HIV/AIDS and Globalization
What is the epidemic telling us about
economics, morality and pragmatism?
Tony Barnett
Contact:
a.barnett@uea.ac.uk
ABSTRACT
Disease
epidemics have been related as both cause and effect to
increasing integration of human economies, societies and
cultures throughout history.
It is well
known that infectious disease is not equally distributed
between different societies and different sections of the same
society. This
clear on a global scale where disparities in exposure to
infection and access to public health provision and health
care are acute.
There is a
debate as to the meaning and effects of “globalization” as
well as about whether it is “new” and, if so, in what
ways. This paper
briefly examines (a) the history of disease in relation to
globalization; (b) the meanings and importance of
“globalization”; (c) where and how the HIV/AIDS epidemic
fits into the picture; (d) some of the theoretical and
ideological implications.
1.
Disease,
Globalization and Integration
William
McNeill (1977) was among the first to draw our attention to
the role of epidemic disease in human history.
Many subsequent authors have noted its importance, and
most recently Jared Diamond (1998) has informatively discussed
its role in the increasing integration of human society and
economy over the past 13,000 years (which may be another way
of talking of “globalization). Scott and Duncan (2001),
argue that the “Black Death” in medieval Europe and other
plague events must be understood as events affecting “metapopulations”,
a term used by ecologists to describe “populations of
populations” (Scott and Duncan, 2001, 13).
They note that the term is not usually applied to human
populations but that it is appropriate in relation to studies
of spatial heterogeneity of disease “where individuals can
be either infected or uninfected, an example of the
interaction between demography and disease” (Scott and
Duncan, 2001, 13). HIV/AIDS
is a global pandemic affecting the ultimate metapopulation –
the entire human community.
Its distribution is unequal: spatially in terms of
countries and parts of countries; socially, in terms of social
and cultural groups; and economically, in terms of income and
wealth classes. The
evidence on this is not at all clear but some patterns seem to
be apparent (see for example Carael, 1995; Over, 1998;
Ainsworth and Semali, 1998; Filmer 1998; Farmer, 1999; and
more generally on the relationship between ill health and
inequality, Wilkinson, 1996).
2.
Globalization:
Health Promoter or Health Hazard?
There
are numerous definitions of globalization (Went, 2000). They emphasise different aspects of the process and in so
doing express different evaluations and ideological stances.
For example
§
The intensification of global
linkages across a wide sphere - across transnational corporate
business structures, international finances, people mobility
(migration, tourism), global cultural exchange, global
environmental issues, and technology and electronic
communication.
§
Globalization not only refers
to economic processes or the development of economic
institutions, but also describes the interconnection between
individual life and global features; the process of increasing
economic, political, and social interdependence and global
integration that takes place as capital, traded goods,
persons, concepts, images, ideas and values diffuse across
state boundaries. Routes of globalization are in the
industrial revolution and laissez-faire economic policies of
the last century.
§
Globalization and
liberalization are a fast, new express train and countries
have been told that all they need to do was get on
aboard…those that fail to get aboard will find themselves
marginalized in the world community and world economy.
§
Globalization is not a new
phenomenon (the 16th and late 19th centuries are both
characterized by the development of communication,
transportation, and production systems) but the present era
has distinctive features. Shrinking space, shrinking time and
disappearing borders are linking people's lives more deeply,
more intensely, more immediately than ever before (Human
Development Report 1999, 1)
The
term refers to some or all of the following phenomena:
§
Global markets which are more
closely and immediately linked, de-regulated and accessible to
more people than hitherto;
§
Tools of communication such
as cell phones and the internet which enable the creation and
maintenance of more flexible and responsive networks of
communication – both financial and non-financial.
§
New “actors” and
“agents” which transcend national boundaries, for example
the World Trade Organisation.
Such agencies may have or claim to have authority over
governments. Indeed
the role and potential for action of nation states – with
the exception of the largest and most powerful, the US – may
be questioned by the existence of such global organisations.
Some multinational corporations have global reach and more
economic power than many states.
Some NGOs are able to mobilise globally in opposition
to and independently of states.
3.
How does globalization
affect health?
There
are two broad views of how globalization affects health.
§
There is a view which sees
the increased interdependence attendant upon globalization
resulting in an increased willingness of nations to work
together in pursuit of improved health because this would
serve their rational self-interest.
This offered an optimisic analysis of the health
benefits of globalization to poor countries and to poor
communities in rich countries. These included: increased
trade, easier diffusion of new technologies, and – at a
cultural-political level - acceptance and application of common human rights throughout
the world. This view argues that increased pace of
cross-national exchanges should facilitate diffusion of
technological innovations such as new and effective
contraceptive methods, techniques for enabling access to clean
water, inexpensive refrigeration, efficient transport and
communication technologies, and new and effective systems for
prevention and treatment of infectious disease.
§
Constrastingly, the
pessimistic view sees globalization as a phenomenon which
because of the increasing loss of sovereignty by nation states
means that states are less willing to pool resources. The
result might be less co-operation and more protectionism,
increased competition and insistence in maintaining those
spheres of influence that still seem intact.
