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Neoliberal Globalisation and Health in a Time

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Article in Social Theory & Health November 2011

DOI: 10.1057/sth.2011.16

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Original Article
Neoliberal globalisation and health in
a time of economic crisis
Roberto De Voglia,b
a
School of Public Health, The University of Michigan, USA.
b
Department of Epidemiology and Public Health, University College London,
1-19 Torrington Place, London WC1E 6BT, UK.

PY
Abstract The 2008 global financial crisis has been one of the outcomes of more
than three decades of neoliberal globalisation policies. These reforms, implemented by
the international financial institutions such as the International Monetary Fund, the
O
World Bank and the World Trade Organisation, under the pressure of wealthy nations and
transnational corporations, have also produced negative health effects. The advent of
C
these economic measures since the late 1970s and early 1980s coincided, in fact, with
reduced worldwide gains in both economic growth and life expectancy. They also have
generated larger economic and health gaps between and within countries. This article
R

reviews the major bodies of evidence on the multiple links between neoliberal globa-
lisation policies, economic inequalities and health. It also discusses the future prospects
O

for global health in light of contemporary policy responses to the crisis by national
governments and the G-20.
TH

Social Theory & Health (2011) 9, 311325. doi:10.1057/sth.2011.16

Keywords: globalisation; health inequality; social determinants of health;

neoliberism; political economy of health; global financial crisis
U
A

Introduction

On 29 October 2008 in Foley Square, New York, close to the heart of Wall Street,
artists Nora Ligorano and Marshall Reese decided to celebrate the 79th anni-
versary of Black Tuesday in their own way. In the morning of that day, they
installed an ice sculpture with the word economy to let everyone see the
changing face of our economic system. The literal meltdown of the ice sculpture
in the hours after captured metaphorically the transformation of the world
economy after more than three decades of unregulated markets and financial
innovations (The Economist, 2008). To be sure, the collapse of the global
financial system took free market economists by surprise. Most of them had
religiously believed that financial markets are inherently self-correcting and
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www.palgrave-journals.com/sth/
 De Vogli

conducive to efficient, optimal outcomes. For years, the whistle-blowers

warning that something was wrong with the idea of unfettered, deregulated
financial markets have been ridiculed in the media. When the world economy
went down on its knees in 2008, however, the evidence indicating that financial
liberalisation is a serious risk factor for economic crises could no longer be
ignored. Indeed, it had to be taken very seriously. Figure 1 covers more than 200
years (18002008) of data on international capital mobility and the frequency of
international banking crises worldwide (Reinhart and Rogoff, 2009). Not sur-
prisingly, as the figure shows, periods of high international capital mobility
happen to be associated with a higher frequency of international banking crises
throughout the 200-years timeframe.
The figure also shows that, without considering the world wars, the two major

PY
collapses of the world economy in the past 100 years (1929 and 2008), coincided
with political economic circumstances that have been, in many respects, similar.
The era before the 1929 stock market crash was, in fact, a time of high finance,
O
reckless speculation, financial innovations and large-scale global investments.
This era ended in the burst of a gigantic financial bubble and one of the worst
C
epidemic of banking crises in history (Eichengreen and Fishlow, 1998). After
a time of relative economic stability during the post-war era, characterised by
policies restricting speculations, deregulated banking activities and freedom of
R

movement of capital, high finance gradually resurged around the 1970s and
O

1980s. Since then, capital markets were liberalised, offshore centres proliferated
and financial instruments such as derivatives (BIS, 2010), mortgage-backed
TH

securities (Johnson and Kwak, 2010) and credit-default swaps (Tett, 2009) gained
U
A

Figure 1: Capital mobility and the incidence of banking crises: All countries, 18002008.
Source: Reinhart and Rogoff, 2009.

