Article Text

Download PDFPDF

Globalisation and public health
  1. D Bettcher1,
  2. K Lee2
  1. 1Framework Convention on Tobacco Control, Tobacco Free Initiative, World Health Organisation, Geneva, Switzerland
  2. 2Centre on Globalisation, Environmental Change and Health, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to:
 Dr D W Bettcher, Framework Convention on Tobacco Control, Tobacco Free Initiative, World Health Organisation, Geneva, Switzerland;


At the dawn of the 21st century, globalisation is a word that has become a part of everyday communication in all corners of the world. It is a concept that for some holds the promise of a new and brighter future, while for others it represents a threat that needs to be confronted and counteracted. In the area of public health, a wide range of claims have been made about the various impacts, both positive and negative, that can be attributed to globalisation. In the ever expanding literature on globalisation and health, it has become apparent that considerable confusion is emerging in both the ways that terminology is applied and concepts are defined. The determinants of health are increasingly multisectoral, and in tackling these challenges it is necessary to take a multidisciplinary approach that includes policy analyses in such areas as trade, environment, defence/security, foreign policy, and international law. In assembling the terms for this glossary, we have attempted to demonstrate the richness of the globalisation and public health debate, and in so doing have selected some of the core terms that require definition. We hope that this glossary will help to clarify this interesting and challenging area, and will also serve as a useful entry point to this new debate in public health.

  • glossary
  • globalisation

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


This dimension concerns changes to the creation, exchange and application of knowledge, ideas, norms, beliefs, values, cultural identities and other thought processes as a consequence of globalisation. The driver of these changes centres on the rapid spread of communication and information technologies in recent decades, resulting in a more widespread and intense flow of information across national boundaries via the mass media, advertising agencies, think tanks, consultancy firms, public relations bodies, educational institutions, scientists, and religious groups.1 The implications for public health are many. Most prominent is the influence on lifestyles (for example, diet, smoking) and health seeking behaviour. Less directly is the impact on knowledge creation and dissemination concerning health and health care through scientific research, policy ideas, training, and business and management practices. The spread of a particular set of policies under the broad theme of health sector reform, for example, has been a global phenomenon beginning in the US and UK, with support from major aid agencies, and embracing both high and low income countries over the past two decades.


Most closely associated with the origins of the League of Nations, and later the Security Council of the United Nations, is the notion of collective security that asserts that the security dilemma of states in a world without an over-arching government, is best overcome by the implementation of communal commitments whereby each state pledges to join in common actions against those which threaten the integrity or independence of others.2 To supplement these principles of state security, analysts have argued that “globalisation has made individual human suffering an irrevocable universal concern. While governments continue to be important, global integration of world markets and instant communication have given a role and a profile to those in business, civil society, NGOs, and intergovernmental organizations”.3 Therefore, an emerging definition of security also includes the safety and wellbeing of individual citizens, and can be expanded to include health matters (see human health security below).


A framework convention is a type of treaty (see definition below), and like other treaties is legally binding on those states that choose to ratify a specific instrument. Though “framework convention” does not have a technical meaning in international law, it has been used to describe a variety of international agreements, for example the Framework Convention on Climate Change, whose principal function is to establish a general system of governance for a particular issue area, and not detailed obligations. The so called framework convention/protocol approach to international lawmaking allows states to proceed incrementally. Firstly, the framework convention establishes the general norms and institutions of the regime—for example, its objective, principles, basic obligations, and institutions, as well as procedures regarding decision making, finance, dispute settlement, and amendment. Then, the protocols build on the parent agreement through the elaboration of additional (or more specific) commitments and institutional arrangements.4 By analogy, the framework convention/ protocol approach is like building a house: the foundation is comparable to the framework convention, and the protocols are analogous to completing the details of a building. For the first time in the history of the World Health Organisation (WHO), its 191 member states are negotiating, under Article 19 of the WHO Constitution, a Framework Convention on Tobacco Control (FCTC). When the FCTC enters into force and is implemented it will assist in tackling the globalisation of the tobacco epidemic.5 The “power of the process” of negotiating the FCTC is already galvanising new mechanisms of multisectoral collaboration at both national and global levels (A L Taylor, the world conference on tobacco or health, Chicago, August 2000).


Describes an indicator which was initiated in 1992 at the request of the World Bank for use in its World Development Report 1993: Investing in Health.6 This indicator quantifies the loss of healthy life from disease as measured in disability adjusted life years (DALY). The DALY is a unit that has been used for measuring both the burden of disease and the cost effectiveness of health interventions, as indicated by reductions in the burden of disease. The DALY is calculated as the present value of the future life years of disability free life that are lost as the result of the premature deaths or cases of disability occurring in a particular year.6 One of the objectives of the Global Burden of Disease is to develop projection scenarios of mortality and disability disaggregated by cause, age, sex, and region to the year 2020. These data have been used to project major threats for global health now and in coming decades, and to define “basic packages” of cost effective health interventions that national governments may use to set policy priorities. For example, based on the results of the global burden of disease project, the Ad Hoc Committee on Health Research Relating to Future Intervention Options7 identified the following threats requiring greater attention in the future:

  • Four communicable disease clusters: tuberculosis, pneumococcus, malaria, and a cluster of sexually transmitted diseases including HIV/AIDS;

  • Non-communicable diseases, especially psychiatric and neurological conditions and cardiovascular disease, cancers, and diabetes mellitus. Tobacco was identified as a major risk factor that threatens the developing world.

  • Injuries, including both unintentional injuries (such as road traffic accidents) and intentional injuries (for instance, as a consequence of interpersonal violence, suicide and war).

