Diseases of Globalization

Socioeconomic Transition and Health

Christine McMurray, Roy Smith

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781134200290
• Edition: 1
• Topic: Medicine
• Subtopic: Ecology

The emergence of a global economy has led to the erosion of local autonomy and national sovereignty with an associated emphasis on the spread of liberal, free-market economics. A clear divide is appearing between those benefiting from and those disadvantaged by this process. Among the most important consequences are changes in the patterns of health and the prevalence of disease.

While infant mortality is declining in most countries, and many formerly prevalent diseases are being successfully tackled, the move from subsistence to cash economies brings with it changes in diet, alcohol consumption and high levels of smoking; with the result that non-communicable, 'lifestyle illnesses' such as heart disease and diabetes are spreading rapidly. Similarly, growing divisions of wealth add to the problem, bringing diseases relating to poverty and malnourishment as well as those caused by affluence and over-consumption.

Issues covered in this book include equitable and sustainable modernization, the determinants of health, the process of marginalization, and survival strategies on the periphery. The authors draw on primary case study material, largely from societies in the Pacific region undergoing modernization, to provide invaluable information for tracking and assessing the full impacts of these changes.

Chapter 1

The Issues

‘Health is a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity’ (WHO Charter, 1946).

It is becoming increasingly evident that modernization is leading to changing patterns of health. While there have been many improvements in general population health, new health problems have developed. Some are related to the adverse consequences of industrialization, such as environmental contamination, some are related to inadequate health care, and some are related to social change and the development of unhealthy lifestyles. Certain patterns of health tend to be consistently associated with certain patterns of political and economic development. In particular, there is a tendency for health and living standards to be lower among those groups that have been marginalized by the process of ‘globalization’; that is, various processes that undermine local autonomy, such as international flows of capital and investments, and the promotion of Western values and lifestyles through global media transmissions. States and individuals have become interconnected under the general rubric of ‘globalization’. Many communities have adopted the capitalist model of development and patterns of consumption, even though they have maintained distinctive cultures and characteristics. Not all, however, have benefited equally from this process. For many people advances in areas such as medical science and telecommunications have brought undoubted benefits, but many others have been denied such benefits.

A characteristic of globalization is that it facilitates uneven growth. While some regions have become cores of economic progress, others have been relegated to the periphery. Less developed health services in peripheral countries have slowed their progress in controlling infectious diseases. At the same time many peripheral countries are experiencing a rising incidence of NCDs related to a shift away from subsistence agriculture to a growing cash economy, urbanization and more sedentary lifestyles. There is evidence that these diseases are occurring at increasingly younger ages. This book is concerned with the ways in which globalization has fostered deteriorating health among some groups.

Our approach is cross-disciplinary. We consider aspects of sociology, economics, political science and health care. Such an approach is needed to make sense of the increasingly complex patterns of human behaviour that affect health. A key concern is the extent to which people are passive ‘victims’ of the processes of modernization and globalization, or, alternatively, openly embrace the perceived benefits of social and economic change. We therefore examine the levels of empowerment and the capacity of various groups to adopt healthier lifestyles, and the factors that limit their options.

We use examples from various countries to illustrate the key mechanisms through which globalization impacts on population health: quality of health services, environmental contamination and the adoption of new lifestyles. We look in detail at three case studies: Mongolia, Uzbekistan and the Republic of the Marshall Islands. Mongolia and Uzbekistan, which were in the former Soviet sphere of influence, are examples of countries where the main impacts on health have been related to industrialization and economic transition. Mongolia's population health has deteriorated in recent years because the health system has been severely disrupted by the transition to a market economy. Uzbekistan has experienced severe environmental contamination which has impacted on population health. At the same time it has experienced a deterioration of health services as a consequence of loss of Soviet budgetary assistance.

In the Western sphere of influence the Republic of the Marshall Islands serves as an example of one of the world's most geographically remote communities which has been inextricably drawn into the global economy, even though it has no industrial base. Although it has felt the impact of environmental contamination from nuclear testing, Marshallese health has also been profoundly affected by new patterns of aspiration, consumption and lifestyle resulting from contact with the USA. The Marshall Islands thus serves as our main example of the increase in lifestyle-related diseases in modernizing countries.

