Greg Guest, ed. Globalization, Health, and the Environment: An Integrated Perspective. Lanham: Alta Mira Press, 2005. 288 pp. $80.00 (cloth), ISBN 978-0-7591-0580-5; $30.95 (paper), ISBN 978-0-7591-0581-2.
Reviewed by Sunil Amrith (Birkbeck College, University of London)
Published on H-Environment (November, 2006)
Forty years ago, Rene Dubos wrote in Man Adapting that "demographic changes have been so large and so rapid during recent decades that they have come to play an increasingly important role in determining the social patterns of disease." "In particular," he argued, "a host of difficult medical problems have been created by the mass population movements so characteristic of our times--whether involuntary, as in the case of refugees, or voluntary." At the same time, he suggested that "almost daily and in every part of the world, new health hazards arise from modern technology. Some of these hazards make an immediate public impact, for example radiation fallout, the acute effects of smog"; others took generations to manifest themselves. Embellished and updated, this is essentially the message of this collection, Globalization, Health, and the Environment.
There is little in this book that is new or surprising; rather, it provides a helpful illustration of some familiar themes. Like many similar collections of essays, this one is very uneven. To begin with, much of the discussion of "globalization" in this book relies too much on well-worn generalizations. The opening paragraph indicates the rather glib tone: "While a German tourist savours a Coke and e-mails home from a mountain hut 16 thousand feet up Mount Everest, a hungry teenager consumes a Big Mac in Beijing" (p.3) This is not the last of the clichés. In general, the problematic of "globalization" is presented in an uncritical way, and fits uneasily with the authors' much more sophisticated discussion of health and the environment. There are points in the book where a notion of the onward march of globalization serves to silence important questions about the persistence and hardening of national boundaries (immigration restriction informed by racialized anxieties, for example), to say nothing about the impact of good old-fashioned imperialism in transforming ecological and health conditions.
Between them, however, the essays in this collection identify four main pathways linking globalization, environment and health. The book's main contribution lies in establishing and explaining these connections. First is environmental degradation and resource depletion. The book makes a clear case that "current rates of industrial production require unsustainable exploitation of natural resources and produce significant amounts of pollution ... the world has not seen such a rate of increase for 20 thousand years or more" (p. 9). Greg Guest and Eric Jones give a clear account of the environmental changes of recent decades, which they associate with economic globalization: atmospheric pollution, and the erosion of topsoil because of the "unsustainable exploitation of land," the loss of bio-diversity, and the generation of unmanageable quantities of solid waste. The underlying point is well captured by the authors' quotation from a UN report: "At a time when the developed world needs to cut back on per capita consumption, transnational businesses are engaged in efforts to create a giant global middle class" (p. 10). The authors also highlight the threat of climate change, perhaps the environmental issue closest to the headlines."Changes in atmospheric chemistry and planetary physics," Guest and Paul Epstein argue, "are affecting biological and social systems" (p. 240).
The second is emerging and re-emerging diseases. The book makes a direct connection between the environmental changes outlined above and threats to human health. Citing the World Health Organization's estimate that "poor environmental quality is responsible for 25 percent of the world's burden of disease" (p. 10), a number of the essays in this collection trace the connections between ecological degradation and the emergence of new and devastating pathogens. Ecological change creates the condition for pathogenic mutation. George Armelagos and Kristin Harper argue that we are witnessing a "third" phase of the epidemiological transition "characterized by both the emergence of new diseases and the re-emergence of newly antibiotic-resistant familiar infections on a global scale" (p. 40). Driving this transition, they argue, is the "interaction of social, demographic, and environmental changes in a global ecology and in the adaptation and genetics of the microbe." They point to "agricultural development projects, dams, deforestation, floods, droughts and climatic changes" as causal factors in the emergence of new diseases (p. 41). In their research on urban Manila, Mary Anne Alabanza Akers and Timothy Akers draw attention to the rise in vector-borne and water-borne diseases "during the El Nino and La Nina periods" (p. 183). At the same time, a number of the authors point to SARS as the quintessential illustration of how the massive increase in air travel allows these new pathogens to spread with great rapidity. John Eyles and Nicole Consitt point out, that in the panic over SARS in Canada, blame quickly came to focus on Toronto's Chinese community (p. 170). In general I would have liked to see more discussion in this book of how emerging diseases like SARS have been interpreted according to older colonial and racial stereotypes; doing this might have cast a more critical light on some of the truisms about globalization.
The ever-brilliant Mike Davis has recently made many of the same arguments in a way more accessible to a general audience. In Monster at Our Door: The Global Threat of Avian Flu (2006), Davis paints a lurid--some would say alarmist--picture of mutant pathogens emerging from a neglected and miserable "planet of slums." I would recommend Davis as a lively, more provocative counterpoint to the sober analysis of "emerging and re-emerging diseases" in this book.
