Globalization and social determinants of health: The role of the global marketplace (part 2 of 3)

Glossary on free trade agreements and health part 1: the shift from multilateralism and the rise of 'WTO-Plus' provisions

The global trading system has undergone a shift away from multilateral trade negotiations to a 'spaghetti-bowl' of regional and bilateral free trade agreements (FTAs). In this two-part glossary, we discuss why this shift has occurred, focusing on how it poses new challenges for public health. Specifically, we introduce key terms that shape this new trading environment and explain them through a public health lens. Part 1 of this glossary focuses on provisions in FTAs that build on previous agreements of the World Trade Organization (WTO). These provisions are commonly designated as 'WTO-Plus'. This approach continues into part 2 of the glossary, which also considers components of FTAs that have no precedent within WTO treaties. Following a broader discussion of how the current political context and the COVID-19 pandemic shape the contemporary trade environment, part 2 considers the main areas of trade and health policy incoherence as well as recommendations to address them.

Institutional practices in maternal health according to social class. Bogotá, Colombia, 2018

OBJECTIVE

To understand institutional practices in healthcare as relates to women during pregnancy, childbirth and the postpartum period according to social class in Bogota.

METHODS

Qualitative study based on the critical hermeneutics paradigm. Critical ethnographic method with theoretical sampling. The participants included 9 women and 8 health-care professionals from the city of Bogotá, attending public and private healthcare institutions that serve populations under both the subsidized as well as the contributive regimes of the General Social Security System. Overall, 38 in-depth interviews were conducted during a 13 month period, with 62 instances of support to the mothers in terms of prenatal care, vaccination, labor, postpartum visits, follow-up tests, psychoprophylactic course, hospitalization and waiting room. Triangulation analysis on Atlas Ti.

RESULTS

Taking into account the discourse of the different players, observations and context, two categories were found to be determining factors of inequities: "Market-regulated health" and "Over- sight and control in health services".

CONCLUSIONS

It is advisable in medical practice to build competencies in the population in order to ensure the realization of the rights of women and healthcare personnel. Qualitative research offers the opportunity to promote the transformation of medical rationale affecting women.

The Trend and Prospect of Medical Sociology: Its Concepts and the Interface with Medical History

Medical sociology has a long history, and it has been institutionalized and developed since the 1940s. This paper is about the history, trends, and prospects of medical sociology from the perspective of concepts as well as its interface with medical humanities. Sociology is a discipline that conceptualizes and theorizes social phenomena on the basis of collected data to best understand them. For this reason, we think that one of the best ways to understand medical sociology is to track the changes and developments in the concept and theory of medical sociology over time. Moreover, the development of concepts and theories does not occur only within the discussion of experts but also actively in interactions with the institutional position of medical sociology, medical knowledge and institutions and society. By reflecting on the changes in the theory and concept of medical sociology over the past 70 years from the 1950s to the present, we were able to understand the changes in research interests and research subject of medical sociology. Medical sociology has developed in response to the needs of the medical community and society. On the one hand, it developed a diverse understanding of healthcare, one of the key elements of the structure and culture of modern society, and on the other hand, it developed an understanding of how each individual experiences medical care as a dominant power. Since the 1990s, these seemingly conflicting two areas integrated into one through research subjects such as the growth of the general population and the health and social movement. Furthermore, the emergence of biotechnology, which began to develop in earnest beginning in the 1980s, presented a challenge for medical sociology. If the role of Parsons in the 1950s was to reflect the American medical system based on bacteriology and therapeutic drugs, after the 1960s, chronic disease became an important health problem due to changes in American society, and the experiences of patients suffering from chronic diseases became an important research subject. However, the rapid development of biotechnology from the 1980s was powerful enough to change the way we perceive our bodies. Our society has regarded our body as a sum of cells and a combination of various organs and body parts since the birth of modern medicine, but with the development of biotechnology, including genetics, we began to recognize our body as an expression of information contained in genes. The capitalist force driving biotechnology has degraded our bodies to the extent of our resources for the accumulation of genomic information. Finally, the concepts and theories developed by medical sociology can also be applied to understand the trends of medical history in the Korean Journal of Medical History provided that medical sociology and the medical history were embedded in the particular Korean historical context. Therefore, we hope these two medical disciplines cooperate further on the medical issues in Korea.

The Relative Importance of Globalization and Public Expenditure on Life Expectancy in Europe: An Approach Based on MARS Methodology

BACKGROUND

There has been a widespread debate about the overall impact of globalization on population, not just economically, but also in terms of health status. Moreover, the current health crisis is going to force governments to review the structure of the public budget to most effectively alleviate the negative economic and health effects on the population.

OBJECTIVE

The aim of this paper is to analyze the relative importance of globalization and the public budget composition-specifically the participation of public expenditure on healthcare, social services and environment in gross domestic product (GDP)-on life expectancy at birth in European countries during the period 1995-2017.

