2.

1 Globalization
Kelley Lee
Abstract
Introduction
What is globalization?
Features of contemporary globalization
The implications of globalization for public health
Conclusion
References

Abstract

Globalization, defined as the closer integration or interconnectedness of human societies across national borders
through spatial, temporal, and cognitive changes, is creating wide ranging impacts on public health. This
interconnectedness is characterized by crossborder flows of people, other life forms, goods and services, capital,
and knowledge to an unprecedented degree in terms of intensity and extensity (geographical reach). The
emergence of a global economy, for example, has led to the restructuring of many health-related industries such
as pharmaceuticals, food, and tobacco. Other global changes taking place, such as the increased movement of
populations, environmental change, and financial transactions, have had indirect yet profound impacts on health
determinants and outcomes.

To date, the public health community has played a limited role in influencing the nature of the changes taking
place, which have been largely driven by powerful economic and political interests. Contemporary globalization,
as a result, has been characterized by an inequitable distribution of costs and benefits within and across
countries. For the public health community, there is a need to better understand the linkages between
globalization and health, and the possible interventions available to protect and promote public health. A review
of key activities in public health practice suggests the need for a ‘global public health’ approach which seeks to
minimize the costs, and maximize the benefits, to public health arising from globalization. Recent developments
in infectious disease outbreak control, environmental health, health promotion, and monitoring of health status
provide examples of the challenges faced. These include opposition by powerful vested interests to stronger
regulation, the need for effective collective action across all societies to tackle crossborder public health issues,
and the current weaknesses of global health governance. Nonetheless, there are opportunities for the public
health community to influence globalization by demonstrating the shared benefits to be gained. Greater attention
to the public health impacts of globalization, through redistributive policies, greater attention to health equity,
and appropriate social and environmental protections will, in turn, contribute to more sustainable forms of
globalization.

Introduction

‘Globalization’ is a term associated with complex and varied changes to the world around us, and has received
substantial research and policy attention in a wide range of fields. While scholars, policy makers, and
practitioners continue to debate the benefits and drawbacks of these changes, there is agreement that better
understanding of the nature of these changes, and their specific impacts on human societies, is much needed.
There is now a substantial body of scholarship on globalization and public health which seeks to explain how
contemporary flows of people, other life forms, goods and services, capital, and knowledge are influencing the
determinants of health and health outcomes (Lee 2003b; Lee & Collin 2005; Kawachi & Wamala 2006). The
unprecedented scale of these flows, in some cases rendering the national borders of individual countries
irrelevant, has posed three major challenges for the public health community: How can the evidence base on
globalization and health be strengthened; what effective policy responses are needed to optimize the benefits,
and minimize the costs to public health, arising from globalization; and how can these policy options be
practically and effectively implemented?

This chapter is concerned with how globalization is influencing public health. It begins by defining globalization,
and how it is a distinct and contemporary phenomenon. This includes the increasingly used concept of ‘global
public health’. The key drivers of globalization are described, alongside an understanding of the types of changes
occurring as a result. The chapter then focuses on the implications raised by globalization for key functions of
public health policy and practice. Many of the issues raised in this chapter are addressed in more detail
elsewhere in this textbook, a reflection of the importance of global forces now at play in so many aspects of
public health. The chapter concludes by considering the governance issues raised. While the public health
community has found itself at the frontline of many of the impacts resulting from globalization, and needing to
adapt to many of the changes taking place, it remains somewhat in the background when it comes to shaping
and managing globalization. The public health community must increase its capacity to influence such decisions if
globalization is to prove a positive force for human health.

What is globalization?
 

The popular and widespread use of the term ‘globalization’ has led to considerable variation, and at times lack of
clarity, of what it actually means. In many cases, the term has been used to replace ‘international’, denoting
subjects that concern two or more countries. Alternatively, the term is defined more narrowly to refer to
increased international trade, the spread of Hollywood films or other relics of western culture, or the greater
movement of people across borders. Alongside definitional vagueness lie marked differences in how globalization
is normatively assessed. Some writers see globalization as a unifying and progressive force, bringing
unprecedented economic growth and prosperity (Dollar & Kraay 2000; Feachem 2001). Others believe that
globalization is a new form of colonialism which serves to reinforce inequalities of wealth and power, and
consequently health and other social conditions, within and across countries (Cornea 2001; Labonte et al. 2005).
These differences in perspective are reflected in the highly contested nature of scholarship in this field.
While it is beyond the scope of this chapter to review these debates in detail, including the substantial evidence
now accumulating of the costs and benefits of globalization, it is an important starting point to approach the
term critically. In the broadest sense, globalization has become widely understood as the closer integration or
interconnectedness of human societies across national borders. Different societies have long interacted across
vast distances (e.g. migration of the human species out of Africa in one million BC, the Silk Road trade route,
and the Age of Discovery from the fifteenth century). Globalization can thus be recognized as an historical
process. At the same time, we can see that there are contemporary forms of globalization in which there has
been intensified flows of people, other life forms, goods and services, capital, and knowledge across borders to
an unprecedented degree since the mid to late twentieth century. In recent decades, not only has there been a
vast increase in the quantity of social interaction across populations, but the reach of those linkages to virtually
all parts of the world is also new. Held et al. (1999) write that it is this greater intensity and extensity of linkages
across human societies that define globalization today.
Three types of changes to human societies are occurring as a result of globalization (Lee 2003a). The spatial
dimension refers to changes to how people organize and interact with physical or territorial space. The now
clichéd image of globalization as a shrinking world or ‘global village’ refers to the extension of economic, political,
and social linkages to a worldwide scale. E-mail, long-haul package holidays, cyberspace, and the global
operations of transnational corporations are all examples of the restructuring of social space. For the most part,
our experience of the world is that it is ‘shrinking’ because of a greater capacity to access distant locations. In
other cases, novel ways of organizing social interactions are emerging, largely through new information and
communication technologies. The creation of virtual communities, such as YouTube™ and Facebook ®, for
example, allow individuals to communicate, and form social connections and networks, irrespective of
geographical location.
The temporal dimension concerns changes to how we think about and experience time. The contemporary world
is largely characterized by an acceleration of the timeframe which things can be, and are expected to be, done.
For instance, financial transactions involving currency trading, buying and selling of equities (stocks and shares),
and the securing of credit can take place in a matter of seconds through global information and communication
systems, even when involving parties located in different parts of the world. Similarly, advances in transportation
technology have enabled larger numbers of people to travel greater distances in shorter amounts of time (e.g.
bullet train, supersonic jets). Modern life has been one of time pressures to ‘multi task’, speed dial and ‘drive
through’.
Third, the cognitive dimension concerns changes to how we think about ourselves and the world around us. The
dissemination and adoption of knowledge, ideas, values, and beliefs have become worldwide in scale through the
global reach of the mass media (including the advertising industry), research and educational institutions,
consultancy firms, religious groups, and political parties. The ascendance of English, as the leading language for
diplomacy, science, air transportation systems, and entertainment is also a result of cognitive globalization. Some
argue that this is leading to the marginalization of local cultures and languages, and corresponding domination
by Western values and beliefs defined by individualism and consumerism (Barber 2003). Huntington
(2002) warns of a potential ‘clash of civilizations’ as competing ideologies and value systems come together to
cause religious or political conflict. However, others believe cognitive globalization is progressively spreading
shared ideas and principles which support human rights, gender equity, environmental and labour standards, and
democracy. In public health, Benatar et al. (2003) write of the development of global health ethics such as the
human rights based approach. Overall, the three types of changes taking place as a result of globalization—
spatial, temporal, and cognitive—are closely intertwined, and together are leading to a mixture of positive and
negative impacts.
Another point of substantial debate surrounding globalization is an understanding of what is driving these change
processes. Globalization is clearly enabled by technological advances which make flows across borders possible.
As the capacity of these technologies expands, and the cost of using such technologies decline, they have
become more accessible to larger numbers of people. For example, the industrial policies pursued by many
governments since the 1970s has emphasized the achievement of increased economic competitiveness through
promoting access to cheaper transport and fuel. This has led to a decline per ton of sea and air freight which, in
turn, has encouraged the rapid growth of international trade (US Department of Transport 2000; Teitel 2005).
Overlooking the environmental impacts, the advent of low cost air travel amid fierce competition has made
holidays abroad accessible for the first time to millions of people (Swan 2007). Communication costs have
declined even more rapidly. When desktop computers (microcomputers) became commercially available in the
late 1970s, a desktop computer cost around US$5000, putting them out of reach of most private users. By 2007,
the cost had declined to a few hundred dollars for many times the processing power of the original machines
(Lee & Collin 2005). Not surprisingly, information and communication technologies have been frequently cited as
the major force behind globalization (Hundley et al. 2003).
For some writers, however, technology is an enabler, but not the driver, of globalization. The real factors driving
technological developments and their application are, it is argued, economic in nature. The global spread of
capitalism has been driven, on the one hand, by untold thousands of producers seeking access to the cheapest
inputs (i.e. raw materials, labour, research and development, transport and communications), most efficient (and
greatest) economies of scale, and largest potential markets. Millions of consumers around the world, on the
other hand, fuel this process by demanding the highest quality and quantity of goods and services at the lowest
possible price. The millions of economic transactions that result, what eighteenth century economist Adam Smith
called the ‘invisible hand’ of the market, is seen as the real force behind globalization (Dicken 1999).
A further perspective rejects globalization as an essentially technological or economically driven process which
implies a degree of rationality and progress. Instead, some scholars point to current and dominant forms of
globalization as driven by certain ideologically-based values and beliefs broadly referred to as neo-liberalism. It
has been the global spread of this ideology that has, for instance, defined the industrial policies facilitating the
development of such technologies (e.g. the promotion of an information economy through deregulation and
privatization of telecommunications sector), and their dissemination for particular purposes (e.g. deregulation of
financial markets). It is argued that neo-liberalism has also defined economic policies which encourage
international trade (e.g. trade negotiations), market driven competition, and foreign investment (e.g. tax
incentives, and a minimal role for the state at the expense of social welfare and environmental protections (Falk
1999).
Not surprisingly, differences in perspective about the drivers of globalization reflect variation in views about
whether, on balance, such changes are beneficial or costly to human societies. So-called globalists (supporters of
contemporary globalization) predict a world of closer integration, shared identities, greater efficiency and
productivity, more rapid economic growth, and increased prosperity. While there may be bumps to negotiate
along the way, such as temporary inequalities in wealth within and among countries, it is believed that the
globalization path is progressive in the longer term, and will bring largely benefits for the greatest number of
people. In sharp contrast, the opponents of contemporary globalization, who see its associated changes as
largely driven by a neoliberal defined agenda, do not agree that the resultant changes taking place are mainly
positive. A broad range of individuals and organizations, often referred to as the anti-globalization movement,
see fundamental flaws inherent within the assumptions underpinning current globalization processes. Of
particular note are stark imbalances in power and influence within the emerging global order, dividing the world
into winners (those with access to technology, capital, knowledge and gainful employment) and losers (i.e. poor,
unskilled), with the latter far greater in number. Although globalization may generate increased aggregate
wealth, critics challenge the assumption that this wealth will eventually ‘trickle down’ to those at the bottom of
the global pecking order. Rather, anti-globalists cite substantial evidence which is strongly suggestive that,
without strong commitment to redistributive policies, along with appropriate social and environmental
protections, neo-liberal globalization will lead to a widening gap between haves and have-nots including health
inequities (Kim et al. 2000; Mittelman 2002). Moreover, if allowed to continue unabated, many critics argue that
current forms of globalization are socially and environmental unsustainable in the longer term.

