THINK AND ACT GLOBALLY AND INTERSECTORALLY TO PROTECT NATIONAL HEALTH

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THINK AND ACT GLOBALLY AND INTERSECTORALLY TO PROTECT NATIONAL HEALTH
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THINK AND ACT GLOBALLY AND INTERSECTORALLY TO PROTECT NATIONAL.! IEALTII

Contents
Preface and Overview

4
1

Glossary of Acronyms and Abbreviations

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2.

I. The Rationale for a Global Intersectoral Review
Introduction

3

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Goals

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II. Globalization: The New Realities for Health Development

3
e

Theoretical Perspective

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Transnational Challenges

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Health Implications of Global Trends

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Globalization of Travel and Trade
Globalization of Infectious Diseases ..............................................
International Trade and Promotion of Harmful Products: Tobacco
Transnational Trade in Psychoactive Drugs

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Environmental Degradation

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A

Macroeconomic Implications
Globalization, Structural Adjustment, and Health Status
Macroeconomic Determinants: Global Intersectoral Action
Shared Responsibilities

15
16
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Technology and Communications

20

Population Growth and Mass Migration

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Food Security

Concentrating WHO’s Global Efforts for Greatest Impact

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III. Think and Act Globally and Intersectorally to Protect National Health

[
The World Health Organization: An Intersectoral Pioneer?

WHO’s Global Partnerships
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THINK AND ACT GLOBALLY AND INTIE RS ECTO RALLY TO PROTECT NATIONAL JIEALT11

Institutional Mandates and Comparative Advantage

33

Institutional Arrangements at the Intergovernmental
Level for Intersectoral and Interagency Collaboration

34

Implementation of WHO’s Global Health Policy for the 21st Century

36

Global Context of WHO Reform

37

Outstanding Issues and Conclusions

38

Annex A: Global Intersectoral Action Case Studies

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♦

40

Annex B: Monitoring and Evaluation

45

Annex C: Determinants of Health Status: Key Intergovernmental Alliances

46

Annex D: International Conferences Since 1990

48

Bibliography

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U THINK AND ACT GLOBALLY AND INTERSLCTORALLY TO I’ROTI-CT NATIONAL HEALTH

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Glossary of Acronyms and Abbreviations

■ sibili
Administrative Committee on Coordination
ACC
Codex Alimcntarius Commission
CAC
Council for International Organizations of Medical Sciences
CIOMS
Canadian International Development Agency
CIDA
Cooperative Information Network Linking Professionals in Africa and Europe
COPINE
Children’s Vaccine Initiative
CVI
Disability-adjusted Life Years Lost
DALY
Deoxyribonucleic acid
DNA
Economic and Social Council
ECOSOC
Division of Emerging and other Communicable Diseases Surveillance and Control
EMC
Essential Public Health Function
EPHF
European Space Agency
ESA
Food and Agricultural Organization of the United Nations
FAO
General Agreement on Tariffs and Trade
GATT
Global Information Network on Chemicals
GINC
Hazard Analysis and Critical Control Point system
HACCP
Human Chorionic Gonadotrophin
hCG
Human Immunodeficiency Virus
HIV
International Atomic Energy Agency
IAEA
Inter-Agency Committee on Sustainable Development
IACSD
International Conference on Population and Development
ICPD
International Fund for Agriculture and Development
IFAD
Intergovernmental Forum on Chemical Safety
IFCS
International Bank for Reconstruction and Development
IBRD
Intergovernmental Organization
IGO
International Health Regulations
IHR
International Labour Organisation
ILO
International Monetary Fund
IMF
International Telecommunications Union
ITU
Least Developed Countries
LDCs
Nongovernmental Organization
NGO
Organisation for Economic Cooperation and Development
OECD
Pollutant Release and Transfer Registers
PRTRs
Sanitary and Phytosanitary Measures
SPS
Technical
Barriers to Trade
TBT
United Nations
UN
Joint United Nations Programme on H1V/AIDS
UNAIDS
United Nations Conference on Environment and Development (1992)
UNCED
United Nations Centre for Human Settlements (HABITAT II)
UNCHS
United Nations Development Programme
UNDP
United Nations Environment Programme
UNEP
United Nations Educational, Scientific and Cultural Organization
UNESCO
United Nations Population Fund
UNFPA
United Nations Office of High Commissioner for Refugees
UNHCR
United Nations Development Fund for Women
UNIFEM
United Nations Children’s Fund
UNICEF
United Nations Industrial Development Organization
UNIDO
UN/OOSA United Nations Office of Outer Space Activities
United Nations “
Research
UNRISD
’ Institute for Social Developmentr
Ultraviolet Radiation
UVR
World Food Programme
WFP
World Health Organization
WHO
World Intellectual Property Organization
WIPO
World Meteorological Organization
WMO

WTO

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World Trade Organization

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THINK AND ACT GLOBALLY AND 1NTERSECTORALLY TO PROTECT NATIONAL 1IEALTI1

Preface an cl Overview

he findings and recommendations of this
globaf intersectoral review will be pre­
sented, in conjunction with national and
local intersectoral reviews from developing and
developed countries, to an international group of

environment for intersectoral action for health at
national and local levels. This document will

experts at a WHO international conference,
Intersectoral Action for Health: A Cornerstone for
Health'for'AU in the Twenvy-first Century, to be held
in Halifax, Canada in April 1997. This document
will also be used as a working paper at this confer­
ence. The Intersectoral Action for Health project
represents an integral component in the devel­
opment of a Health-for-All policy for the twenty-

broad determinants of health status.

f

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first century.
The major premise of this paper is that
transnational threats and opportunities for health
improvement in the twenty-first century will have
major implications for WHO’s future strategies and
patterns of alliance. Global intersectoral collabo­
ration will become more important in order to
address the health status repercussions of, inter alia,
global trade and travel, environmental degrada­

tion, new technology and communications, mac­
roeconomic change and adjustment, and the
transnationalization of unhealthy lifestyles and risk
factors. As a response to these changes it will be­
come increasingly important that WHO builds
global alliances in order to create a facilitating

consider how WHO might build competencies
and partnerships at the intemational/regional
intergovernmental levels in order to address the

In order to address the challenges of an increas­
ingly globalized and rapidly changing world it is
imperative that WHO’s future actions not be con­
ditioned by a business as usual approach. Only by
thinking and acting globally and intersectorally to improve national health can WHO expect to bend glo­
bal trends which have negative implications for
‘ achieving future health gains. Towards this end,
it will become more important that WHO coor­
dinates its policies and actions with its various
health partners. At the international intergov­
ernmental level of analysis it is crucial that the
Specialized Agencies, Funds, and Programmes of
the United Nations system and the Bretton Woods
institutions/WTO form alliances to address the
major transnational issues and broad determinants
of health status, in order that human health be­
comes a primary objective of sustainable develop­
ment. Moreover, it is important that these inter­
national institutional alliances are used to pro' mote development settings at global, national, and
local levels which lead to tangible health gains.

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THINK AND ACT GLOBALLY AND INTERS ECTO RALLY TO PROTECT NATIONAL HEALTH

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World society now recognizes more clearly than ever before its mutual needs; it mnst accept a shared responsibility for meeting them (Brandt et al., 1981).

A new kind of citizen is necessary if the human race is to survive. That citizen's loyalty should not stop at
anything short of world loyalty (Chisholm, 1948).

I. Section One : The Rationa Ie for a Global Intersectoral
Review
Introduction I
In the ‘global village’ of the late twentieth century it is increasingly evident that the health of
populations is dependent on numerous external
factors which include, inter alia, market forces,
environmental hazards, access to mass commu­
nications and technology, and cultural influ^
ences. As a result, a global health strategy must
consider the broad determinants of health sta­
tus. International development strategies which
aim to improve the health of populations must
therefore include a key role for intersectoral ini­
tiatives (Neufeld,Bergevin & Tugwell,1993).
Complex, interrelated health development chal­
lenges increase the need for the health sector to
“share power with other sectors, other disciplines,
and most importantly with people themselves”
(Ottawa Charter for Health Promotion,1986).
Although intersectoral action is necessary to
address the multiple determinants of health the
practical implementation of these initiatives
has often proven to be “an illusory goal”
(Yach,1997,p.250). Moreover, the cumulative
experience in implementing intersectoral col­
laboration for health initiatives underscores the
“real difficulties of the task” (Sindall,1997,p.5).

However, a multi-dimensional approach
needs to be stressed in the World Health Organi­
zation’s updated policy if it is to maintain its lead­
ership within the international health develop­
ment community in the twenty-first century.
WHO’s Task Force on Health in Development has
recently observed that the rapidly changing con­
text of health development makes it imperative
that WHO use its international leadership role

to become “a truly global organization” (WHO,
1997a,p.4). At the global level an intersectoral
approach means revisiting the way that WHO
thinks and acts; failing to do so would risk be­
coming ineffective given the rapidity and com­
plexity of change. It is within this context that
this global intersectoral review aims to determine
the implications of major global trends for
WHO’s global alliances in the twenty-first
century.

Goals
The primary goals of this global intersectoral re­
view are:

i.

To review the health challenges, determi­
nants
of
health
status,
and
context of health development from a glo­
bal perspective.

ii.

To identify the principal transnational chal­
lenges to health improvement for the
twenty-first century.

iii. To propose solutions to address these
transnational health problems

iv. To assess the implications for WHO’s future
global actions, institutional structures, and
interactions with its global health partners.
v.

To identify case studies of intersectoral ac­
tion for health at the international intergov­
ernmental level of analysis which suggest
“best practices” for future global intersectoral
action.

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THINK AND ACT GLOBALLY AND INTERS ECTO RALLY TO PROTECT NATIONAL I iEALTl I

This paper will concentrate primarily on
WHO’s interaction with its partners within the
United Nations System, including the Bretton
Woods institutions and the World Trade Organi­
zation (WTO). This analysis will also analyse
transnational health problems within the con­
text of an international society of states, taking
into consideration WHO’s responsibilities to
Member States. Furthermore, since the prob­
lems and opportunities identified in this docu­
ment are transnational in nature, this paper,
while concentrating at the intergovernmental
level of analysis, will also stress that global alli­
ances with other transnational/national actors,
such as regional development banks, international/grassroots nongovernmental organizations,
the private sector, and local governments are
equally as important to address the global health
development challenges facing humanity now
and in the future.

The Definition of Intersectoral
Action: A Global Perspective

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Most analyses of intersectoral strategies fail to
delineate at the outset what comprises a sector.
For purposes of this paper a sector will be de­
fined according to the definition suggested by
Degeling et al. (1992) in Can Intersectoral Co­
operation be Organized? This definition includes
the following criteria: institutionalized patterns
of knowledge and expertise; well-defined ‘prev
fessional/administrative/political territory; continuity in planning, accountability, and action
strategies; formalized hierarchies; and established
resource allocations fot specific functions and
work. Further, the concept of intersectoral col­
laboration in health development implies that
the formalized institutional structures which con­
stitute a sector develop “a recognized relationship between part or parts of the health sector
and part or parts of another sector, that has been
formed to take action on an issue or achieve
health outcomes...in a way that is more effec-

tive, efficient, or sustainable than could be
achieved by the health sector working alone1'
^(National Centre for Health Promotion, 199^).
A global intersectoral review will examine
how specialized intergovernmental agencies such
as WHO can address the emerging development
challenges of the next century. According to
the definition of a sector, quoted above, the Spe­
cialized Agencies of the United Nations system
also meet the ‘institutional’ criteria of a sector.
Accordingly, one approach would be to assume
that a ‘global’ intersectoral health action includes
the World Health Organization and at least one
other Specialized Agency, such as the Food and
Agricultural Organization. However, this does
not take into account that other United Nations
bodies (Table 1) described as “Funds”, as well as
the Bretton Woods bodies and the World Trade
Organization (WTO), are also engaged in health
related activities (Lee et al., 1996), and are in­
volved in standard-setting in the health domain
(WHO,1997,p.2)1. Therefore, for purposes of
this analysis the term intersectoral/ interagency
collaboration will refer to collaborative under­
takings between WHO and one or more of the
UN Specialized Agencies/United Nations Funds
or Programmes, the Bretton Woods institutions/

WTO to protect and improve the health status

of populations within countries.
TABLE 1.
UNITED NATIONS HEALTH RELATED ORGANIZATIONS

Worid Health Organization
World Bank
UN Children’s Fund (Unioef)
UN Population Fund (UNFPA)
UN Educational, Scientific, and Cultural
Organisation (UNESCO)
Food and Agricultural Organization (FAO)
World Food Programme
: UN High Commissioner for Refugees
International Labour Organisation
UN Environmental Programme
UN Fund for Drug Abuse Control
. Source. Lea £t al. 1936, p.302

definition reiers
refers to
Likewise, at tne national level of analysis the work of the health sector, which in its narrowest aetiniuon
io Ministries of .Health,
>Oa.u>,
overlaps with the work of numerous other sectors, tor example Ministries of the Environment, Education, and Social Affairs, which are
involved directly with health-related activities.

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T1IINK AND ACT GLOBALLY AND INTERS ECTO RALLY TO PROTECT NATIONAL 1IEALTI1

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II.

Section Two: Globalization - The New Realities for Health
Development

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Theoretical Perspective

I

The world political economy is presently under­
going a global revolution in such areas as finance,
trade, communications, research and technologi­
cal development, and intellectual and knowledge
services. This section will document these al­
terations in the world’s political economy and
identify challenges for health development that
will affect the health objectives of all nations.
Despite major health gains throughout the world,
significant global threats to future health im­
provement exist in the late twentieth century
which could jeopardize future health improve­
ment. The following analysis will document the
primary transnational issues that will likely af­
fect future global health status, and will suggest
how intersectoral/interagency initiatives can
address these problems.

Transnational Cliallenoes

Globalization, defined as the process of increas­
ing economic, political, and social interdepend­
ence and global integration which takes place as
capital, traded goods, persons, concepts, images,
ideas, and values diffuse across state boundaries,
is occurring at ever increasing rates
(Hurrell,1995, p.447). This broad definition
contrasts with others which limit the term to fi­
nancial and trade areas. Globalization will have
both negative and positive repercussions for fu­
ture health development activities and the health
status of human populations. The principal fea­
tures of this global transformation include, inter
alia, the following global trends (UNRISD,1995)

E3

The expansion of liberal democracy

□

The dominance of market forces

E2

The integration of the global economy

E3

The transformation of production systems and
labour markets

□

The speed of technological change

E

The media revolution and consumerism

□

The pressure for governments to reduce budgets
and increase internal efficiency

For purposes of the following analysis it will
be assumed that global transformation is occur­
ring at two primary levels*:

First, the globalization of the state which in­
volves diverse phenomena such as complex com­
munication systems, ecological issues such as en­
vironmental degradation and climate change,
and mass movements of populations across bor­
ders. These factors have resulted in transnational
policy linkages between states which are of mu­
tual concern for state governments and policy­
makers. The idea of transnational problems tran­
scends the conventional boundaries of domestic
and international policy-making.
Secondly, the globalization of the world’s
economy which has resulted in an explosion of
cross-border trade and financial transactions
forming complex networks of economic interde­
pendence. Accompanying these changes is an
intense competition for international market
share and market access.
Political, social, and economic integration
is also occurring at the regional level, and this is
enhancing the interdependence and transna­
tionalization of the world’s political economy3.

2 This approach is adapted from Professor Sakamoto's description of globalization in the United Nations study Global Transformation.
Challenges to the State System (1994).
3 Soo for example, Hoallh Systems In an Era ol Globalizatlon(Frer\k ol al,1995), and a rocont FAO publication Ovorall Socio-Political and
Economic Environment for Food Security at National, Regional and Global Leue/s(FAO,1996): both of tnese analyses assume that global
and regional integration are complementary processes. An opposing view in the literature is that regionalization and globalization could
bo conflicting processes, especially if closed regional blocs were to evolve. A variant on this theme is provided by Huntington's “Clash of
Civilizations^; in this scenario future conflict is based on cultural allegiance and identity.

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THINK AND ACT GLOBALLY AND INTERS ECTORALLY TO PROTECT NATIONAL 11EALTII
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The Globalization of Liberalism
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; The .roots of globalization can be traced back to the industrial revolution and the laissez faire economic
policies of the nineteenth century. However, the globalization of the late twentieth century is assuming a
‘ magnitude, and taking on patterns, that are unsurpassed in world history (Ruggie,1995,pp.507). The rej drawing of the world’s political economic map has been facilitated by the end of the Cold war, the fall of the
T command economy system in Eastern Europe and the rest of the former Soviet bloc, and the subsequent
: dissolution of the former Soviet Union. Yet, the seeds of this global restructuring were well established
' amongst the OECD countries before these events took place. Since the late 1960s, the ’Western’ industrialk ized nations were linked into a process of progressive economic liberalization as offshore financial markets
j grew and trade liberalization expanded. In the 1980s global integration coincided with recessions in the
V ‘Western’ world and a debt crisis in the ‘Third’ world: these constraints resulted in more acute economic
competition and inter-state economic rivalry, which in turn, resulted in a push to accelerate the restructuring
• process along neo-liberal lines. The debt crisis and decreased terms of trade for third world exports meant
? that many of these countries faced recurrent economic crises. These problems set the stage for the IMF and
: World Bank structural adjustment policies (GiH,1994,pp.175-176).

1
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■These alterations in world politics have impli­
cations for the autonomy of the state and its free­
dom to set ‘national’ policies: states cannot set
policy without accounting for external factors
and constraints in a globalized world. It has be­
come apparent that no “sovereign” state can take
actions in complete isolation from other state ac­
tors. States who act as loners in international
society risk damaging their own economic and
political well-being (Sakamoto, 1994, p.1-2).
The blurring of boundaries, which attends a
transnational shift in the political and economic
interactions of individuals, multinational com­
panies, IGO/NGOs, and collectivities such as
nation-states, requires a reconstruction or many
of the ‘traditional’ premises and paradigms of
policy action. The UNDP, in its Human Devel­
opment Report (1993), observed that certain con­
straints exist within the global decision-making
environment:
ij L Pressures on the nation-state, from above and
below, are beginning to change traditional con­
cepts of governance. On the one hand, globali­
zation on many fronts-from capital flows to in­
formation systems-has eroded the power of indi­
vidual states. On the other, many states have
become too inflexible to respond to the needs of
specific groups within their own countries. The
nation-state now is too small for the big things,
and too big for the small (UNDP,1993,p.5). Q h

Since the processes of global integration are ex­
erting ‘pressures on the nation-state from above
and below’, global initiatives to foster
intersectoral/ interagency collaboration should
maximize the opportunities for renewed forms
of governance for health to coordinate and share
responsibilities for these initiatives at global, na­
tional, regional, and local levels. Also, the issue
of improving internal efficiency of public insti­
tutions, a point well documented within the
World Bank’s literature, poses another challenge
to implementing effective development strate­
gies.
The accelerated process of change docu­
mented herein could spell both great opportuni­
ties for improving the livelihood and social well­
being of millions of persons, but, it could also
mark a time of potential political and economic
disorder, if the changes lead to a breakdown in
the social contract between state and society
(Ruggie,1995,p.525-526). Moreover^the ‘men­
tal maps’ that policy makers rely on as policy tem­
plates in order to guide their decisions have be­
come ‘severely strained’ because of the blurring
of the boundaries between domestic and inter­
national spheres by the processes of globalization.

