Is globalization dangerous to our health? West J Med 2000;172:332-334
Stephen Bezruchka
When asked about globalization, Margaret Thatcher, the former Prime
Minister of Great Britain, replied, "There is no alternative." Her reply
was shortened to "TINA," which some people think is a newly discovered law
of nature. Yet, public resistance to this new corporate-centered trade is
increasing. What relevance does this have to American physicians? Does
globalization affect health?
Many think about the health effects of modern global trade as involving
increased pollution as corporations strive to limit environmental
restraints or global warming caused by the increased reliance on cheap
fossil fuels. Others focus on the changes in diet produced by genetically
modified foods or the increase in the tobacco market penetration. The
expansion of global cigarette exports is a dramatic example, totaling 223
billion (10,000,000,000) cigarettes in 1975 and rising to 1.1 trillion
(10,000,000,000,000) cigarettes in 1996 (a 5-fold increase). Others might
consider the health of child laborers in Pakistan who produce many of the
disposable surgical instruments that are increasingly used in US
hospitals. Or they might consider deaths from toxic exposures in poor
countries as US corporations evade environmental restraints at home. One
such example occurred 15 years ago in Bhopal, India, where 5 tons of
poisonous methyl isocyanate gas leaked into the air from a Union Carbide
pesticide plant, killing more than 3,000 people.
These effects are real, but they pale in comparison with globalization's
effect on increasing inequality, the most powerful factor affecting
population health and responsible for perhaps 14 to 18 million deaths a
year (18% of total deaths) worldwide.1
DANGERS OF HIERARCHY IN HEALTH
To understand this factor, we need to recognize that the health of the US
population is disgracefully poor compared with that of other rich
countries. In the ranking of countries by life expectancy in 1997, the
United States stood 25th, behind all the other rich countries and even a
few poor ones.2 The country that has won the gold medal in this "health
Olympics" every year since 1977, Japan, is also tied for the gold medal in
the "smoking Olympics." That is, the prevalence of smoking in Japan is
tied with that in China as the highest in the world and 3 times that of
the United States; yet, the Japanese do not die of smoking-related
diseases to the extent that Americans do. Lung cancer mortality rates in
Japan are one half to one third of those in the United States. How does
Japan do it?
The answer is simple. The health of populations in rich countries is
determined primarily not by the health care system-- we have the most
sophisticated and expensive, so it cannot be that--or by individual risk
factors such as smoking, but rather, by the gap between the rich and the
poor. Many recent studies show that populations with a greater income
hierarchy are less healthy, and specifically have shorter lives, than
populations that are more equitable.3 These studies have looked at
mortality and income distributions among countries, within countries such
as each of the 50 US states, and within 282 standard metropolitan areas
(US cities). They have also looked at homicide rates, teen births, and
specific diseases. Independent investigators have studied many different
populations using different methods, and all agree: the strongest factor
affecting health is the size of the gap between the rich and poor. Other
studies suggest physiologic mechanisms through which greater hierarchy
results in worse health and posit that humans are by nature
egalitarian.4,5,6 The analysis has the same level of validity as the
relationship between smoking and lung cancer, using the criteria
postulated in this country by the Surgeon General's report in 1964. (The
data and scientific analyses can be seen at
http://depts.washington.edu/eqhlth.)
THE WEALTH AND INCOME GAP
The United States has the greatest wealth and income gap of any rich
country, which is the main explanation for its dismal health ranking among
developed countries. We did not always fare so poorly: in 1960, we were
13th.7 As our wealth and income gap have grown,8 so has our distance from
the healthiest country. After the second world war, Japan restructured its
economy to be egalitarian. Today, during its economic crisis, managers and
chief executive officers are taking cuts in pay rather than laying off
workers, something that is inconceivable in the United States (Market
Reform for Economic Survival: "Constancy and change in Japanese
management," Japan Echo 1999 April;26:26-28).
