When health is seen as security it conjures up fear of bio-terrorism, terrorists, and the general inclination towards border protection, ‘whether the invaders are pathogens or people’ (Labonte 2008:468). This idea has given more political clout to public health measures, particularly with global epidemics, but it is also associated with ‘repressive political measures’, such as the rhetoric and actions of the war on terror (Labonte 2008:468). Instead of encouraging high-income nations to help those less fortunate it has privileged those diseases most likely to inconvenience global trade and finance or travel to wealthy countries. Fear of epidemics such as avian flu or H1N1 (swine flu), has also proven a major windfall for the pharmaceutical industry, particularly Roche, the company that makes Tamiflu. Labonte (2008) suggests a shift from the national security approach to one of working towards human security. The latter is based on a core moral value of individual security, including income, health care, housing, education, environmental security and other essentials for life (Labonte 2008). This indicates the political nature of health promotion, and the need for vigilance, activism and community participation to shift ideas, attitudes, resources and power to focus on strengthening the health and wellbeing of the population (Sparks 2009).

The Millennium Development Goals (MDGs) have been described as ‘the most concentrated and collected global statement of development intent in human history’ (Labonte 2008:470) (see Figure 3.1). MDGs clearly situate health as a development outcome. The MDGs, to be achieved by the year 2015, were defined at a UN summit of 191 nations to address the effects of poverty on health in the developing nations. They are aimed at addressing extreme poverty, hunger, disease, lack of adequate shelter and exclusion while promoting education, gender equality and environmental sustainability (Sachs 2005). The Millennium project, under the auspices of the Director-General of the UN, is based on the assumption that sound, proven, cost-effective interventions can ameliorate and often eliminate extreme poverty, especially where it is most needed, such as in the countries of sub-Saharan Africa. To achieve the goals requires investment of wealthy countries in the poorer nations to help develop capacity in education, the environment, health care, nutrition and social programs, especially those that foster equity.

The intention of the MDG project has been no less than to change the world. If the goals are met, 500 million people will be lifted out of extreme poverty. More than 300 million will no longer suffer from hunger.

The lives of 30 million children and 2 million mothers will be saved. Hundreds of millions of people will have safe drinking water and basic sanitation. Hundreds of millions of women and girls will go to school, be able to access economic and political opportunities and be safer and more secure (Sachs 2005). Yet to date, there have been only modest gains in achieving the goals, although there has been a renewed Global Campaign for achieving the MDGs, which is centred around improving maternal health through innovative financing and better health services (http://www.un.org/News/briefings/docs/2008/080925_MDG_Health.doc.htm [accessed 15/07/09]). However, long-term trends show that progress has been slow. The ratio between the richest and poorest countries continues to increase significantly, and the number of people living in absolute poverty (less than $US2 per day) has also increased (Baum 2009). One billion people worldwide try to survive on less than $US1 per day while 35000 of the world’s children die (Mooney & Ataguba 2009).

Criticisms of the MDGs focus on the lack of equity and inclusiveness of the goals in terms of human development. The objective of human development is to try to ensure that everyone develops to their maximum potential as a human being (Hancock 2009). The UN Development Programme is based on the holistic nature of human development in terms of securing essential areas of choice, including political, economic and social opportunities for being creative and productive, and enjoying self-respect, empowerment and the sense of belonging to a community (Hancock 2009).

Because of the way the goals are cast, and their emphasis on economic goals it would be possible to meet their criteria by improving the health of the wealthy while worsening the health of the poor (Labonte 2008). The goals are also difficult to measure and do not identify the causes of the problems that need to be addressed (Labonte 2008). They are unambitious, setting only minimal standards (Baum, 2009 and Labonte, 2008) and the target of Goal 8 to further an open trading and financial system may be at odds with the others, given the disadvantage created thus far by open markets (Labonte 2008).The MDGs have been lauded for their call to wealthy countries to support those at an economic disadvantage. However, even in this respect, there have been significant problems in relation to foreign aid. In general, with the exception of the Nordic countries, aid levels remain ungenerous (Labonte 2008). Aid given to Africa has not created economic development, but instead most has been lost to ‘capital flight’ (the removal of funds to wealthy countries). Some aid arrangements have been used to pressure poor recipient countries into trade treaties that favour wealthy, donor nations. Over 60% of the increase in donor aid between 2001 and 2004 has gone to Afghanistan, Iran and the conflict-ridden, mineral-rich Democratic Republic of the Congo, which together constitute less than 3% of the world’s poor. This calls into question whether aid is protecting the interests of the givers or the recipients (Mooney & Ataguba 2009).

Australia provides $A42 billion in aid, yet the funds are now tied to long-term anti-terrorism projects in the Asia–Pacific region, officially reoriented towards combating terrorism and promoting regional security (Mooney & Ataguba 2009). In New Zealand, election of a National government in 2008 has seen a re-orientation of New Zealand aid policy from a focus on social equity to one on sustainable economic growth (McCully 2009), resulting in a total redistribution of New Zealand’s aid. This demonstrates how even within countries, differing government agendas can have a wide-ranging impact on global health (http://www.beehive.govt.nz/release/aid+increases+nzaid+changes+focus).