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THINK AND ACT GLOBALLY AND INTERSECTORALLYTO PROTECT NATIONAL HEALTH

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Health Implications of Global

Globalization of Trave and

Trends

Trade

It is becoming obvious that the “polarizing ef­
fects of globalization” pose a major threat to pub­
lic health (UNRISD, 1995,p.26), and at the same
time offer major opportunities. The implications
of globalization and transnational trends for
health development are primarily fourfold:

This section will examine the transnational
policy implications of increased trade and travel
for health development. The globalization of
trade and travel poses major challenges transcending national boundaries. These newly
emerging challenges make the need for global
intersectoral, multi'disciplinary collaboration
more urgent.

EJ

the globalization of health risks and disease,
as well as opportunities such as the diffusion
of ideas and technology;

El

the need for global intersectoral action
through transnational cooperation and part­
nerships;

□

an enhanced role for international legal instruments/regimes, standard-setting, and glo­
bal norms;
the need for new intersectoral forms of glo­
bal vigilance, monitoring and assessment are
essential because information on health sta­
tus and the global determinants of health are
vital for defining future actions in a rapidly
changing policy environment.

The following analysis will summarize these ma­
jor transnational themes and demonstrate where
global intersectoral initiatives are critical.

Globalization of Infectious

Diseases

A consequence o: the increase in
transnational trade, travel, and migration is the
greater risk of cross-border transmission of infec­
tious diseases (WHO/EMC, 1995): "Disease
Knows No Boundaries, and Borders are Porous to
Disease” (Kamel, 1996). As the world becomes
more interconnected, diseases are able to dissemi­
nate more rapidly and effectively. The world­
wide spread of the human immunodeficiency
virus (HIV) epitomizes this trend towards the
globalization of infectious diseases.

"v.." / ..;z--v'* -*

Globalization of Infectious Diseases
■

In the past 200 years the average distances travelled and the speed of travel have increased a thousandfold,
whereas disease incubation times have not changed; as a result, an infected person may now arrive at their
. destination and not .develop symptoms for many days (WHO,1995a; Garrett,1996). With the number of"
passengers travelling by air increasing by seven percent per year in the past twenty years, and projected to
increase by over five percent per year over the next twenty years, more people are trave’ling for recreational
and business purposes today than any other period in history (De Schryver and Meheus. 1989;WHO,1996a).
. The movement of persons across international borders has increased by 7.5 to 10 percent since the middle
of this century, so that over one million persons now cross international borders per day (Garrett, I994,p.xi),
—

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Also, global trade liberalization has resulted
in multinational food production, processing and
distribution, as the international trade in food
and food products has soared4. The mass pro-

. ... .................................. ..

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duction and extensive distribution systems in the
food industry, combined with a surge in interna'
tional food trade, favour the spread of infectious
diseases over wide areas (WHO/EMC, 1995;

4 The vaiue of global food trade in 1994 was USS266 billion, almost 300 percent greater than it had beer 20 years ago (Kaforstein et

al,1997).

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THINK AND ACT GLOBALLY AND INTERS ECTO RALLY TO PROTECT NATIONAL IIEALTII

Wilson,1995,p.43). Further, with approximately
400 million persons travelling across interna'
tional borders every year the transmission of
foodborne diseases presents a significant inter'
national health problem (Kaferstein et al.,

tury. Four specific goals were proposed for this
global plan (WHO, 22 February 1995):

1991, p.41).

S

establishment of national and international
infrastructures to recognize and respond to
new disease threats; ’

H

further development of applied research;

E

strengthening of international capacity for
infectious disease prevention and control.

In the 1990s stagnation in funding for com­
municable disease surveillance programmes has
left many states poorly equipped to manage new
and re-emerging disease problems. One factor
that has contributed to the inadequate levels of
funding for public health infrastructures is in­
creased levels of global economic competition,
which have placed pressure on national govern­
ments to adopt budget austerity measures
(Fidler,1996). Also, with the collapse of public
health systems in many countries, for example
in the former Soviet Union, old diseases such as
diphtheria have re-emerged. Moreover, the post­
war optimism created by the development of new
antibiotics and vaccines led to a complacent at­
titude and decreased vigilance towards infectious
disease threats. Combined with several other
emerging realities cited below it is evident that
communicable diseases will remain a major and
unpredictable public health problem in the
twenty-first century.
JSZ• • Av. .»

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Infectious Disease: A Lingering Transnational
Problem

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; Numerous recent trends favour the spread of com; municable diseases. These include inter alia:

□
□
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new and re-emerging infectious agents
new drug resistant strains
pharmaceutical research not keeping pace
with microbial resistance
erosion of disease sun/eillance systems
increased urban population density and
number of persons living in poverty
increased susceptible populations e.g. the
aged
wider distribution of communicable disease
vectors due to global warming.

In 1995 it was proposed to the Forty-Eighth
World Health Assembly that a global plan be
established to combat emerging and re-emerging infectious diseases and to meet the commu­
nicable disease realities of the late twentieth cen­
8

B

strengthening the global surveillanc^Tof in­

fectious diseases;

To combat the transnational problem of
communicable disease dissemination and to act
effectively on the four above-mentioned recom­
mendations global intersectoral collaboration
will be essential.

Globa! Disease Surveillance: A Challenge for
the Future
. WHO in conjunction with its various health sector
partners is presently involved in establishing a
global surveillance system which will focus on,
inter alia, developing global monitoring and alert
systems for communicable diseases from all coun­
tries. This system will facilitate the sharing and
exchange of information globally via electronic and
printed media. The dissemination of information
collected through this global monitoring system
will involve the most recent communication tech­
nologies (WHO/EMC,1996a, p.9; WHO/
EMC,1997,p.9). The establishment of complex
communications networks, such as a global dis­
ease surveillance system, is partly dependent on
the normative role of several specialized United
Nations agencies: global liberalization of telecom­
munications has been and is facilitated by the ac­
tivities of the ITU, WIPO, and the GATT (see
Lee,1996,p.114). Since “epidemiological surveil­
lance requires the collection and analysis of large
amounts of varied data about the locations where
diseases and health related problems occur* it is
important that WHO’s global surveillance sys­
tem covers al! regions of the world. However,for
example, at the present time only 12 countries of
the 49 countries in “continental Africa" are able to
access the full range of Internet services, and 30
countries have direct e-mail links (WHO,January
6,1997). A comprehensive electronically linked
surveillance system will require that these serv­
ices are upgraded in the least developed regions
of the world. In addition, the monitoring of infec­
tious diseases amongst refugee populations will
require close collaboration with UNHCR.

!
i

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<i-

THINK AND ACT GLOBALLY AND INTERSECTORALLY TO PROTECT NATIONAL IIEALTH

A recent WHO initiative to revise the Iri$
temational Health Regulation^ (IHR), the sole
piece of internationally binding legislation re­
quiring the “mandatory reporting” of certain in­
fectious diseases, aims to transform this interna­
tional legal regime into a working global alert
system where sanctions for reporting will be mini­
mum and all diseases posing a major threat to
the health of populations will bp reported
(WHO,1995a). Thejevised IHR will be imple­
mented in close conjunction with the global sur­
veillance system outlined above. At the global
level, the implementation of the revised IHR, as
will be elaborated further in a case study in An­
nex A, will require close collaboration with inter­
governmental agencies such as the World Trade
Organization (WTO) and the Food and Agri-

cultural Organization (FAO) in order to control
and prevent the dissemination of infectious dis­
eases across borders via traded food products.
Finally, global intersectoral/interagency ini­
tiatives such as the Children’s Vaccine Initiative
which was launched at the World Summit for
Children in New York in 1990 represents a major
step in the direction of eradicating and control­
ling many vaccine preventable diseases. Moreo­
ver, the quest to develop new vaccines, for ex­
ample against the HIV, will be a Herculean task
requiring close global collaboration between, in­
ter alia, WHO and other United Nations organi­
zations, such as UNAIDS, and the international
research community, the private sector, and

Member State governments.

A Global Summit in ActiomThe Children's Vaccine Initiative

UNICEF:1998).
.
International Trade and Promotion

of Harmful Products :Iobacco

Another harmful side effect of globalization is
associated with the negative effects upon health
of exporting harmful products/lifestyles through
international trade, and the associated advertis­
ing of certain products by multinational corpo­
rations. Tobacco-related diseases represent the
single most preventable adult health problem.
__________________________________________________ -—-

•

I

Smoking has been associated with, inter alia, an
increased risk of several different cancers, includ­
ing lung and bladder cancer, ischemic heart dis­
ease, bronchitis and emphysema, and an in­
creased perinatal mortality of infants whose
mothers smoked during pregnancy (Stanley et
al., 1989, p.5). Also, environmental exposure
to'smoke, also known as passive smoking,
presents health risks to nonsmokers (United
States Environmental Protection Agency,
December 1992).

■■■■'-—■

F The Global Tobacco Pandemic: Facts and Figures
1 1 billion smokers in the world, 800 million In developing countries.
C

□
□

JXSSXSSKSi- -

A(Sounds;YaeV^,pp.4,21-22;V.r:OTobacco Alert,lO96;Chandler.1986).

*w»

i I

iJSS

THINK AND ACT GLOBALLY AND INTERSECTORALLYTO PROTECT NATIONAL HEALTH

The growth in tobacco consumption has
been magnified by the aggressive advertising
methods of multinational tobacco conglomerates
that have increasingly targeted women, adolescents, and developing country markets (Coun­
cil on Scientific Affairs, 1990). Tobacco com­
panies have encountered declining sales in de­
veloped country markets, and thus, are looking
to penetrate new markets in Asia, Africa, and
Eastern Europe (Connolly,1992):
££ Cigarette smoking threatens to
reach epidemic proportions in many
countries in the coming decade if dras­
tic measures are not taken to curb the
efforts of transnational tobacco corpo­
rations who see their future “dying” out
in the developed world. Many Asian
and Third World populations have al­
ready proven themselves to be eager con­
sumers of a product whose harmful ef­
fects are obscured by the sophisticated
promotional schemes which portray
smoking as an inexpensive way to buy
into the glamorous life of the upper class
(Stebbins, 1991 ,p.l322). uG

The soaring tobacco trade in the develop­
ing world is related to the liberalization of the
world’s marketplace.

In contrast to those markets whicn nave been
pried open, the world’s largest market, China,
with a population of 1.1 billion, remains rela­
tively closed to foreign tobacco multinationals.
However, recent joint ventures have given for­
eign companies an opening into the potentially
lucrative Chinese market. These companies are
exploiting this opportunity through advertising,
with the three largest multinationals each spend­
ing more than $US 20 million/annuady on ad­
vertising in China (Frankel et al.,1996). Adver­
tising associates smoking with exciting new life­
styles which appeal to the desire of young peo­
ple to feel “contemporary and worldly’ (Jing Jie
Yu etal., 1990,p.1578).

10

. ... . ....... - -............ ................. .
The Political Economy of the International
Tobacco Trade
<... ,
The international trade in tobacco is dominated
by six transnational tobacco companies (TTCs),
' two of which are British and four American. To­
gether these companies control 85% of the to­
bacco sold on the world market. Market penetra■ tion by the TTCs has been facilitated by the re­
moval of trade barriers which has hitherto been
\ used by state monopolies to keep foreign compe; tition out. Such monopolies are generally “ineffi­
cient” in comparison with the advertising and mar­
keting strategies of the TTCs. In effect, the “mar­
keting inefficiencies” of state monopoly companies
may have had an “unintended public health ben­
efit" by keeping smoking r&tes down in countries
not dominated by foreign TTCs. TTCs have also
' allied with governments to assist the penetration
F of certain key markets. For instance, “in 1986-87
US cigarette companies asked key members of
[the US] Congress to pressure the trade officials
' of Korea, Taiwan, Japan, and Tnaiiand to open up
their cigarette markets.” Threats of US protectionist
trade legislation, retaliatory trade threats, and trade
sanctions were made against these countries
unless the American cigarette companies were
given free access(Connoliy;1S92,pp.29-31).
Therefore,the liberalization of world trade, often
under the threat of trade sanctions, has acceler­
ated the soread of tobacco globally (Roemer and
Roemer,1990). Although American public health
: experts warned of the detrimental health conse­
quences of opening the Asian markets to tobacco
products trade officials claimed that this issue was
only one of free trade (Frankel,November

181996,p.11).

Future initiatives to address the global to­
bacco pandemic will have to address the thorny
issue of linking the trade and health sectors both
at the national and global levels. For the health
sector this represents a major challenge consid­
ering that “at the national level Ministries of
Health generally are not the most powerful mem­
bers of the Cabinet” and that “internationally,
health remains at the fringes of the socioeco­
nomic
decision
making
process
(Pannenborg,1991,p.183). Moreover, it will be
important that WHO develop channels of com­
munication with WTO on trade issues, such as
tobacco, which have scientifically established
deleterious effects on health.

L

i

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THINK AND ACT GLOBALLY AND 1NTERSECTORALLY TO PROTECT NATIONAL 11EALTII

In this respect, although the "Final Act Em*
bodying the Results of the Uruguay Round of Multi­
lateral Trade Negotiations” (GATT, 15 December
1993) makes special provisions under Article 8,
Principles for Member States, for States “to adopt
measures to protect public health and nutrition’^
WHO should not expect that the WTO will uni­
laterally initiate measures to protect human
health status in matters of trade. In support of
this conclusion is the WTO’s recent ruling that,
in response to a complaint filed by the United
States, Canada, and the European Union, Japan
should expedite measures to reduce its duties on
imported liquours5. Thus, any form of global
intersectoral initiative to counteract the adverse
effects of international trade should be spear­
headed by individual countries and WHO, in col­
laboration with WTO. A major step in this di­
rection is represented by WHO’s commitment to
develop an International Tobacco Convention.
WHO’s Tobacco Convention: A Globa!
Intersectoral Initiative?

The Worid Health Assembly, in May 1996 adopted
Resolution WHA49.17 “to initiate the development
of a framework convention in accordance with
Article 19 of the WHO Constitution”. The conven­
tion will incorporate “a strategy to encourage Mem­
ber States to move progressively towards the
adoption of comprehensive tobacco control poli­
cies and also to deal with aspects of tobacco con­
trol that transcend national borders” (WHO, 25 May
1996). This convention should contain, inter alia,
the follov/ing provisions and objectives :
G

E

Q

it should move towards implementation of
comprehensive tobacco control strategies;
it should encourage cooperation in research,
programme, and policy development;
it should encourage the sharing of
information, technology, arid knowledge;
it should provide for regular meetings to
strengthen global tobacco control and develop
detailed protocols related to this convention
(Collishaw,1996).

To be effective the International Tobacco Con­
vention will have to make explicit reference to
the need for intersectoral collaboration to cur-

tail the trade in tobacco, as well as to develop a
surveillance system to document the burden of
disease associated with tobacco use and to moni­
tor compliance with the norms of this conven­
tion. Within the framework of the Tobacco Con­
vention it should be explicitly stated that the
international trade norms of multilateralism,
reciprocity, and most-favoured nation trading
status, which are embodied in the framework
agreements of the WTO, should not necessarily
apply to traded goods which have a well docu­
mented adverse effect on human health status.

Transnational Trade in
Psychoactive Drugs

The cross-border trade in psychoactive sub­
stances, other than alcohol and tobacco, also
presents another important transnational policy
issue.
The retail value of illicit drugs traded inter­
nationally now exceeds SUS 500 billion per year,
an amount which exceeds the international trade
in oil. The international drug trade is only sec­
ond to the arms trade industry. The hundreds of
thousands of destitute farmers in developing
countries enter the drug trade business to reap
its benefits. The international drug trade has
continued to flourish despite the control activi­
ties of the international community.

L

Trade which evades control measures?

Neither importing nor exporting countries have
been able to stop the trade in illicit drugs, and as
a result it has continued to grow rapidly
(Griffin, 1992,p.114). Since they live in the world's
most economically deprived areas the “high re: turns make the risk worthwhile” for growers.
Moreover, “traffickers have proved more than a
match for national or international authorities, con­
centrating their activities at points of least resist■ ance where national governments have little
control...Drug syndicates launder around
> $85 billion through financial markets each year
(UNRISD,1995,pp.85-86).

5 Also, see a recent report, “The World Trade Organization and sustainable development: An independent assessment (1996)", by the
International Institute for Sustainable Dovelopmont in which the WTO's reluctance to develop links with other bodies, especially NGOs,
and “its failure to integrate sustainable development concerns into trade policies" is critiqued.

11

I

I

IJ
THINK AND ACT GLOBALLY AND INTERSECTORALLY TO PROTECT NATIONAL 11EALTI1
Over the past two decades the problems due
to the use of psychoactive substances have be­
come globalized. It is estimated that about 15
million persons are at risk of serious health im­
pairment as a result of the abuse of psychoactive
substances, other than alcohol and tobacco; of
these it is estimated that 5 million persons in­
ject. The number of drug injectors appears to be
escalating in both developing and developed
countries. It is estimated that between 100,000
to 200,000 persons die as a result of drug injec­
tion annually. Moreover, the sharing of inject­
ing equipment results in the transmission of HIV,
hepatitis B and C, and other blood-borne infec­
tions (WHO,1996d).
Control programmes for legal and illegal
drugs need to concentrate on prevention and
reducing demand, as well as curbing international
and national drug supplies. All of these inter­
ventions require intersectoral collaboration with
other partners outside of the health sector. WHO
recognizes that the control of demand and sup­
plies calls for international collaboration between
Member States, intergovernmental and
nongovernmental organizations to effectively
address this global problem (Nakajima, June
1996).