Most countries in the world are poor, with most people subsisting to
produce their own food, often supplementing their income by sending family
members to cities to work in factories or abroad and sometimes by engaging
in illicit commerce. In some countries, such as Nigeria with its oil
riches, immense wealth lines the pockets of only a few people. In poor
countries, the evidence suggests that equitable development that focuses
on providing basic needs is the route to improving the population's
health.9,10
THE PROBLEMS WITH CORPORATE-CENTERED TRADE
In the past 1 or 2 decades, world trade could be more accurately described
as trade that is corporate-centered. This change began in the mid-1970s
and was boosted by the economic policies of Thatcher in Great Britain and
Ronald Reagan in the United States. Today the dogma governing economic
activity, deemed the "Washington consensus," is founded on the principle
that the market knows best and should govern the world.11 The implicit
assumptions are that economic transactions involve a buyer and a seller
who are on an equal footing and that the price accurately reflects the
cost. The influence of indirect subsidies in tipping the scales is
overlooked, as shown by countless examples. In 1995 Boeing, one of this
country's largest exporters and most successful corporations, received a
tax credit of more than $33 million. In 1999 Microsoft, another highly
successful company, increased profits by 71% in 1999 over the previous
year, yet paid $226 million less in federal tax.12 "Flexible taxation" is
just one of the many ways in which the public subsidizes economic
activity. Of the world's 100 largest corporations, 20 would have gone
bankrupt without such assistance.13
This so-called free trade in poor countries has produced great wealth for
multinational corporations and provided low-wage jobs that keep many
people in poverty. Among countries, the gap between the richest and the
poorest fifth was 3 to 1 in 1827, rising to 30 to 1 in 1960, to 60 to 1 in
1990, and to 76 to 1 in 1997.2 Recent studies have shown that where there
is increased penetration of foreign investment in poor countries, slower
economic growth and greater inequality result.14,15,16,17 Global economic
greed is the problem.
But what of the effects of global trade in rich countries? In the past 25
years, during which globalization has become common parlance, most people
in the United States have seen a decline or stagnation in incomes after
adjusting for inflation. This has come during a period of record profits
for corporations and a booming stock market. According to economist Edward
Wolff, 95% of American households had a decline in their net worth from
1983 to 1995.18 The United States has begun to look more and more like a
third world economy, with a fabulously wealthy elite few surrounded by a
mass of people not sharing in the globalized pie. The top 1% of families
in this country holds more than 40% of the wealth.
What are the population health effects of corporate-centered economic
policies? In rich countries, capital (material wealth, monetary, and
other) is abundant, whereas in poor countries, labor is plentiful.
Production moves to poor countries where labor is cheapest. Free trade in
goods and services leads businesses to produce goods that are
capital-intensive in high-wage countries but labor-intensive in poor ones.
Benefits from trade and investment generally flow to the rich countries
rather than to poor ones, and thus, income inequality among countries is
increased.19 Within poor countries, more people have been displaced from
their subsistence economies than have been able to find jobs in the
manufacturing sectors in overcrowded cities.20 In poor countries, as an
elite profits immensely from this shift, the income gaps in those
countries increase. In rich countries, the demand for labor is lowered,
wages become relatively depressed, and income inequality increases.17 For
most of the world's people, it is a lose-lose situation.
HOW ARE PHYSICIANS AFFECTED?
Physicians recognize that the advice a cell biologist would give to, say,
a cardiac muscle cell to be healthy--trap all glucose and oxygen
available, but avoid free radicals--is not the best advice for the
collection of cells that makes up a human being. Unfortunately, today we
are doing just that, as shown by our rising rates of obesity. Health
professionals need to understand that what seems best for an individual
patient (the usual do's and don'ts) may not benefit the population, if the
goal is to maximize its health. Individual risk factors need to be
de-emphasized and population risk factors addressed. The most important
risk factor is the gap between the rich and poor.
Genuine, widespread improvements in health and quality of life will take
structural changes in the distribution of income and wealth. The evidence
is clear that in rich countries, health care has not had a major effect on
reducing mortality in populations, and in poor countries, the effect pales
to that obtained by equitably distributing the fruits of economic growth.
Alex Carey, an Australian sociologist, remarked that the 20th century will
be remembered for 3 developments: the growth of democratic processes, the
growth of huge corporations, and the creation of ways in which
corporations could ignore democracy.21 An alternative to
corporate-centered trade requires rethinking economic policies whose major
effect has been to increase inequality worldwide. Calling it the "free
market" hides extensive indirect subsidies to corporations. The size of
the economic gap is the critical factor affecting population and policies
that increase that gap limit health improvements.
If a healthy population is our goal, the winds of health policy are taking
us in the wrong direction. We need vigorous debate over who is subsidized
and by how much. Changing who shares the benefits in the world economy
today is the challenge of the new century. The health of our nation and
our people depends on it.