In addition, the increasing concentration of the
international pharmaceutical industry has been an important
factor. The more ready availability of large profits from
treatments of disease in rich countries and communities has
meant that – for example – there has been markedly less
attention to the needs of communities and countries which have
lower ability to express their needs through markets.
It has been argued (Thomas 2001) that pursuit of an
HIV/AIDS vaccine has been of less interest to big
pharmaceutical companies. These stand to profit more from
development of treatments than vaccines.
The debate about the TRIPS agreement and generic
versions of anti-retroviral drugs before, during and most
significantly after the XIII International AIDS Conference in
Durban, 2000, is indicative of the kinds of challenge we
confront in trying to ensure access to drugs through market
mechanisms. The fate of the Global Fund for TB, Malaria and HIV/AIDS
which was an outcome of the UNGASS meeting in 2001 still hangs
in the balance as the rate of commitment from the main donor
countries remains disappointing.
4.
Neo-liberalism and global health
Although
neo-liberal economic ideologies and the World Bank have not
always been identical, they have certainly been very close
during the past twenty years.
The World Bank has had a profound influence on health
provision in poor countries as the largest external financer
of health activities in low and middle income countries.
It has also been a major voice in national and
international health policy debates and an important
contributor to health policy research.
Over the past two decades, the Bank has addressed the
following three main health policy issues:
1.
Systemic reform.
2.
Targeting public sector investment.
3.
Encouraging donors and governments to operate within
the framework of the first two.
The thrust of these strategies was to emphasise the role of
the market in health care provision. Government's role was to
be mainly regulatory, by supervising the marketplace,
insurance legislation, ensuring “acceptable” levels of
access.
Criticisms
of the Bank’s policy include the view that this is an
approach which:
1.
ignores the social ethics of health care and defines
health services as commodities to be delegated to the market
sector of an
economy.
2.
ignores the provision of public goods such as
immunization and public sewage;
3.
generally seeks to shift the larger burden of curative
services to the private sector, which makes it available to
foreign investment.
5. Individual health, public health and wellbeing
“Health”
is not simple. It
is a cultural artefact. It appears to be a quality of our
body. That is
where we feel unwell, where the symptoms of disease are
experienced. It
appears “natural” that we should see health, or its
opposite: sickness, as an individual, isolated experience for
which we take individual responsibility.
The underlying metaphor is of a machine that we either
maintain or neglect. Such ideas link with broader notions in western thought
concerning the importance of the individual and his/her
responsibility for her/his actions. This is where it links to
markets which are also sometimes seen as interactions between
“individual” economic agents. This is not the only way to
see the issue. Consider
the following two problems:
§
is health really the issue or
is there something broader called “well-being” which
questions the purely individual and bodily nature of
“health” and places more emphasis on the social and
economic origins of “ill-being”?
§
Do we need to understand the
idea of “the
individual” differently?
This is not to suggest that individuals do not exist or
have significance. It
is to point out that the centrality of the individual as an
acting and responsible entity is a product of western history
and experience. Others, elsewhere, see things differently,
placing the social nature of the individual centre-stage.
Amartya
Sen
is an important commentator on these issues. His approach to
problems of poverty and well being starts from the use which
people get from their lives, how they are able to express
and/or present themselves in the world.
To understand the injustice of inequality, we need to
see how economic, social, institutional and cultural
structures stunt people’s abilities to gain access to the
resources which enable them to function as full human beings.
These
ideas were foreshadowed in the work of Karl Polanyi (Polanyi,
1945). Polanyi’s
view was that in past societies the market mechanism was
closely integrated with other aspects of social relations. But
in ”the west” it became separated, “disembedded”, and
thus uncontrolled and unmoderated by considerations of values
other than price. In
its most extreme manifestation, “the market” is today held
up by many politicians and philosophers as the best and only
“rational” way to decide on the allocation of goods and
services, including health and welfare.
Polanyi’s
perspective engages with a question that takes us beyond the
conventional perspective of the “individual”.
While the western medical tradition deals with
“individuals” and even dissects individual’s complaints
into “specialisms”, this question locates individuals in
their social field. It asks whether social relations can be
considered as ends as well as means. In other words, whether
social relations should themselves be considered as part of
well being. If this were to be the case, then the social relations
of making a living, living with other people, and rearing
children, would have to be taken seriously as components of
“well-being” in ways which are not currently the case in
the “health” industry.
We
live our lives in our minds but also through and in our
bodies. We guard
and worry about our health.
Our health, our
individual body, our
well being or our ill-being. Medical
doctors deal with our individual health. We pay them or make
public provision for them to be paid. But is this really what
health, well-being and ill-being are about?
These questions confront us with the necessity to
consider how we relate to each other in an era of increasing
globalization.
Such
ideas are rich in their implications for thinking about public
health in general. They
also draw attention to some of the questions posed by the
HIV/AIDS epidemic – perhaps the first global epidemic of
which there has been a global political and public
consciousness. The
most important possibility that needs to be considered is that
public health should be seen as a communal process. That it
has elements of both a public good and a relational
good: the good is consumed and enjoyed but the
relationships through which it is provided are in themselves a
“good”. This “good” is one which demonstrates care for
others, an aspect of living with others. The problem is to
develop an institutional locus for provision of such goods.
