The Group of Eight (G8) countries "account for 48% of the global economy and 49% of global trade, hold four of the United Nations' five permanent Security Council seats, and boast majority shareholder control over the International Monetary Fund and the World Bank." (1) The G8 provide roughly 75% of the world's development assistance; their deep pockets, organizational resources and superior bargaining power provide them with formidable advantages in trade negotiations and dispute-resolution proceedings. The G8 "lacks the two main characteristics of more structured international governmental organizations ...: a constitutive intergovernmental agreement, and a secretariat." (2) Nevertheless, the Group's annual summits and periodic ministerial meetings have emerged as important forums for coordinating social and economic policy. Above and beyond policy and resource commitments, annual G8 summits "have value in establishing new principles in normative directions, in creating and highlighting issue areas and agenda items, and in altering the publicly allowable discourse used." (3)
Social determinants of health, of which health care is only one, are affected by social and economic policy choices made outside the health sector, notably "those central engines in society that generate and distribute power, wealth and risk." (4) Globalization is a key influence on those processes, and major "asymmetries" of power and resources between rich and poor countries characterize the institutions of globalization and the resulting distribution of gains, losses and policy autonomy. (5) In an interconnected world, influences on the social determinants of health cannot be understood in isolation from those asymmetries and the policy choices in which they originate. (6-8) The G8's economic and political power makes it a logical starting point for any such enquiry.
In this article, we articulate an explicitly normative perspective on how the policies of G8 countries affect population health outside their borders. We then examine G8 policies in three areas--development assistance, debt relief and trade policy-that represent major channels of influence on the resources available in developing countries to meet basic health-related needs. Despite promising initiatives, G8 performance has been inadequate when viewed against demonstrated levels of need and against an emerging consensus in the relevant policy communities on how best to meet those needs. Those of us concerned with global health equity must intensify advocacy efforts directed at the G8. To be effective, we must also increase efforts to understand what elements of the domestic political context within G8 countries make some government leaders, and some polities, more receptive to such efforts.
The G8 and global health: why care?
Mainstream perspectives on international relations are sceptical about applying ethical criteria to the actions of national governments, viewing expectations that they will be driven by considerations other than national self-interest as unrealistic. An alternative view is gaining prominence: "Global actors and institutions, whether they act bilaterally (especially direct overseas development assistance, trade agreements) or multilaterally (through, e.g., the United Nations system, World Bank or International Monetary Fund), are obligated to remedy global inequalities that exist in affluence, power, and social, economic and political opportunities". (9) As applied to the G8, at least five arguments for this view can be identified.
First, the G8 themselves are committed to "make globalization work for all [their] citizens and especially the world's poor." (10) At a minimum, this means the G8 are committed to improving the ability of the world's poor, however defined, to meet basic health-related needs.
Second, the international community, as represented by the UN General Assembly, has committed support to achieving the Millennium Development Goals (MDGs) by specified target dates, usually the year 2015. …