International human rights

A long-standing and fundamental facet of global governance for health has been the development of an international human rights framework. Arising from the aftermath of World War II, human rights are comprised of several different covenants that constitute international law, albeit lacking in international enforcement measures. When these rights are instantiated within national laws or constitutions, however, they become justiciable within a country’s legal system. There are also global bodies responsible for oversight of their implementation. Their strength, as with that of the Sustainable Development Goals’ Agenda 2030, may rest more on their normative force—how the world’s people imperfectly expressed through their governments believe the world should work and look like. Given a growing illiberal temper in the emerging post-truth world, whether the norms embedded in human rights law can rise to the challenge of ‘taming’ globalization’s neoliberal underpinnings is a pivotal question still awaiting a firm answer.

Global flows

Health systems rely upon two groups of people: health workers and patients. In recent decades both groups have been on the move globally, with the creation of internationalized labour market opportunities (the hunt for skilled labour in the case of health workers) and private investments in high-end health care on lower-cost developing countries (one of the key incentives for patients seeking care outside of their own country, for uninsured or under-insured services). Both flows raise a number of health equity concerns. Health worker migration can pose undue hardships on low-resource, high-disease burden countries who lose their workers to richer nations, creating a ‘perverse subsidy’ of poor to rich. With medical tourism, private, fee-paying foreign patients in poorer countries could ‘crowd out’ access to care for domestic patients in those countries, while potentially returning with drug resistant infections or complications burdening their home country’s health systems.

International development assistance and health

The pursuit of global health gains has been one the aims of international development policy for several decades. Along with migration, trade agreements and dominant macroeconomic policies (i.e., neoliberalism), development assistance (aid) is one of the defining elements of contemporary globalization, a noblesse oblige on the part of wealthier nations to support the improvement of lives in poorer, often former colonized, nations. Rarely achieving its stated commitments, and declining since its peak-generosity in the 1960s, aid has been subject to intense disagreements, vacillating between being seen as creating a neocolonial dependency, to arguments for its absolute necessity in saving lives. Since 2000 the aid discourse has been dominated by global development goals, the first set expiring in 2015 (the Millennium Development Goals) and the next and more exhaustive set running until 2030 (the Sustainable Development Goals). Whether these new goals will deliver on their commitments remains an open question.

Trade and investment liberalization

One of the major drivers of contemporary global market integration is trade and investment liberalization. Disease risks and health opportunities have long travelled the same routes of trade and commerce. Today’s binding and complex trade rules introduce new health complications. Using a number of recent trade agreements as exemplars, this chapter reviews the basic premises of liberalization, its claimed benefits, its purported or actual health risks, and how different provisions in trade and investment treaties (which unlike most global governance rules carry economic enforcement measures) are constraining important public health policy flexibilities in countries that are party to such agreements. From initial opposition to trade liberalization in general, progressive global health movements now focus more on how such rules could be written or revised in order to protect governments’ regulatory policy space, and to promote greater global health equity.

Globalization as a ‘determinant of the determinants of health’

International health, a concern with the high burden of preventable disease in poorer countries, is long-standing. In late nineteenth century sanitary reforms and early twentieth century philanthropic financing to control infectious diseases in the Americas, this concern also foreshadows more contemporary debates over global health financing and the ‘health securitization’ of wealthier nations against diseases spreading from poorer ones. By the late twentieth century, however, there was a shift in discourse from ‘international’ to ‘global’ health underpinned by the growing awareness that there are inherently global reasons for why some countries are wealthier and healthier, while others remain poorer and sicker. Two different frameworks are used to unpack these causal pathways, in which globalization processes are regarded as meta-determinants of health inequities within and between nations. Although researchers argue that globalization processes have been good for health, others are much less sanguine on this claim.

Imperilling the health of the global environmental commons

Alongside persisting and massive wealth inequalities, the ecological toll that human population growth and the economic appropriation of natural resources has taken on the sustainability of the myriad ecosystems essential to human survival is now the major threat to future health and human survival. With ecologists arguing that we have entered a new geologic era (the Anthropocene) in which our planet is shaped almost entirely by human activity, the greatest environmental threat is often considered to be climate change. But there are few of the ecological boundaries on which life depends that are not in crisis of being breached. The causes and the consequences of this looming health catastrophe are wholly inequitable: the wealthy benefit, the poor pay the price. There is some technological optimism on the horizon, but fundamentally the present excesses of human consumption and productions, and their misallocation globally, require a rapid reversal if the intent of the Paris Agreement on Climate Change, and the targets of the new Sustainable Development Goals are to have any chance of attainment.

Globalizing health systems

Strengthening health systems in poorer countries has long been a focal point in development aid debates. Visionary models of comprehensive primary health care caught the global imagination in the late 1970s but were quickly eclipsed with the rise of neoliberal globalization in the 1980s, truncated into ‘selective’ silos appealing to donor nations. ‘Investing in health’ for economic growth eclipsed more humanitarian principles for health assistance. Corporate philanthropies began to set health agendas resonant with those of a century earlier, while private health care financing and delivery models that grew under neoliberalism’s first wave (structural adjustment) have yet to yield to the evidence of the efficiencies of public health care models. The current push to achieve Universal Health Coverage captures the ongoing tension between the interests of private capital and the need for public goods.

Disrupted labour markets

The search for employment is one of the major drivers behind migration. Globalization processes have had profound impacts on the world’s labour markets, creating opportunities for some (through out-sourcing) while dislocating work for others. This global redistribution of labour is not motivated by concerns for the livelihoods of workers so much as by the pursuit of profits by transnationally liberated capital. Net effects include increases in precarious work, declines in labour’s share of global economic product, and a continuous ‘flexibilization’ of labour markets excused by competitive pressures. Such changes bring new health risks associated with insecurity for many and downwards pressure on wages for some. International policy discourse lauds efforts to improve social protection measures for affected workers, while the growing gap between productivity and wages is giving rise to a call for universal basic incomes to compensate for globalization’s victory of capital over labour.

Migration

Migration, the movement of people from birthplace to other-place, whether within their own borders or internationally, is one of globalization’s leitmotifs. The scale of migration has risen rapidly in recent decades, some of it the ‘pull’ of opportunities in other countries, but much of it the ‘push’ of poverty, unemployment, conflicts, and environmental degradations that make life unlivable for many. Migration can improve the health and well-being of migrants, and the remittances sent home by overseas émigrés can contribute to domestic poverty reduction in the countries they leave. But forced migration, migrant exploitation, and increasing barriers to the lesser-skilled irregular migrants or asylum-seekers most able to benefit by moving abroad have given rise to new global imperatives to ‘manage migration’ ethically and effectively. Both men and women may be vulnerable to exploitation along the migratory path, but women face additional gendered discriminations in the risk of assault and trafficking.

Globalization

Globalization is not a new phenomenon but the rise of industrialization and capitalism changed earlier periods of global expansionism to one that is dominated more by transnational corporations and global capital than by governments and their armies. Globalization is not a singular event, but a confluence of multiple, dynamic, and inter-linked processes. Some of these processes reflect changes in perceptions of time, space, and ideas, while others are shaped primarily by economic relations. The term, globalization, only began to replace an older concept (internationalization) in the 1990s, and was used principally to describe global market integration, hinting at the role economic interests have always played in what many in the world would now describe as ‘globalization’. In overviewing the entire book, this chapter also begins to engage in the debate: is globalization good for health, or bad for health?