In addressing this transnational problem
WHO would have less of a role to play in the
control and interdiction of the international drug
trade. In an address to the UN General Assem­
bly (October 1996) on the issue of International
Drug Control, WHO stressed that “there is a
need for solidarity, intersectoral and international
partnerships to respond effectively to the range
and complexity of problems related to substance
abuse’'. Towards this end, WHO emphasized the
need to develop and adopt “Guiding Principles for
Demand Reduction,” and to develop “a compre­
hensive demand reduction approach “irrespec­
tive of the legal status of individual drugs”
(Riley,1996). Accordingly, WHO should focus
on, and collaborate closely at the international
level with, The United Nations Fund for Drug
Abuse Control, and with Member States to cur­
tail drug demand.

Chapter Six of the Report of the United Nations
Conference on Environment and Development
(Rio de Janeiro, 3-14 June 1992) stresses that
the objectives of health improvement and de­
velopment are “intimately connected”,
£ £ Both insufficient development leading

to poverty and inappropriate develop­
ment resulting in overconsumption, cou­
pled with an expanding world popula­
tion, can result in severe environmen­
tal health problems in both
developing and developed nations
(UNCED, 1992,p.54), jjg
The global problems associated with envi­
ronmental degradation represents another
transnational policy issue having major health
status implications. One likely future trend given
the effects of continued population expansion0,
combined with the increasing consumer expec­
tations that will accompany global trade liber­
alization and rapid industrialization of many
economies of the developing world, will be a geo­
metric, unsustainable increase in energy con­
sumption and environmental damage, if sustain­
able development models are not adopted
(Sakakibara,1995).
The United Nations Conference on Envi­
ronment and Development (UNCED) held in
Rio de Janeiro in June 1992, emphasized the in­
terrelationship between environmental degrada­
tion and ill-health (Johnson,1993,p.167). Re­
cent research, for example the report by the
WHO/WMO/UNEP task force on Climate
Change and Human Health concludes that global
warming and climate change due to the accu­
mulation of greenhouse gases will likely lead to
adverse health effects such as major shifts in in­
fectious disease patterns and vector distribution,
deaths from heat waves, increased trauma due to
floods and storms, and the exacerbation of food
shortages and malnutrition in many regions of

6 Although it must bo noted that the rate o' population growth has slowed in the 1990s: “me rate of world popuiaiion growth slowed
significantly in the first half of the 1990s" as compared to the previous decade (United Nations, 1995,p.145). However, the actual number
of persons added per year has remained relatively stable at 85 million persons per year (FAO, March 1996,p.1).

12

11

THINK AND ACT GLOBALLY AND INTERS ECTORALLY TO PROTECT NATIONAL HEALTH
the world. Further, the depletion of stratospheric
ozone, as well as increasing the incidence of skin
cancer in light-skinned populations, may result
in an increased incidence of cataracts and may
contribute to a weakening of human immune
systems. The findings of this task force empha­

size three major points:

these projected health hazards are “not of a
localized kind”, but rather, are widespread
and will affeqt “whole populations”;
G

E3

the risks described cannot be described as
“more of the same”. These health distur­
bances will occur as a result of disturbances
to natural systems;

the forecasting of these risks involve a long­
term time frame.

In addition, the hazards of other forms of
environmental contamination/disasters may the
cross borders of sovereign states, resulting in ad­
verse effects on human health. For instance, the
radiation contamination after the Chernobyl
accident, which “released radioactive materials
over a wide area totalling more than 100 times
that of Hiroshima and Nagasaki”, demonstrated
how interdependent the world of states has be­
come (WHO,1996e). Also, the potential for
toxins, the result of pollution of the world’s seas,
such
as
halogenated
hydrocarbons,
polychlorinated biphenyls (PCBs), and
tribur/ltin (TBT) to become incorporated into
marine organisms, and thereby becoming incor­
porated into the human food chain, underscores
the interconnectedness between the world’s ma­
rine environment and human health
(Tolba,1992,pp.37-38).
The recommendations of the WHO/WMO/
UNE? task force stress the need for decision­
making elites to think in terms of a ‘global com­
munity’ so that strategies of cooperation between
developed and developing nations can be formed
(McMichael et al.,1996). One example of glo­
bal intersectoral cooperation at the environmen­
tal level is the UNEP Global Environment
FaciEry.

.. ................ T”

The Global Environment Monitoring System-

. WHO collaborates with other United Nations agen­
cies on a number of monitoring programmes. For
instance, within UNEP’s Global Environment
f Monitoring System (GEMS), WHO and UNEP
; “produce guideline documentation on issues re: lated to the monitoring and assessment of air and ■
L water quality and pollution, on dietary intake of
L contaminants, and on the genetic effect of envi• ronmental contaminants. Additional resources are
needed to extend these systems to include the
> direct and indirect risks associated with climate
j change, such as increased UVR and the rise in
< sea !evels(McMichael et.al, 1995,p.210).
-.

. .. x . x.'x.<<•'< ; x

x-

s ', s.• -v.- vk

a'X-k;kxx .< .

vA-kvx*

Since the activities of many United Nations
agencies overlap, a framework, entitled The cli­
mate agenda, for integrating climate-related pro­
grammes was adopted by the WMO Congress in
1995. The climate agenda is intended to help in­
ternational agencies harmonize their climaterelated activities and to facilitate interagency
collaboration in the following four main areas:
E

new frontiers in climate science and predic­
tion;

E

climate (rather than weather) prediction for
sustainable development;

E

studies of climate impact assessments and of
response strategies for reducing vulnerabil­
ity’;

E

observation of the climate system.
(McMichael et al., 1996,pp.210-211)

Likewise, GLOBE a group of environmental
parliamentarians from different parties and from
all European countries, warns that inaction in
responding to climate change will have detrimen­
tal effects. The multi-disciplinary’, intersectoral
approach which they recommend emphasizes,
inter alia, the following principles:

□

integration of environmental matters into
decision-making at all levels of government;

D

public participation;

□

effective implementation of international
commitments;

adoption of sustainable consumption pat­
terns;
13

H
THINK AND ACT GLOBALLY AND INTERS ECTORALLY TO PROTECT NATIONAL 11EALTII
Q

incorporation of the above principles with
economic (market based) principles.

In light of the serious health threats posed
by environmental degradation and the need for
urgent action it is evident that WHO’s future
policy must stress intersectoral strategies at all
levels of development, and that the normative
commitments at the global level must be linked
to national and local initiatives. The recently
completed WHO Task Manager's Report, pre­
pared for the ImeT-Agency Committee on Sustain­
able Development (1ACSD) to review the progress,
five years after UNCED in implementation of
the objectives set out in Chapter 6 of Agenda
21, stresses the role of several global intersectoral
initiatives to promote sustainable human­
centered development:

□

WHO’s initiative Information for Decision.making in Environment and Health
(1DEAH) aims to develop an effective envi­
ronmental information system.

E

Intersectoral links between the international
level and local government are required to
implement the global agenda for sustainable
development outlined in HABITAT 11.

□

The Intergovernmental Forum on Chemi­
cal Safety (IFCS) was set up in 1994 at the
invitation of UN EP, WHO and ILO to ex­
tend the understanding of the cumulative
effects of chemicals on human health.

□

The WHO, FAO, UNEP, and UNCHS
Panel of experts on Environmental
Management of Vector Control (PEEM) pro­
motes the incorporation of health concerns
into environmental impact assessments.

E

The UNDP/World Bank-WHO Special Pro­
gramme for Research and Training in Tropi­
cal Diseases (TDR), since 1994, has been
funding research projects which aim to re­
duce the impact of development projects on
the risk of dissemination cf tropical diseases.

Besides these initiatives the V.’HO Task Manag­
er’s report recommends that future intersectoral
efforts in the area of sustainable development and
the environment will need to focus on the rela­
tionship between human health and other fac­
14

tors such as consumption and production pat­
terns, including trade, employment and sustain­
able livelihoods, and energy and transport, as well
as understanding the environmental determi­
nants of emerging and re-emerging diseases.
It is apparent that the breadth of these issues will
require a wide degree of collaboration with nu­
merous agencies at the intergovernmental level,
in conjunction with local and national develop­
ment partners (WHO,1996g).
Taking into consideration the findings and
recommendations of other groups such as
GLOBE it is also evident that the protection of
the global environment to protect human health
will have to stress the role of legislative instru­
ments, both at the domestic and international
levels. Also it will be necessary that realistic
compromises between developed and develop­
ing countries are reached so that the world can
meaningfully address the problem of ozone de­
pletion and the accumulation of greenhouse
gases. In areas such as the reduction of green­
house gases little progress has been made
(1ACSD,1997, p.12). It is imperative that de­
veloping countries are not expected to shoulder
all of the burden of adjusting: rich industrialized
countries, which consume a disproportionate
amount of energy per capita, as compared to de­
veloping countries, should make significant life­
style adjustments and take concrete action. In
this regard, the Intergovernmental Panel on Cli­
mate Cliange (IPCC) 1995 report outlines key
mitigating actions, including inter alia, more en­
ergy efficient industrial operations, agricultural
conservation, forest management, and rehabili­
tation policies, conversion to alternative sources
of energy, and changes in the lighting and heat­
ing of residential, commercial, and public build­
ings. International carbon taxes and other forms
of national taxation to deter the use of private
vehicles are other options which must be ex­
plored. However, to make a meaningful impact
it will be necessary to implement intersectoral
policies based on the interdependence of many
global issues.

iJ

Tl IINK AND ACT GLOBALLY AND INTERS ECTORALLY TO PROTECT NATIONAL 1IEALTI1
: -."■'J •

“Cross-cutting” issues in Sustainable Development

Proposals for the future programme of action for the IACSD emphasize the need for linking “relevant chapf ters of Agenda.21 to the role.of relevant sectors and major groups”. This strategy would promote “cross; cutting issues”, including inter alia, production and consumption patterns, population, and health, in order
' that integrated, practical policies are developed (UN,1997,p.26). In this regard, the IACSD has observed
: that, in the face of globalization, sustainable development will require that trade liberalization be accompa' nied by environmental and resource management policies. Towards this end the IACSD recommends that
: the WTO Committee on Trade and Environment, UNCTAD, and UNEP continue to collaborate In order to
promote integrated trade, environment and development policies (IACSD, 1997^.7,21). Further, the impact
of trade and environment issues on health status underscores the need for WHO to play a key role in elabo­
rating a sustainable trade and environment policy for the future.
......

.

■

As emphasized in the Ottawa Charter for
Health Promotion (1986) it is crucial that the links
between the natural environment and human
health provide the foundation for a “socio-ecological” approach to health, which encourages
“nations, regions, and communities” to cooper­
ate in a spirit of “reciprocal maintenance” and

..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................-

Globalization and Marginalization

their trading relations in an attempt to increase
and diversify' their output and exports. However,
a dependence on production and export of pri­
mary’ commodities has hindered the expansion
of many of these countries’ exports.

; Generally, an increase in manufacturing output has
■ been responsible for much GDP growth in successful developing countries, particularly those in
• East and Southeast Asia, that have liberalized their
. trading relations. Nevertheless, in marginalized
’ economies trade liberalization has been accom­
panied by ‘deindustrialization’, particularly
amongst African countries. According to a recent
: UNCTAD analysis, trade reform and structural
' adjustment programmes have not taken into con. sideration the different structural conditions of LDC
• economies: for instance, some of these countries
have a low or non-existent Industrial base, and as
a result, have faced an adverse external economic
environment in the 1980s and 1990s (Shafaeddin.
. 1995). Economic globalization has transferred
about SUS 422 billion of new supplies, factories,
and equipment to developing countries between
. 1988 and 1995, and according to the World Bank
1 this investment has allowed many people to es■ cape poverty. However, these positive effects of
globalization have excluded “large parts of the de­
veloping world, including most of Africa and Latin
America, [which] have been bypassed by the flows
of private money or have yet to see its effects
among the poor”(Richburg, 1996,p.4),

Therefore, it is becoming increasingly evi­
dent that the globalization of finance, trade, and
technology facilitated by the series of GATT
. agreements, including the recently concluded
Uruguay Round agreement, has resulted in win­
ners and losers. The neo-liberal restructuring of
the world’s economy, which has gained momen­
tum since the end of the Cold War, has contrib­
uted towards an increased gap between rich and
poor, even within rich Northern economies

(Sakamoto,1994,p.4). The introduction of mar­
ket mechanisms of competition in the former so­
cialist bloc has been accompanied by a widen­
ing socioeconomic gap between the haves and
have nots. Moreover, the economic disparity be­
tween the industrialized and least developed
countries has increased. Even within many in­
dustrialized countries, as neo-liberal restructur­
ing has gained momentum the spread between
rich and poor has grown (Sakamoto. 1994,p-4);

“global responsibility”.
Macroeconomic Implications

Although global liberalization has resulted in
wealth creation and concomitant improvements
in health status, for example in the Newly In­
dustrialized countries of Asia (e.g. South Korea,
Taiwan, and Singapore), the results of these
changes have not been so encouraging for other
countries. Many least developed countries
(LDCs), especially in Africa, have been
marginalized by the process of global liberaliza­
tion. Since 1980 many LDCs have liberalized

ZA.:

V

A

.................... ............................ ............................... ... ............ .A-,:-

15

Ii

>— ■

THINK AND ACT GLOBALLY AND 1 NTH RS ECTO RALLY TO PROTECT NATIONAL HEALTH
unskilled workers find themselves exposed to
harsh competition and the prospect of downward
social mobility (Reich,1991).
The expansion of the global economy has
increased competition, and as a result “all work­
ers, communities and countries have effectively
become competitors for the favours of
transnational corporations (UNICEF, 1996).”
One consequence of this global trend towards
economic competition is that more children have
entered the workforce,

circumstances of different countries and commu­
nities (Bjorkman et al.,1997,p.9).
Moreover, considering that the links be­
tween poverty and ill-health are well established
(WHO,1996a,p.l) the potential economic in­
equalities of global financial and trade liberali­
zation, especially if the needs of the most vul­
nerable are not taken into consideration in so­
cial and economic policies, could have signifi­
cant negative implications for improving the
health status of the world’s population. The eco­
nomic and political stresses brought on by glo­
balization present potential threats to public
health including:

In India, which has only in recent
years opened up fully to the global
economy, international competition has
already led some sectors of industry’ to
seek an advantage by recruiting cheap
child labour-children’s wages in Indian
industry are less than half those of adults
for the same output. Increases in child
labour are reported in sericulture, fish
processing and genetic engineering of
seeds (UNICEF,1996,p.69)^g

EJ

Stresses generated by incorporation into the
global economy - the loss of jobs, reduction
in wages and safety standards, access to
health damaging products such as tobacco
and agrochemicals, migration and the sense
of alienation can ” threaten the physical and
mental health of many persons.

E

Also, rapid, cheap travel in a globalized travel
market have encouraged the phenomenon of “sex
tourism” which has resulted in the recruitment
of children into prostitution; these markets are
often controlled by international syndicates spe­
cializing in the exploitation of young children
(UNICEF,!996,pp.36-37) with serious health
consequences.

The processes of urbanization, migration, and
the involvement of increasing numbers of
persons in informal economic activities
makes many persons “invisible” to public
health programmes. As a result, this may
threaten the effectiveness of global public
health programmes, for example interven­
tions to control and eradicate the spread of
infectious diseases such as poliomyelitis.

E

In today’s globalized economy “the prices of
some medical products and services have
increased through privatization”. Also, there
is the risk that the “quality of medicine”
available may fall, especially in developing
countries, if trade liberalization makes it
easier to “dump” expired and/omnsafe medi­
cations or obsolete technology’ which can­
not be maintained.

Globalization, Structural

Adjustment, and. Health Status

The effects of globalization of the world’s
economy has resulted in increasing competition
between national economies and as a result of
budget austerity “the ability of many govern­
ments to provide effective health services is de­
creasing” (UNRISD,1995,p.26). Further, the
globalization of “one size fits al!” reforms fails to
appreciate that “no institution, policy, or pro­
gramme” can be simply transplanted from one
context to another (Marmot,!997,p.348). This
approach reflects international ideologies, con­
cerns, and perceptions rather than the specific
16

As globalization gathers pace and as essen­
tial social support netv/orks are weakened
health status may be compromised since
“families and communities” are not able to
provide essential care “for preventing disease
and aiding recovery” (UNRISD,1995
pp.26-27).

'

»■!

d

THINK AND ACT GLOBALLY AND INTERS ECTORALLY TO PROTECT NATIONAL HEALTH

K3

The health risks of involving increasing
numbers of young children in hazardous, low
paying jobs and the sex industry are indis­
putable.

■

The links between chronic unemployment
and structural unemployment and
higher mortality rates have been supported
by
research
(Martikainen
et
al. 1996). In this respect, increased global
competition for employment is giving
rise to a widening gap between the “knows
and
the
know
nots”
(World
Economic Forum, 1996).

Structural adjustment programmes aim to
reduce the role of state institutions in national
economies and to open up these economies to
international competition by the reduction of
external trade baniers, and market deregulation.
This involves the removal of internal price con'
trols and subsidies, the encouragement of private
foreign investment and privatization of state
companies, and limiting public spending
(Woodward,1992,pp.36-38). Numerous studies
have documented the potential health and so­
cial effects of structural adjustment programmes.

’

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.

-

.

.

Structural Adjustment and Health
xz- •*

< A:?;'x;'-

(1) Food availability and access to education and health services for children in selected African, Latin
American, and Asian countries undergoing economic adjustment programmes deteriorated (Cornia and
Joliyr1987).
(2) In several Eastern and Central European countries the ‘protracted crisis' of reform placed heavy burdens
on the health and welfare of children, as household incomes fell, and as social expenditure on health, eduction and child care were cutback (Cornia, 1991; Sipos,1991).
(3) A recent study of the effects on health status of structural adjustment on rural and urban pooulations of
Zimbabwe concludes that the government’s cutbacks in the health sector, since structural adjustment was
introduced to the country in 1991, has had an adverse effect on the welfare of the poor in both urban and
rura. areas, and that there has been a “serious economic degradation” of the rural and urban poor. The
investigators conclude, that the World Bank's report Adjustment in Africa (1994), in which it is observed that
“the majority of the poor are probably better off and almost certainly no worse off” (World Bank,p.73), is
over'y optimistic. However, this report concedes that the negative results of the study cannot be separated
from the negative health impacts caused by the severe drought in that country in 1991-92 and the HIV/AIDS
epidemic (Bijlmakers et al., 1996,p.74).
(4) A study by the World Bank, Egypt: Alleviating Poverty During Structural Adjustment suggested that the
health status of the poorest rural inhabitants has not improved, and that additional reductions in resources
might compromise the coverage and quality of programs in health and education, particularly in rural areas
(Wcr.d Bank,1991,p.xviil).

A-ithough the social and health effects of
structural adjustment programmes have been
hard to pinpoint precisely, the evidence indicates
a need for concern for the health and social sta­
tus ot the most vulnerable and marginalized
populations in societies, particularly when soci­
eties undergo rapid economic adjustment.