There has been widespread debate of the methodology and conclusions of the Global Burden of Disease approach to measuring health needs and priorities. The appropriateness of setting health priorities on the basis of economic utility, for example, has been challenged on ethical and scientific grounds. In one critique, Williams states that the “focus on diseases as the central concept is mistaken and should be replaced by a focus on interventions”, and calls for a strategic reappraisal of the Global Burden of Disease enterprise.8 In response to such critiques, Murray and Lopez urge commentators to “make the fundamental distinction between assembling the vast body of empirical epidemiological estimates of diseases, injuries and risk factors” ( a major focus of the Global Burden of Disease analysis), and “the methodological, ethical, and conceptual issues that pertain to development of summary measures of population health”.9 It is evident, however, that addressing global social policy issues in an era of globalisation will require more precise and accurate estimates of disease burdens in order to plan future interventions.


Global civil society is the extension of the term civil society to the global level. Civil society is “the space of uncoerced human association and also the set of relational networks—formed for the sake of family, faith, interest, and ideology—that fill this space”.10 While definitions vary in the types of organisations considered part of civil society, these usually include trade unions, NGOs, academic institutions, charitable foundations, religious organisations, and community groups. Some definitions include business associations while others exclude them. The fostering of civil society at many levels is considered a key feature of democratic politics. At the global level, civil society takes on additional importance given the absence or weakness of formal governmental institutions, and the strength of private sector institutions. This imbalance, it is argued, requires a strong civil society to ensure that powerful business interests are kept in check. The advent of global campaigns against prominent transnational and multinational organisations (for example, Nike, McDonalds, Nestle) is seen as a sign of the maturation of global civil society and their influence on policy change.11


During the latter part of the 20th century, humankind became increasingly aware of the need for a more collective approach to tackle certain urgent environmental problems. This recognised that the interconnectedness of human societies with each other and the natural environment was intensifying in a globalising world. Concern about climate change led to the establishment of an Intergovernmental Panel on Climate Change in 1989 to study the effects of increased emissions of anthropogenic emissions of greenhouse gases, such as carbon dioxide, methane, and nitrous oxides on global warming and climate change. Emerging scientific evidence combined with worldwide political concern led to the negotiation and entry into force in 1993 of the Framework Convention on Climate Change, and the subsequent negotiation in 1997 of the Kyoto Protocol. The links between climate change and public health were detailed in a joint report by the WHO, World Meteorological Organisation (WMO), and the United Nations Environment Programme (UNEP), which concludes that global warming and climate change due to the accumulation of greenhouse gases will probably lead to shifts in disease patterns and vector distribution, deaths from heat waves, increased trauma due to floods and storms, and exacerbation of food shortages and malnutrition in many regions of the world.12 Global environmental issues raise bioethical concerns in that one of the principal tenets of “principle based ethics” is the concept of “non-maleficence,” to do not harm.13


Governance can be defined as the sum of the ways that individuals and institutions, public and private, manage their common affairs.14

This may be through explicit rules in the form of laws, regulations, religious principles enforced by formal institutions (for example, judiciary, ministry, church), or more implicit rules such as cultural norms, custom and ethical standards enforced by more informal means (for example, declarations, voluntary codes of conduct). Global governance refers to the sum of the ways individuals and institutions manage their common affairs of a global nature. However, global governance is distinct given the absence of an overriding authority to govern (that is, government) and is thus described as governance are without government.15 This means a broader range of actors involved in global governance. Along with states, global governance is characterised by a plethora of regional and international organisations composed of state (public or interstate) members. In the health sector, these are led by United Nations organisations (for example, WHO, UNICEF). Private sector interests (for example, multinational corporations, international business associations) may also participate in global governance by seeking to influence the activities of international organisations or engaging in their own systems of governance. Finally, civil society organisations may organise across countries (for example, global social movements) in an effort to influence global governance. Charitable foundations, non-governmental organisations and health professionals have been prominent in global governance of health.


Political economy can be defined as the study of the interrelations between politics (state) and economics (market). There are many schools of thought and theoretical perspectives in political economy, some arguing that the separation of politics and economics in the first place is located in liberal theory and is historically specific. The revival of political economy as a scholarly field in recent decades has been based on a recognition of the mutual influence, even inseparability, of politics and economics. This inseparability extends to the international and global levels where the lines between the state and market become even more blurred. The term global political economy refers to this realm. It is distinguished from international political economy to emphasise those issues that cannot be reduced to national boundaries and impact on the world as a whole (for example, environmental degradation, militarisation of space).


At the national level, the concept of public goods has long been an integral part of economic theory, with its roots in eighteenth century scholarship. As defined by Kaul, Grunberg and Stern,16 public goods are non-excludable (no one can be barred from consuming the good) and non-rival (can be consumed by many without becoming depleted) in consumption. A classic example is a lighthouse. In public health, the benefits of immunisation programmes or epidemiological surveillance of infectious diseases can be described as public goods. Despite their benefits, public goods can suffer from a provision problem; by their nature public goods cannot easily be provided by the “invisible hand” of the market and therefore require government to overcome the failures of the market in order to achieve efficient allocation of essential resources. Global public goods can be sorted into two categories:

  • Final public goods are outcomes rather than “goods” in the standard sense. For example, the reduction of the burden of disease due to tobacco would be a final public good.

  • Intermediate public goods, such as international legal regimes contribute towards the provision of final global public goods. For instance, the WHO Framework Convention on Tobacco Control will contribute to the attainment of the final public good of reducing the burden of disease attributable to tobacco use.17 Disease and risk factor surveillance would be another apt example of intermediate public goods in the realm of international health.

