Are we still talking about globalisation and health?

Do you remember that Special Theme Issue of the Bulletin of the World Health Organization back in 2001? Yes, the one on globalisation and health. Well, it’s celebrating its twentieth birthday this year. How time flies, eh? Globalisation was all the rage when I was completing my masters degree, and ’79(9)’ – as I affectionately liked to call it – was a surprisingly exciting read! So it was almost nostalgic to be discussing one of the articles from that special issue with a post-graduate student yesterday. Perhaps you’ve read it? David Woodward, Nick Drager, Robert Beaglehole and Deborah Lipson’s: ‘Globalization and health: a framework for analysis and action*’. The framework is quite well-known in certain niche corners of global health (it’s been cited 106 times) and – seeing as it’s on my mind and is celebrating a significant milestone this year – I thought I’d ‘critically reflect’ on its merits.

Here’s a question: twenty one years into the twenty first Century, are we still talking about globalisation and health? Good news! Doing a basic search of Web of Science (globali$ation AND health. Topic) yields the graph below which suggests that, yes, we are still talking about it.

Globalisation and health topic by number of citations

Research output on the topic has also steadily increased over the years (see below). So I think we can confirm that the relationship between globalisation and health continues to attract some interest, at least in academia. It’s important to start with that. I mean, why write a blog post about a topic nobody cares about anymore, right?

Globalisation and health topic by number of publications

But I can’t help wonder whether our understanding of ‘it’ has moved on that much since Woodward et al’s day. It’s curious, don’t you think, that besides Woodward’s framework there is just one other framework on offer. I’m referring, of course, to the much more colourful framework by Maud Huynen, Pim Martens and Henk Hilderink published a few years after Woodward’s.

So, do we need a new framework for a new world? Let’s see. Below is the simplified version of Woodward’s framework:

Woodward et al’s 2001 framework

Note that although the framework purports to visually represent the relationship between globalisation and health, it is actually more modest in its aim, focusing on just the “economic aspects” of globalisation which, according to the authors, “has been the fundamental driving force behind the overall process of globalization over the last two decades”.

But what if we’re interested in other ‘processes’ of globalisation besides economic, i.e. the socio-cultural, technological, political or ecological processes and their impact on health? Jan Aart Scholte wasn’t that fussed about defining globalisation in economic terms. In his 2008 article Defining Globalisation he argued that “globalisation refers to a shift in the nature of social space”. Circa 2021, our “social space” is being redefined, redrawn, expanded but also, perhaps, eroded. But we are only just beginning to concede that there may be consequences of that for our health. So let me start with a shout-out for a non-economic-oriented framework for globalisation and health.

Another question we might ask of Woodward’s framework, indeed of any framework purporting to map the relationship between globalisation and health, is: are you sure that you’re describing something that is conceptually distinct from pre-existing concepts such as internationalisation, liberalisation, westernisation or universalisation? This, of course, is the main point of Scholte’s critique i.e. protecting the concept of globalisation from redundancy. Unfortunately, the Woodward framework is very international, referring explicitly to “cross-border flows”, “international trade”, “opening of economies”, “lowering of trade barriers”, international relations between ‘developing’ and ‘developed’ states, etc. This is the language of internationalisation and liberalisation, so is it falling foul of Scholte’s observation?

I can’t move on from the opening paragraphs of Woodward et al’s analysis without making a couple of additional observations, again perhaps reflecting the times. First, what to make of this: “Financial flows from developed to developing countries have increased much more dramatically over the last decade”? If it was the case back in the early 2000s that finance flowed from rich to poor (seriously, has that ever been the case), then it certainly isn’t the case now. I’ve cited Jason Hickel’s work many, many times in my blog posts, so forgive me if I sound like a broken iTune, but do read the section in his book The Divide where he quantifies what he terms ‘aid in reverse’ (pp 24-31). Yes, rich countries give poor countries $128bn in aid each year, but poor countries give rich countries $200bn in interest on debts, $500bn in profits to financial investors, $60bn to patent holders, $23.6tn (yes, tn not bn) in capital flight, etc, etc. If the starting point of your analysis of the global economy, is the claim that finance flows from rich to poor, how accurate is your framework really going to be?

The second point to make relates to migration. Here’s Woodward et al:

“A major difference from the last major period of globalization, over the period 1870– 1914, has been in the composition of the cross- border movements of people. These are now dominated by travel and tourism, with a smaller proportion of legal migrants as developed countries have sought to close their borders, except to highly skilled people or those with capital”.

Woodward et al 2001, p876

It’s interesting that “cross-border movements of people” is interpreted in these terms. Pre-Covid-19, there were approximately 40m flights annually (both national and international). According to the International Organisation for Migration, the number of international migrants is around 272m people or 3.5% of the global population. That doesn’t include internally displaced people, which – if included – would be a more accurate comparison. So that needs revision.

But also note that 3.5% is not very many as a proportion of the total (i.e. 96.5% live where they were born). This reminds me of the need to approach globalisation with an open and empirical mind. I’m sure you remember Hirst and Thompson’s late 20th Century critique of globalisation – it had something of the au contraire about it. Here’s a taster. I love going back in time – read the depressingly prescient abstract: “both the global economy and national governments will face crucial challenges during this century, the chief of which is climate change”. Theirs is a Realist perspective and a cautionary note to not just assume globalisation but to demonstrate it.

