Stephen Bezruchka
When
asked about globalization, Margaret Thatcher, the former Prime Minister of Great
Britain, replied, "There is no alternative." Her reply was shortened
to "TINA," which some people think is a newly discovered law of
nature. Yet, public resistance to this new corporate-centered trade is
increasing. What relevance does this have to American physicians? Does
globalization affect health? Many think about the health effects of modern
global trade as involving increased pollution as corporations strive to limit
environmental restraints or global warming caused by the increased reliance on
cheap fossil fuels. Others focus on the changes in diet produced by genetically
modified foods or the increase in the tobacco market penetration. The expansion
of global cigarette exports is a dramatic example, totaling 223 billion
(10,000,000,000) cigarettes in 1975 and rising to 1.1 trillion
(10,000,000,000,000) cigarettes in 1996 (a 5-fold increase). Others might
consider the health of child laborers in Pakistan who produce many of the
disposable surgical instruments that are increasingly used in US hospitals. Or
they might consider deaths from toxic exposures in poor countries as US
corporations evade environmental restraints at home. One such example occurred
15 years ago in Bhopal, India, where 5 tons of poisonous methyl isocyanate gas
leaked into the air from a Union Carbide pesticide plant, killing more than
3,000 people. These effects are real, but they pale in comparison with
globalization’s effect on increasing inequality, the most powerful factor
affecting population health and responsible for perhaps 14 to 18 million deaths
a year (18% of total deaths) worldwide.
DANGERS
OF HIERARCHY IN HEALTH
To
understand this factor, we need to recognize that the health of the US
population is disgracefully poor compared with that of other rich countries.
In
the ranking of countries by life expectancy in 1997, the United States stood
25th, behind all the other rich countries and even a few poor ones. The country
that has won the gold medal in this "health Olympics" every year since
1977, Japan, is also tied for the gold medal in the "smoking
Olympics." That is, the prevalence of smoking in Japan is tied with that in
China as the highest in the world and 3 times that of the United States; yet,
the Japanese do not die of smoking-related diseases to the extent that Americans
do. Lung cancer mortality rates in Japan are one half to one third of those in
the United States. How does Japan do it? The answer is simple. The health of
populations in rich countries is determined primarily not by the health care
system– we have the most sophisticated and expensive, so it cannot be that–or
by individual risk factors such as smoking, but rather, by the gap between the
rich and the poor. Many recent studies show that populations with a greater
income hierarchy are less healthy, and specifically have shorter lives, than
populations that are more equitable. These studies have looked at mortality and
income distributions among countries, within countries such as each of the 50 US
states, and within 282 standard metropolitan areas (US cities). They have also
looked at homicide rates, teen births, and specific diseases.
Independent
investigators have studied many different populations using different methods,
and all agree: the strongest factor affecting health is the size of the gap
between the rich and poor. Other studies suggest physiologic mechanisms through
which greater hierarchy results in worse health and posit that humans are by
nature egalitarian. The analysis has the same level of validity as the
relationship between smoking and lung cancer, using the criteria postulated in
this country by the Surgeon General’s report in 1964. (The data and scientific
analyses can be seen at http://depts.washington.edu/eqhlth.)
THE
WEALTH AND INCOME GAP
The
United States has the greatest wealth and income gap of any rich country, which
is the main explanation for its dismal health ranking among developed countries.
We did not always fare so poorly: in 1960, we were 13th. As our wealth and
income gap have grown, so has our distance from the healthiest country. After
the second world war, Japan restructured its economy to be egalitarian. Today,
during its economic crisis, managers and chief executive officers are taking
cuts in pay rather than laying off workers, something that is inconceivable in
the United States (Market Reform for Economic Survival: "Constancy and
change in Japanese management," Japan Echo 1999 April;26:26-28).
Most
countries in the world are poor, with most people subsisting to produce their
own food, often supplementing their income by sending family members to cities
to work in factories or abroad and sometimes by engaging in illicit commerce. In
some countries, such as Nigeria with its oil riches, immense wealth lines the
pockets of only a few people. In poor countries, the evidence suggests that
equitable development that focuses on providing basic needs is the route to
improving the population’s health.