In an era of increasing globalisation the issue of providing global public goods for health will become a more important policy issue. The challenge of providing public goods lies in the fact that in international relations there is no government; the provision of such goods at the international level has been the subject of investigation by Charles Kindleberger.18 In the sphere of international health cooperation the provision of such goods carves out a major role for cooperation between the State, civil society, and international organisations such as the WHO.


Given growing recognition of the importance of health issues that transcend national borders, increasing attention has been given to finding new forms of health cooperation that bring together a more diverse range of actors to address specific challenges. GPPPs are one such form of cooperation, defined as collaborative relationships that transcend national boundaries and bring together at least three parties, among them a corporation (and/or industry association) and an intergovernmental organisation, so as to achieve a shared health creating goal on the basis of a mutually agreed and explicitly defined division of labour. While public-private partnerships have long been found in health development, the distinct features of GPPPs are the closer links between the UN and private companies, and the forms of governance that define these relationships. The change in the role of private companies, from financial contributors to participants in decision making bodies, is of particular note. Specific GPPPs that have been formed in recent years largely focus on specific disease areas. These may be product-based (for example, Malarone Donation Programme), product development based (for example Medicines for Malaria Venture), or systems/issues-based (for example, Children's Vaccine Initiative).19


Social policy is traditionally concerned with “those state and nongovernmental activities within one country that are designed to intervene in the operations of the free market in the interests of social protection and social welfare”.20

Amid globalisation, the increasingly transnational activities of the private sector circumvents and even undermines the capacity of individual countries to ensure social protection and welfare. The latter is concerned with the so called “race to the bottom” whereby countries competing for foreign investment may reduce their social policy standards to be more economically attractive. This has led to discussion of the need for effective social policy institutions in a global era, either through closer cooperation among states or supranational authority over transnational corporations.


A metaphor originally coined by Canadian scholar Marshall McLuhan to describe the perceived experience of the world, as a result of modern communication technologies, as a more familiar and shared society. The image juxtaposes the vast geography of the globe with the closeness and shared identity of village life. This is a generally positive view of globalisation as a bringing together of people across different countries and cultures through technological advances.


The term globalisation is a highly contested one that is defined in a wide range of ways. It is also often confused with similar terms such as internationalisation (see internationalisation below) and regionalisation. The original meaning of “global” is whole or entire. Globalisation can be defined as a set of processes leading to the creation of a world as a single entity, relatively undivided by national borders or other types of boundaries (for example, cultural, economic). Lee1 defines globalisation as processes contributing to intensified human interaction in a wide range of spheres (that is, economic, political, social, environmental) and across three types of boundaries—spatial, temporal and cognitive—that have hitherto separated individuals and societies. While the diminished importance of spatial boundaries (deterritorialisation), notably national borders, have received the majority of scholarly and policy attention, globalisation is also impacting on the timeframe of human interaction and our thought processes. The substantial literature about globalisation is divided along many lines, notably whether or not globalisation is occurring, the extent or speed to which it is happening, and whether it is having positive or negative impacts on individuals and societies.


The HDI was constructed by the United Nations Development Programme (UNDP) to measure average achievements in basic human development in one simple composite index and to produce a comparative ranking of countries. The HDI reflects achievements in the most basic human capabilities—leading a long life, being knowledgeable and enjoying a decent standard of living. Three variables are chosen to represent these dimensions, namely life expectancy, educational attainment, and income. In order to monitor disparities, the UNDP has recently expanded their menu of indicators to include a gender related development index (GDI) to capture achievements in basic human development adjusted for gender equality; the gender empowerment measure (GEM) to measure gender inequality in economic and political opportunities; and the Human Poverty Index (HPI), which is a multidimensional measure of poverty. Within this context of global development disparities, the UNDP Human Development Report 199921 reviews the prospects for attaining “globalisation with a human face.”


The study of security issues in international relations has been extended by some analysts beyond inter-state military force to include emerging threats, including environmental degradation, economic instability, ethnic violence, and health. Often these new threats stem from complex systems, both natural (the ecosystem) and human made (the global economy), in which individuals, states, and the system all play a part, and in which economic, societal, and environmental factors are as important as political and military ones.22 Moreover, the complex web of democratisation, human rights, and individualism that define many modern societies has shifted the referent object of security from the state to the individual. In this regard, Axworthy3 observes that “globalisation has made individual human suffering an irrevocable universal concern.” In this respect, a central security obligation of governments is the safety and wellbeing of its citizens. Many health risks, including the spread of infectious diseases, drug addiction, bioterrorism, civil violence, and the spread of small weapons, constitute threats to global public health and political stability. In order to appropriately address health in this context, security must imply a dynamic development oriented concept that seeks to find solutions to problems at their source. In 2000, the United Nations Security Council adopted its first resolution on a health issue, asking countries to wage a “peaceful war” against HIV/AIDS. When debating the issue in the Security Council, US Ambassador Richard Holbrooke stated, “AIDS is as great a security challenge as we have faced since the founding of the Security Council.” A school of thought is emerging that moving health issues, like AIDS, on to the security agenda offers an opportunity to shift security away from a focus on balance of power politics and self help in international relations towards the attainment of a more secure and humane international society. These developments could be seen as an updating of the thinking of liberal internationalism and functionalism of the post second world war era that led to the establishment of the United Nations, of which David Mitrany is perhaps the most prominent writer. He argued that functions of everyday social life, including health, are no longer carried out assiduously within the confines of individual states but are undertaken across frontiers on a regional, continental, or universal basis. These activities would be overseen by international organisations, like WHO, and non-governmental organisations. Not only would this development benefit general social welfare of the world, he argued that it would help to solve the problem of peace and security.23


