Feature

‘La globalisacion nos matan’ – globalisation is killing us

What is globalisation and what does it have to do with health? Carolyn Stephens reports on the struggles to protect and promote health in a rapidly globalising world

Globalisation’ is a term that has been used in academic and political circles for around 10 years to describe the acceleration of processes which have, in reality, been going on for hundreds of years. ‘La globalisacion nos matan’, a recent comment by an elderly woman in Northern Argentina, tells me that ‘globalisation’ has now moved from academic to popular language. Technically it describes the integration of economic systems, capital movements and opportunities for different peoples through improved information and communication technologies. But locally it has come to mean the increased insecurity and powerlessness that people (particularly poor people) feel in the face of global processes.

Globalisation has been most equated with economic liberalisation and the ‘freeing’ of trade. But for many of the 5,000 people participating in a recent World Bank/Panos Institute internet debate on globalisation there was ‘a distinction between trade and market liberalisation and the broader economic, political, social and cultural process of globalisation accelerated by new information and communication technologies’.

Will globalisation be good or bad for health – either directly or indirectly? It is the multibillion dollar question. It is inevitable that changing trade processes and social and cultural shifts will have an impact on populations’ health. But most public or government debate has not revolved directly around health but around changing structural conditions, with long-term indirect health implications.

These separate into economic shifts, which affect employment, inequality and resource control (land, water, utilities and so on), and political and cultural shifts, which affect control over policy decisions. The limited public health concern has focused on trying to equate globalisation with direct health impacts such as: shifting disease patterns; shifting behaviour patterns (diet and smoking); changes in trade laws affecting workers’ health; and the effects of trade on agriculture and food security.

For optimists – mostly outside the health and social sectors – economic globalisation, in the form of more mobile capital movements and shifts in labour ‘flexibility’, presage economic growth which, in theory, has social and health benefits. In this context, any concentration of power in transnational corporations is simply an ‘economy of scale’ leading to more efficient investments and returns. In parallel, deregulated ‘free’ trade allows incentives for foreign investments to move into poorer regions. Meanwhile, these poorer regions will benefit from diminished unfair subsidies to richer countries and these economic changes will have knock-on benefits for health.

More basically, for optimists, globalisation is a project of world connectedness – the same project that set up the United Nations and systems of international co-operation. The very existence of internet ‘globalisation’ debates indicate the benefits of the ‘world village’ process.

Optimists argue this cultural/technological shift has benefits for ‘democracy’. The essence of their thesis is the pursuit of freedom and ‘democracy’. ‘Freedom’ will allow all to ‘compete’ in a free world.

But when we move from the theory to hear opinions about globalisation’s benefits, few throw a positive glow from a social or health perspective, not even the billionaire president of the World Bank. The panel opposite highlights views from very different sources over globalisation’s meaning and impact. They range from comments on the political process to concerns over cultural diversity, workers’ health and control over policy.

Perhaps the most interesting part of the debate is the discussion of ‘control over one’s life’. The recent events in Seattle marked the coming of age of ‘globalisation’ in the public consciousness. Health was not widely mentioned but words like hegemony, justice, freedom, anarchy and domination were bandied around at will. It turned out that what we are talking about is not global integration but global control, by a very small number of agents – corporations – over everything from food, land and air to health services, education and political rights.

This is a very old debate, argued through the centuries by writers as diverse as Aristotle, Machiavelli, Heidegger, de Maistre, Thoreau and Kropotkin. It is the profound structural nature of globalisation that makes the multibillion dollar question hard to answer.

Health professionals have a technical problem in answering: we do not forecast with skill. Macro-economic and macro-political changes characteristically have a timelag in their social and health effects. But we can learn from recent decades. For example, in 1990 the world’s poorest countries were forced into structural adjustment packages (SAPs) by international financial institutions led by the International Monetary Fund and World Bank.

SAPs were organised economic globalisation: countries ensured capital mobility so that the money of speculators, investors or creditors entered or exited a country freely with minimal risk. Capital mobility was facilitated through privatisation of state-owned assets (utilities, health and education facilities, factories) and liberalisation or deregulation of trade, investment and finance.¹ In theory this would enhance growth and then health. It was called the ‘Washington consensus’.

Health professionals could not say in 1990 that SAPs would be bad for health. But 10 years later there is more than enough evidence of increasing inequality, increased poverty and worse health.^{2 3} The latest World Bank evidence from 28 poorer countries undergoing structural adjustment shows that from 1981–1999, in more than half people experienced stagnating per capita income, rising poverty, declining life expectancy or a combination of all of these.

Further, the US-based Centre for Concern has recently accused the IMF and World Bank of being ringleaders of globalisation. They argue that ‘with the rise of “casino capitalism”, governments are weakened and marginalised. Through deregulation, governments transfer power to the market. Some governments become more accountable to external investors and creditors than to their own citizens. Thus, globalisation can wither the potential for democracy’.

