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Commentary

Globalization And The Challenges To Health Systems

Abstract

 
The shift of human affairs from the nation-state to the vast theater of planet Earth is changing the nature of health challenges. In addition to their own domestic problems, all countries must now deal with the international transfer of risks. These new challenges are demanding novel forms of international cooperation, which, if developed, may also help to reconcile general national self-interest with international mutual interest. This paper discusses the possibility of using health as an instrument of foreign policy and of developing new forms of cooperation around three key elements: exchange of experiences around common problems, evidence on alternatives, and empathy.

International Transfer Of Risks And Opportunities

Top International Transfer Of Risks... Social Exclusion And... New Forms Of International... NOTES

 
Intense international contacts are not new; the forces of trade, migration, war, and conquest have long bound together persons from distant places. After all, the expression "citizen of the world" was coined by the Greek philosopher Diogenes in the fourth century b. c . What is new is the pace, range, and depth of integration. Like never before, the consequences of actions that are taking place far away show up at our doorsteps.

One of the great revolutions of the twentieth century was, in the words of the historian Eric Hobsbawm, the virtual annihilation of time and distance.⁴ The degree of proximity in our world can be illustrated by the fact that the number of international travelers has tripled since 1980—three million people now travel abroad every day. In addition, last year the traffic on international telephone switchboards topped 100 billion calls for the first time in history.⁵

Transfer of risks. We cannot underestimate the implications of these changes for health. In addition to their own domestic problems, all countries must now deal with the international transfer of risks.⁶ The most obvious case of the blurring of health frontiers is the transmission of communicable diseases. Again, this is not a new phenomenon per se. The first documented case of a transnational epidemic was the Athenian plague of 430 b.c.⁷ The Black Death of 1347, which killed one-third of the European population, was the direct result of international trade. In the sixteenth century the conquest of the mighty Aztec and Inca empires was an early example of involuntary microbiological warfare through the introduction of smallpox. More recently, the global spread of the influenza pandemic of the early twentieth century accounted for far more casualties than did World War I.

What is new is the scale of what has been called "microbial traffic." The explosive increase of world travel produces thousands of potentially infectious contacts daily, and jet planes have made even the longest intercontinental flights briefer than the incubation period of any human infectious disease. Thus, a Peruvian outbreak of cholera turned into a continental epidemic in a matter of days in the early 1990s. Drug-resistant strains of tuberculosis have traveled from detention centers in Russia to Paris in just a few hours.⁸ Likewise, the Asian "tiger mosquito," a potential vector for dengue fever virus, was introduced into the United States in the 1980s in a shipment of used rubber tires imported from northern Asia.⁹ These are all examples of what Arno Karlen has called our new biocultural era, generated by radical changes in our environment and lifestyles.¹⁰

Indeed, to make matters more complex, it is not only people, microbes, and material goods that travel from one country to another; it is also ideas and lifestyles. Smoking provides a clear example. Whenever a legal or regulatory battle against the tobacco companies is won in the United States, everyone rejoices for the American public but trembles for the consequences in other countries, because those very victories give those same companies the incentive to look for new markets with less stringent regulations. Already about four million people die from smoking-related causes every year. By 2020 that number will grow to ten million, making tobacco the leading killer worldwide.¹¹ This shows why effective national policies must be coupled with global action, such as the international convention now being promoted by the World Health Organization (WHO), whereby governments will join forces to match tobacco’s transnational power. This legally binding instrument intends to limit the global spread of tobacco products by addressing issues as diverse as tobacco advertising and promotion, agricultural diversification, smuggling, taxes, and subsidies.¹²

Ripple effects from one system to another. The globalization of health goes beyond diseases and risk factors to include health care and its inputs. For example, careful regulations on access to prescription drugs in one country may be subverted when its neighbor allows the unrestricted purchase of antibiotics, thereby stimulating the appearance of resistant microbes that show up in the first country.

The growing commerce of health care services through conventional procedures and the Internet is another good example of how frontiers are becoming blurred. International health tourism is providing Cuba earnings in excess of $25 million a year.¹³ The cross-border mobility of health care consumers is so common that the United States now includes the "export of medical services" in its national accounts. The selling of medical services through the Internet is also ubiquitous, from procedures in sophisticated Swiss hospitals to slow down the effects of aging to traditional massage in Bangkok clinics for chronic low-back pain. Online drug sales are another way in which national regulatory authorities may be bypassed.

Opportunities for global action. Interdependence has also opened up new avenues for international collective action. For instance, efforts in the 1990s to secure cheaper AIDS drugs in poor countries yielded only modest results. In mid-2001, however, strong international mobilization persuaded several major multinational drug companies to establish agreements with developing countries to sell AIDS drugs at heavily discounted prices. Forces related to globalization also prompted the organization of the United Nations (UN) General Assembly Special Session on HIV/AIDS in June 2001, which approved a historical Declaration of Commitment "to enhance coordination and intensification of national, regional and international efforts to combat AIDS in a comprehensive manner."¹⁴ UN Secretary-General Kofi Annan announced that day the creation of the Global AIDS and Health Fund, which intends to raise $7–$10 billion a year for the prevention and treatment of this and other diseases. This was the first time in UN history that a session of the General Assembly was devoted to a health topic, thus underscoring the growing link between health, economic development, and global security.

