All periods of global integration have left their mark on these relationships and the past few decades are no exception. Deforestation—largely as a consequence of logging for the global market—has brought human beings into contact with a wider range of infections, as humans invade the wild habitats of other animals. The rapid growth of cities such as Kinshasa and Chongqing reflects the economic advantages to be gained from concentrating people and resources, but a penalty has usually to be paid.
Dense populations allow diseases to circulate and mutate more quickly. Poorly planned construction provides ample breeding sites for mosquitoes carrying diseases such as dengue and malaria.
Burgeoning populations outstrip the supply of wholesome water. Most worrying of all, perhaps, are [End Page ] the consequences of feeding such conurbations. In many parts of Asia, rapid urbanization is the chief driver of intensive animal production, as it was in the West a century or so before. As well as affording greater opportunities for the mutation of viral diseases such as influenza, the subtherapeutic use of antibiotics in intensive farming has been linked to bacterial resistance, for example, to the drug tetracycline.
In view of the powerful interests involved, and the desire to maintain or secure competitive advantage, the prospect of concerted global action appears dim. So far, I have discussed globalization in relation to pandemic diseases and that is largely because the epidemiological consequences of integration are generally seen in that way. However, there is growing recognition that changing lifestyles, which are directly and indirectly linked to globalization, are transforming patterns of morbidity in both highly developed and low-income countries.
Globalization has lifted millions from poverty and has contributed in many instances to the improvement of health infrastructure and the provision of vital utilities such as clean water.
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It has also enabled governments in developing countries to afford more medicines and vaccines, thereby reducing deaths from easily preventable and curable diseases. These results have been most spectacular in nations such as Bangladesh that have high levels of civic activism, female education, and state involvement in health care. Causing around 25 percent of deaths worldwide in , infectious diseases were responsible for less than 16 percent of global mortality in However, longevity and prosperity have created new problems.
An aging population is more likely to suffer degenerative diseases such as dementia, and this is placing an enormous burden on even the richest nations. Rising incomes in developing countries have also brought an increase in alcohol- and tobacco-related diseases. Global mortality from tobacco-related illness, for example, is projected to increase to around ten million per year by The costs for the countries that are most affected—principally China and India—will be staggering, not to mention the impact on productivity.
These rapid changes in food culture have been fueled by some of the indirect effects of globalization such as economic insecurity and urbanization, while their detrimental effects on human health have been exacerbated by more sedentary working patterns and increasing reliance on motor transport.
It is presently unclear whether these harmful trends can be countered, but the problem appears rather differently in different countries. In rapidly developing countries there are stark contrasts between the mortality and morbidity profiles of the new middle class and the very poor, many of whom still die as a result of exposure to infectious diseases, accidents, and violence. Obesity, cardiovascular disease, and type 2 diabetes are usually to be found among [End Page ] those unable to reap the benefits of globalization: the poorly educated and unskilled who have suffered economically and psychologically from the decline of traditional heavy industries.
In many affluent and middle-income countries there is also a third group of persons who present a complicated mixture of problems: economic migrants. Low-skilled migrant workers are not always from foreign countries but are often first-generation immigrants from rural areas. Like their foreign counterparts, they tend to lack basic rights, including the right to health care and health insurance; their hours of work are long and their job security low. They typically suffer from health problems that show the consequences of new dietary habits e.
Migrant workers—whose status is sometimes that of illegal immigrants—also exhibit a range of mental health problems caused by overwork, poverty, abuse, and deracination. They share these problems with many persons who arrive in countries of all types as refugees following famine, war, and natural disasters. For some, globalization may provide a release from social and cultural restraints, whereas for others economic insecurity results in depression and anxiety.
What is certain, however, is that current problems of mental health, like those of physical health, cannot be understood independently of the global forces that govern so many aspects of our lives. The effects of globalization have been equally apparent in the field of health care, most obviously in a shift from public to private provision. The mid-twentieth century saw the idealization of the state as a provider of health care and in most countries its contribution continued to grow [End Page ] for decades.
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Western social democracies expanded the range of health care available to the public, while some authoritarian regimes like South Korea under Park Chung-hee favored state-funded health insurance as a way of co-opting and mobilizing the population for nationalist ends. By the s, however, a radically different form of consensus was emerging, closely aligned with the ascent of neoliberal ideology.
Neoliberalism was sustained by the growing belief that the state impeded efficiency and prevented formerly dominant nations from competing in a global market with states that had lower taxes and production costs. However, the effects of neoliberal thinking were most immediately apparent in low-income countries that were forced to cut back on state expenditure as a condition for financial assistance.
So-called public-private partnerships were promoted vigorously by governments of all complexions. Beginning in Australia in the s, but later taken up enthusiastically in the United Kingdom and other European countries, PPPs seemed to offer substantial savings. The results, however, were mixed, and the cost of such schemes was often massively underestimated. Privatization has been driven by rising costs as much as by political ideology.
In countries with substantially state-funded health services, access to new drugs is normally regulated by bodies that assess value for money and clinical efficacy, so the cost of health care has risen more slowly than in countries in which the private-sector dominates. In , the United States, with its predominantly private system of health care, spent However, the insatiable demand for new medicines is no longer confined to the West, if it ever was.
Medical consumerism is now a global phenomenon, and its appetites are sharpened by a cosmopolitan market in goods and services. Western medicine has to compete with other forms of healing such as traditional Chinese medicine and ayurveda, both of which have found niches in a global market.
