Globalization and Health: A New, Critical View
By
Ronald Labonte And Ted Schrecker
* Ronald Labonte (rlabonte@uottawa.ca) and Ted
Schrecker (tschreck@uottawa.ca) are,
respectively, Canada Research Chair and Senior
Policy Researcher at the Institute of Population
Health, University of Ottawa, Canada. 'Health for
Some: Death, Disease and Disparity in a
Globalizing Era' by Ronald Labonte, Ted
Schrecker and Amit Sen Gupta is available from
http://www.socialjustice.org/cart.php?fil
Current economic policies mean that those not
able to join the global marketplace are
considered disposable, or as the World Bank has
previously termed it, the "unintended and
regrettable consequences" of adjustment policies.
Recent commitments to improve Africa's situation
within this context provide reasons for both
optimism and pessimism ahead of a G8 summit in
July, which will show whether leaders of the
industrialized world are serious about improving
the health of all Africans.
In Zambia, a woman named Chileshe is dying of
AIDS. She was infected by her now dead husband,
who once worked in a textile plant along with
thousands of others but lost his job when Zambia
opened its borders to cheap, second-hand
clothing. Resorting to work as a street vendor,
he would get drunk and trade money for sex -
often with women whose own husbands were
somewhere else working, or dead, and who
desperately needed money for their children.
Desperation, she thought, is what makes this
disease move so swiftly; she recalls that a woman
from the former Zaire passing through her village
once said that the true meaning of SIDA, the
French acronym for AIDS, was "Salaire Insuffisant
Depuis des Années" (Schoepf, 1998).
Chileshe's is one of four stories we used in a
report that has just been published by Canada's
Centre for Social Justice (Labonte, Schrecker & Sen Gupta, 2005b) to dramatize the health impacts
of transnational economic integration
('globalization'). It is a composite, like the
stories used in the World Bank's 1995 'World
Development Report'. The Centre for Social
Justice report, which grew out of a contribution
to the first 'Global Health Watch Report'
(forthcoming in July at http://www.ghwatch.org),
directly challenges the elite religion of
neoliberal, market-oriented economic policy, as
promoted by agencies like the World Bank and the
International Monetary Fund. Drawing on an
extensive research base, we describe the causal
pathways that link globalization to unequal and
deteriorating health outcomes by way of
increasing inequalities in access to the social
determinants of health, and policies that tilt
the economic playing field even more steeply
toward the rich countries.
Sometimes, the impact is straightforward, as
when public spending cutbacks combined with
onerous debt repayment terms mean that
governments opt for "cost recovery" in health
care or water and sanitation. This process played
a role in Chileshe's story. As part of a
structural adjustment program attached to loans
from the International Monetary Fund, Zambia
imposed user fees, cut health staff and reduced
the salaries of those who remained - just at a
time when the AIDS epidemic was surging out of
control.
In other cases, the causal pathways operate less
directly, by reducing economic insecurity and
magnifying inequalities. The same adjustment
program required Zambia to open its borders to
second-hand clothing in 1992. Its domestic
clothing manufacturers, valuable though they were
as providers of employment, could not compete
with imports of used clothing with zero
production costs. Within eight years, Zambia's
clothing and textile industry all but
disappeared, along with 30,000 jobs; large
numbers of previously employed Zambian workers
were thrust into the informal, ill-paid and
untaxed underground economy. The World Bank
called these "unintended and regrettable
consequences" of the adjustment process (Jeter,
2002). For classical economists, the market was
working as it should: consumers get more and
cheaper stuff, and inefficient producers are
driven out of business. For the losers and the
left-behind, the consequences can be deadly.
Zambia's required privatization of state
enterprises eliminated a further source of
revenues that might have been used to support
social programs, such as education and health
care.
