Ronald Labonté

Medical tourism today: What is the state of existing knowledge?

AbstractOne manifestation of globalization is medical tourism. As its implications remain largely unknown, we reviewed claimed benefits and risks. Driven by high health-care costs, long waiting periods, or lack of access to new therapies in developed countries, most medical tourists (largely from the United States, Canada, and Western Europe) seek care in Asia and Latin America. Although individual patient risks may be offset by credentialing and sophistication in (some) destination country facilities, lack of benefits to poorer citizens in developing countries offering medical tourism remains a generic equity issue. Data collection, measures, and studies of medical tourism all need to be greatly improved if countries are to assess better both the magnitude and potential health implications of this trade.

Addressing social determinants of health inequities: what can the state and civil society do?

In this Health Policy article, we selected and reviewed evidence synthesised by nine knowledge networks established by WHO to support the Commission on the Social Determinants of Health. We have indicated the part that national governments and civil society can play in reducing health inequity. Government action can take three forms: (1) as provider or guarantor of human rights and essential services; (2) as facilitator of policy frameworks that provide the basis for equitable health improvement; and (3) as gatherer and monitor of data about their populations in ways that generate health information about mortality and morbidity and data about health equity. We use examples from the knowledge networks to illustrate some of the options governments have in fulfilling this role. Civil society takes many forms: here, we have used examples of community groups and social movements. Governments and civil society can have important positive roles in addressing health inequity if political will exists.

Capacity building in health promotion, Part 2: Whose use? And with what measurement?

Capacity building has been a topic in health promotion literature for several years. In our previous article, we discussed community capacity building as both means and end in health promotion work, and reviewed seven theoretical and empirical models of community capacity which provide a total of nine separate capacity domains. In this article we discuss the parallel tracking of community capacity building in health-promotion program planning, implementation and evaluation, and describe workshop methodologies for incorporating capacity assessments within health-promotion program planning. We conclude with a discussion of measurement options for community capacity building.

Canada: a land of missed opportunity for addressing the social determinants of health.

The first 25 years of universal public health insurance in Canada saw major reductions in income-related health inequalities related to conditions most amenable to medical treatment. While equity issues related to health care coverage and access remain important, the social determinants of health (SDH) represent the next frontier for reducing health inequalities, a point reinforced by the work of the World Health Organizations Commission on Social Determinants of Health. In this regard, Canadas recent performance suggests a bleak prognosis. Canadas track record since the 1980s in five respects related to social determinants of health: (a) the overall redistributive impact of tax and transfer policies; (b) reduction of family and child poverty; (c) housing policy; (d) early childhood education and care; and (e) urban/metropolitan health policy have reduced Canadas capacity to reduce existing health inequalities. Reasons for this are explored and means of advancing this agenda are outlined.

Globalization and social determinants of health: The role of the global marketplace (part 2 of 3).

Globalization is a key context for the study of social determinants of health (SDH): broadly stated, SDH are the conditions in which people live and work, and that affect their opportunities to lead healthy lives.In the first article in this three part series, we described the origins of the series in work conducted for the Globalization Knowledge Network of the World Health Organizations Commission on Social Determinants of Health and in the Commissions specific concern with health equity. We identified and defended a definition of globalization that gives primacy to the drivers and effects of transnational economic integration, and addressed a number of important conceptual and methodological issues in studying globalizations effects on SDH and their distribution, emphasizing the need for transdisciplinary approaches that reflect the complexity of the topic.In this second article, we identify and describe several, often interacting clusters of pathways leading from globalization to changes in SDH that are relevant to health equity. These involve: trade liberalization; the global reorganization of production and labour markets; debt crises and economic restructuring; financial liberalization; urban settings; influences that operate by way of the physical environment; and health systems changed by the global marketplace.

Priorities for research on equity and health: towards an equity-focused health research agenda.

Piroska Östlin and colleagues argue that a paradigm shift is needed to keep the focus on health equity within the social determinants of health research agenda.