Ironically, the globalization of these products and the medical traditions which purportedly spawned them was possible only because they emulated many features of Western medicine and pharmaceutical manufacture. The tendency toward uniformity has been most evident in the pharmaceutical sector, however. Although they have been marketed as alternatives to mass-produced, synthetic pharmaceuticals, many so-called traditional medicines are manufactured industrially and sold in much the same way as their Western counterparts.
Purveyors of these pharmaceuticals have created many global brands but practitioners of non-Western medicine have also had to adapt to local cultures. This is the case with traditional Chinese medicine in East Africa, where, despite the training of African practitioners in Chinese institutions, local expectations have led to significant modifications of practice.
While some forms of traditional medicine have taken advantage of globalization, others—such as Korean medicine—have yet to establish themselves internationally. Nor should we exaggerate the status that even the most successful forms of non-Western medicine currently enjoy. In some Chinese hospitals, integration of Western, TCM and ethnic minority medicines works extremely well, assisted by the fact that practitioners of all systems have identical pay scales.
IM also affords less equality to traditional medicines than might be supposed, for non-Western therapies—which were originally formulated to meet the needs of individual patients—are appraised by randomized control trials and other methods that take no account of such variations.
Biomedicine therefore remains in the ascendant in most countries and is becoming more powerful in some which had vibrant traditions of their own. Western medicine is now seen as a lifestyle choice—just as alternative medicines are for many people in the West—affirming modernity and membership of a global community.
It also provides quick and effective remedies that are well suited to the pace of life in a modern, globalized world. As a result of these and other local factors, practitioners of traditional medicine in some countries have seen their status fall. Traditional medical schools in South Korea, which used to attract the best students from high school, now appear to be struggling to fill places as star pupils flock to colleges of Western medicine.
The choices made by individuals within the global market are normally innocuous but in some cases the most affluent exercise their choice at the expense of the poorest and most vulnerable. Perhaps the most notorious example of this is the trade in organs intended for transplantation. Though this trade is distasteful to many, a number of prominent ethicists have made strong arguments in favor of it, albeit in strictly controlled circumstances. Questions of equity and efficiency also come into play when the global market is allowed to govern matters of public health, not least the development and distribution of vaccines.
During the H1N1 influenza pandemic of , stocks of vaccine were quickly exhausted as they were purchased by affluent nations. Practically none of the vaccine reached African countries, but ironically much of the unused stock from rich countries was dumped there. In this article I have made a case for the relevance of global history to historians of health, disease, and medicine.
Globalization and Global History
It has not been my intention to [End Page ] be prescriptive or to devalue other approaches but merely to affirm that a global perspective can illuminate some of the central problems of our field. A global perspective also enables us to see connections between what at first appear to be random events, such as the growing prevalence of many diseases human, plant, and animal; infectious and noninfectious simultaneously in different parts of the world. All manner of pathogens came to circulate the globe, while the environments receiving them were transformed by commercial agriculture and industrial enterprise.
It soon became clear that a divergence had occurred, for the countries that gained most from global integration enjoyed improving health while conditions often worsened elsewhere. Better nutrition and sanitary infrastructure in the richer nations began to reduce mortality from infectious disease, but improvements occurred fitfully or considerably later in their colonies.
It was not until the s that the situation began to improve. At that time, international comparisons, rising expectations, and concerns over international competitiveness led to an escalation of state intervention and more standardized conceptions of health and illness. This transition was aided by the increasing availability of Western pharmaceuticals and services, particularly in industrial and commercial centers that had grown with the global market. These products paved the way for medical and sanitary interventions by normalizing Western medicine and the biological concepts that underpinned it.
Our present era bears some resemblance to this earlier period of integration. Once again, there is an increasing threat from certain infectious diseases, but with the exception of tuberculosis and influenza these are different from those that plagued the nineteenth century.
There are other differences, too. Chronic diseases and degenerative conditions once found predominantly in the West are now ubiquitous, while health inequalities within nations—even affluent ones—are almost as striking as those which exist between them. This gradual shift reflects the emergence of a social structure that has global dimensions and of a distribution of power that is less geographically localized than in the age of empires. The response to health problems arising from global integration is also rather different.
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Although the organizations involved in public health and health care have always been diverse, the period from roughly to was [End Page ] characterized by the growth of the state. Its increasing role in matters of health reflected a belief that government intervention ameliorated social inequalities and that the welfare of all classes was mutually dependent. Though spurious in many respects, this internationalism brought real improvements and helped to stabilize the global economy.
Today, there is no real consensus on how to deal with the health problems arising from global integration. Whereas previous generations looked primarily to the state, its role in the provision of health care is decreasing in rich and poor countries alike. While global threats to health appear to have increased, the authority of global institutions has not. All over the world, the young and idealistic are drawn to work in a field which appears to embody humanitarian ideals.
But global health remains an elusive concept. It is not at all clear whether it is a noble aspiration or a new type of policy that transcends the concerns of nation-states. However, the mantle of global health often disguises other motives. The term frequently dignifies the pursuit of national interests, not simply the protection of borders but foreign health interventions that are designed primarily to secure economic and political objectives. It would be unrealistic to expect otherwise, especially in view of the competitive pressures exerted by globalization.
But global health can be more than an aggregation of interests. While public health has always been part of statecraft, it has also—since its inception—reflected a shared understanding of health as a common good. M ark H arrison is professor of the history of medicine and director of the Wellcome Unit for the History of Medicine, University of Oxford. The author would like to thank the editors for their constructive criticisms of earlier drafts of this article, as well as professors at Peking and Kyung Hee universities for giving him the opportunity to visit hospitals and medical schools of varying types.
He also expresses his gratitude to the Wellcome Trust for their support whilst researching this article. A good starting point is D.