This chapter is broadly located within the latter perspective. From a public health perspective, globalization is
leading to diverse and complex changes to health determinants, resulting in both positive and negative health
outcomes. For the protection and promotion of public health, and to ensure the longer-term sustain ability of
globalization, these changes must be actively managed to ensure that the positive outweigh the negative
impacts, and that any costs to health are equitably and fairly shared across societies. In order to develop
effective responses to the public health implications raised by globalization, it is useful to consider in greater
detail what changes are taking place.

Features of contemporary globalization

 

Current forms of globalization can be seen as dominated by the integration and convergence of systems of
economic production, distribution and consumption on a worldwide scale. While economist have varied opinions
on the precise timing of when these processes began to emerge, most agree that the creation of the Bretton
Woods Institutions—the World Bank, International Monetary Fund (IMF) and General Agreement on Tariffs and
Trade (GATT) after the Second World War laid its institutional and normative foundations. Each has played an
important role in facilitating the emergence of a global economy defined by the liberalization of capital flows, and
opening of national markets to trade and investment.
The first major pillar of the global economy, liberalization of capital flows, was introduced in the US from the mid
1970s which, in turn, precipitated a complete restructuring of financial markets across the world. Historically,
banks, insurance companies, investment companies, and brokerage firms have been subject to heavy
governmental regulation. Deregulation of financial markets, such as the removal of restrictions on the types of
securities that financial institutions could trade, levels of interest that could be paid on specific types of securities
and bank accounts, and types of institution entitled to act as financial intermediaries, was introduced to increase
competitiveness within the market and encourage greater capital flows within and across countries. Information
and communication technologies enabled high-speed electronic-based transactions which eventually linked
financial markets across countries. The result has been the creation of a globally integrated financial market
capable of 24-hour trading in foreign exchange and related money markets, the international capital markets, the
commodity market, and the markets for forward contracts, options, swaps, and other derivatives (Valdez 2006).
The scale of capital flows has correspondingly boomed. The world’s financial assets totaled US$136 trillion in
2005, and will exceed US$228 trillion by 2010. Global crossborder capital flows reached a record US$6 trillion in
2006, more than double their level in 2002. Foreign exchange trading increased from US$17.5 trillion/year to
US$1.5 trillion/day between 1979 and 2002 (OECD 2005; McKinsey & Company 2007).

A second key pillar of the global economy is the trade of goods and services. While trade has been the lifeblood
of commerce for thousands of years, it is the restructuring and integration of production processes across the
world, accompanied by the growth in scale and scope of trade, which characterizes the global economy of recent
decades. Historically, trade among countries has been dominated by raw materials and natural resources (e.g.
oil, timber), commodities (e.g. grains, metals) or manufactured products (e.g. textiles and clothing, food
products). In 1948, the GATT was established as an agreement under which signatories could negotiate
reductions in tariffs on traded goods. Originally, the GATT was to become an international organization like the
World Bank or IMF. However, without consensus among member states, this could not be achieved. Instead, the
GATT remained an agreement under which eight trade rounds were carried out between 1948 and 1994 through
which thousands of concessions on tariff reductions were reached. During this period, membership grew from 23
countries in 1947 to 125 countries in 1994, thus establishing a worldwide trading system.
The boom in traded goods and services since 1945 led to renewed support for a permanent organization. In
1995, following the conclusion of the Uruguay Round of trade negotiations, the GATT was replaced by the World
Trade Organization (WTO). Membership has since increase to 150 member states, with many more countries
seeking accession. Moreover, the scope of the world trading system has broadened to embrace trade in services,
agriculture, intellectual property rights, government procurement and other areas (Wilkinson 2006). The overall
effect has seen a growth in the scale and range of international trade. Since 1948, world trade has consistently
grown faster (6 per cent annually in real terms) than world output (3.9 per cent). In 2006, this trend continued
with world merchandise exports increasing by 15 per cent to US$11.76 trillion, and commercial services exports
growing by around 11 per cent (US$2.71 trillion) compared with global gross domestic production (GDP) growth
of 3.7 per cent (WTO 2007).
The global restructuring of production and exchange processes has been an integral part of the boom in
international trade over the past half century. In many sectors, transnational corporations (TNCs) have emerged
which have geographically relocated components of their business to different parts of the world (Dicken 1999).
Thus, resource extraction may take place in one country, manufacturing in another, and research and marketing
in still others. The targeted consumers have also changed, with TNCs increasingly seeing the world as a single
marketplace. According to the Forbes Global 2000, a ranking of the world’s top corporations by sales, profit,
assets and market value, the increase in so-called ‘global brands’ has been a key feature of a restructured world
economy. In 2005, BusinessWeek ranked the top five global brands (measured as the ‘most valuable’) as Coca-
Cola, Microsoft, IBM, General Electric and Intel (Anon 2005).
While global restructuring has not occurred in all industrial sectors, it can be observed in many sectors with
direct or indirect impacts on public health. One important example is the pharmaceutical industry which, as a
result of mergers and acquisitions, is today dominated by a small number of large companies. Pharmaceutical
companies ranked among the largest 100 global corporations in 2006 led by Pfizer (35), Johnson and Johnson
(57), Sanofi Aventis (58), GlaxoSmithKline (82), Novartis (83), Unilever (87), and Roche (97) (Forbes 2006).
Table 2.1.1 describes the largest companies in 2004 by sales, growth and market share, all of which are
headquartered in major industrialized countries. Table 2.1.2 lists the leading pharmaceutical trading countries,
led by Switzerland with a trade surplus of £5561 million in 2004. The overall trend in the sector has been
towards larger and fewer companies, controlling a growing share of the market. In 1992, the 10 largest
companies accounted for one-third of world revenue (Tarabusi & Vickery 1998). By 2002, this share had
increased to one-half (Busfield 2005). The trend towards larger pharmaceutical companies has been driven by
global competition. The cost of research and development (R&D), large-scale manufacturing, and worldwide
marketing and distribution, means that successful companies need to be of a certain size with considerable
resources. For example, the industry estimates that developing and launching a new drug product onto the world
market costs around US$403 million in 2000 (DiMasi et al. 2002). The desire to gain access to overseas markets
and ‘pipeline’ products has further encouraged mergers and acquisitions with local companies.

Table 2.1.1 Top world pharmaceutical corporations (2007)

Sales (£) Growth* Market share**
Country million (%) (%)
Pfizer USA 22 292 –2 6.7
GlaxoSmithKline UK 18 847 1 5.6
Novartis SWI 17 154 9 5.1
Sanofi Aventis FRA 16 788 8 5.0
Astrazeneca UK 15 010 9 4.5
Johnson & Johnson USA 14 478 5 4.3
Roche SWI 13 814 18 4.1
Merck & Co USA 13 631 8 4.1
Abbott USA 9570 8 2.9
Lilly USA 8335 13 2.5
Leading 10 149 920 6 44.9
Amgen USA 8188 1 2.5
Wyeth USA 7949 8 2.4
Bayer GER 7020 13 2.1
Bristol-Myers Squibb USA 6519 6 2.0
Boehringer GER 6277 11 1.9
Ingelheim
Schering-Plough USA 6181 10 1.9
Takeda JAP 5479 9 1.6
Teva ISR 5300 12 1.6
Novo Nordisk DEN 3336 18 1.0
Daiichi Sankyo JAP 2925 7 0.9
Leading 20 209 093 7 62.6

* Calculated in US$

** IMS audited markets

Source: Reprinted with permission by the Association of the British Pharmaceutical Industry (ABPI).
Available athttp://www.abpi.org.uk/statistics/section.asp?sect=1.

Table 2.1.2 World trade in pharmaceuticals, 2007

Exports (£) Imports (£) Balance (£)
Switzerland 20 206 9336 10 870
Ireland 9664 1520 8144
Germany 24 395 18 810 5586
UK 14 567 10 291 4276
France 13 675 10 135 3540
Sweden 4726 1731 2995
Netherlands 7439 7276 163
Italy 7607 8466 −859
Spain 4142 5227 −1085
Japan 1736 4625 −2889
USA 17 491 35 801 −18 310
Source: Reprinted with permission by the Association of the British Pharmaceutical Industry (ABPI).
Available at:http://www.abpi.org.uk/statistics/section.asp?sect=1.

As industry ownership has become more concentrated, and so-called ‘Big Pharma’ has pursued the most
profitable products to recover associated costs, concerns have been raised within the public health community
about the neglect of certain diseases and populations deemed to offer insufficient financial returns. For
conditions where there are a relatively small number of sufferers, or the potential market is a population unlikely
to afford available treatment, companies have not invested resources (Trouiller et al. 2002). Another major
concern is the assertion of intellectual property rights (IPRs) by pharmaceutical companies over new drugs.
Patent protection entitles companies to exclusive marketing rights and to charge higher prices in order to recover
R&D investment. Higher prices, however, has meant reduced access to new drugs by the poor. The need to
improve access to essential medicines, such as second line anti-retroviral drugs, to treat major public health
problems led to the Doha Declaration on IPRs and Public Health in 2003. Tensions between trade and public
health policy, however, persist as practical implementation of the declaration’s provisions in low-income countries
remains a major challenge (Kerry & Lee 2007).

