Has global health become medicalised?

Many people have heard of ‘global health’. In fact, it is hard to get away from it, particularly on the medical side of college campuses, in health policy discussions, or the media when a newsworthy epidemic breaks out somewhere. Global health is generally code for (unfair) health disparities and the unhappy tendency of health crises walk or fly across national borders. Perhaps less familiar is the concept of ‘medicalization’. Roughly speaking, it is the process by which human problems are understood as (or ‘reduced to’) medical problems. For example, one could view diabetes as a purely medical problem, for which better treatments are needed, rather than (say) a condition implicating a host of social, political and economic factors, such as the low-cost of processed food, changes in work conditions and the structure of built environments. So what happens when you put ‘global health’ and ‘medicalization’ together?

Jocalyn Clark has written some intriguing exploratory pieces on the links between medicalization and global health in the online journal Global Health Action. Do global health initiatives tend to medicalize the problems that they set out to tackle? And if so, what effects does this process of medicalization then have? Certainly there is a tendency to seek technological (‘innovative’) solutions to health problems in developing countries, often with mixed results. To the extent that the determinants of poor and better health are social, political and economic, purely medical interventions are likely to have superficial impact. I wonder if there is also something else at play: not just medicalization, but the allure of objectivity and neutrality – think Red Cross -- associated with Western medicine. Coming into a developing country with medical interventions seems far less politically fraught than proposing large-scale changes to ways of life. So there is a tension between a major tenet of global health (that health is socially determined) and the political implications of trying to improve health globally. The tendency towards medicalization may paradoxically reflect a need to look for a ‘safe space’ for global health practice.

Global health research ethics in Vanity Fair

Vanity Fair, normally associated with glossy celebrity photo shoots next to swimming pools, is running something this month on ethics and the globalization of clinical trials. It really is. The basic thrust of the dramatically entitled article ('Deadly Medicine') is that pharmaceutical companies are guilty of a whole range of shady practices, from suppression of negative testing results to knowingly promoting products with serious side-effects or unknown efficacy, and there is little effective regulation to prevent or punish their irregularities and abuses. Furthermore, when pharmaceutical research takes place abroad in low- and middle- income countries, as it increasely does to cut costs, what goes on becomes even more obscure; when particular wrongdoings emerge from the global shadows, you can only guess how much exploitation, manipulation and harm is taking place on a regular basis.

What struck me reading the Vanity Fair article was a strong sense of deja vu. How essentially different is its content from those seminal Washington Post articles, the 'Body Hunters' series, written back a decade ago? Those were the exposes that blew the lid on the practices of global pharma and kick-started all manners of initiatives to raise consciousness about the ethics of global health research. So what happened in the meantime? A lot of activity in the public sector: the NIH consolidated its clinical ethics center, other bioethics centers popped up at universities around the country, new ethics journals were established, research ethics committees were established in developing countries, grants for research ethics projects were established, and so on. And yet, what did all this do in regard to the practices of for-profit multinational pharmaceutical companies as they scour the world for sites and populations favorable to their own economic interests? Did all this have any sort of impact?

From the looks of the Vanity Fair article, not much. The same sorts of 'irregularities' go on; what has changed through globalization is the quantity of institutions, investigators and researchers involved. Paradoxically, the bigger global health research becomes, the less visible its operations and effects seem to get.

The tobacco wars go global

Smoking isn't good for you. Of course, there are a lot of things that aren't good for you, but we are starting to get more and more data about what habitual smoking does to the human body, both to the user and to bystanders, and it is not at all pretty. Although there are strong ethical arguments against the practice (including its contribution to health care costs for smokers and non-smokers alike), smoking would be impractical to outlaw outright. In developed countries, smoking is increasingly frowned upon socially and curtailed legally: it is getting more and more difficult to smoke in public space, smokers are regarded insurance risks, direct tobacco advertising pretty much a thing of the past, and only last week tobacco companies were required by the US Food and Drug Administration to put rather graphic warning labels on their cigarette packs. Not exactly a friendly business climate for marketing and sales.

Which is why developing countries have become so attractive for multinational cigarette companies over the last decade. The regulations -- for instance on tobacco advertising -- in some developing countries are less restrictive than those in the United States or Europe, and so companies search the world for regions marked by weak legislation and a strong consumer base, such as Indonesia. In this struggle between global big tobacco and global health agencies, the gloves are apparently off. Philip Morris has sued the country of Uruguay for loss of profits due to 'excessively restrictive' advertising policies. The World Health Organization, for its part, is advocating for stronger tobacco policies and laws globally, and encouraging individuals and governments to sue tobacco companies for harms to health. The WHO has even chosen to sponsor a summit in Uruguay this week, attended by representatives of over 170 nations, to analyze and support policies that reduce the prevalence of smoking on this planet.

The struggle against smoking that started in the United States and Europe is now to be played out around the globe, on very many fronts. A complicating factor in the debate is that tobacco is also grown in some developing countries (such as Malawi), and curtailing tobacco sales could in the short term have a negative impact (health and otherwise) on poor tobacco farmers, pickers and processors. These considerations are not without merit, but they are ultimately outweighed by the damage (long and short term) smoking causes, particularly in developing countries that do not have the health care systems to adequately cope with the effects tobacco has on its users.

