Globalization is the process through which distant territories and regions develop contacts that create interdependence and connectedness for economic, political, and cultural interests (Beck, 2018). In the context of our society, it is the flow of people, products, information, knowledge, and culture from one country (or continent). According to Lechner & Boli (2020, p4), globalization is not a new phenomenon. Although some scholars argue that it was alive and well in Europe in the 16th century, there is overwhelming evidence that globalization became more popular in the last quarter of the 20th (Rahim et al., 2014). The impact of globalization on health has sparked a hotly contested debate in contemporary society. According to the World Health Organization’s definition, health refers to being physically, psychologically, and socially fit (WHO, 2015). Alternatively, health is attained when essential body functions and processes are at their optimum performance. Presently, Diabetes Mellitus is categorized as a non-communicable disease epidemic (Kharroubi & Darwish, 2015). Diabetes incidences are escalating rapidly, with the latest WHO statistics showing that there are over 450 million cases worldwide. Besides, WHO records show that Diabetes alone kills over 1.5 million people each year.
Moreover, much of the incidences and deaths related to Diabetes are experienced in middle and low-income countries. Diabetes Mellitus consists of types 1 and 2, which are caused by a broad range of factors. According to the American Diabetes Association (2013), type 1 diabetes occurs when the pancreas produces little or no insulin, thus building up sugar in the bloodstream resulting in further complications. Although type 1 diabetes mainly affects children and adolescents, studies indicate that it can emerge at any age and is managed by adopting a healthy lifestyle (Zimmet et al., 2016). T2D occurs due to the underutilization of sugar in the blood, which gradually leads to high blood sugar levels (American Diabetes Association, 2013). In recent years, incidences of type 2 diabetes have increased dramatically, with health statics ranking it the ninth deadliest illness globally. Presently, China has the highest prevalence of T2D cases globally, with more than 10% of its adult population suffering from the condition (Ma, 2018). This paper employs China as a case study to examine the influence of globalization on the increasing incidence and prevalence of T2D globally and the strategies and interventions sought to address the problem.
Agents of globalization contributing to the increased incidences of T2D
- Mass culture
Arguably, much of the debate concerning globalization and health centers on the spread of infectious diseases due to the massive movement and interaction between people from diverse regions (DeLae t& DeLaet, 2020). In the context of T2D, only specific agents of globalization are responsible for the escalating incidences. Firstly, the increased consumption of mass culture has contributed to the increased cases of T2D, especially in low and middle-income countries. According to Abdurashidovich and Botirovich (2020), mass culture refers to beliefs, values, and practices that dominate society for a particular period. Typically, mass culture spreads with the information and the knowledge disseminated through various media like magazines, social media platforms and movies, and television programs. Presently, most developing countries are ardent consumers of western culture, which dictates language, cuisine, education, and national policies. Due to excessive consumption of mass culture, most societies have switched their indigenous nutrition patterns for Western foods and recipes which are perceived as modern and civilized ( Ma, 2018). Unfortunately, most foods glorified and popularized by mass culture contain high fat and lack meaningful nutritional benefits. This situation has seen the rise of obesity and, consequently, T2D cases in many countries. For instance, 23 years ago, T2D incidences in China and the larger Far East were modest and often linked to adults. Due to mass culture and popular food chains, obesity and T2D have become major health threats in the region (Shen et al., 2016). As Ma (2014) points out, most people have ceased consuming a traditional healthy diet in China, opting for a Western diet consisting of refined carbohydrates, low fiber, and high cholesterol content.
- Liberalization and trade
Trade is another aspect of globalization that has perpetuated the increase in the incidences of T2D, especially in emerging economies. Due to liberalization, most countries have exponentially increased their capacity to export and import goods and services to do business, increase wealth and grow their economies. Like during colonialism, developed and developing countries exchange innovation, goods, services, and resources in the international market (Dix-Carneiro & Kovak, 2017). Regardless of whether it is fair or not, free trade has brought about numerous benefits. Firstly, the flow of goods and services from one region to another has created employment for millions of people worldwide and generated vast amounts of revenue for the governments involved.