A concept from discussions of global public goods whereby it is argued that international cooperation on certain types of issues can be undermined by a lack of motivation to do so. International cooperation is broader in scope than before, moving from interstate and at the border issues (for example, rules governing international aviation) to behind the border issues (for example, prevention of infectious disease). The implementation of international agreements are more important than ever, but much of these operational activities are heavily reliant on aid mechanisms. This ignores the practical benefits of international cooperation to all countries, and requires other policy options that strengthen the incentive to strengthen the operationalisation of such cooperation.16


A term which implies that actors are interrelated or connected in such a way that, if something happens to at least one actor, then the other actors will be affected. Whether all actors are affected equally will define whether the interdependence is symmetrical (mutual interdependence) or asymmetrical (dependence). Within the context of globalisation, interdependence is frequently used synonymously. Hence, globalisation is often defined as leading to the increased mutual interdependence of individuals and societies on one another (for example, global environment). However, they are distinct terms. While globalisation can be described as creating a greater degree of interdependence, there remain fundamental questions about the direction, duration, seriousness and balance of the dependencies involved. Given stark inequalities in resources, mobility, power, and other capabilities, certain individuals and societies are more vulnerable to adverse consequences of global change.


Modern international organisations can be broken down into two main types: the public “variety” known as intergovernmental organisations (IGOs), for example the WHO; and the private variety, which are referred to as international non-governmental organisations (INGOs), such as Amnesty International and the International Committee Red Cross.

International intergovernmental organisations are formal institutional structures that function across national borders and come into existence through multilateral agreement. IGOs are established by formal agreement between states (that is, treaties) and states retain ultimate authority over these organisations. In a world faced with increasingly complex global problems international organisations provide important channels of communication and mechanisms for engendering international cooperation and action on a multiplicity of issues and fronts. These organisations represent important actors in an increasingly complex global governance structure.2


A term drawing on a medical analogy to describe the different ways in which events in one country may spread and affect a possible crisis, in other countries. It has been used most prominently in recent years to describe the global financial crisis of the late 1990s that began in South East Asia and rapidly spread to other parts of the world notably Latin America and eastern Europe. Given far greater financial integration of national economies, characterised by the growth of foreign direct investment, financial deregulation, and the advent of the “electronic herd” of small investors worldwide,24 financial crisis in one part of the world can quickly impact on other economies in a global economy. Contagion theory can also be applied to other events that have possible spillover effects on other countries, such as population movements and environmental hazards.


The WHO International Sanitary Regulations were adopted under Article 21 of the WHO constitution by the Fourth World Health Assembly in May 1951 as a revision and consolidation of International Sanitary Conventions that have roots in the International Sanitary Conferences of the 19th century. These regulations were again revised in 1969, and renamed the IHR. The regulations were originally adopted to protect public health from the spread of certain infectious diseases amid burgeoning international trade links across the world. A core axiom of these regulations remains that measures taken should “ensure the maximum security against the international spread of disease with the minimum interference with world traffic” (a principle that includes interstate trade). Despite the further intensification of trade and other global links in recent decades, the regulations remain the only existing international legislation to protect public health from a global threat of selected (that is, cholera, yellow fever and plague) communicable diseases.25 These legally binding regulations are currently being revised and updated under a process initiated by a World Health Assembly resolution of 1995. Proposals are now being made within the framework of the revision of the IHR to include the use of WHO's global alert and response network as an additional source of information on public health risks of urgent international importance together with reports from countries. The use of a more flexible means of defining the jurisdiction of the IHR beyond a few named diseases, such as a syndromic or decision tree approach, is being explored.26 The revision of the IHR is an important step in confronting the health security threats posed by the globalisation of infectious diseases.


The body of rules binding on states and other subjects of international law, in particular international organisations, in their relations with each other.27

Closely related to the concept of sovereignty (see Sovereignty) of states, the norms of international law are binding because states consent that they should be. The expression of this consent appears from the actual practice of states in the case of customary international law and from ratifications in the case of treaties, to which the concept of pacta sunt servanda applies,28 which asserts that treaties are binding on the parties to them and must be executed in good faith. To the extent that the rules of international law influence the behaviour of states in world politics they constitute a “social reality”, thus constituting an institution of “international society”,29 or proof of the existence of an international community.30 As the society of states is not characterised by the existence of a formal written constitution and an international legislative body, such as is the case within states, there are various sources of international law.2 These sources are listed in Article 38(1) of the Statute of the International Court of Justice as follows:

  • International conventions (see Treaties), which are binding on just the parties thereto;

  • International custom, which describes the rules derived from the general practice, based on the perception of a legal requirement, among states in international relations, and are, with few exceptions, binding on all states;

  • General principles of law, such as “good faith” recognised by civilised nations, which are also binding on all states;

  • Judicial decisions, for example of international tribunals, and the writings of eminent scholars help to determine the existence and the interpretation of these several types of binding rules.

More recently, several other writers have asserted that the sources of international law may not be confined to those defined by the Statute; “soft law”, for instance non-binding resolutions of international organisations, are also cited as credible sources,31,32 consists of rules that are not actually binding but that are expected to be and usually are complied with, and that may gradually harden into binding law.