Setting global health research priorities

When the G8 countries met in Canada in 2002 the topics of security, health, and Africa figured prominently. The three issues are related. Africas human health is reeling from HIV/AIDS and other infectious diseases, posing national and regional security risks. The continents economic health is stagnant or eroding, the result of structural adjustment programmes,1 domestic conflicts, corruption, and deteriorating human health. Recognising the complexities of these entwined relations, the G8 Africa action plan included a commitment to support health research on diseases prevalent in Africa. How well G8 member nations—Canada, the United States, England, France, Germany, Italy, Japan, and Russia—abide by this commitment is a matter of time and lobbying efforts. But what form should this new health research investment take? Should it emphasise specific diseases affecting poor people most, as favoured by the Commission on Macroeconomics and Health of the World Health Organization?2 Should it heed the call of biotechnology researchers, who have tabled their list of “top 10” research investments for global health, which range from better …

Beyond the divides: Towards critical population health research

The term ‘population health’ has supplanted that of public health and health promotion in many Anglophone countries. The ideas underlying the term are not new and owe much to the legacies of nineteenth-century public health radicalism, Latin American social medicine and, more recently, social epidemiology. Its influential modeling by the Canadian Institute for Advanced Research in the early 1990s, however, was criticized for a lack of theory, reliance on large data sets, a simplistic modeling of the healthcare/economy relationship, little attention to the physical environment and an absence of human agency. While researchers working under the rubric of population health have addressed many of these early limitations, there has yet to be an articulation of what comprises a critical population health research practice. This article, based on the discussions and work of an interdisciplinary group of researchers in the Saskatchewan Population Health and Evaluation Research Unit (SPHERU) in Canada, argues that such a practice proceeds from a theoretical engagement (theories of knowledge, society and social change), community engagement (a politicization of research knowledge) and policy engagement (which must extend beyond the simplistic notions of ‘knowledge translation’ that now permeate the research communities). A critical population health research practice, it concludes, is a moral praxis built upon explicit social values and analyses.

A new generation of trade policy: potential risks to diet-related health from the trans pacific partnership agreement.

Trade poses risks and opportunities to public health nutrition. This paper discusses the potential food-related public health risks of a radical new kind of trade agreement: the Trans Pacific Partnership agreement (TPP). Under negotiation since 2010, the TPP involves Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, the USA, and Vietnam. Here, we review the international evidence on the relationships between trade agreements and diet-related health and, where available, documents and leaked text from the TPP negotiations. Similar to other recent bilateral or regional trade agreements, we find that the TPP would propose tariffs reductions, foreign investment liberalisation and intellectual property protection that extend beyond provisions in the multilateral World Trade Organization agreements. The TPP is also likely to include strong investor protections, introducing major changes to domestic regulatory regimes to enable greater industry involvement in policy making and new avenues for appeal. Transnational food corporations would be able to sue governments if they try to introduce health policies that food companies claim violate their privileges in the TPP; even the potential threat of litigation could greatly curb governments’ ability to protect public health. Hence, we find that the TPP, emblematic of a new generation of 21st century trade policy, could potentially yield greater risks to health than prior trade agreements. Because the text of the TPP is secret until the countries involved commit to the agreement, it is essential for public health concerns to be articulated during the negotiation process. Unless the potential health consequences of each part of the text are fully examined and taken into account, and binding language is incorporated in the TPP to safeguard regulatory policy space for health, the TPP could be detrimental to public health nutrition. Health advocates and health-related policymakers must be proactive in their engagement with the trade negotiations.

The Growing Impact of Globalization for Health and Public Health Practice

In recent decades, public health policy and practice have been increasingly challenged by globalization, even as global financing for health has increased dramatically. This article discusses globalization and its health challenges from a vantage of political science, emphasizing increased global flows (of pathogens, information, trade, finance, and people) as driving, and driven by, global market integration. This integration requires a shift in public health thinking from a singular focus on international health (the higher disease burden in poor countries) to a more nuanced analysis of global health (in which health risks in both poor and rich countries are seen as having inherently global causes and consequences). Several globalization-related pathways to health exist, two key ones of which are described: globalized diseases and economic vulnerabilities. The article concludes with a call for national governments, especially those of wealthier nations, to take greater account of global health and its social determinants in all their foreign policies.