Macroecono tn ic Determ in ants:

are circumscribed. Although the Organization
should continue to advocate for equity and the
protection of social safety nets for vulnerable
groups, a great deal of the work in this area will
have to be done in conjunction with other inter­
governmental organizations. Three major areas
on which WHO should , inter alia, focus upon are:

E3

to clearly define the nature of health risks
associated with structural adjustment pro­
grammes;

□

to make the reduction of social gaps in health
and health care a top priority on the agen­
das of all of WHO’s health partners;

Global Intersectoral Actions

The aoility of WHO to have a major impact on
the macroeconomic repercussions of globaliza­
tion and structural adjustment on health status

17

u
THINK AND ACT GLOBALLY AND INTERSECTORALLYTO PROTECT NATIONAL HEALTH

Q

to support targeted research” and continu­
ous monitoring activities in “selected coun­
tries as a means of developing and evaluat­
ing policies to reduce social differences in
health and health care;

E

to promote international exchange of infor­
mation and experience in ameliorating the
social differences in health status and health
care (WHO/SIDA, 1996,p.25).

While structural adjustment policies may

represent a method of placing countries’ eco­
nomic development on a sustainable path, it is
evident that in the complex, political and eco­
nomic environment of the late 1990s these poli­
cies must define the role of the state in with re­
spect to crucial social services8. In this regard,
WHO must project a clear view of the role of
state institutions in public health in the face of
public sector austerity. In particular, WHO
should work with the World Bank and other part­
ners to ensure that (,essemial public health func^
tions1" are delivered as a prerequisite for privati­

zation and reform to proceed. A working croup
at WHO headquarters has documented that, in
practice, certain essential public health functions
are not being protected as privatization,
“downsizing” and reform policies have taken
hold, particularly in least developed countries
and many of the Newly Independent States. As
a result of these public health functions not be­
ing provided preventable disease morbidity and
mortality has ensued.

Therefore, it is imperative that WHO work
with the Vorld Bank and other partners, for
example the Regional Development Banks, to
ensure that the role of the state in providing
monitoring and support responsibilities for cer­
tain high priority areas of public health are not
neglected. In effect, WHO should aim to

'

18

delineate and define the role of the state and the
limits of “downsizing” in reform and structural
adjustment packages, and in particular to ensure
that the public health needs of the most vulner­
able in society are not compromised by reform
initiatives. This line of thinking would seem to
be gaining currency within the World Bank: the
1997 World Development Report will examine
the role of the state in development. Moreover,
bank officials have recently emphasized that the
“the World Bank will continue to collaborate
with governments, in partnership with the World
Health Organization and other agencies and in­
dividuals to address priority aspects of disease
control, making cost-effective and feasible inter­
ventions more widely available” (Claeson et al
1996,p.268).
Therefore, WHO should continue to build
closer ties with the World Bank and the inter­
national Monetary Fund (IMF). As part of a
closer relationship between WHO and the
Bretton XX^oods institutions it should advocate
strongly for social safety-net schemes as part of
enacting structural adjustment policies, and sup­
port the World Bank’s recent moves towards debt
alleviation for the poorest countries of the world.
Shared Global Responsibilities

Recent work done by the World Bank, the
OECD and UNDP have strengthened WHO’s
view that equity is a central concern for long'
term health improvement and sustainable eco­
nomic development. The fact remains that the
absolute number of persons living in poverty, de­
nned as less than $l/capita/day (Figure 1), has
continued to increase to reach 1.3 billion per­
sons in 199o (^ach,1996). Although global eco­
nomic expansion is a necessary precondition for
improving the health status of the world’s

recen1' inHQrn,a' ^«8ssmeW 01 World Bank

-——-

-

'mplomentation strategies (The Waphenran's

-----------------------------------

I

I i

THINK AND ACT GLOBALLY AND INTERSECTORALLY TO PROTECT NATIONAL 1IEALTII
Figure 1

population, “trickle down” economic policies will
not benefit the poor, even in countries with high
rates of economic growth (WHO/SIDA,1996,
pp.12-13). Addressing the needs of the world’s
poor represents an area of shared responsibility
for the world’s development community.

;Population living below US$1 a day
jj
1987 and 1993

n ’

r«
i-

I

L.i

For example, WHO should collaborate with
organizations such as the ILO which has encour­
aged prudence in introducing reform packages
so that health and social gains can be sustained.

a

UNDP. 1996

-♦X.-

pyAWsj,

V. v

?.

.,

Preventing the Big Bang approach to Globalization

The ILO warns that “introducing reforms on all fronts at once has often proved counterproductive: “A big
bang approach is likely to lead to socially unacceptable increases in unemployment, underemployment, and
poverty” and threaten to compromise the entire package of reforms. The ILO argues for a “phased and more
gradual”approach which takes into consideration the need for taking time for difficult reforms “such as strength­
ening of administrative capacity, the streamlining of the tax system and privatization. Tne ILO notes that the
"trickle down approach” to development is ineffective and that reform initiatives need to promote the develop­
ment of “rural infrastructure, credit schemes, and improved access to education and health services” (ILO. 1996).
Therefore, if the process of globalization is to be sustained, social policy must focus on the losers in the new
open world economy who are affected by rising inequality, job insecurity, and chronic unemployment
(Kapstein,1996,p.17).
ZZZ. >

. ZZ WAS • Z’.-ZZ. V . .W.V.

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Also, in defining the role of the state in
health development WHO needs to reinforce its
links with agencies such as UNESCO and
UNICEF to ensure that other social services that

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have health benefits, such as primary education
(especially for girls), are adequately provided. A
related policy issue is the provision of credit to
the most vulnerable members of society.

Credit schemes for the poorest members of society

The experiences of countries v/hich have implemented credit schemes targeted to the needs of the most
vulnerable in society is that these initiatives have tangible social benefits, especially when the health compo­
nent has been emphasised. These include, inter alia,
E improved nutritional status;
D improved ability to pay medical bills;
D increased savings for health and economic investment;
O a better physical environment;
E new technologies purchased with credit allow increased economic output;
□ rural/urban migration is reduced as a result of better living standards.
In Nigeria, for example, an intersectoral initiative combined the credit facilities of a national financial institu­
tion and a WHO sponsored project, "Promoting health through female literacy and Intersectoral Action'. Poor
women, in particular, have the greatest difficulty in gaining access to credit. Research has shown that when
women are given access to primary eduction and a greater share of the household income their families'
health status is more likely to improve. Therefore, microcredit schemes targeting women should be given
greater attention (WHO/IBRD,1994,pp.4-8). At the intergovernmental level intersectoral microcredit schemes
between WHO, the Bretton Woods institutions and the Regional Development Banks, as well as other
organizations such as UNDP, UNESCO, and ILO should be encouraged.
.

>..

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19

^2,

Ii

1
THINK AND ACT GLOBALLY AND INTERS ECTO RALLY TO PROTECT NATIONAL DEALT! I

WHO, in collaboration with other interested
international parties, for example involving
mechanisms such as the ILO/WHO Committee
on Occupational Health, must ensure that the glo­
balization of trade and production is supported
by appropriate measures and international instru­
ments to protect the occupational health and.
safety of the world’s labour force. WHO should
also work with organizations such as the ILO and
UNICEF to strengthen, monitor and enact in­
ternational instruments, such as the United Na­
tions Convention on the Rights of the Child, to prd*
tect the rights of children, in areas of child la­
bour, exploitation of children through debt bond­
age, and other “contemporary forms of slavery”
such as child prostitution (ILO, 1996a). WHO’s
role in such initiatives may be limited to an ad­
vocacy and information gathering role in con­
junction with other organizations such as the ILO
and UNICEF. In global intersectoral initiatives
such as these, the comparative advantage may
rest with other organizations: for instance, inter­
national instruments relevant to child labour ex­
tend from the 1919 ILO Convention on child
labour to the United Nations Convention on the
Rights of the Child (1989), which represents the
most comprehensive international treaty on the
rights of children (ILO,1996a,p.28). Although
child labour and exploitation has serious health

ramifications, in issue areas such as these WHO’s
role should be supportive, in recognition of other
organization’s expertise.

In addressing the macroeconomic determi' .
nants of health status it is crucial that WHO work
closely, at the intemational/regional intergovem'
mental level, with its partners in the United Nations system, the Bretton Woods institutions, the
WTO, and the Regional Development Banks.
Initiatives to address the economic determinants
of health exhibits how interdependent WHO’s
actions are with those of its development part­
ners. Through global intersectoral initiatives
WHO can ensure that appropriate and effective
action is taken to address the health conse­
quences of poverty and economic adjustment.
Technology and

Communications

The globalization of international trade and tech­
nology has allowed the diffusion of products and
scientific knowledge resulting in extensive ben­
efits for the health status of developing
countries.

Technologies for Health

Roemer and Roemer emphasize that teohnoiogy spread to developing countries has been vast, and that
even it some technology has been misused. i‘ must be recognized that appropriate technologies have benefitted
the health of millions of people and will continue to benefit millions more. A list of such advances would
include effective methods of contraception, techniques for obtaining safe drinking water, low-cost refrigera­
tion, efficient transport and communication, fertilizers and pesticides to enhance agriculture and nutrition,
new therapeutic agents that can effectively treat leprosy, schistosomiasis, trachoma, onchocerciasis (river
blindness), and other scourges of the developing world, once regarded as hopeless (Roemer and
Roemer, 1990, pp. 1189-90).
v-X" - .-z.-..'.■x:<v.avz.w.--:. :

In the future, technological innovations in
areas such as telemedicine and biotechnology' will
have profound effects on world health. Also, new
mapping technologies have become available
which are appropriate forms of technology for
the control of tropical diseases such as malaria
(Yach,1996,ln press), and it is possible that in­
ternational efforts to map the human genome will
lead to “methods and techniques of testing and
20

therapy that are affordable” to populations in de­
veloping countries (Bankowski et.al.,1991,p.3).
The research and information dissemination
made possible by globalization could facilitate
widespread accessibility to advanced technolo­
gies such as these. However, it is important that
the development of health-related technologies
consider the needs of developing countries and
the affordability of new technologies for the

Ii

THINK AND ACT GLOBALLY AND 1NTERSECTORALLY TO PROTECT NATIONAL 1IEALTII

poorest members of all societies, so that the
health benefits impact the lives of the most vub
nerable members of world society.
7

WHO needs to strengthen its existing ar­
rangements for global intersectoral collaboration
in the area of informatics and telemedicine so
that the least developed areas of the world can
enjoy the health benefits made possible by the
communications revolution.
y-S-

■<

-- ------------ --------------------------------------------------------------------------- ------------

“Breaking down the barriers towards the glo­
bal information society” (ITU, 7th World
Telecommunications Forum,1995).
r

> '
•
The potential uses of modern information tech­
nology in the area of health development include,
’ interalia, telemedicine, interactive health networks,
epidemiological surveillance and telecommunica­
tion services in remote areas, human resources
development and continuing education, and “dis■ tance learning." WHO has collaborated with the
International Telecommunication Union (ITU), for
example under "the aegis of the TELECOM and
Telecommunications Development studies”, forthe
“promotion and validation of new methods and
tools for the support of health care services”, for
example Telemedicine (Mandil,1995,p.5). In rec­
ognition of the inadequate communications infra, structure and services in many developing coun­
tries the European Space Agency (ESA) and the
United Nations Office of Outer Space Activities
(UN/OOSA) have made a joint proposal for the
establishment of a satellite based “Cooperative In­
formation Network linking Professionals in Africa
and Europe" (COPINE). WHO has been involved
in initial studies in selected African countries to
delineate the potential needs of COPINE users in
the health sectors of African countries. If the
COPINE project is developed it could have “a major
; effect on health care in developing countries, es­
pecially where the telecommunications infrastruc­
ture is poor" (WHO, 1996,7 January 1997).

WHO in conjunction with UNESCO and
other international agencies needs to work to­
wards the “globalization of scientific policies” so
that the benefits of new knowledge is readily
available to the world’s poorest populations.

The globalization of scientific knowledge to improve health will also have to involve other or­
ganizations such as WIPO and the WTO to en­
sure that provisions for least developed countries
to develop their technology base, under the
TRIPS agreement are practically applied9.
'■.....................................■

The globalization of scientific policies
< A recent UNESCO publication Memory of the Fu> tore (Mayor,1995) stresses that science can make
J major contributions io addressing problems which
} extend beyond national borders. Also, since policy
; issues are becoming more complex and unpre1 dictabie, interdisciplinary approaches are required
: to keep pace with the increased pace of world
events and problems. Therefore, in many areas
such as the "environment, telecommunications,
health, energy, education, science policy, and pro­
tection of intellectual property’ it is not rational to
think of problems in purely national terms. In this
respect, UNESCO is dewsing new ways of trans­
ferring knowledge to communities most in need.
These strategies seek to reverse the “short; sighted" concept in science and technology,
"techno-nationalism”, which Threatens to perpetu­
ate the dangerous gap between ths haves and
; have-nots (Mayor, 1995, pp.63-69).

An urgent need exists for international or­
ganizations such as WHO, the World Bank, Re­
gional Development Banks, NGOs, development
and professional agencies to formulate global
frameworks and guidelines in the area of
bioethics. The globalization of bioethics is indi­
cated because medical sciences do not have all
the answers, and thus there is a need to “rede­
fine the field of bioethics” (Bryant, 1995,p.61).
Given the global challenges and inequities fac­
ing WHO’s Health-for-AU policy for the twentyfirst century a recent international conference
on “Ethics, Equity and Health-for-All,
cosponsored by the Council for International
Organizations of Medical Sciences (OOMS) and
WHO, has recommended an international fo­
rum be created for “advancement of global health
equity through the use of ethics and human
rights” which should include intersectoral col-

Tho Final Act Embodying the Results of tho Uruguay Round of Multilateral Trado Negotiations (GAi i ,1933) makes provisions under the
TRIPS agreement (agreement on Trade-Related Aspects of Intellectual Property Rights), to recognize the special needs of least­
developed countries to create a “sound and viable technological base.’

21

1

Ii
THINK AND ACT GLOBALLY AND INTERSECTORALLY TO PROTECT NATIONAL IIEALTII

laboration in the areas of education, research,
policy and global monitoring (C1OMS/
WHO,March 1997). In light of the transnational
problems outlined in this section it is apparent
that the ethical/normative dimension of inter­
national health development must be given the
highest priority. Only by encouraging shared
community interests can present and future gen­
erations hope to address the daunting tasks which
await humankind in the future.

displaced persons are vulnerable and require
international assistance to meet their health,
education, social services, and shelter needs;

E

the international traffic in undocumented
migrants, especially women, youth, and
children, are the objects of exploitation
and abuse (United Nations, 1995,
pp.72-73;UNRISD,1995,p.62).

Although international migration is not a
recent phenomena the “global extension of mar­
ket forces” has caused increased disruption for
millions of persons, and thus, the pattern of mi­
gration would “seem to be taking on a difrerent
shape and character” in the increasingly glo­
balized world of the late twentieth century
(UNRlSD,1995,p.59). The mass movements of
the world’s population are related to inter alia “in­
ternational economic imbalances, poverty and
environmental degradation” as well as other fac­
tors such as human rights violations, resurgent
ethnic tensions, social dislocation, and looser
border controls (United Nations, 1995,p.67;
UNR1SD, 1995,p.59). These problems also
threaten to undermine social stability.

Ethical Dimensions of Recent Scientific Advances

Science has made rapid leaps forward in the ar; eas of genetics and biotechnology. Advances in
the biotechnology industry have facilitated the pro; duction of hepatitis B vaccine, insulin, erythropoif etin, and human growth hormone, and if technoloF gies such as these become more access:b!e to
developing countries their benefits could become
globalized. However, biotechnological advances
. are also the subject of safety and ethical consid­
erations (WHO,8 November 1994). For instance,
f the need to develop international safeguards and
guidelines was raised after scientists experimen­
tally cloned human cells from human embryos in
1993 .Therefore, it is important that wor'.dwide
. consultations involving many sectors are under­
taken because ‘"technology cannot be left to gov­
ern ethics on an empirical basis” (Nakajima,29
November 1993). Therefore, for humankind to
address the ethical ramifications of these complex
- issues, bioethics will have to become truly glo­
balized.

'

-

............................................................................................................................. ..........

■

'

■

■

■

The Coming Anarchy?

Population G rowtli an J Mass
Migration
o

Q

1

The stresses of economic, environmental, demo­
graphic, and political change could result in the
unravelling of many nation states, to be “replaced
by a jagged-glass pattern of city-states, shanty­
states, nebulous and anarchic regionalisms" in
what Robert D. Kaplan has referred to as The
Coming Anarchy (1994). Social cohesion within
states may weaken as a result of the cumulative
pressures of, inter alia, crime, overpopulation,
scarcity, tribalism, and disease. In Kaplan’s future
scenario as crime and war become ‘'indistinguishable”, ‘•'national defense" may become regarded
as a “local concept". The escalation of violent
deaths and diseases associated with civilian dis­
placement would pose a major threat to human
security.

In an era of transnationalizarion of the world’s j
political economy the mass migration c: persons
across borders represents one more issue which
has led to increased interdependence cetween
states:
I This transnational problem has many determi­
nants and the actions of WHO should therefore
E in 1993 over 100 million persons, about 2
be circumscribed. For instance, in the area of
percent of the world’s population, including
reproductive health WHO will continue to play
economic migrants and political refugees,
a front line role.
were living outside their country c: origin;
22

I i

THINK AND ACT GLOBALLY AND INTERS ECTORALLY TO PROTECT NATIONAL 11EALT11

■ Reproductive Health
r y- ■ ■
A" :
/
'/Inadequate reproductive health and poor access
■ to family planning services for women, men and
; “youth" are major factors which contribute to poor.
. health and “sustained rates of populations growth”
(CIDAJ996,p.3). It is important that WHO contin­
ues to work with Its health partners to ensure that
comprehensive reproductive health care prof grammes, including inter alia, a comprehensive
and appropriate contraceptive method mix, ante­
natal and postnatal care,treatment of sexually
i transmitted diseases, and monitoring and treat­
ment of other diseases (e.g. anaemia) which "dis­
proportionately”, affect women are provided
(WHO,1994b,p.1). At the international intergovemmental level the UNDP/UNFRA/WHO/World Bank
Special Programme of Research, Development
and Research Training in Human Reproduction
represents a successful intersectoral initiative.
This initiative should continue to stress private and
public sector collaboration so that new contracep­
tive technologies, such as an anti-hCD vaccine
and acceptable forms of male contraception can
be developed (WHO, 1994c).
......................... -

...........................

