Health matters in a globalising world

Transnational corporations
A transnational corporation (TNC) is a company that operates in at least two countries. It is common for TNCs to have a hierarchical structure, with the headquarters and R&D department in the country of origin, and manufacturing plants overseas. As the organisation becomes more global, regional headquarters and R&D departments may develop in the manufacturing areas.
TNCs take on many different forms and cover a wide range of companies involved in the following primary, secondary (manufacturing) and tertiary (service) activities: * Resource extraction, particularly in the mining sector, for materials such as oil and gas * Manufacturing in three main sectors: 1. High-tech industries such as computers, scientific instruments, microelectronics, pharmaceuticals 2. Large-volume consumer goods such as motor vehicles, tyres, televisions and other electrical goods 3. Mass-produced consumer goods such as cigarettes, drinks, breakfast cereals, cosmetics, branded goods * Services such as banking/finance, advertising, freight transport, hotels and fast-food operations

TNCs are the driving force behind economic globalisation. As the rules regulating the movement of goods and investment have been relaxed and the sources and destinations of investment have become more diverse, such companies have extended their reach. There are now few parts of the world where the influence of TNCs is not felt and in many areas they are a powerful influence on the local economy. TNCs tend to be involved in a web of collaborative relationships with other companies across the globe.

The significance of TNCs * TNCs control and coordinate economic activities in different countries and develop trade within and between units of the same corporation in different countries. * TNCs can exploit differences in the availability of capital, and costs of labour, land and building. * TNCs can locate to take advantage of government policies in other countries, such as reduced tax levels, subsidies/grants or less strict environmental controls. They can get around trade barriers by locating production within the markets where they want to sell. * The large size and scale of operations of TNCs means they can achieve economies of scale, allowing them to reduce costs, finance new investment and compete in world markets. * Large companies have a wider choice when locating a new plant, although governments may try to influence decisions as part of regional policy or a desire to protect home markets. Governments are often keen to attract TNCs because inward investment creates jobs and boosts exports which assist the trade balance. TNCs have the power to trade off one country against another in order to achieve the best deal. * Within a country, TNCs have the financial resources to research several potential sites and take advantage of the best communications, access to labour, cost of land and building, and government subsidies.

Pharmaceutical transnationals
Modern pharmaceutical drugs can be seen as authority in pill form. Effectively encapsulated in each pill is a long, expensive chain of scientific research and marketing. Each pill embodies the faith which doctors and patients place in Western medicine. Each pill promises a chance of better health. Each pill, in a way, symbolises power.

The modern pharmaceutical industry is a lucrative one. The largest ten pharmaceutical companies in the world each feature in the top 400 companies in the world (Table 8.8). The geographical distribution is interesting: five have headquarters in the USA, two in Switzerland, one in France and two in the UK. They are all successful examples of globalisation. For example, Johnson & Johnson has more than 190 operating companies in 52 countries, selling products to 175 countries.

Branded pharmaceuticals
Pharmaceuticals can be sold under two broad categories: generic or branded.
Branded medicines, as with branded clothes, are more expensive than their generic counterparts. However, the generic name of a drug is its chemical description. This means that generic drugs are chemically identical to their brand-named equivalents. The generic name for a drug tends to be long and hard to remember whereas the brand name is often catchy. For example, the generic drug fluoxetine hydrochloride is marketed successfully as Prozac by its manufacturer Eli Lilly. The same drug is also marketed by other companies under the names of Erocarp, Lovan and Zactin. Branded drugs may be three to thirty times more expensive to purchase, making them prohibitive for much of the world's population. For any brand-name drug to be more well-known and popular than the generic equivalent, marketing forces must be involved.

