Globalization, Rapid Urbanization and Health Infrastructure

Introduction: Contemporary globalization is reproducing the classic conditions historically associated with the emergence of infectious diseases and the periodically recurring pattern of epidemics and pandemics. This chapter explores the current relationship of rapid globalization with emergent infectious disease and links it to other globalization elements that both define and impinge on the generalized notion of “health infrastructure.” The dynamics of contemporary globalization are contributing to various institutional gaps that make dealing with infectious disease increasingly difficult and threaten concentrated human populations with potential calamity.

Historically, the classic conditions associated with epidemics include rapid increases and migration of populations, crowded urban conditions that concentrate the poor, weak regulatory structures that inhibit effective intervention, climate changes associated with higher temperatures, and dislocation of traditional boundaries between microbial and human populations. (McNeill, 1976) Very rapid urbanization and its persistent association with increased poverty act to reproduce many of these conditions. What Kofi Annan has called “the urbanization of poverty” [1] results from the pattern of growth without development that Fantu Cheru situates at the core of the complex of events in which increasing numbers of the world’s poor find themselves. Growth without development leads to a weak state in which “public health” broadly defined struggles to gain an effective institution foothold.

Emerging Infectious Disease:

The past two decades have witnessed a resurgence of known infectious disease incidents and a blossoming of newly emergent diseases. Among the former has been a sharp reoccurrence of traditional water-borne diseases such as those indicated again by Cheru: cholera, enteric fevers, guinea work, schistosomiasis and trachoma, often in epidemic proportions. Mosquito vectored diseases, which can be viewed as water-related, such as malaria and dengue fever have made startling recoveries.  Leptospirosis, another waterborne disease, is now understood to be far more widely prevalent than previously thought, its symptoms often misdiagnosed at the clinical level. (Vinetz, 2005) Zoonotic diseases, those transmitted from animals to humans, have emerged as of relatively greater threat to human populations over the latter decades of the 20th and the early years of this century. Table Two provides a comparison of infectious disease profiles. (Wilcox, 2004) Appendix One provides illustrative data on selected emergent diseases.

Of most concern are new flu strains such as H5V1 emergent in Asia, which if it follows one possible course could mutate into a form for which human populations have no resistance. The CDC estimates that should an outbreak follow the characteristics of the 1918-1919 Spanish Flu pandemic, the world casualty rate could reach 100,000,000.

Many of these diseases are recognized as “diseases of poverty” in that their incidence rate among the poor is highest in the societies in which they occur and the incidence rate greatest among the poorest of the poor. (Appendix Two contains data that demonstrate the macro linkages between poverty/prosperity and illness/health.) Tuberculosis, for example, began its dramatic world-wide re-emergence in the 1980 paralleling increased labor migrations from the developing to the developed world: in effect global labor migratory practices were relocating the reservoir for the disease from the one set of countries where in conditions of persistent poverty it had remained a potent disease to another set of more prosperous countries from which it had been largely eliminated. Paul Farmer has argued persuasively that HIV/AIDS is a disease of poverty (Farmer, 2004), a logic that can also be applied to most water borne diseases given the direct and persistent association between clean water availability and income levels in most developing countries. (UN-Habitat, 2003).

Table One: Principal Infectious Diseases

Source: Wilcox, 2004.

Three other globalization dynamucs are directly implicated in either the spread or emergence of infectious disease. As SARS and Ebola fever dramatically demonstrate, microbes are persistent airline hitchhikers accomplishing moves simply impossible without this medium. The devastating virulence of these two diseases in particular dramatizes the vulnerability of large distant populations and suggests the outlines of a correspondingly effective public health regime—of which more later. (In these instances the very virulence of the disease spared larger populations as the disease killed its hosts before it could become viable through transmission---precisely the scenario that public health workers fear in new flu strains with more efficient air borne transmission capabilities.) Combinations of modern transportation mechanisms have been responsible for the rapid dissemination of Lyme Disease in the United States (from North Africa), and of Dengue fever from the Old to the New world. (See Appendix One) [2]

Environmentalists are gauging the effects of steadily increasing shipping tonnages, understanding that bilge discharges are rapidly transporting microbial populations from one part if the globe to another in ways that require yet additional surveillance and monitoring.

The collapse of global time and space (Harvey, 1990) brought on by the combination of modern transportation and communications constitutes a second factor in the emergent infectious disease. Increased penetration of geographic interiors with accompanying cash crop agriculture and deforestation reduce traditional species barriers bringing human populations into new or intensified contact with microbial populations. (Garrett, 1995) Much of the increase in hemorrhagic fevers and other traditional Arboviruses arises out of such conditions, exposing humans to diseases to which longer and enduring population settlement may have created patterns of immunity. The primary anthropoid vectors for these diseases (mosquitoes, sand-flies, fleas, ticks, lice, etc) are likely to be particularly opportunistic in contact with populations without previously acquired resistance. [3] Other emergent Zoonotic diseases, distinct from the Arboviruses arise out of similar conditions. The genetic reservoir for Asian avian flu types, for example, is wild ducks, which mingle with domestic flocks and pass along the virus.

