Social Rights, Health, and Globalization: an Unfinished Agenda Timothy H. Holtz, MD, MPH, FACP Social Medicine, Human Rights, and the Physician Rollins

Social Rights, Health, and Globalization:

an Unfinished Agenda

Timothy H. Holtz, MD, MPH, FACP

Social Medicine, Human Rights, and the Physician

Rollins School of Public Health

March 28, 2005

Outline

Economic, social, cultural rights History of labor rights Overview of myths of growth, structural

adjustment, and globalization Role of transnational corporations (non-

state actors)

Civil/Political (CP) versus Economic/Social/Cultural (ESC)?-1

Dichotomy born from the cold war Economic/social/cultural rights are

actually quite old, but nonetheless excluded from many discussions of human rights in general

1st/2nd/3rd generation issues are mute Is it an either/or situation?

“East versus West” debate

Civil/Political (CP) versus Economic/Social/Cultural (ESC)?-2 Most human rights organizations have traditionally

focused on civil and political rights: arbitrary detention, torture, disappearances, maltreatment in prison

Concept of human rights has been historically narrowed to exclude social rights

Only recently have human rights organizations focused on ESC rights Center for Economic and Social Rights, NY Food First, CA Human Rights Watch, NY

The false dichotomy

Most scholars now recognize civil vs social/economic as interwoven, as Roosevelt/Cassin intended them to be

Interdependent Indivisible

This has not, however, translated itself into policy

What are economic rights?

Right to a standard of living Right to work, just and favorable conditions of

work, protection against unemployment, fair wages

Right to social security Right to own property Freedom of peaceful assembly

What are social rights?

Right to marry and form a family Freedom of religion/expression Right to rest and leisure Right to education

What are cultural rights?

Everyone has the right to freely participate in the cultural life of the community, to enjoy the arts, and to share in scientific advancement and its benefits. (Article 27, UDHR)

Everyone is entitled to a social and international order in which the rights and freedoms set forth in the Declaration can be fully realized. (Article 28, UDHR)

Cultural rights violations

Yanomami Indians in Amazon and “anthropologic” research – abuses of self-determination and respect for cultural values

Amungme people on Irian Jaya, Freeport-McMoRan gold mines

Peruvian Indians and oil drilling/Mobil Suppression of indigenous arts in South

Africa during apartheid

Labor Rights-1

*Labour* rights are among the oldest human rights in contemporary times

Most well defined, easy to enforce Mentioned in all core documents

UDHR Article 23 ICESCR Articles 7, 8 ICCPR Article 22

Labor Rights-2

The International Labor Organization (ILO) is one of the oldest human rights organizations in the world, established at the Treaty of Versailles in 1919

ILO has 177 conventions covering all aspects of labor rights standards

Membership organization (like UN) Conventions are binding to signatory states Conducts investigations, writes reports US a member from 1934-1977, 1980-present

Labor Rights-3ILO Conventions

No. 87 - Freedom of association – often the first human right to be violated in a repressive regime, can be used as a litmus test for the status of human rights in general

No. 98 - Freedom to organize and bargain collectively No. 105 - Freedom from forced labor (only core

convention signed by US, which has signed only 12) Governments do not pay as much attention to these

conventions as the UN conventions Why? Trade unionists are deeply involved in local

economic issues and have a pragmatic approach to solving them

Labor Rights-4Core labor rights found in ICCPR,

ICESCR, and ILO Right to work Right to just and favorable conditions of work

(wages and safe workplace) Right to protection against unemployment Right to equal pay for equal work Right to form trade unions Right to reasonable limitation of working

hours Right not to be subjected to forced labor

Labor rights violations and health

Assassination/murder Workplace injuries: deaths on the job Repetitive motion injuries – carpal tunnel

syndrome Testing female workers for pregnancy as

condition of work (maquiladoras) Using prisoners for labor – health effects of

poor working conditions (good examples in China, but also “chain gangs” in the US)

Is poverty a human rights violation?