Essential drugs
WHO regularly publishes updated lists of ‘essential drugs' These are generic drugs that can provide safe, effective treatment for most communicable and non- communicable diseases such as diarrhoea, tuberculosis and malaria. These lists are widely regarded as an important tool in increasing access for the world's populations to effective healthcare. They are, however, unpopular in countries with strong pharmaceutical industries. The WHO essential drugs list is not implemented in the USA or any EU country. This is because of the business goals
(i.e. profit) of manufacturers. In the USA the federal government is now prevented from encouraging the use of generic drugs following legal action from the Pharmaceutical Manufacturers' Association.

Drug development
The largest profits in the pharmaceutical industry come from the sale of brand-name drugs in developed countries. Research into tropical diseases affecting hundreds of millions of people in less developed countries receives only a small proportion of the sum spent on cancer research. Most money is spent on developing drugs to control 'diseases of affluence' such as heart disease, cancer and high blood pressure. Patents for new drugs are viewed as 'intellectual property' and it is illegal to make generic 'copies' of them for 20 years. Therefore, many new drugs that WHO may regard as 'essential' are not available in generic form. Pharmaceutical companies are criticised for this but point out the enormous investment in R&D required to develop a new drug. The money to fund this research comes partly from their profits.

Marketing and distribution
Branded drugs are unusual among consumer goods in the developed world in that their consumers tend to have little choice in the drug they purchase and use. Patients tend to use what their doctor prescribes for them. Therefore, the industry heavily targets doctors with its marketing, providing free samples of drugs, giving away everyday items (pens, calendars etc.), advertising in medical journals and arranging visits of sales representatives to surgeries and offices. Another criticism aimed at pharmaceutical companies and WHO is that they tend to treat the symptoms rather than the root cause of the problem. For example, iron folate, a vitamin supplement, is on WHO's list of essential drugs. It is included because of its ability to prevent anaemia in pregnant women, a common problem in both the underdeveloped and developed world. However, a similar compound, with the same anaemia-preventing properties, is found in leafy green vegetables. It is possible that encouraging the growth of these vegetables would be more valid than promoting vitamin supplements.

Tobacco transnationals
Philip Morris, R. J. Reynolds and British American Tobacco (BAT), the world's largest non-state owned tobacco producing TNCs, own or lease plants in more than 60 countries. These three companies have a total revenue of more than US$70 billion, a sum greater than the combined GDP of Costa Rica, Lithuania, Senegal, Sri Lanka, Uganda and Zimbabwe. Of the 1.2 billion smokers in the world, 800 million are in the developing world. Countries where consumption is growing the fastest are also among the world's poorest, and it is these countries that the major tobacco TNCs are targeting with their advertising and marketing campaigns. China's increase in tobacco consumption has been the most dramatic. Nearly 70% of Chinese men smoke, compared with just 4% of Chinese women. This means that China alone accounts for 300 million smokers, almost the same number as in all the developed world.

India
BAT has targeted the expanding market in India. According to the International
Non-Governmental Coalition Against Tobacco (INGCAT): * Each day 55,000 children in India start using tobacco in some way * About 5 million children in India under the age of 15 are already addicted to tobacco * Although cigarettes form only about 20% of the Indian tobacco market, BAT is engaged in campaigns to convert 250 million tobacco users, particularly the young, to cigarette smoking * The Indian government has relaxed investment rules so that TNCs can now have100% ownership of their manufacturing plants (previously they had to be joint ventures)

Production in developing countries
Tobacco TNCs are turning to developing countries not only to expand their markets but also as a source of cheaper tobacco. The danger with this is that tobacco cultivation will replace food crops. In Kenya, food production in tobacco-growing districts has decreased as farmers have shifted from food crops to tobacco. BAT is the largest agribusiness company in Kenya, contracting over 17,000 farmers to cultivate tobacco in an area of around 15,000 hectares. The situation is similar in Brazil, the world's largest exporter of tobacco. Brazilian tobacco is primarily used by Philip Morris to make less expensive brands. Cigarettes made with tobacco grown in the USA cost twice as much.

