The global context of health Session aims • To demonstrate how the global context influences individual health • To demonstrate how inequality on a global scale affects and determines health • To illustrate how globalisation impacts upon health in a number of contradictory ways Why is global health important? • Health is bound up in global relationships; the global context in which we are located influences our health • The notion that we live in a global society is supported by evidence showing that trends and relationships exist between health and well-being in many societies across the globe • Individual health is increasingly conditioned and determined by both global processes and relationships (Yuill et al 2010) • There are a number of health problems and issues that require tackling on a global scale, hence the need for global solutions Global health challenges • The World Health Organisation (2008c) has identified a number of global health challenges – One fifth of all global deaths in 2004 were children under five, often as a result of malnutrition – Smoking related lung cancer is the leading cause of cancer-related death for men – Ischemic heart disease and cardiovascular disease are the leading causes of death in the world – In Africa, the main cause of death amongst 15-59 year olds is the HIV/AIDs virus. HIV/Aids is responsible for forty per cent of female deaths in Africa – The global burden of mental illness is also increasing, with depression resulting in many instances of disability – Road traffic accidents are also increasing across the globe as a result of increased car numbers and urbanisation Globalisation • Godden's (2009:126) defines globalisation as ‘the fact that we all increasingly live in one world, so that individuals, groups and nations become ever more dependent’ • Globalisation is defined in a number of ways but it encompasses economics as well as social and cultural aspects and hence is important in relation to health • The idea of an interconnected global society raises several questions about health especially as many more health issues are now being conceptualised as ‘global’ and therefore in need of global solutions • Debates continue in relation to whether globalisation is good or bad for health Areas where globalisation impacts upon health (Lee 1998) • The spread of disease within and across countries (are epidemiological patterns changing and what implications are there for the prevention and treatment of disease?) • The global financing of health care (how has the globalisation of finance influenced health care funding?) • Global trade and production (are more regulations needed to protect health?) • Global information (are there inequalities in access to health care information?) • Global governance (who are the key players and is their role positive in terms of improving health?) • Global law (what global health issues need to be dealt with via the legal system?) Globalisation and migration • Threats from emerging and re-emerging infectious diseases are increased by globalisation (Feacham 2001) and the movement of people around the world • Migration has resulted in ‘brain drain’; high proportions of doctors and nurses who are trained and educated in their own countries leave to work elsewhere for better pay. • Health consumers are patients are also increasingly travelling to access medical care. This is called health tourism Globalisation and trade • Bettcher & Lee (2002) discuss the negative health impacts of financial liberalisation and trade such as the extended marketing and promotion of harmful products such as tobacco • Macdonald (2007) argues that as a result of neo-liberal globalisation, many companies have worked unethically to increase their profits and therefore have had a negative impact upon health • The drive for economic growth has also increased the consumption of processed food and cigarettes (Graham 2010) Trade and health – global pharmaceuticals • The common diseases affecting lower income countries do not attract research funding because market forces determine levels of spending (Macdonald 2006) • Only 5% of the money spent on medical research and development is directed towards diseases which affect lower income countries (Shuklenk 2003) • In the last quarter of a century there have been 1400 new drugs launched but only four of these were for malaria and just thirteen for tropical diseases (Kaufmann 2007) • The costs charged by large pharmaceutical companies for essential medication means that those who are least able to afford such costs are paying them (WHO-WTO 2002) or not getting access to them • The existence of trade agreements means that prices of some drugs have risen to unaffordable levels (Stiglitz 2006) Globalisation and the environment • Globalisation is a massive threat to the environment, causing both environmental and health damage (Feacham 2001) • Globalisation contributes to climate change in several ways for example, as a result of increased travel and pollution, the increased demand and use of energy sources and the consumption of products and associated waste • Wilkinson (2005) argues that new environmental threats are emerging through complex and extended pathways that are global in their reach Global inequalities • There are massive inequalities globally in relation to health • Despite economic growth large variations still exist across the globe in relation to life expectancy • The relationship between income and health is complex with those living in high income countries tending to experience much better health and life chances than those in lower income countries Global poverty • Poverty and the powerless