On the other hand, free trade has increased the availability and access to various goods and services. Moreover, through trade, developing economies have significantly reduced the percentages of their populations living in poverty. For instance, due to liberalization, China has significantly reduced its poverty levels to emerge as the fastest growing economy in the world (Lee& Wong, 2012). Although progress indicates that liberalization works effectively in alleviating poverty, its ramifications on health are dire. Firstly, due to trade, more people in China have a higher purchasing power, which has translated to a shift from agriculture, increased consumption, and diet change, hence the rising incidences of T2D and other nutritional illnesses. Besides, free trade has provided an opportunity for multinational food corporations like KFC, Burger King, and Cocacola to extend their operations into low and middle-income countries (Pan et al., 2012). Although such companies are popular, their main intention is to make more sales, and thus they mostly neglect the nutritional requirements of their clients (Rehman, 2016). Due to poor regulatory policies and corruption in developing countries, most multinational corporations often resort to producing substandard and potentially harmful products in the name of free trade. Combined with cheap imports, the consumption of unhealthy but popular foods and beverages has seen escalating cases of T2D in developing countries.
- Urbanization
Urbanization is the process through which small settlements develop and expand into towns and cities. Throughout history, urbanization has been a result of industrial and infrastructural development (Richie & Hoser, 2018). According to recent statistics, by the year 2050, more than half the world’s population will be living in urban areas. While urbanization is inevitable, there is still a considerable debate concerning its impacts on society and, more importantly, on health. To economists, such predictions inspire hopes of more connectivity and productivity in the industrial sector. To environmentalists, such urbanization will inevitably lead to environmental and biodiversity destruction. According to Bishwajit et al. (2020), the rapid urbanization rate has created challenges that gradually culminate in public health issues. Even with its benefits, it is true that urbanization promotes inequality, especially to people earning inadequate income and living in poverty-stricken neighborhoods. Regardless of economic development, most cities worldwide have a considerable population consisting of homeless families and people living in deplorable conditions. In China, recent statistics indicate that more than 2 million people are homeless, with most of them living in the cities without a formal work permit (He et al., 2020). Although the number is negligible compared to the country’s total population, homeless people are at a greater risk of developing T2D due to malnutrition and other causes (Gong et al., 2012). This situation is more or less the same in other developing countries like India and Bolivia (Hu, 2011, p1250). Observably, such statistics mean that these and other people living in the cities are highly at risk of developing T2D due to a lack of healthy foods and physical exercise. Apart from the poor and homeless, even the working class struggling to survive in the cities is vulnerable to T2D due to working long hours, consuming an unhealthy diet, and lacking time to engage in fitness activities. As we examine the relationship between urbanization and the prevalence of T2D, one might conclude that the wealthy urban populations are less affected by the epidemic.
On the contrary, they are equally and perhaps more at risk of developing T2D due to adopting a sedentary lifestyle and consuming popular but unhealthy foods, beverages, and other harmful products like tobacco. According to recent statistics, 47% of male adults in China are smokers. Combined with a sedentary lifestyle, lack of physical activity, and consumption of less healthy food, it is no wonder why the country has high T2D incidence and prevalence rates (Hu, 2011, p1255).
- Migration
Migration is a fundamental aspect of globalization that started millions of years ago with the movement of the early man from Africa to other parts of the world. Although it is not a new phenomenon, the present rate of cross-border migration is significantly higher than that experienced in the previous decade and century due to the enhancement of transport channels (Hobabagabo et al., 2020). Migration due to globalization involves the movement of people between different regions to seek employment and do business. As stated earlier, such a high migration rate does not necessarily mean that governments have allowed the free movement of people across borders. Even with globalization, a fair portion of the immigrant populations in the world migrate to particular countries without authorization, using fake documentation, or by other dubious channels. Such a renewed interest to migrate to overseas countries has led to the present crisis witnessed throughout the world as people from low and middle-income countries unlawfully attempt to gain entry into developed countries, searching for employment or business opportunities that promise higher income. According to (Shuai & Liu, 2020), China has a considerable number of both legal and illegal immigrants living within different regions in the world. As (Illegal Chinese Migration To Europe ‘Commonplace’ Despite Risks, 2019) reported, numerous human trafficking organizations ship adults and children in and out of China to and from different destinations