Globalisation Ã¯Â¿Â½ PAGE Ã¯Â¿Â½17Ã¯Â¿Â½
Running Head: GLOBALISATION AND HEALTH
Globalisation and Health
Globalisation and Health
The impact of Globalisation on health is complex, having both positive and negative aspects. There is no doubt that the spread of Western medicine throughout the world and the implementations of global health programs have brought enormous benefits. At the same time, Globalisation has promoted patterns of dependency, development, settlement, and lifestyles that have been detrimental to health.
A key characteristic of Globalisation is that it promotes uneven development. All places become "core" or "peripheral" in relation to other places, as they become increasingly interconnected by trade, international flows of capital and investments, and by media promotion of the values, lifestyles, and material goods of the more-developed countries. Although there is perhaps a hierarchy of core countries, it is more useful from a health perspective to think of all of the more-developed countries as the global core, where the best health services and greatest range of lifestyle options are available.
The periphery comprises the less-developed nations that have a dependent relationship with developed nations, but are unable to offer a comparable range of services and lifestyle options. Most peripheral of all are the poorest countries of Africa and Asia and the remote island nations of the Pacific.
The core/periphery pattern promotes both benefits and disparities in health. On the one hand, linkages between core and peripheral places facilitate the spread of knowledge about medicine and good health. On the other hand, global forces concentrate the best facilities in core places and reduce the options and choices available in the periphery. Although disparities in the general health of countries and regions and between individuals in a single society have always existed, globalisation intensifies disparities and increases the difficulty of achieving equity in health.
This core/periphery pattern is replicated within every nation, with each having its own core where the best services and most lifestyle options are to be found. Other places that are peripheral in relation to this core exist in a state of dependency that determines the services and lifestyle options available in outer areas. While wealthy countries may have the resources to ensure that health services in peripheral areas are of a high standard, less-developed countries tend to concentrate most of their resources in their core and offer only rudimentary services in peripheral areas.
The nature and pattern of disparities between core and peripheral areas, however, is sometimes unexpected and paradoxical. In particular, disadvantaged groups can be found within the most highly developed core areas, while the health of residents of the core areas of the most peripheral nations may be inferior to that of those residing outside their cores. This paper examines the mechanisms through which Globalisation intensifies disparities in health between and within nations, and shows how it may create a paradoxical situation on the periphery.
The Epidemiological Transition
To understand the manner in which Globalisation impacts on health it is necessary to consider the general improvements in population health that occurred during the nineteenth and twentieth centuries. One of the most important benefits of modernization has been the Epidemiological Transition. This refers to the transition from a state of relatively high mortality from infectious diseases to a state where most infectious diseases are controlled and the main causes of death are non-communicable diseases occurring in old age (Frenk et al. 1999: 16). It occurs largely as a result of improved sanitation and hygiene, immunization, antibiotics, and surgical advances. These improvements are complementary in their impact on health.
The essential process of the Epidemiological Transition is that the general reduction in the prevalence of infectious diseases leads to a consequent increase in life expectancy. In the post transition phase, infectious diseases are controlled, and most people die in their seventies or eighties from non-communicable diseases (NCDs), such as coronary malfunctions and cancer (Frenk et al. 1999: 20). The Epidemiological Transition began in the early nineteenth century in Europe, and subsequently spread to other industrialized countries. Its progress across the world can be tracked by the dates when various countries achieved major increases in longevity United Nations 1982).
The benefits of modern medicine and disease control have now spread throughout the entire world to some extent. Although the quality of care and service delivery, affordability and availability of medicine and treatments may vary, some form of modern medical care is now available virtually everywhere. In addition, mass disease control campaigns, such as the World Health Organization's Expanded Programme of Immunization (EPI), have reached the world's poorest countries (Henderson 2004: 475).