METHODS

The Multivariate Adaptive Regression Splines (MARS) methodology was applied to analyze the socioeconomic determinants of life expectancy at birth.

RESULTS

Our findings show that globalization has no relative importance as an explanatory variable of life expectancy in European countries, while government expenditure on social protection is the most relevant followed by public expenditure on health, gross national income per capita, education level of the population and public expenditure on environmental protection.

CONCLUSION

European strategies intended to impact on health outcome should spend more attention to the composition of public budget.

Trends in Work Conditions and Associations with Workers' Health in Recent 15 Years: The Role of Job Automation Probability

Job automation and associated psychosocial hazards are emerging workplace challenges. This study examined the trends in work conditions and associations with workers’ health over time in jobs with different automation probabilities. We utilized data from six waves of national questionnaire surveys of randomly selected 95,762 employees between 2001 and 2016. The Job Content Questionnaire, the Copenhagen Burnout Inventory, and the Self-Rated Health Scale were applied, and working time was self-reported. Automation probability was derived for 38 occupations and then categorized into three groups. Trends in work conditions and the associations between automation probability, work conditions and health were examined. We observed a 7% decrease in high automation probability jobs, an overall increase in job demands for and prevalence of shift work, and a decrease in job control. Workers with high automation probability jobs had low job demands, low job control and high job insecurity. Low automation probability was associated with burnout in logistic regression models. The odds ratio of job insecurity, long working hours, and shift work relating to health was higher in the later years of the surveys. In conclusion, there has been a decrease in high automation probability jobs. Workers employed in jobs with different levels of automation probability encountered different work condition challenges.

What is global health? Key concepts and clarification of misperceptions: Report of the 2019 GHRP editorial meeting

The call for "Working Together to Build a Community of Shared Future for Mankind" requires us to improve people's health across the globe, while global health development entails a satisfactory answer to a fundamental question: "What is global health?" To promote research, teaching, policymaking, and practice in global health, we summarize the main points on the definition of global health from the Editorial Board Meeting of Global Health Research and Policy, convened in July 2019 in Wuhan, China. The meeting functioned as a platform for free brainstorming, in-depth discussion, and post-meeting synthesizing. Through the meeting, we have reached a consensus that global health can be considered as a general guiding principle, an organizing framework for thinking and action, a new branch of sciences and specialized discipline in the large family of public health and medicine. The word "global" in global health can be subjective or objective, depending on the context and setting. In addition to dual-, multi-country and global, a project or a study conducted at a local area can be global if it (1) is framed with a global perspective, (2) intends to address an issue with global impact, and/or (3) seeks global solutions to an issue, such as frameworks, strategies, policies, laws, and regulations. In this regard, global health is eventually an extension of "international health" by borrowing related knowledge, theories, technologies and methodologies from public health and medicine. Although global health is a concept that will continue to evolve, our conceptualization through group effort provides, to date, a comprehensive understanding. This report helps to inform individuals in the global health community to advance global health science and practice, and recommend to take advantage of the Belt and Road Initiative proposed by China.

International migration and health: it is time to go beyond conventional theoretical frameworks

The large-scale international migration in the 21st century has emerged as a major threat to the global health equity movement. Not only has the volume of migration substantially increased but also the patterns of migration have become more complex. This paper began by focusing on the drivers of international migration and how health inequalities are linked to migration. Situating migration within the broader structural contexts, the paper calls for using the unharnessed potential of the intersectionality framework to advance immigrant health research. Despite coming from poorer socioeconomic backgrounds and facing disparities in the host society, the immigrants are often paradoxically shown to be healthier than the native population, although this health advantage diminishes over time. Studies on immigrant health, however, are traditionally informed by the acculturation framework which holds the assimilation of unhealthy lifestyles primarily responsible for immigrant health deterioration, diverting the attention away from the structural factors. Although the alternative structural framework came up with the promise to explore the structural factors, it is criticised for an overwhelming focus on access to healthcare and inadequate attention to institutional and societal contexts. However, the heterogeneity of the immigrant population across multiple dimensions of vulnerability demands a novel approach that can bring to the fore both premigratory and postmigratory contextual factors and adequately capture the picture of immigrant health. The paper concludes by questioning the acculturation perspective and pushing the structural paradigm to embrace the intersectionality framework which has the potential to address a wide range of vulnerabilities that intersect to produce health inequalities among the immigrants.