312 r 2011 Macmillan Publishers Ltd. 1477-8211 Social Theory & Health Vol. 9, 4, 311325
 Neoliberal globalisation and health

increasing predominance until they end up to cause another gigantic housing

bubble that burst in 2008 together with the entire global economy.
The aim of this article is to review existing evidence on the impact of neoliberal
globalisation policies on health outcomes in light of the contemporary macro-
economic conditions that led to the global financial crisis of 2008. First, it describes
the major actors and institutions that have promoted global economic deregulation
since the late 1970s and early 1980s. Then, it assesses the impact of neoliberal
globalisation policies on health outcomes by reviewing evidence on global health
trends before and after neoliberal globalisation policies. Evidence from studies on
the health effects of single neoliberal globalisation policies will also be presented.
The article will finally tackle the distributional effects of neoliberal globalisation on
health outcomes between and within countries and will concentrate on the role of

PY
economic inequalities in explaining the linkages between these policies and health.
A final discussion of the prospects for global health in light of contemporary
economic and political responses to the 2008 global economic crisis by national
governments and the G-20 will conclude the article. O
C
Neoliberal Globalisation: Institutions and Policies
R

The major institutions that have promoted global economic integration over the
O

past 60 years have been founded at the end of the second world war, in 1944, to
form what have been called the Bretton Wood System that included the Inter-
TH

national Monetary Fund (IMF), the World Bank and the General Agreement on
Tariff and Trade (GATT) later converted into the World Trade Organisation
(WTO). The IMF, World Bank and GATT, designed by John Maynard Keynes and
Harry Dexter White, were initially conceived to provide a regulatory framework
U

fostering and maintaining peace and economic stability worldwide and avoid
disasters such as the Great Depression and the two World Wars. Keynes
A

and White were fully aware that global collective action was necessary to
prevent free markets from generating instability and conditions leading to
persistent unemployment and insecurity that could lead to crises, war and so-
cial unrest. Indeed, the political economy of the post-war period, sometimes
called the Golden Era of capitalism, was inspired by Keynesianism, an eco-
nomic model favouring state interventions, capital controls, fixed exchange
rates, welfare and full employment policies. However, in the early 1970s the
Bretton Wood System underwent dramatic political changes reflecting a radical
shift toward neoliberalism and unfettered free markets. Neoliberalism, often
called market fundamentalism, is an economic doctrine born out the in-
tellectual achievements of Friedrich von Hayek and Milton Friedman, and
based on the view that governments should limit as much as possible their
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 De Vogli

interference with market forces. According to the prophets of neoliberalism,

governments should also make sure to protect property rights and corporate
freedom. The rise of neoliberal market policies in the late 1970s and early 1980s
coincided with the combined presence of two radical pro-business governments
in the United States and United Kingdom. Ronald Reagan took power in the
United States and Margaret Thatcher in the United Kingdom. Neoliberal policies
came out of the growing unhappiness of the business class with the New Deal
and were essentially aimed at recreating the favourable conditions of the Gilded
Age of high finance and speculation. During what has been defined as a revolu-
tion of the powerful against the weak, or the neo-conservative revolution
(Gill, 2005), a powerful elite headed by big corporations managed to influence
governments and international financial institutions to embrace orthodox free

PY
market policies, or what Thomas Friedman called as the golden straitjacket.
These policies consisted in privatization, low inflation, reduction government
bureaucracy, balance of the budget, liberalize trade, deregulate foreign invest-
O
ment, deregulate capital markets, make the currency convertible, reduce cor-
ruption and privatize pensions (Friedman, 1999). The virtues of the neoliberal
C
doctrine were preached in academic institutions, think tanks, and widely pro-
moted by mainstream media organisations to persuade governments that eco-
nomic prosperity could be only advanced by dismantling the welfare state,
R

labour unions and environmental protections together with the deregulation of

O

capital and financial markets. Virtually all countries have been affected by the
neoliberal economic ideology sponsored and funded by wealthy elites, trans-
TH

national corporations and implemented by governments and international

financial institutions such as the IMF, World Bank and WTO. Through a
remarkable strategy of propaganda, the neoliberal school of thought persuaded
people and governments that only neoliberalism could free human beings
U

from the oppressive intrusion of states in their lives. In reality, however, the
only freedom neoliberalism promoted was that of transnational corporations
A

and wealthy investors to advance their profit and power worldwide. As Percy
Barnevik, European Businessman of the Year (for several years) once admitted,
globalisation is y the freedom for my group of companies to invest whether it
wants when it wants; to produce what it wants, to buy and sell where it wants
and to support the fewer restrictions possible coming from labour laws or social
conventions (George, 2004).