that is associated with it negatively affect the health of those experiencing it. • Extreme poverty is the most serious cause of disease, with 70% of deaths in developing countries attributable to five causes that can be easily and cheaply combated; pneumonia, diarrhoea, malaria, measles and malnutrition (WHO 1995). • In 2001, the deaths of two million people could have been prevented simply if they had been given access to uncontaminated food and clean drinking water (Kindhauser 2003). • Women and children bear the brunt of global health inequalities. • In 2007, women made up sixty one per cent of HIV infections in SubSaharan Africa (UNAIDs 2007). • Within all societies death rates are typically highest amongst the poorest. • The global burden of disease is disproportionately experienced by those in lower income countries Higher death rates in poorer countries • Africa accounts for the majority of HIV infections. Not only are the numbers of infected individuals unequal across the globe, the implications of such a diagnosis also vary massively according to location, those in lower income countries have more negative outcomes (Macdonald 2006) • 4, 500 children die every day from preventable diseases (WHO 2007b) • Malaria is a huge global killer, infecting one child in Africa every thirty seconds • Infectious diseases remain a large global problem. • Kaufmann (2009) argues that figures are simply abstract because it is impossible for most people to grasp the fact that fifteen million people die as a result of infectious diseases every year Global financing and health care • Poorer countries have far less money available to spend on health care, less developed health care infrastructure, staff shortages and in many cases a lack of basic supplies such as drugs • Spending on healthcare is incredibly unevenly distributed globally • The poorest countries spend the equivalent of $11 per year per person, compared to an average US spend of $2000 (WHO 2000) • The thirty most developed nations (all members of the Organisation for Economic Cooperation - OCED), are made up of 20% of the world’s population yet they account for 90% of the world’s total health expenditure (WHO 2007b) Low income countries and health service provision • People in lower income countries tend to have far less access to modern technology and adequate healthcare and are often reliant upon donor aid to provide health care • Health care systems found in some lower income countries do not perform well. Thirty five of the fifty worst health care systems are found in Sub-Saharan Africa (Macdonald 2007) • Just to meet the most basic of health needs, the World Health Organisation suggests that at least $66 billion should be invested in low income countries (WHO 2002a) • Financing health care is a complex task associated with managing difficult budgets and making ethically challenging decisions Global governance • The forces of globalisation have led to an increased range of global policy actors, shaping health policy, funding and provision • Many organisations assume a role in creating and maintaining the conditions required for good health and health care on a global level (Davies 2010) • Global actors affect our abilities to improve both national and local health too (Labonte 2010) Key global actors Organisation Remit World Health Organisation • • • • The World Bank • Provision of loans and grants • Public sector reform • Encourages user charges The World Trade Organisation • Promotion of free trade International Monetary fund • Public sector reform • Reduced public spending i.e. on health Non-governmental organisations • Each has a remit e.g. The Gates Foundation, Aid agencies, charities Immunisations Disease eradication Development of primary health care Annual world health reports The work of global players questioned • The overall impact of such organisations in shaping better health outcomes has been questioned (Fidler 2007) • Some critics have suggested that the list of global health priorities simply reflects the issues that are threatening to the interests of the industrialised western world (Ollilia 2005) • The need to tackle social inequality remains (CSDH 2008) Positive global governance • The Millennium Development Goals to deal with poverty and inequality, to improve health, to develop a cleaner and more sustainable environment and promote a fairer world are positive • The goals are an attempt to promote global collective responsibility for health threats, defined in the broadest possible sense as they include poverty, preventable communicable disease and environmental degradation (Davies 2010) • The work of global health actors has also led to – large scale vaccination schemes – education and health promotion to try to combat the HIV/Aids epidemic – strategies to deal with tuberculosis and malaria (Kaufmann 2009) – some notable successes such as the impressive global eradiation of the smallpox virus by the WHO (Macdonald 2008) Summary • Globalisation as a social process is influencing health in a number of ways, with debates about whether this is positive or negative on-going • The global governance of health has expanded in recent years, with a large number of global actors working on health issues and problems. There have been some successes and targets are often set however, the neoliberalist framework underpinning the work of some of these organisations does not result in positive health outcomes for the poorest people in most instances • There are major health problems across the globe but these are spread unequally as inequality means that the global burden of disease is borne by the world’s poorest inhabitants.