Does trade liberalization reduce child mortality in low- and middle-income countries? A synthetic control analysis of 36 policy experiments, 1963-2005

Scholars have long argued that trade liberalization leads to lower rates of child mortality in developing countries. Yet current scholarship precludes definitive conclusions about the magnitude and direction of this relationship. Here I analyze the impact of trade liberalization on child mortality in 36 low- and middle-income countries, 1963–2005, using the synthetic control method. I test the hypothesis that trade liberalization leads to lower rates of child mortality, examine whether this association varies between countries and over time, and explore the potentially modifying role of democratic politics, historical context, and geographic location on the magnitude and direction of this relationship. My analysis shows that, on average, trade liberalization had no impact on child mortality in low- and middle-income countries between 1963 and 2005 (Average effect (AE): −0.15%; 95% CI: −2.04%–2.18%). Yet the scale, direction and statistical significance of this association varied markedly, ranging from a ∼20% reduction in child mortality in Uruguay to a ∼20% increase in the Philippines compared with synthetic controls. Trade liberalization was also followed by the largest declines in child mortality in democracies (AE 10-years post reform (AE₁₀): −3.28%), in Latin America (AE₁₀: −4.15%) and in the 1970s (AE₁₀: −6.85%). My findings show that trade liberalization can create an opportunity for reducing rates of child mortality, but its effects cannot be guaranteed. Inclusive and pro-growth contextual factors appear to influence whether trade liberalization actually yields beneficial consequences in developing societies.

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Impact of trade liberalization on child mortality is currently unclear.

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Analysis of this relationship using synthetic control method.

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There is no universal association between trade liberalization and child mortality.

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Impact of trade liberalization and child mortality varies substantially.

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Reductions in child mortality greatest in democracies, Latin America, and pre-1990.

"Better Than Bank Robbery": Yuezi Centers and Neoliberal Appeals to Market Birth Tourism to Pregnant Chinese Women

"Birth tourism" has rarely been addressed by scholars. The ways that pregnant women are encouraged to leave their homelands and give birth abroad have not been investigated. Birth tourism agencies may seek to persuade women that particular destinations-such as the US-are ideal places for giving birth. An examination of how birth tourism agencies frame birth tourism may offer initial insights into this phenomenon. This study examines 34 agencies' home pages and their arguments advocating birth tourism for Chinese expectant mothers. Using a thematic approach, we find four reasons offered to pregnant Chinese women that make birth tourism appealing. This perspective helps us to understand birth tourism both as a health-related behavior and a cosmopolitan issue. We use neoliberalism as an analytic framework to examine how birth tourism may enhance inequality in health resource distribution both domestically and internationally.

Impact of the North American Free Trade Agreement on high-fructose corn syrup supply in Canada: a natural experiment using synthetic control methods

BACKGROUND:

Critics of free trade agreements have argued that they threaten public health, as they eliminate barriers to trade in potentially harmful products, such as sugar. Here we analyze the North American Free Trade Agreement (NAFTA), testing the hypothesis that lowering tariffs on food and beverage syrups that contain high-fructose corn syrup (HFCS) increased its use in foods consumed in Canada.

METHODS:

We used supply data from the Food and Agriculture Organization of the United Nations to assess changes in supply of caloric sweeteners including HFCS after NAFTA. We estimate the impact of NAFTA on supply of HFCS in Canada using an innovative, quasi-experimental methodology — synthetic control methods — that creates a control group with which to compare Canada’s outcomes. Additional robustness tests were performed for sample, control groups and model specification.

RESULTS:

Tariff reductions in NAFTA coincided with a 41.6 (95% confidence interval 25.1 to 58.2) kilocalorie per capita daily increase in the supply of caloric sweeteners including HFCS. This change was not observed in the control groups, including Australia and the United Kingdom, as well as a composite control of 16 countries. Results were robust to placebo tests and additional sensitivity analyses.

INTERPRETATION:

NAFTA was strongly associated with a marked rise in HFCS supply and likely consumption in Canada. Our study provides evidence that even a seemingly modest change to product tariffs in free trade agreements can substantially alter population-wide dietary behaviour and exposure to risk factors.

The health impact of trade and investment agreements: a quantitative systematic review and network co-citation analysis

BACKGROUND

Regional trade agreements are major international policy instruments that shape macro-economic and political systems. There is widespread debate as to whether and how these agreements pose risks to public health. Here we perform a comprehensive systematic review of quantitative studies of the health impact of trade and investment agreements. We identified studies from searches in PubMed, Web of Science, EMBASE, and Global Health Online. Research articles were eligible for inclusion if they were quantitative studies of the health impacts of trade and investment agreements or policy. We systematically reviewed study findings, evaluated quality using the Quality Assessment Tool from the Effective Public Health Practice Project, and performed network citation analysis to study disciplinary siloes.

RESULTS

Seventeen quantitative studies met our inclusion criteria. There was consistent evidence that implementing trade agreements was associated with increased consumption of processed foods and sugar-sweetened beverages. Granting import licenses for patented drugs was associated with increased access to pharmaceuticals. Implementing trade agreements and associated policies was also correlated with higher cardiovascular disease incidence and higher Body Mass Index (BMI), whilst correlations with tobacco consumption, under-five mortality, maternal mortality, and life expectancy were inconclusive. Overall, the quality of studies is weak or moderately weak, and co-citation analysis revealed a relative isolation of public health from economics.

