Globalization and social determinants of health: Promoting health equity in global governance (part 3 of 3)

For the children? A mixed methods analysis of World Bank structural adjustment loans, health projects, and infant mortality in Latin America

Background

The World Bank wields immense financial and normative power in health in the developing world. During the 1980s and 1990s, in the face of intense criticism of its structural adjustment policies, the World Bank purportedly turned its attention to “pro-growth and pro-poor” policies and new lending instruments. One focus has been an investment in maternal and infant health. My analysis uses a mixed methods approach to examine the relationship between traditional structural adjustment and health loans and projects and infant mortality in Latin America and the Caribbean from 2000 to 2015.

Results

My answer to whether the World Bank’s projects in Latin America worked “for the children” is: somewhat. The results are heartening in that quantitatively, health projects are associated with lower infant mortality rates, net of controls, whereas traditional structural adjustment loans do not appear to be negatively associated with infant mortality, though examined across a short time horizon. Qualitative data suggest that infants, children, and mothers are considered in World Bank loans and projects in the context of an economic logic: focusing on productivity, economic growth, and human capital, rather than human rights.

Conclusion

Taken together, my results suggest that the World Bank appears to, at least partially, have amended its approach and its recent work in the region is associated with reductions in infant mortality. However, the World Bank’s economistic approach risks compartmentalizing healthcare and reducing people to their economic potential. As such, there remains work to do, in Latin America and beyond, if health interventions are to be effective at sustainably and holistically protecting vulnerable groups.

Trade, investment and public health: compiling the evidence, assembling the arguments

Trade has long been an axiomatic characteristic of globalization, although international rules governing trade are of more recent vintage. Notably in the post-World War II period, an ever increasing number of countries began negotiating treaties to reduce, first, tariff barriers and, later, non-tariff barriers (government measures of any sort) that could impede the cross-border flow of goods. The rationale, in part, was that countries that became more entwined economically would be less likely to go to war with each other. It wouldn't be in their own economic interests to do so, or at least that of the firms based within their borders but engaged in transnational trade and dependent upon global supply chains. At first primarily an undertaking of developed (high-income) countries, developing (low and middle-income countries) slowly enjoined in what, in 1995, became the World Trade Organization. The WTO locked in scheduled declines in tariffs (border taxes), albeit with lesser obligations on developing country members (a problematic nomenclature given the vast geographic, economic, and development differences between such countries, but which nonetheless persists within the WTO). Importantly, a slew of new agreements that coincided with the establishment of the WTO also sought to liberalize trade in services (not just goods) (The General Agreement on Trade in Services), create new rules for agricultural trade (Agreement on Agriculture), expand intellectual property rights protections (The Agreement on Trade-Related Aspects of Intellectual Property Rights), limit trade-distorting government subsidies (Agreement on Subsidies and Countervailing Measures), and ensure that government food, health, or environmental regulations would not pose an unnecessary barrier to trade (the Technical Barriers to Trade and the Sanitary and Phytosanitary Measures Agreements). Outside of the WTO system, bilateral or regional investment treaties granting special rights to foreign investors to sue governments for actions perceived to affect the value of their investment (such as direct expropriation or passage of new laws and regulations considered 'tantamount to expropriation') similarly exploded in number, dispute frequency, and the size of monetary claims. The breadth and depth of these post-1995 Agreements meant that few areas of general public health concern are potentially untouched.

Trade is central to achieving the sustainable development goals: a case study of antimicrobial resistance

Johanna Hanefeld and colleagues highlight the links between trade and health and argue for greater consideration of trade agreements in actions to meet the sustainable development goals

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.

Determinants of Subjective Social Status and Health Among Latin American Women Immigrants in Spain: A Qualitative Approach

This qualitative study was carried out to better understand factors that determine the subjective social status of Latin Americans in Spain. The study was conducted following a theoretical framework and forms part of broader study on subjective social status and health. Ten immigrant participants engaged in semi-structured interviews, from which data were collected. The study results show that socioeconomic aspects of the crisis and of policies adopted have shaped immigrant living conditions in Spain. Four major themes that emerged from the analysis were related to non-recognition of educational credentials, precarious working conditions, unemployment and loneliness. These results illustrate the outcomes of current policies on health and suggest a need for health professionals to orient practices toward social determinants, thus utilizing evaluations of subjective social status to reduce inequalities in health.