These outcomes suggest that the development agenda and the notion of ‘aid’ needs to be recast in terms of human potential through ‘redistributive obligations’ rather than market performance (Labonte 2008:473). This would help temper investments in health to distinguish the objective (human development) from the tool (economic growth). An alternative way of approaching global health is to see health as a public good.

One approach to promoting global health that has gained momentum since the 1990s is the notion that when wealthy nations provide health assistance to the less fortunate it is not only humanitarian aid, but a selfish investment in protecting health in their own population (Smith & MacKellar 2007). This conception of health is one that evokes community, where the emphasis is on the collective, and stable, sustainable systems that support health and nation building. Globally, this idea of sharing would see a broader perspective where all countries became concerned about risks (risk pooling) and worked towards developing common financial regulations to benefit everyone, not just those in positions of wealth and power (Baum, 2009 and Labonte, 2008).

The Commission on the Social Determinants of Health (CSDH) has done some analysis of financial possibilities in relation to this type of aid, especially in the context of the 2009 global financial crisis. They agreed that it was important for the world’s economies to prop up the financial systems of industrialised nations to prevent normal families from falling victim to the lack of credit, but the amount spent on the initial stimulus packages at the beginning of the crisis was beyond what was required. The commission estimated that for $100 billion, far less than what was spent in the stimulus packages in either the US or the United Kingdom (UK), the world’s slums could have been upgraded (Marmot 2009). For one-ninth of what the banks received, every urban citizen of the world could have clean, running water, and every child could have free education (Marmot 2009). This leaves us to ponder the argument that even global institutions such as financial organisations must be based on global social justice and world citizenry, without a return to the open, competitive market system of the past (Mooney & Ataguba 2009).

This view of health is that conveyed in the People’s Health Movement, which has support from 40 countries. Its focus is on a bottom-up mobilisation of action through training, capacity building, documenting health rights violations, and lobbying governments for policy change. It has created the momentum for a global health ethic which would entrench rights, regulations, redistributive justice and a concern with the inequality of persistent poverty.

Health promotion in this context is through global health diplomacy, based on the need for ethical, rights-based, public good, development, and security in the foreign policy of all governments (Labonte 2008). Baum (2009) uses the metaphor of a nutcracker, explaining that grassroots or bottom-up pressure is most effective when combined with top-down policy action to open up the issue for discussion.

Employment is absolutely critical to human rights. Mary Robinson, the former UN Commissioner for Human Rights argues that job creation must be the central objective for private companies as well as governments. This includes respecting core labour standards such as non-discrimination and workplace health and safety, promoting social protection by income security and supporting those who are ill, providing insurance for older persons, and promoting social dialogue between governments, employers and workers (Robinson 2009). Questions to ponder in relation to health promotion in an era of globalisation are listed in Box 3.2.

Epidemiology is the traditional starting point for developing a base of evidence on health and its determinants in specified populations. Epidemiological studies are designed to gather sufficient data to monitor trends and inform planners and policy-makers on ways of improving health (Bezruchka, 2006 and Kawachi, 2002). Until recently, epidemiology has been overly focused on uncovering the causal connections between exposure to risk factors and the development of disease, rather than health and wellbeing.

Epidemiology as a discrete area of study, began with John Snow, an English physician who was concerned with the number of people dying of cholera. He plotted the incidence of deaths in a London neighbourhood, and found an association with the pump supplying the local drinking water by talking with local residents about their daily habits. Although he did not know the causative agent (a bacteria) he understood that the source of the problem was the water supply. He removed the pump handle and the death rate declined. His actions therefore controlled the epidemic.

John Snow had a major influence on epidemiology (www.ph.ucla.edu/epi/snow.html) yet his action-oriented approach, to follow up on epidemiological data is rarely included in accounts of epidemiological studies (Bezruchka 2006). Snow and others investigating the sources of diseases in the 19th century began to draw a connection between poverty and material disadvantage and ill health, which called into question whether dissecting single factors provided a viable base of evidence for intervention (Bezruchka 2006). Single risk factors are easy to measure and there are clear-cut statistical conventions for linking them to specific outcomes. However, the effects of culture, community trust and fairness, and the elements of social capital are more challenging. Yet the evidence base is incomplete without this knowledge, which is a missing link in the global research agenda.

To inform national and international health policies for prevention and control of disease and injury, in 1990, researchers from the Harvard School of Public Health, the World Bank, and the WHO began an epidemiological investigation into the worldwide burden of illness. This is called the global burden of disease (GBD) study (WHO 2005). The goal of the study was to draw on many sources of data to develop internally consistent estimates of incidence, health state prevalence, severity and duration, and mortality for over 130 major causes of disease. The original studies identified the major causes of death, disability and disease for various demographic groups in eight regions of the world (Murray & Lopez 1997a). The findings calculated the burden of disease (Murray & Lopez 1997b). Some 20 years later, the original findings have limited usefulness for health planning at the local level, partly because of the way data were aggregated to show an international picture, and also because of the time delay between collection and dissemination of the information. However, the GBD study has provided a template for calculating where each country fits on an international scale of health, how widespread some diseases are, particularly the lifestyle diseases such as cardiovascular disease and diabetes, and what trends are most likely to occur in the future. What is as yet unknown is how health service planners will use the data to persuade governments to develop population-wide strategies for better health, or to fund protective supports that will help people live healthier lives.