In an era of globalisation the structures of governance are changing, and according to Basedow,33 in order to maintain a hold on the economic and social conditions in their respective countries, states will try to enact supranational regulations (either at the global or regional level). Therefore, the role of international law in regulating a globalised world is envisioned by some thinkers as becoming more prominent. The relevance of international conventions to public health, such as the proposed Framework Convention on Tobacco Control, and rules formulated by international organisations such as WHO's International Health Regulations, are outlined elsewhere in this glossary. Norms of customary international law, for example the customary duty to notify other states of infectious disease outbreaks, are also relevant to international public health in a rapidly changing world.34


The term international regime refers to the convergence and acceptance among a group of states of mutual expectations, rules and regulations, organisational plans, energies, and financial commitments.35 For instance, in the sphere of global public health the mutual expectations of the Member States of the WHO have recently converged around the idea of negotiating rules and regulations, in the form of a Framework Convention on Tobacco Control. These mutual expectations and future global rules and regulations for tobacco control constitute a new international regime. Regime theorists in international relations believe that humankind's survival depends on our capacity to mutually regulate global activities by means of international regimes.36


The discipline of international relations is “the study of the nature, conduct of, and influences upon, relations among individuals or groups operating in a particular arena within a framework of anarchy”.37 The term anarchy refers to the absence or weakness of overarching (supranational) authority above the level of the state. The primacy of state sovereignty means that the state retains formal power and authority over its designated territory and population. Traditionally, the study of international relations has focused on the role of the state and interstate interactions. In recent decades, however, recognition of the importance of nonstate actors (that is, private companies, civil society) and the development of limited forms of supranational authority (for example, European Union) has shifted attention to the complex interdependencies between and across states.


Internationalisation processes are “the simple extension of economic [or other types of] activities across national boundaries. It is simply a quantitative process which leads to a more extensive geographical pattern of economic activity.” This is qualitatively distinct from globalisation processes in the sense that globalisation “involves not merely the geographical extension of economic activities across national boundaries but also—and more importantly—the functional integration of such internationally dispersed activities”.38


A concept from discussions of global public goods that argues that there is a discrepancy in governance authority between a globalised world and one divided into separate national units of policy making. Policy making remains predominantly national in focus and scope, and traditionally focused on diplomacy between national governments. However, many of today's challenges go beyond national borders and involve actors and forces that are transnational in nature. Global governance in most policy areas, including health, remains weakly developed, leaving a gap in jurisdiction over who should and can act effectively to address global policy issues.


Liberal philosophy distinguishes “economic” life from “political” life, and privileges “economics” based on the principle of “individual market rationality.” The present incarnation of liberalism, a major driving force behind economic globalisation, is the concept of “neo-liberalism”, which extrapolates liberal thinking to the international system of states, arguing that “unfettered global markets” and a “consumer-based individualist ethic” transcends national communities, and thereby providing an efficient mechanism on which to base a new global economic order.39


Multinational describes activities taking place in more than one country, and a multinational corporation is a business concern operating in more than one country. It is distinct from a transnational corporation (TNC) by the structure of its business. TNCs operate as a single headed business, with branches of its operations in different countries. MNCs are many headed, replicating its business structure in different countries (for example, McDonalds, British American Tobacco Company). Importantly, MNC activities may not necessarily involve a great deal of international business but may be largely confined to domestic business in those places where it has a presence. In practice, most MNCs have a strong international business structure and network including source of materials, networking technologies, expertise, and clientele.


The term NGO is variably defined but is essentially characterised by non-affiliation with government and the state sector. Sometimes used interchangeably with terms such as grassroots organisations, voluntary sector, civil society, independent sector and non-state actors, the key features of the term NGOs in popular use denotes organisations that are non-profit making, non-violent, organised group of people who are seeking to influence policy but are not seeking government office.40 In addition, they are voluntary in membership and seek to remain independent of state influence. Definitions of NGOs generally exclude for-profit organisations (that is, private companies, business associations), criminal organisations, political parties, mass media, insurgent movements and churches in their strictly religious sense.41 NGOs vary remarkably in size, resources, scope of activity, and goals. They range from the hundreds of thousands of local community groups around the world to large, relatively well funded and transnational NGOs such as Oxfam, Médecins Sans Frontiéres, and Save the Children.


A concept from discussions of global public goods that argues that, despite the emergence of new actors (that is, global civil society groups and private sector actors) with activities and influence across national borders, international cooperation remains primarily an interstate or intergovernmental process. Many of these actors, notably civil society groups, remain on the fringes of formal policy making, thus undermining efforts to address global policy issues. This gap in participation is especially relevant for the poorly resourced, disadvantaged and marginalised people who struggle to have a voice in global policy dialogues. Others are concerned that large private sector interests are wielding increased influence non-commensurate with mechanisms of accountability and transparency. Globalisation thus raises the challenge of how to create democratic political systems at the global level that enable relevant stakeholders to be appropriately heard.