CONCLUSION

We identified limitations in existing studies which preclude definitive conclusions of the health impacts of regional trade and investment agreements. Few address unobserved confounding, and many possible consequences and mechanisms linking trade and investment agreements to health remain poorly understood. Results from our co-citation analysis suggest scope for greater interdisciplinary collaboration. Notwithstanding these limitations, our results find evidence that trade agreements pose some significant health risks. Health protections in trade and investment treaties may mitigate these impacts.

Trade liberalization and social determinants of health: A state of the literature review

The health impacts of trade liberalization are often described in relation to access to medicines, changing dietary patterns, tobacco use and alcohol consumption. The impacts of trade liberalization on the social determinants of health (SDH), are by contrast, less well known. Missing is an account of how liberalizing processes identified across different research areas relate to each other and how the association between trade liberalization and health is conceptualized within each of them, especially with reference to SDH. This paper presents a systematic review which provides a more complete picture of the pathways between trade liberalization and health, with special attention to SDH pathways. This picture captures the interrelationships between different areas of investigation, along with current limitations of our understanding and recommendations for future research.

Globalization, Work, and Cardiovascular Disease

Cardiovascular disease (CVD), a global epidemic, is responsible for about 30% of all deaths worldwide. While mortality rates from CVD have been mostly declining in the advanced industrialized nations, CVD risk factors, including hypertension, obesity, and diabetes, have been on the increase everywhere. Researchers investigating the social causes of CVD have produced a robust body of evidence documenting the relationships between the work environment and CVD, including through the mechanisms of psychosocial work stressors. We review the empirical evidence linking work, psychosocial stressors, and CVD. These work stressors can produce chronic biologic arousal and promote unhealthy behaviors and thus, increased CVD risk. We offer a theoretical model that illustrates how economic globalization influences the labor market and work organization in high-income countries, which, in turn, exacerbates job characteristics, such as demands, low job control, effort-reward imbalance, job insecurity, and long work hours. There is also a growing interest in “upstream” factors among work stress researchers, including precarious employment, downsizing/restructuring, privatization, and lean production. We conclude with suggestions for future epidemiologic research on the role of work in the development of CVD, as well as policy recommendations for prevention of work-related CVD.

Where Are Socioeconomically Deprived Immigrants Located in Chile? A Spatial Analysis of Census Data Using an Index of Multiple Deprivation from the Last Three Decades (1992-2012)

Introduction and Purpose of the Study

Immigrants in Chile have diverse characteristics and include socioeconomically deprived populations. The location of socioeconomically deprived immigrants is important for the development of public policy intelligence at the local and national levels but their areas of residence have not been mapped in Chile. This study explored the spatial distribution of socioeconomic deprivation among immigrants in Chile, 1992–2012, and compared it to the total population.

Material and Methods

Areas with socioeconomically deprived populations were identified with a deprivation index which we developed modelled upon the Index of Multiple Deprivation (IMD) for England. Our IMD was based upon the indicators of unemployment, low educational level (primary) and disability from Census data at county level for the three decades 1992, 2002 and 2012, for 332, 339 and 343 counties respectively. We developed two versions of the IMD one based on disadvantage among the total population and another focused upon the circumstances of immigrants only. We generated a spatial representation of the IMD using GIS, for the overall IMD score and for each dimension of the index, separately. We also compared the immigrants´ IMD to the total population´s IMD using Pearson´s correlation test.

Results

Results showed that socioeconomically deprived immigrants tended to be concentrated in counties in the northern and central area of Chile, in particular within the Metropolitan Region of Santiago. These were the same counties where there was the greatest concentration of socioeconomic deprivation for the total population during the same time periods. Since 1992 there have been significant change in the location of the socioeconomically deprived populations within the Metropolitan Region of Santiago with the highest IMD scores for both the total population and immigrants becoming increasingly concentrated in the central and eastern counties of the Region.

Conclusion

This is the first study analysing the spatial distribution of socioeconomic deprivation among international immigrants and the total population in a Latin American country. Findings could inform policy makers about location of areas of higher need of social protection in Chile, for both immigrants and the total resident population in the country.

Globalization and the health of Canadians: 'Having a job is the most important thing'

BACKGROUND

Globalization describes processes of greater integration of the world economy through increased flows of goods, services, capital and people. Globalization has undergone significant transformation since the 1970s, entrenching neoliberal economics as the dominant model of global market integration. Although this transformation has generated some health gains, since the 1990s it has also increased health disparities.

METHODS

As part of a larger project examining how contemporary globalization was affecting the health of Canadians, we undertook semi-structured interviews with 147 families living in low-income neighbourhoods in Canada's three largest cities (Montreal, Toronto and Vancouver). Many of the families were recent immigrants, which was another focus of the study. Drawing on research syntheses undertaken by the Globalization Knowledge Network of the World Health Organization's Commission on Social Determinants of Health, we examined respondents' experiences of three globalization-related pathways known to influence health: labour markets (and the rise of precarious employment), housing markets (speculative investments and affordability) and social protection measures (changes in scope and redistributive aspects of social spending and taxation). Interviews took place between April 2009 and November 2011.