The food industry has undergone similar pressures to ‘go large’, with the ascendance of TNCs increasingly
controlling food production from ‘plow to plate’. The history of food production and consumption is closely linked
to the migration of human populations, raising and exchange of food crops, and domestication of animals. The
distinct feature of contemporary globalization is the industrialization of food production and consumption into a
complex of global businesses (excluding subsistence farming). Among the Fortune Global 500 are food retailers
Wal-Mart (2), Carrefour (25), Metro (55), and Tesco (59), and manufacturers Nestlé (53), Unilever (106), and
PepsiCo (175), all of which command sizeable proportions of the world market. As global food brands have
gained ground, local and small-scale producers have become increasingly marginalized in the name of economies
of scale and efficiencies.
The globalization of the food industry raises a wide range of public health issues. The rapid rise in rates of
obesity, as discussed further below, has led to concerns about the global trend towards diets high in fat, salt and
sugar intake (Cassels 2006). In a follow-up to WHO’s Global Strategy on Diet, Physical Activity and Health (WHO
2004), Lang et al. (2006) assessed compliance by 25 of the world’s largest food manufacturers and retailers to
recommendations concerning such factors as ingredients, advertising, portion size, and labelling. The report
found only a small proportion of companies acting to reduce salt, sugar, and fats from their products, four
(Cadbury Schweppes, Danone, Nestlé, and Unilever) had any policies on advertising, two (Kraft and McDonalds)
were acting to reduce portion sizes, and 11 were improving labelling. While the public health community has
pushed for stronger regulation of this hugely powerful industry, governments to date have largely resisted in
favour of voluntary codes.
The tobacco industry offers a further example of the public health implications arising from the global
restructuring of the world economy. As smoking prevalence has steadily declined in high-income countries, the
tobacco industry has turned its efforts to so-called ‘emerging markets’ in Asia, Africa, Eastern Europe, and Latin
America. Consequently, the industry has consolidated through numerous mergers and acquisitions into four
transnational tobacco companies (TTCs) which control around 75 per cent of the world cigarette market: Philip
Morris, British American Tobacco, Japan Tobacco International, and Imperial Tobacco. This excludes the Chinese
National Tobacco Corporation, a state monopoly which supplies 98 per cent of the 300 million smokers in China,
the world’s largest tobacco market. Importantly, globalization has facilitated the tobacco industry’s expansion
into emerging markets through trade liberalization, overseas manufacturing, marketing and advertising, and
economies of scale (Bettcher & Yach 2000; Callard et al. 2001). Consequently, based on current trends, it is
predicted that deaths from tobacco use will rise from 5 million in 2006 to 8.4 million by 2020, with 70 per cent
occurring in the developing world (WHO 2002b).
Finally, the global economy has a dark underbelly of illicit activity with important implications for public health. Of
particular note is the growing problem of smuggled and counterfeit goods. The trade in illegal psychoactive drugs
is a serious worldwide problem, with 200 million people (or 5 per cent of the global population age 15–64)
having used illicit drugs at least once in the last 12 months. In recent decades, the trade has become global in
the number of countries in which (producers and consumers are located), and the transnational network of
criminal organizations involved. In 2003, the retail (street) value of the trade was estimated at US$322 billion
(United Nations Office on Drugs and Crime 2006). The global nature of cigarette smuggling, representing around
20–25 per cent of total consumption, also poses a major problem by supplying the market with cheaper priced
products and thus undermining national tobacco control policies. Counterfeit goods now comprise 5–7 per cent
of world trade. Many counterfeits, notably medicines, food products and cigarettes, are of dubious quality and
content, and can pose direct risks to public health. WHO estimates that counterfeit drugs account for 10 per cent
of all pharmaceuticals, with the number rising to as high as 60 per cent in developing countries. For example, a
survey in Nigeria found 80 per cent of drugs distributed in major pharmacies in Lagos to be counterfeit (WHO
2006a). Counterfeit baby milk powder in rural China caused the deaths of 50 children and acute malnutrition in
hundreds of others (Watts 2004).
As well as the restructuring of economies, globalization has contributed to unprecedented levels of population
mobility in terms of frequency and distance travelled. Population movements are not new—humankind has been
on the move since Homo erectus migrated out of Africa in one million BC. Mass migrations, both voluntary and
forced, have been prompted by the search for food, water, and arable land, and to escape hardship, conflict, and
natural disasters. The migration of Europeans to the Americas from 1492 marked a period of large-scale
movement of populations over the next 500 years. For example, 15 million slaves were transported from Africa
to the Americas during the eighteenth and nineteenth centuries. More than 30 million people moved as
indentured workers after the abolition of slavery in 1850. Around 59 million people migrated from Europe to the
Americas, Australia, New Zealand, and South Africa between 1849 and 1939 in search of economic opportunities
(ILO 2000). Global migration is thus part of an ongoing historical process.
What have characterized population movements since the mid twentieth century are the unprecedented volume,
speed, and geographical reach of travel. All regions of the world have seen increasing numbers of people on the
move. International migration now accounts for approximately 130 million people (2 per cent of the world’s
population) per year. Two million people cross international borders daily, and 500 million people cross borders
on commercial airlines annually. Between 1995 and 2010, an increase of 80 per cent in long haul travel is
predicted (Anon 2007). Total international tourist arrivals reached 842 million in 2006, growing by 20 per cent
since 2002. International refugees receiving UN assistance increased from 1.4 million in 1961 to 9.2 million in
 2004. It is estimated that 900 000 people were trafficked internationally in 2003. For all of these reasons above,
by 2006 up to 200 million people (1 in 33 people) were living outside their country of birth, compared with 75
million in 1965 (UNFPA 2003). Furthermore, internal migration (movement within a single country) has occurred
at an even greater magnitude. In the mid-1980s, one billion people, or about one-sixth of the world’s population,
moved within their own countries (Castles & Miller 2003).
The International Labour Organisation (ILO 2007) reports that, although more people globally are working than
ever before, the number of unemployed remained at an all time high (195.2 million) in 2006. For the relatively
educated, highly skilled, and mobile, globalization has created new employment opportunities. For the poorly
educated and low skilled, globalization has brought employment insecurity. For healthcare, the most direct
impact has been the accelerated migration of health workers. While the migration of health workers from poor
countries, notably sub Saharan Africa, to the industrialized world has received much needed attention, migration
patterns are recognized to be more widespread. The decision to migrate is an individual one, based on personal
circumstances and employment prospects, but broader forces shaped by globalization, affecting work and living
conditions are also at play (Bach 2003). The World Health Report 2006 (WHO 2006c) estimates that there are
59.2 million full-time paid health workers worldwide, and an estimated shortage of almost 4.3 million doctors,
midwives, nurses, and support workers. The shortage is most critical in 57 countries, especially in sub-Saharan
Africa and parts of Southeast Asia. The African region has 24 per cent of the global health burden but only 3 per
cent of health workers commanding less than 1 per cent of the world health expenditure. The so-called ‘brain
drain’, caused by the flow of health workers from low- to high-income countries, has gravely worsened this
problem. On average one in four doctors and 1 in 20 nurses trained in Africa is working in OECD countries.

The implications of globalization for public health

(The Institute of Medicine 1997) defines ‘global health’ as ‘health problems, issues, and concerns that transcend
national boundaries, may be influenced by circumstances or experiences in other countries, and are best
addressed by cooperative actions and solutions’. Public health is concerned with improving the health of whole
populations, rather than the health of individuals (Walley et al. 2001: 19). (The US Health and Human Services
Public Health Service 1995) identifies 10 core activities of public health:
1. 1. Preventing epidemics
2. 2. Protecting the environment, workplace, food, and water
3. 3. Promoting healthy behaviour
4. 4. Monitoring the health status of the population
5. 5. Mobilizing community action
6. 6. Responding to disasters
7. 7. Assuring the quality, accessibility, and accountability of medical care
8. 8. Reaching out to link high-risk and hard-to-reach people to needed services
9. 9. Researching to develop new insights and innovative solutions
10. 10. Leading the development of sound health policy and planning

Global public health, in this sense, concerns how globalization is impacting on each of these core activity areas.
Globalization is not only leading to public health issues transcending national boundaries, but to the need for
collective efforts across countries to help shape more socially just and sustainable forms of globalization. The
remainder of this chapter examines some of these key functions of public health, how globalization may impact
on their practice, and how the public health community might effectively respond to these impacts.

Globalization and the control of infectious disease outbreaks

The prevention, control, and response to, infectious disease outbreaks are a core activity in public health.
Historically, disease-causing microbes have travelled across vast distances for as long as mobile human
populations have come into contact with each other and other animal species. For example, the shift from
hunting-gathering to agrarian societies and the domestication of animals, between 8000 and 3500 BC, led to the
emergence and spread of new zoonotic diseases (Swabe 1999). The so-called ‘Columbian exchange’, following
the arrival of Christopher Columbus in the Americas, is noted by historians for the widespread exchange of
plants, animals, foods, human populations (including slaves), and ideas that followed. Diseases, such as bubonic
plague, cholera, influenza, measles, malaria, smallpox and tuberculosis, were also exchanged, resulting in the
decimation of up to 90 per cent of the indigenous American population (Crosby 1972). Another notable example
is the influenza pandemic of 1918–1919 at the end of the First World War, which killed around 25 million people.
The pandemic similarly demonstrated the capacity of infectious disease to spread across the world amid large-
scale human migration and weakened social structures.

