For nearly two decades, there has been a positive, dreamy side to globalization. Building on the 1948 founding of the World Health Organization and its stated mission of health for all, the early twenty-first century saw billions of dollars moving yearly from the wealthy world to poorer countries, which financed treatments, medical systems, public health infrastructures, safe water and waste disposal, training and education for millions of health workers, routine vaccination against a raft of microbes, and rapid responses against dangerous outbreaks.

From that dream emerged institutions like the Global Fund to Fight AIDS, Tuberculosis, and Malaria, Global Alliance for Vaccines and Immunization, Roll Back Malaria, Global Health Security Agenda, and thousands of nongovernmental and humanitarian organizations. The Millennium Development Goals, followed by the current Sustainable Development Goals, represented UN targets for raising life expectancies, slashing acute poverty, and improving equity and education worldwide. Public health became one of the top ten aspirations for American college students, and global health drew thousands of idealistic students to graduate schools.

The entire mission relied on globalization, here defined as a recognition of intertwined national interests in open trade, freedom of movement, access to the Internet, shared risks offset by shared benefits, and long-term economic and security improvements in wealthy countries that derive from subsidies and investments in poorer ones.

And much of it actually worked.

In 1970, only a handful of northern European nations, France, and Japan had child mortality rates below 20 deaths by age five per 1,000 live births, and many countries had hideous rates above 400 per 1,000 births—in some African countries half of all children born in 1970 failed to reach their fifth birthdays. In contrast, most children born in 2013 will survive, and even in the poorest central African countries the mortality rate has fallen below 200 per 1,000 births. One of the major reasons children are living longer is global measles vaccination, which has saved the lives of 17.1 million youngsters since 2000. If worldwide contributions to vaccine efforts stay on course, the combined impact of all immunizations from 2011 to 2020 will be 23.3 million lives saved, most of them children under five.

Global mobilizations that have shifted wealth and expertise from rich countries to poorer ones pushed annual malaria death rates down nearly 60 percent, from 839,000 in 2000 to 438,000 in 2015. Since 1990 tuberculosis death tolls have plummeted 47 percent—and an astounding 43 million lives were saved so far in the twenty-first century—thanks to worldwide access to combination antibiotic treatment. At the dawn of the twentieth century childbirth was so dangerous in the United States that about 9 percent of all births were fatal for the mother. Today such tragedies are extremely rare in America and declining all over the world. In 1996, drugs were discovered that could control HIV infection, allowing a person living with the virus to have a normal life expectancy. Thanks to a massive mobilization of billions of dollars yearly, especially from the U.S. government, 36.7 million HIV-positive people were alive in 2016, and annual death rates were cut by half. All over the world life expectancies rose thanks to improved prosperity and global interventions, reaching an average of seventy years by 2012—an enormous jump from the 1950 global average of merely forty-eight years.

So auspicious was the global health venture that by 2007 political leaders of the G7 and OECD were calling for its expansion, to include financial coverage for health for every person on Earth and access to medical services for non-infectious diseases such as cancers, diabetes, and cardiovascular disease. Indeed, debates arose over which ought to be the focus of global dollars: infectious or non-communicable diseases. Aspirations ballooned, as advocates called for the inclusion of mental health services, nutrition, trauma centers, and tertiary care for every person on the planet, from Pretoria to St. Petersburg.

The financial crash of 2008, euro-crisis of 2010, and Chinese currency crash of 2015, coupled with record levels of humanitarian crises, the siege of Aleppo, and refugee movements, brought the dreamy side of globalization to its knees.

Initially, funding for multinational global health efforts remained at 2007 highs, but over time its donor sources concentrated as economically strapped BRICS and European countries dropped out of the efforts. By 2015 most global health program funding had stagnated, and its sources were concentrated to just three donors, including the governments of the United States and United Kingdom and the private Bill & Melinda Gates Foundation. On the humanitarian side the situation was far worse, as funding for food programs and relief fell far short of need. In 2015, a record 65.3 million people were forcibly relocated from their homes, forming the world’s largest movement of refugees and stateless people in known history. Days before Christmas, the UN World Food Program announced it had run out of food and money for 150,000 war refugees stranded in the Central African Republic and would abandon that effort. And in January 2017, the UN Office for the Coordination of Humanitarian Affairs issued a global plea for $22.1 billion to aid 96.2 million people.