Factory agriculture enters the picture as a derived third globalization dynamic, one that parallels that of rapid urbanization and which is a principal cause of the former. The cycle of market/production/market leads to a dynamic that ends in higher potential for disease. Factory agriculture is made possible by concentrated capital in the service of large concentrated markets (or distant markets made accessible through transportation) that allow unit costs to be significantly reduced. Cost competition weighs heavily on traditional producers who lose markets even as in many rural areas lose populations to urban areas, In factory farming enormous flocks of chickens and ducks (or herds of cattle in feed lots) become prime transmission sites for disease. Farmers strive to protect their animals through liberal doses of anti-biotics, which in turn leads to the development of new resistant bacteria. When virulent viruses strike, it is often with a swiftness that precludes the effective development of a vaccine for the affected animals. The only remedy is to slaughter entire flocks or herds to control the spread of the disease.

When global warming is added to this mix of factors related to rapid urbanization under conditions of contemporary globalization, all the factors are in place that McNeil identifies as the classic preconditions for epidemics. Recognition of this potent combination (which I have called “global stew” on another occasion) lead

many experienced hands in both national and international health organizations to caution that globally we are poised in the brink of a significant disaster, one that can only be averted through extraordinary global effort. Unfortunately, and ironically, just the opposite is occurring.

Neoliberalism, public health and disease.

Life is full if chicken and egg stories from contemporary cosmology and quantum physics (Green, 2004) to globalization and neoliberalism. Neoliberalism could not have come about at a worst time for global and national public health. Just at the time that maximal efforts seem to be required to meet the threat of emerging infectious diseases, neoliberal policies are having powerful negative impacts on public health in general. That may be the chicken. But, it is the very dynamics of contemporary globalization that bring these factors into play. That may be the egg. Globalization and neoliberalism are to significant degrees inseparable, and while they are, bringing effective public health measures to bear on the threat of emerging infectious disease is extraordinarily difficult…indeed, it may be impossible.

To frame the argument, I have derived from the literature nine propositions that represent the requirements for an effective regime of public health. Within these lies the issue of the requirements for a necessary health infrastructure. Each of these can be tested against the policies of neoliberal regimes.

The tension between neoliberal constructions of public responsibility and the health challenges posed by increasing globalization play off against a background of the presumptions of effective public health. Summarizing from accepted notions of public health policy, but with a particular debt to Laurie Garrett and William McNeil, these nine basic propositions can be adduced for as conditions for effective public health.

Proposition One: Good public health depends on effective public policy.

This seemingly self-evident proposition conceals a greater subtlety, as the current regime of globalization relies on the state and its capacity to effect purposeful public health policy. Public health issues devolve into weak state/strong state issues. Weak states can often create, but are challenged toimplement public policy. (Neubauer, 1998) Much of the world continues to live in “weak” states in which governments (central as well as regional and local) have difficulties ranging from grave to impossible in carrying out policy intentions, particularly those regarding public health. [4] In these circumstances, creating and maintaining good public health becomes impossible. Within this construction public health as a construct owes more to the adjective than the noun.

Proposition Two: Effective public health is dependent on sufficient social investment.

Overall, public health is losing comparative budget parity with the rising costs of curative medicine in both developing and developed nations. In the United States, with overall medical costs once again breaking out into double digit annual increases and running well ahead of the consumer price index, the relative share of national budgets devoted to public health declines. Especially in times of economic downturn, and absent compelling crisis conditions, social investment in public health is uncertain in most national budgets. The policy entailment is that to “succeed”, public health needs to operate in crisis modes. (Garrett, 2000)

Proposition Three: Sufficient social investment is dependent on prevailing political and economic ideology.

Neo-liberalism’s call for reduced taxes, a dismantling of welfare state structures, increased individual responsibility for social consumption, deregulation of the private sector, and reduced governmental spending directly impact public health. Indeed, those who see global public health structures as incapable of meeting the public health challenges spawned by globalization, identify the major culprit as reductions in net public spending. (Garrett, 2000. Kotz, 1999). Harris and Seid (2003) put the matter as succinctly as it can be stated: “globalization is deteriorating health services due to the adoption of neo-liberal economic policies and subsequent cutbacks in health care funding.”

Historically, adoption of necessary regulatory regimes has been viewed not only as a constraint on one set of interests in favor of another (or others), but more broadly as a kind of social investment. The unwillingness of the U.S. and China to participate in the Kyoto accords for the same reasons—that to do so would threatened continued levels of economic development—is a testament to the power of neo-liberalism. [5] The endorsement of the protocols by Russia in October 2004 (in addition to the relative advantage this gives Russia within the accord group) is a measure of its relative irrelevance to the current politics and economics of Russia.

Proposition Four: Inequality is detrimental to good public health.