daily. Most times, human trafficking rings pose as legitimate overseas employment agencies only for victims to later realize that they have been smuggled halfway across the globe to serve as sex slaves, masseurs, manual workers, and other forms of exploitation (Shuai & Liu, 2020). Much worse, some of the victims lose their lives on the journey to overseas destinations. The recent discovery of 39 dead Chinese nationals inside a storage container in the U.K depicts the ordeal that illegal immigrants from China and other emerging economies endure to migrate into developed countries (Illegal Chinese Migration to Europe ‘Commonplace’ Despite Risks, 2019). According to international police reports, an organized crime unit called “snakehead” is responsible for most incidences of human trafficking occurring in East Asia. Ultimately, illegal immigration culminates into increased immigrant populations with no access to healthcare, housing, and a healthy diet, all of which are important in preventing T2D. Besides illegal immigration and human trafficking, globalization has prompted a massive cross-border migration in other dimensions. As developed nations and even emerging economies have increased their trading operations in developing countries, growing countries increasingly export more of their trained professionals to work in the former. This situation has adversely impacted each of the parties involved. For the developing nations, increased migration of workers into developed spells doom for indigenous production and promotes consumption of unhealthy diet, which gradually leads to the development of T2D. For instance, according to Yun et al. (2010), China has many trained healthcare professionals like nurses. Nevertheless, due to increased cross-border migration instigated by globalization, the country’s healthcare faces a severe problem due to the shortage of nurses and escalating turnover due to overburdening of the available HCPs. On the other hand, the influx of immigrants into developed countries places a burden on the healthcare systems and, more importantly, overstretches the available resources leading to poverty, hunger, and diseases, mainly to the immigrant population (Holzman & Munz, 2018).
2. Intervention measures taken by various agencies
Even as an NCD, T2D ranks 9th in the list of the world’s deadliest illnesses. According to the WHO, T2D has contributed to more male deaths than other diseases since the dawn of the new millennium. In consideration of these grim facts, governments, organizations, groups, and even individuals worldwide have embarked on a mission to reduce the prevalence of T2D through prevention, treatment, and management.
- World Health Organization
From a global perspective, the WHO is the most prominent organization in the fight against increasing T2D cases across the globe. As a United Nations agency, the WHO was founded in 1948 as a global public health organization. In partnership with the member states, the WHO guides on critical health issues that require a joint effort. Besides, WHO assists countries in developing and implementing favorable and equitable health policies (WHO, 2016). Moreover, the WHO avails technical assistance and capacity building mechanism to increase efficacy within the healthcare systems of its members. Also, the WHO is involved in research on health, knowledge generation, and information dissemination to improve global health standards. Furthermore, the WHO creates specific health values and standards and supervises their implementation. Lastly, the WHO analyses the global health trends and addresses any emerging issues (CDC, 2020).
The WHO provides member states with prevention guidelines to increase a healthy diet and physical exercise as the primary prevention approaches. Such policies are implemented through the programs like the “Global strategy on diet, physical activity, and health.” Besides, on the 14th of November each year, the WHO sensitizes the public on T2D by observing World Diabetes Day (Roglic, 2016). Again, WHO employs scientific research to develop more practical approaches to diagnosing, treating, and managing T2D (WHO, 2016). Such mechanisms include the WHO module on diagnosis and management of type 2 diabetes. Lastly, the WHO carries extensive diabetes research and publishes reports with profound information on the status, prevalence, and risk factors related to the epidemic. These reports provide information on the overall disease burden, the outcomes of previously applied interventions, and recommendations for countries, organizations, and individuals. For instance, the Global Report on Diabetes (2016) recommends the Chinese government and public health agencies combat the rising cases of T2D by promoting prevention and early detection through increased diagnosis and increase public access to healthcare, affordable healthy diet, and physical fitness facilities (WHO, 2016).
- The International Diabetes Foundation.
Below WHO, transnational nonprofit organizations play a crucial role in reducing T2D prevalence across the world. The International Diabetes Federation (IDF) is among the top independent multinational organizations leading the fight against Diabetes. IDF was formed in 1950, and it consists of over 200 national diabetes organizations drawn from over 100 countries in Africa, Europe, Middle East, South East Asia, Western Pacific, North America, and South America (Atlas, 2015). Through working with WHO, IDF seeks to influence health policies to mitigate TD2. Besides, IDF has an extensive awareness initiative to sensitize the public on the need to adopt healthy lifestyles to reduce the risks of developing T2D.