I often show this slide when I’m lecturing. The data come from Pankaj Ghemawat’s book World 3.o:

Activity or flow% of total flow that actually crosses national borders
Information: mail, telephone calls, internet1%, 2%, 18%
People: 1st generation immigrants, overseas students3%, 2% – 90% of world’s population will never leave their home country
Products/services exported as % of GDP29% (2008); 23% (2009) – if no borders we’d expect 90%
Foreign Direct vs domestic Investment 10% foreign; 90% domestic

Surprising, isn’t it. The data are from 2011 but likely still roughly accurate. I refer you back to Woodward at al’s comment about cross-border travel being dominated by travel and tourism. This is a poverty-blind perspective of globalisation. Most people (by a large margin) will never board a plane in their lives, probably because they can’t afford to. Woodward et al are all for quantitative data, by the way, arguing that: “To be fully effective in this respect, however, the framework needs to be supplemented with empirical evidence on the various linkages involved”. But you kind of wonder whether they are encouraging you to look for data to support their presumptions about globalisation.

If Woodward et al’s paper stopped here, all would be good in the world. You could chalk this down to the happy outcome of an intellectually stimulating cocktail party and head home. But it doesn’t. Instead, we’re given an ‘agenda for action’ which also serves as a damning character assassination – imagine how poorly globalisation must have served humanity in the 80s and 90s for the following to be the principal action points for a new century:

  • “First, it is essential that the economic benefits of globalization extend to all countries, and especially to low-income countries”;
  • “Secondly, the economic benefits of globalization need to be translated into health benefit…This requires that economic growth be sustainable and consciously directed towards the poor”;
  • “Thirdly, potentially adverse effects of globalization on population-level health influences (e.g. on tobacco marketing and cross-border transmission of infectious disease) must be minimized. This requires action at the international level, e.g. an effective Framework Convention on Tobacco Control” – I quote this in full mainly because of a report in the Guardian this week with the headline: “Number of smokers has reached all-time high of 1.1 billion, study finds”. Here’s a link to the Lancet study on which the news story is based.
  • “A genuinely health-centred process of globalization can be achieved only by ensuring that the interests of developing countries and vulnerable populations are fully represented in international decision-making forums”.

These bullet points don’t really constitute an agenda for action – it’s hard to see them as more than aspirations and, personally, this is where I would have started my analysis of globalisation. If you want to know, for example, whether globalisation is ‘good for your health’ – a popular essay question – then ask yourself: do the economic benefits of globalisation extend to all countries, especially LICs (they don’t); is economic growth sustainable and consciously directed towards the poor (it isn’t and it isn’t); and are the adverse effects of globalisation minimised (no, they aren’t).

If that’s your starting point, you can then begin to construct a more substantive to do list:

  • The economic benefits of globalisation aren’t distributed equally or equitably? Well, why not!? To answer that question will require you to confront globalisation and hold its agents and structures to account. What if globalisation is not a politically neutral set of processes but is the consequence of a series of familiar, and quite deliberate, extractives practices just done more quickly, in more places and more intrusively?
  • The economic benefits of globalisation need to be translated into health benefits? Why aren’t they already!? And hang on, I thought we established in point one that the economic benefits of globalisation weren’t distributed equally or equitably? So while we’re trying to re-orient globalisation so that it benefits all countries and not just a few (i.e. the richest) we also have to align whatever benefits accrue to health?
  • And we must ensure that any ‘adverse effects’ of globalisation are minimised? On one level, this is tautological – globalisation is inherently adverse in the sense that it has not, ever, benefitted all countries or populations and doesn’t align with health benefits. So are we being asked to minimise the adverse effects of something that is inherently malign? On another, economic globalisation is predicated on – amongst other things – trade in inherently harmful goods. It’s staggering to realise, for example, that global military spending rose to $2 trillion last year. Even if the economic benefits of economic globalisation were to trickle down to everyone (which they don’t) then those benefits would be off the back of a security paradigm imbued with the wisdom of a global industrial-military complex. You want to ‘ensure’ that the adverse effects of globalised are minimised? Then prepare to take on the arms trade; every single Minister for Peace (aka war); and make sense of our mind-bogglingly destructive international system of states.

Twenty years on, do we have a “genuinely health-centred process of globalisation”? Clearly not. And if we’re not going to have one until we’ve completed the agenda for action’ outlined by the authors, then it looks like we aren’t going to have one any time soon. But more to the point, what does a health-centred process of globalisation even look like? I’m not sure Woodward et al get us very far in answering that question. The framework makes a number of assumptions about globalisation and I think there is still a lot of empirical analysis to be done here; it explores just one facet of globalisation – economic globalisation – when other facets are demanding more of our attention; and it is built on now dated analysis of various indicators, not least aid flows and migration patterns.

I’m glad that we are still talking about globalisation and health because, clearly, there is still so much to say. Happy birthday 79(9)!


Published by andrew

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