1.

International health, also called geographic medicine, international medicine, or global health, is
a field of health care, usually with a public health emphasis, dealing with health across regional or
national boundaries. One subset of international medicine, travel medicine, prepares travelers with
immunizations, prophylactic medications, preventive techniques such as bednets and residual
pesticides, in-transit care, and post-travel care for exotic illnesses. International health, however,
more often refers to health personnel or organizations from one area or nation providing direct
health care, or health sector development, in another area or nation. It is this sense of the term that
is explained here. More recently, public health experts have become interested in global processes
that impact on human health. Globalization and health, for example, illustrates the complex and
changing sociological environment within which the determinants of health and disease express
themselves.

2. Global health’ is coming of age, at least as measured by the increasing number of academic centres,
especially in North America, which use this title to describe their interests (1). Most global health
centres are in high-income countries although several have strong links with low- and middle-income
countries. A task force is establishing a mechanism to coordinate European Academic Global Health
initiatives through ASPER. Two recent papers raise important issues about the meaning and scope of
global health (2, 3) and highlight, yet again, the need for a common definition of global health which
is short, sharp and widely accepted, including by the public (4).

Koplan et al. from the Consortium of Universities for Global Health Executive Board point out that
without an accepted definition of global health, it will be difficult to agree on what global health is
trying to achieve and how progress will be made and monitored (2). This is particularly important
given the recent global crises – climate change, economic, food and energy crises – that make global
health efforts even more challenging (5).

Koplan and colleagues propose a definition of global health which they hope will receive wide
acceptance and thus encourage global health efforts. They distinguish between global health,
international health and public health; tropical medicine has close connections with international
health (1). However, there is widespread confusion and overlap among the three terms.

International health, in Koplan's view, focuses on the health issues, especially infectious diseases, and
maternal and child health in low-income countries. However, elsewhere international health is also
used as a synonym for global health. For example, Merson et al. view international health as ‘the
application of the principles of public health to problems and challenges that affect low and
middle-income countries and to the complex array of global and local forces that influence them’ (6).
The term ‘international health’ has also been used to refer to ‘the involvement of countries in the
work of international organizations such as WHO, usually through small departments of international
health in the Ministries of Health and as development aid and humanitarian assistance’ (7).

Public health is usually viewed as having a focus on the health of the population of a specific country
or community, a perspective shared by Koplan et al. (2). Fried et al. dispute any distinction between
public health and global health and suggest that ‘public health is global health for the public good’ (3).
Their strong arguments are based on the need for both global and public health to address the
underlying social, economic, environmental and political determinants of health, irrespective of
whether the primary focus is national or global health.

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Current definitions of global health

Koplan et al. define global health as: ‘an area for study, research, and practice that places a priority on
improving health and achieving health equity for all people worldwide’. This is a useful definition with
a broad focus on health improvement and health equity. However, it is wordy and uninspiring.
Kickbush defines global health as: ‘those health issues that transcend national boundaries and
governments and call for actions on the global forces that determine the health of people’ (7). This
definition also has a broad focus but has no clear goal, is passive in its call for action, and omits the
need for collaboration and research. Elsewhere, the European Foundation Centre calls for a European
approach which makes global health a policy priority across all sectors based on a global public goods
foundation (8).

In an important policy document, the UKGovernment refers to global health as ‘health issues where
the determinants circumvent, undermine or are oblivious to the territorial boundaries of states, and
are thus beyond the capacity of individual countries to address through domestic institutions. Global
health is focussed on people across the whole planet rather than the concerns of particular nations.
Global health recognises that health is determined by problems, issues and concerns that transcend
national boundaries’ (9). This definition contains important ideas but is convoluted and not outcome
focussed. Macfarlane et al. usefully describe global health as being the ‘worldwide improvement of
health, reduction of disparities, and protection against global threats that disregard national borders’
(1).