Following the 2008 near-collapse of the worldwide economy, wealth shifted within countries over the recession and recovery period, largely at the expense of middle classes. According to the World Bank and Washington Center for Equitable Growth this shift pushed middle class wealth in the United States down from its 1970s status of controlling a quarter of national wealth, to just 12 percent by 2015. In contrast, the richest 1 percent of Americans controlled just over a tenth of U.S. wealth in the 1970s, but by 2015 their share surpassed 22 percent. Similar trends in wealth redistributions were felt across the world.

Anger over job losses and economic pain boiled. Populism and nationalism brewed. And in 2016 the UK voted to withdraw from the European Union, the United States voted in extremely anti-immigrant populists in all branches of government, and much of the world swung into anti-globalization fever.

The challenge facing global health advocates is to salvage the dreams spawned by globalization, while separating the missions from the pain that has arisen from the tremendous inequities it has wrought. This will be tough given all of the institutions key to health are heavily funded by Bill Gates, the richest man in the world, and/or heavily dependent on U.S. foreign assistance, the future of which is uncertain.

As the Institute for Health Metrics and Evaluation at the University of Washington has shown, most poor and middle-income countries have substantially increased their financial contributions to the health of their own over the last two decades, and some, such as South Africa, are striving to achieve full self-reliance. But ensuring that national prosperity translates into strong support for public goods, especially healthcare and public health services, requires citizen demand. A key weakness of the globalization-driven multinational approach to health has been the generation of ideas and missions from the top, often in the absence of consumer demand at the grassroots. As Heidi Larson of the London School of Hygiene and Tropical Medicine has shown, lack of attention to local demand generation has fueled opposition to vaccination campaigns.

Demand for safe drinking water, sewage systems, clean air to breathe, 24/7 obstetric services, immunization, safe food, reliable and affordable medicines, rapid and effective outbreak responses, and full ranges of chronic disease treatment must be generated from average citizens. Pressure must arise not from Geneva or Washington, but from the homes and schools of Soweto and Caracas. The globalized wealthy world must continue to provide financial resources and expertise, but with intent to meet local demand. And as climate change increasingly takes its toll on planetary systems, health leaders must become nimble, able to heed new types of demands from populations facing severe weather, drought, vector-borne diseases, and food shortages.

In January 2017, the World Health Organization issued an historic 700-page tobacco report, demonstrating that 1.1 billion people were smokers, 80 percent of them living in poor and middle-income countries. The net health impact of their tobacco use was estimated to cost the world economy $1 trillion per year—about a sixth of worldwide annual health expenditures ($6.5 trillion). Tackling demand for tobacco, raising taxes on all tobacco products, and putting the burden for cancer and cardiovascular treatment of afflicted smokers on tobacco-exporting nations and national distributors would go a long way toward realizing global health dreams.

Health must be for all. But achieving it with a wagon hitched to globalization will not succeed in a populist world. Disease fights fueled by G7 security concerns, such as HIV and Ebola, will need to find new causes for attention in an increasingly nationalistic era. And assumptions that Americans and other residents of wealthy nations “should” give generously, or owe money to the poorer world, will have to undergo a radical reappraisal in an age of massive wealth redistribution and middle-class exhaustion.

In 1936, the great health writer Paul de Kruif demanded to know why the scientific achievements of the day, chiefly nutrition and disease prevention, hadn’t been applied to all the babies of the planet, rich and poor alike. “When you think that this science is really the right of all humanity, should be owned by humanity, by the living, by all who, half-dead, have a chance for life,” he wrote in Why Keep Them Alive?. “Then what, fundamentally, could be more hopeful? Because, when they understand that all of their own babies can be brought to this strong and beautiful life, the people of the world will at last rise up and ask: Are or are not all of our children really going to live?”

It is time to ask this question again, against a far more sophisticated, spectacular array of scientific discovery. Global health should not be a matter of endless charity, political whim, profiteering, or philanthropic trendiness. Health is a right, which must be demanded from the bottom up, and achieved through the largesse, skills, and commitment of all, sharing and hoping for the future of humanity. Period.
 

Laurie Garrett is a senior fellow for global health at the Council on Foreign Relations. Follow on Twitter @Laurie_Garrett.