RESULTS

Families experienced an erosion of labour markets (employment) attributed to outsourcing, discrimination in employment experienced by new immigrants, increased precarious employment, and high levels of stress and poor mental health; costly and poor quality housing, especially for new immigrants; and, despite evidence of declining social protection spending, appreciation for state-provided benefits, notably for new immigrants arriving as refugees. Job insecurity was the greatest worry for respondents and their families. Questions concerning the impact of these experiences on health and living standards produced mixed results, with a majority expressing greater difficulty 'making ends meet,' some experiencing deterioration in health and yet many also reporting improved living standards. We speculate on reasons for these counter-intuitive results.

CONCLUSIONS

Current trends in the three globalization-related pathways in Canada are likely to worsen the health of families similar to those who participated in our study.

Inernational research in health care management: its need in the 21st century, methodological challenges, ethical issues, pitfalls, and practicalities

PURPOSE

This commentary argues in favor of international research in the 21st century. Advances in technology, science, communication, transport, and infrastructure have transformed the world into a global village. Industries have increasingly adopted globalization strategies. Likewise, the health sector is more internationalized whereby comparisons between diverse health systems, international best practices, international benchmarking, cross-border health care, and cross-cultural issues have become important subjects in the health care literature. The focus has now turned to international, collaborative, cross-national, and cross-cultural research, which is by far more demanding than domestic studies. In this commentary, we explore the methodological challenges, ethical issues, pitfalls, and practicalities within international research and offer possible solutions to address them.

DESIGN/METHODOLOGY/APPROACH

The commentary synthesizes contributions from four scholars in the field of health care management, who came together during the annual meeting of the Academy of Management to discuss with members of the Health Care Management Division the challenges of international research.

FINDINGS

International research is worth pursuing; however, it calls for scholarly attention to key methodological and ethical issues for its success.

ORIGINALITY/VALUE

This commentary addresses salient issues pertaining to international research in one comprehensive account.

Trade policy and public health

Twenty-first-century trade policy is complex and affects society and population health in direct and indirect ways. Without doubt, trade policy influences the distribution of power, money, and resources between and within countries, which in turn affects the natural environment; people's daily living conditions; and the local availability, quality, affordability, and desirability of products (e.g., food, tobacco, alcohol, and health care); it also affects individuals' enjoyment of the highest attainable standard of health. In this article, we provide an overview of the modern global trade environment, illustrate the pathways between trade and health, and explore the emerging twenty-first-century trade policy landscape and its implications for health and health equity. We conclude with a call for more interdisciplinary research that embraces complexity theory and systems science as well as the political economy of health and that includes monitoring and evaluation of the impact of trade agreements on health.

Eyes wide open: an essay on developing an engaged awareness in global medicine and public health

BACKGROUND

There is a growing understanding of the role social determinants such as poverty, gender discrimination, racial prejudice, and economic inequality play on health and illness. While these determinants and effects may be challenging to identify in parts of high-income countries, they are patently obvious in many other areas of the world. How we react to these determinants and effects depends on what historical, cultural, ideological, and psychological characteristics we bring to our encounters with inequity, as well as how our feelings and thoughts inform our values and actions.

DISCUSSION

To address these issues, we share a series of questions we have asked ourselves-United States' citizens with experience living and working in Central America-in relation to our encounters with inequity. We offer a conceptual framework for contemplating responses in hopes of promoting among educators and practitioners in medicine and public health an engaged awareness of how our every day work either perpetuates or breaks down barriers of social difference. We review key moments in our own experiences as global health practitioners to provide context for these questions. Introspective reflection can help professionals in global medicine and public health recognize the dynamic roles that they play in the world. Such reflection can bring us closer to appreciating the forces that have worked both for and in opposition to global health, human rights, and well-being. It can help us recognize how place, time, environment, and context form the social determination of health. It is from this holistic perspective of social relations that we can work to effect fair, equitable, and protective environments as they relate to global medicine and public health.

Are women deciding against home births in low and middle income countries?

BACKGROUND

Although there is evidence to tracking progress towards facility births within the UN Millennium Development Goals framework, we do not know whether women are deciding against home birth over their reproductive lives. Using Demographic and Health Surveys (DHS) data from 44 countries, this study aims to investigate the patterns and shifts in childbirth locations and to determine whether these shifts are in favour of home or health settings.

METHODS AND FINDINGS

The analyses considered 108,777 women who had at least two births in the five years preceding the most recent DHS over the period 2000-2010. The vast majority of women opted for the same place of childbirth for their successive births. However, about 14% did switch their place and not all these decisions favoured health facility over home setting. In 24 of the 44 countries analysed, a higher proportion of women switched from a health facility to home. Multilevel regression analyses show significantly higher odds of switching from home to a facility for high parity women, those with frequent antenatal visits and more wealth. However, in countries with high infant mortality rates, low parity women had an increased probability of switching from home to a health facility.

