Global trade and international trade agreements have transformed the capacity of governments to monitor and to protect public health, to regulate occupational and environmental health conditions and food products, and to ensure affordable access to medications. Proposals under negotiation for the World Trade Organization's General Agreement on Trade in Services (GATS) and the regional Free Trade Area of the Americas (FTAA) agreement cover a wide range of health services, health facilities, clinician licensing, water and sanitation services, and tobacco and alcohol distribution services. Public health professionals and organizations rarely participate in trade negotiations or in resolution of trade disputes. The linkages among global trade, international trade agreements, and public health deserve more attention than they have received to date.

Academics and World Bank officials argue that, by reducing out-of-pocket expenditures, expanded private insurance may improve access to needed health services in less developed countries. In this empirical response, the authors examine this recommendation through observations from their research on privatization of health services in the United States, Argentina, Chile, and Mexico. Privatization, either through conversion of public sector to private sector insurance or by expansion of private insurance through enhanced participation by corporate entrepreneurs, generally has not succeeded in improving access to health services for vulnerable groups. Although the impact of privatization has differed among the Latin American countries studied, expansion of private insurance often has generated additional co-payments, which have increased rather than decreased out-of-pocket expenditures, thereby worsening access to needed services. Privatization usually has improved conditions for private corporations and has led to higher administrative costs. To address the devastating problems of access to services worldwide, we must find ways to enhance the delivery of public sector services and must move beyond conventional wisdom about market-based policies such as privatization.

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In this article we analyze the corporate dominance of health care in the United States and the dynamics that have motivated the international expansion of multinational health care corporations, especially to Latin America. We identify the strategies, actions, and effects of multinational corporations in health care delivery and public health policies. Our methods have included systematic bibliographical research and in-depth interviews in the United States, Mexico, and Brazil. Influenced by public policy makers in the United States, such organizations as the World Bank, International Monetary Fund, and World Trade Organization have advocated policies that encourage reduction and privatization of health care and public health services previously provided in the public sector. Multinational managed care organizations have entered managed care markets in several Latin American countries at the same time as they were withdrawing from managed care activities in Medicaid and Medicare within the United States. Corporate strategies have culminated in a marked expansion of corporations' access to social security and related public sector funds for the support of privatized health services. International financial institutions and multinational corporations have influenced reforms that, while favorable to corporate interests, have worsened access to needed services and have strained the remaining public sector institutions. A theoretical approach to these problems emphasizes the falling rate of profit as an economic motivation of corporate actions, silent reform, and the subordination of polity to economy. Praxis to address these problems involves opposition to policies that enhance corporate interests while reducing public sector services, as well as alternative models that emphasize a strengthened public sector.The process of globalization raises several problems regarding health care and public health. Influenced by public policy makers in the United States, such organizations as the World Bank, International Monetary Fund (IMF), and World Trade Organization (WTO) have advocated policies that encourage reduction and privatization of health care and public health services previously provided in the public sector (Stocker et al. 1999;Iriart et al. 2001; Rao 1999;Turshen 1999; World Health Report 2000). These policies in turn have affected policies of the World Health Organization (WHO), the Pan American Health Organization, and the U. In addition to these non-commercial organizations, multinational corporations based in the United States have expanded worldwide. Managed care organizations, health care consulting firms, and pharmaceutical and medical equipment companies have entered foreign markets. U.S. industrial corporations also have operated in foreign countries; the participation of workers and the promotion of products in those countries have raised concerns about the impacts on local economies, environmental health, and occupational health (Kim et al. 2000). The "flight" of multinational corporations to f...

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Medicine and public health have played important roles in imperialism. With the emergence of the United States as an imperial power in the early twentieth century, interlinkages between imperialism, public health, and health institutions were forged through several key mediating institutions. Philanthropic organizations sought to use public health initiatives to address several challenges faced by expanding capitalist enterprises: labor productivity, safety for investors and managers, and the costs of care. From modest origins, international financial institutions and trade agreements eventually morphed into a massive structure of trade rules that have exerted profound effects on public health and health services worldwide. International health organizations have collaborated with corporate interests to protect commerce and trade. In this article we clarify the connections among these mediating institutions and imperialism.<p class="mrlink"><p class="mrpurchaselink"><a href="http://monthlyreview.org/index/volume-67-number-3" title="Vol. 67, No. 3: July 2015" target="_self">Click here to purchase a PDF version of this article at the <em>Monthly Review</em> website.</a></p>