, 2005). Global media also may influ-
ence population health by informing individuals, communities and nations
about global issues that may have local impacts and allowing an opportunity for
prevention or intervention. Media coverage of global events allows collective
awareness of political, social and ecologic realities across the world. Global
media also presents the potential for views and ideologies of powerful people or
groups to dominate and skew the objectivity of reporting of events of global
importance.
Despite the rapid growth in global information technologies in recent years,
some evidence exists that the gap in access to these technologies is widening,
particularly between rich and poor nations as well as between rural and urban
areas within nations (Arnett, 2002; United Nations Development Programme,
2001). This suggests that the relationship between global communications and
population health may be mediated by various national and community level fac-
tors. We might consider the mediating effect of culture, for example. Research
by Holton (2000) examines three cultural responses to the global information
influx: homogenization, polarization and hybridization. Homogenization occurs
when a local culture merges with global culture, a phenomenon sometimes
called “Coca-Colonization” or “McDonaldization”. This may result in adoption
of poor health behaviors, such as smoking and drinking alcohol, as well as
healthy behaviors, such as increased hand washing. Polarization consists of dia-
metrically opposed cultural groups that create conflict and brew hatred for one
another. In that such hatred ends in war or ethnic cleansing, the negative health
implications are obvious. Finally, global communications may also lead to the
formation of hybridized cultures, which incorporate elements from a variety of
cultural sources. The health effects of hybridization of culture may be beneficial
if it leads to enhanced understanding and cooperation among different local cul-
tures. Some evidence exists to support the “politics of difference” theory,
whereby group members become empowered by drawing upon identities and
beliefs that are counter-hegemonic (Williams, Labonte, & O’Brien, 2003). This
empowerment may provide enhanced collective actions of communities to seek
healthier environments and encourage healthier behaviors. In contrast, some
individuals in a culture may resist hybridization while others support it, creating
inter-group conflict and a dissolution of social trust and cohesion. One example
involves intergenerational differences in responses to global media in Japan
(Arnett, 2002). Attempts have been made to mathematically model the dynamic
between global processes, such as population density, and the maintenance of
cultural identities in order to quantify the potential for homogenization, polariza-
tion or hybridization of cultures (Hochberg, 2004). However, few have investi-
gated how these cultural adaptations affect health outcomes, suggesting that
much more research is needed.
36 Florey et al.
5. Example Mechanisms
Here we present three specific examples to illustrate mechanisms through which
global factors exert influences on population health. Consider that these path-
ways are likely to be highly complex and multidirectional and aspects of
national- and community-level environments may mediate or modulate the
effects of global factors on health. In addition, one global factor may influence
health outcomes via multiple pathways. We present simplified examples, which
serve to highlight the logistical and methodological challenges, as well as the
importance of including the global context in epidemiologic population health
research.
5.1. Diarrheal Mortality Rates
A common theme presented in this chapter is the health importance of access
to clean water. We may use community mortality rates due to diarrheal disease
caused by unclean water sources to examine how population movement may
influence one particular health indicator. In order to understand the causes of high
rates of deaths due to diarrhea in a community we have to consider community-
level factors that have been shown to be important predictors, such as the age
distribution of the population, local environmental conditions (sanitation), breast-
feeding practices, malnutrition, personal hygiene and access to medical supplies
and services (such as oral rehydration solutions, ORS) (Feachem, 1984; Kosek,
Bern, & Guerrant, 2003; VanDerslice, Popkin, & Briscoe, 1994). Limiting our
study to community-level factors may be misleading, however. By including
national-level variables, we might find that although community hygiene prac-
tices significantly predict diarrheal mortality rates at the community level, when
we take national population densities into account, hygiene practices are no
longer predictive. This might be because personal hygiene is associated with
protection from infectious diarrhea-causing agents in countries with low popula-
tion densities where these behaviors are mostly sufficient to protect against dis-
ease. In highly populated countries these behaviors may not be sufficient to
provide protection (maybe due to high contact rates with the infectious agents).
For example, high regional population densities have been found to be associ-
ated with greater child mortality rates in Zimbabwe (Root, 1997) and to be pre-
dictive of cholera outbreaks in Bangladesh (Myaux, Ali, Felsenstein,
Chakraborty, & de Francisco, 1997). Global factors may be essential in under-
standing and predicting the pathway between national population densities,
community hygiene and population diarrheal mortality rates. National popula-
tion densities may be highly dependent on global migration patterns and not just
on domestic fertility rates as is the case in the United States, France and
Germany (Cohen, 2003). This example demonstrates how our understanding of
the underlying causality of health outcomes is improved by widening the scope
of study to include the global context.
2. Macrosocial Determinants of Population Health 37
5.2. Maternal Mortality Rates
Maternal mortality rates are one of the few standard measures of health used to
compare health conditions across nations or regions. We argue that in order to study
the factors that contribute to high maternal mortality rates it is important to investi-
gate community-, national- and global-level conditions. For example, at the com-
munity level, past research has shown that maternal anemia, poor health care and
lack of skilled birth attendants predict high maternal mortality (Rush, 2000). These
factors are likely to be influenced by national-level factors such as infrastructural
resources available for health services. Evidence for this surfaces from a study in
which maternal mortality rates were shown to be negatively correlated with national
health expenditures (Betran, Wojdyla, Posner, & Gulmezoglu, 2005). The relation-
ship between national health spending and maternal mortality rates may in turn be
determined by global level factors such as integration into the global market.