Like many other international companies, tobacco TNCs are shifting production overseas to take advantage of cheaper labour costs. They have all started production in Asian countries. For example, R. J. Reynolds has a factory in Vietnam which is used to supply German and Canadian markets. Damon, one of the world's largest tobacco-leaf dealers, also has an office in Vietnam, where it is developing new crop varieties for what it hopes to be a growing market. Vietnam sells most of its tobacco for less than US$3 per kg.

Regional variations in the UK

Life expectancy
Life expectancy in the UK is increasing. Across the country as a whole, men aged 65 can expect to live a further 16.6 years and women a further 19.4 years if mortality rates remain the same as they were in 2005. Women continue to live longer than men, but the gap is decreasing. In 1985, there was a difference of
4 years between male and female life expectancy at age 65 in the UK (13.2 and 17.2 years respectively). By 2005 this had narrowed to 2.8 years.

There are slight variations in life expectancy between the constituent countries Life expectancy in of the UK, as shown in Table 8.9. English men and women have the highest life years, 2005 expectancy at age 65, at 16.8 and 19.6 years respectively. Scotland, at 15.5 and 18.4 years respectively, has the lowest life expectancy at this age.

There are also more local variations. The southeast, southwest and east of England have the highest life expectancies. Scotland, the northeast and northwest of England have the lowest. All the ten local authorities with the highest male life expectancy at birth are in England: five in the southeast, three in the east of England and one each in the southwest and London. Eight of the ten local authorities with the lowest male life expectancy are in Scotland (Table 8.10). Glasgow City (69.9 years) is the only area in the UK where life expectancy at birth is less than 70 years. Kensington and Chelsea is the local authority with the highest male life expectancy. A similar situation exists for female life expectancy (Table 8.11).

Morbidity
A considerable amount of research has been conducted into regional variations in morbidity in the UK. The purpose of this research is to try to identify patterns of morbidity and the factors that contribute to these patterns, with a view to targeting elements of healthcare to combat them. The results are far from clear; variations exist for some aspects of morbidity but not for others. The links between factors such as age, income, occupation, education and environment and types of morbidity are also difficult to establish. They tend to be based on speculative association rather than clearly established causal links.
The research so far has shown that, at a country level: * Scotland has the highest rates of lung cancer, heart disease, strokes, and alcohol and drug-related problems * Wales has the highest incidence of breast, prostate and bowel cancer * Northern Ireland has the highest rate of respiratory diseases * England has the lowest rates for most of these

At regional level within England, a north-south divide in health is evident in some cases but not in others. Regions in the north have a higher mortality from heart disease, strokes and lung cancer. London has the highest rates for infectious and respiratory diseases. Alcohol-related problems do not show a regional pattern
(Figures 8.8 and 8.9). There is little variation in the incidence of bowel cancer, whereas breast and prostate cancer rates are higher in the south than in the north. Age appears to be a factor for some aspects of morbidity.
For example, in London heart disease incidence at ages 45-64 is below average, whereas the incidence of strokes for this age group is high.

A central finding of the research is that differences between countries and regions of the UK are less important than the wide differences than exist within regions. Urban areas tend to have higher levels of morbidity. Deprivation is often given as the main reason for this, but many areas of deprivation exist in rural parts. The examples in Figures 8.8 and 8.9 illustrate the problems of trying to establish clear patterns of morbidity.

Factors affecting regional variations
One explanation put forward for regional differences in health and morbidity is that they simply reflect a concentration of people of lower socioeconomic status.
However, other factors also appear to influence patterns in the UK.

Socioeconomic status does appear to be significant. In all regions of England, babies born to fathers in social class 5 (unskilled and unemployed) have higher infant mortality rates than those born to fathers in social class 1 (professional and managerial). Men aged 20-64 within social class 5 themselves have higher mortality than those in social class 1. Furthermore, men in this class in the north of England have higher mortality and morbidity than those in the same class in the south of England. It is believed that the explanation for this lies in material deprivation particularly in terms of employment and housing. In addition, people in this social class display different behaviours towards health — more smoking, less uptake of healthcare, lower ability to maintain health — and there is a cumulative effect of disproportionate numbers of disadvantaged people living in deprived areas. There is little geographic difference in mortality among those in social class 1.