Contemporary globalization, characterized by unprecedented volume, speed, and geographical reach of

population mobility, is leading to growing evidence that infectious disease outbreaks have a greater capacity to
emerge and spread more rapidly and further afield. This is because globalization, in its current forms, potentially
influences a broad range of biological, environmental, and social factors that influence human infections.
First, globalization may alter what populations are at risk of certain infections. The Global Burden of Disease
Study estimates that infectious diseases were responsible for 22 per cent of all deaths and 27 per cent of
disability-adjusted life years worldwide in 2000 (Lopez et al. 2006). Many infections continue to
disproportionately affect the poor within and across countries, and globalization can worsen their vulnerability by,
for example, contributing to rapid urbanization without sufficient attention to basic needs such as water,
sanitation, gainful employment, and healthcare. This lesson was gradually recognized in nineteenth-century
Europe during the Industrial Revolution, which prompted social reforms that eventually led to a decline in
infectious diseases, and vast improvements in health status, during the first half of the twentieth century. Today,
it is no coincidence that infectious diseases still account for a large proportion of death and disability among
those who have been excluded from, and in many cases bear a disproportionate share of the costs associated
with, globalization processes.
At the same time, globalization can ‘democratize’ certain infectious diseases, making all populations vulnerable to
them. While tuberculosis and cholera are diseases historically associated with poverty, because of the role of
poor quality housing and sanitation in their spread, other infections do not discriminate by socioeconomic class.
Some infections, such as measles, diphtheria, and tetanus, can be caught by any population, but vaccination
reduces their reach. Where prevention is not possible, such as pandemic influenza, the consequences for whole
populations, regardless of socioeconomic status, can be devastating. The rapid and extensive reaction to the
outbreak of severe acute respiratory syndrome (SARS) in 2002–2003 was due to the perceived vulnerability of all
populations, rich or poor (Woollacott 2003). Moreover, the rapid spread of SARS from China to around 25
countries within weeks, illustrated how quickly infectious diseases can spread within a globalized world. There
are similar concerns about the potential for avian influenza to cause a human influenza pandemic of
unprecedented proportions amid globalization.
Second, globalization may influence the prevalence (number of people with a disease within a given population)
and incidence (number of new cases of a disease in a specified period of time per total population) of infectious
diseases. (De Vogli and Birbeck 2005) argue that vulnerability to HIV/AIDS, tuberculosis, and malaria is closely
linked to poverty, gender inequality, development policy, and health sector reforms that involve user fees and
reduced access to care.Dorling et al. (2006) similarly argue that ‘global inequality in wealth will have
compounded the effects of AIDS on Africa’, notably caused by globalization-related policies such as structural
adjustment programmes.
Third, globalization may influence the emergence of novel infections or re-emergence of diseases previously in
decline. Environmental degradation, such as the felling of rainforests or dumping of toxic wastes, can increase
contact with new sources of infection or lead to mutation of existing infectious agents (e.g. cholera Bengal).
Perhaps the most worrying potential ‘public health emergency of international concern’ is an influenza pandemic
involving a highly pathogenic strain such as H5N1. Intense animal rearing practices, alongside human
populations, is believed to be contributing to an increased risk of antigenic shift of the influenza virus. The
prospect of an influenza pandemic spreading across continents today has led to unprecedented efforts to prepare
and coordinate across countries and regions (Lee & Fidler 2007). The SARS outbreak provided a worrying
example, not only of the speed and reach of outbreaks, but the weak capacity by public health systems around
the world to cope with a large-scale outbreak of this kind.
A cautionary note should be appended here. To prove that globalization is responsible for the increasing
prevalence of a specific infection would require standardized monitoring of the exposure (the process of
globalization being studied), the outcome (incidence of a particular infectious disease), and other determinants of
disease (e.g. immunity, treatment, socioeconomic factors) over many years. The necessary studies would be
extremely difficult to construct, and highly vulnerable to confounding due to new and unforeseen factors
developing out of the enormous transformations occurring in most aspects of contemporary political, economic
and cultural life. In addition, surveillance systems describing the incidence and prevalence of infectious diseases
over time are very rare, particularly for populations in low-income countries, who are often the most likely to
experience the adverse health effects of global transformations. Even if a causal association were detected, there
would likely be considerable dispute over whether the relevant process, for instance global warming, was in fact
caused by globalization. Thus, the assessment of health risks associated with globalization must accommodate
much unavoidable uncertainty (Saker et al. 2006). This does not mean that no conclusions should be drawn on
the influence of global processes on past, present and future disease patterns. Indeed, poor or absent supportive
evidence of the benefits of globalization has not dissuaded proponents of unregulated economic globalization
from arguing forcefully for its introduction. The need to respond in situations where we do not have full and
incontrovertible evidence for our actions is well expressed by the precautionary principle: ‘Where there are
threats of serious or irreversible damage, lack of full scientific certainty shall not be used for postponing cost-
effective measures’ (UN Conference on the Environment and Development 1992).
The perceived heightening of infectious disease risks from a globalizing world has prompted actions to develop
more effective public health responses. Alongside risks, globalization brings opportunities to improve the capacity
of public health institutions to respond more effectively to infectious disease outbreaks. Foremost is the advent
of new information and communication technologies which, in principle, enable faster, cheaper, and more
efficient gathering and sharing of knowledge. ProMED-mail (see Box 2.1.1) and regional disease surveillance
networks have sprung up to facilitate the collection and reporting of epidemiological data. The lessons learned
from SARS led to renewed efforts to revise the International Health Regulations (IHR), which came into effect in
2007, to harness a broader range of information sources. Another change is the expansion of the scope of the
IHR beyond named diseases, notably plague, yellow fever, and cholera, to the broader term ‘public health
emergencies of international concern’. This may include human or natural disasters. Beyond surveillance,
technological advances are also permitting faster development, such as drugs, vaccines, because of the capacity
for more rapid development and testing, and potential dissemination of new knowledge within the medical
research community (WHO 2005).

Box 2.1.1 Programme for Monitoring Emerging Diseases (ProMED-mail)

The Programme for Monitoring Emerging Diseases (ProMED)—mail was established in 1994,
with the support of the Federation of American Scientists and SatelLife, as an Internet-based
reporting system dedicated to rapid global dissemination of information on outbreaks of
infectious diseases and acute exposures to toxins that affect human health, including those
in animals and in plants grown for food or animal feed. Electronic communications enable
ProMED-mail to provide up-to-date and reliable news about threats to human, animal, and
food plant health around the world, seven days a week.
By providing early warning of outbreaks of emerging and re-emerging diseases, public
health precautions at all levels can be taken in a timely manner to prevent epidemic
transmission and to save lives.
ProMED-mail is open to all sources and free of political constraints. Sources of information
include media reports, official reports, online summaries, local observers, and others.
Reports are often contributed by ProMED-mail subscribers. A team of expert human, plant,
and animal disease moderators screen, review, and investigate reports before posting to the
network. Reports are distributed by email to direct subscribers and posted immediately on
the ProMED-mail Web site. ProMED-mail currently reaches over 30 000 subscribers in at
least 150 countries.
A central purpose of ProMED-mail is to promote communication amongst the international
infectious disease community, including scientists, physicians, epidemiologists, public health
professionals, and others interested in infectious diseases on a global scale. ProMED-mail
encourages subscribers to participate in discussions on infectious disease concerns, to
respond to requests for information, and to collaborate together in outbreak investigations
and prevention efforts. ProMED-mail also welcomes the participation of interested persons
outside of the health and biomedical professions.
Source: International Society for Infectious Diseases. About ProMED-
mail. http://www.promedmail.org/pls/promed/f?p=2400:1950:17654933971171386906 (accesse
d 12 March 2007)
Protecting environmental health in a global context
The discipline of environmental health concerns ‘the theory and practice of assessing, correcting, controlling, and
preventing those factors in the environment that can potentially affect adversely the health of present and future
generations’ (Pencheon et al. 2001: 206–207). Environmental threats to public health range from local, small-
scale factors (e.g. household exposures) to widespread exposures affecting whole populations. Protecting against
a perceived environmental health threat involves identifying the hazard, determining the relationship between
the hazard and the effect (dose-response assessment), exposure assessment, and risk characterization.
The possible impacts of globalization on environmental health are wide-ranging, going beyond global-scale
threats to potentially affecting populations at the regional, community, occupational and household levels.
Impacts from globalization can be direct, such as through the transport and dumping of hazard waste across
borders, relocation of hazardous occupations (such as ship breaking in low-income countries), or damage caused
by acid rain or a nuclear accident. Economic globalization, in which companies compete on a worldwide scale to
increase returns, are raising concerns that there are incentives to undermine environmental health.
Governments, seeking to attract foreign direct investment to fuel economic growth and employment, may
engage in a so-called ‘race to the bottom’ by offering reduced taxation rates, low wages, or weak environmental,
health and safety protections (Brecher & Costello 1994). As stated by the environmental organization, the Sierra
Club (2000), ‘By promoting economic growth without adequate environmental safeguards, trade increases the
overall scale and pace of resource consumption; promotes adoption of high-consumption, high-polluting
lifestyles; and prompts countries to seek international advantage by weakening, not raising, environmental
protections’. China’s rapid integration into the global economy, for example, has come at the cost of severe
environmental degradation:
Scores of rivers have dried up in northern China over the past 20 years. More than 75 per cent of river waters
are not suitable for drinking or fishing. China’s cities are an environmental disaster, since urban infrastructure
has not kept up with the influx of people. Many cities face serious sanitation problems, with sewage and
wastewater going straight into rivers. Large cities, including Beijing, are smothered in smog. Old and weak
people are often warned to stay indoors. Between 2001 and 2020 almost 600 000 people in China are expected
to suffer premature death every year due to urban air pollution.  (Lovgren 2005)
The World Bank (2000) argues that ‘[e]very society has to decide for itself on the relative value it places on
economic output and the environment’. Others argue, however, that there can be substantial inequity in who
bears the environmental costs. In addition, many of the environmental impacts can affect more than one country
and can even be global in scope. More commitment is thus needed to better balance the ‘tradeoffs’ between
economic growth and environmental protection, including a fuller understanding of environmental health risks.
In managing this trade-off, the indirect effects of globalization on environmental health must also be recognized.
A change in investment or lending policy by a global financial institution, such as the IMF, can have health
consequences for local communities. For example, policy conditions set by the World Bank, or requirements to
repay substantial sums of foreign debt, can restrict the public expenditure of borrowing countries on
environmental protection or investment in basic infrastructure, such as water and sanitation. A cholera outbreak
in South Africa in 2000–2001, which led to around 120 000 cases and 265 deaths, has been blamed on the
introduction of user fees following the privatization of water utilities as part of the country’s structural adjustment
programme. As water supplies were cut to poor people unable to pay for the new charges, many resorted to
using polluted river water (Anon 2006). Today, more than 2.6 billion people—over 40 per cent of the world’s
population—do not have access to basic sanitation, and more than one billion people still use unsafe sources of
drinking water (WHO/UNICEF 2006). Predictions of the growing scarcity of fresh water supplies globally, and the
continued trend towards the privatization of water utilities with ownership dominated by large TNCs, is likely to
worsen this situation.
The capacity of the public health community to correct, control, and prevent environmental health risks can be
affected by globalization. For example, globalization poses additional challenges for identifying a hazard. In a
more interconnected world, causal relations can become more extended and complex. The tasks associated with
identifying a hazard must take account of factors that extend far beyond national borders, a greater range of
stakeholders, and jurisdictions that lie beyond the reach of public health authorities. A good example is the
increase in reported outbreaks of foodborne illnesses involving more than one country which has been linked, in
part, to the globalization of the food industry (Kaferstein et al. 1997; Hall 2002). Tracing the source and cause of
such an outbreak can be hindered by inadequate recordkeeping in some countries, lack of timely sharing of
information, inconsistency in labelling, or lack of access to production facilities abroad. The work of
environmental health workers can be made even more difficult by hazards arising from illicit activities such as
dumping, counterfeiting or smuggling across borders (Kimball 2006).
The undertaking of risk assessment, defined as ‘the process of estimating the potential impact of a chemical,
physical, microbiological, or psycho-social hazard on a specified human population or ecological system under a
specific set of conditions and for a certain timeframe’ (Pencheon et al. 2001: 208), is also made more challenging
by globalization. The population of interest may be widely dispersed, because of their mobility or transience, and
identifying and measuring a suspected hazard requires large-scale analysis. Weiland et al. (2004) study 650 000
subjects as part of the International Study of Asthma and Allergies in Childhood. A collaboration with 155
participating centres worldwide, it is the first study ‘to take a global view [of] … the relationship between asthma
and eczema and climate’ (Graham 2004).