These ideas about public health, health, medicine and the
individual confront us with both challenges and opportunities
in an era of “globalisation”.
Discussion of these issues is – perhaps – one important
“good” which might arise from the HIV/AIDS epidemic.
6. Irony and Pragmatism
It
is ironic that at a time when the importance of past epidemics
is increasingly recognised and discussed by historians, there
is very little appreciation of how AIDS impact is already
affecting many societies now and into the future. There is
much talk of “emerging” and “re-emerging” diseases.
HIV/AIDS is a harbinger of the global public health crisis.
Epidemics
such as HIV/AIDS and their impact do not take place in
isolation. They need to be related to other events – changes
in political regime, new ideas, global warming, the global
distribution of power. We
cannot deal with these events in isolation from each other.
We live in a world where perception of inter-related
multiple long-wave events must be on the agenda of every
politician and policy-maker.
We can no longer deal with issues piecemeal and
sincerely claim that we have given them our full attention.
As social scientists, we may engage with the oh
AIDS
epidemic for many reasons.
Because it is an interesting phenomenon; because of a
pressing desire to help those in distress now and in the
future; because it makes a mockery of international
development goals and prospects for progress in some
countries; because resulting poverty may be a threat to the
national security of the USA; or yet again because of a fear
that “AIDS refugees” may flood the countries of the north
in a search for treatment – a “therapeutic pilgrimage”
which is a small but significant component of the enormous
body of migration which characterises this period of
globalization. It
is clear that there is a premium on pragmatism as opposed to
compassion. Pragmatism
tends to capture resources.
Social scientists may wish to explore further the links
between pragmatism, self-interest, morality and public health.
After all, economics was once described as a
“moral” science!
Refererences and Further Reading
Afshar,
Farokh. "Balancing Global City with Global Village"
Habitat International. Volume 22: no. 4. 375-387
Bruni,
L. and Sugden, R., 2000, Moral Canals: Trust and Social
Capital in the Work of Hume, Smith and Genovesi, Economics and
Philosophy, 16:21-45.
Carael,
Michel, “Sexual Behaviour”, chapter 4 in Cleland, John and
Ferry, Benoit, Sexual Behaviour and AIDS in the Developing
World, London, Taylor and Francis, 1995.
Diamond,
Jared, Guns, Germs and Steel: a short history of everybody for
the last 13,000 years, London, Vintage House, 1998.
Drèze,
Jean and Sen, Amartya, 1989, Hunger and Public Action, Oxford,
Clarendon Press
Farmer,
Paul, Infection and Inequalities: the modern plagues, London,
University of California Press, 1999.
Gui,
B., 2000, Beyond Transactions: on the Interpersonal Dimension
of Economic Reality, Annals of Public and Cooperative
Economics, 71:139-169.
Kickbusch,
Ilona. "The development of international health
policies-accountability intact?" Social Science and
Medicine. Volume 51: Issue 6; 15 September 2000. 979-989.
McNeil,
William, Plagues and Peoples, Oxford, Basil Blackwell, 1977
Polanyi,
K., 1945, The
Origins of Our Times: The Great Transformation, London,
Gollancz.
Thomas,
Patricia, “Big Shot: Passion, Politics and the Struggle for
an AIDS Vaccine”, New York, Public Affairs
UNDP,
Human Development Report, Globalization with a Human Face, New
York and Oxford, Oxford University Press, 1999.
Wilkinson,
Richard G., Unhealthy Societies: the afflictions of
inequality, London, Routledge, 1996
Yach,
Derek and Bettcher, Douglas. "The Globalization of Public
Health, I: Threats and Opportunities.
American Journal of Public Health. Volume 88: No. 5;
May 1998. 735-741.
Polanyi,
K., 1945, The
Origins of Our Times: The Great Transformation, London,
Gollancz.
Putnam,
Robert D., 2000, Bowling Alone, New York, Simon &
Schuster, New York.
Sen,
A. K., 1985, Commodities and Capabilites, Amsterdam, North
Holland
Sen,
Amartya, 1987 Jul, Gender and Cooperative Conflicts, Helsinki,
Finland, World Institute for Development Economics Research
Sen,
A., 1997, On Economic Inequalities: an expanded edition with a
substantial annexe by James Foster and Amartya Sen, Clarendon
Press, Oxford.
Sen,
A. and Sengupta, S., 1983, Malnutrition of rural children and
sex bias, Economic and Political Weekly, No. 19.
Sugden,
R., 2000, Team
Preferences, Economics and Philosophy, 16:175-204.
Went,
R., 2000, Globalization: Neoliberal Challenge, Radical
Response, London, Pluto Press.
These definitions are taken from a very useful discussion on the
internet by Tamara Hattar, Debra Berliner, and Flavio
Casoy, dated October 17, 2000 and entitled Globalization:
Health Promoter or Health Hazard?
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