As part of promoting sustainable development in an increasingly globalised world (that is, environmentally sustainable approaches to social and economic development) the polluter pays principle is an important one. As public health is intimately linked to the integrity of the environment, the principle is also salient for global public health policy in the 21st century. The polluter pays principle, as first enunciated by the Council of the Organisation for Economic Cooperation and Development (OECD), states:

that the polluter should bear the expenses of carrying out the measures . . .to ensure that the environment is in an acceptable state. In other words, the cost of these measures should be reflected in the cost of goods and services which cause pollution in production and/or consumption. The uniform application of this principle, through the adoption of a common basis for Member countries' environmental policies, would encourage the rational use and the better allocation of scarce environmental resources and prevent the appearance of distortions in international trade and investment.42


A principle that “exhorts the adoption of prudent social policy ahead of empirical scientific confirmation of `the facts'. Precaution can be applied in remedial action, moving to reduce environmental damage ahead of full knowledge of the consequences of that existing damage, and in the pre-emptive assumption that proposed environmental changes are likely to have adverse consequences”.43 The need to apply the principle has been debated in relation to a wide range of public health issues of a potentially global nature, and where a substantial degree of uncertainly exists, such as the health and environmental risks of genetically modified organisms, and the health effects of global climate change. Recent debates have focused on the existing rules of the WTO that require parties seeking to impose trade restrictions on the grounds of protecting public health to provide empirically-based “burden of proof”. This requirement has been criticised, using the precautionary principle as a reference point, as constraining policy actions needed to address current and potentially irreversible risks, on the basis of the limitations of present scientific knowledge.


A core principle in international relations is sovereignty, which presupposes the existence of independent political communities, each possessing a government that asserts its sovereign authority over a specific territorial land mass and a particular population. Hedley Bull proposes that the concept of sovereignty consists of external sovereignty, which infers independence of a particular state of outside authorities, and internal sovereignty, which means supremacy of the state over all other authorities within its territory and population.29 Globalisation theorists such as Scholte argue that: “the concept of sovereignty continues to be important in political rhetoric, especially for people who seek to slow and reverse progressive reductions of national self-determination in the face of globalisation. However, both juridically and practically, state regulatory capacities have ceased to meet the criteria of sovereignty as it was traditionally conceived”.44


This dimension concerns changes to how we actually experience and perceive physical space as a consequence of globalisation. On the one hand, there is a feeling of the world as a single place, the so called “global village,” as we are brought together across the boundaries of nation-states by the increasing interrelatedness of our social and natural environments. Most prominently, the global economy is leading to a reconfiguration of how we produce and exchange goods and services worldwide. Also, innovative conceptualisations of space are emerging through the spread of communication technologies (for example, cyberspace, virtual reality). On the other hand, many argue that globalisation creates new divisions that threaten to fragment the world along new lines. Interstate and intrastate conflict remains a defining feature of international relations in a globalising world, accompanied by new divisions across societies between the global haves and have nots. The spatial dimension is thus about the reterritorialisation, rather than deterritorialisation, of human interactions. Physical geography remains highly central to how individuals and societies come together, but the nation state increasingly does not define these interactions. The impact on public health concerns how many of the determinants of health, traditionally addressed by nationally defined health systems, can no longer be confined to nation states. Forces such as global environmental change, human migration, illicit drug trade, antimicrobial resistance and the global economy requires a rethinking of how we define and respond to the determinants of health.


The core building block of international relations is the state which, in international law, is said to exist when a government is in control of a community of people living in a defined territory. In international relations each state is also commonly referred to as a country. During the 19th century the political legitimacy of states was increasingly rooted in the political loyalty of the nation, a group of people that share a common identity, with that loyalty focusing on a common homeland. The principal difficulty in fusing the two concepts into the term nation state, hinges on the fact that each state usually consists of several nations, and in turn, these national communities do not always recognise the legitimacy of the state in which they are situated.45 In strict terms, when a state is inhabited predominantly by a single people with shared national or ethnic identity (for example, Japan), the term nation state is used. The US, Canada, and Australia are examples of states with multiethnic populations and are thus states rather than nation states. Also, in a world of increasing cultural globalisation national loyalties often cut across state borders, and may command greater political loyalty than to any particular state.


The depletion of the ozone layer and the international actions to confront this environmental problem provides a case study of concerted global action of states and civil society. The depletion of the stratospheric ozone layer is due to manmade chemicals, especially chlorofluorocarbons (CFCs); the documented health effects of depletion of stratospheric ozone includes skin cancer in light skinned populations, an increased incidence of cataracts, as well as a probable weakening of the human immune system.12 Such concerns as these led to the negotiation and implementation of the Vienna Convention on Ozone Depletion and the subsequent Montreal Protocol. The effective implementation of these treaties has led to a reduction of global consumption of CFCs by more than 70% from 1.1.million tons worldwide to 160 000 tons between 1986 and 1996.46 As a result of these reductions, atmospheric concentrations of ozone depleting substances are levelling off or are beginning to decline.46 More than any other example of global cooperation, the reduction of CFC consumption provides a major success story for humanity living in a increasingly globalised world.


The structural adjustment policies adopted by the International Monetary Fund (IMF) and the World Bank since the 1980s have the paramount aim to enhance the external viability of the adjusting countries and the stability of the international financial system, and are consistent with the overarching liberal ideology that drives globalisation processes in the financial and trade sectors. The macroeconomic objectives, advocated by the IMF involve devaluation, public spending reduction, tax increases, and tighter monetary policy. The World Bank's policies, which followed the IMF measures, involve reducing the role of the state, for example through privatisation and opening up of the economy.47 Criticisms of structural adjustment policies began to emerge shortly after their introduction in the 1980s. Early studies argued, inter alia, that adjustment policies failed to protect key health and education spending on the supply side, and on the demand side adversely affected household access to health services.48 Another study “Adjustment with a human face”,49 argued that structural adjustment policies needed to pay more attention to pro-poor adjustment programmes.”


