Globalization: from rhetoric to evidence.

Every silver lining has a cloud. The shift with development from food scarcity to food surplus is accompanied by rising obesity and all its associated health consequences. The steady reduction in mortality rates (until HIV/AIDS came along) has allowed people to live long enough to develop unpleasant chronic and degenerative diseases. And so with globalization, a process that has unquestionably brought benefits to many countries, is also accompanied by risks and negative consequences. In the last two years there has been increasingly lively discussion, particularly about the negative consequences of globalization, actual or potential. The argument needs to be balanced though, and that means including three important considerations. The first is that substantive economic evidence exists for the benefits of globalization (see for example the article by Dollar in this issue, pp. 827–833). Of particular note here are the established links between openness to trade, economic growth, incomes of the poor and the health of the poor. Second, due recognition must be given to the political and social benefits of openness. Egregious human rights abuses, whether acute (as in genocide) or chronic (as in the treatment of women) are more able to persist in closed societies that are sheltered from international scrutiny and intervention. ‘Open’ countries (such asMalaysia) have clearly benefited, in contrast to ‘‘closed’’ ones (such as Myanmar). Thirdly, where the dangers or ill-effects of globalization are emphasized, some kind of counterfactual or alternative pathway has to be put forward if the objections are to carry weight. If not globalization, then what? The critical task now is to promote a debate on globalization that is calm, rational and evidence-based. We hope that this issue of the Bulletin makes a contribution towards meeting this need. Openness to trade, technology and inward investment will (when accompanied by appropriate domestic economic policies) bring economic benefits including a reduction in poverty. This increasing income will in turn generate health benefits because of the strong link between wealth and health. However, openness also brings health risks and adverse consequences, many of which are set out in the papers of this issue. Such risks are not new: perhaps the most devastating impact of globalization was the spread of deadly epidemics that accompanied European expansion and colonization between roughly 1500 and 1800. These epidemics decimated immunologically naı̈ve populations, especially in the Americas and Oceania. Global spread of infection continues today, although (with the notable exception of AIDS) we now have better knowledge and tools with which to ameliorate the consequences. With research on the nature and extent of both positive and negative health consequences of globalization, must come new thinking about enhanced international mechanisms to optimize the net outcome. New global initiatives in infection control and control of smoking-related illness are examples of the way we need to go. Public–private partnerships (see last month’s issue of the Bulletin) and Kofi Annan’s call for a new global fund for the control of AIDS, malaria and tuberculosis are others. Lastly, globalization provides new opportunities for investing in global public goods that enhance health (see Kaul & Faust pp. 869–874). Up till now, most transfers of resources from rich countries to poor ones have focused on country-specific projects. The track record of this form of aid has been disappointing, as the new aid effectiveness literature shows. By contrast, some multi-country and multi-regional initiatives in health have been spectacularly successful. Examples include massively effective offensives against smallpox and poliomyelitis worldwide, and against river blindness in West Africa. Research on diseases of the poor, and international efforts to generate standardized data on disease burden and health system performance, are other noteworthy examples of global public goods for health. A globalized world with rapid transit of ideas, people, and money provides a setting for a new generation of successful investments in health that benefit people of all nations. n