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Proposed definition

Our proposed definition for global health is collaborative trans-national research and action for
promoting health for all. This definition is based on Koplan et al. but has the advantage of being
shorter and sharper, emphasises the critical need for collaboration, and is action orientated.

Key aspects of the definition deserve further explanation.

The term global health is used rather than global public health to avoid the perception that our
endeavours are focussed only on classical, and nationally based, public health actions. Global health
builds on national public health efforts and institutions. In many countries public health is equated
primarily with population-wide interventions; global health is concerned with all strategies for health
improvement, whether population-wide or individually based health care actions, and across all
sectors, not just the health sector.

Collaborative (or collective) emphasises the critical importance of collaboration in addressing all
health issues and especially global issues which have a multiplicity of determinants and a complex
array of institutions involved in finding solutions.

Trans-national (or cross-national) refers to the concern of global health with issues that transcend
national boundaries even though the effects of global health issues are experienced within countries.
Trans-national action requires the involvement of more than two countries, with at least one outside
the traditional regional groupings, without which it would be considered a localised or regional issue.
At the same time, trans-national work is usually based on strong national public health institutions.

Research implies the importance of developing the evidence-base for policy based on a full range of
disciplines and especially research which highlights the effects of trans-national determinants of
health.

Action emphasises the importance of using this evidence-based information constructively in all
countries to improve health and health equity.

Promoting (or improving) implies the importance of using a full range of public heath and health
promotion strategies to improve health, including those directed at the underlying social, economic,
environmental and political determinants of health.
Health for all refers back to the Alma Ata Declaration and positions global health at the forefront of
the resurgence of interest in multi-sectoral approaches to health improvement and the need to
strengthen primary health care as the basis of all health systems.

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Global health: a high-income country concern?

Although the burden of preventable disease is predominantly in middle- and, especially, low-income
countries, most global health centres are located in high-income countries. There are several
explanations for this anomaly including the following:

Centres in low- and middle-income countries are engaged in global health issues but under other
labels. For example, several centres in low- and middle-income countries have recently been funded
by the National Heart, Lung and Blood Institutes to undertake chronic disease prevention activities,
though the focus seems to be on national programmes of work (see
http://www.fogartyscholars.org/articles/nhlbi-centers).

Global health builds on international health interests stemming from institutions in high-income
countries over a century ago.

Global health may be seen to be divorced from the health needs of low- and middle-income countries
which are grappling with a range of pressing and challenging health issues.

An interest in global health stems from strong national public health institutions which are usually not
a feature of low- and middle-income countries.

Whatever the explanation, encouraging and supporting the establishment of global health centres in
low- and middle-income countries, and south–south collaborations, are essential if countries with the
greatest burden of diseases are to have the best opportunity to respond appropriately. Development
agencies, foundations and national ministries of health could do much more to build public health
capacity at the national level. By doing so, they will also strengthen research and policy interests in
global health and its evaluation (10).

3. What Is Globalization?

Globalization is a process of interaction and integration among the people, companies, and governments of
different nations, a process driven by international trade and investment and aided by information technology.
This process has effects on the environment, on culture, on political systems, on economic development and
prosperity, and on human physical well-being in societies around the world.

Globalization is not new, though. For thousands of years, people—and, later, corporations—have been buying
from and selling to each other in lands at great distances, such as through the famed Silk Road across Central Asia
that connected China and Europe during the Middle Ages. Likewise, for centuries, people and corporations have
invested in enterprises in other countries. In fact, many of the features of the current wave of globalization are
similar to those prevailing before the outbreak of the First World War in 1914.

