In a recent Foreign Affairs article, Laurie Garrett argues that the current economic crisis represents “a watershed moment for global public health” because of the probable stagnation of development assistance for health. In fact, the situation is even more serious than Garrett’s analysis would indicate, because of the interaction of multiple crises in which the stakes for social determinants of health are even higher.

Nutrition is one of the most basic prerequisites for good health. Sharply rising food prices in 2007-08 led to short-term increases in undernutrition in many low-income countries. The health and social consequences will probably multiply over the longer term—for instance, because parents are forced to choose between buying food and paying school fees. In the low-income world, the financial crisis that spread across the globe in 2008 magnified the effects of food price increases on the poor. Elsewhere, it has ‘brought the war home’ to many OECD economies, with unemployment above 23% (50% for youth) in Spain, an invisible army of 14 million U.S. households facing foreclosure, and more than 46 million Americans (including almost one in four children) receiving the federal food vouchers known as Supplemental Nutrition Assistance (food stamps). Again, the longer-term consequences for health are uncertain, but likely to be substantial and to operate across generations.

“It is difficult to envision mechanisms for controlling multiple crises and their health impacts without commitments on the part of national governments to both domestic and multilateral regimes of regulation and redistribution.”

Climate change unfolds over a longer time scale, but some effects may already be upon us. A 2009 analysis in The Lancet describes global warming as “the biggest global health threat of the 21st century” because of impacts including the expanded range of disease vectors, increased incentives for migration, and effects on crop yields.

These multiple crises have several features in common. Worst affected by financial volatility, food insecurity and climate change are poor and otherwise marginalized people who had no role in creating the crises and have no control over their outcomes. Financial volatility and climate change, in particular, impose large negative externalities far outside the borders of the countries that contribute most to the problems. Financial stability and climate stability also represent true public goods, which will remain seriously undersupplied in the absence of both national and supranational mechanisms of regulation and accountability.

To understand the formidable challenges involved, think of an analogy with lighthouses—the textbook example from the pre-GPS era of how to supply a public good. In the absence of lighthouses, during the eighteenth and early nineteenth centuries, wreckers in coastal England would appropriate the cargo of shipwrecked vessels (and, in extreme cases, would actually lure vessels onto the rocks). Trying to stabilize today’s world financial system through re-regulation is like trying to build lighthouses in a world in which a large, wealthy wreckers’ lobby funds political campaigns and former wreckers are often placed in charge of granting lighthouse permits. Reducing greenhouse gas emissions may be an even more daunting task because of the domestic power of both energy producers and energy-using households (as we in Canada know all too well). Yet success on both fronts is essential in order to avoid a future of deepening health disparities both within and across national borders.

Food is not a public good, and the world’s food system is increasingly dominated by transnational corporations and buyers at the top of global commodity chains. After a decline in 2008, as agri-commodity prices tracked oil prices downward, food price indices again began a steady climb. By August 2011, one widely-used index was higher than at its earlier peak, despite oil prices far below their recent levels, and despite the demand-dampening effects of recession. Higher prices and more volatility are probably the new normal. Fighting food insecurity will be further complicated by the accelerated pace of major acquisitions of agricultural land for export production (‘land grabs’) by foreign investors and food-importing governments. The extent of this phenomenon (which is sometimes financed by the commercial arm of the World Bank) is unclear;  in April 2011, the largest international conference on land grabs heard estimates of recent acquisitions totalling 80 million hectares (about three times the area of the United Kingdom).

The land grab phenomenon suggests that if one characteristic of the new global health policy environment involves generation of large-scale, cross-border negative externalities, another is an intensification of cross-border bidding wars in which the rich simply outbid the rest of the world’s population for valuable resources. An interesting parallel can be drawn with the growth of medical tourism, in which affluent foreigners buy access to developing country health systems—often with no local benefits except to the revenue streams of care providers.

For equitable responses, two points are especially important. First, researchers and practitioners in global health must overcome a certain learned helplessness with respect to globalization and international political economy. Basic familiarity with these spheres should become recognized as a core competency. Collaborations with social scientists working in relevant disciplines must be encouraged and nurtured rather than disparaged (as is often the case within medicine and health sciences, at least).

Second, the pursuit of ‘post-Westphalian’ governance as a solution to multiple crises is a mistake.  Although globalization has shifted power to largely unaccountable private actors such as transnational corporations, bond investors and credit rating agencies, the nation-state is alive and well. It is difficult to envision mechanisms for controlling multiple crises and their health impacts without commitments on the part of national governments to both domestic and multilateral regimes of regulation and redistribution. The core question remains that of whose interests, and which projects, are favoured and advanced by the state.

Ce billet est basé sur un article dans Global Public Health.

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