A term popularised by the UN World Commission on the Environment and Development in 1987 that defines sustainable development as “meeting the needs of today's generation without compromising the needs of the future generations.” The term “sustainable” has subsequently come to be used extensively in debates about economic development, often in an ambiguous and contradictory manner. If development is defined in terms of economic growth, the aims of improving the quality of human life to the material standards of high income countries and protecting the environment from long term degradation and depletion are contradictory. If development refers to social equity, protection of ecosystems and increased life satisfaction from resource sparing activities, then it can be considered ecologically sustainable. As such, ecologically sustainable development means “social and material progress within the constraints of sustainable resource use and environmental management”.43 This requires use of renewable resources (for example, trees, animals and soil) at rates no faster than they can be regenerated; use of non-renewable resources (for example, fossil fuels) at rates no faster than substitutes can be found; and generation of pollutants at rates no faster than can be absorbed and neutralised by the environment.


This dimension concerns changes to (largely an acceleration of) the actual and perceived timeframe in which human interaction occurs as a consequence of globalisation. Largely enabled by modern communication and transportation technologies, cross border flows of people, goods and services, financial capital, ideas, and other variables is happening at an increasingly faster rate.1 The most prominent impact on public health is on the spread of infectious disease worldwide. Diseases such as HIV/AIDS, cholera and influenza are being given the opportunity to spread more rapidly as a consequence of globalisation.


The links between trade and health can be traced back to the Black Death, which followed international trading routes in the 14th century. Though many of cross border challenges associated with international trade are admittedly not new, it has been argued that the global public health challenges of today exceed those of earlier periods by an order of magnitude, for example the increased velocity and density of human travel across borders has magnified the risk of disease transmission between countries. On the one hand, global trade offers opportunities for public health improvements by the potential diffusion of information technologies to developing countries. On the other hand, the negative health repercussions of trade and financial liberalisation, such as the extended promotion and marketing of harmful commodities, especially tobacco, cannot be overlooked.50,51


The increased globalisation of health services is being manifested by four main modes of supply: firstly, the movement of natural persons, for example medical personnel, to supply medical services; secondly, the movement of persons as consumers, for instance, patients travelling abroad to access medical services; thirdly, the establishment of a foreign medical presence exemplified by the penetration of foreign markets by new forms of business organisations, such as Health Maintenance Organisations (HMOs); and finally, cross border trade in health services, which has been facilitated by the use of services such as telemedicine to provide health services to poor countries and also to remote regions within countries. The General Agreement on Trade in Services (GATS) is one of the main pillars of the WTO, and has provided the first multilateral framework for regulating and liberalising trade in services, including health services.52


This is a general term for the gradual reduction or complete removal of existing impediments to trade in goods and services. This term is directly related to the concept of “free trade”, which may be the ultimate aim of trade liberalisation, but a more practical goal is “freer trade.” The reduction of investment restrictions may also be covered by this term if investment in a target market is necessary for the realisation of effective market access.53 Trade liberalisation in the postwar world is an integral part of the construction of a postwar liberal monetary system, also known as the Bretton Woods order. As one of the three pillars of this order (alongside the International Monetary Fund and the International Bank for Reconstruction and Development—that is, World Bank), an International Trade Organisation (ITO) was proposed. Because it was never ratified by the US, an interim facility, the General Agreement on Tariffs and Trade of 1947 (the progenitor of the present WTO) was established.54 Conflicts between labour standards and environmental protection have emerged as one impediment to further trade liberalisation.55 Also global public health issues and trade liberalisation are closely linked; trade liberalisation is associated with transborder health risks and benefits. It has been proposed that “healthy trade” policies, based on firm empirical evidence and designed to protect and promote health status, are an important step towards reaching a more sustainable form of trade liberalisation.50


Intellectual property refers to rights of ownership placed on certain ideas, inventions and creative products by an individual or organisation. Types of intellectual property are copyright, patent, and trademark. Intellectual property was one of the “new issues” negotiated in the Uruguay Round of negotiations, which led to the establishment of the WTO. Because of the increasing globalisation of economic activities in the latter part of the 20th century, there was a growing demand from industrialised economies and multinational companies for the protection of intellectual property. The proposals for such an agreement were initially opposed by most developing countries, on the grounds that the agreement would constitute the transfer of rents from South to North. The resulting agreement, the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), is much broader than any previous international agreement in the field. The agreement established minimum global standards governing the scope, availability and use of intellectual property rights, and extended patent protection, including both product and process patenting, to a minimum term of 20 years from the filing date. In the area of health, this agreement is directly linked to pharmaceutical and health technology patents; has implications for trademark provisions for harmful products such as tobacco; and is relevant for the transfer of scientific knowledge to developing countries.50


This term is used to indicate those “risks to human health that transcend national borders in their origin or impact”.56 The diversity of interpretation attached to the constitutive elements of the term is indicative of the broad range of hazards that may be described by it. “Transborder” indicates the crossing of national frontiers, and is often used interchangeably with transboundary, the latter term being widely used in the context of environmental risk (as in the Basel Convention on the Control of Transboundary Movements of Hazardous Wastes, 1989, and the Convention on Long-Range Transboundary Air Pollution, 1979). The terms are not necessarily entirely synonymous, because boundary refers to the specific line of demarcation between jurisdictions whereas border may also apply to a region within which such a line(s) is situated.57 Transborder health risks may be identified across the various categories generated by the risk literature, including the longstanding distinction between objective and perceived risk. They are particularly significant in the context of what has been identified as the emergence of risk society, whereby naturally occurring external risks are superseded by newly pervasive manufactured risk; for Giddens58 “very few new-style risks have anything to do with the borders of nations.” Transborder health risks are clearly closely linked with globalisation but can also accompany regionalisation. Moreover, while they may be regarded as increasing in scale and significance, they are not intrinsically new. The historical development of national public health systems can be traced to the medieval emergence of quarantine in response to outbreaks of plague and cholera.