But policy and technological developments of the past few decades have spurred increases in cross-border trade,
investment, and migration so large that many observers believe the world has entered a qualitatively new phase
in its economic development. Since 1950, for example, the volume of world trade has increased by 20 times, and
from just 1997 to 1999 flows of foreign investment nearly doubled, from $468 billion to $827 billion.
Distinguishing this current wave of globalization from earlier ones, author Thomas Friedman has said that today
globalization is “farther, faster, cheaper, and deeper.”
This current wave of globalization has been driven by policies that have opened economies domestically and
internationally. In the years since the Second World War, and especially during the past two decades, many
governments have adopted free-market economic systems, vastly increasing their own productive potential and
creating myriad new opportunities for international trade and investment. Governments also have negotiated
dramatic reductions in barriers to commerce and have established international agreements to promote trade in
goods, services, and investment. Taking advantage of new opportunities in foreign markets, corporations have
built foreign factories and established production and marketing arrangements with foreign partners. A defining
feature of globalization, therefore, is an international industrial and financial business structure.

Technology has been the other principal driver of globalization. Advances in information technology, in particular,
have dramatically transformed economic life. Information technologies have given all sorts of individual
economic actors—consumers, investors, businesses—valuable new tools for identifying and pursuing economic
opportunities, including faster and more informed analyses of economic trends around the world, easy transfers
of assets, and collaboration with far-flung partners.

Globalization is deeply controversial, however. Proponents of globalization argue that it allows poor countries
and their citizens to develop economically and raise their standards of living, while opponents of globalization
claim that the creation of an unfettered international free market has benefited multinational corporations in the
Western world at the expense of local enterprises, local cultures, and common people. Resistance to
globalization has therefore taken shape both at a popular and at a governmental level as people and
governments try to manage the flow of capital, labor, goods, and ideas that constitute the current wave of
globalization.

To find the right balance between benefits and costs associated with globalization, citizens of all nations need to
understand how globalization works and the policy choices facing them and their societies. Globalization101.org
tries to provide an accurate analysis of the issues and controversies regarding globalization, without the slogans
or ideological biases generally found in discussions of the topics. We welcome you to our website.

4. AS DEBATE surrounding the impact of globalisation on our lives continues apace,

punctuated by events such as the collapse of trade negotiations under the auspices of the
World Trade Organization in Cancun, Mexico, in September 2003, there is an intuitive sense
within the health community that it needs to roll up its sleeves and get more involved. The
challenge is to determine how.

Discussion has focused extensively on the degree to which globalisation is happening (or
not), its main drivers, and its actual timeframe. However, the key debate among academics
and policymakers remains whether globalisation is “good” or “bad” for our lives, and
particularly for human health. Opinions on this are deeply divided: Richard Feachem,
Director of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, acknowledges that
the “risks and adverse consequences of globalisation must be confronted”, but argues that
“they must not be allowed to obscure its overall positive impact on health and
development”.1 In striking contrast, Fran Baum, Professor of Public Health at Flinders
University, Adelaide, writes, “All the indications are that the current forms of globalisation
are making the world a safe place for unfettered market liberalism and the consequent
growth of inequities . . . [and] posing severe threats to both people’s health and the health
of the planet”.2 Such fierce disagreement can be bewildering and feel somewhat removed
from the everyday work of health professionals at the coalface. Nevertheless, it is crucial for
us to understand and engage in such debates.

What is globalisation?

Globalisation is highly contested on many fronts and will remain so. The term
“globalisation” has been misused and overused. I believe it is best defined in terms of three
types of changes,3 which have been occurring at unprecedented rates over the past few
decades:

Spatial changes. Globalisation affects how we perceive and experience physical or territorial
space. Movement of people, other life forms, information, capital, goods and services has
not only intensified across the borders of countries but, in some cases, has rendered
national borders irrelevant. Trafficking of illicit drugs, cigarette smuggling, undocumented
migration, money laundering and global climate change are transborder phenomena that
are challenging the capacity of governments to effectively regulate them. New social
geographies are being formed that redefine how individuals and populations interact with
each other. Some argue that we are moving towards a “global village”; others argue that
societies are fragmenting and, in some cases, imploding. Even more novel is the creation of
new forms of space, such as cyberspace and virtual reality, which challenge traditional
notions of a physical location.3

Temporal changes. Globalisation affects how we perceive and experience time. On the one
hand, social interaction is speeding up through modern communication and transportation
technologies. “Hooked on speed”,4 we race through life under ever-increasing pressure to
“multitask”, eat fast food, obtain instant credit, and even “speed date”. On the other, our
lives are slowed down by other modern complexities that bring us information overload,
ballooning bureaucracies, and gridlocked roads.