CONCLUSIONS

There is clear evidence that women do change their childbirth locations over successive births in low and middle income countries. After two decades of efforts to improve maternal health, it might be expected that a higher proportion of women will be deciding against home births in favour of facility births. The results from this analysis show that is not the case.

Trade liberalization and tuberculosis incidence: a longitudinal multi-level analysis in 22 high burden countries between 1990 and 2010

Background Trade liberalization is promoted by the World Trade Organization (WTO) through a complex architecture of binding trade agreements. This type of trade, however, has the potential to modify the upstream and proximate determinants of tuberculosis (TB) infection. We aimed to analyse the association between trade liberalization and TB incidence in 22 high-burden TB countries between 1990 and 2010.

Methods and findings A longitudinal multi-level linear regression analysis was performed using five different measures of trade liberalization as exposure [WTO membership, duration of membership, trade as % of gross domestic product, and components of both the Economic Freedom of the World Index (EFI4) and the KOF Index of Globalization (KOF1)]. We adjusted for a wide range of factors, including differences in human development index (HDI), income inequality, debts, polity patterns, conflict, overcrowding, population stage transition, health system financing, case detection rates and HIV prevalence.

None of the five trade indicators was significantly associated with TB incidence in the crude analysis. Any positive effect of EFI4 on (Log-) TB incidence over time was confounded by differences in socio-economic development (HDI), HIV prevalence and health financing indicators. The adjusted TB incidence rate ratio of WTO member countries was significantly higher [RR: 1.60; 95% confidence interval (CI): 1.12–2.29] when compared with non-member countries.

Conclusion We found no association between specific aggregate indicators of trade liberalization and TB incidence. Our analyses provide evidence of a significant association between WTO membership and higher TB incidence, which suggests a possible conflict between the architecture of WTO agreements and TB-related Millennium Development Goals. Further research is needed, particularly on the relation between the aggregate trade indices used in this study and the hypothesized mediators and also on sector-specific indices, specific trade agreements and other (non-TB) health outcomes.

Understanding the impact of global trade liberalization on health systems pursuing universal health coverage

In the context of reemerging universalistic approaches to health care, the objective of this article was to contribute to the discussion by highlighting the potential influence of global trade liberalization on the balance between health demand and the capacity of health systems pursuing universal health coverage (UHC) to supply adequate health care. Being identified as a defining feature of globalization affecting health, trade liberalization is analyzed as a complex and multidimensional influence on the implementation of UHC. The analysis adopts a systems-thinking approach and refers to the six building blocks of World Health Organization's current "framework for action," emphasizing their interconnectedness. While offering new opportunities to increase access to health information and care, in the absence of global governance mechanisms ensuring adequate health protection and promotion, global trade tends to have negative effects on health systems' capacity to ensure UHC, both by causing higher demand and by interfering with the interconnected functioning of health systems' building blocks. The prevention of such an impact and the effective implementation of UHC would highly benefit from a more consistent commitment and stronger leadership by the World Health Organization in protecting health in global policymaking fora in all sectors.

Understanding health systems, health economies and globalization: the need for social science perspectives

The complex relationship between globalization and health calls for research from many disciplinary and methodological perspectives. This editorial gives an overview of the content trajectory of the interdisciplinary journal 'Globalization and Health' over the first six years of production, 2005 to 2010. The findings show that bio-medical and population health perspectives have been dominant but that social science perspectives have become more evident in recent years. The types of paper published have also changed, with a growing proportion of empirical studies. A special issue on 'Health systems, health economies and globalization: social science perspectives' is introduced, a collection of contributions written from the vantage points of economics, political science, psychology, sociology, business studies, social policy and research policy. The papers concern a range of issues pertaining to the globalization of healthcare markets and governance and regulation issues. They highlight the important contribution that can be made by the social sciences to this field, and also the practical and methodological challenges implicit in the study of globalization and health.

Social determinants of health in Canada: are healthy living initiatives there yet? A policy analysis

INTRODUCTION

Preventative strategies that focus on addressing the social determinants of health to improve healthy eating and physical activity have become an important strategy in British Columbia and Ontario for combating chronic diseases. What has not yet been examined is the extent to which healthy living initiatives implemented under these new policy frameworks successfully engage with and change the social determinants of health.

METHODS

Initiatives active between January 1, 2006 and September 1, 2011 were found using provincial policy documents, web searches, health organization and government websites, and databases of initiatives that attempted to influence to nutrition and physical activity in order to prevent chronic diseases or improve overall health. Initiatives were reviewed, analyzed and grouped using the descriptive codes: lifestyle-based, environment-based or structure-based. Initiatives were also classified according to the mechanism by which they were administered: as direct programs (e.g. directly delivered), blueprints (or frameworks to tailor developed programs), and building blocks (resources to develop programs).