Breast cancer in the global south and the limitations of a biomedical framing: a critical review of the literature

Public health researchers are devoting increasing attention to the growing burden of breast cancer in low-and middle-income countries (LMICs), previously thought to be minimally impacted by this disease. A critical examination of this body of literature is needed to explore the assumptions, advantages and limitations of current approaches. In our critical literature review, we find that researchers and public health practitioners predominantly privilege a biomedical perspective focused on patients' adherence (or non-adherence) to 'preventive' practices, screening behaviours and treatment regimens. Cost-effective 'quick fixes' are prioritized, and prevention is framed in terms of individual 'risk behaviours'. Thus, individuals and communities are held responsible for the success of the biomedical system; traditional belief systems and 'harmful' social practices are problematized. Inherently personal, social and cultural experiences of pain and suffering are neglected or reduced to the issue of chemical palliation. This narrow approach obscures the complex aetiology of the disease and perpetuates silence around power relations. This article calls for a social justice-oriented interrogation of the role of power and inequity in the global breast cancer epidemic, which recognizes the agency and experiences of women (and men) who experience breast cancer in the global south.

The multiple meanings of global health governance: a call for conceptual clarity

BACKGROUND

The term global health governance (GHG) is now widely used, with over one thousand works published in the scholarly literature, almost all since 2002. Amid this rapid growth there is considerable variation in how the term is defined and applied, generating confusion as to the boundaries of the subject, the perceived problems in practice, and the goals to be achieved through institutional reform.

METHODOLOGY

This paper is based on the results of a separate scoping study of peer reviewed GHG research from 1990 onwards which undertook keyword searches of public health and social science databases. Additional works, notably books, book chapters and scholarly articles, not currently indexed, were identified through Web of Science citation searches. After removing duplicates, book reviews, commentaries and editorials, we reviewed the remaining 250 scholarly works in terms of how the concept of GHG is applied. More specifically, we identify what is claimed as constituting GHG, how it is problematised, the institutional features of GHG, and what forms and functions are deemed ideal.

RESULTS

After examining the broader notion of global governance and increasingly ubiquitous term "global health", the paper identifies three ontological variations in GHG scholarship - the scope of institutional arrangements, strengths and weaknesses of existing institutions, and the ideal form and function of GHG. This has produced three common, yet distinct, meanings of GHG that have emerged - globalisation and health governance, global governance and health, and governance for global health.

CONCLUSIONS

There is a need to clarify ontological and definitional distinctions in GHG scholarship and practice, and be critically reflexive of their normative underpinnings. This will enable greater precision in describing existing institutional arrangements, as well as serve as a prerequisite for a fuller debate about the desired nature of GHG.

Education modifies the association of wealth with obesity in women in middle-income but not low-income countries: an interaction study using seven national datasets, 2005-2010

BACKGROUND

Education and wealth may have different associations with female obesity but this has not been investigated in detail outside high-income countries. This study examines the separate and inter-related associations of education and household wealth in relation to obesity in women in a representative sample of low- and middle-income countries (LMICs).

METHODS

The seven largest national surveys were selected from a list of Demographic and Health Surveys (DHS) ordered by decreasing sample size and resulted in a range of country income levels. These were nationally representative data of women aged 15-49 years collected in the period 2005-2010. The separate and joint effects, unadjusted and adjusted for age group, parity, and urban/rural residence using a multivariate logistic regression model are presented.

RESULTS

In the four middle-income countries (Colombia, Peru, Jordan, and Egypt), an interaction was found between education and wealth on obesity (P-value for interaction <0.001). Among women with no/primary education the wealth effect was positive whereas in the group with higher education it was either absent or inverted (negative). In the poorer countries (India, Nigeria, Benin), there was no evidence of an interaction. Instead, the associations between each of education and wealth with obesity were independent and positive. There was a statistically significant difference between the average interaction estimates for the low-income and middle-income countries (P<0.001).