Global health promotion

The rapid growth of the health burden from non-communicable diseases (NCDs) worldwide in recent decades,
such as ischemic heart disease, cancer, and diabetes (Beaglehole & Yach 2003; Matthews & Pramming 2003) has
led to growing attention to the need for global approaches to health promotion (Lee 2007). NCDs are the leading
causes of death and disability worldwide. Disease rates from these conditions are accelerating globally,
advancing across every region and pervading all socioeconomic classes. The World Health Report 2002:
Reducing risks, promoting healthy life, indicates that the mortality, morbidity, and disability attributed to the
major chronic diseases currently account for almost 60 per cent of all deaths and 43 per cent of the global
burden of disease. By 2020, their contribution is expected to rise to 73 per cent of all deaths and 60 per cent of
the global burden of disease. Moreover, 79 per cent of the deaths attributed to these diseases occur in the
developing countries. Four of the most prominent chronic diseases—cardiovascular diseases (CVD), cancer,
chronic obstructive pulmonary disease, and type 2 diabetes—are linked by common and preventable biological
risk factors, notably high blood pressure, high blood cholesterol and overweight, and by related major
behavioural risk factors: Unhealthy diet, physical inactivity, and tobacco use. Action to prevent these major
chronic diseases should focus on controlling these and other key risk factors in a well-integrated manner.
Health promotion is the process of enabling people to increase control over, and to improve, their health (WHO
1986). Interventions address three areas of activity in order to prevent disease and promote the health of a
community: Communication, service delivery, and structural (enabling factor) components (Walley et al. 2001:
147). A global approach to health promotion takes into account the ways in which globalization may be
influencing the broad determinants of health, and health behaviours, as well as offering opportunities for
providing appropriate interventions. The adoption of the Bangkok Charter for Health Promotion in a Globalized
World in 2005 was in recognition of the major challenges, actions, and commitments needed to address the
determinants of health in a globalized world by reaching out to people, groups, and organizations that are critical
to the achievement of health. How this might be achieved can be understood in relation to two key issues—
obesity and tobacco control.
The rapid increase in the incidence of overnutrition and obesity, among both adults and children, has attracted
substantial public health concern in recent years (Taubes 1998). According to WHO and the International Obesity
Taskforce (IOTF), around 300 million people worldwide are obese (BMI > 30), with levels continuing to rise
rapidly in the early twenty-first century. At least 155 million school-age children are overweight or obese, with
30–45 million classified as obese. This accounts for 2–3 per cent of the world’s children aged 5–17 years. In the
EU, childhood obesity is described as ‘out of control’:
The number of children affected by overweight and obesity is now rising at more than 400 000 a year and
already affects almost one in four across the entire EU, including accession countries in 2002. The new
prevalence of 24 per cent in 2002 is five points higher than had been expected based on original trends in the
80s and is already higher than the predicted peak for 2010. (IOTF 2004)
Also, the obesity epidemic is not limited to high-income countries. Changes in diet, levels of physical activity, and
nutrition (known as the ‘nutrition transition’) have led to sharp increases in rates of obesity in such wide ranging
countries as India, Thailand, Brazil, and China. As (Drewnoski and Popkin 1997: 32) write:
Whereas high-fat diets and Western eating habits were once restricted to the rich industrialized nations … the
nutrition transition now occurs in nations with much lower levels of gross national product (GNP) than
previously…. First, fat consumption is less dependent on GNP than ever before. Second, rapid urbanization has a
major influence in accelerating the nutrition transition.
Similarly, Prentice (2006) links the trend to globalization of food production and lifestyles:
The pandemic is transmitted through the vectors of subsidized agriculture and multinational companies providing
cheap, highly refined fats, oils, and carbohydrates, labour-saving mechanized devices, affordable motorized
transport, and the seductions of sedentary pastimes such as television. This trend has been linked to the
globalisation of sedentary lifestyles alongside changes in food production and consumption.
Many interventions to address the obesity epidemic have focused on the modification of individual behaviours,
such as healthy eating initiatives and the promotion of physical activity. Global health promotion, however, must
also seek to tackle the structural factors that constrain or enable lifestyle choices. This includes what and how
food is produced and marketed by an increasingly globalized food industry. For example, the Institute of
Medicine (2005) report, Food Marketing to Children and Youth: Threat or Opportunity? recognizes that dietary
patterns begin in childhood and are shaped by an interplay of many factors—genetics and biology, culture and
values, economics, physical and social environments, and commercial media environments. Importantly, the
report provides the most comprehensive review to date of the scientific evidence on the influence of food
marketing on diets and diet-related health of children and youth. It argues that environments supportive of good
health require leadership and action from the food, beverage, and restaurant industries; food retailers and trade
associations; the entertainment industry and the media; parents and caregivers; schools; and the government.
Global-level regulation of food-related industries, however, remains problematic. The process of adopting the
WHO Global Strategy on Diet, Physical Activity and Health was fraught with efforts by the food industry to avoid
the setting of explicit recommendations on healthy levels of salt, sugar, and fats intake, amid calls for binding
regulation of marketing, labelling and other industry activities by public health advocates (Lang et al. 2006). In
the US, the politically powerful food industry has instead succeeded in promoting self-regulation. As Kelly
(2005) writes:
The global hegemony of the United States in the production and marketing of food, while a marvel of economic
success, has contributed to the epidemic of obesity that is particularly afflicting children. So far the U.S.
government has declined to regulate the aggressive ways in which food producers market high-energy, low-
nutrition foods to young people. That public-health responsibility has been left to an industry-created scheme of
self-regulation that is deeply flawed; there is a compelling need for government involvement.
Lessons for global health promotion can also be drawn from efforts to strengthen tobacco control worldwide. As
described above, the globalization of the tobacco industry has led to a rise in tobacco consumption, facilitated by
the industry’s consolidation, greater economies of scale, and aggressive marketing strategies to gain entry to
emerging markets (Bettcher & Yach 2000). WHO initiated negotiations for a Framework Convention on Tobacco
Control (FCTC) in the mid 1990s in recognition of the need to globalize tobacco control policies (Reid 2005).
Referring to the impact of globalization on the tobacco pandemic, then WHO Director-General Gro Harlem
Brundtland stated:
[O]ver the past fifteen years, we have seen that modern technology, has limited the effectiveness of national
action. Tobacco advertising is beamed into every country via satellite and cable. Developing countries are the
subject of massive marketing campaigns by international tobacco companies. In the slipstream of increasing
global trade, new markets are opened to international tobacco companies which see these emerging markets as
their main opportunity to compensate for stagnant or dwindling markets in many industrialized
countries. (Brundtland 2000)
As the first multilaterally negotiated public health treaty, the FCTC negotiation process encompassed regional
consultations, public hearings, contributions by civil society organizations, and old-fashioned diplomacy among
WHO’s 192 member states. The process also faced extensive efforts by the powerful tobacco industry to
undermine negotiations through seeking representation on some national delegations, lobbying of tobacco
producing countries and farmers, orchestrated criticism of WHO for neglecting other public health priorities, and
even challenges to long established science on tobacco and health (Lynn & Lerner 2002; Waxman
2002; Hammond & Assunta 2003).
Despite persistent industry opposition, public health advocates prevailed in successfully adopting a
comprehensive treaty which sets out measures to address both the supply of and demand for tobacco. As of
October 2008, 168 countries have signed, and 160 countries have fully ratified the treaty. Importantly, the FCTC
represents a collective effort across WHO member states to address a clear global public health challenge. The
involvement of a broad spectrum of stakeholders, notably civil society organizations, was critical to raising public
awareness and support at the regional, national and local levels. The mobilization of public health advocates, led
by the Framework Convention Alliance, was greatly facilitated by the use of the Internet (focused on
the Globalink network) which allowed groups to keep abreast of negotiations, organize advocacy activities, and
share experiences to an unprecedented degree (Collin et al. 2004). While weaker on some aspects of
globalization, such as international trade, than initially hoped, the treaty will accommodate other transborder
issues such as smuggling and marketing (e.g. sports sponsorship, satellite broadcasting) through the negotiation
of additional protocols.
Initiating high-profile policies, such as the Global Strategy on Diet, Physical Activity and Health and the FCTC,
can raise the profile of health promotion and be effective vehicles for addressing the global aspects of the
challenges faced. The experiences of established campaigns, such as the WHO/UNICEF International Code on
the Marketing of Breastmilk Substitutes and Health Cities Initiative, and more recently initiatives such as the
Public–Private Partnership for Handwashing, shows that adoption of agreements is a starting point.
Implementation requires longer term mobilization of political will, resources and technical capacity to translate
commitments into effective action. In the context of globalization, trade flows, information and communication
technologies, and marketing strategies are beginning to be harnessed for health promotion purposes. For
example, the tobacco control community has developed countermarketing campaigns to challenge the use of
advertising imagery associating cigarette smoking with glamour and excitement in emerging markets (Box2.1.2).
Worldwide consumer boycotts of TNCs, such as Nestlé and McDonalds, have been organized to pressure
companies to change their marketing practices or unhealthy product ranges (Yach & Beaglehole 2003).

Box 2.1.2
 In summary, the global spread of unhealthy lifestyles and behaviours pose new challenges for health promotion.
In many cases, powerful vested interests within key sectors of the global economy have facilitated this process
through foreign investment, production, trade and marketing practices. There is accumulating evidence that
these practices are resulting in a sharp increase in NCDs. The public health community faces major challenges in
influencing these practices, as well as opportunities to harness aspects of globalization to promote healthier
lifestyles and behaviours. Collective efforts across countries to appropriately regulate harmful aspects of the
global economy is clearly needed.