RESULTS

60 initiatives were identified in Ontario and 61 were identified in British Columbia. In British Columbia, 11.5% of initiatives were structure-based. In Ontario, of 60 provincial initiatives identified, 15% were structure-based. Ontario had a higher proportion of direct interventions than British Columbia for all intervention types. However, in both provinces, as the intervention became more upstream and attempted to target the social determinants of health more directly, the level of direct support for the intervention lessened.

CONCLUSIONS

The paucity of initiatives in British Columbia and Ontario that address healthy eating and active living through action on the social determinants of health is problematic. In the context of Canada's increasingly neoliberal political and economic policy, the public health sector may face significant barriers to addressing upstream determinants in a meaningful way. If public health cannot directly affect broader societal conditions, interventions should be focused around advocacy and education about the social determinants of health. It is necessary that health be seen for what it is: a political matter. As such, the health sector needs to take a more political approach in finding solutions for health inequities.

Tobacco control, global health policy and development: towards policy coherence in global governance

The WHO Framework Convention on Tobacco Control (FCTC) demonstrates the international political will invested in combating the tobacco pandemic and a newfound prominence for tobacco control within the global health agenda. However, major difficulties exist in managing conflicts with foreign and trade policy priorities, and significant obstacles confront efforts to create synergies with development policy and avoid tensions with other health priorities. This paper uses the concept of policy coherence to explore congruence and inconsistencies in objectives, policy, and practice between tobacco control and trade, development and global health priorities. Following the inability of the FCTC negotiations to satisfactorily address the relationship between trade and health, several disputes highlight the challenges posed to tobacco control policies by multilateral and bilateral agreements. While the work of the World Bank has demonstrated the potential contribution of tobacco control to development, the absence of non-communicable diseases from the Millennium Development Goals has limited scope to offer developing countries support for FCTC implementation. Even within international health, tobacco control priorities may be hard to reconcile with other agendas. The paper concludes by discussing the extent to which tobacco control has been pursued via a model of governance very deliberately different from those used in other health issues, in what can be termed 'tobacco exceptionalism'. The analysis developed here suggests that non-communicable disease (NCD) policies, global health, development and tobacco control would have much to gain from re-examining this presumption of difference.

The manufacture of lifestyle: the role of corporations in unhealthy living

Recently, researchers have debated two views on the connection between lifestyle and health. In the first, health-related lifestyles including tobacco and alcohol use, diet, and physical activity are seen as primary influences on health. In the second, social stratification is the dominant influence with lifestyles simply markers of social status. Neither approach leads to interventions that can reverse the world's most serious health problems. This article proposes that corporate practices are a dominant influence on the lifestyles that shape patterns of health and disease. Modifying business practices that promote unhealthy lifestyles is a promising strategy for improving population health. Corporations shape lifestyles by producing and promoting healthy or unhealthy products, creating psychological desires and fears, providing health information, influencing social and physical environments, and advancing policies that favor their business goals. Public officials and health professionals can promote health by advocating policies to modify these corporate practices.

Collaboration between infection control and occupational health in three continents: a success story with international impact

Globalization has been accompanied by the rapid spread of infectious diseases, and further strain on working conditions for health workers globally. Post-SARS, Canadian occupational health and infection control researchers got together to study how to better protect health workers, and found that training was indeed perceived as key to a positive safety culture. This led to developing information and communication technology (ICT) tools. The research conducted also showed the need for better workplace inspections, so a workplace audit tool was also developed to supplement worker questionnaires and the ICT. When invited to join Ecuadorean colleagues to promote occupational health and infection control, these tools were collectively adapted and improved, including face-to-face as well as on-line problem-based learning scenarios. The South African government then invited the team to work with local colleagues to improve occupational health and infection control, resulting in an improved web-based health information system to track incidents, exposures, and occupational injury and diseases. As the H1N1 pandemic struck, the online infection control course was adapted and translated into Spanish, as was a novel skill-building learning tool that permits health workers to practice selecting personal protective equipment. This tool was originally developed in collaboration with the countries from the Caribbean region and the Pan American Health Organization (PAHO). Research from these experiences led to strengthened focus on building capacity of health and safety committees, and new modules are thus being created, informed by that work.The products developed have been widely heralded as innovative and interactive, leading to their inclusion into "toolkits" used internationally. The tools used in Canada were substantially improved from the collaborative adaptation process for South and Central America and South Africa. This international collaboration between occupational health and infection control researchers led to the improvement of the research framework and development of tools, guidelines and information systems. Furthermore, the research and knowledge-transfer experience highlighted the value of partnership amongst Northern and Southern researchers in terms of sharing resources, experiences and knowledge.

Social science implications for control of helminth infections in Southeast Asia

Social science perspectives can inform helminth disease control in Southeast Asia. The social science literature offers theoretical and conceptual models; research methods; recommendations for training and capacity building, health education and health care professional training; and practice guidelines, including implementation of evidence-based interventions. Priority themes include poverty, gender differences, health inequities and access to social resources. Implications for helminth control include broadening disease monitoring and surveillance to include social and economic variables and subjective measures of well-being; training for health professionals and researchers in the social determinants of health; and application of social science models, specifically the expanded 'Chronic Care Model', to the planning and evaluation of interventions. The chapter posits that helminth diseases meet the World Health Organization's expanded definition of chronic conditions, and that integrated delivery of multiple interventions is needed to address the full range of risks and outcomes due to helminth infection.