Neoliberal Globalisation, Health and Health Inequalities

Although international institutions such as the World Bank claim that neoliberal
globalisation promoted economic growth (Dollar, 2001) and good health
314 r 2011 Macmillan Publishers Ltd. 1477-8211 Social Theory & Health Vol. 9, 4, 311325
 Neoliberal globalisation and health

(Feachem, 2001), the bulk of evidence shows quite a different picture. One way
to assess the health effects of globalisation policies is to compare panel data on
health before and after the 1980s, when neoliberal policies started to be widely
applied worldwide (Cornia, 2001). Figure 2 shows regional trends in life
expectancy at birth across the major regions of the world. When examining the
effects of neoliberal globalisation by region, one cannot fail to observe that, in
spite of the large health improvements in East and South Asia, these policies
have been disastrous in sub-Saharan Africa. Since the 1980s, the poorest con-
tinent of the world has been affected by decreasing life expectancy, economy
stagnation and rising poverty (Schrecker et al, 2008). A major culprit for the
increasing mortality rates in sub-Saharan Africa is surely the spread of HIV.
However, neoliberal reforms have created conditions leading to socioeconomic

PY
vulnerability to HIV/AIDS such as commercial sex and reduced access to
health-care services that contributed to the spread of the epidemic in the region
(De Vogli, 2005). The other major areas of the world particularly and negatively
O
affected by neoliberal globalisation is the former USSR that, after the economic
transition of 1989, experienced increasing mortality rates, economic recessions,
C
skyrocketing unemployment rates, higher crime and social breakdown.
Neo-liberal globalisation has not only resulted in reduced gains in life expec-
tancy and increasing mortality in sub-Saharan Africa and the former USSR, but
R

also in widening health inequalities between and within countries. Globally,

O

after a sustained period of health convergence between countries in the 1960s

and 1970s, a pattern of divergence began in the 1980s (McMichael et al, 2004;
TH

Moser et al, 2005). When considering health inequalities within nations, gaps
U
A

Figure 2: Regional trends in life expectancy at birth.

Source: Authors elaboration of data from the globalization and health nexus database.
Department of Economics, University of Florence (2009).

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 De Vogli

in health outcomes across socioeconomic groups have widened in both deve-

loped nations and developing nations (Machenbach et al, 2003; Minujin and
Delamonica, 2003). Figure 3 presents trends in health inequality within 21
sub-Saharan African countries. The figure shows that the under five mortality
rate ratios between the lowest versus the highest income groups has increased
in 16 out of 21 countries. In countries such as Namibia this ratio even doubled
between baseline and follow up.
The health effects of neoliberal globalisation have also been analysed
by scrutinising the consequences of single policy reforms. Policies of the
Washington Consensus such as financial deregulation, privatization and trade
liberalisation have been found to be associated with higher poverty rates
(Hanson and Harrison, 1999; Milanovic and Ersado, 2007; Jerzmanowsky and

PY
Malhar, 2008), poorer health outcomes (Naterop and Wolffers, 1999; Hopkins,
2006; Stuckler et al, 2008a; Stuckler et al, 2008b), health-determining social
conditions (Shaffer, 2005; Blouin et al, 2009), and behavioural risk factors such
O
as smoking (Bettcher, 2001) and obesity (Evans et al, 2001; Hawkes, 2006). IMF
austerity programmes have been linked to lower public health expenditure
C
(Ooms and Schrecher, 2005) and disease outcomes such as tuberculosis (Stuckler
et al, 2008c). Researchers also paid particular attention to the impact of structural
R
O
TH
U
A

Figure 3: Trends in inequality in under five mortality rates within countries: Evidence from sub-
Saharan Africa.
Source: Authors elaboration of data from the Demographic and Health Surveys (DHS), World
Bank.