Sharing and comparing information. Increasing communication, in the face of the growing complexity of health systems, has also made international comparisons more valuable than ever. Given the enormous economic and social impact of policy decisions, countries can benefit from shared learning. This was the significance of the recent effort by WHO to assess the performance of all 191 health systems of the world.¹⁵ It is hoped that the identification of relatively good and bad performances will promote the international dissemination of good practice. Imperfect as it is, this exercise has nourished an intense and fruitful debate, which builds on previous efforts by many academic and intergovernmental organizations. This kind of comparative analysis has the virtue of turning information into a global public good.¹⁶

The performance of local health systems can also be enhanced by one of the most potent motors of globalization: telecommunications. Telemedicine increases the potential for improving access to care by underserved populations and points the way to a future when distance does not impede care. The challenge, of course, will be to make sure that the distance divide is not merely replaced by the digital divide and that the new technologies do not generate new forms of social exclusion. The magnitude of this challenge becomes clear when we realize that the 80 percent of the population living in developing countries represents less than 10 percent of Internet users.¹⁷ Canada, the United States, and Sweden rank among the most wired nations, with 40 percent of their populations regularly connected to cyberspace. In contrast, most African and south Asian countries claim fewer than ten Internet users per 10,000 population.¹⁸

Social Exclusion And Globalization

Top International Transfer Of Risks... Social Exclusion And... New Forms Of International... NOTES

 
The new forms of social exclusion feed on the old scourges of poverty and inequality. The 1.3 billion people who survive on one dollar per day are a reminder to all of the enormous gaps that must still be overcome within and between countries. These gaps have consequences for health as expressed by the existing and, in some regions, growing inequalities in health conditions and access to care.

Exclusion and inequality are one dark side of globalization. Insensitivity to local cultures is another. Together they may explain a painful paradox of our days: Precisely when technology has brought human beings closer to each other than ever before, we are witnessing the reappearance of intolerance in its ugly guises of xenophobia, ethnic cleansing, and oppression. And with intolerance, as a Siamese twin, comes terrorism, traditionally the instrument of offended fanatic minorities that resist believing in persuasion. At its essence, terrorism is the worst form of dehumanization, as it turns innocent people into mere targets.

The arsenal of terrorism has expanded to include chemical and biological weapons. According to intelligence agencies, in recent years several militant groups across the world started developing or tried to purchase biological weapons for terrorist use.¹⁹ There is a lot of discussion around the viability and possible magnitude of such attacks. What seems clear, though, in the face of the September 11 events and the rapidly growing power of biotechnology, is the urgent need to strengthen our surveillance capabilities through actions such as building international networks of public health laboratories, strengthening information sharing among national surveillance authorities, and joint training of specialized personnel. Whether a bioterrorist attack materializes or not, these measures could improve the daily functioning of our public health systems for the general good.²⁰

New Forms Of International Cooperation

Top International Transfer Of Risks... Social Exclusion And... New Forms Of International... NOTES

 
In the long run, the challenge is to build a world order characterized by peace in the midst of diversity. Instead of asserting one’s identity by rejecting or destroying what is different, we must try to soften collisions, balance claims, and reach compromises.²¹ In this way, we may try living according to what President Vaclav Havel of the Czech Republic has called a basic code of mutual coexistence.²²

In the pursuit of such a goal, we must all come together in the search for new ways of making our interdependence a force for peace and prosperity. As Prime Minister Blair said, the best memorial for those who lost their lives on September 11 will be

a new beginning, where we seek to resolve differences in a calm and ordered way; greater understanding between nations and between faiths; and above all justice and prosperity for the dispossessed, so that people everywhere can see the chance of a better future through the hard work and creative power of the free citizen, not the violence and savagery of the fanatic.²³

Health may contribute to this pursuit because it involves domains that unite all human beings. It is in birth, in sickness, in recovery, and ultimately in death that we can all find our common humanity. At critical moments for the world, health has consistently remained one of the few truly universal aspirations. In fact, before the constitution of specialized technical agencies, health affairs were a staple of international diplomacy. Health now offers again a concrete opportunity to reconcile national self-interest with international mutual interest. More today than ever, health is a bridge to peace, a common ground, and a source of shared security. For this to happen, we must renew international cooperation for health. We suggest three key elements for such renewal: exchange, evidence, and empathy.

Exchange. Health systems around the world are facing similar challenges; many of them, as we just discussed, are related to globalization. Developed countries are witnessing problems of cost explosion, irrational use of technologies, and consumer satisfaction. Developing nations are dealing with problems of access to care, quality of services, and unregulated growth of the private sector. The communication revolution provides the opportunity to exchange information about the challenges facing national health systems and about the initiatives to deal with them.

