Richard A. Cash, MD, MPH

4 September 2013

Globalization and its Impact on World Health

Globalization – I

• Rapid economic integration carried out on a global scale • Compression of time and space• Technology facilitated• Values driven – accumulation of wealth,

growth, social connectors• Capitalism unchecked• Integrating and fragmenting

Globalization II• New heights of achievement in wealth,

technology, and food production: Since 1820, 50-fold increase in real world output and 6-fold increase in world population

• New heights in disparities: Trends in global income inequality by (income/cap ratio between world’s richest and poorest countries): 1800—3:1 ; 1900—10:1; and by 2000—60:1

Globalization - III• Not new but more rapid• European conquest of Americans from 15th

century onward• Introduction of tuberculosis, smallpox, yellow

fever, malaria in immunologically naive population led to 50-80 million deaths

• Agriculture products to Europe - corn, potatoes, tomatoes, tobacco, chillies etc.

Globalizations Impact on Health?

• Shapes the determinants of health• Directly affects health status and outcome• Societies must adapt collective responses to

changing health determinants and outcomes

Transitional Factors• Macroeconomic –(structural adjustment etc.)• Trade—liberalization, foreign investment• Travel• Communication• Migration and demographic changes• Behavioral changes• Food production/security and dietary habits• Environmental degradation• Technology development and transfer (IPR)• Break down of public sector programs

Health Risks • Pollution of air and water• Export of tobacco, alcohol, psychoactive drugs • Production of unsafe drugs, counterfeit drugs, spread of

drug resistance• More rapid spread of infectious diseases• Export of life styles—diet, less physical activity • Increase consumption of foods increasing risks—

saturated fats, salt, sugar• Inappropriate health products• Global warming

Other Factors Impacting on Health

• Marketing• Role of public and private sectors• Health care financing and service provision• Pharmaceutical industry—development,

production, and distribution• Health sector reform• Manpower development and migration

Public Health Benefits of Globalization

• Disease eradication (smallpox)• Vaccines & therapeutic agents R & D• Drugs and vaccines that are inexpensive and

more widely available• Diagnostic techniques improved • Communications improved • Access to scientific data and literature• More safe water• Better surveillance

SmallpoxSmallpox

Changes in life expectancy at birth for both sexes in eight representative countries during the last 55 years.

Bangladesh: Life Expectancy at Birth

0

10

20

30

40

50

60

70

Years

ex

19602002

Bangladesh: Infant and Child Mortality

0

50

100

150

200

250

Infant Mortality Rate < 5 Mortality Rate

196019902002

Childhood Mortality BangladeshChildhood Mortality Bangladesh

2011 BDHS: NIPORT, Mitra and Associates, ICF International, and USAID

Trends in Neonatal Mortality Rates; Trends in Neonatal Mortality Rates; Bangladesh Bangladesh

2011 BDHS: NIPORT, Mitra and Associates, ICF International, and USAID

Trends in Infant Mortality Rates: Trends in Infant Mortality Rates: Bangladesh Bangladesh

2011 BDHS: NIPORT, Mitra and Associates, ICF International, and USAID

48

Trends in Childhood Mortality Rates:Trends in Childhood Mortality Rates: BangladeshBangladesh

2011 BDHS: NIPORT, Mitra and Associates, ICF International, and USAID

Childhood Vaccinations—Bangladesh-2011Childhood Vaccinations—Bangladesh-2011

2011 BDHS: NIPORT, Mitra and Associates, ICF International, and USAID

Bangladesh: Birth Rate and Death Rate

05

101520253035404550

Crude Birth Rate Crude Death Rate

19602002

Bangladesh: Total Fertility Rate

0

1

2

3

4

5

6

7

TFR

196019902002

Causes of Maternal Deaths: BD 2010

Undetermined1%

Defining and Improving Global Health

Global Health-Definitions

• Limited definitions are often based on the following: health problems (ID, NCDs); populations of interest (the poor); geography (global South); mission (equity)

• Two key elements to a definition: level of analysis; degrees of interdependence

• Two dimensions should be analyzed: health conditions; how society responds

Global Health-Definitions II

• An area of study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide (Koplan et al-Lancet)

• The goal of global health is to improve the health of all people in all nations by promoting wellness and eliminating avoidable diseases, disabilities, and deaths. It can be attained by combining clinical care….. with population-based measures to promote health and prevent disease. (IOM—US—2008)

Health as a Public Good - I

• Non-divisibility - none cut out• Non-excludability – all benefit• Broad themes

• Equity – Increased disparity• Markets – Privitization• Opportunity

Health as a Public Good - II

• Forces pushing the agenda• Trade, migration, information• Increased pressure on common pool resources

– esp. air and water• Responsibilities for health is local, but the

determinants of health are increasingly global

Health as a Public Good

• Non-divisibility - none cut out• Non-excludability – all benefit• Increasing disparity in terms of equity, and

privatization of markets• Increased pressure on common pool resources

– esp. air and water• Responsibilities for health is local, but the

determinants of health are increasingly global

Why Improve Health?

• Reduce unnecessary morbidity• Reduce premature mortality• Improve individual and group potential for

development• Create greater equity • Reduce the cost of poor health in terms of trade,

and travel

Globalizing Health and the Health Sector

• Disease—democratization of microbes, NCDs• Risk factors—diet, smoking, air and water pollution

(common public goods)• Health professionals—movement of nurses, doctors,

allied professionals• Drugs—availability, production, standardization,

counterfeit products, trade• Technologies—rapid spread of information, wide

availability of devices

Global Efforts to Improve Health

• Convention on the Rights of the Child• Polio eradication campaign• Global Outbreak Alert and Response Networks

(GOARN--built on Flu Net etc.)• Tobacco treaty• WTO agreement an drug pricing• Global Fund for HIV/AIDS/TB/Malaria• GAVI

Global Health Governance

• WHO – WH Assembly one vote per country• World Bank – Executive Board – Directors

representing members with votes weighted by ownership of Bank’s capital

• Global Fund and GAVI – Board with members including governments, agencies, CSOs, private sector

• National Aid Agencies – politicians, citizens• Private Philanthropy and Corporations – owners

Global Health—Challenges

• Unfinished agenda of infectious diseases, under nutrition, reproductive health issues

• Rising burden of NCD’s and associated risk factors (smoking, diet etc.)

• Globalization and risk factors that are outside the traditional health areas

• Local and global inequities in health and national differences in health and health systems

• Changing definitions of diseases and risk factors