Cognitive changes. Globalisation is profoundly influencing how we see ourselves and the
world around us. The main agents of change here are the mass media, the advertising
industry, consultancy firms, research institutions, political parties, religious groups and other
institutions seeking to win “hearts and minds”. In the process, our cultures, wants or
perceived needs, values, beliefs, knowledge and aspirations are being changed.3

How is globalisation linked to health?

Humans have lived with continual change since the migration of Homo erectus out of Africa
a million years ago. Globalisation, in this sense, has gone hand in hand with the evolution of
human societies.5 But our current phase of globalisation is distinctive in its unprecedented
intensity and extent of change.

It would be overly simplistic and inaccurate to describe globalisation as either “good” or

“bad” for health. For example, spatial change is leading to increased migration of people
throughout the world. For high-income countries, the debate surrounding globalisation and
health tends to focus on the perceived threat, from low- and middle-income countries, of
acquiring certain acute and epidemic infections, such as HIV/AIDS, tuberculosis, plague and,
more recently, severe acute respiratory syndrome (SARS).6 Richer countries also fear the
potential financial burden of unhealthy populations migrating from the developing world.
What are less appreciated are the risks that high-income countries may export to other parts
of the world through products such as tobacco and fast food and, more indirectly,
macroeconomic policies affecting foreign direct investment and debt burdens. There is also
a tendency to overlook the benefits to high-income countries from population mobility —
the migration of health professionals from poorer countries offers benefits to understaffed
health systems in high-income countries (but at the expense of capacity in the developing
world).7 In other words, the increased movement of people and other items creates a
complex equation of pluses and minuses for each society.

Similarly, temporal change affects the spread of disease. The speed of modern
transportation systems means that infections can potentially move around the world within
a few hours (as illustrated by the SARS outbreak in 2002–03).8 On the other hand, modern
technology potentially enables the health community to respond more quickly to such
emergencies. For example, an international network of institutions coordinated by the
World Health Organization (WHO) via global telecommunications can readily detect and
rapidly respond to changes in the influenza virus9 — such a capacity was unavailable after
the First World War, when an estimated 20 million people died of influenza worldwide.

Finally, cognitive changes brought about by advertising and marketing Western consumer
goods have facilitated the global spread of so-called “lifestyle” diseases (eg, obesity) in
certain populations within low- and middle-income countries.10 The shift in the tobacco
pandemic to the developing world has been clearly driven by the tobacco industry.11 It is
estimated that, by 2030, 70% of all tobacco-related deaths (7 million annually) will occur in
developing countries.12 The spread of health sector reform can also be seen as a form of
cognitive globalisation in transferring policies about health service provision and financing
across the world.13 National health systems thus face the challenge of sifting through and
adapting these policies to local contexts. Global consciousness is also leading to the
increased sharing of principles, ethical values and standards that underpin decision making
about health. Examples of this are the 1964 Helsinki declaration on ethical principles for
medical research involving human subjects,14 the International code on the marketing of
breast-milk substitutes adopted by the WHO and the United Nations Children’s Fund
(UNICEF) in 1981,15 and the Framework convention on tobacco control adopted by the
WHO in 2003.16

What can health professionals do?

We can draw three main conclusions from these brief examples. Firstly, it is essential for the
health community to appreciate that, in most cases, the effect of globalisation on health is
both positive and negative. Moreover, the specific balance between the two depends on the
individuals or population groups concerned. Certain aspects of globalisation may bring
widespread benefits or costs, depending on one’s geographical location, sex, age, ethnic
origin, education level, socioeconomic status and so on. The difficult challenge is to untangle
these varied impacts and understand how they are distributed across different populations.