CONCLUSIONS

The findings suggest that education may protect against the obesogenic effects of increased household wealth as countries develop. Further research could examine the factors explaining the country differences in education effects.

A multi-layered governance framework for incorporating social science insights into adapting to the health impacts of climate change

Background

Addressing climate change and its associated effects is a multi-dimensional and ongoing challenge. This includes recognizing that climate change will affect the health and wellbeing of all populations over short and longer terms, albeit in varied ways and intensities. That recognition has drawn attention to the need to take adaptive actions to lessen adverse impacts over the next few decades from unavoidable climate change, particularly in developing country settings. A range of sectors is responsible for appropriate adaptive policies and measures to address the health risks of climate change, including health services, water and sanitation, trade, agriculture, disaster management, and development.

Objectives

To broaden the framing of governance and decision-making processes by using innovative methods and assessments to illustrate the multi-sectoral nature of health-related adaptation to climate change. This is a shift from sector-specific to multi-level systems encompassing sectors and actors, across temporal and spatial scales.

Design

A review and synthesis of the current knowledge in the areas of health and climate change adaptation governance and decision-making processes.

Results

A novel framework is presented that incorporates social science insights into the formulation and implementation of adaptation activities and policies to lessen the health risks posed by climate change.

Conclusion

Clarification of the roles that different sectors, organizations, and individuals occupy in relation to the development of health-related adaptation strategies will facilitate the inclusion of health and wellbeing within multi-sector adaptation policies, thereby strengthening the overall set of responses to minimize the adverse health effects of climate change.

Conceptualizing a Human Right to Prevention in Global HIV/AIDS Policy

Given current constraints on universal treatment campaigns, recent advances in public health prevention initiatives have revitalized efforts to stem the tide of HIV transmission. Yet, despite a growing imperative for prevention-supported by the promise of behavioral, structural and biomedical approaches to lower the incidence of HIV-human rights frameworks remain limited in addressing collective prevention policy through global health governance. Assessing the evolution of rights-based approaches to global HIV/AIDS policy, this review finds that human rights have shifted from collective public health to individual treatment access. While the advent of the HIV/AIDS pandemic gave meaning to rights in framing global health policy, the application of rights in treatment access litigation came at the expense of public health prevention efforts. Where the human rights framework remains limited to individual rights enforced against a state duty bearer, such rights have faced constrained application in framing population-level policy to realize the public good of HIV prevention. Concluding that human rights frameworks must be developed to reflect the complementarity of individual treatment and collective prevention, this article conceptualizes collective rights to public health, structuring collective combination prevention to alleviate limitations on individual rights frameworks and frame rights-based global HIV/AIDS policy to assure research expansion, prevention access and health system integration.

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.

Governing for a healthy population: towards an understanding of how decision-making will determine our global health in a changing climate

Enhancing the adaptive capacity of individuals, communities, institutions and nations is pivotal to protecting and improving human health and well-being in the face of systemic social inequity plus dangerous climate change. However, research on the determinants of adaptive capacity in relation to health, particularly concerning the role of governance, is in its infancy. This paper highlights the intersections between global health, climate change and governance. It presents an overview of these key concerns, their relation to each other, and the potential that a greater understanding of governance may present opportunities to strengthen policy and action responses to the health effects of climate change. Important parallels between addressing health inequities and sustainable development practices in the face of global environmental change are also highlighted. We propose that governance can be investigated through two key lenses within the earth system governance theoretical framework; agency and architecture. These two governance concepts can be evaluated using methods of social network research and policy analysis using case studies and is the subject of further research.

