Health in an Age of Globalization

When economists write about globalization, they focus on the movement of goods, people, information, and ideas, and they look at the effects on economic growth, poverty, and inequality. Health is not a primary focus of their attention. By contrast, much of the literature in public health views globalization as a threat to international health. On the relatively few occasions when economists have addressed health, they focus on the indirect effects, arguing that the economic benefits of globalization are good for health—because poverty is the major determinant of health in poor countries—and that if there are unwelcome side effects on health, they can best be dealt with by suitable public health measures, not by policies that slow the globalization process. Both sides of this (mostly non-) argument have substance, and one aim of this paper is to present some of the arguments from the public health literature as seen through the eyes of at least one economist. There is also much to be learned from looking at previous episodes of globalization and at the history of trade and health, and it is with this that I begin.

If it is true that income is the primary determinant of health—at least in poor countries—then the consequences of globalization for public health depend on its well-researched (although still disputed) consequences for economic growth, particularly for the poorest countries. Although the income-to-health mechanism is undoubtedly present—everything is easier with money, and some improvements are impossible without it—I argue that the transmission of health-related knowledge is ultimately more important. Social forces, including not only income but also education and politics, are central because they govern the way in which new knowledge is transformed into population health. The health and life expectancy of the vast majority of mankind, whether they live in rich or poor countries, depends on ideas, techniques, and therapies developed elsewhere, so that it is the spread of knowledge that is the fundamental determinant of population health. The trade-borne transmission of infectious disease has been the focus of international health authorities since seventeenth-century Italy and remains important today. But, at least since the middle of the last century, a more important influence has been the international transmission of ideas, techniques, and technologies. It is plausible that the recently accelerated pace of globalization has been accompanied by faster transmission of health information between rich countries, although it is probably too soon to be sure. But the current lack of treatment of HIV/AIDS in sub-Saharan Africa, as well as the annual deaths of 10.5 million children in poor countries—which would not have occurred had they been born in rich countries—are major failures of globalization to date.

Health and Globalization in History

Disease has been an unwelcome companion of trade at least since the plague of Athens in 430 B.C. killed perhaps as much as one-third of the population. The black rats, which carried bubonic and pneumonic plague to Europe in 1347, were most likely brought by trading ships. More than three hundred years later, the city-states of northern Italy developed the first systems of national and international public health in an attempt to control recurrent episodes of the disease.¹ Merchants wanted quarantine restrictions to be internationally coordinated to minimize the disruption to their business. Yet even at this early date, health concerns tended to run second to the needs of trade. In 1630-31, when Pistoia (near Florence) had locked its gates to quarantine itself against the encroaching plague and had expelled all foreigners, mountebanks, and Jews, the city was temporarily opened up to all comers to facilitate the export of its wine.² And in the trade and health dispute between Florence and Genoa in 1652, quarantines were used to favor domestic over foreign traders as much as to protect public health. At the same time, the fundamentally mistaken notions of how the plague...