Economic rights - Gross inequality

The top quintile (20%) of the world’s people living in the high income countries control:

86% of world gross domestic product (GDP) 82% of the world’s export markets 68% of foreign direct investment

The bottom quintile (20%) of the world’s poorest countries control less than 1% in each category.

1999 Human Development Report, UN Development Program

The real rich

The 200 richest people in the world more than doubled their net worth in the four years prior to 1998, to $1 trillion.

The wealth of the richest 225 people in the world is greater than the collective wealth of 2.5 billion people (47% of the world’s population).

1998/9 Human Development Report, UN Development Program

Where are they?

Of the 225 richest individuals in the world:

60 come from the United States 21 come from Germany 14 come from Japan

147 live in developed countries 78 live in developing countries


Worsening inequality in the US

Left Business Observer

Disparities in wealth are reflective of disparities in political power

Mass deprivation

1.3 billion people live on less than $1/day. 3 billion people live on less than $2/day. 11% of people in developed countries live on

less than $14.40/day. 2.6 billion without access to adequate sanitation 2 billion deprived of electricity 1 billion without adequate shelter 840 million malnourished 880 million without access to medical care


Consumption vs Priorities?

Cosmetics in the US – $8 billion

Ice cream in Europe - $11 billion

Perfumes in US/Eur - $12 billion

Pet foods in US/Eur - $17 billion

Cigarettes in Europe - $50 billion

Basic education for all – $6 billion

Water and sanitation for all - $9 billion

Repr. health for all women - $12 billion

Basic health/nutrition for all- $13 billion


Inequality in spending on health($ expenditure per capita, 1990)

Top five countries

USA $2,765

Switzerland $2,520

Sweden $2,343

Finland $2,046

Canada $1,945

Bottom five countries

Vietnam $3

Sierra Leone $4

Tanzania $4

Laos $5

Mozambique $5


ESC rights violations

Government action or inaction leading to poverty, or failing to respond to conditions that create, exacerbate, or perpetuate poverty are “reflective” or “connected” to human rights violations.

Governments should be accountable for progressively correcting conditions that impede achieving the right to health

Strive for equal opportunity in health for those who have suffered marginalization (equity/HR/SJ angle)

Address disparities in underlying conditions – class/SES status, education, env. conditions – without ignoring the links between poverty and ill health, and that those can be ameliorated

What do social rights violations have to do with health?

The burden of ill-health

Five million die per year of diarrheal diseases

Three million die per year of TB Two million die per year of malaria Nearly 50 million HIV infected persons

by the year 2000 (roughly 90% in developing countries)


Life expectancy differentials (years)

Highest life expectancy:

Cyprus 77

Costa Rica 77

Barbados 76

Cuba 76

Chile 75

Lowest life expectancy:

Rwanda 28

Sierra Leone 35

Uganda 41

Zambia 43

Afghanistan 45


Under-five mortality differentials(per 1,000 live births)

Lowest under-five mortality rates:

Korea, Rep of 7

Cuba 10

Jamaica 13

Malaysia 13

Chile 14

Highest under-five mortality rates:

Niger 320

Sierra Leone 284

Mali 225

Mozambique 220

Malawi 219


Causes of death, 1990

0102030405060708090

Globalpoorest

20%

Worldaverage

Globalrichest

20%

CommunicableDisease

Non-communicablediseases

Injuries

Gwatkin DR, Guillot M, Heuveline P. The burden of disease among the global poor. Lancet 1999; 354: 586-9.

What’s behind all this inequality and imbalance of disease prevalence?

What is this concept of “globalization” we hear about every day? What does it mean that we live in a “global economy.” Does anyone know what that really means?

“Globalization is the growing interdependence of the world’s people through shrinking space, shrinking time, and disappearing borders.”

Markets, the HDR states, have been allowed to dominate the process, and the benefits and opportunities have not been shared equally.

The result is that “global inequalities in income and living standards have reached grotesque proportions.”


Globalization

Globalization is….