In the last few decades, however, a new variant of the Epidemiological Transition has emerged. Although this variant still brings a general reduction in infectious diseases and increased life expectancy, the general improvement in population health is less than was experienced by industrialized countries during the twentieth century. Its main features are a slower decline in life expectancy, and a dramatic increase in the prevalence of NCDs among adults at increasingly younger ages, so extensive that it can be thought of as a "second wave" of disease (Coyne 2000:6). The most common early-onset NCDs are diabetes mellitus, curunary and vascular diseases, and ubesity. All are related tu lifestyle. At the same time, infectious diseases are less well controlled than in the classic Epidemiological Transition model. This new variant is usually found in "the less- and least-developed countries," as opposed to the "more developed countries" and is largely a consequence of Globalisation.
How Globalisation Impacts Health
In the preglobalized world, disparities in health were usually a consequence of differences in wealth and living standards and geographical variations in the risk of infectious disease. There is no question that this remains the case today, with a close positive association of health indicators and life expectancy at both the national and individual levels. It is overly simplistic, however, to explain differences in health primarily as differences between rich and poor nations, because such an approach fails to take account of the specific mechanisms through which Globalisation impacts health, both positively, by increasing the availability of health care, and negatively, by intensifying disparities in health. The three main mechanisms through which Globalisation operates are, first, its impact on environmental quality; second, its impact on the quality and accessibility of health services; and third, its promotion of unhealthy lifestyles.
The following sections examine these mechanisms. Most of the examples relating to peripheral countries are drawn from the small island nations and territories of the Pacific, since they are strongly influenced by the forces of Globalisation and because their small size and isolation enable the effects of Globalisation to be seen very clearly. Similar patterns of disadvantage, however, can be seen in peripheral countries and communities everywhere.
Globalisation and Environmental Health
As discussed above, safe water and sanitation, in addition to medical advances and health service delivery were an essential part of the improvements in population health associated with the Epidemiothgira Transition in the more-developed countries. The extent to which they are available in any particular place depends primarily on national resources, but also on the advice received and the strategy adopted. As centres of innovation and technology, the global cores set the technical standards for the rest of the world. An obvious manifestation of this is the use of the word "alternative" to describe any technology that differs from these global standards. For example, "alternative medicine" is used to describe traditional as opposed to modem medicine, and "alternative energy" is used for renewable energy as opposed to fossil fuel and large-scale hydroelectricity.
In thinly populated rural areas, where populations are sparse, the traditional use of the bush and ocean as toilets and for garbage disposal does not necessarily lead to dangerous levels of contamination, and surface water may be potable. As population densities increase, however, systems of waste management are essential to ensure safe water and prevent environmental contamination. Modernization has led to the development of urban centres in virtually all nations. Initially centres of culture and government, urban centres evolved into centres of trade and commerce (McGee 1997). The international forces of Globalisation have concentrated settlement in urban areas in most countries. Most developed countries now have 700 0 or more of their population in urban areas, and the percentage of population in urban areas is increasing in most less-developed countries (UNFPA 1999:25).
The global standards for water and sanitation were established in the most-developed countries: high cost networks piped to or from a central source. This is a very costly model, and less- and least-developed countries are generally able to provide such services only in their main urban areas. Many date from colonial times, or have been constructed with development assistance. Since there is often a shortage of resources and technology to maintain them, they are subject to breakdown and contamination.
In the early 1990s, for example, lack of maintenance caused the water supply in Majuro in the Marshall Islands, total population around 50,000, to become contaminated with seepage from adjacent sewage pipes and nitrates leached from human graves. Another Pacific nation, Kiribati, is experiencing severe environmental contamination in its main center, South Tarawa. Although Kiribati has only 90,000 people and comprises 33 coral atolls scattered across a vast expanse of the Pacific Ocean, around 35,000 people live on a 100-200 metre wide, 30 kilometre long coral strip on the rim of shallow, sandy, Tarawa Lagoon. Some South Tarawa houses and public buildings are connected to piped water and sewage systems, but many are not, while the services that do exist often malfunction. Refuse disposal services are inadequate and infrequent, and some areas of the beachfront are piled high with household waste. As a consequence, Tarawa Lagoon is severely contaminated, and outbreaks of diarrhoeal disease are common.