Second, we are only beginning to tease out the complex processes that we call globalisation
and their direct and indirect links to health. It will be essential, for example, to analyse the
impact of specific multilateral trade agreements on the health of specific populations.
Similarly, we need to understand how global changes in the environment, world economy,
population mobility and so on affect population health determinants and outcomes. In some
cases, empirical proof of causal pathways may not be possible, and methodological hurdles
may be unavoidable. Nonetheless, such evidence is needed for effective policy.

Third, and as a corollary to the above, we need to identify policy actions that better manage
the health impacts of globalisation. Globalisation is neither predetermined nor singular in its
form. David de Ferranti, of the World Bank, has described globalisation as a natural force,
like gravity, which people are powerless to stop.17 I would argue, on the contrary, that
globalisation is a social force, created and controlled by human beings. The key challenge is
to manage globalisation processes better than they have been managed in the past. This
means recognising that globalisation does not have a predetermined trajectory, but is taking
a particular form that favours certain interests while disadvantaging others. For globalisation
to be both socially and environmentally sustainable in the long term, we need a better
balance between the winners and losers. Just where that tipping point is, and how to
achieve that balance, remain fiercely debated. Nonetheless, it is clear that we are not there
yet.

Conclusion

The church of globalisation is a broad one, and its denominational factions full of perceived
sinners and saints, but lacking clear revelation of the future to lead us all forward. The health
community needs to find a way into this debate without feeling overwhelmed by it. This
means moving into unfamiliar territory and engaging in debate on subjects that have
traditionally been seen as outside the health field. As Ruggie writes,

Globalisation does not come in tidy sectoral or geographically demarcated packages. It is all
about interconnections — among people; across states, in production networks and
financial markets; between greed and grievance; among failing states, terrorism, and
criminal networks; between nature and society. The complex interrelatedness of issues and
their cumulative, often unforeseen, consequences demand far greater policy coherence than
the existing system of national and international institutions has been able to muster.18

Engaging with the globalisation debate is only the starting point. Adding informed voices,
backed by sound evidence, about the value of promoting and protecting human health will
help move the debate forward at a time when it is much needed.

B. About social determinants of health

The social determinants of health are the conditions in which people are born, grow, live, work
and age. These circumstances are shaped by the distribution of money, power and resources at
global, national and local levels. The social determinants of health are mostly responsible for
health inequities - the unfair and avoidable differences in health status seen within and between
countries.

EMPLOYMENT CONDITIONS The most important factors shaping people’s social position
include employment and working conditions. The Employment Conditions Knowledge Network
(EMCONET) developed models and measures to clarify how different types of jobs, conditions of
underemployment and the threat of becoming unemployed affect workers’ health.

Pathways by which employment and working conditions affect the health of workers and their
families were identified, with the goal of demonstrating how such knowledge can be translated
into labour and health policy measures. The health of workers and their families will ultimately be
improved by strengthening fair access to employment and the other dimensions of decent work.
SOCIAL EXCLUSIONS Exclusion consists of dynamic, multi-dimensional processes driven by
unequal power relationships interacting across four main dimensions - economic, political, social
and cultural - and at different levels including individual, household, group, community, country
and global levels. It results in a continuum of inclusion/exclusion characterised by unequal
access to resources, capabilities and rights which leads to health inequalities.

The Social Exclusion Knowledge Network (SEKN) examined the relational processes that lead to
the exclusion of particular groups of people from engaging fully in community/social life. These
processes operate at: the macro-level (access to affordable education, equal employment
opportunity legislation, cultural and gender norms), and/or the micro-levels (income,
occupational status, social networks - around race, gender, religion).

It examined the linkages between social exclusion and proximal concepts such as social capital,
networks and integration. The nature and operation of such processes and their association with
population health status and health inequalities were analyzed in a diversity of country contexts,
chosen to reflect the impact of differing structural (political, economic and social) constraints.