EXPANSION AND MARGINALIZATION

From the early works of Marx and Engels to contemporary political scientists such as Beck, there is a common theme of assessing the social implications of the driving forces of politics and the striving for economic growth.¹ Many have used the core-periphery model developed by Wallerstein, Myrdal and Frank.² Chomsky, Buchanan and others consider geographical and spatial dimensions of this model.³ These can be any form of unequal relationship, whether based on the traditional analytical triumvirate of race, class and gender or other evolving social, economic and political classifications and divisions. Local cultures are increasingly overlaid by the influence of global economic forces. Robertson makes reference to a ‘single space’, a concept evolved from McCluhan's metaphor of a ‘global village’ and similar imagery suggesting time and space compression.⁴ Advances in transport and telecommunications undoubtedly facilitate the interconnection of individuals and communities. A discipline of globalization studies has emerged in recent years in which writers such as Tomlinson discuss ‘cultural imperialism’.⁵ He argues that imposed Western values are coming into conflict with indigenous cultures around the world. The replacement of traditional subsistence practices by Western lifestyles that are deleterious to health is an example of this process.

International political and economic forces determine the lives of the world's population. In core–periphery terms this can be seen in the ongoing flow of resources from the least to the most developed states. The UN Human Development Report 1997 states that the per capita income of the richest 20 per cent in industrial countries is 11 times that of South Asia.⁶ Even greater disparities of wealth can be identified within states. An extreme example is that the richest Mexican in 1995 owned assets worth US$6.6 billion, which was equal to the combined income of the 17 million poorest Mexicans.⁷ Similarly, the dominance of the key international financial institutions, The World Bank, the International Monetary Fund (IMF) and the World Trade Organization (WTO), by the most developed states also enhances the comparative advantage they enjoy in relation to the developing world. This is central to the pattern of development currently emerging. ‘Free’ trade is biased in favour of the most developed states. By removing trade barriers, the most developed states can use their multinational corporations to exploit economies of scale, to diversify investment and take advantage of cheap labour markets. Writers in the field of international political economy, such as Cox and Strange, have highlighted the significance of these structural elements within international relations.⁸

Since the end of the Cold War the most important international relations involve trade patterns, foreign direct investment and the flow of capital. The WTO has issued directives discouraging subsidies and tariff barriers. These directives are designed to prevent governments giving their goods an advantage in the international market place. This strategy assumes a ‘level playing field’ for international trade. Such a framework for trade does not exist; states operate within a hierarchical system, with some having a competitive advantage over others. The peripheral states are the most disadvantaged by this so-called free market system.

Frank described a process of ‘development of underdevelopment’.⁹ His arguments were based primarily on Latin America, but still have validity for all peripheral states and individuals. The process Frank describes suggests that although there can be mutual benefits from international trade they are almost always unequal in nature. Keohane and Nye's work on interdependence between states also highlights the inequality in international transactions.¹⁰ Frank goes further in drawing attention to the flow of resources from periphery to core. He argues that in addition to being an unequal exchange, trade can actively undermine the development of the peripheral states. Given the complex mix of benefits from contact with core states, such as the opportunity for technology transfer, infrastructure improvements and possible education and employment opportunities, it is difficult to weigh the costs and benefits. Losses might include lack of control over commodity prices, an over-reliance on the export of primary resources and a lack of growth in domestic capital surpluses which are needed for more rapid economic and social development.

Chomsky takes the extreme position that there is a capitalist conspiracy towards global domination.¹¹ It is evident that there has been a widespread adoption of market-led policies reinforcing the ideology of capital accumulation. A symptom of this is that the most marginalized groups are those most likely to suffer ill health and are also those least able to improve their health. The key point is that structures exist that foster inequitable economic development. This includes the state itself, international economic institutions or even the ideological mind-set that since ‘growth is good’ policies should be driven by market forces as opposed to addressing basic needs.

Fukuyama draws attention to the dominance of liberal economics, particularly after the collapse of the Soviet Union and the end of the Cold War.¹² He argues that the failure of the Communist system under Soviet direction is symptomatic of the triumph of capitalism. There is certainly a strong argument that the spread of the capitalist system is self-reinforcing and, as such, will become increasingly difficult to displace with an alternative system. The capitalist model of development is having a tremendous influence on a global scale. This can be related to the types of lifestyle being increasingly adopted, and to the impact of social change on health.

Hagen argues that the main instigators of social change are those with the ability to become entrepreneurs, while others who lack the capacity or opportunity to become entrepreneurs are forced into ‘retreatist’ behaviour.¹³ Global economic growth in recent years has brought increasing disparities in wealth. Growing numbers of people are failing to reap the benefits of modernization. Moreover, modern lifestyles involving varying degrees of individual choice, are actively contributing to poorer standards of health at older ages. Merton described a syndrome of retreatist behaviour, including excessive smoking and drinking and high rates of suicide, which have been observed in various marginalized communities in virtually all parts of the world.¹⁴ This is sometimes a result of prejudice against certain groups. Such prejudices are influential in determining social standing and equality of opportunity.