While there is no doubt that the more-developed country model of water and sanitation infrastructure can be extremely efficient and is desirable, the point to be made here is that, because of Globalisation, it tends to be accepted without question by less- and least-developed countries. Often it was simply a case of colonial powers installing the type of infrastructure to which they were accustomed, without thinking of the long-term affordability and sustainability. In much of the Pacific, water and sanitation infrastructure dates from colonial times or was funded by external donors, who assumed that recipient countries would take responsibility for maintenance. Small island nations, however, may lack the resources and expertise to maintain such facilities, or simply have other priorities for their limited budgets (SPC 2001).
In recent decades, more attention has been given to sustainability, but new solutions still tend to be perceived as "alternative" or "appropriate technology" because they differ from the standard set by Globalisation. In the Pacific, it is becoming more common to use roofs of houses for water catchment, but uptake of even this simple and obvious technology has been slow because storage tanks, metal roofs and gutters are expensive, and the costs must be borne by individual household owners rather than municipal authorities. In the Marshall Islands, the water contamination problem was solved by a major donor project to re-lay the pipes; similar projects are planned for Kiribati. In other countries, such as Papua New Guinea, the scale is larger and the costs of providing reliable services much greater. In 1992 a doctor working in Port Moresby Public Hospital, Papua New Guinea, remarked to the author that, until the local city council makes the water supply safe and reliable, his efforts to treat children with diarrhoea was nothing more than a "bandaid" solution to the problem. Although there have since been major upgrades to Port Moresby's water and sewerage services (Inter Financial, 1999: 71), access to safe water in rural areas is probably still close to the UNFPA estimate of 310 o UNFPA 1999:7 1).
The paradox of the periphery is evident in the case of environmental health. In the less-developed, peripheral nations, environmental health is often better in the thinly settled areas outside the national core, even if no special services are provided. This is because there tends to be less crowding in rural areas than in urban areas, so reliance on streams and simple waste disposal methods is adequate, while the infrastructure in urban areas is likely to be inadequate and a greater source of contamination than are the rudimentary facilities.
Globalisation and Health Services
As stated at the beginning of this paper, modern Western medicine has spread throughout the world, and is available virtually everywhere, although the level of service available varies. Medical services in less- and least-developed countries are generally limited and vastly inferior to those in more-developed countries. It is interesting to consider that few people, in either more- or less developed nations, would expect them to be otherwise. While this is largely a perceived difference between rich and poor, the role of Globalisation as a determinant of health services is sometimes overlooked.
Since Western medicine has been adopted as the universal standard, most less-developed countries receive development assistance to help support their health programmes. In most cases, their health programs are determined by global health policies, set by the World Health Organization and other health sector donors. This can lead to management conflicts and can also compromise the appropriateness of health service delivery. Donor assistance fosters dependency and imposes conditions such as requirements that donor policies are adopted and drugs and consultants are sourced from donor countries. It also contributes to fragmentation of activities and conflict in health policies and programmes due to different political and financial agendas. Some countries may have in excess of 100 donor projects operating outside the national health management structure, with the poorest countries tending to have the most fragmentation and the least sustainable systems (Berer 2002:10).
Core/periphery relations also influence the choice of health care model adopted by less-developed countries. Since the evolution of Western curative health care played a pivotal role in the health transition in industrialized countries, it was widely assumed by colonial powers that this was the best model of health care for developing countries, including small island nations such as those of the Pacific. The more-developed countries set international health policy and standards, and provide significant amounts of health assistance, so the Western medical package tended to be accepted uncritically by health officials in the Pacific. For example, a distinctive feature of the US-designed health systems introduced to the Northern Pacific was a sharp division into preventive and curative services. Although this ensured that at least some attention was given to preventive medicine, the rigid separation of function led to inefficiencies in the provision of health care, especially since there were few trained personnel. Opportunities to provide preventive care, such as advice on nutrition or disease prevention or counselling in family planning for high- parity mothers, were lost because such care was outside the brief of those providing curative services (McMurray and Smith 2001).