“When the profit motives of market players get out of hand, they challenge people’s ethics – and sacrifice respect for justice and human rights.”

“More progress has been made in norms, standards and policies for open global markets than for people and their rights.”

“Patent laws pay little attention to the knowledge of indigenous people. The result – a silent theft of centuries of knowledge from developing to developed countries.”


Globalization also is... “The collapse of space, time, and borders

may be creating a global village, but not everyone can be a citizen. The global, professional elite now faces low borders, but billions of others find borders as high as ever.”

“The new rules of globalization – and the players writing them – focus on integrating global markets, neglecting the needs of people that markets cannot meet. The process is concentrating power and marginalizing the poor.”


Free markets make free men.

Milton Friedman

University of Chicago

Nobel Laureate, Neoliberal Economics

Rats and roaches live by competition under the laws of supply and demand; it is the

privilege of human beings to live under the laws of justice and mercy.

Wendell Berry

Growth

Myth: neoliberal capitalism is the only way to achieve economic growth (Does everyone “know this to be true?”)

Myth: Growth will automatically translate into greater prosperity for all

Myth: Growth is an sufficient objective Myth: Economic laws and markets

function independently of politics

Golden Age of Growth

1945-1970 was golden age of capitalism, industrialized countries grew at 5% annually

Managed growth by governments (Keynes) High trade flows, low currency flows (restrict

mobility of capital) Oil crisis of 1973 heralded end of age Stagflation (high rates of inflation and

unemployment) Election of anti-state governments in UK and

US

Development

Is economic growth necessary for social development?

GDP growth remains dogma, most commonly used indicator to measure our progress in reducing poverty

GNP and life expectancy

1979 Data

GNP and life expectancy

74

52

GNP per capita and Life Expectancy at Birth, 1994

From Development as Freedom, Amartya Sen 1999. Figures from Country Data World Bank, World Bank Development Report, 1996

Debt crisis of 1982 (to present)

Commercial banks loaned vast amounts of capital to developing nations at high interested rates, not predicting….

Changes in international economy Expanded bank lending fueld by oil Increased government borrowing

…many countries stretched to thin - July 1982 Mexico defaults, heralding beginning of crisis

The crippling burden of debt

Countries of Sub-Saharan Africa spent an average of $12 billion annually on debt repayments from 1990-1995, while their total debt increased by $33 billion.

For 27 highly- indebted nations, debt is greater than their GNP.

Tanzania’s debt service payments are nine times what it spends on primary health care and four times what it spends on primary education.

Mozambique has a debt burden nine times the value of its exports.


Neoliberal diagnosis

State playing too large a role Markets are being inhibited, state

intervention is preventing markets from being efficient

Government should stick only to property rights and enforcing contracts

International Financial Institutions

“Bretton Woods Institutions,” NH, July 1944 World Bank (WB)

Support embedded liberalism “Free trade”, restrictions on capital mobility, and

domestic social contract Provided loans to countries for development

projects International Monetary Fund (IMF)

Prevent currency fluctuations/devaluations Contain 1930-style economic crisis

GATT – General Agreement on Tariffs and Trade

Neoliberal prescription

Reduce role of state relative to the market Allow floating currency rates, and wages to

be determined by market forces and interest rates

Lift all barriers to trade and investment (opposite of Adam Smith’s “invisible hand” – free movement of labor but not capital)

World Bank program of “Structural Adjustment” of the world’s poorest countries

Re-orienting economies toward export production, away from self sufficiency

Removing restrictions on foreign investment Reduction of wages Cutting tariffs Imposing consumption taxes (value added tax/VAT) Eliminating price subsidies on essentials like food and

housing Devaluing local currency Privatizing state enterprises Deregulating gov’t oversight of economic activity

Structural adjustment report card

75 countries had received loans by 1991 30 in SSA, 18 in Latin America Overal debt increased, both official debt and

commercial debt Did not reduce debt, reduce poverty, or

increase growth New category HIPC – Bolivia, Burkina, Ivory

Coast, Guyana, Moz, Uganda

What are the health effects of the IFIs?

