Globalization and Health: A new, critical view Ronald Labonte And Ted Schrecker In Zambia, a woman named Chileshe is dying of AIDS. She was infected by her now dead husband, who once worked in a textile plant along with thousands of others but lost his job when Zambia opened its borders to cheap, second-hand clothing. Resorting to work as a street vendor, he would get drunk and trade money for sex - often with women whose own husbands were somewhere else working, or dead, and who desperately needed money for their children. Desperation, she thought, is what makes this disease move so swiftly; she recalls that a woman from the former Zaire passing through her village once said that the true meaning of SIDA, the French acronym for AIDS, was “Salaire Insuffisant Depuis des Années” (Schoepf, 1998). Chileshe’s is one of four stories we used in a report that has just been published by Canada’s Centre for Social Justice (Labonte, Schrecker & Sen Gupta, 2005b) to dramatize the health impacts of transnational economic integration (‘globalization’). It is a composite, like the stories used in the World Bank’s 1995 ‘World Development Report’. The Centre for Social Justice report, which grew out of a contribution to the first ‘Global Health Watch Report’ (forthcoming in July at http://www.ghwatch.org), directly challenges the elite religion of neoliberal, market-oriented economic policy, as promoted by agencies like the World Bank and the International Monetary Fund. Drawing on an extensive research base, we describe the causal pathways that link globalization to unequal and deteriorating health outcomes by way of increasing inequalities in access to the social determinants of health, and policies that tilt the economic playing field even more steeply toward the rich countries. Sometimes, the impact is straightforward, as when public spending cutbacks combined with onerous debt repayment terms mean that governments opt for “cost recovery” in health care or water and sanitation. This process played a role in Chileshe’s story. As part of a structural adjustment program attached to loans from the International Monetary Fund, Zambia imposed user fees, cut health staff and reduced the salaries of those who remained – just at a time when the AIDS epidemic was surging out of control. In other cases, the causal pathways operate less directly, by reducing economic insecurity and magnifying inequalities. The same adjustment program required Zambia to open its borders to second-hand clothing in 1992. Its domestic clothing manufacturers, valuable though they were as providers of employment, could not compete with imports of used clothing with zero production costs. Within eight years, Zambia’s clothing and textile industry all but disappeared, along with 30,000 jobs; large numbers of previously employed Zambian workers were thrust into the informal, ill-paid and untaxed underground economy. The World Bank called these “unintended and regrettable consequences” of the adjustment process (Jeter, 2002). For classical economists, the market was working as it should: consumers get more and cheaper stuff, and inefficient producers are driven out of business. For the losers and the left-behind, the consequences can be deadly. Zambia’s required privatization of state enterprises eliminated a further source of revenues that might have been used to support social programs, such as education and health care. The Zambian government is trying to undo some of this damage. But like many other governments, it is hampered by the rich world’s failure to cancel more of the developing world’s crippling debt, or to provide it with the resources it needs to sustain its peoples’ health. Writing about another African country, journalist Ken Wiwa noted: “You’d need the mathematical dexterity of a forensic accountant to explain why Nigeria borrowed $5 billion, paid back $16 billion, and still owes $32 billion” (Wiwa, 2004). Not until 1996 did the rich world respond collectively with the so-called Heavily Indebted Poor Countries or HIPC initiative. This has freed up more money for health and education. But much of the HIPC countries’ debt will remain unpaid and uncancelled at the conclusion of the initiative, most of the world’s poor live in countries that are not eligible for HIPC and the price of debt relief is often more privatization and trade liberalization, now dressed up in the rhetoric of poverty reduction strategies. Development assistance is by no means a panacea. At the same time, a wealth of experience now exists on how to make aid work for basic needs, if the political will is there on the part of donor and recipient countries. The most authoritative estimate is that meeting the Millennium Development Goals’ 2015 targets, most of which are health-related, would require an additional $60 – $120 billion a year in aid from the industrialized to the developing world. This would represent a doubling or tripling of current aid flows, but hardly a formidable sacrifice: less than the cost of 57 Big Macs per Canadian per year, or 43 Big Macs per German per year (Schrecker, Labonte & Sen Gupta, 2005a). The cost would also be a fraction of what the United States spends on its armed forces, or of the value of the tax breaks that the richest Americans and Canadians have received in recent years. Reasons exist for optimism. Both the UN Millennium Project, which generated the cost estimates we have quoted, and the UK Commission for Africa were emphatic about the need for more development assistance and more effective ways of using it. In the words of the UN Millennium Project, “Even if we don’t know everything about such challenges, we know enough to achieve the [Millennium Development] Goals. Moreover, the necessary interventions are utterly affordable” (UN Millennium Project, 2005). Partly because the British government has placed African development high on the agenda, this July’s G8 Summit may represent a turning point for population health in Africa, and elsewhere in the developing world. A minimal “health equity agenda” for the Summit (Labonte & Schrecker, 2005) includes not only clear timetables for aid increases tied to comprehensive strategies for improving population health, but also expanded debt cancellation, acceptance of development-friendly trade policies such as special and differential treatment (SDT), and explicit acknowledgment that human rights – including the right to health – take precedence over trade and financial liberalization. In addition, because of the importance of capital flight in undermining African economies, the G8 must quickly ratify the United Nations Convention Against Corruption (which would provide for repatriation of assets illegally shifted offshore) and pressure other industrialized countries, as well as offshore financial centres, to do the same. To the credit of the UK Commission on Africa, it was emphatic on these points. Unfortunately, reasons also exist for pessimism. The Millennium Project and the UK Commission were less emphatic in acknowledging the need for fundamental redesign of the international economic order. Canada’s finance minister, who was a member of the UK Commission, is making breathless speeches about how Africa needs “a strong indigenous private sector to create jobs” and must “improve the business and investment climate … building entrepreneurial and marketing skills, domestic capacity and improving access to finance” (Goodale, 2005). This language suggests a development policy triage in which people not strong, young, or lucky enough to make it into the entry levels of the global marketplace (like Kenya’s call centres; see Lacey, 2005), or predatory enough to establish business alliances with foreign corporations, are considered disposable. In the discourse of growth through entrepreneurship those Africans who are already seropositive, or at highest risk for HIV infection because of their economic vulnerability, become invisible. By the end of the July Summit we will have a much better sense of whether the industrialized world is serious about improving the health of all Africans, or whether the best it can come up with is selective and targeted policies that represent only incremental departures from a past posture of ‘Fatal Indifference’(Labonte et al., 2004). * Ronald Labonte (rlabonte@uottawa.ca) and Ted Schrecker (tschreck@uottawa.ca) are, respectively, Canada Research Chair and Senior Policy Researcher at the Institute of Population Health, University of Ottawa, Canada. ‘Health for Some: Death, Disease and Disparity in a Globalizing Era’ by Ronald Labonte, Ted Schrecker and Amit Sen Gupta is available from http://www.socialjustice.org/cart.php?fil ter= &action=add_item&id=23&qty=1 * Please send comments to editor@pambazuka.org References Goodale R (2005). 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