Monitoring the health status of the population

Assessing the health of a given population is the starting point for a wide range of public health activities such as
policy reviews, programme development, goal setting and resource allocation. There are well recognized steps
for assessing population health status:
 ♦ Define the purpose of the assessment
 ♦ Define the population concerned and any comparator population
 ♦ Define the aspects of health to be considered
 ♦ Identify and review existing data sources
 ♦ Select the most appropriate existing data (Gentle 2001)
In assessing the linkages between globalization and population health status, two challenges are presented.
First, there is variable capacity across countries to collect and manage basic health data. Data remains of poor
quality or limited in availability in many low- and middle-income countries. According to WHO (2006b):
A country health information system comprises the multiple sub-systems and data sources that together
contribute to generating health information, including vital registration, censuses and surveys, disease
surveillance and response, service statistics and health management information, financial data, and resource
tracking. The absence of consensus on the relative strengths, usefulness, feasibility, and cost-efficiency of
different data collection approaches has resulted in a plethora of separate and often overlapping systems. Too
often, inappropriate use is made of particular data collection methods, for example, the use of household surveys
to produce information on adult mortality.

The WHO Health Metrics Network (HMN) is a global partnership working to strengthen and align health
information systems around the world. The partnership is comprised of countries, multilateral and bilateral
development agencies, foundations, global health initiatives, and technical experts that aim to increase the
availability and use of timely, reliable health information by catalysing the funding and development of core
health information systems in developing countries. As described by WHO:
HMN partners agree to align around a common framework that sets the standards for health information
systems. The HMN framework will serve to define the systems needed at country and global levels, along with
the standards, capacities and processes for generating, analysing, disseminating, and using health information. It
links the normative framework for measurement in health with participatory assessment, planning, and
implementation modalities that are objective, transparent, and include all stakeholders. Thus, it focuses the
inputs of donors and technical agencies around a country-owned plan for health information development,
thereby reducing the overlap and duplication. At both the country and global level, the HMN framework will
enable access to and use of health information, thereby serving the needs of individual countries while also
generating global public goods.
In seeking to improve health information systems, a second challenge is the limitations of existing data sources
in capturing health needs that cut across the national level (i.e. transnational). For each country, health data is
collected and managed by a department of health and associated institutions. The WHO Statistical Information
System (WHOSIS), in turn, collects and coordinates data on core health indicators, mortality and health status,
disease statistics, health system statistics, risk factors and health service coverage, and inequities in health from
its 192 member states. This is compiled in the World Health Statistics. By definition, globalization is eroding, and
even transcending, national borders so that health and disease patterns may be emerging that do not conform to
such delineations. As a result, national level data may need to be aggregated and disaggregated in novel ways to
reveal these new patterns.

A good example is the above discussed increase in obesity rates. Improving data on trends in different countries
reveal a complex picture. In high-income countries, obesity is rising rapidly across all social classes but is
particularly associated with social deprivation. In the UK, for example:
Obesity is linked to social class, being more common among those in the routine or semi-routine occupational
groups than the managerial and professional groups. The link is stronger among women. In 2001, 30 per cent of
women in routine occupations were classified as obese compared with 16 per cent in higher managerial and
professional occupations. (UK Office of National Statistics Office)
In France, Romon et al. (2005) found that genetic predisposition influences the prevalence of obesity and
changes in body mass index (BMI) among children from the higher social class. For children within the lowest
social class, which has seen an increase in BMI across the whole population, environmental factors appear to
have played a more important role. In contrast, in low- and middle-income countries, the total number of obese
or overweight people is projected to grow by 50 per cent by 2015 alongside the persistence of undernutrition
(Table 2.1.3). Social class is one factor. In such diverse countries as Kenya, China, India, and Brazil, obesity
among an increasingly affluent middle class has been observed (McLellan 2002). A high BMI may even be
considered socially desirable as a sign of affluence. At the same time, some populations within the lower social
classes are also experiencing rising rates of overweight and obesity. For example, Monteiro et al. (2004) find that
a country’s level of wealth is an important factor, with obesity starting to fuel health inequities in the developing
world when the GNP reaches a value of about US$2500 per capita. Trends in over/undernutrition, in other words,
are complex and changing over time, and require sufficiently detailed and comparable data across population
groups defined along additional variables (e.g. gender, socioeconomic status, occupation).

Table 2.1.3 Per cent of population that is overweight, selected countries, 2002
and 2010 (Projected)
Note: ‘Overweight’ is defined as having a body mass index (weight in kilograms divided by height in metres
squared) of between 25 and 30. ‘Obese’ is defined as having a body mass index of 30 or more.
Source: Reprinted with permission from the Population Reference Bureau.

The need to improve available data on the health of populations affected by globalization is illustrated by a wide
range of other examples. The outsourcing of manufacturing to the developing world by TNCs, for example, has
led to the employment of hundreds of thousands of workers. What public health needs to these workers have
and are they addressed by local occupational health policies? Similarly, the greater movement of people across
national borders may require increased attention to the health needs of different types of migrants. Alternatively,
what public health issues arise for populations from global environmental change? All of these examples suggest
the need to redefine new population groups within a global context, and to develop data sources that measure
population health patterns which do not conform to national borders.

The governance of global public health

Governance broadly concerns the agreed actions and means adopted by a society to promote collective action
and solutions in pursuit of common goals. Governance takes place whenever people seek to organize themselves
to achieve a shared end through agreed rules, procedures, and institutions. This can take place at different levels
of decision-making and action. In public health, if a local community decides to initiate a campaign to slow traffic
speed and improve road safety, this requires some form of governance to organize the effort. If a global
campaign is initiated to strengthen tuberculosis control, an agreed form of governance is needed to take
decisions, for example, on agreed treatment, resource mobilization, and implementation of agreed actions across
countries. To what extent is there need for more effective governance to protect and promote global public
health? What rules, procedures, and institutions do we need to improve the protection and promotion of public
health within an increasingly globalized context.
The existing institutional architecture for global health development and cooperation traces its historical roots to
the International Sanitary Conferences of the nineteenth century. This series of meetings, largely dominated by
European countries, focused on protecting trading interests from certain epidemic diseases such as cholera and
plague. The institutions eventually created, such as the Office International d’Hygiène Publique, were primarily
concerned with collecting and disseminating epidemiological data on these diseases (Fidler 2001). The creation
of the WHO as a specialized agency of the United Nations in 1948 was intended to universalize the membership,
and broaden the scope of, international health cooperation. Its objective, ‘the attainment by all peoples of the
highest possible level of health’, was reflected in the vast array of programmes initiated under WHO’s auspices.
Recent decades have seen challenges to WHO’s designated role as ‘the directing and co-ordinating authority on
international health work’ [WHO Constitution, Article 2(a)]. In part, this has arisen from differences in
perspective on whether WHO should be biomedically (disease) focused, or whether the organization should
address the broad determinants of ‘health for all’. These debates have been accompanied by rapid changes in
WHO’s operating environment, with the ascendance of new institutional players and ideological perspectives.
From the 1980s, the World Bank became a major influence as the biggest source of financing for health
development (Buse 1994), while other UN bodies such as the UN Children’s Fund and UN Development
Programme (UNDP) expanded their health portfolios. The 1990s saw the creation of numerous global public-
private partnerships for health which attracted additional resources, but rendered the policy environment far
more complex and crowded (Buse & Walt 2000). In recent years, charitable foundations led by the Gates
Foundation, have also become major players in the funding of health projects in the developing world (Birn
2005). This influx of institutions and resources has, on the one hand, reflected the higher priority to health
development given by governments, corporations and civil society organizations. On the other hand, there is
substantial evidence of overlapping mandates, duplication of effort, and, above all, a lack of collective strategic
thinking about how to effectively tackle the public health challenges posed by globalization.
The governance of global public health can thus be presently seen as undergoing a period of transition. In
principle, the formal institutions governing public health remain focused on governments. Public health authority
lies within the ministries of health of each WHO member state, and collaboration across countries and regions
takes place on a wide range of functions through governmental bodies. However, as described in this chapter,
intensified flows of people, other life forms, goods and services, capital, and knowledge are influencing the
determinants of health and health outcomes in diverse ways. Effective regulation of these flows can require
collective action across governments and, in some cases, the participation of institutions beyond government.
Many scholars of global governance point to the need for new institutional arrangements, a kind of political
globalization, to enable more effective action. AsHomedes and Ugalde (2003) write, ‘If international health
problems are to be solved, political, cultural, and social interdependence need to be built with the same impetus
by which policymakers promote international trade’. Examples described in this chapter—such as tobacco control,
food and nutrition, and infectious disease outbreaks—demonstrate the need for innovation.
What can the public health community do to foster such innovation? Globalization is now an established subject
of discussion and debate at public health meetings around the world, and there has been no shortage of
commitments to address its impacts. The Final Communiqué of the 13th Commonwealth Health Ministers
Meeting (2001) included attention to the ‘Impact of Globalisation on Health’ as follows:
In discussing globalisation, Ministers identified poverty as the main obstacle to development. Poverty prevents
countries from exploiting the potential benefits of globalisation, which has the effect of widening the gap
between rich and poor countries. Ministers urged the Commonwealth to develop structured responses to
globalisation that would promote positive impact on health. These responses should acknowledge the
inextricable links between health and the wider socio-economic development agenda. They should take account
of moral and ethical considerations relating to equity in resource distribution.
Ministers expressed strong views about the imposition of conditions linked to development assistance, such as
the removal of public subsidies. This militates against the development efforts of poorer countries, and is unfair if
not applied in the same way to the more developed countries. Ministers urged the Commonwealth to work for
fairness in financing and ensure that the rules apply to developing and developed countries alike.
In 2001, the World Federation of Public Health Associations issued a Call to Action which commits itself to work
with WHO ‘to clarify areas of emerging public health risk associated with globalization, ranging from infectious
and occupational diseases to diseases which are a product of the growing world-scale of anti-health forces’
(World Federation of Public Health Associations 2001). The Mumbai Declaration of the People’s Health
Movement, agreed in 2004, calls for an end to ‘corporate-led globalization’ (People’s Health Movement 2004).
The Sixth Global Conference on Health Promotion in 2005 issued the Bangkok Charter which identifies actions,
commitments and pledges required to address the determinants of health in a globalized world through health
promotion.
Given widespread recognition of the need to address the impacts of globalization within the public health
community, the essential next step is to seek influence within those policy communities which drive
contemporary globalization. Public health representation within ongoing trade negotiations, for example, is
critical. WHO and other public health institutions have so far remained marginal observers in the WTO and other
key decision-making forums. The controversy surrounding intellectual property rights and access to medicines,
the substantial concern by consumers about the social and environmental harms of globalization, and the
potential costs to the global economy of a major infectious disease pandemic demonstrate the scope for greater
collaboration across sectors. Lee et al. (2007) describe the potential role of health impact assessment for
informing non-health-policy proposals. The global public goods for health approach addresses the growing
globalization of health from an economic perspective. The concept identifies where a good or service (such as
knowledge of an infectious disease outbreak), which would be of benefit globally, will not be produced or
disseminated if left to the market because no one can be excluded from accessing the good, and thus no charge
can be levied for its use and no costs recouped. At the national level, the production of these goods is usually
ensured by government intervention, but at the global level there remains no ‘global government’ to undertake
this role. Certain functions of public health may be classed as global public goods (e.g. immunization
programmes, disease surveillance), which require collective action to overcome market failures (Smith et al.
2003). The concept might thus be an appealing rationale to non health policy makers shaping global change.

