We are still in the middle of a dramatic experience. Will the pandemic’s impact on health and health systems help us comprehend the value of health and how little health-friendly is the present globalisation? Can it, consequently, help in the creation of a multidimensional, health supportive new global planet?
- Globalisation - the growing interdependence of the world’s economies, cultures, and populations, brought about by cross-border trade, technology, and flows of investment, people, and information.
- Health - as defined by the Constitution of WHO, is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
- Pandemic - an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people.
- COVID-19 - an infectious disease caused by a newly discovered coronavirus, a group of related RNA viruses that cause diseases in mammals and birds.
- Distal and proximal determinants of health- indirect or direct factors influencing health.
- Enlightenment - cultural movement born in eighteenth-century Europe, aimed at renewing the intellectual and moral sensitivity of the time and at reforming the traditional political and religious institutions of society, fully relying on the critical and rational abilities of man.
- Complexity - the quality or condition of being difficult to understand or of lacking simplicity.
Globalisation is certainly per se a difficult subject to approach, considering its complexity, its many facets, and its many interpretations. It becomes harder, but in the meantime more challenging, having to write about it in the middle of the so called new pandemic wave, which has hit all the countries and areas of the world. The different dramatic seriousness of the impact should teach us a lot. A new awareness and consequent actions, however, will take place only if scientists, specialists of all disciplines, health operators of all kind of persons directly involved in the battle, together with politicians and policy makers, will have a holistic approach, and humility and honesty to meet, even remotely, and virtually exchange analyses of the events and share ideas, coordinate action for local and global solutions.
I will get back to this vision to reflect upon the question: is it a choice or an obligation, a mild necessity or an impellent urgency to work for a new concept of global? The best possible point of departure in the present historic moment appears to be to focus on health. One of the most relevant results of the pandemic, in fact, is that it has made us more aware that health and wellbeing are the most important value for all and any of us, no matter the colour of our skin or where we were born or live on this planet. We have seen at work one of the most devastating aspects of globalisation that is the speed in the diffusion of the pandemic. We should consequently reflect about globalisation, starting with the pre-COVID 19 outbreak. Why did we not understand the health implications of the ongoing crisis under our global eyes? What should we not repeat and what should we change to avoid the replication of another pandemic at a global scale?
The Process of Globalisation and Pandemics Before COVID-19
Globalisation has been under the scrutiny of scholars of many disciplines for quite some time. Without digging into its history and speaking of the very early phases of exchanges among people living in different part of the world, we can agree that the early forms of globalisation that can be of our interest were determined initially by the process of industrialisation and the parallel development of transports.
Historically it is recognised, in fact, that globalisation during the 19th century was shaped by the industrial revolution, when in parallel the rapid population growth sustained the demand of the new standardised product. The transportation revolution is considered another crucial factor in enlarging continental and intercontinental trade, with an increasing drive for also expanding new forms of political domination, subsequently defined colonialism. Especially with regards to Africa and Asia, many scholars of different disciplines have concluded in an even stronger way that globalisation in the 19th century was shaped by imperialism.
Towards the end of the century and in early 20th century, progressive changes in the economic structures, created by the rapid diffusion on neo-capitalism and neo-liberal ideologies produced a rapid growth of economic relations, of different forms of communication, and cultural exchanges, even if the latter had less relevant impact and diffusion.
In such a period, the need for cooperation in the fastest growing areas produced the first international organisations, of which examples are the International Telegraph Union founded in 1865, and the Universal Postal Union established in 1874. The necessity of some control and governance produced the Permanent Court of Arbitration, which was implemented in 1902. These were, in effect, dealing in specific matters. Only after World War I, international holistic institutions started to appear. In 1919 the League of Nations was created, the predecessor of the United Nations, when the International Labour Organisation was put in place as an affiliated agency of the league. Specifically concerning health, our focus, it needs to be reported that a widespread pandemic, called the Spanish Flu, exploded in February 1918, in the final year of World War I and lasted until April 1920. It infected 500 million people - about a third of the world’s population at the time - in four successive waves. “The death toll is typically estimated to have been somewhere between 17 million and 50 million, and possibly as high as 100 million, making it one of the deadliest pandemics in human history” (Spreeuwenberg et al. 2018).
The forgotten images of that period constitute a reminder of how history can repeat itself, without us having learned the lessons and being astonished in discovering the similarities.
The devastation of communities and the impact on economies were felt all over the world; nonetheless it took until after the Second World War, in 1948, to arrive at the creation of a world organisation focused on health - the World Health Organization (WHO). It was the beginning of the official recognition that the world was becoming connected, that this was an important factor for the attacks to health spreading fast and that they were involving all areas of the planet, beyond natural and anthropic boundaries.
