Globalization and health: Now more than ever, a need for scepticism and multidisciplinarity

We who have been working in global health for a long time will recall Richard Feachem’s 2001 argument that ‘Globalisation is good for your health, mostly’.  The claim was that the economic growth stimulated by globalization – specifically, increased volumes of trade as a share of a country’s gross domestic product (GDP) – reduced poverty and increased resources available for providing health care.  Although the role of poverty as a primary determinant of ill health is beyond dispute, later assessments called into question both the World Bank data on trade flows and growth on which Feachem relied and the necessary connection among economic growth, poverty reduction and better health.  The work of historian Simon Szreter is especially noteworthy on this latter point.

More than 20 years on, it is disturbing to find The Economist’s leader writers ignoring much of the evidence that has since accumulated about the questionable human benefits of globalization.  Instead, they call (in the weekly’s January 14 issue) for governments to reject such policies as national or regional industrial strategies in a world that has been transformed by the pandemic and the knock-on effects of Russia’s invasion of Ukraine.  The claim in the leader and accompanying briefing (which, to be fair, is considerably more nuanced) is that only renewed efforts to support the global reorganization of production that has occurred over the last four decades or so, in the name of economic efficiency, will continue past progress in reducing poverty and render less formidable the costs of decarbonizing the world economy.

Neither the desirability of reducing poverty nor the imperative of decarbonization is in question, but globalization in anything like its pre-pandemic form is as likely to make things worse as it is to make things better, with important implications for the health of people worldwide.  

Let’s take the decarbonization claim first.  In 2020, the United Kingdom’s National Audit Office (NAO) produced a remarkably detailed examination of the economic and societal changes that will be needed if the UK is to reach its stated goal of ‘net zero’ emissions by 2050.  Any thoughtful reader of this report, which can serve as a model for similar analyses elsewhere, will conclude that market theology of Ayn Randian proportions is consistent with belief that so-called free markets will do the job.  Creative, thoughtful dirigisme across a range of sectors will be necessary, although not sufficient.  The same is true of any other complex economy one can think of.  The work of innovation scholar Mariana Mazzucato is especially persuasive on this point, and on the misguidedness of past decades’ market fundamentalism more generally.  

Then, there is the claimed connection between globalization and poverty reduction.  Based on the World Bank’s contentious definition of extreme poverty, the meanness of which was commented on by The Economist itself in 2016 (‘It is hard to imagine how anyone could subsist on so little’), hundreds of millions of people have been lifted out of poverty since the start of the era of contemporary globalization.  Even leaving aside the problematic nature of the definition, until early in the new millennium global extreme poverty reduction was entirely a China story.  In other words, everywhere outside China as someone escaped poverty on the World Bank’s definition, someone else fell into it.  According to the Food and Agriculture Organization and other United Nations agencies, before the pandemic healthy diets were unaffordable to three billion people on ‘the most conservative estimate’ and ‘[t]wo billion people, or 25.9 percent of the global population, experienced hunger or did not have regular access to nutritious and sufficient food in 2019’.  This is hardly stellar performance on the part of the dominant paradigm for organizing the global economy during a period when the value of the world’s economic product roughly tripled.

Perhaps the most problematic aspect of The Economist’s encomium to globalization is its indifference to inequality.  In 2013 Serge Halimi, the editor of Le Monde Diplomatique, described globalization – correctly, in my view – as ‘[t]he inequality machine [that] is reshaping the planet’.  The effects have now become too conspicuous to ignore within national borders, and despite some short-term ameliorative effects associated with programmes to compensate for earnings losses, the pandemic amplified the reshaping process.   For example, a 2022 annual report on the world economic situation – one of several under-used resources generated annually by United Nations agencies – observed:  ‘According to preliminary estimates, the top 1 per cent of income earners in the United States registered net wealth gains of about $3.5 million per person between the first quarter of 2020 and the second quarter of 2021. The bottom 20 per cent recorded an increase of only about $5,300 per person’. 

Complicating the picture, even as pre-pandemic globalization eased extreme poverty in China, and more recently in other jurisdictions outside the high-income world, it devastated the economic futures of many working families in countries like the United States – contributing to what Anne Case and Angus Deaton eloquently describe as ‘deaths of despair’ among the left-behind.  In the US the ready availability of guns, the marketization of health care and the criminal marketing practices of commercial opioid producers also played a role, which is probably why the pattern identified by Case and Deaton was distinctive to that country before the pandemic.  Even before we consider the implications of continued growth on earth systems – what key researchers on the Anthropocene Epoch of geological time have called the Great Acceleration – the report card on globalization’s human benefits is decidedly mixed. 

Much more can and should be said about all these matters.  With important exceptions, researchers and practitioners writing in the global health literature do not provide adequate discussions, despite their importance for the future of the field.  Indeed, the same is true of population health more generally.  Rather, it is necessary to explore work that has been generated and published in various areas of social science and law that are not necessarily connected to health in obvious ways – at least, not in ways that are apparent to the biomedical gaze.  This is where multidisciplinarity comes in: ability to engage with a range of disciplines and assess the implications of their findings for global health is indispensable for critical assessment of claims like those about the benefits of globalization. 

The Economist itself is among the business-oriented sources – another being the Financial Times – that have sometimes generated valuable correctives to Panglossian views of globalization.  The Economist’s reckoning, for example, suggests that deaths outside Ukraine from Russia’s weaponization of gas exports will outnumber war fatalities within the invaded country’s borders – hardly a ringing endorsement of the ‘borderless world’ beloved of globalization’s enthusiasts as it involves energy.  Globalization of financial markets has not only multiplied opportunities for fiscally debilitating tax avoidance and capital flight, which among other consequences undermine social protection measures and progress towards universal health coverage, but also facilitated recurring debt crises in the developing world.  The most recent such crises – again as The Economist pointed out – compromised many responses to the Covid-19 pandemic, and are squeezing already straitened low- and middle-income health budgets.

Before I retired, some of my postgraduate students wondered why the learning objectives in my global health courses included the ability to read articles in the business press and explicate their implications for global health.  This is why.

Acknowledgements and disclosures

A shorter version of this commentary has been posted on the web site of the Collective for the Political Determinants of Health, based at the University of Oslo’s Centre for Development and the Environment. Parts of this analysis are based on the author’s chapter on globalization in L. Bharadwaj and C. Schuster-Wallace, eds., Handbook on Global Health and Sustainable Development (Edward Elgar, forthcoming).  The author owns shares in firms including Intel and TSMC that will benefit from US technology subsidy programmes critiqued in the Economist leader cited here, although the merits of that critique were not addressed.  Unfortunately, some of the links used here are protected by paywalls.  The author will endeavour to provide copies of the cited materials for the personal use of readers without access.