Moreover, IDF has an open forum in which organizations from diverse regions exchange knowledge and information to curb the prevalence of T2D. Furthermore, IDF directly educates communities, diabetes patients, and healthcare providers on the most practical and recommended ways of managing the condition. Lastly, IDF publishes annual reports that show the prevalence of T2D and the outcomes of the interventions employed within the regions in which it operates. For instance, according to the IDF report of 2019, more than 110 million people in China (10% of the total population) live with TD2. Besides, the report establishes that most TD2 patients are more likely to develop complications like kidney failure, stroke, and heart attack (Cho et al., 2018).
- National health agencies
At the national level, governments worldwide employ various mechanisms to promote health and wellness standards in their populations. The complexity and efficacy of national health agencies rely mainly on the degree of economic and industrial development of a particular country. The ministry of health of the People’s Republic of China (PRC) was created in 1949. Primarily, it consists of 16 specialized departments like maternal health and child care, public health policy, community health, medical administration, research and disease prevention, planning and finance, technology and education, etc. Besides, the ministry of health collaborates with various public health institutions, healthcare facilities, and research organizations. These include the Beijing Hospital, the Chinese Center for Disease Control and Prevention (CDC), and the Peking Union Medical College. The ministry of health (PRC) is responsible for formulating and implementing national health policies, coordinating and spearheading health programs, engage governmental and non-governmental stakeholders in creating and executing health programs, and supervise disease prevention and management interventions (WHO,2021). Besides, the ministry assists regional and local governments and any other actor in responding and mitigating emergency health issues like epidemics. Lastly, the ministry partners with other stakeholders to promote quality healthcare by integrating specific aspects of traditional Chinese and Western medicine (WHO 2021). Considering the rapid increase of T2D cases in China, the ministry of health embarked on several projects to alleviate the crisis. Through the Healthy 2030 plan, the ministry initiated a nationwide program to diagnose and treat T2D patients and increase awareness of lifestyle change. Besides, since 2010, the ministry has partnered with local and transnational agencies like CDC in researching the National Diabetes Audit (NDA) program (Yin et al., 2016). Furthermore, the ministry has created provincial frameworks to enhance self-management and peer support for patients living with T2D in rural areas. Lastly, the National Metabolic Disease Management Center has unveiled a complex data system for analyzing vast medical examinations to assist in the prevention, detection, and management of T2D cases.
- Healthcare providers (HCPs) and other actors
Below the national perspective, countless individuals work in the public and private sectors to address critical health issues like T2D. Although these individuals are often overlooked compared to national, transnational, and global agencies, their efforts are much more impactful since they relate directly with the population. In every healthcare facility, healthcare professionals HCPs who carry out diagnoses provide care and help T2D patients manage their condition. Besides, healthcare professionals educate and train families and communities as a prevention strategy against T2D. In China, primary healthcare workers are the most reliable option for T2D patients. These consist of diabetologists, nurses, and other healthcare professionals practicing in diverse healthcare settings. Moreover, most clinical teams in rural areas have a peer supporter who helps patients in managing their T2D by regularly checking their blood pressure, blood sugar levels and ensuring that they are emotionally stable and happy to avoid the risk of developing more complications due to loneliness, stress, and depression (Deng et al., 2016)
3. Challenges encountered in the interventions to mitigate the increasing T2D cases
Regardless of the interventions made so far, the rising cases of T2D throughout the world indicate that there are underlying issues that limit the effectiveness of the intervention measures taken. Despite being a well-organized global health agency, the WHO encounters numerous challenges in the fight against T2D and other NCDs. Firstly the spread of infectious diseases somehow derails the efforts in eradicating seemingly harmless NCDs like T2D and Obesity. For instance, in 2020, much of the WHOs resources allocated to China and other countries were depleted in a bid to control the spread of the ravaging COVID-19 pandemic (Xu et al., 2020). Much less, it is critical to note that other illnesses like HIV/AIDS and Tuberculosis also claim thousands of lives every year. Given this situation, the WHO faces a crisis in prioritizing T2D prevention and management since other health issues require urgent solutions. Besides the chaos stemming from having to deal with multiple health crises, international organizations also encounter problems in promoting health due to politics and tensions between countries. In recent years, more and more countries are embroiled in issues that, most of the time, escalate into armed interstate conflicts. Such trends of aggression are why there are many ongoing civil wars worldwide and increasing political and economic tiffs between countries. Although China has been peaceful for many years, President Xi Jinping’s agenda to restore the country’s lost glory has led to tensions with her neighbors and powerful countries like the United States (China’s Current Problems and Prospects | Middle East Policy Council, n.d.). Although the WHO is a nonpartisan organization of the U.N, the increasingly severed relations between China and other global powers could eventually limit the WHOs capacity to combat the rising incidences of T2D in the country. Combined with allegations that China deceived the WHO about the COVID-19 situation in 2020 before the outbreak of the pandemic, China could lack international support against her increasing health issues in the future (Gilsinan, 2020)
Like WHO, transnational organizations like IDF face similar challenges in addressing T2D. Firstly, due to differences in leadership, politics, and national ideologies, multinational organizations experience problems developing uniform solutions and policy recommendations for different countries. For instance, if IDF recommends partner organizations to influence policies opposed to the consumption of animal proteins, there should be broad consultation since animal protein consumption varies according to different regions. Besides, multinational diabetes organizations experience problems due to disengagement with critical stakeholders like national health agencies. Regardless of how international organizations provide resources to promote health, they lack the authority to implement and enforce policies. In this state of affairs, if national health agencies fail in implementation, the whole effort to reduce T2D goes to waste. For instance, as per the WHO Tobacco policy, IDF has restated the need to curb tobacco consumption as one of the prominent T2D risk factors.