We will only mention two other outbreaks of influenza of the XX century, with some characteristics of a pandemic: the Asian and Hong Kong of 1957 and 1968 respectively. The epidemics frequently mentioned in the XXI century are SARS, that mainly hit China, from where it originated and in 2009, the inappropriately called Swine Flu.
No epidemic of the XXI century had the serious planet impact of the Spanish Flu of the preceding century, but scientists were alerting of the possible risk. Michael Osterhom, at that time Director of the Center for Research and Management for Infectious Diseases of the U.S. State Department, wrote: “A series of scientific studies have shown that a pandemic is expected in the short term ......the effects cannot be predicted, but preparing for this event is indispensable and a lot of work on the part of the institutions is needed” (Osterhom 2005). Obviously this call for attention did not produce great effect and got progressively lost in the mist of many other economic and social problems in most nations of the world.
But now, in the present time, COVID-19 has unequivocally made us aware that the warning was real. In addition, we have to recognise that we are in a world that is hyper-connected and that no country is in a position to manage their health problems independently, especially during a pandemic. “Viruses travel with us, cross borders without needing a passport; and then suddenly we are in the middle of a pandemic, a global epidemic (Missoni 2020).
In addition to the movement of people and merchandise, we are becoming aware now that climate change, pollution, social inequalities, lifestyles and other factors play a fundamental role in determining the vulnerability that we are witnessing and suffering from at the present time.
The fact that climate change affects the health of the entire planet cannot be denied any more, as well as the fact that we are in a world of increasing complexity, which requires greater understanding and new approaches that are different from traditional disciplines, as well as greater more connection and integration. The hyper-connected world in which we live obeys laws different from those typical of mechanistic thinking, governed by a linear approach, which must now be accompanied by a new systemic and holistic way of thinking.
To avoid getting lost in this complexity, it is important to leave aside the specific pandemic that is scourging us and that is claiming lives in the four corners of the world. We cannot objectively think that we can go back to a non-globalised world, so in preparing for a post-pandemic world, we have to think about a different globalisation, and we need to start exploring, more closely, the health impact of globalisation.
The Health Impact of Globalisation
The economic impacts of globalisation in their multifaceted aspects have already produced relevant studies relatively a long time ago, because globalisation has been seen for some time, mostly an economic process.
The examination of the relationship between globalisation and health started relatively in recent times. In 2001 in a bulletin of the World Health Organization a group of scholars (Woodward et al. 2001) published an interesting article “Globalisation and Health: a framework for analysis and action.” The article was mostly focused on economic aspects related to globalisation and how they were having negative effects on health. The study that followed by Labonte and Torgeson (2002), also connected with WHO, enlarged the analysis to the links between economic globalisation, international governance and health.
It has become slowly evident that the health effects of the globalisation needed a more holistic approach. In fact in 2005, a group of Dutch scholars published an article focused on producing a conceptual framework “rooted in a broad conception of both population health and globalisation” (Huynen et al. 2005).
The article presented an analytical evaluation of the determinants of the population health and in parallel, the levels and the areas of influence of the globalisation process. We consider that this work has fulfilled its goal of constituting a “conceptual framework, a well-structured think-model or concept map” as the authors called it, because “an interdisciplinary approach towards globalisation and health is required, which draws upon the knowledge from relevant fields such as, for example, medicine, epidemiology, sociology, political sciences, (health) education, environmental sciences and economics” (ibidem).
We will therefore build on what this methodology has achieved, naturally trying to introduce what additional knowledge has been given to us. A clear contribution is given with two schemes: the “multi-nature and multi-level framework for population health” followed by the “conceptual framework for globalisation and population health.”
The determinants of health are distinguished by nature: institutional /economic/socio-cultural/environmental, but the scheme intends to indicate that “the chain of events leading to a certain health outcome includes both proximal and distal causes; proximal factors act directly to cause disease or health gains, and distal determinants are further back in the causal chain and act via (a number of) intermediary causes. In addition, we also distinguish contextual determinants. These can be seen as the macro-level conditions shaping the distal and proximal health determinants; they form the context in which the distal and proximal factors operate and develop.”
By studying the determinants of health of a population, it appears clear that globalisation can have an impact on all the determinants that indirectly influence health. The most relevant are economic development. Some optimistic studies consider globalisation having had a positive role in decreasing inequalities among countries and improving conditions inside countries. Even in scarcity of complete data such a statement appears not to have ground.