The literal meaning of transnational is “across nations,” but the term is widely used to mean activities that cross state rather than national (international), boundaries. This may be activities that cross above (global) or below (subnational) state boundaries in ways that cannot be reduced to the boundaries of states, nor often times can be controlled by governments. A prominent example of transnational activities is the use of the internet of which governments are struggling to regulate. Similarly, flows of financial capital (money and credit) across states challenge the control of states to make economic policy and protect countries from financial crisis.


This term refers to a business concern that is essentially based in one country but with elements of its operations (for example, primary resource extraction, manufacturing, assembly) located in other countries. It is distinct from a MNC by the structure of its business. Key financial and strategic decisions are taken at the headquarters of a TNC, which are then translated into practice throughout the company's different operational arms. Examples of TNCs are Monsanto, Sony Corporation, and Glaxo-Wellcome.


A treaty is an international legal agreement concluded between states in written form, and governed by international law, whether embodied in a single instrument or two or more related instruments.59 Alternative names for treaties include pact, covenant, and convention, and are binding legal agreements between countries that choose to ratify a given instrument. The WHO Framework Convention on Tobacco Control will be a type of treaty.


The United Nations came into being with the adoption of the Charter of the United Nations at the San Francisco Conference in 1945. Building on the experience , but at the same time trying to correct the problems, of the League Nations from the interwar period, the founders of UN were determined to create a new intergovernmental organisation (see intergovernmental organisation) to ensure peace and to create the economic, social and political underpinnings by which these goals could be achieved.2,60 Built on the twin tenets of state sovereignty and collective security (see state sovereignty and collective security), there was optimism that “the world community of tomorrow will grow out of the United Nations of today as the United Nations of today has grown out of the League of Nations of yesterday, and League itself grew out of the Concert of Europe”.61 Reflecting the central concern of the United Nations system, namely security, one of the main pillars of the central system is the Security Council. Another central organ of the UN is the General Assembly, a world assembly of representatives of all of the members, which functions as a world forum. The central system also consists of the Secretariat, headed by the Secretary General, and the Economic and Social Council (ECOSOC). The General Assembly alongside the Secretariat and ECOSOC are responsible for overseeing the activities of other institutions which comprise the United Nations system; in addition to the central system, the UN system is comprised of two types of institutions, Specialised Agencies (for example, WHO) and Funds and Programmes (for example, United Nations Development Programme and the World Food Programme).60 The new global challenges of the post-Cold War era, and the emergence of New Agenda problems, including environmental degradation, HIV/AIDS, international terrorism, and refugees, has stimulated the need for major UN global conferences, for example focusing on the environment in Rio in 1992 and on population in Cairo in 1994.62 Recent analyses have argued for enhanced multisectoral collaboration across the UN system to address globalised public health problems,63 and have emphasised the important part that intergovernmental organisations, such as the UN, can play in the provision of global public goods (see global public goods), including those to improve public health.16 There are at least five UN organisations with substantial involvement in global health activities, leading to considerable confusion over their distinct and appropriate mandates. The identification of each organisation's comparative advantage, from the local to the global level, is one way of understanding what each organisation does best and perhaps should be doing.64


The present society of states, upon which many of the core principles of today's discipline of international relations are based, can be traced back to the Peace of Westphalia in 1648, which concluded the Thirty Years' War in Europe. The series of treaties agreed at Westphalia gave rise to a system of international relations based on the principle of statehood and state sovereignty. The modern post-Westphalian state was a centralised, formally organised political entity that exercised comprehensive, supreme, unqualified, and exclusive control over its territory. It also recognised the legitimacy of all forms of government and established the notion of religious freedom and tolerance. This secular concept of international relations replaced the medieval idea of a universal religious authority (that is, Holy Roman Empire) acting as final arbiter of Christendom. Analysts such as Scholte44 have argued that, in an era of “intensified globalisation” and interdependence, the Westphalian state order is a historical phenomenon and sovereign statehood is not a timeless, natural condition.


A major impetus for the liberalisation of global trade has been the eight rounds of multilateral trade negotiations held over the past 50 years, the most recent being the Tokyo and Uruguay Rounds. The conclusion of the Uruguay round negotiations in 1994, marked by the Final Act, transformed the General Agreement on Tariffs and Trade (GATT) into a permanent international organisation, the WTO. With about 90% of world trade carried out under its normative framework, WTO is the principal international institution for the management of international trade.50 The legal framework constituting WTO has been compared to a tricycle: “a driver (WTO), two large wheels (Multilateral Agreement (in Goods) Agreements (MTAs) and the General Agreement on Trade in Services (GATS), and a smaller one (Trade-related Aspects of Intellectual Property Rights (TRIPS))”.65 With respect to public health, Article XX(b) under the General Exceptions section of the General Agreement on Tariffs and Trade (1994)* allows each contracting party to set its human, animal or plant life or health standards if these restrictions do not represent an unjustifiable discrimination or a disguised restriction on international trade. This public health provision was recently upheld in a WTO dispute settlement panel, which upheld a French ban on asbestos that was challenged by Canada. Similarly, other WTO agreements, for example the Technical Barriers to Trade (TBT) (Article 2(2)) and the TRIPS Agreement (Article 8), contain similar provisions for the protection of public health and safety.



  • * Under the single package of MTAs, Article XX(b) is part of GATT 1994, which contains the provisions of the original GATT 1947 as rectified, amended or modified.

Linked Articles