The Zambian government is trying to undo some of
this damage. But like many other governments, it
is hampered by the rich world's failure to cancel
more of the developing world's crippling debt, or
to provide it with the resources it needs to
sustain its peoples' health. Writing about
another African country, journalist Ken Wiwa
noted: "You'd need the mathematical dexterity of
a forensic accountant to explain why Nigeria
borrowed $5 billion, paid back $16 billion, and
still owes $32 billion" (Wiwa, 2004).
Not until 1996 did the rich world respond
collectively with the so-called Heavily Indebted
Poor Countries or HIPC initiative. This has freed
up more money for health and education. But much
of the HIPC countries' debt will remain unpaid
and uncancelled at the conclusion of the
initiative, most of the world's poor live in
countries that are not eligible for HIPC and the
price of debt relief is often more privatization
and trade liberalization, now dressed up in the
rhetoric of poverty reduction strategies.
Development assistance is by no means a panacea.
At the same time, a wealth of experience now
exists on how to make aid work for basic needs,
if the political will is there on the part of
donor and recipient countries. The most
authoritative estimate is that meeting the
Millennium Development Goals' 2015 targets, most
of which are health-related, would require an
additional $60 - $120 billion a year in aid from
the industrialized to the developing world. This
would represent a doubling or tripling of current
aid flows, but hardly a formidable sacrifice:
less than the cost of 57 Big Macs per Canadian
per year, or 43 Big Macs per German per year
(Schrecker, Labonte & Sen Gupta, 2005a). The cost
would also be a fraction of what the United
States spends on its armed forces, or of the
value of the tax breaks that the richest
Americans and Canadians have received in recent
years.
Reasons exist for optimism. Both the UN
Millennium Project, which generated the cost
estimates we have quoted, and the UK Commission
for Africa were emphatic about the need for more
development assistance and more effective ways of
using it. In the words of the UN Millennium
Project, "Even if we don't know everything about
such challenges, we know enough to achieve the
[Millennium Development] Goals. Moreover, the
necessary interventions are utterly affordable" (UN Millennium Project, 2005). Partly because the
British government has placed African development
high on the agenda, this July's G8 Summit may
represent a turning point for population health
in Africa, and elsewhere in the developing world.
A minimal "health equity agenda" for the Summit
(Labonte & Schrecker, 2005) includes not only
clear timetables for aid increases tied to
comprehensive strategies for improving population
health, but also expanded debt cancellation,
acceptance of development-friendly trade policies
such as special and differential treatment (SDT),
and explicit acknowledgment that human rights -
including the right to health - take precedence
over trade and financial liberalization. In
addition, because of the importance of capital
flight in undermining African economies, the G8
must quickly ratify the United Nations Convention
Against Corruption (which would provide for
repatriation of assets illegally shifted
offshore) and pressure other industrialized
countries, as well as offshore financial centres,
to do the same. To the credit of the UK
Commission on Africa, it was emphatic on these
points.
Unfortunately, reasons also exist for pessimism.
The Millennium Project and the UK Commission were
less emphatic in acknowledging the need for
fundamental redesign of the international
economic order. Canada's finance minister, who
was a member of the UK Commission, is making
breathless speeches about how Africa needs "a
strong indigenous private sector to create jobs"
and must "improve the business and investment
climate building entrepreneurial and marketing
skills, domestic capacity and improving access to
finance" (Goodale, 2005). This language suggests
a development policy triage in which people not
strong, young, or lucky enough to make it into
the entry levels of the global marketplace (like
Kenya's call centres; see Lacey, 2005), or
predatory enough to establish business alliances
with foreign corporations, are considered
disposable. In the discourse of growth through
entrepreneurship those Africans who are already
seropositive, or at highest risk for HIV
infection because of their economic
vulnerability, become invisible.
By the end of the July Summit we will have a
much better sense of whether the industrialized
world is serious about improving the health of
all Africans, or whether the best it can come up
with is selective and targeted policies that
represent only incremental departures from a past
posture of 'Fatal Indifference'(Labonte et al.,
2004).
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