ESAFs have failed to significantly raise GDP of participating countries

ESAFs have failed to reduce external debt burden of most highly indebted countries

Social safety nets are nonexistent: for education, health, housing, social security

“Cost-effectiveness” calculus further hurts the most vulnerable populations, violates their social rights, and results in continued stagnating health outcomes

The crippling burden of debt

Countries of Sub-Saharan Africa spent an average of $12 billion annually on debt repayments from 1990-1995, while their total debt increased by $33 billion.

For 27 highly- indebted nations, debt is greater than their GNP.

Tanzania’s debt service payments are nine times what it spends on primary health care and four times what it spends on primary education.

Mozambique has a debt burden nine times the value of its exports.


New poverty agenda - 1990

Labor intensive growth, invest in human capital, promote social safety nets

Enhanced Structural Adjustment Facility (ESAF)

Progress has still not been achieved, as documented by Weisbrot et al.

Growth for whom?

Only 33 countries achieved sustained three percent annual growth in gross national product (GNP) per capita during 1980-1996.

For 59 countries, mainly in sub-Saharan Africa and the countries of the former Eastern Bloc, GNP per capita declined from 1980 to 1996.


For many peoples of the third world, globalization is just the latest buzzword for late 20th century neoliberal capitalism

Promotion of “free markets” Relaxation of trade barriers Reduction of subsidies for the poor Privatization of public assets Weakened role of government Growing dominance of western-based

transnational capital Continued high military expenditures

The “global economy”

Growth of “free trade”

Role of transnational corporations

Accelerated capital flows and impacts of privatization

Diminished aid from the West

1.1 World Trade: separate worlds

48 poorest countries account for 0.4% of global exports

Share of world’s exports by least developed nations fell from 15% in 1968 to 13% in 1998

Transnational trade (globalized economy) reaches AT MOST only 1/3 of the world’s population

1.2 “Free trade”

More trade between nations in late 1800s than there is now

46% of world trade is between EU, US, and Japan (OECD)

Actually 30-40% of “trade” consists of transactions within same TNC, trading with their own affiliates

1.3 More on trade

Most new manufacturing growth comes from NICs (SK, HK, RoC, Sing.)

Single commodity exports account for half of export earnings for many countries

And besides, the US, S Korea, Taiwan, Japan ALL developed under restricted and protective trade laws

1.4 World Trade Organization

WTO created in 1990 to supersede GATT Set up to manage world trade system Extensive set of regulations and rules are

required (free is a misnomer) Many argue these rules are set up to benefit

the powerful, the TNCs, big finance capital from West

All meetings held closed door

2. TNCs

Consist of the largest economies in the world

TNCs have expanded due to communication, transportation technology, and shift to export oriented development strategies

3.1 Global finance capital

Dramatic increase in movement of capital

Principle of free trade to capital? Daily trading in foreign exchange is over

$2 trillion per day Control of capital is increasingly

centralized

3.2 Foreign Direct Investment: skewed away from the poor

FDI is dominated by TNCs FDI in developing countries increased from

$18.3 billion in 1983 to $149 billion in 1997 (out of a total of $400 billion)

FDI is highly concentrated: 80% went to only 10 developing countries

The 100 smallest countries received less than 1% of worldwide FDI

Only 5% of FDI to developing countries goes to Africa

4.1 Diminishing aid from the West

US is steadily decreasing its annual contribution in foreign aid, which is now below 0.5% of US annual GNP

Many other countries, especially Scandinavia, devote much higher percentages of their GNP for foreign aid

source: New York Times, October, 1997

Investing in Health, World Bank 1993

Promoted cost-efficiency approach to health care in developing countries in a world awash with capital.

Medical care defined as a commodity, and health defined as the absence of disease.

The concept of disability adjusted life years (DALYs) promoted.

Marked the entry of the World Bank in funding large health care projects in poor countries, such as vertical vaccine campaigns, TB control, etc.