Is income inequality related to childhood dental caries in rich countries?

BACKGROUND

The aim of this study was to assess the correlates of income and income inequality with dental caries in a sample of all countries, as well as in rich countries alone.

METHODS

In this ecological study, the authors analyzed national data on income, income inequality and dental caries from 48 countries. Of them, 22 were rich countries (according to World Bank criteria). The authors determined income by gross national income (GNI) per capita (formerly known as gross national product) and income inequality by the Gini coefficient (a measure of income inequality on a scale between 0 and 1). They assessed dental caries according to the decayed, missing, filled teeth (dmft) index in 5- to 6-year-old children. The authors used Pearson and partial correlation coefficients to examine the linear associations of income and income inequality with dental caries.

RESULTS

GNI per capita, but not the Gini coefficient, was inversely correlated with the dmft index in the 48 countries. However, the results showed an opposite pattern when analyses were restricted to rich countries (that is, the dmft index was significantly correlated with the Gini coefficient but not with GNI per capita).

CONCLUSION

These findings support the income inequality hypothesis that beyond a certain level of national income, the relationship between income and the population's health is weak. Income inequality was correlated more strongly with dental caries than was income in rich countries.

CLINICAL IMPLICATIONS

Among rich countries, income inequality is a stronger determinant of childhood dental caries than is absolute income.

Fair and Ethical Trade in Health: Lessons from Surgical Instruments

The NHS spends £20 billion on procuring a wide range of medical goods every year. Worldwide, the amount traded in products for health care runs into trillions of dollars. With such large sums of money we quite rightly ask about value for money as well as the quality of the goods we buy. But in addition to quality we should, but don't, ask about the conditions under which those goods are made. Unfortunately, recent research has found that some of the products we are using to promote health in the UK may actually be damaging health elsewhere, through unethical labour practices in their manufacture.

Denaturalizing scarcity: a strategy of enquiry for public- health ethics

Most scarcities that underpin health disparities within and among countries are not natural; rather, they result from policy choices and the operation of social institutions. Using examples from the United States of America: the Chicago heat wave and hurricane Katrina, this paper develops "denaturalizing scarcity" as a strategy for enquiry to inform public-health ethics in an interconnected world. It first describes some of the resource scarcities that are of greatest concern from a public-health perspective, and then outlines two (not mutually exclusive) lines of ethical reasoning that demonstrate their importance. One of these involves the multiple relationships that link rich and poor across national borders in today's interconnected world. The paper then briefly describes ways in which globalization and the associated institutions are linked to health-threatening scarcities. The paper concludes that denaturalizing scarcity represents a valuable alternative to mainstream health ethics, directing our attention instead to why some settings are "resource poor" and others are not.

Tobacco industry issues management organizations: creating a global corporate network to undermine public health

Background

The global tobacco epidemic claims 5 million lives each year, facilitated by the ability of transnational tobacco companies to delay or thwart meaningful tobacco control worldwide. A series of cross-company tobacco industry "issues management organizations" has played an important role in coordinating and implementing common strategies to defeat tobacco control efforts at international, national, and regional levels. This study examines the development and enumerates the activities of these organizations and explores the implications of continuing industry cooperation for global public health.

Methods

Using a snowball sampling strategy, we collected documentary data from tobacco industry documents archives and assembled them into a chronologically organized case study.

Results

The International Committee on Smoking Issues (ICOSI) was formed in 1977 by seven tobacco company chief executives to create common anti-tobacco control strategies and build a global network of regional and national manufacturing associations. The organization's name subsequently changed to INFOTAB. The multinational companies built the organization rapidly: by 1984, it had 69 members operating in 57 countries. INFOTAB material, including position papers and "action kits" helped members challenge local tobacco control measures and maintain tobacco-friendly environments. In 1992 INFOTAB was replaced by two smaller organizations. The Tobacco Documentation Centre, which continues to operate, distributes smoking-related information and industry argumentation to members, some produced by cross-company committees. Agro-Tobacco Services, and now Hallmark Marketing Services, assists the INFOTAB-backed and industry supported International Tobacco Growers Association in advancing claims regarding the economic importance of tobacco in developing nations.

Conclusion

The massive scale and scope of this industry effort illustrate how corporate interests, when threatened by the globalization of public health, sidestep competitive concerns to coordinate their activities. The global network of national and regional manufacturing associations created and nurtured by INFOTAB remains active, particularly in relation to the recently negotiated global health treaty, the Framework Convention on Tobacco Control. Policymakers should be aware that although these associations claim to represent only national or regional interests, they are allied to and coordinated with a confederation of transnational tobacco companies seeking to protect profits by undermining public health.