316 r 2011 Macmillan Publishers Ltd. 1477-8211 Social Theory & Health Vol. 9, 4, 311325
 Neoliberal globalisation and health

adjustment, programmes demanded by the World Bank and IMF in exchange of

loans allowing developing countries to reschedule their external debts after
economic crises. The World Bank claimed that adjuster countries generally
succeeded in improving health, education and social welfare programmes
compared to non-adjusters (World Bank, 1993, 1994; Jayarajah et al, 1996).
The majority of studies analysing the impact of these policies, not conducted by
the World Bank or its consultants, however, have generally showed negative
health effects (Cornia et al, 1987; Ekwempu et al, 1990; Wakhweya, 1995;
Alarcon-Gonzalez and McKinley, 1999; Gilson and McIntyre, 2005; Dao et al,
2008). A review of 76 studies on the impact of structural adjustment showed a
preponderance of adverse health outcomes particularly in the poorest region of
the world, sub-Saharan Africa (Breman and Shelton, 2001).

PY
Globalisation, Economic Inequalities and Health
O
Of the major mechanisms by which neoliberal globalisation reduced health
C
improvements and widened health inequalities between and within countries,
the widening economic inequalities are one of the most plausible. Several
bodies of evidence found that neoliberal economic reforms tend to depress
R

economic growth and accentuate inequalities in wealth. Indeed, the advent of

O

the Washington Consensus coincided with poorer economic performance

worldwide: the overall rate of gross domestic product (GDP) growth per capita
TH

in the world economy was 2.6 per cent during the Golden era (between 1960
and 1979), but only 1.0 per cent during the neoliberal period (between 1980 and
1998) (Cornia, 2001). More analytic investigations have also shown that IMF
austerity programmes are associated with poorer, not better macroeconomic
U

performance (Ozdemir, 2001; Dreher, 2006). It is also important to observe the

highly heterogeneous pattern of economic growth experienced by different re-
A

gions of the world during the neoliberal period. Figure 4, which shows regional
trends in GDP per capita in International US$ Purchasing Power Parity over
time, clearly suggests that the wealth gap between the richest (OECD) versus
the poorest region (sub-Saharan Africa) has increased exactly after the begin-
ning of the neoliberal period.
Neoliberal reforms have been associated with increasing economic inequal-
ities not only between countries, but also within countries (Bergh and Nilsson,
2010). After the advent of these policies, the income gap between the highest
versus the lowest social classes has generally widened. For example, in the
United States, in 1980, a typical big-company CEO earned about 40 times as
much as the average worker; by 1990, however, the same rate increased to
100 times to become 350 times in 2001 (Frydman and Saks, 2005). In 2005,
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 De Vogli

PY
Figure 4: Regional trends in GDP per capita (US$ PPP).
Source: Authors elaboration of data from the globalization and health nexus database.
Department of Economics, University of Florence (2009).
O
C
Wal-Marts CEO Lee Scott Jr earned 15.5$ million, that is about 900 times the
pay and benefits of the average Wal-Mart worker (Reich, 2007). But what this
has to do with health? According to a substantial body of research, high eco-
R

nomic inequalities are correlated to worse health and quality of life indicators.
O

In The Spirit Level, Richard Wilkinson and Kate Pickett have shown that,
compared to relatively egalitarian countries, more unequal societies rank poorly
TH

in a long list of social and health outcomes including physical health, mental
health, drug abuse, imprisonment, violence, education, obesity, social mobility,
trust and community life, teenage pregnancy, and child mortality. The most
common ways by which inequality makes countries unhealthier are poverty
U

(Lynch et al, 2000) and psychosocial conditions (Marmot and Wilkinson, 2001).
On the one hand, higher inequality is associated with reduced welfare spending
A

and systematic underinvestment in human-related services such as health and

education leading to higher poverty (Lynch et al, 2000; Wilkinson and Pickett,
2006). On the other, higher inequality is linked to psychological distress (Lee
et al, 2008), mental illnesses (Pickett et al, 2006) and social distrust (Kawachi
et al, 1999; Uslaner and Brown, 2005).
Figure 5 presents time trends analyses on economic inequalities (mean Gini
coefficient) and health (mean life expectancy at birth) in 136 countries.
The figure indicates that, during the neoliberal globalisation era, the world
experienced lower rates of health improvements: between 1960 and 1980 life
expectancy roughly increased from 55 to 62 for a total gain of 7 years of life
expectancy in 20 years; between 1980 and 2005, however, life expectancy
roughly increased from 62 to 66 for a total gain of 4 years of life expectancy in
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 Neoliberal globalisation and health

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Figure 5: Worldwide trends in health and wealth inequalities.
source: Authors elaboration of data from the globalization and health nexus database.