Health-related behaviours may also affect geographic variations in health. Levels of smoking vary considerably across the countries of the UK and within the regions. It is well known that those of lower economic status are more likely to be heavy smokers, and it is this that drives the pattern of lung cancer by deprivation. Levels of education may also be a factor. Alcohol consumption and diet vary only a little between regions and therefore are likely to have limited influence on patterns of health. Attitudes to health, and in particular to exercise (again a reflection of education), may have an effect, but it is far from straightforward to quantify the effects.

Environment is also cited as a factor. The relationship between the weather and various aspects of health has been studied in great detail. Relationships have been found between: * Temperature, heart disease and pneumonia, but these are more associated with seasonal variations of temperature than regional variations * Rainfall and heart disease, which may impact on regional variations

Seasonality of mortality has declined in the UK since the 1960s, possibly due to the increased use of central heating. Air pollution was responsible for high morbidity and mortality from respiratory diseases before this period, and has declined.

Other smaller-scale aspects of the environment have an influence on morbidity. The impact of background radiation may be a factor in some diseases. For example, some rocks in the southwest of England contain high amounts of radon, and the radioactivity from this is thought to be responsible for a higher risk of lung cancer in the area. Issues of water quality are significant. Hard water is found in the south and east, soft water in the north and west. A consistent relationship has been shown between Soft water and high levels of heart disease. Deficiencies and excesses of certain trace elements in water are known to be harmful. Excesses of nickel, cadmium, mercury and lead are hazardous and high concentrations of aluminium in water have been suggested as an explanation for the geographic distribution of Alzheimer's disease.

The influence of age, gender and wealth
One way in which you can study the impact of age, gender and wealth on access to healthcare and exercise facilities is to study one or more small-scale areas through primary research and/or fieldwork.

The specification requires you to study two or more such areas, as detailed in Chapter 5. This could be extended to consider healthcare, exercise and nutrition. For the first time in 2001, the UK census asked people to describe their health over the previous 12 months as
'good', 'fairly good' or 'not good'

Tables 8.12 and 8.13 give general health information from census data for an inner-city area and a suburban area. A greater range of general statistics for these census areas is given in Tables 5.18 and 5.19, pages 196 and 197. The health data may reflect the access to facilities for exercise and healthcare of people in those localities, as well as nutrition levels. They could form the basis for investigation, possibly by using a questionnaire with residents, businesses and healthcare or exercise providers. We recommend you complete an investigation in a locality of your choice.

Implications for the provision of healthcare systems
Healthcare in the UK is provided within the context of the National Health Service (NHS). You are advised to study healthcare systems in an area of your choice.
However, the following gives some background information on the NHS and illustrates its operation in two specific areas: a larger area (the Wirral in northwest England) and a city (Sheffield).

The NHS
The NHS was founded in 1948 by Aneurin Bevin, who was determined to make good health a priority for all citizens: The essence of a satisfactory health service is that rich and poor are treated alike.'

There have been profound changes in the NHS since 1948. Successive governments have found it difficult to manage, and costs have risen as people live longer and medical advances take place.

In 2000, the government produced the NHS Plan. A number of reforms were implemented based around the creation of primary care trusts (PCTs). Primary care is the care provided by the people you see when you first have a health problem, including doctors, dentists, opticians and pharmacists. NHS walk-in centres and the phone service NHS Direct are also parts of primary care (Photograph 8.8). All of these are managed by a local PCT. These trusts are at the centre of the NHS and control about 80% of its budget. Their aims are to: * Engage with the local population to improve health and well-being * Commission a comprehensive and fair range of high-quality, responsive and efficient services, within allocated resources * Directly provide high-quality, responsive and efficient services where this gives the best value

Healthcare in the Wirral
Four NHS trusts provide services to the people of the
Wirral:
* Wirral Primary Care Trust (PCT) * Wirral Hospital NHS Trust * Cheshire and Wirral Partnership NHS Trust * Clatterbridge Centre for Oncology NHS Foundation Trust

Wirral Primary Care Trust
The PCT is responsible for deciding on the health service needs of the population of the Wirral and securing the continual provision of the services required. It achieves this by providing primary care and community services itself and commis- sioning secondary care from the other three trusts.

