The globalisation of health

What does global health mean at the beginning of the 21st century? What is it aiming to do? What does it mean in terms of practice and the way that we understand things?

A lot of the time when we think about health and healthcare policy, we imagine that it happens at the national or domestic level. A country makes its own healthcare policy and expects that this will impact the health of its citizens. More recently, however, due to increased globalisation, we’ve come to realise that people’s health outcomes are affected by different things happening around the world.

Pepsi or running water?

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There are ongoing debates about how to understand the many transnational factors that impact illness and disease within countries. Take Brazil, where certain places, particularly in rural areas or deep in the forest, lack clean running water. What you will find is that you can get a carbonated beverage instead – usually a Coca-Cola or Pepsi. Children who do not have access to clean running water are drinking carbonated sugary drinks and getting cavities.

This shows how international trade can impact disease and distribution of health in a country much more than local factors do. The country has to manage both. It needs to provide clean running water but it also needs to address international factors such as trade regulations. A national government may have mixed ideas about how to address this. It wants to provide clean water, but it can’t stop international trade because that brings in resources to provide that water. Sometimes international trade regulations don’t allow it to limit different imports into the country, so there is a complicated web of both mixed motives and certain restrictions that countries have to deal with in trying to regulate activities that impact the health of their own citizens.

Global health is a First World problem

A lot of people use “global health” as a euphemism for “health in developing countries”. This is not a good use of the term. We need to focus more on the idea of the transnational aspects of health and to understand that there are transnational actors now that never existed before.

In the 1950s, following the set-up of the United Nations in 1945, the only transnational entities were nation-states. Those were the only entities that were recognised across national borders and which had legal standing. Today, we have many more entities such as international NGOs that are incredibly powerful and spread across many countries. We have enormous transnational corporations that are more powerful and have access to more resources than many countries. We also have profoundly influential individuals such as philanthropists who can move countries and international institutions. And we have political organisations spanning multiple countries and movements. All these entities have a role to play in the causation and distribution of disease in different countries, and in being able to regulate and address these problems.

To only focus on this euphemistic notion of global health as “health in other places” (usually distant, poor countries) is both a profound misunderstanding and a lost opportunity. What we really need to be thinking about is global health at this new level of transnational interactions, and how that influences health inequalities in countries.

The lessons of HIV/AIDS

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HIV/AIDS transformed our notions about infectious diseases and ethics. Before HIV in the 1980s, there was a clear sense in medical research and health policy that infectious diseases only affected poor countries and that most developed countries had essentially controlled them. Now it was all going to be about chronic diseases. Records show that in the United States National Institutes of Health, there was only one individual who was a researcher in infectious diseases; everybody else was focused on chronic diseases. But what the spread of HIV showed is that, in fact, we do not have control over infectious diseases in rich countries.

It’s also important to understand that the rapidity at which new and resurgent infectious diseases arise is increasing. In the 1980s, we might have thought that HIV was this one rare occasion, but if we examine the evidence, we can see that around the world we are having more and more outbreaks of infectious diseases. We can expect this trend to continue, as evidenced by the COVID-19 pandemic we are experiencing now.

The ethics of infectious diseases

The ethics that come with this rising prevalence of infectious diseases within and across countries is at a very nascent stage. That’s because all our ethics before have been about chronic diseases, doctor-patient relationships and how we deal with different health policies and health inequalities.

The rise of infectious diseases transforms our ethics because infectious diseases are spread through social interactions. It’s not about a disease randomly affecting people but about how individuals interact with one another. At a very fundamental level, infectious diseases raise questions about how we treat one another in a more ethical way so that we can protect everyone’s health.

There are also profound ethical challenges. Who is going to control infectious diseases and how? What sort of resources do they have? Is the solution going to be a therapy or a vaccine? Who will produce those therapies and vaccines and who will be able to access them? Will international institutions be able to co-operate in order to contain an epidemic, think about solutions such as vaccines and therapies and make sure everyone has access to them? None of these are scientific questions. They are deeply political and concern ethical choices that countries have to make.

COVID-19: a natural disaster?

If we look around the world, not every country has had the same experience with the spread of COVID within its borders. Some countries have succeeded in controlling it. Others, including those we thought would be the best-performing countries, have failed. In a way, it’s a natural experiment in which we have exposed the world to COVID to see how countries would respond. What we know is that how COVID has spread within countries is very much determined by the policies that were implemented by national governments and their experts, and by the values that were expressed or neglected in those policies. All of those things together shape the course that the epidemic has taken across different societies. There is no way to call this a natural disaster when it’s very clear that the social, political and economic system determines how the epidemic has spread within your country.

COVID’s winners and losers

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Once COVID-19 began to spread, it didn’t progress in a random way across all individuals or social groups but in a very particular pattern. This is why we see that minorities in the United Kingdom, what we would call Black and ethnic minorities or minority ethnic groups, were profoundly more at risk of becoming infected and indeed of dying. Individuals who are 65 or older also have a far greater risk of dying from COVID than any other group.

The initial lack of understanding of health inequalities and vulnerabilities has resulted in an acute experience of morbidity and mortality among socially powerless and biologically weaker groups – and we see this not only in one country but in every country, and even in countries that have done really well. In Southeast Asian countries that seem to have controlled the epidemic, what we actually see is that socially vulnerable groups such as migrant workers have been disproportionately affected. Even in epidemics, social inequalities matter and infectious diseases spread according to the social gradient and patterns of social inequality.

Discover more about

global health in the age of COVID-19

Venkatapuram, S. (2020). How Should We Allocate Health and Social Resources During a Pandemic? In Vulnerable: The Law, Policy and Ethics of COVID-19. (1 ed., Vol. 1). [CHAPTER D-1]. University of Ottawa Press.

Venkatapuram, S. (2016). Justice and Global Health Research. The American Journal of Bioethics, 16(10), 46–47.

Venkatapuram, S. (2020). Human Capabilities and Pandemics. Journal of Human Development and Capabilities, 21(3), 280–286.

Global health in the age of COVID-19