O
Department of Economics, University of Florence (2009).
C
25 years. The figure also suggests that the slower rate of health improvement
worldwide after the 1980s occurred together with the rise of economic inequa-
R

lities as indicated by the rise of the mean Gini coefficient from 62.2 in 1980 to
O

65.5 in 2005.
Cornia and colleagues have analysed these time trends more analytically
TH

through a multivariate regression analysis that compared the period 19802005

against a counterfactual presuming continuation until 2005 of trends observed
in the 19601980 period. According to their results, the rise in income in-
equality has generally been detrimental to health improvements worldwide and
U

accounted for a world life expectancy reduction of 2.52 years when compared to
the counterfactual (Cornia et al, 2007).
A

Prospects for Global Health in a Time of Economic Crisis

After more than three decades of disastrous results in terms of health and eco-
nomic outcomes, and after having produced the 2008 global financial crisis, the
neoliberal globalisation model is under fire. While numerous voices in acade-
mia and civic society are calling for a stable and fairer global economic system,
so far, the policy responses to the crisis have been disappointing. In the after-
math of the financial crash, governments intervened with emergency packages
to buy up all the toxic mortgage debts of the too-big-to-fail-banks and have
probably prevented further problems for the world economy. However, the price
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 De Vogli

of the bailouts has been extremely high. IMF economists estimated that the
bailouts cost to governments and taxpayers a staggering $11.9 trillion that is
around a fifth of the entire globes annual economic output (Conway, 2009a).
This gigantic rescue package for the too-big-to-fail banks that caused and
gained the most from the crisis contrasted against the government inaction on
behalf of the too-small-to-save victims of the crisis. To add injury to insult,
while millions have lost their jobs or their houses or both, the bailout packages
have been used to pay large executive bonuses (Cho and Brady, 2009). Even
after the 2008 crisis, the top hedge fund managers had had their third-best year
on record and staff at Goldman Sachs (bailed out with $6 billion by the US
government) had some of the largest bonuses in the firms 140-year history
(Farrell and OConnor, 2009).

PY
In June 2010, the Obama administration passed a financial bill that included
regulations on the derivatives market, some restrictions on troubled financial
companies and other rules designed to protect consumers (New York Times,
O
2010). Although the bill has been described in the media as the most important
effort to re-regulate the economy since the Great Depression, it presents several
C
weaknesses. First, the bill failed to restore the barrier between commercial
banking and Wall Street trading, adopted as part of the GlassSteagal Act in
1933 and repealed in 1999 by the Clinton Administration. Second, the bill inclu-
R

ded no amendments to impose size limits on the large financial banks and
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companies that continue to be too-big-to-fail and continue to pose a threat to

the future financial stability of the world economy. Third, the proposed ban on
TH

the credit-default swaps, the very group of derivatives at the roots of the crisis,
or what Warren Buffett called weapons of mass financial destructions, has
been voted down by the Senate.
If at the national level, the bailouts came as a blank check for Wall Street, at
U

the global level the rescue package consisted in saving the bankrupted IMF with
a package of about $750 billion (De Vogli and Gimeno, 2009). This can be called
A

a bailout of bailouts as the IMF had a long history of using taxpayers money to
rescue failed, bankrupt lenders that lost their capital in financial crises in the
developing world. From 1995 to 2004, for example, the IMF gave emergency
crisis-stemming loans totalling $312 billion to Mexico, Thailand, Indonesia,
South Korea, Russia, Brazil, Turkey and Argentina to save big investors (George,
2004). The approach used for the Wall Street banks was also used for the IMF.
No conditionality, no internal reforms, no structural adjustment programmes.
These blank checks ensured that Wall Street will continue to trade derivatives
and highly speculative financial instruments while the IMF can persist in
applying the same failed policies that have exacerbated financial crises in
the developing world (Krugman, 1999; Stiglitz, 2004) and that wealthy nations
usually avoid when hit by a crisis (Chang, 2008; Press TV, 2009). These rescues
320 r 2011 Macmillan Publishers Ltd. 1477-8211 Social Theory & Health Vol. 9, 4, 311325
 Neoliberal globalisation and health