••

-

-•

...

.................................

..

.................

.

.

U.

..

...

■................

In other areas, such as providing direct re­
lief assistance for displaced populations, WHO’s
role will be most prominent in the area of technical/information support in the health field. In
this respect, some key global intersectoral actions
between WHO and other agencies to prevent
the health problems associated with displace­
ment and rapid population growth would include,
inter alia, the following:

B

WHO should continue to provide research
and technical assistance for the the devel­
opment of new, appropriate contraceptive
techniques and be involved in integrated
reproductive health programmes in associa­
tion with agencies such as the World Bank,
UNDP, and UNFPA, in order to implement
the recommendations of the 1994 Interna­
tional Conference on Population and De­
velopment.

□

Regarding relief assistance to displaced
refugee populations WHO should cooperate
with UNHCR and other agencies to improve
surveillance, and to ensure the delivery’ of
essential public health functions and health
services to these vulnerable groups.

E

In conjunction with UNCHS and other
agencies WHO should provide support for*
the implementation of the Habitat II agenda*'
particularly in the following areas: integrate :
ing health and human development policies
for human settlements, promoting and pro^
tecting health and specific health problems,
and ensuring equitable access to health serv­
ices. These objectives can be accomplished
in concert with other United Nations organi­
zations, Member States, in conjunction with
local authorities and NGOs in Healthy
Cities Programmes (UNCHS, 1996,p. 162). |

G

WHO’s participation in the Inter-Agency
Standing Committee (1ASC) in association
with UNDP, UNICEF, UNHCR, WFP,
FAO, and numerous intemational/national
NGOs provides an excellent mechanism for
coordination of the various inputs required
to address the health, social, and other'
hazards associated with complex emergency
situations.
In this area WHO should once again em­
phasize its strengths, realizing that it cannot do
everything, everywhere.

Food Security

Global food security, defined as “a state of affairs
where all people at all times have access to safe
and nutritious food to maintain a healthy and
active life” and where there is no risk of house­
holds losing “physical and economic access to
adequate food” (FAO,January’ 1996,p.5), repre­
sents a crucial transnational policy issue for the
twenty-first century’. Access to safe, nutritious,
and sufficient food is a major determinant of
health. Today it is estimated that over 800 mil­
lion persons worldwide do not have access to
adequate supplies of food to satisfy their basic
needs.
Global integration of markets has facilitated
an exponential expansion of trade in agricultural
and food commodities However, other trends,
including inter alia the following, indicate that
food security will remain a major problem for
23

-IM’

J

11
I
THINK AND ACT GLOBALLY AND INTERSECTORALLY TO PROTECT NATIONAL IIEALT11

justment programmes need to focus on the
requirements of underprivileged populations
(FAO,1996,p.12; FAO,January’ 1996,p.13;
WHO,1994a,p.15).

human health and sustainable development in
the next century:

In the past two decades food trade, facili­
tated by trade liberalization policies, has in­
creased by 300 percent to reach US$ 266 bil­
lion, and over the same period the volume
of international agricultural trade has in­
creased by 75% to reach US$ 485 billion.

□

□

The global food trade has expanded more
than production.

E

Globalization of international food markets
will probably not affect the global availabil­
ity of food as decreasing output in “high cost
countries” will likely be made up by “in­
creased output in other countries”.

□

There has been a sharp decline in food aid
availability in the 1990s from a record 15
million tons in 1992/93 to an estimated 8
million tons in 1995/96, which may be linked
to the effects of trade liberalization .

E

Increased food consumption in the rapidly
growing, high population areas of Asia might
result in structural food security problems in
marginalized economies of the world, it sup­
ply does not keep up with rising demand. The
poorest countries of the world would be in
no position to pay hard currency for
these products if decreased food supplies be­
come available on a concessionary basis.

E

There is a long-term trend towards decreased
growth in agricultural production of food,
which does not mean that the world is inca­
pable of producing more food, but rather
these trends indicate that “the people that
would consume more do not have sufficient
incomes to demand more food and thus
cause it to be produced” .

□

Considering the combined effects of popu­
lation growth, the possible effects of climate
change and environmental degradation on
future world food production, the issue of
food security will remain a key global issue
in the next century.

□

24

The solution to these problems will not only !
entail the production of more food, but also
must emphasize the adequate distribution of
any extra food; in particular structural ad-

The recommendations of the 1996 World
Food Summit stress that a Universal Food Secu^

rity plan will depend on global interagency CO'
operation. There is a role for WHO in collabo­
ration with other international organizations,
such as FAO, UNEP, WMO, and WTO, to em­
bark on global intersectoral action with the aim

of:
£ Assisting member countries to im­
plement the international conventions
and agreements(on biodiversity and
plant genetic resources,.on pesticide use,
food standards and the Codex
Alimentarius,
drought
and
desertification, climate change, respon­
sible fishing, straddling and migratory
fish stocks, sustainable forestry) which
contribute towards ensuring sustainable
food production; and develop coopera­
tive programmes to this effect
(FAO,1996,p.16).

Obviously WHO’s involvement in some of
these activities would be greater than others. In
particular, WHO enjoys a distinct advantage in
the area of food safety and in activities related to
climate change, while its activities in some of
the other above mentioned areas would be less
apparent. For example, the production of suffi­
cient quantities of food for the world’s population
will entail the use of new biotechnologies, such as
genetic modification. These technologies offer
many benefits such as increased food production,
improved nutrient content, resistance to pests, and
improved food processing and storage character­
istics (FA0/WT10,1996,pp.1-2). However, these
new technologies also cal! for increased interna­
tional collaboration in order to address issues of

safety’. In this regard, WHO and FAO have initi­
ated joint consultations on the issue of biotech­
nology' and food safety, k is important that the
intersectoral linkage between WHO and FAO10
continues to address, in conjunction with other
interested groups, the potential human health

<

I i

THINK AND ACT GLOBALLY AND INTERS ECTORALLY TO PROTECT NATIONAL 1IEALTII

<

concerns related to genetically modified agricul­
tural and food commodities. Moreover, this com­
plex issue also involves other sectors. For instance,
concerns have been raised regarding the environ­
mental safety of foods, food organisms, and food
components produced by biotechnology. Further,
considering that globalized trade links the produc. tion of raw materials to processing and distribu­
tion to consumers in all regions of the world, it is
important that safety assessments of food pro­
duced, for example, by recombinant DNA tech­
nologies are worldwide (FAO/WHO,1996).

On the other hand, in areas such as food se­
curity other international organizations such as
the World Food Programme (WFP), the Inter­
national Fund for Agricultural Development
(IFAD) and FAO are better placed to take a lead
in addressing this crucial global determinant of
health status. These organizations should expand
and strengthen global warning systems for im­
pending famines as a way of mobilizing neces­
sary’ international assistance and preventing mass
migration of populations. In this regard, WHO’s
role will be a supportive one, in which, for in­
stance, the Organization should document the
global impact of hunger on human health and
nutritional status.

WHO Global Database on Child Growth and
Malnutrition

WHO’s Global Database on Child Health is a
standardized compi'ation-of anthropometric data
derived from popuia-ion-based nutritional surveys
which have been conducted throughout the world
since 1960. The database covers 90% of the
world’s total population of under-5-year olds. This
I global database provides an accurate picture of
' child growth and offers a basis for intercountry and
interregional comparisons, which in turn, facilitates
the monitoring of national, regional and global
trends. This nutritional data is designed to assist
national authorities in planning and evaluating
. nutrition interventions. Thib-database represents
a major source of information/estimates of mal/.

i

10

• nutrition, and has been used by FAO (e.g. World
Food Summit, 6th World Food Survey), UNDP in
! the construction of the poverty index, and the ■
: World Bank. Further, disaggregated longitudinal
data on differences in child growth can provide an
important indicator of equity In populations (De
• Onis,1997).

Concentrating WHO’s Global Efforts
for Greatest Health Impact
The foregoing analysis of transnational
health threats and the global intersectoral ini­
tiatives to address them has demonstrated four
main principles:

i. The health risks to populations and disease
transcends state borders.
ii. The globalization of disease and health risks
requires global intersectoral action to pro­
mote and protect human health.
iii. Certain transnational health problems are
more or less amenable to global intersectoral
initiatives.

iv. WHO enjoys a distinct advantage as far as it
is equipped to address certain global deter­
minants of the burden of disease, whereas
its activities in other areas will be by neces­
sity more peripheral.
Global intersectoral initiatives need to be
focused on global health problems which repre­
sent the greatest burden of disease now and in
the future. Also, to ensure that equity is an im­
portant component of these strategies interven­
tions need to pay special attention to the poor­
est segment of the world’s population. Accord­
ing to a recent report of the Intemational Health
Policy Program11 the greatest percentage of deaths
and DALY loss12 among the world’s poorest bil­
lion people is caused by communicable diseases
(52.7%
DALY
loss),
followed
by
noncommunicable diseases (32.7% DALY loss),
and injuries and violence (9.7% DALY loss). The
greatest share of disease burden in the least de­
veloped countries is due to inadequate water and

The co/aDoration betwee-. FAO/WHO in the area of food safety represents an example of sustained and effective global intersectoral action
for healtn. and suggests numerous best practices for future global initiatives (see Annex A).

” An initiative by the Pew Cnantable Trusts and The Carnegie Corporation of Nev/ York in cooperation with the World Bank and the World
Health Organization.
12 Disability Adjusted Life Years lost

25

*

I
THINK AND ACT GLOBALLY AND INTERSECTORALLY TO PROTECT NATIONAL 11EALT11

substances such i^tobacco, high fat foods, and

sanitation, under-nutrition and behavioural de­
terminants, especially unsafe sex. However, fu­
ture projections suggest that in the year 2020 the
poorest billion will increasingly suffer from dis­
ease associated with behavioural determinants,
such as tobacco use, in addition to the common
causes of disease mortality and disability seen at
present (Yach,1997). As depicted in Figure 2
industrial development and higher incomes are
associated with certain risk factors such as urban
air pollution, increased consumption of harmful

alcohol, which wi^ foose additional health threats
to developing countries in the future. It is pro­
jected that thereilill be a transition, as a result
of the world’s changing age distribution, such that
the burden of death, disease, and disability
caused by noncommunicable diseases will pre­
dominate (Figure 3). The Global Burden of Dis­
ease Study assumes that a linear epidemiological
transition based on past and present trends/observations will occur in the developing world13.

Figure 2
I Exposure to risk factors related to social class *|
10

i
Uroan SO2

BoCy Mean Inoex

&OCM CUA4

To&acco U3e

AiconO
[NegrM.con3»=uerxu»S of incon-.e g^n are becoming

corrot. ecuccoo.'. pnervg) occus a~c usuaiiy sfw
(spoarnTL Eert, ecaon coUd prever-.T*sa Tends.

Figure 3

and slower

boato problems become

CHANGE IN DISTRIBUTION OF CAUSES Or DEATH
i Causa ol Dca'.h - 2C20
and

World

I

ixrxjwaw)

World

Unaaaaa

a
ICauso of Death - 19fiO|

Developing Countries 1

I Cause of Des'.n -19901

Dovotopod Countries

El
I Cause of Death - 2020
Dovoopod Countries I

Causa of Death - 2020
Developing Countries'

Fl

.

The conTnued shift from mfecuous cseasest0

a

__

__ _

»rsuSs3°2-an Atrto^ich by the

diets will
wJI occur
exxer in all
al coo
T^tr
niab|(( dea.hs _nd
of a„ 0i2rrtl0ea deaths (up
increased tobacco and high fat die:s
9^70^
account for 93% of all malana
dCG.ns,deaths
61 /o ©•anc
a 32.2% for diarrhoea deaths m 1990^---------------------- ------------------?0_2_°twill
COfor
immunise
from 85.5% for malaria, 43.4% for immunizable oeaths

■ ’3 See for example, The Global Burden of Disease Summary (Murray and Lopez.1996).

26

I

I

i1

THINK AND ACT GLOBALLY AND I NTH RS ECTO RALLY TO PROTECT NATIONAL IIEALTII
Table 2. HEALTH-RELATED FEATURES OF GLOBAL CHANGE

Feature

Quality of evidence

Impact

Global warming
Climate change
Sea level rise
Heatwaves, etc

Fair to good, based on
models and empirical
observations

Entire world

.Ozone Repletion
UVRadiation increase

Good: based on
observations

Entire world

Resource depletion
Fresh water
Food supplies

Fair to good

Hits developing
countries
hardest

Environmental
pollution

Good, but health impacts
not always firmly linked
to pollutants

Mainly
Regional,e.g.
E.Europe,
Former Soviet
Union

Demographic changes
Population growth
Migration
Aging

Good, but many details
based on estimates

Developing
countries,
especially
Africa

Emerging, re-emerging
pathogens

Good

Varies; HIV and
some others
global, some are
regional

Other factors:
Rise of transnational
corporations, advances
in technology,
*
communication
political volatility,
religious fundamentalism,
conflicts

Fair to good

Mainly regional,
but some is
global

-T

I

I

________
Source-. Last 1997

However, it should be emphasized that some
of the global trends outlined in this section could
result in some dramatic deviations from these fu­
ture projections. While some global burden of
disease projections, for example those associated
with tobacco use, are phased on sound scientific
understanding and information concerning
present global patterns, the projected burdens as­
sociated with communicable diseases, malnutri­
tion, and violence could be underestimated, and

may not be adequately modelled with existing
equations. Further, as demonstrated in Table 2
the scientific evidence concerning the future
health impact of many determinants of health
status related to global change, for instance the
disease burden associated with environmental
degradation, are quire conclusive. As a result, it
is worth noting that the expected epidemiologic
transition and burden of disease estimates, which
are based on linear projections grounded in
27

I

u
T11INK AND ACT GLOBALLY and INTERSBCTORALLY TO PROTECT NATIONAL health

present experience, do not factor in complex and
unpredictable variables, and as a result may not
affect ail countries equally.
While many countries may benefit from the
economic and technological opportunities being
created by the process of globalization,
marginalized areas of the world could suffer from
pockets of political anarchy, famine, violence,
mass migration, and institutional collapse. Com­
bined with the health effects of environmental
degradation it is equally conceivable that many
less fortunate areas of the world could simulta­
neously suffer from double or even triple disease
burdens (noncommunicable, communicable dis­
eases and violence/trauma). Moreover, some
transitional economies, witness the recent po­
litical and economic chaos in Albania, may
suffer from infrastructural and institutional strain
as they struggle to adjust to an increasingly com­
petitive and complex world political economy.
Also, it is conceivable that some industrialized
countries, faced with the downward social mo­
bility and marginalization of disadvantaged
groups in their population may experience the
emergence of old health problems, such as in­
fectious diseases; this has already happened in
the case of tuberculosis. Therefore, a strong case
can be made that unless appropriate preventive
actions are taken it is possible that the trend to­
wards a submerged “third world” in many indus­
trialized countries could alter present disease
burden predictions.

While these future possibilities may sound
rather ominous, these examples underscore the
need for WHO’s new global health policy to be
based on sufficiently complex variables and de­
terminants so that it does not become locked into
a paradigm which limits its perception of the fu­
ture. In a similar respect, a recent analysis by
John Last, Ethical Dimensions of Global Ecosys­
tem Sustainability and Human Health, emphasizes
that the global ecosystem is a complex system of
“interconnected and interactive components in
which each living component interacts with and
is interdependent with the others”
(Last,1997,p.l). In this regard, the future mod­

elling of human health status may fit closer with
an order out of chaos paradigm: in other words, it
has been recently argued that models of all natu­
ral systems are affected by unpredictable turbu­
lence which tends to undermine linear, orderly
predictions about the future14. Likewise, it seems
likely that our present models of disease burden
will also be affected by similar patterns. For in­
stance, present predictions concerning the glo­
bal disease burden associated with tobacco use
would seem to rest on firm ground and favour
current linear models of disease burden based on
present experience and expectations. However,
other determinants of health such as the future
availability of food, environmental degradation
and global climate change, the access to health
services and availability of public goods in the
face of macroeconomic reform and public sector
“downsizing”, and the transnationalization of
health risks associated with the liberalization of
trade, introduce additional, interdependent, and
potentially chaotic variables into existing disease
burden equations.
If we consider some of the unexpected “re­
alities” which have evolved over the past 25 years
the need for a flexible and complex paradigm for
modelling future disease burdens becomes appar­
ent. The global spread of the AIDS virus, the
dissolution of the former Soviet Union and the
public health problems which have ensued, and
the rapidity of scientific advances, for example
in genetic cloning, should convince us that our
future equations of disease burden must provide
for unpredictable “X” factors. These “equations”
of course must also factor in the possibility for
major scientific advances, for example the dis­
covery of a cost-effective, efficacious vaccine
against HIV, which would render future predic­
tions concerning the global burden of disease
associated with HIV inaccurate. Moreover, the.
predictions of future tobacco deaths could prove
incorrect if an effective, cheap, and acceptable
(i.e.to the consumer) nicotine replacement is
developed.

Therefore, decisions about where WHO
must place its resources and attention in the

’* See Prigogine,!. et.al., Order out of Chaos: Man's New Dialogue with Nature (1984).

28

11

THINK AND ACT GLOBALLY AND INTERS ECTO RALLY TO PROTECT NATIONAL HEALTH
1

t.

s
i

r
1

future will need to be based on more complex
global equations, a taste of which has been of­
fered in the foregoing analysis. If WHO’s new
policy becomes constrained by linear, inflexible
models the Organization risks being ill-prepared
for future problems. Furthermore, the complex­
ity and interdependency of the challenges and
future opportunities outlined in this section un­
derscore the importance of global intersectoral
collaboration. Only by taking advantage of the
-.strengths of different health partners at global,
national, and local levels can the world hope to
address the complex, inter-linked, and poten­

Table 3: Potential Threats of Globalization for Health

1

1

4

tially chaotic problems which will affect human
health status in the future. If the paradigm which
guides WHO’s future global health policy is based
on a complex system of variables, which are ame­
nable to ongoing re-adjustment based on new
information, the Organization will be better pre­
pared to address global human health threats in
the future. In this respect, the following two rec­
ommendations made by WHO’s Task Force on
Health in Development (1997a, p.5), concerning
WHO’s future role and global health foresight
are particularly apposite:

Global transnational
factors

Consequences and possible negative impact on
health

Macroeconomic prescriptions
e.g. structural adjustment
policies and “downsizing”

* marginalization, poverty, inadequate and
decreased safety nets

Trade
e.g tobacco, alcohol,
psychoactive drugs

+ increased marketing, availability, and use

Travel

ft infectious disease transmission across borders and
export of harmful lifestyles

Migration and demographic
(e.g. increased refugee
populations and population
growth)

# ethnic and civil conflict

Food security issues

* structural food crises; greater vulnerability in
marginalized areas of the world's economy as rapidly growing
economies in Asia demand for food increases

Environmental degradation
and unsustainable world
consumption patterns

+ global and local environmental health impact
. ....
.
.