But it is not just the south. All over the world governments are losing control of macro-economic policy, with knock-on social and health impacts. By 1996 foreign exchange trading by big investors was worth $35bn, 10 times more than the world’s gross economic product of $30bn. Of the world’s largest economies, over half are now not countries but companies. Increasingly it is transnational business which is the provider of a whole range of public essentials – transport, utilities, welfare and health services. Transnational corporations, shareholders and investors, control the world. So where does this leave health?

In terms of important structural determinants of health, things look bad. Inequality and labour conditions are worsening. Analysts point out economic globalisation in its current form, combined with changing technology, ‘naturally’ exacerbates world unemployment (now at 12–15 per cent), and pits workers against each other to the detriment of security, labour conditions and incomes.⁴ This is the consequence of ‘social and economic Darwinism’ – survival of the fittest. Corporations have investors. Investors want profits, preferably maximal profit with minimal cost. Technology is developed with this aim, which affects labour. Gradually, ‘economies of scale’ emerge: smaller farmers, producers and businesses cannot ‘compete’; larger ones too cut costs or merge. Governments begin to change their constituencies. For example, in the UK: ‘We need to be a government which listens but also responds to concerns expressed by business. If we are to exploit the potential of our companies and our people to the full we also need to create an environment in which enterprise is more highly valued and can flourish.

World unemployment runs at 30 per cent. Even Europe’s globally powerful population of 872 million faces rising unemployment rates — up from 7.8 to 10.2 between 1990 and 1995. The US is the ‘richest country’ in the world, but it is not the country that is rich but the one per cent of the population who own 40 per cent of the wealth: unemployment runs at 12 per cent and per capita incomes are falling for the majority.⁵

Unemployment, combined with insecure labour conditions and worsening wages, are major factors in the creating and perpetuating social exclusion and inequality. Internationally, during ‘globalisation’, inequality has increased radically: the ratio between the average income of the world’s top five per cent of people and the bottom five per cent increased from 78:1 to 123:1 in just five years (1988–1993). It is well documented that health inequalities result from social and economic inequalities between groups both within countries and internationally.^{6 7}

The debate intensifies daily. In June, the author of the forthcoming World Bank World development report, Attacking Poverty, resigned. Ravi Kanbur, Harvard professor and long-term World Bank consultant, left when US Treasury Secretary Larry Summers got directly involved in rewriting the report’s globalisation sections.

But it is not all bad. Perhaps it is important to think of globalisation and health in the context of sustainable development – ensuring the health of people in the future as well as the present. Perhaps John Donne did best define what globalisation could come to mean: we are moving into a period where we know that the actions of each of us as individuals and groups have impacts on the environment and health of others.

The president of Cuba summed it up recently: ‘Globalisation is an objective reality underlining the fact that we are all passengers on the same vessel, that is, this planet where we all live. But passengers on this vessel are travelling in very different conditions. Trifling minorities are travelling in luxurious cabins furnished with internet, cell phones and access to global communication networks. They enjoy a nutritional, abundant and balanced diet as well as clean water supplies. They have access to sophisticated medical care and to culture.

‘Overwhelming and hurting majorities are travelling in conditions that resemble the terrible slave trade from Africa to America in our colonial past. That is, 85 per cent of the passengers on this ship are crowded together in its dirty hold suffering hunger, diseases and helplessness. Obviously, this vessel is carrying too much injustice to remain afloat and it pursues such an irrational and senseless route that it cannot call on a safe port. This vessel seems destined to clash with an iceberg. If that happened, we would all sink with it.’⁸

Globalisation is not just something ‘out there’, nor something out of control. It is the shirt you are wearing, that you now know better than ever was sewn in the sweatshops of India or China (whichever label) made from cotton (maybe) grown in export monocultures of a green ‘revolution’ that put immense power into the hands of transnational agri-chemical industries. It is the gold wedding rings, or any jewellery, for which miners in Liberia, Brazil, India and South Africa sweat, are paid little and die. It is the wood of paper bought with sweat, destruction and contamination. It is food – cheap, available and shiny – bought at the expense of contaminated land, air, and water and the working conditions of workers and their families internationally. It is the real cost of cheap petrol, cars, flights and holidays. It is water, air, food – and health.

Not just that. It is ‘cheap’ political systems – representative ‘democracies’ or other systems – where ‘representatives’ are gradually bought by CEOs of multinational corporations.

Health professionals may not be good at forecasting, but more and more understand this and support the sustainable development movement in calling for change. We are developing the ‘precautionary principle’, environmental justice , the new public health and the renewal of global health co-operation. Globalisation and health? John Donne was right.