were opportunities to re-regulate banking activities, capital movement and

financial markets as occurred during the New Deal era and finally reject the idea
of a global self-regulating market freed from any interference from national
governments and global governance. Even the guru of neoliberal economics
Alan Greenspan, while grilled by a US congressional committee, declared to be
in a state of shock disbelief as admitted: I made a mistake y (there was)
a flaw in the model that I perceived (to be the) critical functioning structure
that defines how the world works (the self-regulating market) y I found a flaw.
I dont know how significant or permanent it is, but I have been very distressed
by that fact (Greenspan, 2008). Greenspan had a lot of reasons to be distressed:
the global financial meltdown produced a domino of social and economic ef-
fects throughout the world. The World Economic Forum estimated that about 40

PY
per cent of the world wealth has been destroyed by the crisis (Conway, 2009b).
Since the eve of crisis in 2007, global unemployment increased of 34 million
people in 2010, while up to 60 million people may have been pushed into severe
O
poverty in the low-income countries because of the crisis (ILO-IMF, 2010).
Nobody has estimated yet how many people have lost their lives because of the
C
global financial meltdown, but we know that economic crises can kill. Although
recessions are not necessarily accompanied by worsening health standards,
they have been associated with increases in adult male mortality in Russia,
R

Thailand, Mexico and higher child mortality in Peru and Indonesia (WHO,
O

2009) and a sample of 59 developing countries (Baird, 2009). Economic shocks

have also been related to increased suicide rates as shown in studies conducted
TH

in Europe (Stuckler et al, 2009), Japan, New Zealand, Russia and the United
States (WHO, 2009).
U

Conclusions
A

As stimulus packages around the world are slowly dissipating, superseded by

austerity programmes designed to reduce budget deficits and restore investors
confidence, citizens of developed and developing countries alike are suffering
the consequences of drastic reductions of social spending. The combined effects
of the crisis and the social cuts are expected to produce serious consequences
on global health. Many more lives will be lost unnecessarily because of neo-
liberal globalisation while social unrest can become a further threat to economic
stability in the years to come. Under such circumstances, will national and
global institutions finally decide to tackle the root causes of the global financial
crisis? Will the governments of the G-20 and the IMF finally start to promote
reforms aimed at economic redistribution and economic stability? These are
everybodys questions. So far, timid attempts to propose measures reducing the
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 De Vogli

impact of the crisis and prevent future ones include the development of a global
social fund, taxation of the richest individuals and corporations, the abolition of
tax havens and the imposition of taxes of international financial transactions.
Because wealthy investors do not welcome any of these reforms, they are
therefore considered politically unrealistic. Indeed, wealthy elites, megabanks
and transnational corporations that for years advocated for neoliberal globali-
sation and ultimately promoted the 2008 financial crisis, continue to lobby
against any serious reform of this unfair, unhealthy and anti-social global
economic system. Until they continue to succeed, reckless speculation, too-big-
to-fail banks and grotesque economic inequalities will persist, and prospects for
promoting global health and reducing health inequalities will remain uncertain.

PY
Acknowledgements

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Roberto De Vogli is supported by a grant from the Economic and Social Research
Council (ESRC) (RES-070-27-0034). The article was developed from a keynote
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presentation at the last Congress of the European Society for Health and Medical
Sociology, Ghent (Belgium) on 28 August 2010.
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About the Author

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Roberto De Vogli is an Associate Professor in Health Behaviors and Health

Education at the School of Public Health, University of Michigan and a Senior
Lecturer in Epidemiology and Public Health at University College London. He
is a former member of the WHO Commission on Social Determinants of
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Health - Globalization and Health Knowledge Network.

A

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