While this separation has become less rigid since the mid-1980s, when the importance of primary health care was officially recognized and promoted throughout the world (World Health Organization 1978), countries still face the problem of how to share scarce resources between potentially high-cost but necessary curative services and low-cost but vastly more cost-effective preventive strategies.
Most Pacific nations have very small populations with low percentages of the labour force in formal employment. Limited revenue from taxation means few resources to devote to health and insufficient numbers to support health insurance schemes. One very positive aspect of Globalisation is that most Pacific nations receive substantial amounts of development assistance to supplement their health budgets. Usually this comes from the countries with which they had or have a colonial or economic relationship, or from multilateral agencies funded by such countries.
Because of their close connections with other countries, however, self- sufficiency in medicine has never really been contemplated for these peripheral nations. Most small Pacific countries have an internal hierarchy of medical facilities, with hospitals based in main centres, while outer areas are served by health centres and aid posts, the latter often little more than a first-aid kit or treatments administered by someone with only a few weeks training. The general aim is to provide basic services to the level national resources permit, and to rely on developed countries for any advanced treatment. Each nation determines the allocation of resources between in- country facilities and evacuations. Even one of the most highly developed in the Pacific region, the French overseas territory of New Caledonia, evacuates chronic cases and those requiring advanced treatment, most to Australia or France. Although this strategy does give some people access to higher-level medicine, it inevitably means that the poorest countries and poor and remote residents within countries are disadvantaged. Those living in remote or outlying regions, especially, are unlikely to receive adequate health care when it is needed urgently because they may be unable to afford or survive a trip to a main centre.
Whereas some Pacific countries such as Papua New Guinea and the Fiji Islands are large enough and sufficiently well resourced to offer a reasonable standard of hospital services, if only basic surgery, others are less fortunate. For example, despite its remoteness, Kiribati has only the most basic medical capability, and most resources are at the Tarawa hospital, which is readily accessible to only around 40% of the population. An Australian specialist who visited Tarawa in 2001 to train nurses in emergency care informed the author that the only emergency equipment at the hospital was one respirator, which was not operational at the time. Evacuations are mostly via the twice-weekly commercial flights, since the cost of chartering a plane from a neighbouring country such as the Fiji Islands is prohibitive, and medical insurance is unavailable. In view of these conditions, it is hardly surprising that in Kiribati most major injuries are fatal, and generally only expatriates and politicians are evacuated for medical treatment.
Similarly, although the Marshall Islands are much better off because of substantial inflows of US aid, and equipped with two hospitals to serve a smaller and more concentrated population, medical evacuations absorb a significant amount of the annual health budget. The dilemma of how to allocate scarce resources so as to achieve optimum health care is a major issue for Pacific health managers. Although it may seem a very harsh view, it is not hard to understand the comment of a Nauruan official who remarked to the author that palliative care is a luxury Nauru cannot afford, and terminally ill people should not receive any medical treatment. 2
In addition to the limited nature of facilities, an ongoing problem in all peripheral countries, including those of the Pacific, and in peripheral areas within countries, is the loss of skilled health personnel. Migration of skilled personnel in the health sector from peripheral to core areas is a worldwide problem. This is largely a consequence of global forces that concentrate opportunities in core areas. These factors affect most professions, including teaching, as well as the medical professions (Connell 2001: 21; Voigt-Graf 2002: 33). Lower salaries, inferior working conditions, smaller facilities with fewer opportunities for promotion, and increased responsibility are some of the many factors that encourage skilled migration from peripheral to core areas. Core places offer better career opportunities, better facilities in the workplace, and more lifestyle options. Of particular importance is that health professionals receive more support from colleagues in core areas, whereas in peripheral areas they may be obliged to work alone, offer a wide range of services, and be held solely responsibility for patient care. Often, however, the motive for migration of health professionals is simply a desire to live where their children can receive the best education and their spouse can find employment (Connell 2001: 23).