The globalization of capital brings increasing numbers of people into its sphere of influence. Regardless of choice, or even willingness to participate, the world's population is feeling an increased impact from these global trends. A dramatic example of this is the projected sea-level rise associated with global warming due to industrialization. This is a process over which atoll dwellers in the Pacific have virtually no control, and yet, in a worst-case scenario, it could make many low-lying atolls and islands uninhabitable. In this example the potential negative impact is clear. More opaque are the effects of other factors such as fluctuating world commodity prices and the influence of imported television programmes, which are positive for some and negative for others. The global spread of such consequences of modernization sharpens the divide between the core dwellers and the peripheral and marginalized dwellers.

SHIFTING BOUNDARIES AND CHANGING VALUES

Core-periphery relationships are often fluid. A range of race, class and gender studies can be viewed as having a core–periphery structure. Classifications, or boundaries, shift according to the political, social or economic context in which a given scenario is enacted. An advantageous position with respect to one relationship can simulta-neously be disadvantageous in another. Mapping core–periphery boundaries can thus involve overlapping complexities that vary depending on the focus of the analysis. For example, states may be defined as peripheral in relation to their respective superpower's or former superpower's sphere of influence, but the perceptions of some groups within each of the states referred to may differ depending on their own sense of identity, history and culture. Most individuals emphasize their nationality or their small group affiliation at different times, depending on their circumstances.

Despite strong national identities, the ability of people to act, such as in response to illness, is affected by their position in relation to the relevant core. The accessibility and affordability of health services are influenced by this relationship. On the one hand economic growth supports advances in medical treatments and other relevant science and technologies. On the other hand, globalization actively disadvantages growing numbers of people in terms of health and other aspects of well-being.

A general trend in the processes of modernization and globalization is increased urbanization and a growing dependence on the cash economy at a time when governments have declining control over international economic developments. When economic growth takes place the benefits do not necessarily ‘trickle down’ to the lower income sector. Often it has led to growing social segregation and the environmental degradation of marginal land. One of the great ironies of modernization is that there now exists the knowledge and capability to effect widespread improvements in the provision of basic needs and yet disparities in well-being are increasing. As indicated by the quotation from the World Health Organization (WHO) Charter at the beginning of this chapter, health is inextricably linked to political, economic and social issues and to distance from the core.

Modernization also affects health by changing values; for example, by devaluing the ‘accumulated wisdom’ of older generations. Although emotional attachment and societal expectations demand that provision is made to care for and support older generations, there is minimal financial return available from such expenditure. Traditional knowledge and skills may become irrelevant when new technologies and new methods of production are introduced. This may erode the customary norms and values of respect and deferment to elders. At the same time, the dominance of market forces in relation to most elements of community health raises the issue of whether care of the aged is the responsibility of the state or the family. This is an instance of market-led policies having social and cultural impacts.

THE DEMOGRAPHIC AND HEALTH TRANSITION

The process of modernization has also affected patterns of population change, which are fundamental to human welfare. Most industrialized countries have experienced the process of demographic transition, which is a shift from an almost stationary population balance with high fertility and mortality to another with low fertility and mortality. There is usually a period of substantial population growth in the interval between the first and second balance because mortality rates tend to decline before fertility rates.

In the 1940s, when demographic transition was first described, it was generally assumed that it was an automatic process that naturally accompanied modernization. It is now evident that, for various reasons, this theory is not a good explanation of patterns of population in some contemporary developing countries. In most of Europe, mortality decline was a slower process and more directly related to economic development than it has been in the post-war years. In contrast, many contemporary developing countries have experienced rapid declines as a result of the importation of modern medical technology such as immunization. However, fertility has declined only slowly, and the period of population growth has been sustained for so long that it is contributing to widespread poverty and can be seen as a serious obstacle to economic progress. The rate of population growth has become one of the most important concerns in the contemporary world.

One part of the process of demographic transition is health transition.¹⁵ This refers to the changes in disease patterns and health-related behaviour associated with mortality decline. The key process of health transition is a reduction in ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acronyms and Abbreviations
• 1 The Issues
• 2 Equity, Sustainability and Modernization
• 3 The Determinants of Health
• 4 The Process of Marginalization
• 5 Economic Survival on the Periphery
• 6 Population and Health in Socialist Peripheral Countries
• 7 Uneven Progress in Health in the Pacific Region
• 8 A Portrait of Life at the Periphery
• 9 Economic and Social Supports for Unhealthy Lifestyles
• 10 Conclusion
• Notes
• References
• Index