On the other hand, on other distal determinants influencing health, the increase of interactions and exchanges, and more occasions for high level education, constitute the most positive aspect relate to globalisation and global communication. This however, is partly counteracted by the possibility of the increase in conflicts stimulated among others by changes of values and taking place of norms marked by individualism and self-interest, materialistic goals.
From the determinants directly connected with health, health services are among the most relevant. Health services privately delivered have always existed in the so-called western world, even where there were national services with relatively good performance. Globalisation has confirmed the perception that health is no more a right, as the constitution of WHO and of many countries state, creating space for an increase of privatisation in health services. Charities, at best, can provide minimum support for groups deprived even of the most basic medical services, having lost the possibility to access and use naturalistic remedies.
Directly acting on health and deriving from the movements of people, information of media etc... lifestyles have been imported in many countries of the world, characterised by unhealthy diet, smoking, drugs, the latter moving illegally facilitated by legal commerce. Naturally, positive lifestyles also travel, get absorbed and can have a positive impact, but, as studies show, they seem to have less impact.
The Framework to Build a New Global: Health and Climate - The Twin Goals
The preceding synthetic analysis doesn’t assume to have identified all the possible effects of the globalisation process on human health. We consider that we are still lacking data, of intellectual and scientific instruments to fully understand the complexity of our global system.
Keeping in mind this, we have tried to clarify some relevant inadequacies of the characteristics of the present process of globalisation. We are rationally conscious that we cannot go back, we cannot avoid globalisation, but we do realise that this is not the globalisation that can improve the major determinants of health and consequently improve the wellbeing of the world population. Furthermore, the tragic events of the present pandemic situation and the likely possibility of other pandemics coming, according to many scientists, impose that we cannot passively accept this situation.
As a contribution to the framework of a “new global,” we will start to point out the changes that could help in building these “new ways to go global.” One of these changes, certainly the most difficult, but also the most important is a progressive change of values of our global society. I was surprised to hear in an interview of the Foreign Affairs Minister of a European country, where she concluded her answers by saying that what we need now is “the humanisation of globalisation.” Are these just empty words or an indicator of a need for new paradigms that also touch the policymakers?
The hope of change could become a reality if these circumstances get realised. The first: health of people of the world shall become the priority of the new paradigms, enhancing the concern for the environment and its health and, the other side of the coin, of human health.
The second: the community in social terms and its physical environment from the village to the city, will re-conquest their value and role, defeating the de-territorialisation produced by the actual globalisation process.
The ground for these two goals to be reached lie in the situation that the world is living. The COVID-19 viral infection has become a pandemic producing a dramatic and fast hit globally. Scientists repeat that there is the possibility of a next one, similar or worse than this, sooner or later. A sense of insecurity in and around almost all cultures in the world is growing and with it the growing awareness of the fragility of human health.
The planet’s disastrous ecologic conditions extend this sense to the ecologic surrounding. As the framework, even the foundations of our knowledge are shaking. After more than 300 years, our interpretation of the world, based on this enlightenment, is no more sufficient. Globalisation is the quintessence of complexity and complexity requires the introduction of new systems of understanding.
It is clear that the first goal cannot be reached if the highest level of policymakers of every sector don’t embrace this cause. The “top down” does help change, but it is not easy to make it start, nor to keep it moving in the right direction. The second goal therefore is essential. The change that starts “bottom-up” is not simple either, but in the present circumstances, possibly easier to attain.
To reach some success and make the examples become viral, to use a word of the most common media, is the first milestone of a bottom-up path.
As I had occasion to write in another article, communities working to get liveable cities, with clean air and environment, good health services, social justice, eradication of poverty, would become the “viral” seed that keep policymakers going and defending the environment against the most un-human and ecologically devastating enterprises.
One somewhat influential figure, Pope Francis, has given two complementary examples: the Encyclicals “Laudato si, mi Signore” (Be Praised, my Lord) in 2015 and recently the second “Fratelli tutti” (All Brothers). The first is concerned with environmental matters, the latter calls for more human fraternity and solidarity, and is a plea to reject wars. These are policy/political in the highest sense of the word, not religious documents and it seems to me that they should and hopefully will produce action to save the planet’s environment and to stimulate humanism in a profoundly changing scale.
They both require great mobilisation and acceptance of the share of responsibility from all and each of us. I figure that environment and human health should and have to constitute the content of a positive “Trojan Horse” that breaches the thick wall of self-interest, greediness, search for conflicts and wars, bringing a new global. Is it day dreaming? Utopia? My honest answer is that it is simply a necessity for us in order to give a future to our children and subsequent generations.
Conflict of Interest