Do we really live in a “global village”?

*Marshall McLuhan

Sou

rce:

Adb

uste

rs

“I see in the near future a crisis approaching that unnerves me and causes me to tremble for the safety of my country. Corporations have been enthroned and an era of corruption in high places will follow, and the money power of the country will endeavor to prolong its reign by working upon the prejudices of the people until all wealth is aggregated in a few hands and the Republic is destroyed.”

President Abraham Lincoln, November 21, 1864, letter to Colonel William F. Elkins.

Takeover in Nigeria

150 Ugborodo and Arutan women successfully shut down a Chevron/Texaco oil plant in Escavros for several weeks in June/July 2002 by occupying an pipeline terminal, trapping 150 workers inside

Demands: Jobs for locals and electricity for their villages

Damage to Nigerian environment and health of villagers throughout Niger River Delta from oil and gas drilling is extensive

New York Times, July 14, 2002, Foreign Desk

Gas flaring in Ogoniland, Niger River Delta, December 2002Credit: Owens Wiwa

Transnational CorporationsTNCs

“Non-state actors” Characteristics

Economic power International character Impact of activities Regulatory difficulty in LDCs

Transnational capital flows

Currency flows reach trillions of dollars every day, mainly between developed countries.

Foreign direct investment (FDI) reached $400 billion in 1997, but 58% of it went to developed nations, and just 5% to the transition economies of Central and Eastern Europe.

Of the FDI that went to developing countries in the 1990s, more than 80% went to just 20 countries, and mainly to China.


TNC Economic Power-1

Industrialized countries control 97% of all patents worldwide.

The top ten transnational corporations in each field control:

86% of telecommunications 85% of pesticides 70% of computer production 35% of pharmaceuticals



Of the 100 largest economies in the world, 51 are corporations (sales versus gross domestic product/GDP)

The top 200 corporations’ sales are growing at a faster rate than global economic activity

The top 200s’ combined sales are 18 times the size of the combined annual income of 1.2 billion people living in severe poverty

US firms dominate the top 200 (82), while Japanese firms are second with 41


The sales of the Top 200 are the equivalent of 28% of world economic activity, they only employ 0.8% of the world’s workforce

Between 1983 and 1999 Top 200 profits grew by 362%, but employment grew by only 14%

44 of 82 US Corporations in the Top 200 did not pay full taxes; Seven actually paid <0% - Texaco, Chevron, Pepsico, Enron, McKesson, Wal-Mart

TNC International Character-1

The top corporations earn 40-50% of their yearly profits from sales overseas

Assets of TNCs are also located overseas, 33% of pharmaceutical industry, and 75% of electrical industry

Many examples of individual factories and entire industries moving overseas to benefit from reduced wages, lower standards, higher profit margin

HR Impact of TNC Activities-1

Civil and political violations Violate right to self-determination Violate freedom of association Perpetuate racial discrimination Genocide against indigenous peoples Violate right of people to dispose of the natural

wealth Bodily harm to people opposed to TNC by security

forces


Violations of ESC rights Right to work freely chosen Right to just and favorable working conditions, fair

wages, equal pay for equal work, safe and health working conditions, reasonable limit on working hours

Right to education Right of children to be protected from economic

and social exploitation Right to an adequate standard of living for

individuals and their families


Indirect impact Pursuit of export oriented economic

policies Destruction of environment Urbanization Engaging in business with repressive

regimes

TNCs and Repressive Regimes

Loans to repressive regimes Breaking sanctions against repressive

regimes Buying from repressive regimes Selling to repressive regimes Lending credibility to repressive regimes

Health and Human Rights Impact of TNC Activities-1

Oil/power exploration Texaco-Gulf in Ecuador – environmental destruction BP in Colombia – private security abuses Royal Dutch Shell in the Niger Delta – murder and

environmental destruction Mining industry

Freeport-MacMoRan in PNG – mine tailings Chemical Industry

Union Carbide - Bhopal Disaster 1984 Manufacturing industry

Wal-Mart, Disney, K-Mart, Kathy Lee Gifford

Health Impact of TNC Activities-2

Maquiladora sector on US-Mexican border has blossomed to over 2,500 factories

Assembly plants, part of export processing strategy to develop Mexico (though most people there live in squalor)