Conclusion

This chapter has described key ways in which globalization is relevant to the theory and practice of public health.
There are both threats and opportunities arising from the complex and diverse changes created by globalization,
although current forms of globalization is clearly characterized by an inequitable distribution of winners and
losers. For the public health community, there is a need to understand and contribute to more effective
management of the rapid changes taking place. Greater attention to these public health impacts will, in turn,
contribute to more socially and environmentally sustainable forms of globalization.

References

1. Anon (2005). Global Brand Scorecard, The 100 Top Brands. BusinessWeek, 1 August.
2. Anon (2006). Report: Water problems remain in rural areas. Guardian and Mail, 12 July.
3. Anon (2007). World tourism marks another record year with 842 million arrivals, UN agency reports. UN
News Service, 30 January.http://www.un.org/apps/news/story.asp?
NewsID=21383&Cr=tourism&Cr1=# (accessed 26 March 2007).
4. Bach, S. (2003). International migration of health workers: labour and social issues. Working Paper, Sectoral
Activities Programme, ILO, Geneva.http://www.ilo.org/public/english/dialogue/sector/papers/health/
wp209.pdf (accessed 26 March 2007).
5. Barber, B. (2003). Jihad vs McWorld. In The Globalization Reader (eds. H. Lechner and J. Boli), pp. 21–26.
Blackwell Publishing, London.
6. Beaglehole, R., and Yach, D. (2003). Globalisation and the prevention and control of non-communicable
disease: the neglected chronic diseases of adults. Lancet, 362, 903–6.[CrossRef] [Web of Science] [Medline] 
7. Benatar, S., Daar, A.S., and Singer, P.A. (2003). Global health ethics: the rationale for mutual
caring. International Affairs, 79(1), 107–38.
8. Bettcher, D.W., and Yach, D. (2000). Globalisation of tobacco industry influence and new global
responses. Tobacco Control, 9(2), 206–16.
9. Birn, A.E. (2005). Gates’s grandest challenge: transcending technology as public health
ideology. Lancet, 366(9484), 514–9.[CrossRef] [Web of Science] [Medline] 
10. Brecher and Costello (1994), Global Village or Global Pillage, Economic Reconstruction from the Bottom Up ,
South End Press, Cambridge, MA.
11. Brundtland, G.H. (2000). Opening Statement. First Meeting of Intergovernmental Negotiating Body,
Framework Convention on Tobacco Control, Geneva, 16
 October. http://www.who.int/director-general/speeches/2000/english/20001016_tobacco_control.html (acces
sed 27 March 2007).
12. Buse, K. (1994). Spotlight on international organizations: The World Bank. Health Policy and Planning, 9, 95–
9.
13. Buse, K., and Walt, G. (2000). Global public-private partnerships: Part I – a new development in
health? Bulletin of the World Health Organisation, 78(4), 549–61.
14. Busfield, J. (2005). The globalization of the pharmaceutical industry. In Global change and health (eds. K.
Lee and J. Collin), pp. 94–110. Open University Press, Maidenhead.
15. Callard, C., Chitanondh, H., and Weissman, R. (2001). Why trade and investment liberalisation may threaten
effective tobacco control efforts. Tobacco Control,10, 68–70.[Abstract/Full Text]
16. Castles, S., and Miller, M. (2003). The Age of Migration, International Population Movements in the Modern
World, 3rd edition. Macmillan, London.
17. Collin, J., Lee, K., and Bissell, K. (2004). Negotiating the Framework Convention on Tobacco Control: The
politics of global health governance. In The Global Governance Reader (eds. R. Wilkinson and C. Murphy),
pp. 254–73, Routledge, London.
18. Commonwealth Health Ministers Meeting (2001). 13th Commonwealth Health Ministers Meeting Final
Communiqué, 25–29 November, Christchurch, New
Zealand. http://www.thecommonwealth.org/document/34293/35232/35242/13th_commonwealth_health_mi
nisters_meeting_final_c.htm (accessed 20 June 2007).
19. Cornea, G.A. (2001). Globalization and Health: results and options. Bulletin of the World Health
Organization, 79(9), 834–41.
20. Crosby, A. (1972). The Columbian Exchange: Biological & Cultural Consequences of 1492 . Greenwood Press,
Connecticut.
21. De Vogli, R., and Birbeck, G.L. (2005). Potential Impact of Adjustment Policies on Vulnerability of Women and
Children to HIV/AIDS in Sub-Saharan Africa.Journal of Health Population and Nutrition, 23, 105–20. [Web of
Science] [Medline] 
22. Dicken, P. (1999). Global Shift, Transforming the World Economy. Paul Chapman Publishing, London.
23. diMasi, J.A., Hansen, R.W., and Grabowski, H.G. (2002). The price of innovation: new estimates of drug
development costs. Journal of Health Economics, 22, 151–85.[CrossRef] [Web of Science]
24. Dollar, D., and Kraay, A. (2000). Growth is good for the poor. Research Paper, World Bank, Washington DC.
25. Dorling, D., Shaw, M., and Davey Smith, G. (2006). Global inequality of life expectancy due to
AIDS. BMJ, 332, 662–4.[Abstract/Full Text]
26. Drewnoski, A., and Popkin, B. (1997). The Nutrition Transition: New Trends in the Global Diet. Nutrition
Reviews, 55(2), 31–43. [Web of Science] [Medline] 
27. Falk, R. (1999). Predatory globalization, a critique. Polity Press, London.
28. Feachem, R. (2001). Globalisation is good for your health, mostly. BMJ, 323, 504–6.[Abstract/Full Text]
29. Fidler, D. (2001). The globalization of public health: the first 100 years of international health
diplomacy. Bulletin of the World Health Organization, 79(9), 842–9.
30. Forbes (2000). The world’s biggest public
companies. http://www.forbes.com/lists/2006/18/Rank_1.html (accessed 20 June 2007).
31. Gentle, P. (2001). Assessing health status. In Oxford handbook of public health practice (eds. D. Pencheon,
C. Guest, D. Melzer and J.A. Muir Gray). Oxford University Press, Oxford.
32. Graham, S. (2004). Global Study Links Climate to Rates of Childhood Asthma. Scientific American, 21
June. http://scientificamerican.com/article.cfm?chanID=sa003&articleID=000624A7-66A2-10D3-
A6A283414B7F0000 (accessed 27 March 2007).
33. Hall, G., D’Souza, R.M., and Kirk, M. (2002). Foodborne disease in the new millennium: out of the frying pan
into the fire? MJA, 177(1112), 614–8. [Medline] 
34. Hammond, R., and Assunta, M. (2003). The Framework Convention on Tobacco Control: promising start,
uncertain future. Tobacco Control, 12(3), 241–2.[Abstract/Full Text]
35. Held, D., McGrew, A., Goldblatt, D., and Perraton, J. (1999). Global transformations. Stanford University
Press, Stanford.
36. Homedes, N., and Ugalde, A. (2003). Globalization and Health at the United States-Mexico Border. American
Journal of Public Health, 93(12), 2016–22.[CrossRef] [Web of Science] [Medline] 
37. Hundley, R.O., Anderson, R.H., Bikson, T.K., and Neu, C.R. (2003). The Global Course of the Information
Revolution, Recurring Themes and Regional Variations. RAND National Defense Research Institute,
Washington DC.
38. Huntington, S. (2002), The Clash of Civilizations and the Remaking of World Order, 2nd edition . Free Press,
New York.
39. ILO (2007). Global Employment Trends Brief 2007. International Labour Organisation,
Geneva.http://www.ilo.org/public/english/employment/strat/download/getb07en.pdf (accessed 20 June
2007).
40. ILO (2000), Workers without Frontiers - The Impact of Globalization on International Migration . International
Labour Organization, Geneva.
41. IMF (2005). The IMF and the Fight against Money Laundering and the Financing Of Terrorism. Fact Sheet,
September, Washington DC.http://www.imf.org/external/x10/changecss/changestyle.aspx (accessed 13
March 2007).
42. Institute of Medicine (1997). America’s Vital Interest in Global Health. National Academy Press, Washington
DC.
43. Institute of Medicine (2005). Food Marketing to Children and Youth: Threat or Opportunity? National
Academy Press, Washington DC.
44. IOTF (2004). EU childhood obesity ‘out of control’. Press Release, International Obesity Taskforce,
Geneva. http://www.iotf.org/popout.asp?linkto=http://www.iotf.org/media/IOTFmay28.pdf (accessed 28
March 2007).
45. Kaferstein, F.K., Motarjemi, Y., and Bettcher, D.W. (1997). Foodborne disease control: A transnational
challenge. Emerging Infectious Diseases , 3(4), 503–10.
46. Kawachi, I., and Wamala, S. (eds.) (2006). Globalization and Health. Oxford University Press, Oxford.
47. Kelly, D. (2005). To quell obesity, who should regulate food marketing to children? Globalization and
Health, 1(9).http://www.globalizationandhealth.com/content/1/1/9
48. Kerry, V.B., and Lee, K. (2007). TRIPS, the Doha declaration and paragraph 6 decision: what are the
remaining steps for protecting access to medicines? Globalization and Health, 3(3), 1–12.[CrossRef]
49. Kim, J.Y., Irwin, A., Millen, J., and Gershman, J. (2000). Dying for Growth: Global inequality and the health of
the poor. Common Courage Press, Monroe ME.
50. Korten. D. (1995) When Corporations Ruled the World. Kumerian Press and Berrett-Koehler, Bloomfield,
Connecticut.
51. Kimball, A.M. (2006), Risky Trade Infectious Disease in the Era of Global Trade. Ashgate, London.
52. Labonte, R., Schrecker, T., and Sen Gupta, A. (2005). Health for some: death, disease and disparity in a
globalizing world. Centre for Social Justice, Toronto.
53. Lang, T., Rayner, G., and Kaelin, E. (2006). The Food Industry, Diet, Physical Activity and Health: a Review
of Reported Commitments and Practice of 25 of the World’s Largest Food Companies . Centre for Food Policy,
City University, London.http://www.city.ac.uk/news/press/The%20Food%20Industry%20Diet%20Physical
%20Activity%20and%20Health.pdf (accessed 13 June 2007).