Evidence. To be informative, such exchange should be based on sound evidence about alternatives, so that we may build a solid knowledge base of what really works that may be transferred across countries when it is culturally, politically, and financially reasonable. This obviously implies the need to promote and strengthen health international comparative analysis.

Empathy. The late British philosopher Isaiah Berlin proposed the comparative study of other cultures as an antidote to intolerance, stereotypes, and the dangerous delusion by individuals, tribes, states, ideologies, or religions of being the sole possessors of truth.²⁴ This leads us to empathy, the human characteristic that allows us to emotionally participate in a foreign reality, understand it, relate to it and value the core elements that make us all members of the human race.

As we engage in the process of renewal, we would do well to remember the words of Martin Luther King Jr.: "It really boils down to this: that all life is interrelated. We are all caught in an inescapable network of mutuality, tied into a single garment of destiny. Whatever affects one directly, affects all indirectly."²⁵ Let us continue to weave together the destiny of better health for all the citizens of our world.

Editor's Notes

 
Julio Frenk, a physician, is Mexico’s minister of health. Until November 2000 he was executive director of evidence and information for policy at the World Health Organization. From 1987 to 1992 he served as the founding director general of Mexico’s National Institute of Public Health. Octavio Gómez-Dantés, also a physician, is assistant director for performance evaluation at the Ministry of Health. Until December 2000 he was director of health policy and planning at the Center for Health Systems Research, National Institute of Public Health.

This paper is a modified version of a keynote address delivered at the Commonwealth Fund 2001 International Symposium on Health Care Policy: Health Care System Reforms and Strategies to Improve Access and Quality of Health Care for At-Risk Populations, 9–11 October 2001, in Washington, D.C.

NOTES

Top International Transfer Of Risks... Social Exclusion And... New Forms Of International... NOTES

 

1. Speech by Tony Blair, Prime Minister, Labour Party Conference, Brighton, 3 October 2001.
2. K. Valaskakis, "Westfalia II: por un nuevo orden mundial," Este País (September 2001): 4–13.
3. Institute of Medicine, America’s Vital Interest in Global Health: Protecting Our People, Enhancing Our Economy, and Advancing Our International Interests (Washington: National Academy Press, 1997).
4. E. Hobsbawm, The Age of Extremes: A History of the World, 1914–1991 (New York: Pantheon Books, 1994), 12.
5. A.T. Kearny Inc. and Foreign Policy, "Midiendo la globalización," Este País (May 2001): 2–9.
6. J. Frenk et al., "The New World Order and International Health," British Medical Journal 314, no. 7091 (1997): 1404–1407.[Free Full Text]
7. L.C. Chen et al., "Health as a Global Public Good," in Global Public Goods: International Cooperation in the Twenty-first Century, ed. I. Kaul et al. (New York: Oxford University Press, 1999), 284–304.
8. G. York, "A Deadly Strain of TB Races toward the West," Globe and Mail, 24 March 1999.
9. W.A. Hawley et al., "Aedes albopictus in North America: Probable Introduction in Used Tires from Northern Asia," Science 236 (1987): 1114–1116.[Abstract/Free Full Text]
10. A. Karlen, Man and Microbes: Disease and Plagues in History and Modern Times (New York: Simon and Schuster, 1995).
11. World Health Organization, The Framework Convention on Tobacco Control: A Primer (Geneva: WHO, 2000).
12. Ibid.
13. United Nations, "United Nations Special Session on HIV/AIDS," 25–27 June 2001, www.UNAIDS.org (26 December 2001).
14. J. Frenk et al., "The Globalization of Health Care," in International Cooperation in Health, ed. M. McKee et al. (New York: Oxford University Press, 2001), 31–47.
15. WHO, World Health Report 2000, Health Systems: Improving Performance (Geneva: WHO, 2000).
16. Kaul et al., Global Public Goods.
17. UNDP, Human Development Report 1999 (New York: Oxford University Press, 1999).
18. R. Prescott-Allen, The Wellbeing of Nations: A Country-by-Country Index of Quality of Life and the Environment (Washington: Island Press, International Development Research Center, 2001).
19. L. Garrett, "The Nightmare of Bioterrorism," Foreign Affairs 80, no. 1 (2001): 76–89.
20. Donald A. Henderson, director, Center for Civilian Biodefense Studies, Johns Hopkins University, Hearing before the Senate Foreign Relations Committee on "The Threat of Bioterrorism and the Spread of Infectious Diseases" (5 September 2001).
21. I. Berlin, "The Pursuit of the Ideal," chap. 1 in I. Berlin, The Crooked Timber of Humanity (New York: Vintage Books, 1992), 1–19.
22. V. Havel, "A Courageous and Magnanimous Creation," Harvard Gazette, 15 June 1995, 9–10.
23. Speech by Blair.
24. I. Berlin, "Nacionalismo: notas para una conferencia futura," Letras Libres 3, no. 34 (2001): 105–106.
25. M.L. King Jr., The Trumpet of Conscience (New York: Harper, 1968).

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