Public health programmes and social determinants Public health programmes often neglect
the contribution that addressing social determinants of health can make to achieving health
targets, including the Millennium Development Goals. Working with public health programmes to
identify social determinants and health equity issues specific to public health programmes, and
support to address those are important mandates of the Department of Ethics, Equity, Trade and
Human Rights (ETH).

Priority Public Health Conditions Knowledge Network (PPHC KN) was one of the Knowledge
Networks that was created to support the Commission on Social Determinants of Health
(CSDH).

Women and gender equityGender inequality damages the physical and

mental health of millions of girls and women across the globe, and also of boys and men despite
the many tangible benefits it gives men through resources, power, authority and control.
Because of the numbers of people involved and the magnitude of the problems, taking action to
improve gender equity in health and to address women’s rights to health is one of the most direct
and potent ways to reduce health inequities and ensure effective use of health resources.
Deepening and consistently implementing human rights instruments can be a powerful
mechanism to motivate and mobilize governments, people and especially women themselves.

The Women and Gender Equity Knowledge Network focused on mechanisms, processes and
actions that can be taken to reduce gender-based inequities in health by examining the following
five areas:

Factors affecting social stratification and how to improve women's status relative to men.

• Differential exposures to health-damaging factors.

• Differential vulnerabilities leading to inequitable health outcomes.

• Differential economical and social consequences of illness and reproductive health needs.

• Engendering health systems and health research.

Early child development The early child period is considered to be the most important
developmental phase throughout the lifespan. Healthy early child development (ECD)—which
includes the physical, social/emotional, and language/cognitive domains of development, each
equally important—strongly influences well-being, obesity/stunting, mental health, heart disease,
competence in literacy and numeracy, criminality, and economic participation throughout life.
What happens to the child in the early years is critical for the child’s developmental trajectory and
lifecourse.

The evidence of successful models and challenges to implementing early child development
programs (pre-natal through to eight years ) was collected from countries, international agencies,
NGOs and civil society. Criteria for successful implementation was developed for a range of
country contexts, with particular focus on low income countries. Additionally, a database of
successful program models was created and is now accessible via this site.

Globalization The scope of the Globalization Knowledge Network (GKN) was to examine how
globalization’s dynamics and processes affect health outcomes. Among the aspects of
globalization studied were trade liberalization, integration of production of goods, consumption
and lifestyle patterns, household level income. The uneven distribution of globalization’s gains
and losses and the impact it has on inequities was analyzed for its aspects to inform policies
aimed at mitigating the actual and potential harmful effects of globalization on health.

Health systems The way health systems are designed, operate and financed act as a
powerful determinant of health. Evidence on the effectiveness of different models for health
systems to improve health equity outcomes will be reviewed. In an effort to gather and
subsequently mainstream knowledge and action on how to overcome social barriers to health,
the focus will be on innovative approaches that effectively incorporate action on social
determinants of health. The recommendations will be highly relevant for countries with tight
resources.

Measurement and evidence The MEKN led on the development of

methodologies and tools for measuring the causes, pathways and health outcomes of policy
interventions to tackle the social determinants of health and health inequities. There was also an
emphasis on documenting processes of change and attributing improvements in health
outcomes to social determinants programs and policies. Guidelines on designing evaluations
include recommendations on appropriate quantitative and qualitative evidence, selection of
indicators and variables, and development of measurement tools.

This knowledge also served as a resource for the work of the other knowledge networks in
collecting evidence and for the evaluation of the Commission on Social Determinants of Health
as a whole.

URBANIZATION The Urban Settings Knowledge Network focused on broad policy interventions
related to "healthy urbanization", and closely examined slum upgrading as an entry point among
other possible interventions. The upstream determinants of healthy urbanization include:
stimulation of job creation, land tenure and land use policy, transportation, sustainable urban
development, social protection, settlement policies and strategies, community empowerment,
vulnerability reduction and better security among others.