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Globalization and Health
Let me start these reflections by stating the obvious: globalization is evolving at such speed and with such complexity that it challenges our ability to grasp it in its full extent. Obvious as it may be, this dynamism is a good reason to constantly renew the discussion around the forces of globalization and their impact on everyday life.
The shift of human affairs from the nation-state to planet Earth is affecting not only trade, finance, science, the environment, crime, and terrorism; it is also influencing health. In 1997, a report by the U.S. National Institute of Medicine stated:
“Distinctions between domestic and international health problems are losing their usefulness and are often misleading.” By 2001, HIV/AIDS had become such a pressing international problem that the United Nations made it the subject of the first-ever General Assembly session on health, underscoring the growing link between economic development, global security, and pandemics such as AIDS.
I do not mean to argue that intense international contacts are new. From time immemorial the forces of trade, migration, war, and conquest have bound together persons from distant places. 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, literally, at our doorsteps.
The degree of proximity in our world can be illustrated by the fact that the number of international travelers has tripled since 1980, and it now reaches 3 million people every day.
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 health risks and opportunities.
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 BC. The Black Death of 1347 was the direct result of international trade. The global spread of influenza in the early 20th century accounted for far more casualties than World War I.
Also new is the scale of what has been called “microbial traffic.” The explosive increase of world travel produces thousands of potentially infectious contacts daily. Thus, in 1991, a Peruvian outbreak of cholera turned into a continental epidemic in a matter of weeks. Likewise, drug-resistant strains of tuberculosis have traveled from detention centers in Russia to Paris in just a few hours.
To make matters more complex, it is not only people and microbes that travel from one country to another; it is also lifestyles. Smoking provides a clear example. The most powerful tobacco companies are able to expand their marketing efforts into countries lagging in regulatory capacity.
Furthermore, the globalization of health includes health products. To mention but one example, 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 foregoing examples illustrate the growing complexity of health systems under globalization. But globalization also affords tools and opportunities to respond to longstanding and emerging health threats.
Allow me to give an example of a major health care reform in my own country, Mexico. The process began at an international level, with the development by academic and international organizations of a novel analytical tool: national health accounts. By applying this tool to local data, we showed that more than half of total health expenditure in Mexico was out-of-pocket, because approximately half of the population lacked health insurance.
The careful interplay between national and international analyses generated the advocacy tools to promote a major legislative reform in 2004, which will ultimately provide universal health insurance, including the 50 million Mexicans who had been excluded until then from formal social insurance.
This is a clear example of how globalization can turn knowledge into an international public good that can then be brought to address a local problem. Such application, in turn, feeds back into the global pool of experience, thus generating a process of shared learning among countries.
The performance of local health systems can also be enhanced by one of the most potent motors of globalization: the telecommunications revolution. The pioneering work in the field of telemedicine by one of my mentors at the University of Michigan, Professor Rashid Bashshur, points to a future when physical distance may no longer be a significant barrier to health care.
The challenge, of course, will be to make sure that the distance divide is not merely replaced by the digital divide. The magnitude of this challenge becomes clear when we realize that the 80 percent of the human population living in developing countries represents less than 10 percent of internet users.
The challenge we have before us is to build a world order characterized by peace in the midst of diversity. Health may contribute to this pursuit because it involves those domains that unite all human beings. It is there, in birth, in sickness, in recovery, and ultimately in death that we can all find our common humanity. More today than ever, health is a bridge to peace, a common ground, a source of shared security.
But for this to happen, we must renew international cooperation for health. I suggest three key elements for such renewal, three e’s: exchange, evidence, and empathy.
Health systems around the world are facing similar challenges. The communications revolution provides the opportunity to exchange information about these challenges and about initiatives to deal with them.
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, which may be transferred across countries when its culturally, politically, and financially reasonable.
But there is another value, empathy, that human characteristic which allows us to emotionally participate in a foreign reality, understand it, and, in the end, 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 a universal person, Dr. Martin Luther King, Jr., who wrote, “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.”
Let us continue to weave together the destiny of better health for all the inhabitants of our common world.