THE
PROBLEMS WITH CORPORATE-CENTERED TRADE
In
the past 1 or 2 decades, world trade could be more accurately described as trade
that is corporate-centered. This change began in the mid-1970s and was boosted
by the economic policies of Thatcher in Great Britain and Ronald Reagan in the
United States. Today the dogma governing economic activity, deemed the
"Washington consensus," is founded on the principle that the market
knows best and should govern the world. The implicit assumptions are that
economic transactions involve a buyer and a seller who are on an equal footing
and that the price accurately reflects the cost. The influence of indirect
subsidies in tipping the scales is overlooked, as shown by countless examples.
In 1995 Boeing, one of this country’s largest exporters and most successful
corporations, received a tax credit of more than $33 million. In 1999 Microsoft,
another highly successful company, increased profits by 71% in 1999 over the
previous year, yet paid $226 million less in federal tax. "Flexible
taxation" is just one of the many ways in which the public subsidizes
economic activity. Of the world’s 100 largest corporations, 20 would have gone
bankrupt without such assistance. This so-called free trade in poor countries
has produced great wealth for multinational corporations and provided low-wage
jobs that keep many people in poverty. Among countries, the gap between the
richest and the poorest fifth was 3 to 1 in 1827, rising to 30 to 1 in 1960, to
60 to 1 in 1990, and to 76 to 1 in 1997. Recent studies have shown that where
there is increased penetration of foreign investment in poor countries, slower
economic growth and greater inequality result. Global economic greed is the
problem.
But
what of the effects of global trade in rich countries? In the past 25 years,
during which globalization has become common parlance, most people in the United
States have seen a decline or stagnation in incomes after adjusting for
inflation. This has come during a period of record profits for corporations and
a booming stock market. According to economist Edward Wolff, 95% of American
households had a decline in their net worth from 1983 to 1995. The United States
has begun to look more and more like a third world economy, with a fabulously
wealthy elite few surrounded by a mass of people not sharing in the globalized
pie. The top 1% of families in this country holds more than 40% of the wealth.
What
are the population health effects of corporate-centered economic policies? In
rich countries, capital (material wealth, monetary, and other) is abundant,
whereas in poor countries, labor is plentiful. Production moves to poor
countries where labor is cheapest. Free trade in goods and services leads
businesses to produce goods that are capital-intensive in high-wage countries
but labor-intensive in poor ones. Benefits from trade and investment generally
flow to the rich countries rather than to poor ones, and thus, income inequality
among countries is increased. Within poor countries, more people have been
displaced from their subsistence economies than have been able to find jobs in
the manufacturing sectors in overcrowded cities. In poor countries, as an elite
profits immensely from this shift, the income gaps in those countries increase.
In rich countries, the demand for labor is lowered, wages become relatively
depressed, and income inequality increases. For most of the world’s people, it
is a lose-lose situation.
HOW
ARE PHYSICIANS AFFECTED?
Physicians
recognize that the advice a cell biologist would give to, say, a cardiac muscle
cell to be healthy–trap all glucose and oxygen available, but avoid free
radicals–is not the best advice for the collection of cells that makes up a
human being. Unfortunately, today we are doing just that, as shown by our rising
rates of obesity. Health professionals need to understand that what seems best
for an individual patient (the usual do’s and don’ts) may not benefit the
population, if the goal is to maximize its health. Individual risk factors need
to be de-emphasized and population risk factors addressed. The most important
risk factor is the gap between the rich and poor.
Genuine,
widespread improvements in health and quality of life will take structural
changes in the distribution of income and wealth. The evidence is clear that in
rich countries, health care has not had a major effect on reducing mortality in
populations, and in poor countries, the effect pales to that obtained by
equitably distributing the fruits of economic growth.
Alex
Carey, an Australian sociologist, remarked that the 20th century will be
remembered for 3 developments: the growth of democratic processes, the growth of
huge corporations, and the creation of ways in which corporations could ignore
democracy. An alternative to corporate-centered trade requires rethinking
economic policies whose major effect has been to increase inequality worldwide.
Calling it the "free market" hides extensive indirect subsidies to
corporations. The size of the economic gap is the critical factor affecting
population and policies that increase that gap limit health improvements.
If
a healthy population is our goal, the winds of health policy are taking us in
the wrong direction. We need vigorous debate over who is subsidized and by how
much. Changing who shares the benefits in the world economy today is the
challenge of the new century. The health of our nation and our people depends on
it.