Nonetheless, the Chinese government is yet to employ any meaningful strategies to curb smoking. Currently, almost 50% of the adult male population in China smokes cigarettes. Unfortunately, most people in this group are young adults at a higher risk of developing Diabetes and T2D due to eating sugary foods and consuming alcohol (Yu & Baade, 2018). Although studies establish that China has incredibly fewer female smokers (1%), they may also increase due to the rapid cultural changes instigated by globalization and cigarette manufacturers explore more markets (Koplan & Eriksen, 2015). Notably, China’s failure to regulate tobacco consumption and the importation of unhealthy food and beverage is one of the main reasons why the country is yet to win the war against T2D and obesity.
Like the preceding agencies, healthcare professionals face many problems in their effort to prevent and manage T2D. However, such challenges resonate with a particular country’s economic state and the general national health policies. Typically, HCPs in low and middle-income countries encounter more issues due to lack of resources, inadequate knowledge and skills required to address the illness, a negligent patient population, and staff shortage. As much as China has made efforts (even with assistance from the international community) to curb the escalating T2D, most of the challenges are within the healthcare practice. According to Yin et al. (2016), China has considerably fewer HCPs than required to address the T2D crisis. Such shortages are stemming from the exact causes of the illness-globalization. As China exports more of its HCPs to other countries, fewer nurses, doctors, and other professionals are left to manage many patients.
Another problem is that most HCPs operating in ill-equipped rural healthcare facilities lack academic and professional qualifications. This situation has created mistrust within the public, and thus, most patients prefer big and reputable hospitals in the city, thus overburdening the HCPs working in urban healthcare facilities (Zhen et al., 2019). Furthermore, studies indicate that most people in China neglect regular health check-ups that could prevent T2D. Much more surprising, even those under treatment show less concern in managing their blood sugar levels. Again, access to healthcare is a challenge to most people since a considerable portion of the population is uninsured. Lastly, most T2D patients in rural provinces lack knowledge on the illness and self-management strategies which has led many people to revert to unreliable treatment approaches, posing a greater risk to their conditions (Deng et al., 2016). With these challenges, it is evident that the battle against T2D may last longer than expected.
Conclusion
Using China as a case study, this paper examined the implication of globalization on the prevalence of T2D, the interventions applied and the challenges encountered within various dimensions. Firstly, mass culture has led to a nutrition transition characterized by excessive consumption of foods associated with the popular Western culture. On the other hand, free trade has led to the extinction of traditional diets due to flooding food markets with cheaply imported, less nutritional food sources. Besides, urbanization has the emergence of a sedentary lifestyle and less physical activity. More importantly, urbanization has forced a considerable global population to rely on refined and processed foods that increase the risk of T2D. Lastly, migration has had adverse impacts on healthcare systems and other mechanisms useful in the fight against the T2D epidemic. In response to the crisis, international, transnational, national, and local agencies have intervened to prevent and manage T2D through diverse approaches. Nonetheless, such efforts have attained dismal results due to poor policy enforcement, lack of coordination between stakeholders, lack of monumental leadership, lack of resources, and political instability. Given the situation, developing countries are in a worse position because they are experiencing numerous problems and lack an independent economic capacity to fight against T2D.
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