The third pathway is poverty and inequality. An underlying connection between environmental degradation and illness, of course, is poverty. Global poverty and inequality form a key theme in this collection of essays. The stance taken by most of the contributors is that globalization has led to an accentuation of inequalities, and has increased the vulnerability of the poor, both to infectious disease and to the destruction of their local ecologies. This is a plausible and, for me, convincing claim, but the essays largely fail to engage with the counter-claim, that globalization has increased living standards, and made--through technology transfer--health care more accessible. Nevertheless, the evidence presented here is striking. Thomas Leatherman puts it starkly: "Despite remarkable achievements in global health over the last four decades ... there remains a 16-fold difference in infant mortality between the 26 wealthiest nations and the 48 least developed countries. Half of the people in the world's poorest 46 nations are without access to modern health care" (p. 57).
Growing inequalities of power, too, are seen as an effect of globalization, manifested in the ability of international financial organizations to dictate terms to poorer countries, forcing "structural adjustment" upon them. In ten out of thirteen countries implementing World Bank structural adjustment packages, Guest and Jones show, government spending on public health and welfare reduced sharply (p. 12). Guest and Epstein deliver a damning verdict, too, on the effects of recent World Trade Organization agreements on health, which have led to widespread privatization, and which have prevented poor countries from producing generic versions of essential drugs. "The former is reprehensible," the authors declare, while "the latter is unconscionable" (p. 248).
Indeed, the essay by Linda Whiteford and Beverly Hill, contrasting dengue control efforts in the Dominican Republic and in Cuba, suggest that it is precisely Cuba's relative isolation from the pressures of neo-liberal globalization that explains the success of the State's anti-dengue campaigns. This begs the question, however, as to the broader role of U.S. foreign policy (American imperialism, if you like), in fostering violence and ecological destruction, while blocking attempts at health reform throughout the world. This is an uncomfortable question many authors in this collection allude to, but skirt over.
Fourth is the impact of cultural change. Some of the most interesting papers in the book focus on the impact of globalization on local cultural practices, often with serious health consequences. David Casagrande's paper tells the surprising story of how it is not global pharmaceutical companies, but indigenous healers that have been responsible for the "commodification" of medical knowledge in Chiapas, Mexico. "What was once free information available to all," he writes, "is becoming concentrated in the hands of fewer individuals and being transformed into a commodity" (p. 104). Casagrande ends with a provocative question, well worth considering: "Do the seeds of hegemony, so often attributed to global interests, already exist within indigenous communities" (p. 104). A more familiar story emerges from George Luber's work on "Second Hair" illness (a form of severe malnutrition) among the Tzeltal Mayan community. Increasingly dependent on seasonal wage labor and on commodity crops (particularly coffee), the community has become increasingly dependent on a "junk food diet." The move towards commodity crops has reduced sharply "the availability of uncultivated foods, which are an important nutritional resource for subsistence agriculturalists" (p. 150).
A somewhat different picture is presented by Suzanne Joseph's article on the Bekaa Bedouin. She shows that the Bedouins' greater reliance on agriculture has in fact led to an improvement in health: "In the Bekaa Bedouin setting, high maternal and child nutritional status and moderate-low mortality are linked to a flexible or mixed agro-pastoral economy with access to modern health care" (p. 212). Yet, she argues that the decline in diversification could have adverse consequences for the Bedouin in the future.
The final chapter, the culmination of the book, is less convincing. Calling for a radical re-design of global institutions, Guest and Epstein imply that the time has come for an epochal change, and set out a path to sustainable development. Guest and Epstein make the case that we are at a turning point in history through an excessively simplistic reading of the past, "a brief history of world orders" that would make most historians flinch. The policy recommendations--all eminently sensible ones--are, to put it mildly, unrealistic in the current climate. Sadly, it seems like a re-design of the global institutional architecture is less likely than ever to take place.
. René Dubos, Man Adapting (New Haven: Yale University Press, 1965), pp. 236-237.
. Ibid., p. 196.
. See Nicholas B. King, "Immigration, Race and Geographies of Difference in the Tuberculosis Pandemic," in The Return of the White Plague: Global Poverty and the "New" Tuberculosis, ed. M. Gandy and A. Zumla (London: Verso, 2003).
. For a thoughtfully argued example of this stance, see Angus Deaton, "Health in an Age of Globalization" (Princeton: Center for Health and Wellbeing, 2004). For an influential view which reached a wide audience, see J. Sachs, The End of Poverty: Economic Possibilities for Our Time (London: Penguin, 2005).
. This is an ethical argument made with greater force in Paul Farmer, Pathologies of Power: Health, Human Rights and the New War on the Poor (Berkeley: University of California Press, 2003).
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Sunil Amrith. Review of Guest, Greg, ed., Globalization, Health, and the Environment: An Integrated Perspective.
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