Technology

# the benefits of new technologies developed in global
market are not affordable to the poor

Foreign policies based
on national self-interest

# xenophobia, tough immigration laws as some
states try to isolate themselves from global
forces; threat to multilateralism and global
cooperation to address shared transnational concerns

Communications and media
e.g. global advertising of
harmful commodities
such as tobacco

+ marketing of health damaging behaviour; erosion
of cultural diversity and social cohesion

‘ possible short-term problem that could reverse in time
+ long-term impact negative
# uncertainty
Source: Yach, 1997

29

H..- THINK /\Nl) ACT GLOBALLY AND INTLRSl-CTORALLY TO PROTECT NATIONAL IILALI11_________

□

WHO should function as a global “clearing
house” where the most up-to-date scientific
information and health situation in all re­
gions of the world is disseminated globally.

□

WHO as the world’s “health caretaker” needs
to ensure that public policy is always con­
cerned with health concerns, so that it is able
to alert its health partners where action must
be taken based on emerging realities and new

information.
Nevertheless, the global and transnational
determinants of health status, outlined above,
need not undermine WHO’s attempts to
prioritize which global intersectoral actions will
have the greatest impact on the burden of dis­
ease so that the Organization can identify which

initiatives should receive greatest attention in
the future. Yet, the preceding analysis offers a
note of caution: the Organization must retain a
flexible outlook so that it does not become com­
placent and locked into a static vision of the fu­
ture. Moreover, the future implications of glo­
bal trends outlined in this section underscore the
importance of sound and continuous global
monitoring and surveillance as a means of early
warning and vigilance. In this respect, Table 3
summarizes the primary transnational challenges
to future health improvement in an era of glo­
balization. Furthermore, annex 3 identifies par­
ticular alliances of international/regional inter­
governmental organizations to address certain
transnational health threats and the broad de­
terminants of health status. For instance, in cer­
tain transnational issue areas such as tobacco

trade and use, which will have a major impact
on the future burden of disease, existing global
intersectoral initiatives are quite weak, in light
of the projected importance of this transnational

risk factor in the twenty-first century.
a te-^
suit, interventions such as global surveillance of
the tobacco trade must be strengthened in par­
allel with the implementation of international

instruments such as WHO’s Tobacco Conven­
tion. Also, the future burden of disease associ­
ated with global environmental threats is likely
to be profoundly negative. Therefore, global
action focused on monitoring the health effects
of global climate change, and elaborating inter­
30

national norms to protect the environment for
sustainable human health gains need to be
stressed. With macroeconomic determinants of

health status, for instance, structural adjustment
and economic reform, the future impact on the
burden of disease is more uncertain. While the
short term impact of macroeconomic adjustment
may be negative, it is likely that for many
adjusting countries these effects could be reversed
in the future.

In other areas of public health intervention
such as food safety, water and sanitation, moni­
toring and surveillance, and global immunization
programmes future health gains could be ad­
versely aifected if existing initiatives are not
maintained and strengthened. Past successes, for
instance the eradication of smallpox, should not
minimize the need to maintain and even
strengthen global action for global essential public
health functions in light of emerging transnational
trends. Essential public health functions which
benefit the health status of entire populations
represent public health goods which should not
be compromised in the name of public sector

reform and “downsizing”. The recent experiences
of many countries, for example the successor
states of the former Soviet Union, has clearly
demonstrated what negative consequences can
ensue it public health infrastructures are not
maintained. Moreover, the emergence of new
problems, such as emerging infectious disease, in­
dicates that vigilance in areas of “traditional pub­
lic health work” (e.g. monitoring and surveil­

lance) cannot be overlooked.
Finally, other transnational health issues,
such as the need for global disease surveillance
and the enhanced exchange of appropriate tech­
nology’ across national borders, and between de­
veloped and developing countries, have the po­
tential to improve health status significantly.
However, in both of these areas existing levels
of global action need to be enhanced and

strengthened.

t

)L

rl
e
r
c
is
>i

□
e.
ir
□i

tl
h
:o
o
o
nc
ise

ein
or
tr­
ie
ie
id
le
ur
ie
s”
□r
sle
se
le
ze
le
is

O
ie

I i

think and act globally and intersectorallyto protect national I iealti I

fc”

Section III:

b
01

_limk and Act Globally and Intersectorally to
TliinI

•nt
h<
he
•nt
n^
ec

Protect National Health
The World Health Organization:

Al/’YWHO, 1986) and the 1986 cosponsored re­

An Intersectoral Pioneer?

□r
•>r

d-

i

i

ot
or
ot
•n
:c
.11

h

The WHO Constitution stresses the importance
of cooperation between sectors and organizations:
at the intergovernmental level Article 2 (i) states
that the Organization shall “promote, in coop­

:S

n
>t

i

i

Therefore, the Organization’s intersectoral
credentials are based on a firm foundation. How­
ever, based on the foregoing analysis, WHO, in
its future endeavours, will need to more explic­
itly apply this concept to its interactions with its

eration with other specialized agencies where
necessary, the improvement of nutrition, hous­
ing, sanitation, recreation, economic or work­
ing conditions and other aspects of environmen­
tal hygiene” (WHO, 1996,p.2). Formal agree­
ments of cooperation with several International
Intergovernmental Organizations have been
approved by the World Health Assembly. These
include, inter alia agreements with the ILO (10
July 1948), FAO (17 July, 1948), UNESCO (17
July,1948), IAEA (28 May,1959), IFAD (23
May,1980), UNIDO (19 May, 1989).

is
■)t

port of WHO and the Rockefeller Foundation
Meeting in Bellagio, Italy, entitled Intersectoral
Action for Health: The Way Ahead (WHO,1986a).

The importance of intersectoral collabora­
tion has been stressed since WHO was founded.
For instance, in an address delivered at one of
the earliest World Health Assembly technical
discussions, Dr C.E.A. Winslow, at the Fifth
Assembly (1952) emphasized the “vital interre­
lationship between health and social problems”
and the need for WHO to work “in the closest
and most intimate contact with the United Na­
tions and its co-operating bodies” to address the
interdependent determinants of health status
(Winslow,1952,p.7).

Moreover, since Alma Ata in 1978 the
World Health Organization has emphasized the
‘multisectoral character of health development’
as one of the key components of the primary
health care approach. Following Alma Ata,
intersectorality has been featured in several land­
mark papers, for example in WHO’s technical
paper The Role of Intersectoral Cooperation in
National
Strategies
for
Health^

various international intergovernmental health
partners in order to address global health policy
issues efficiently and effectively.

WHO s Globa] Partnerships
Recognizing that emerging global realities make
intersectoral/interagency cooperation imperative
WHO is currently reviewing the need to extend
and broaden its partnership base as part of up­
dating the Organization’s global health policy for
the twenty-first century; Examples of recent steps

to extend WHO’s partnerships with other inter­
national organizations include, inter alia, the fol­
lowing initiatives:
i.

A recent WHO initiative has aimed to build
closer “working partnerships” with interna­
tional organizations involved in health sec­

tor activities. For instance, discussions were
initiated between WHO and the World
Bank in 1994 to strengthen cooperation be­
tween the two agencies. Although collabo­
ration between the two organizations ex­
tends back to the early 1950s there “have
been limitations, duplication and gaps in
their efforts to support Member States in the
health and health-related fields”
(WHO,1995,p.7). The 1994 agreement ex­
tends this previous base of cooperation to
make the wod^qfJxiihjDrganizations more

J H . \ o o> .

04^3

31

I, A .w'iS zY,,:’

u
Tl IINK AND ACT GLOBALLY AND INTERS OCTO RALLY TO PROTECT NATIONAL HEALTH
effective, to prevent “uneconomic” duplica­
tions of work, and to build a partnership base
in order to meet new global realities
(WHO,1995).

ii.

WHO is also participating in the UN Sys­
tem-Wide Special Initiative on Africa which was
introduced by the Secretary-General at the
October 1994 meeting of the Administra­
tive Committee on Coordination (ACC).
The future success of this undertaking is ex­
tremely important given that much of SubSaharan Africa has become increasingly
marginalized by the forces of globalization.
This intersectoral initiative represents an
example of where the collaboration of inter­
governmental organizations and the multi­
lateral banks have been coordinated so as to
work together “collectively for the enhance­
ment of Africa’s development needs”. The
System-Wide Initiative is being coordinated
by a Steering Committee chaired by the
Administrator of UNDP. It is estimated that
about $US 25 billion will be required to fi­
nance the special initiative over a ten year
period. Several key sectors are being imple­

iii. A working group at WHO headquarters is
developing, in the context of the Health-

mented in this intersectoral programme.
The components of the Special Initiative,
as outlined in March 1996, will tocus inter­
national support for priority sectors includ­
ing basic health and education, water and
sanitation, food security, informatics, govern­
ance, and peace-building (WHO, 14 March
1996; WHO, June 1996). This initiative
consists of 20 main priority activities, and

for-All policy for the twenty-first century’, a
framework for extending the Organization s
network of global partnerships. Partnerships
for health, which “bring together public, pri­
vate, and civic sectors for the common goal
of improving the health or populations based
on mutually agreed roles and principles” are
a practical response to a global environment
which is undergoing rapid change. In addi­
tion to strengthening partnerships with other
United Nations organizations, NGOs, local
authorities, bilateral aid agencies, WHO col­
laborating centres, the academic/research
community, religious organizations, and pri­
vate foundations/charitable trusts and or­

for each of these components one or more
lead agencies will be responsible for mobi­
lizing resources and coordinating implemen­

tation. WHO is a “cooperating” agency in
the area of assuring sustainable and equita­
ble supplies of freshwater, and is a lead agency
in the areas of household water security and
health sector reform. As a lead agency for
two components, WHO will be responsible,
inter alia, for developing quantiiiable goals
and indicators to measure the progress of
these initiatives (United Nation^ February7
1996). In the health sector WHO as the lead
agency for basic health programmes will co­
ordinate international efforts in 54 Member
States in Africa, with 33 of these countries
32

belonging to the world’s least developed
countries. Towards this end, WHO held
coordination meetings in Brazzaville to work
out a preliminary health strategy in the con­
text of health care reform. This plan was
directed towards achieving better service
delivery7 and to combat major diseases such
as malaria, tuberculosis, and HIV/AIDS.
WHO is in the process of organizing a re­
gional forum of all partners concerned with
follow-up of the agreement reached in
Brazzaville. This regional forum, which will
also include World Bank, UNICEF,
UNESCO, UNDP, and UNFPA, will work
out an implementation strategy for the
health sector initiative. Similarly, implemen­
tation strategies are being developed in other
priority sectors mentioned above. Improve­
ments in the overall health status of the Af­
rican population will “ultimately depend on
progress to be made under the Special Ini­
tiative” in these other priority sectors
(WHO, June 1996).

ganizations, new links with the private sec­
tor need to developed, lowards this end,
criteria and conditions tor collaboration with
the private sector have been proposed
(WHO,1996f,pp.2,9-12). In addition,
WHO’s collaboration with NGOs, as out­
lined in Article 71 of the WHO Constitu­
tion, is currently under review. The exten­
sion of WHO’s formal relations with na­
tional, regional and international NGOs to

(J

THINK AND ACT GLOBALLY AND 1NTERSECTORALLY TO PROTECT NATIONAL 1IEALTII

include NGOs whose work is unrelated to
the medical, public health sectors, and ah
lied sciences was'discussed in the Ninety­
ninth Session of the WHO Executive Board,
January 1997 (WHO, 2 December 1996).

i
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iv. Reflecting the overlap between trade and
health policy issues a Coordinating Group
for WHO/WTO Cooperation has been re■: centlf established to identify, inter alia, is­
sues which could be subject to WHO/WTO
cooperation. In a recent meeting of this
group it was pointed out that WHO should
influence the formulation of world trade
policies in specific areas, for example the
tobacco trade, that impact health status, and
that WHO should play an “active role” in
bridging the gap between governments ’
health and trade sectors (WHO, 14 Novem­
ber 1996).
v.

I

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The UNICEF/WHO Joint Committee on
Health Policy (JCHP), which was estab­
lished by the First World Health Assembly
(resolution WHA1.120) in July 1948, rep­
resents one of the longest standing
interagency committees within the United
Nations system. The JCHP made major con­
tributions towards the development of pri­
mary health care and the health-for-all
movement, which eventually culminated in
the WHO/UNICEF sponsored International
Conference on Primary Health Care in
Alma-Ata (September 1978). In 1996 steps
were taken to extend the partnership base
of the Joint Qommittee to include UNFPA
(WHO,2 January 1997).

vi. WHO, in addition to being a member of the
recently creating; ACC Task Forces, also
plays an active role within the Inter-Agency
Committee on Sustainable Development
(IACSD). In particular, WHO is the task

manager for Chapter 6 (Health) of Agenda
21. As explained below these initiatives rep­
resent recent attempts to coordinate the ac­
tivities of the United Nations system in sev­
eral crucial areas of international develop­
ment.
Institutional Mandates and

Comparative Advantage
It is becoming increasingly evident that the re­
forms currently underway within the United
Nations system must address the fact that the
mandates15 of these organizations have become
intertwined and have many points of overlap. In
times of resource shortages and budget austerity
it is important that interagency/intersectoral
collaboration between the United Nations or.ganizations, Bretton Woods institutions, and the
WTO is accompanied by a clearer definition of
who does what. This rationalization of activi­
ties within the United Nations system should
be based on the recognized strengths16 of each
organization (Lee et al., 1996, p.3O7). Since the
broad determinants of health status (see Annex
C) can only be addressed by the mutually rein­
forcing actions of numerous sectors working to­
gether, the combined strengths (Table 4) of In­
ternational Intergovernmental Organizations
working together will lead to greater health gains.

Moreover, as outlined below, it is essential
that these joint global activities be coordinated
to avoid overlap and inefficiency. The inter-con­
nected problems which the United Nations sys­
tem must face in the future demand that a
“holistic approach” to policy formulation and
implementation be adopted. This approach needs
to replace the tendency for the Specialized Agen­
cies to resort to a “sectoral approach” whereby they
concentrate on “individual fields of competence”,
and thereby undermine an intersectoral approach
to solving complex problems17.

15 The term mandate describes "a formalized statement...usually worded in broad terms but may specify certain functions for the organiza­
tion to carry out in a particular subject or sectoral area". An organization's formal mandate is ‘usually encapsulated in a constitution,
charter, or articles of agreement" (Lee et ai.l996,p.3O2).
,e The term comparative advantage is used to delineate the relative strengths of a certain economic unit, company, organization etc. and
need not be restricted the economic sphere.
” The tendency of the Specialized agencies to employ a “sectoral approach" to addressing economic and social problems has been
described as a ‘liability" to the work United Nations system (Joint Inspection Unit, 1985), an approach which is out of touch with the
problems of the "real world" (P. Taylor, 1993,pp.8,124).

33

Ii
think and act globally and inti-rsectorally to protect national health

TABLE 4. UNITED NATIONS ORGANIZATIONS AND COMPARATIVE ADVANTAGE
Perceived Strengths
WHO

‘technical & scientific knowledge
‘network of experts
‘links with all Ministries of
Health..’
‘value system (esp. equity)
‘constitutional mandate for global
instruments for health .

WORLD BANK

‘financial resources
policy advice & technical
assistance
‘links to Ministries of Finance &
Planning

UNICEF

‘effective at operational level
‘resources at country level
‘strong country offices
(85% staff at country level)
‘advocacy role

UNFPA

* resources
‘strong advocacy role (family planning)
‘limited technical capacity
‘effective procurement service

UNDP

‘broad development orientation
‘close ties to government
‘coordination role

Source: adapted from Walt 1996, p. 28

Institutional An’angements at
the Interg’ovemmental Level lor
Intersectoral and Interagency
Collaboration

The United Nations reform process has stressed
the issue of interagency cooperation. Recognizing the mounting global challenges facing inter­
national society, the Member Governments of
the United Nations, in 1991, initiated a process
of reform (Blanchard, 1993,pp.8-9). In order to
address the complex, interrelated determinants
of health, and given the global context of health
development outlined above, it is important that
34

mechanisms within the United Nations system,
which facilitate, monitor, and evaluate
intersectoral/ interagency collaboration at the
global level, be strengthened and streamlined.
Further, more efficient mechanisms of collabo­
ration are required to ensure that the objectives
of the recent major world development confer­
ences are realized (see Annex D).
According to the United Nations Charter,
the Economic and Social Council (ECOSOC)
is responsible for coordination within the United
Nations system. Article 62 of the Charter of the
United Nations (1993,p.40) stipulates that
ECOSOC may make recommendations to the
General Assembly, Members of the United

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THINK AND ACT GLOBALLY AND INTERS ECTO RALLY TO PROTECT NATIONAL HEALTH

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II

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t

Nations and to the Specialized Agencies relat­
ing to, inter alia, economic, social, cultural, edu­
cational, and health matters.
However, ECOSOC’s ability to act as a co­
ordinating body for the work of the Specialized
Agencies has never been fully realized (WHO
Task Force on Health in Develop­
ment,1996,p. 11). Accordingly, the recently pubdished Nordic Review: The United Nations in De­
velopment, recommends that the consolidation
at the headquarters level of the UN Funds and
Programmes could be facilitated by a strength­
ened and more “action-oriented” ECOSOC.
This reinforced ECOSOC would provide guid­
ance to all parts of the UN system. In order to
address urgent economic and social development
issues the Nordic report recommends that meet­
ings of ECOSOC be convened whenever neces­
sary (Nordic UN Reform Project, 1996,

E

The ACC provides the Economic and So­
cial Council and the General Assembly with
reliable data' for these two institutions to
conduct their discussions and arrive at deci­
sions.

G

The ACC acts as a “forum for working out
jointly the measures required to implement
the decisions taken by the deliberative or­
gans of the United Nations and, in particu­
lar, by the Economic and Social Council”
(Blanchard,1993).