Primary care and community services provided by the PCT are doctors, dentists, opticians, pharmacists, health visitors and physiotherapists. Its headquarters is at St Catherine's Hospital in Tranmere. There are more than 60 GP surgeries in the region. The formation of the PCT allows local GPs to manage health services in their own districts. They can use the knowledge they have gained from working in a neighbourhood to influence, for example, which operations are bought from the Wirral Hospital NHS Trust and which illnesses are focused on.

Wirral Hospital NHS Trust
The Hospital Trust is responsible for most operations and major specialist treatments for Wirral residents. This may occur when the patient is referred to the trust by his or her family doctor, or brought into the Accident and Emergency department. Although it has departments on various sites around the peninsula, the best-known part of the Hospital NHS Trust is Arrowe Park Hospital.

Cheshire and Wirral Partnership NHS Trust
This is a specialist trust working across Wirral and Cheshire. The PCT commissions specialist mental health, learning disabilities, drug and alcohol services from the Partnership Trust for the people of the Wirral.

Clatterbridge Centre for Oncology NHS Foundation Trust
This is a specialist regional cancer centre. It provides cancer services to patients in Cheshire, Merseyside and the Isle of Man. The PCT commissions services from the Clatterbridge Centre so that Wirral residents can benefit from the centre's expertise.

At a national level, NHS North West oversees the four Wirral trusts. It reports to the Department of Health, which is headed by the secretary of state for health.

Healthcare in Sheffied
The Sheffield PCT serves a population of 520,000 and covers the same area as Sheffield City Council.
Its headquarters are in the centre of the city at Don
Valley House.Secondary care is provided by three hospital NHS trusts: * Sheffield Children's NHS Foundation Trust * Sheffield Teaching Hospitals NHS Foundation
Trust
* Sheffield Care Trust

Sheffield Children's NHS Foundation Trust
This is a major provider of healthcare for children and young people in Sheffield, South Yorkshire and beyond. Its services are located at Sheffield Children's
Hospital on Western Bank and throughout the city at Beighton Community Hospital, Centenary House, Flocton House, Oakwood Young People's Centre, Ryegate Children's Centre, Shirle Hill Hospital and St Peter's Close.

Sheffield Teaching Hospitals NHS Foundation Trust
This manages the five adult hospital services in the city. It provides around 900,000 appointments and operations a year and offers almost every kind of treatment. Its hospitals are Northern General
Hospital, Royal Hallamshire Hospital, Jessop Wing,
Weston Park Hospital and Charles Clifford Dental
Hospital.

Sheffield Care Trust
This delivers mental health services for adults, older people's services, psychology and therapy agencies and specialist learning disability services.

At a national level, the Yorkshire and Humber Strategic Health Authority oversees the three Sheffield trusts. It in turn reports to the Department of Health which is headed by the secretary of state for health.

What is the role of other providers?
The role of private healthcare has increased in recent years. Private health organisations such as BUPA offer a quick and efficient service to people who can pay insurance premiums, which are often met by their employers. Private companies tend to offer a more speedy response to elective surgery whereas acute situations are still dealt with by the NHS. Charitable organisations offer wider support than the NHS. They tend to concentrate on welfare as much as on health. Examples include: * The Down Syndrome Educational Trust * Macmillan Cancer Support * The hospice movement * organisations such as Shelter and Help the Aged

People who work for these organisations are a necessary part of the total provision of health and welfare in the UK. Many of them are unpaid volunteers.