As argued above, a growing consensus holds that contemporary globalization is resulting in increased social and income inequality. [6] A long-range macro analysis of inequality and health status holds that as inequality declines, overall levels of health improve, and the obverse. (Kim, et.al., 2000, Keating and Kertzman, 1999.)

Proposition Five: Regime corruption is detrimental to good public health.

Regime corruption manifests itself when particularized interests subvert public policy for their own benefit. Persistent regime corruption distorts public policy from its intended purposes. It follows that public health’s successes or failures are dependent on levels of regime corruption. (Garrett, 2000)

Proposition Six: Good public health is directly linked to positive social, economic, and political development.

Uneven or ineffective development (i.e. growth with limited development) results in poverty and weak regime states. The social determinants of health school holds, importantly, that good developmental policies contribute more overall to the health of publics than medically oriented individual intervention, no matter how sophisticated and successful the latter. Good development policies lead to improved population health. As argued above, un-even and unsuccessful development leads to inequality, poverty, and deficient provision of clean water, effective sanitation, adequate shelter and diet, as well as the political problems that follow from these conditions. [7]

Proposition Seven: To achieve policy success, public health needs to be able to value its own successes.

The overall goal of public health is to reduce or eliminate the incidence of specific diseases. When public health practices result in lessened disease threats, the relative value of public health in the policy process wanes. In an odd way, public health is successful when things don’t happen, when people do not become ill; it is about negative instances, which are notoriously difficult to “count” and have appropriate weight in overall policy contests that are defined by “crises of incidence” (bad things are happening that need to get fixed right away.) Tying this observation to proposition two above, public health’s budgetary fates rise during times of crisis and suffer during times of normality. The more it succeeds, the less it is rewarded. (Stone, 1997)

Proposition Eight: Public health suffers from the politics of focused expertise and technology.

In a related manner, public health funding tends to lose out when public policy is oriented toward producing focused expertise and technology.  Public sector investment in “health” has reached very high levels: the National Institutes of Health in the United States, for example, received $27,066,782,000 in FY2003. This is only a fraction, albeit a large fraction, of the sums spent in the U.S. on “health research.” These massive levels of investment have produced spectacular successes in knowledge creation, the invention of non-invasive and minimally invasive surveillance of the body, and a vast array of medical interventions, especially pharmaceuticals. At the system level, however, the multiplication and diffusion of highly technologized interventions result in rising expectations for medical care, and increased overall medical care costs, which crowd public health spending in national and sub-national budgets. More damaging, however, is the increased realization that increased expenditures on medical care do not necessarily produce corresponding gains in health, or as John Knowles famously put it in 1977, we are doing better and feeling worse. (Knowles, 1977, Kindig, 1997)

By contrast, much important public health work is low tech. (Farmer, 2003) In a corollary to Gresham’s law, high tech drives out low tech in budget contests (just as specialized medicine trumps primary care, cutting edge proprietary pharmaceuticals trump generics, and in general innovation trumps replication.) Some exceptions to this proposition may exist with emerging tools for micro surveillance devices.

Proposition Nine: Achieving public health is a moving target: notions of acceptable levels of health change over time; new diseases are constantly developing.

Health is a relative value. Achieving it is an uncertain objective. Potentially the demand for health—especially as defined by medical interventions--may be infinite in a social climate in which individuals continually seek and receive new interventions to extend life or improve some aspect of bodily well being. (Elliot, 2003) These observations clash with the languages and perspectives of the policy process in which notions of attacking problems, defeating social ills, or achieving victory in another war on something or other are commonplace. Rhetorical tropes such as these serve well-recognized strategic and tactical means within the policy processes for mobilizing support, achieving agenda positions, and gaining budgetary allocations. When applied to public health, however, they create unrealistic notions of what can and cannot be accomplished within the frame of health by those practices we term public health. The result is that rhetorically, we are always in some ways losing the public health battle (because disease is always readily available in abundant supply including through continuing social construction). These dynamics make it especially difficult to distinguish one set of health problems (e.g. emerging infectious diseases) and others (e.g. the medicalization of life processes within highly developed societies.) The rhetorical confusions about “health” especially cloud the ability of developed societies to clearly see and appreciate the profound health issues of lesser developed societies. (Edelman, 1964. Martin, 1992)

Plan for the remainder of the chapter:

These points about emerging infectious disease and the requirements of effective public health in the context of contemporary globalization lead to a discussion if effective infrastructure for health, especially in developing societies.

Appendix One:

Figure One: An indicator of dispersal: number of countries in the world reporting DHF cases.

Figure Two: An indicator of intensity: number of DHF cases reported 1955-2001

Figure Three: Reported Lyme Disease Cases in the United States by Year

Appendix Two:

 Table 2-1

Lowest Healthy Life Expectancies and GNI Per Capita

Table 2-2

Highest Healthy Life Expectancies and GNI Per Capita

Table 2-3

Selected Healthy Life Expectancies and GNI Per Capita for Large Populous Countries

Sources: Data for these three tables has been extracted from WHO health life expectancy tables and World Bank gross national income per capita data. Figures are primarily for the year 2000.

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