According to a report by Global Health Watch (2005), “many macro-economic fac-
tors that help to keep poor countries poor, by extension, keep levels of health care
expenditure low.” For example, for many developing countries well integrated in the
global economy the 1979–1981 global increase in oil prices led to financial crises
due to reduced trade revenues and greatly inflated debt service payments (Global
Health Watch, 2005). Maternal mortality rates are therefore likely to be determined
not only by local or national conditions, but also by global factors.
5.3. Severe Acute Respiratory Syndrome
One final example that illustrates the importance of global-level health determi-
nants in studies of population health is the recent severe acute respiratory syn-
drome (SARS) pandemic that menaced the globe in 2002–2003. In examining the
causal factors related to the SARS outbreak, community-level determinants have
been shown to be crucial in the emergence of the disease in human populations.
Some key factors that have been identified with SARS are densely populated com-
munities and close, repeated contact with wild animals, especially palm civets
(Paguna larvata) and raccoon dogs (Nyctereutes procuyoinboides) (Breiman et al.,
2003; Poon, Guan, Nicholls, Yuen, & Peiris, 2004; Webster, 2004). On a national
level, China’s deficiencies in health infrastructure allowed the emergence and con-
tinued spread of the disease without appropriate response measures (Liu, 2004). In
contrast, Singapore rapidly introduced strict infection control measures resulting
in low numbers of secondary cases (World Health Organization, 2003). This illus-
trates how national infrastructures and health policies can influence disease spread
at the community level. At the global level, intercontinental travel facilitated dis-
ease spread (World Health Organization, 2003), whereas the existence of global
health infrastructures and global communication networks allowed enhanced
information exchange and rapid implementation of appropriate control and pre-
vention measures worldwide (Fidler, 2004; Heymann, 2004). SARS provides a
recent and fitting example of how global factors influence health at local levels and
illustrates the importance of global perspectives in preserving population health.
38 Florey et al.
As these examples illustrate, asking questions about the global context of
causal pathways leading to health and disease deepens our understanding of
the eco-social mechanisms responsible and allows for more opportunities to
intervene.
6. Future Research
The pathways through which community-, national- and global-level factors affect
population health that are presented in our conceptual model and discussed above
are far from exhaustive. Nevertheless, these examples are illustrative of the
importance of context in public health research. We argue that the global context,
hitherto largely overlooked in epidemiologic studies, is essential for fully under-
standing the determination of population health. Indeed, inclusion of global-level
factors in epidemiologic analyses may reveal complexity of relationships between
more proximal-level factors and health indicators that were previously thought to
be simple and well characterized.
Clarification of research goals is of paramount importance in developing epi-
demiologic investigation of population health determinants in a global context.
First, there is a need for identification of gaps in currently existing knowledge.
We have presented some examples as illustration, but a more systematic examina-
tion of the literature should be undertaken. Second, research needs to focus on
hypothesizing and testing specific pathways through which global factors affect
health. The results of such analysis will enable policy makers to prioritize areas of
intervention and to restructure inefficient or ineffective policies. Furthering this
research will ultimately require enhanced multidisciplinary collaboration, as
changes are likely to be needed not only in health policy, but in economic, social,
and ecologic domains as well.
Achieving these research goals is challenging due to methodological limita-
tions. For example, the measurement of key global-level constructs is compli-
cated by the scale and the lack of precedent. Unstandardized measurements draw
into question the comparability of results across studies. Additionally, the data
collection methods and the data themselves vary in accuracy and completeness
among different countries. Data quality depends on available resources and train-
ing of data collectors, as well as on logistical obstacles to data collection. All
these factors are likely to vary by country or region of the world. Finally, the indi-
viduals and the institutions funding research influence what data are collected and
how they are measured, which may affect the results and policy recommendations
that follow. This is an issue of concern in studies of global contexts since the
number of players is small and largely limited to international organizations with
political agendas, such as the World Bank and the International Monetary Fund.
Analytic limitations also hinder the pursuit of epidemiologic research on path-
ways in a global context. One important issue is the potential for reciprocal inter-
actions among the various levels of health determinants presented in our
framework. For example, income growth may have a positive effect on health, but
2. Macrosocial Determinants of Population Health 39
alternatively, the association seen between these variables may be due to reverse
causation, in which good health may stimulate income growth. Although longitu-
dinal studies can be designed to illuminate the directionality of this association, it
is possible that the reality is bidirectional. In this case, current epidemiologic
methods are unable to measure the relative importance of the directions of associ-
ation. Another analytic challenge lies in the examination of multiple interactions
between inter-level and intra-level components. Current analytic tools are capable
of investigating interactions, but sample size and power become insufficient as
multiple interactions are included in regression models.
Despite these challenges, epidemiologic research must strive to include the
global context in analyses. We must avoid becoming “prisoners of the proximate,”
to borrow McMichael’s (1999) terminology, and instead focus on identifying
modifiable contextual factors likely to have a large impact on population health.
Studying the global context will enable development of effective interventions
and improved promotion and protection of population health.
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