One of the major pillars of this reform proc­
ess has been to streamline the ACC subsidiary
machinery. Attention has concentrated on
strengthening institutional arrangements be­
tween the Bretton Woods institutions and the
United Nations Funds, Programmes, and Spe­
cialized Agencies so as to strengthen capacity and
pp.10-11).
infrastructure development at the national level,
and
to identify important development issues at
Despite its recommendations, the Nordic
the
interagency
level requiring special attention
Review concedes that the consolidation within
(ACC, 1994). The ACC has also created mecha­
the United Nations system could be a lengthy
nisms by which it will be able to take
process. Therefore, in the immediate future other
“interagency initiatives on key global priorities”
mechanisms for coordinating the work of the
(ACC,1996). For example, the Inter-Agency
Specialized Agencies, United Nations Funds and
Committee
on Sustainable Development
Programmes needs to be identified. In this re­
(1ACSD)
was
created as a follow-up to the Rio
gard, WHO’s Task Force on Development has
I
Earth
Summit.
recommended that “the most effective mecha­
nism within the United Nations to coordinate
Also, the following three Task Forces were
activities is the ACC and the Member States
created to sustain the commitment made in re­
themselves” (WHO Task Force on Health in
cent global conferences18:
Development,1996,p. 11).

□ Basic Social Services for All (lead agency
The Administrative Committee on Coordi­
UNFPA)
nation (ACC), which was established in 1946,
is charged with the primary responsibility of en­
□ Enabling Environment for Economic and Sosuring interagency cooperation between the Spe­
cial Development (lead agency World Bank)
cialized Agencies and the International Finan­
cial Institutions within the decentralized United
E
Employment and Sustainable Livelihood for All
Nations structure. The ACC is the only body
(lead agency ILO)
that brings together the Executive Heads of all
the organizations within the United Nations sys­
In addition to these Task Forces an Intertem. In particular, the ACC, an administrative
Agency Committee on Women and Gender
arm of ECOSOC and- the General Assembly, pro­
| Equality has been established and held its first
vides the following two major functions:

1
” The lead agency for each of these task forces will be rotated among the United Nations agencies.

35

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THINK AND ACT GLOBALLY AND INTERS ECTO RALLY TO PROTECT NATIONAL
session in 1996. This Committee will interact
with the three above-mentioned Task Forces
(WHO/UN, June 1996). Although health was
initially conceptualized as being of special rel­
evance to the Basic Social Service for All task force,
it is evident that the multiple determinants of
health status also intersect with the work of all
of these task forces.

Other examples of recent initiatives that
have implications for health development and
which rely on collaboration within the United
Nation’s decentralized machinery include the
follow-up to Agenda 21 and the Systemwide Ini­
tiative on Africa. Other joint mechanisms, such
as the Global Environment Facility (GEF) and the

programme on HIV-AIDS (UNAIDS), are de­
signed to “take advantage of existing synergies
while avoiding institutional proliferation”
(ACC, 1996).
The ACC’s reforms are intended to demon­
strate that the Specialized Agencies, Funds, and
Programmes of the United Nations including the
Bretton Woods Institutions are able to work to­
gether coherently and cost-efrectively. These
changes to the United Nations institutional
machinery' are intended to provide comprehen­
sive solutions to the emerging global challenges
facing the development community (ACC, Oc­
tober 1996). Moreover, the ACC’s recent at­

tempts to encourage cooperation and consulta­
tion between the bodies of the United Nations
system and the Bretton Woods institutions rep­
resents a meaningful step towards reversing a
trend towards “unmanaged, unfocused, and es­
sentially irrational” (P. Taylor, 1993, p.133) eco­
nomic and social arrangements within the “poly­
centric” United Nations system15.
Implementation o£ WHO's

Global Health Policy lor the
21st Century
The World Health Organization committed it­
self to responding to global change according to
the recommendations of Executive Board reso-

H1HALT1I

lution EB97.R2. WHO’s process of reform and
attempts to meet the challenges of new global
realities needs to occur in conjunction with re­
form initiatives within the United Nation’s Ad­

ministrative Committee on Coordination
(ACC). The most efficient means by which
WHO’s future global policy will be able to ad­
dress the transnational problems outlined in this
document is by coordinating and cosponsoring
integrated development initiatives within the
United Nations system. This represents the most
cost-effective means by which an integrated glo­
bal strategy can be initiated and sustained, and
will avoid the inefficiencies of duplicated, over­
lapping development initiatives. The United
Nations Special Initiative for Africa is a prototype
of this type of strategy; this approach utilizes the
comparative advantages of the United Nations’
agencies and Bretton Woods institutions to en­
act integrated development programmes for a
particular region. Also, committees, such as the
1ACSD, represent significant steps towards en­
suring that the commitments made at global fora
and summits lead to sustainable outputs and
achievements.
The ACC has recently adopted several
broad objectives on which it plans to concen­
trate during its future reform process (ACC,
October 1996). Accordingly, in the context of
globalization, WHO should aim to coordinate

its actions with the ACC in high priority areas,
including, inter alia, the following:

£3

a “renewed, system-wide effort” to address
the consequences of globalization and liber­
alization of the world’s economy;

□

mobilizing and coordinating the United
Nations systems’ contribution to the objec­
tives of “poverty eradication and people­
centered sustainable development” in cru­
cial areas including; inter alia, “the elimina­
tion of hunger and malnutrition, social de­
velopment and social integration, the envi­
ronment, health, education, employment
and sustainable livelihoods, population, shel­
ter, gender equality, and the special needs of
children”;

Seo. for
985 report
report prepared
prepared Dy
Dy Maurxe
Maurice Bertrand.
Seme Reflections
Reflections on Reform of the United Nations, for a critique of the
ocu.
iui example,
uAdtiipie, the
ine 1iyat>
Bertrand. Seme
snortcomings of the United Nations System and suggestions for future reform (Joint Inspection Unit. 1985,p.1O).

36

(1

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THINK AND ACT GLOBALLY AND INTERS ECTORALLY TO PROTECT NATIONAL IIEALTII

□

support for democratic governance, human
rights, and the social needs of vulnerable
groups;

B

encouraging the further evolution of inter­
national environmental law and mobilizing
an “effective international response to glo­
bal environmental threats”;

E

I

sustained health gains continue to be realized in
the twenty-first century. The implications of glo­
balization and the existence of transnational so­
cial, economic, and political problems suggest
that WHO’s new policy will be implemented
within the following global context:
i.

Global health policies for twenty-first cen­
tury will need
to address
the
transnationalization of health risks, which
implies that increased interdependence be­
tween national policy-making and the in­
ternational milieux will be required .

ii.

The health impacts of globalization will in­
crease the need for new and innovative part­
nerships for health improvement: these part­
nerships should involve, inter alia, state, non­
state, including private, development actors.
High levels of interagency and intra-agency
cooperation and coordination will be re­
quired at the international intergovernmen­
tal level.

initiating a system-wide response to “global
. probletns such as drug trafficking and abuse
and emerging and re-emerging diseases”.
(ACC, October 1996).

The global advocacy role of both WHO and
the United Nations system should be utilized to
maximum advantage in order to address these
global, transnational policy issues. This approach
will help to promote a new, integrated global
health agenda fon^he twenty-first century which
can tackle the challenges and maximize the
opportunities presented by the forces of globali­

zation.

Global Context of WHO

Reform
In response to global change, ongoing reforms
have been going on within WHO over the past
five years. The process of reform has proceeded
in close collaboration with the Organization’s
“Governing Bodies”. In May 1992, The Execu­
tive Board Working Group on the WHO re­
sponse to Global Change was established, and
has helped to motivate the reform process within
the Organization. The Working Group has made
47 recommendations for reform, which have
been acted upon and
implemented
(WHO,1997b,p.l). In the future, it is impor­
tant, given the dynamic global context in which
WHO will be expected to function, that the “cul­
ture of reform” which has been set in motion
within the Organization continues.

Furthermore, it is important that WHO’s
future reform efforts consider the potential con­
sequences of global trends in order that it main­
tains the vision, flexibility and foresight required
to motivate the international health develop­
ment community, and in order to ensure that

iii. The challenges associated with globalization
will enhance the role for international legal
instruments, standards, and norms to facili­
tate cooperation, coordination, and harmo­
nization of global policies.

iv. These global challenges and opportunities
imply that new forms of governance for glo­
bal health issues, involving shared and com­
plementing responsibilities between nation
states, subnational, and international
intergovernmental actors, will need to
evolve in the future.
v.

Many of the transnational health concerns
outlined in this document constitute areas
of shared interest for WHO’s Member States,
therefore representing areas of collective se­
curity for Member States’ foreign policies.

vi. Within this global context, it is important
that WHO’s future health policy and im­
plementation strategies aim to delineate the
role of the state.

vii. The framework for health development out­
lined herein makes it clear that WHO will
not be able to address the broad determinants
of health status without extensive collabo­
ration with other partners. In some cases, it
37

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T1UNK AND ACT GLOBALLY AND INTERS ECTORALLY TO PROTECT NATIONAL 1IEALTII

will be appropriate for other international
intergovernmental bodies to assume the position of lead agency, in addressing these
determinants.

WHO’s new global health policy for the
twenty-first century should explore the possibili­
ties of translating this altered policy environment
into concrete global intersectoral/interagency
initiatives for health development. Therefore,
WHO’s future structural reforms will need to
consider its global relationships within the
United Nations family, and what fundamental
roles that WHO will need to play with its vari­
ous partners in order to confront emerging
transnational challenges . These initiatives will
need to address the major global determinants
of health status with cost-effective arrangements
based on a spirit of collaboration. Furthermore,
WHO’s future reform initiatives should consider
these emerging global priorities in order to put
human health at the centre of sustainaole hu­
man development.
Considering the increasing importance of
the transnational dimension of global health de­
velopment, it is becoming more crucial that
WHO explicitly links its technical and norma­
tive functions. Towards this end, it is important
that WHO explores avenues to more mdy uti­
lize the provisions of the WHO Constitt :ion for
elaborating international instruments. WHO’s
Constitution (1996h,pp.7-8) provides for the
development of international regulations in cer­
tain defined areas (Article 21), conventions or
agreements “with respect to any matter within
the competence of the Organization (Ar.:de 19),
and recommendations “with respect to any mat­
ter within the competence of the Organization
(Article 23). By exercising its underutilized po­
tential to elaborate international instruments,
WHO would be able to encourage the develop­
ment of national health legislation
(Taylor, 1992,p.331), and in this way the Organi­
zation would be able to support its glozal strat­
egy for achieving Health-for-All in the twentyfirst century.
In. the twenty-first century it is apparent that

WHO needs to think and act globa.iy and |
38

intcrsectorally to address the complex, interde­
pendent, and potentially unpredictable global
trends, and to improve national health status.
By pursuing a broader range of global parmerships and addressing the transnational dimen­
sion of health development WHO will be able
to facilitate settings for intersectoral action for
health at national/local levels. In order to effec­
tively confront the broad determinants of health
it is crucial that WHO’s global institutional
alliances corresponde with concrete actions and
political advocacy at the intergovernmental, na­
tional, local and transnational levels of policy
implementation. To meet these future challenges
WHO will not only have to concentrate on
streamlining its partnerships with its various glo­
bal partners, but will also have to concentrate
on intra-organizational coordination so that it
can face the global problems of the future as a
united Organization with a common purpose and
vision of the future.

Outstanding’ Issues and
Conclusions

The health threats and opportunities which will
confront world society in the next century suggest that the paradigm of health development
for the twenty-first century must include a cen­
tral place for intersectoral/interagency collabo­
ration. Although past experience suggests that
overcoming “turf battles” between specialized
groups is nor always successful, and is never
straightforward, the need to transcend the myo­
pia of rigid boundary-setting between sectors and
disciplines has never been greater.
The foregoing review of global trends and
actions to address them opens up a number of
issues which require further attention. These
outstanding issues would include:
i.

The need for further research on the impact
of global trends on future disease burdens.

ii. The need for a detailed analysis of the health
effects of globalization and glooal trends at
the level of national health systems.

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________ AND z\CT GLOBALLY AND INTERS ECTORALLY TO PROTECT NATIONAL IIEALT! 1

iii. Although this document has not concen­
trated on the issue of monitoring and
evaluation of intersectoral initiatives it is im­
portant that indicators of success (or failure)
are elaborated. Some preliminary sugges­
tions are cited in Annex B.

I

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iv. The implications of globalization for future
human resource development in health is
. particularly important. For example, it is
apparent that more resources should be
allocated to developing expertise in the area*
of international public health law/
v.

!

i

The transnational nature of the problems
and opportunities documented herein, pro­
vides an impetus for global research pro­
grammes which concentrate on developing
cost-effective technologies- to improve the
health status of the world s poor.

In the future, if humanity is to maintain and
improve upon the unparalleled health gains of
the twentieth century we will have to accept that:

&& We are increasingly confronted,
whether we like it or not, with more and
more problems which affect mankind as
a whole, so that solutions to these
problems are inevitably international­
ized. The globalization of dangers and
challenges - war, chaos, self-destruction
- calls for a domestic policy which goes
beyond parochial or even national items.
Yet, this is happening at a snail’s pace
(Brandt et al., 1981 ,p. 19). g

To ensure the health and welbbeing of Ri'
ture generations it is ethically imperative that
present generations should not continue to address these transnational issues at “a snail’s pace”.

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THINK /\ND ACT GLOBALLY AND INTERS ECTO RALLY TO PROTECT NATIONAL 1IEALT11

Annex A: Global Intersectoral
Action Case Studies
The foregoing analysis has outlined the major
transnational problems facing humanity in the
twenty-first century, and some crucial global ac­
tions to address these challenges. This section
will outline two case studies of existing global
initiatives: one, the FAO/WHO Codex
Alimentarius Commission is a longstanding glo­
bal initiative, and the other the International
Forum on Chemical Safety is a recent initiative.
These case studies will be analysed in order to
highlight possible recommended practices of
global intersectoral action for future initiatives.

Case

Study

“a”

WHO/FAO

Codex

Member States and Associate Members ofFAO and/or WHO for acceptance, together
with details of notifications from govern­
ments with respect to the acceptance or oth­
erwise of the standards and other relevant
information”, constitute the Codex
Alimentarius (WHO, 1973,p. 157; FAO/

al
s.

WHO,1995,p.ix).

e
>r

1.2 What are the primary aims and objectives
of this global intersectoral initiative?

h
d
d

The primary objectives of the Codex
Alimentarius (FAO/WHO, 1995,p.5) are :

i-

Alimentarius Commission

1.1 What was the Rationale for the establish­
ment of
this Intergovernmental
Intersectoral Initiative and how has it been
implemented?
The FAO/WHO Codex Alimentarius Com­
mission was established so as to provide an
internationally adopted set of uniform food
standards. These standards are intended to
protect the health of consumers and to fa­
cilitate the international food trade by es­
tablishing a set of definitions and require­
ments for traded food commodities.
Towards this end the FAO/WHO Food
Standards Programme (Codex Alimentarius)
was established in 1962 after the sixteenth
World Health Assembly approved a joint
FAO/WHO programme on food standards,
with the principal organ being the Codex
Alimentarius Commission (CAC). The pri­
mary rationale for the establishment of the
Codex Alimentarius Commission was to
execute the Joint FAOAVHO Food Stand­
ards Programme. The first session of the
Codex Alimentarius Commission was held
in June 1963. In July 1981 at the 14th ses­
sion of the Codex Commission it was decided
that its standards, “which are sent to all
40

i.

ii.

to protect the health of consumers and
ensure fair practices in the food trade;

y
!S

n

to promote coordination of all food
standards work undertaken by
international governmental and
nongovernmental organizations;

e
t

a
d

iii. to determine priorities and to initiate
and guide the preparation of draft stand­
ards through and with the aid of appro­
priate organizations;

iv. to finalize standards elaborated in (i),
and after acceptance by governments,
to publish them in a Codex Alimentarius
either as regional or world-wide stand­
ards, together with international stand­
ards already finalized by other bodies
under (ii.), wherever this is practicable;

1
t

v. to amend published standards, after appropriate survey in light of-develop-

ments.

1

1.3 What have been the major accomplishments

of this initiative?
The Joint FAO/WHO Food Standards Pro­
gramme has established a normative regime
which consists of standards, recommended
codes of practice, and guidelines. Codex
standards, guidelines and recommendations

I

4

ii

THINK AND ACT GLOBALLY AND INTERSECTORALLY TO PROTECT NATIONAL
L HEALTH

relating to food safer}’, while remaining rec­
ommendations of international organizations
which Member States may or may not
choose to put into public health practice,
have, however, now assumed a completely
new dimension as the reference or “measur­
ing stick” of national requirements (WHO,
April 26 1994).

f

—T2 ...

Indications of the level of development of
this international regime for food safety is
the scope of the Codex Alimentarius:

□

The CAC has existed for 35 years and
has grown in membership from an
initial 30 countries to more than 150
countries as of March 1997.

3 The CAC has elaborated over 240 com­
modity standards, more than 40
different codes of hygienic and techno­
logical practices, and over 3000 maxi­
mum levels for a large number of chemi­
cals in food, including food additives,
contaminants and residues of veterinary’
drugs, and pesticides.
Another indication of the success of this glo­
bal intersectoral initiative is that it has
adapted to meet new international chal­
lenges. Since its inception steps have been
taken to strengthen collaborative links be­
tween the FAO/WHO Codex Alimentarius
Commission with other relevant interna­
tional organizations. For example, closer
links were developed with the International
Atomic Energy Agency (IAEA) and the
United Nations Environment Programme
(UNEP), following the Chernobyl nuclear
accident in 1986, to establish recommenda­
tions on maximum levels of radionuclides in
food
traded
across
international
borders(WHO,1993,pp.85-86). In addition,
the standards of the CAC on quality and

I

presentation of food were consulted when
WHO prepared an International Code on
Marketing of Breastmilk Substitutes in 1980
(WHO, 1985,p.91). Close links to the work
of the World Trade Organization have also
evolved, particularly with regards to the
Agreement of Sanitary and Phytosanitary
Measures (SPS)20 and the Agreement on
Technical Barriers to Trade (TBT)21 that
were included in the Final Act of the GATT
Uruguay Round, and which should have di­
rect impacts on health (WHO,20 April
1993, p.17). Also, measures were taken in
the 1980s to enlarge the partnership base of
the CAC by promoting “active collabora­
tion on the part of both the public and pri­
vate sectors and nongovernmental organi­
zations in national Codex work”
(WHO,1993,p.85).