54. Lee, K. (2003a). Globalization and health, an introduction. Palgrave Macmillan, London.
55. Lee K. ed. (2003b). Health impacts of globalization, towards global governance . Palgrave Macmillan, London.
56. Lee, K. (2007). Global health promotion: How can we strengthen governance and build effective
strategies? Health Promotion International , 21(1), 42–50.
57. Lee, K., and Collin, J. (eds.) (2005). Global change and health. Open University Press, Maidenhead.
58. Lee, K., and Fidler, D. (2007). Avian and pandemic influenza: Progress and problems for global
governance. Global Public Health, 2(3), 215–34.
59. Lee, K., Ingram, A., Lock, K., and McInnes, C. (2007). Bridging health and foreign policy: The role of health
impact assessment? Bulletin of the World Health Organization, 85(3), 207–11.[CrossRef] [Web of
Science] [Medline] 
60. Lopez, A., Mathers, C.D., Ezzati, M., Jamison, D.T., and Murray, C.J.L. (2006). Global burden of disease and
risk factors. World Bank Publications, Washington DC.
61. Lovgren, G. (2005). China’s Boom is Bust for Global Environment, Study Warns. National Geographic, 16
May.http://news.nationalgeographic.com/news/2005/05/0516_050516_chinaeco.html (accessed 23 March
2007).
62. Lynn, P., and Lerner, D. (2002). NGOs release new hard-hitting evidence of global tobacco industry tactics to
subvert public policy. Press Release, 20 March, Corporate Accountability International,
Boston. http://www.stopcorporateabuse.org/cms/page1294.cfm (accessed 15 June 2007).
63. Matthews, D., and Pramming, S. (2003). Diabetes and the global burden of non-communicable
disease. Lancet, 362(9397), 1763–4. [Web of Science] [Medline] 
64. McKinsey Global Institute (2007). Mapping the global capital markets, third annual report . McKinsey &
Company, San Francisco.
65. McLellan, F. (2002). Obesity rising to alarming levels around the world. Lancet, 359(315), 1412.
[CrossRef] [Web of Science] [Medline] 
66. Mittelman, J.H. (2002). Making globalization work for the have nots. International Journal on World
Peace, 19(2), 3–25.
67. Monteiro, C.A., Conde, W.L., Lu, B., and Popkin, B.M. (2004). Obesity and inequities in health in the
developing world. International Journal of Obesity, 28(9), 1181–6.[CrossRef] [Web of Science] [Medline] 
68. OECD (2005). Measuring Globalisation, OECD Economic globalisation indicators . Organisation for Economic
Cooperation and Development, Paris.
69. Pencheon, D., Guest, C., Melzer, D., Muir Gray, J.A. (2001). Oxford handbook of public health practice.
Oxford University Press, Oxford.
70. People’s Health Movement (2004). The Mumbai Declaration from the 3rd International Forum for the Defence
of People’s Health. 14–15 January, Mumbai, India. http://www.phmovement.org/files/md-
english.pdf (accessed 15 June 2007).
71. Prentice, A. (2006). The emerging epidemic of obesity in developing countries. International Journal of
Epidemiology, 35(1), 93–9.[Abstract/Full Text]
72. Reid, R. (2005). Globalizing Tobacco Control, Anti-smoking campaigns in California, France, and Japan .
Indiana University Press, Bloomington.
73. Romon, M., Duhamel, A., Collinet, N., and Weill, J. (2005). Influence of social class on time trends in BMI
distribution in 5-year-old French children from 1989 to 1999. International Journal of Obesity, 29, 54–59.
[CrossRef] [Web of Science] [Medline] 
74. Saker, L., Lee, K., and Cannito, B. (2006). Globalization and infectious disease. In Globalization and
Health (eds. I. Kawachi, I., and S. Wamala), pp. 19–38, Oxford University Press, Oxford.
75. Sierra Club (2000). Comments to the Trade Policy Staff Committee, United States Trade Representative , 20
May, Washington DC.http://www.sierraclub.org/trade/summit/testimony2.asp (accessed 20 June 2007).
76. Smith, R., Beaglehole, R., Woodward, D., and Drager, N. (eds.) (2005). Global public goods for health,
Health economic and public health perspectives. Oxford University Press, Oxford.
77. Swabe, J. (1999). Animals, disease, and human society: human-animal relations and the rise of veterinary
medicine. Routledge, London.
78. Swan, W. (2007). Misunderstandings about airline growth. Journal of Air Transport Management, 13(1), 3–8.
79. Tarabusi, C., and Vickery, G. (1998). Globalization in the pharmaceutical industry. International Journal of
Health Services, 28(1), 67–105. [Web of Science] [Medline] 
80. Taubes, G. (1998). As obesity rates rise, experts struggle to explain why. Science, 280(5368), 1367–8.
[Abstract/Full Text]
81. Teitel, S. (2005). Globalization and its disconnects. Journal of Socio-Economics, 34(4), 444–70.
82. Trouiller, P., Olliaro, P., Torreele, E., Orbinski, J., Laing, R., and Ford, N. (2002). Drug development for
neglected diseases: a deficient market and a public-health policy failure. Lancet, 359(9324): 2188–94.
[CrossRef] [Web of Science] [Medline] 
83. UK Office for National Statistics (2001). Obesity among adults: by sex and NS-SeC, 2001: Social Trends 34.
London.http://www.statistics.gov.uk/STATBASE/Product.asp?vlnk=11130&More=Y (accessed 15 June 2007).
84. UN Conference on the Environment and Development (1992). Rio Declaration on Environment and
Development. Rio de Janiero, Brazil.http://www.un.org/documents/ga/conf151/aconf15126-
1annex1.htm (accessed 20 June 2007).
85. UN Office on Drugs and Crime (2006). 2006 World Drug Report. New
York. http://www.unodc.org/pdf/WDR_2006/wdr2006_volume2.pdf (accessed 13 June 2007).
86. US Health and Human Services Public Health Service (1995). For a healthy nation: returns on investment in
public health. US Government Printing Office, Washington DC.
87. Valdez, S. (2006). An introduction to global financial markets . Palgrave Macmillan, London.
88. Walley, J., Wright, J., and Hubley, J. (2001). Public Health, an action guide to improving health in developing
countries. Oxford University Press, Oxford.
89. Watts, J. (2004). Chinese baby milk blamed for 50 deaths. The Guardian, 21
April. http://www.guardian.co.uk/china/story/0,7369,1196996,00.html (accessed 13 June 2007).
90. Waxman, H. (2002). The Future of the Global Tobacco Treaty Negotiations. New England Journal of
Medicine, 346(12), 21 March, 936–9.[CrossRef] [Medline] 
91. Weiland, S.K., Hüsing, A., Strachan, Rzehak, P., Pearce, N., and the ISAAC Phase One Study Group (2004).
Climate and the prevalence of symptoms of asthma, allergic rhinitis and atopic eczema in
children. Occupational and Environmental Medicine, 61(7), 609–15.[Abstract/Full Text]
92. Wilkinson, R. (2006). The WTO, Crisis and the governance of global trade. Routledge, London.
93. World Bank (2000). Is Globalization Causing A ‘Race To The Bottom’ In Environmental Standards? Briefing
Papers, April, PREM Economic Policy Group and Development Economics Group, Washington
DC. http://www1.worldbank.org/economicpolicy/globalization/documents/
AssessingGlobalizationP4.pdf(accessed 27 March 2007).
94. World Federation of Public Health Associations (2001). Public Health and Globalization. Proposed by the
Resolutions Committee, WFPHA 35th Annual Meeting, 14 May, Washington
DC. http://www.wfpha.org/pdf/01.23%20Public%20Health%20and%20Globalization.pdf (accessed 15 June
2007).
95. WHO (1986). The Ottawa Charter for Health Promotion. First International Conference on Health Promotion,
Ottawa, 21 November 1986.
96. WHO (2002a). Global Crises – Global Solutions, Managing public health emergencies of international concern
through the revised International Health Regulations. International Health Regulations Revision Project,
Geneva.
97. WHO (2002b). WHO Atlas maps global tobacco epidemic. Press Release, 15 October, Tobacco Free Initiative,
Geneva.http://www.who.int/mediacentre/news/releases/pr82/en/ (accessed 13 June 2007).
98. WHO (2004). Global strategy on diet, physical activity and health. WHA57.17, 57th World Health Assembly,
Geneva.
99. WHO (2005). The World Health Assembly adopts resolution WHA59.2 on application of the International
Health Regulations (2005). to strengthen pandemic preparedness and response. Epidemic and Pandemic
Alert and Response, Geneva. http://www.who.int/csr/ihr/wharesolution2006/en/index.html (accessed 20
June 2007).
100. WHO (2006a). Counterfeit medicines. Fact Sheet No. 275, 14 November,
Geneva. http://www.who.int/mediacentre/factsheets/fs275/en/print.html (accessed 13 June 2007).
101. WHO (2006b). Health Metric Network (HMN) Workshop – better health information systems . Health
Metrics Network, Geneva.http://www.who.int/healthmetrics/news/20061027/en/index.html (accessed 20
June 2007).
102. WHO (2006c). World Health Report 2006 – Working together for health . Geneva.
103. WHO/International Obesity Taskforce (2000), Obesity – Preventing and Managing the Global Epidemic.
WHO, Geneva.
104. WHO/UNICEF (2006). Meeting the MDG drinking-water and sanitation target: the urban and rural
challenge of the decade. Water, Sanitation and Health,
Geneva. http://www.who.int/water_sanitation_health/monitoring/jmpfinal.pdf (accessed 27 March 2007).
105. WHO/WTO (2002). The WTO Agreements relevant to health. In WTO Agreements and Public
Health (Geneva: WHO/WTO).
106. Woollacott, M. (2003). The new killer threatening rich and poor alike. The Guardian, 25
April. http://www.guardian.co.uk/comment/story/0,,943179,00.html(accessed 20 June 2007).
107. WTO (2007). Risks lie ahead following stronger trade in 2006, WTO reports. Press Release, 472,
Geneva.http://www.wto.org/english/news_e/pres07_e/pr472_e.htm (accessed 13 June 2007).
108. Yach, D., and Beaglehole, R. (2003). Globalization of Risks for Chronic Diseases Demands Global
Solutions. Perspectives on Global Development and Technology,3(1–2), 1–21.