Although virtually all Pacific countries have shortages of trained health professionals, migration of health professionals occurs both internationally and intra-nationally. The international flow is mainly to Pacific Rim countries and also from low income to higher-income countries within the Pacific. For example, Fijian nurses migrate to Northern Pacific countries to obtain higher salaries. This is paralleled by intra national movements to core areas because of the difficulty of retaining staff in underdeveloped peripheral areas (SPC 2001:21).
Shortages of trained personnel mean that lower level facilities have more untrained or informally trained staff although this is intended as an efficiency measure, it can contribute to misuse of skilled personnel. In Papua New Guinea, for example, a frequently mentioned problem during the early 1990s was that the hierarchical nature of medical training contributed to wastage rather than efficiency. Because of the wide disparity in skills between fully trained health professionals and aid post and clinic staff, clients attending clinics insisted on being treated by the most highly trained practitioner, refusing services from less qualified personnel. Although trained doctors were in short supply, they had difficulty delegating even minor procedures, such as dressing small wounds, even though the National Health Plan stipulated that "no person should be engaged to perform a task if a lesser trained, lesser paid worker could be employed to carry out that task adequately" (Papua New Guinea 1996:258).
Another consequence of the Globalisation of health is that senior health officials in peripheral countries are constantly travelling overseas to attend meetings. In small countries, the most qualified professionals are likely to be drafted into management, which itself contributes to wastage of skills. When, in addition to this wastage, they are frequently away from their desks participating in regional policy meetings on a wide range of subjects, in-country management capacity may be compromised.
The impact of Globalisation is also evident in the management of infectious disease in peripheral countries. One very positive impact has been global intervention programs such as Oral Rehydration Salts to prevent fatal dehydration of children with diarrhoeal infections, HIV/AIDS prevention programs and the Expanded Programme of Immunisation, mentioned in the introduction to this paper. This program, initially to immunize children against six major diseases (TB, measles, polio, diphtheria, tetanus, and pertussis) was possibly the most cost-effective primary healthcare intervention ever devised. It came about because of worldwide concern about infant and child mortality in less-developed countries, and although funded by more-developed countries, was delivered to children in both more- and less-developed countries. In Papua New Guinea, however, where pneumonia is a major cause of infant mortality, doctors had difficulty persuading local authorities to add the Haemophilus influenza B (Hib) vaccine to the program, because at that time the global standard was presumed to be sufficient (personal communication, Goroka Hospital medical staff, April 1998).
Impact of Globalisation on Lifestyles
The third major mechanism through which Globalisation impacts health is its promotion of particular lifestyles and lifestyle habits that increase the risk of non communicable diseases. Modernization has brought new technologies and a wider range of goods to peripheral countries, as well as urban lifestyles and wage employment. The polarizing forces of Globalisation, however, mean that in most peripheral countries the demand for modem sector employment exceeds the availability of jobs (McMurray and Smith 2001). This means that not all people have the option of enjoying the benefits of modernization. Many, especially those in urban environments, have access only to inferior goods and limited opportunities, and experience more of the unhealthy aspects of modernization than its benefits. This includes consuming poor diets because healthy diets are unavailable or unaffordable, taking insufficient exercise, smoking and drinking to excess. While such lifestyle habits are by no means unique to peripheral areas, peripheral groups in both more- and less-developed countries are especially likely to adopt them. Coyne (2001) writes of Pacific urban dwellers that they live "an infectious lifestyle indirect, insidious and generational, slowly transmitted and resulting in equally slow morbidity and incessant mortality" (p. 6).
It is widely recognized in developed countries that economically and socially disadvantaged people are more likely to have unhealthy lifestyles, whereas educated people are more likely to be aware of health risks and live a healthier lifestyle (Hetzel and McMichael 1997). It is not just education per se that makes the difference, but the capacity to live a healthy lifestyle. Since the educated are more likely to be employed or to have other economic advantages, they have a wider range of lifestyle options. Heavy drinking, smoking, overeating, underexercising, and unsafe sexual activity occur among both privileged and disadvantaged groups, in both more- and less-developed countries. The privileged have a greater capacity to choose, however, even if they do not always make the wisest choices.
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