Finally, to provide the CAC with the scien­
tific basis for its decision-making, WHO in
collaboration with FAO and IAEA (in the
case of food irradiation) has organized, inter
alia, a series of meetings of three scientific
bodies on food additives, on pesticide
residues, and on food irradiation22. Even
though these bodies are nor part of the CAC
they provide ongoing scientific evidence to
various CAC committees. Also, on a spo­
radic basis, other scientific advisory bodies
have been convened to address biological
aspects of food safety and other issues, such
as biotechnology (WTO, 15 November
1995).
1.4 Has this global intersectoral programme
been a success?
The stated objectives of the 1962 World
Health Assembly Resolution WHA16.42
were to create a FAO/WHO joint pro­
gramme on food standards under the auspices

ro

The SPS agreement stipulates that sanitary and phytosanitary measures are those which t
" '
which are applied to protect human life from risks
resulting from "additives, contaminants, toxins or disease-causing organisms in food or feed-1
' ■■ r
..... .
carried diseases; and to protect animal or plant life from pests, diseases?o'rdise^e^ausi'ng orgaXm^^^^^
plant lite from pests, diseases, or disease-causing organisms (WHO,20 April 1993,p.18).
” SckXTTa^elirn^
inClUd9S ‘teChniCal re9u,alions °n industrial and agricultural products.including
>, including
packaging, labelling and marketing requirements,

!
!

“ im’"“

I
I

■ “sx’,™:: s

" p—“

I
|
41
/it

F*.-.-, - !x' '-J^

THINK AND ACT GLOBALLY AND INTERSECTORALLY TO PROTECT NATIONAL HEALTH

of the Codex Alimentarius Commission.
Since its inception this international body
has created an international normative re­
gime to regulate and ensure international
food safety, while also facilitating interna­
tional trade in food. The abovementioned
accomplishments indicate that the original
objectives of the World Health Assembly in
1962 have been addressed in a very compre­
hensive manner over the past 35 years. The
CAC is a well-developed and sustained glo. bal intersectoral initiative, and in summary
has been successfully implemented.

1.6. Does this initiative suggest any recom­
mended practices for other global
intersectoral initiatives?
In view of the transnational challenges out­
lined in this document the work of the CAC
suggests recommended practices which other
global actions for health could emulate. This
initiative suggests that:

□

uniform international standard-setting
can be an effective approach to
addressing common international prob­
lems, and in particular those which have
a transnational dimension;

o
le

m
1.5 What future challenges does this initiative
face?
The fact that recent data indicates that
foodborne illnesses are on the rise in many
countries indicates that public health strat­
egies founded on regulation alone are not
sufficient. As a result, there is now a greater
emphasis placed on strengthening and bas­
ing Codex recommendations on surveillance
and epidemiological information as well as
integrating the “science of international risk
assessment” (Kaferstein et al., 1997).

The increasing rapidity of globalization un­
derscores the need to link the normative
Codex regime with the improved interna­
tional surveillance of foodborne diseases
(Kaferstein et al.,1997), and the monitoring
of chemical and biological contaminants in
food. In this respect, the WTO has acknowl­
edged WHO’s proposal to integrate the Haz­
ard Arialysis and Critical Control Point system
(HACCP) ar every stage of the human food
chain as one way of implementing the SPS
agreement (WTO, 15 November 1995).
These future global challenges will require
that the CAC integrate its activities with
global risk analysis and surveillance and
monitoring initiatives.

□

□

□

□

:h

international normative regimes in
health should try to strengthen the
basis of their decision-making by resort­
ing to scientific evidence;

in!

ex
3/

international regulatory instruments in
health need to be accompanied by
strengthened surveillance and monitor­
ing mechanisms;

es

iX

an effective regulatory system needs to
be aware of new problems and
issues (for example trade liberalization
as outlined in this case study) so that new
approaches can be developed, which in
turn can involve the extension of an
initiative’s partnership base (for in­
stance, in this case study the
strengthening of links with the WTO);

id

)d
>y

d
:e

1intersectoral initiatives can build on the
strengths of each collaborating sector to
produce a synergistic relationship which
takes advantage of the respective
strengths of each sector; the long-term
nature of the FAO/WHO collaboration
demonstrates that intersectoral initia­
tives need not be short-lived and char­
acterised by “turf disputes and rivalries”
between competing sectors.

),
5,
IS

s

5

42

I

I

THINK AND ACT GLOBALLY AND INTERS ECTO RALLY TO PROTECT NATIONAL DEALT! 1

Case Study “b” Intergovernmental Forum on
Chemical Safety (IFCS or Forum)

□

promote information exchange, identify
gaps in scientific knowledge, and review
the effectiveness of the implementation
of international strategies pertaining to
chemical safety’;

2.1 What was the Rationale for the establish­
ment of this Intergovernmental
Intersectoral initiative and how has it been

provide advise to governments on
chemical safety, with a particular empha­

implemented?

sis on legislative issues;
The I^CS was established in 1994 in re’ sponse to a recommendation of the United
Nations Conference on Environment and De­
velopment (UNCED). The IFCS was initi­
ated by the International Conference on
Chemical Safety (Stockholm, 1994) upon the
invitation of the Executive Heads of WHO,
ILO and UNEP. The Forum is a “non-institutional arrangement” in which three groups,
Governments, Intergovernmental organiza­
tions, and Nongovernmental organizations,
meet to consider the full range of issues as­
sociated with the assessment and manage­
ment of chemical risks. The IFCS does not
represent a “new agency” but rather repre­
sents an international means of promoting
chemical safety’ without establishing another
formal
institution (IFCS,February
1995,pp.14-16; IFCS, 14 February 1997).

2.2 What are the primary aims and objectives
of this global intersectoral initiative?

n

encourage the strengthening of “na­
tional programmes and international
cooperation for the prevention of, and
preparedness for, and response to chemi­
cal accidents, including major industrial
accidents” (IFCS, February 1995,

pp.27-28).
2.3 What have been the major accomplish­
ments of this initiative?

Although the IFCS has only been existence
since 1994 it has made major progress in,
inter alia, the following areas:
i.

This initiative has expanded and accel­
erated the international assessment of
chemical risks. By the end of 1997 it is
projected that over 2C0 assessments will
have been completed.

ii.

Significant progress has been made to­
wards the development of a global “har­
monized” system for classifying and la­
belling of chemicals.

The principal aims of the IFCS include, in­
ter alia, to:
E

E

E

I

identify priorities for cooperative action
on chemical safety and recommend in­
ternational strategies for “hazard identi­
fication and risk assessment” of chemi­
cals, where appropriate;
•
facilitate the collaboration of “national,
regional, and international bodies” in
the area of chemical safety to avoid “du­
plications” of work;
support the “strengthening of national
coordinating mechanisms and national
capabilities for chemical management;
foster international agreements and
commitments on the labelling and clas­
sification of chemicals;

iii. The IFCS has utilized the Global Infor­
mation Network on Chemicals (GINC) to
promote information exchange using the
Internet between “relevant organiza­
tions and countries”.
iv. The Forum has supplied advice on a
number of “priority risk reduction activi­
ties”, and has promoted coordination
amongst its members in this regard.

v.

The IFCS, at the request of UNEP’s
Governing Council, offered recommen­
dations on a “legally binding instrument
on persistent organic pollutants”

vi. The Forum has promoted the use of risk
management tools such as the Pollutant
Release and Transfer Registers (PRTRs).

43

11

I

THINK AND ACT GLOBALLY AND INTERSl-CTORALLY TO PROTECT NATIONAL IIEALTII
Approximately thirty countries are cur­
rently instituting PRTRs (1FCS, 14 Feb­
ruary 1997).

2.4 Has this intersectoral initiative been a
success?

practices for other global intersectoral ini­
tiatives addressing determinants of health
status.

s The IFCS has shown that global
intersectoral initiatives do not necessar­
ily require the creation of new formal

The 1FCS during its brief history' has made

major progress towards realizing its objec­
tives. Its successes are even more impressive
given that the IFCS represents a non-institutional mechanism of international inter­
governmental collaboration. In other words,
this initiative has addressed many of its aims
and objectives without developing another
layer of institutional machinery'.

institutional structures. The Forum has
demonstrated that it is possible to pro­
vide answers and assessments for health
and environmental problems involving
chemicals by means of non-institutional
mechanisms of cooperation.
E

2.5 What future challenges does this initiative
face?
The Forum faces a number of future chal­
lenges and unresolved issues in the future
(IFCS.14 February 1997):
G

The Forum on Chemical Safew lacks
consistent financial support necessary for
its future viability.

In particular, international funding to
ensure the full participation of develop­
ing countries has not been secured.

s

A strengthened commitment from the
partners comprising the Forum is
required so that it can continue to ad­
dress problems relating to chemical
safety.

E

The mechanisms for implementing the
Forum’s recommendations and initia­

tives will need to be strengthened in the
future in order to fulfil the high
expectations of Agenda 21 for the
environmentally sound management of
chemicals.”

2.6 Does this initiative suggest any recom­
mended practices for other global
intersectoral initiatives?
The activities of the Forum on Chemical
Safety suggests particular recommended

44

The Forum has provided a means of fol­
lowing up the expectations of UNCED
relating to chemical safety. Similarly, the
effective implententation of the recom­
mendations of other recent global con­
ferences (Annex D), which are all re­
lated to the broad the determinants of
health status, will require that global fora
concentrate on finding and implement­
ing solutions to pressing global problems.

□

The Forum has provided advice to in­
ternational bodies, such as UNEP,
regarding international legal instruments
in key technical areas relating to chemi­
cal safety. Since the Forum represents a
voluntary', broad-based alliance of glo­
bal partners it is well placed to provide
such advice, and such a fora offers an
excellent opportunity for gaining con­
sensus for international normative in­
struments. Such broad-based global coa­
litions could provide a mechanism for
elaborating international norms and
standards in other technical areas relat­
ing to the protection of health and the
environment.

IJ

I
TIIINK AND ACT GLOBALLY AND INTERS ECTO RALLY TO PROTECT NATIONAL IIEALTII

i

Annex B
Monitoring and Evaluation
The assessment: of health promoting measures in
other sectors has been the subject of numerous
studies. In a recent paper, Assessment of health
producing measures across different sectors (1995),
Drummohd and Stoddart make the following
proposals regarding the economic evaluation of
intersectoral actions for health:

)

4
i.

ii.

I
1

II
I

I

Since health benefits are not confined to
measures within the health sector it is im­
portant that further attempts be taken to
assess non-health sector initiatives which
have impacts on health status. Cost-benefit
analysis which gives an indication of the
“marginal benefits (in improved health)”
achieved from resources allocated to differ­
ent sectors, is one method of increasing the
awareness of policy-makers to the benefits
of non-health care initiatives.

Although there are several methodological
problems associated with intersectoral eco­
nomic evaluations, pilot studies should be
undertaken.

iii. While it is riot possible to undertake full eco­
nomic evaluations of all projects having
health impacts, it might be practical to pro­
vide “minimum data sets” to justify expendi­
ture plans.

iv. Institutional changes would also be needed
to facilitate intersectoral evaluations, given
that ministries/agencies always compete for
scarce resources.

v.

The issue of providing incentives for
intersectoral efforts also needs to be consid­
ered.

In summary’, there is good evidence that bet­
ter methods of economic evaluation for
intersectoral health initiatives can be developed.
However, the practical experience with imple­
menting such evaluations is rudimentary. There­
fore, it is evident that further “pilot studies” to
test methods of evaluation need to be under-

taken. Initially, these “pilot studies” would likely
be most practical at the local or national level,
rather than the global level of analysis which has
been the subject of this document. Nonethe­
less, such evaluations could provide supporting
evidence for the benefits of national/local
intersectoral actions for health, which could also
indirectly support the need for intersectoral ac­
tions at the global level, as well.

It is important to note, however, that evalu­
ations of intersectoral initiatives should not be
limited to economic analyses. As suggested in
Annex A, process indicators are also important
measurements of intersectoral collaboration. For
example, the sustainability’ of intersectoral pro­
grammes, as well as evaluations of the outputs of
such actions, are also important indicators of the
overall success of cooperative arrangements.
Since the success of intersectoral efforts is heav­
ily reliant on dismantling the psychological bar­
riers which prevent groups from interacting,
measures of the effective collaboration of differ­
ent sectors will provide an indication of the suc­
cessful implementation of intersectoral strategies
for health.
In addition, certain benchmark indicators
could be used to target intersectoral initiatives.
For instance, since health status is dependent on
numerous underlying determinants, it is impor­
tant that a wide range of benchmark indicators,
in addition to core health indicators such as
maternal and infant mortality rates, be used to
direct intersectoral strategies. For instance, an­
thropometric data on the nutritional status of
under five-year olds can be used as an indicator
of inequity in order to target maternal and child
health care services and nutritional programmes.
Moreover, this indicator could be used as a
method of targeting intersectoral action initia­
tives, for example microcredit schemes. Other
indicators, such as the Gini coefficient, which
measures the distribution of income within a
population23 and chronic’unemployment rates,
should be used to target health promoting pro­
grammes to vulnerable populations.

n A Gini coefficient of zero indicates that the distribution of income within a population is equal, and the closer the coefficient is to a value
of 1, the more unequal is the distribution of income.

45

u
THINK AND ACT GLOBALLY AND INTE RS ECTO RALLY TO PROTECT NATIONAL 1IEALTII

Ajinex C.
•

r 1

1

’ll

Deterrn.inan.ts or health status:
Key intergovernmental alliances
The following typology relates the work of vari­
ous international intergovernmental organizations
to the principal determinants of health status. Ad­
dressing the broad determinants of health status
should structure WHO’s collaborative relationships
with its various health partners in the twenty-first
FACTORS

century. The following is a possible representa­
tion of how WHO’s future relations at the inter­
governmental level may be conceptualized. These
alliances would need to be coordinated in conjunc­
tion with the ACC Task Forces and Inter-Secre­
tariat Committees such as the IACSD.

KEY INTERGOVERNMENTAL ALLIANCES

ii-

th

al

al
as

♦MACRO FACTORS:

POLITICAL
(e.g. human rights,gender)

WHO + United Nations System-wide Advocacy

ECONOMIC

WHO + World Bank, IMF, UNICEF, UNDP,
ILO, UNCTAD, Regional Development Banks

EDUCATIONAL

WHO + UNESCO, UNICEF, UNDP, UNFPA,
World Bank, UNIFEM

:h
'g
al

ENVIRONMENTAL

WHO + UNEP, UNDP, WMO, World Bank, FAO, IFAD

TECHNOLOGY

WHO + UNESCO, ITU, WIPO, UNCTAD, WTO, UNAIDS

DEMOGRAPHIC/
MIGRATION

WHO + UNHCR, UNFPA, UNCHS

GLOBALTRADE

WHO + WTO, UNCTAD, World Bank, UNDP, FAO, UNIDO,
Regional Development Banks

COMMUNICATIONS/
GLOBAL MONITORING

WHO + UNHCR, ITU, UNAIDS, UN/OOSA

ID
ie

of
•a
s.

ts

ia

♦BIOLOGICAL FACTORS:

GENETIC

P,

WHO/CIOMS + UNESCO, WIPO

e
n

♦PROXIMATE FACTORS:

SAFE, SUFFICIENT
FOOD

WHO + FAO, WFP, IFAD, UNDP, World
Bank, UNEP, WTO

WATER/ SANITATION

WHO + UNICEF, UNDP, World Bank, UNHCR, UNEP

INDUSTRY ACTIONS

WHO + ILO, UNDP, UNIDO, World Bank

>r
d
e

46

11

THINK AND ACT GLOBALLY AND INTERSECTORALLY TO PROTECT NATIONAL HEALT11

SOCIAL NETWORKS ; ;
AND SOCIAL
--CAPnALjij;?

.

WHO + UNDP, UNICEF, UNESCO, ILO, World
Bank, Regional Development Banks
• UNIFEM

SOCIAL BEHAVIOUR
AND CULTURE

WHO + UNESCO, UNICEF, UNDP, UNFPA
UNIFEM

HEALTH SERVICES

WHO + World Bank, UNICEF, UNFPA, UNDP, UNAIDS

In order that WHO’s institutional alliances
at the intemational/regional intergovernmental
level facilitate tangible health gains it will be im­
portant to consider how this might be accom­
plished in a world of sovereign states. In this re­
gard, the research of political science theorists in
the area of international organization may be use­
ful. In particular, it has been suggested that in a
world of sovereign states confronted by global
problems “the collective good appears to be best
served by a sharpening of the realization of self­
interest”. In other words, in order to address
transnational problems, the future policies of glo­
bal international organizations will need to com­
plement and reinforce Member States’ enlightened

self-interests to confront these issues. In support
of this conclusion, the political theory of
consociationalism and symbiosis suggests that “the
level and style of international organization is a
function of sub-units’ (governments’) perception
of how their separate interests are to be reconciled
with those of the collectivity (the regional or inter­
national system) rather than of the emergence of
any transcendental common interest’’ (P. Taylor,
1993, pp.l 13,201). In this respect, WHO’s global
health policy for the twenty-first century should
aim to, inter alia, engage Member States’ inter­
ests to address shared global health policy issues
which represent areas of collectivc/shared secu­
rity for Member States’ foreign policies.

47

I

I

u
THINK AND ACT GLOBALLY AND INTERS ECTORALLY TO PROTECT NATIONAL 11EALT11

Annex D
Major world development conferences since

1990
i.

The World Conference on
Education for All

Jomtien, Thailand

2.

The World Summit for Children

New York, NY, USA
29-30 September,1990

3.

United Nations Conference on
Environment and Development (UNCED)

Rio de Janeiro, Brazil
3-12 June, 1992

4.

International Conference on Nutrition

Rome, Italy
December, 1992

5.

The World Conference on Human
Rights

Vienna, Austria
14-25 June, 1993

6.

The World Conference on Natural
Disaster Reduction

Yokohama, Japan
23-27 May, 1994

The International Conference
on Population and Development

Cairo, Egypt
5-13 September, 1994

8.

The World Summit for Social
Development

Copenhagen, Denmark
6-12 March, 1995

9.

The Fourth World Conference
on Women

Beijing, China
4-15 June, 1995

10. The Global Conference on
Sustainable Development of
Small Island Developing States

Bridgetown, Barbados
6 April-6 May, 1996

11. The United Nations Conference
on Human Settlements

Istanbul, Turkey
3-14 June, 1996

12. The World Food Summit

Rome, Italy
13-17 November, 1996

These conferences represent an attempt to
enhance the effectiveness of the United Nation’s
international programmes in an environment of
mounting global problems. These special confer­
ences, which all have implications for the improve­
ment of the health status of the world’s popula­
tion, provide an important vehicle for arriving at
solutions for transnational problems. On the ether

48

1990

hand, considering the current momentum for re­
form within the United Nations system it is im­
portant that these conferences do not lead to the
proliferation of new institutional machinery which
adds to the “problems of managing the United
Nations’ economic and social activities according
to a rational and comprehensive strategy”
(P.Taylor,1993,p.l32).

i i

rfCo--

THINK AND ACT GLOBALLY AND INTERSECTORALLY TO PROTECT NATIONAL DEALT! I

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