State capacity influences on the epidemiology of neglected tropical and vector-borne diseases in Sub-Saharan Africa

Many neglected tropical and vector-borne diseases continue to emerge and reemerge in Africa where a significant number of governments have limited state capacity. The reasons these diseases resurface are numerous and this problem remains unsolved. This study contributes to existing research by examining how economic and sociopolitical attributes of state capacity influence the transmission of disease in a population. This ecological study examined relationships between state capacity and the epidemiology of five neglected tropical and vector-borne diseases in a sample of 33 African countries. Regression analyses were used to examine the relationships between state capacity, i.e., economic and sociopolitical attributes, and disease burden, incidence, prevention/control and mortality. Results revealed statistically significant relationships between state capacity and the following dependent variables: all disease-burden variables; insecticide-treated-nets prevention and control; and all age-related and human African trypanosomiasis mortalities. A broad range of effect sizes (R(2) = 0.02-0.59) were observed and the economic and sociopolitical attributes of state capacity made different contributions to these effects. Future studies should explore the economic and sociopolitical attributes of state capacity that influence disease transmission by examining different populations or diseases, and by using different research methods.

Re-visioning public health ethics: a relational perspective

Canada is in the forefront of thinking about the unique and complex issues of contemporary public health ethics. However, an inordinate focus on the urgent issues of emergency preparedness in pandemic and reliance on bioethical analysis steeped in the autonomy and individual rights tradition of health care and research do not serve adequately as the basis for an ethic of public health with its focus on populations, communities and the common good. This paper describes some concerns regarding the focus on pandemic ethics in isolation from public health ethics; identifies inadequacies in the dominant individualistic ethics framework; and summarizes nascent work on the concepts of relational autonomy, relational social justice and relational solidarity that can inform a re-visioning of public health ethics. While there is still much work to be done to further refine these principles, they can help to reclaim and centre the common and collective good at risk in pandemic and other emergency situations. Minimally, these principles require a policy-making process that is truly transparent, fair and inclusive; is sensitive and responsive to the workings of systemic inequalities; and requires public recognition of the fact that we enter any crisis with varying degrees of inequity. Public policy response to crisis must not forseeably increase existing inequities.

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.

Re-visioning public health ethics: a relational perspective

Canada is in the forefront of thinking about the unique and complex issues of contemporary public health ethics. However, an inordinate focus on the urgent issues of emergency preparedness in pandemic and reliance on bioethical analysis steeped in the autonomy and individual rights tradition of health care and research do not serve adequately as the basis for an ethic of public health with its focus on populations, communities and the common good. This paper describes some concerns regarding the focus on pandemic ethics in isolation from public health ethics; identifies inadequacies in the dominant individualistic ethics framework; and summarizes nascent work on the concepts of relational autonomy, relational social justice and relational solidarity that can inform a re-visioning of public health ethics. While there is still much work to be done to further refine these principles, they can help to reclaim and centre the common and collective good at risk in pandemic and other emergency situations. Minimally, these principles require a policy-making process that is truly transparent, fair and inclusive; is sensitive and responsive to the workings of systemic inequalities; and requires public recognition of the fact that we enter any crisis with varying degrees of inequity. Public policy response to crisis must not forseeably increase existing inequities.

Trade liberalisation and the nutrition transition: mapping the pathways for public health nutritionists

OBJECTIVE

To describe pathways through which trade liberalisation affects the food environment, relevant to the nutrition transition, in order to enable public health nutritionists to understand trade policy as a macro-level influence on food consumption.

DESIGN

The pathways mapped in the present paper are based on the agreements of the World Trade Organization, which shape national policy. Implications for nutrition are presented based on a comprehensive literature review, and case studies are used to illustrate the various pathways.

SETTING

Developing countries are currently experiencing a nutrition transition, resulting in dietary patterns associated with chronic disease. Chronic diseases are amenable to prevention, and trade policy has been highlighted as a potential avenue for nutrition-related prevention.

RESULTS

Trade liberalisation influences the food environment through facilitating trade in goods and services, enabling investment and decreasing support/protection for domestic industry. These policy outcomes facilitate the nutrition transition particularly through increasing the availability and affordability of processed foods and animal products. The framework highlights the complex relationship between trade policy and the nutrition transition, with both negative and positive outcomes arising from different aspects of trade liberalisation.

CONCLUSIONS

Policy change associated with trade liberalisation has created incentives for consumption patterns associated with the nutrition transition, but has also had some positive nutritional outcomes. As a result, it is important for public health nutritionists to consider the implications of trade policy decisions in their efforts to prevent and control diet-related chronic diseases.