Summary points
-Determinants of population health differ from those affecting individual
health
-Population health in rich countries is determined primarily by the size
of the gap between rich and poor
-The United States ranks behind all other rich countries and a few poor
ones in health outcomes such as life expectancy
-Globalization, or corporate-centered trade, increases the gap between the
rich and poor within and among countries
-Policies that promote substantial corporate subsidies and increase the
rich-poor gap can be changed to improve population health
References
1.Kohler G, Alcock N. An empirical table of structural violence. J Peace
Res 1976; 13: 343 -356.
2.United Nations Development Program. Human Development Report 1999. New
York: Oxford University Press; 1999 .
3.Wilkinson RG. Unhealthy Societies: The Afflictions of Inequality.
London: Routledge; 1996.
4.Erdal D, Whiten A. On human egalitarianism: an evolutionary product of
machiavellian status escalation? Curr Anthropol 1994; 35: 175 -183.
5.Sapolsky RM. Endocrinology alfresco: psychoendocrine
studies of wild baboons. Recent Prog Horm Res 1993; 48: 437 -468.[Medline]
6.Shively CA, Clarkson TB. Social status and coronary artery
atherosclerosis in female monkeys. Arterioscler Thromb 1994; 14: 721 -726.
7.Schieber GJ, Poullier JP, Greenwald LM. U.S. health expenditure
performance: an international comparison and data update. Health Care
Financ Rev 1992;13: 1 -87.
8.Auerbach JA, Belous RS, eds. The Inequality Paradox: Growth of Income
Disparity. Washington, DC: National Policy Association; 1998.
9.Chiang T. Economic transition and changing relation
between income inequality and mortality in Taiwan: regression analysis.
BMJ 1999;319: 1162 -1165.
10.Bezruchka S. Social ordering in developing countries: does hierarchy
have the same effect as in post-industrial nations? a look at Nepal. Ann N
Y Acad Sci 2000; 896: 490 -492.
11.Williamson J. Democracy and the 'Washington Consensus.' World
Development 1993; 21: 1329 .
12.Annual Report. Redmond, WA: Microsoft Corporation; 1999: 17, 35.
13.Ruigrock W, van Tulder R. The Logic of International Restructuring.
London: Routledge; 1995.
14.Braun D. The Rich Get Richer: The Rise of Income Inequality in the
United States and the World. Chicago: Nelson-Hall; 1997.
15.Shen C, Williamson JB. Child mortality, women's status, economic
dependency, and state strength: a cross-national study of less developed
countries. Social Forces 1997; 76: 667 -700.
16.Harrison A, Hanson G. Who gains from trade reform? some remaining
puzzles. J Dev Economics 1999; 59: 125 -154.
17.Beyer H, Rojas P, Vergara R. Trade liberalization and wage inequality.
J Dev Economics 1999; 59: 103 -123.
18.Wolff EN. Recent Trends in Wealth Ownership: Conference on Benefits and
Mechanisms for Spreading Asset Ownership in the United States. New York:
New York University; 1998 .
19.Hahnel R. Panic Rules: Everything You Need to Know About the Global
Economy. Cambridge, MA: South End Press; 1999 .
20.Andes N. Institutional contexts and mortality: the case of Peru. Sociol
Focus 1992; 25: 295 -309.
21.Carey A. Taking the Risk Out of Democracy: Propaganda in the US and
Australia. Champaign: University of Illinois Press; 1997 .
Stephen Bezruchka Department of Health Services School of Public Health
and Community Medicine Box 357660 University of Washington School of
Medicine Seattle, WA 98195-3576
Competing interests: None declared
Correspondence to: Dr Bezruchka [log in to unmask]
Full text and two photographs (one of which is a graphic display of child
labor), and ability to download a pdf version is available at:
http://www.ewjm.com/cgi/content/full/172/5/332
***********
Same Issue:This month in WJM pg 289 Growth of national wealth does not
ensure a healthy population
The United States is one of the richest nations in the world but ranks
behind other countries--wealthy and not--in the health of its population.
As Bezruchka explains on p 332, the greater the economic hierarchy in a
nation, the less healthy are its citizens, and the United States has the
greatest wealth and income gap of any wealthy country. Corporate-centered
tradedubbed globalizationincreases that gap, warns Bezruchka, and only
making a healthy population a goal and making structural changes in the
distribution of income and wealth will bring a turnabout.
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