The ethics of global trade in human flesh and bone

The Bulletin of the World Health Organization has an interesting article out in its November issue, entitled 'Human cells and tissues: the need for a global ethical framework.' The authors describe the technological advances and growing interest in the field of tissue transplantation, and predictably, the rise of private, profit-seeking companies engaged in the procurement, processing and sales of human tissues. The biggest tissue corporations with the most aggressive and questionable practices, from the looks of the article, appear to be American. Medical and public health uses are only one possibility among others. Private companies have an obvious bottom-line interest in trading tissues for expensive cosmetic purposes such as penis widening or lip enhancement, if not more mundane uses, such as those we normally associate with the flesh of horses or fish: paste, glue, powder and suspensions. As far as current practices of informed consent go, those who donate or trade tissue on behalf of family members may or may not know where the tissue ends up, with the unfortunate possibility that your skin from your Granny's forearm unknowingly ends up on some stranger's foreskin. In addition,

there is the usual ethical concern about flesh and bones from the poor being harvested for the bodies of the rich, similar to concerns about the organ trade, only here there are more body parts in stock: heart values, corneas, patellas, powdered bone, hip sockets, you name it.

The authors call for regulation of the global trade in human tissues through the development of a binding ethical framework from the World Health Organization. However, it is clear that their proposal would be labelled 'socialist' by corporate interests in the United States, seeing as the authors call for 'reasonable profits' to be channelled into improvements in quality, safety, accessibility and R&D, and they insist that the ethical framework should 'prohibit financial gain on the human body and its parts.' If formulated this way, the framework would join the list of international guidelines that the United States would not sign onto. Which might not be so bad, if the US was not already such a dominant player in the human flesh and bone market.

Are countries that ratify human rights treatises more healthy than others?

One might think that a country which has ratified human rights treaties, and thus has made them to some extent law, will have better health outcomes than countries where this is not the case, all things being equal or at least controlled for. A study just published in The Lancet indicates otherwise. The researchers looked at some key and often-measured health and social indicators, and sought correlations between number of treatises ratified and changes in health/social indicators before and after ratification of health-related human rights treatises, as well as making comparisons between health/social indicators in a total of 170 countries that did or did not ratify certain treatises.

The results are sobering, or perhaps predictable, depending on one's pre-existing opinions about the power of human rights approaches to health. Ratification of human rights treatises does not seem to have any significant effect on maternal mortality, infant/child mortality and life expectancy. The researchers try to put a brave face on the data, by adding that ratification of human rights treatises can have some indirect (but hard to pin down) effect on health by strengthening legal arguments aiming to ensure access to health care. But in the end, money trumps law: there is much greater evidence of an association between economic conditions and health than there is between the ratification of human rights and health.

One might object by saying that ratification is the mere promise of action, just the signing of a paper, and we should only expect an effect in terms of health outcomes in countries that rigorously monitor, enforce and make its human rights commitments real. In other words, in finding no significant association, what the researchers have actually done is study the global absence of political will in regard to human rights relevant to health.

Economic downturn and global health

Economic crises and economic recovery plans are dominating the news. There is news about macroeconomic indicators (such as unemployment rates) as well as how the economic downturn/recession is affecting the lives of ordinary people. Or at least, the macro- and micro effects of the crisis in America, Europe and better-off nations in Asia. With rare exceptions, there is little talk or concern about how the breakdown of the world's dominant economies is playing out in the world's poorer countries, despite estimates that the numbers of persons living on less than $2 per day will soon swell by the tens of millions.

Last week, the New York Times published an editorial about the situation that many developing countries find themselves. Currency rates are falling as is demand for whatever products those countries export in the global market. Unlike the United States and Europe, these countries don't have a few trillion dollars on hand to stimulate their own economies; they are struggling to pay back the loans taken out in years past to ... stimulate their economies. The NYT editorial claims that affluent nations should give more money to the International Monetary Fund, who in turn can extend more lines of credit to developing countries. The assumption seems to be: we need to maintain the longstanding debt and dependency relationship between developed and developing countries, i.e. prop it up with more cash injections. The editorial is silent about the very spotted history of IMF loan practices and developing countries, and about who is responsible for the culture of toxic financial products that created the global financial crisis in the first place. It has a real 'rearranging deskchairs on the Titanic' feel to it.

Another publication, quite another angle: the British Medical Journal has published a thoughtful piece on the potential effects of the financial crisis on health in developing countries, and how the crisis could be an opportunity to positively change the global financial landscape. Although there is no firm data yet, the consequences of the financial crisis on health in developing countries look very dire: if you take the 'social determinants of health' model, and reasonably assume that the economy (in terms of income) partly determines health, then people in already resource-poor countries are going to get sicker, and more are going to die of preventable and treatable conditions than before. The way out, according to the authors, is not to refill the coffers of the IMF. It would be better to first ditch the idea that the more unregulated a market is, the better off the economy will be, and the better off the health of nations will be. The de-regulation of markets seems to have faciliated the growing inequalities between the health and wealth of nations over the last decades. Moreover, at crucial points where the global market was regulated -- through trade laws and regulations -- the conditions of trade were largely set by and to the advantage of more affluent nations. We therefore need to draw radical lessons from our current predicament, by reflecting on just how we got here. As the authors write, "The financial crisis gives us the opportunity to bring social justice and environmental concerns to bear on the kind of new global economic order that must be put in place." Amazing that health professionals in the BMJ are now giving voice to these views, once the mainstay of activists at global economic forums.