90% are owned by US corporations, though often subcontracted work; Korean corporations also common

Preferential tariffs, low taxation, lax environmental standards

Health Impact of TNC Activities-3

Maquiladora sector characterized by low wages, poor working conditions, environmental abuse, poor infrastructure

Human rights issues center around fair wages, right to organize, hazardous working conditions, disclosure of hazardous waste, safety training, infrequent occupational inspections, occupational compensation for injury, sexual harassment, child labor, housing conditions

Health issues center around repetitive strain, noise/solvent/toxic waste pollution, miscarriages, skin disorders, pulmonary disease/asthma, depression

Approaches to regulate TNC abuses

“Social Responsibility” approach Promotional, use rational persuasion and moral

argumentation TNCs to sign corporate codes of conduct

“Social Accountability” approach TNCs can’t self-monitor, need independent accounting

“Economic threat” approach TNCs only respond when profits threatened with boycotts,

etc. “Punitive” approach

Sanctions, selective purchasing laws, divestment campaigns

Regulating TNCs-1

Commission on Transnational Corporations in 1975 formed draft code – focused on bribery, disclosure of dangerous processes, and export of hazardous products and factories

Blocked by Reagan administration and died a sudden death

As “Non-state actors” they cannot be held accountable to same standards as states in UN

Voluntary codes exist, but no enforcement Declaration and Guidelines on International Investments and

Transnational Enterprises (OECD) Tripartite Declaration on Principles of Transnational

Enterprises and Social Policy (ILO) WHO/UNICEF code on infant formula marketing

TNC Response to Criticism

Avoidance Resistance Acquiescence Compromise

Corporate Codes of ConductBare essentials

Employment standards – nondiscrimination, working hours, compulsory labor, fair wages, child labor, freedom of association, healthy workplace guidelines, excessive punishment guidelines

Environmental standards – protection of biosphere, energy conservation, sustainable use of resources, risk reduction, disposal of waste

Internal compliance regulations – personnel to monitor compliance, business partners to abide by standards (outsourcing), audit instruments to be used on site

Country assessment guidelines – assessment of performance of all affiliates, gathering information from all sources

Independent monitoring

Amnesty International HR Principles for TNCs/companies-1

Explicit company policy/UDHR Security/law enforcement policy Community engagement Freedom from discrimination Freedom from slavery

HR Principles for Companies, Amnesty International

HR Principles for TNCs/companies-2

Healthy and safe work environment Freedom of association and right to

collective bargaining Just and favorable working conditions,

including security and fair compensation/wages

Freedom from child labor Monitoring human rights policy

HR Principles for Companies, Amnesty International

Corporate Codes of ConductCurrent problems

Lack of uniform language Lack of compulsory enforcement mechanisms Lack of language on sexual harassment Fair wage/living wage clauses often

inadequate and vague Codes do not cover contractors and

outsourcers ***Lack of independent monitoring***

“People say, what is the sense of our small effort? They cannot see that we must lay one brick at a time, take one step at a time. A pebble cast into a pond causes ripples that spread in all directions. Each one of our thoughts, words, and deeds is like that. No one has the right to sit down and feel hopeless. There is so much work to do!”

-- Dorothy Day

Summary

Civil-Political rights and Social-Economic-Cultural rights are interdependent and indivisible, cannot have one without the other

Labor rights have long standing tradition in the human rights field

Globalization brings with it many human rights issues not generally discussed

Transnational corporations and other non-state actors have health and human rights impacts that should and can be monitored

Documents

Social Rights, Health, and Globalization: an Unfinished Agenda Timothy H. Holtz, MD, MPH, FACP Social Medicine, Human Rights, and the Physician Rollins