Trade, investment and public health: compiling the evidence, assembling the arguments

Abstract

Trade has long been an axiomatic characteristic of globalization, although international rules governing trade are of more recent vintage. Notably in the post-World War II period, an ever increasing number of countries began negotiating treaties to reduce, first, tariff barriers and, later, non-tariff barriers (government measures of any sort) that could impede the cross-border flow of goods. The rationale, in part, was that countries that became more entwined economically would be less likely to go to war with each other. It wouldn’t be in their own economic interests to do so, or at least that of the firms based within their borders but engaged in transnational trade and dependent upon global supply chains. At first primarily an undertaking of developed (high-income) countries, developing (low and middle-income countries) slowly enjoined in what, in 1995, became the World Trade Organization. The WTO locked in scheduled declines in tariffs (border taxes), albeit with lesser obligations on developing country members (a problematic nomenclature given the vast geographic, economic, and development differences between such countries, but which nonetheless persists within the WTO). Importantly, a slew of new agreements that coincided with the establishment of the WTO also sought to liberalize trade in services (not just goods) (The General Agreement on Trade in Services), create new rules for agricultural trade (Agreement on Agriculture), expand intellectual property rights protections (The Agreement on Trade-Related Aspects of Intellectual Property Rights), limit trade-distorting government subsidies (Agreement on Subsidies and Countervailing Measures), and ensure that government food, health, or environmental regulations would not pose an unnecessary barrier to trade (the Technical Barriers to Trade and the Sanitary and Phytosanitary Measures Agreements). Outside of the WTO system, bilateral or regional investment treaties granting special rights to foreign investors to sue governments for actions perceived to affect the value of their investment (such as direct expropriation or passage of new laws and regulations considered ‘tantamount to expropriation’) similarly exploded in number, dispute frequency, and the size of monetary claims. The breadth and depth of these post-1995 Agreements meant that few areas of general public health concern are potentially untouched.

An Exploration of the Role of Sugar-Sweetened Beverage in Promoting Obesity and Health Disparities

“…Targeted marketing of SSB and other unhealthy foods to people of color and low socioeconomic status takes advantage of their more limited options for healthy food choices and their need for product affordability, while ignoring their greater risk for obesity and obesity-related diseases. Therefore, in response to question 4, we echo others [ 120 ••, 121 , 122 ••, 123 – 127 , 128 ••, 129 , 130 • 131 – 133 , 134 ••, 135 , 136 •, 137 – 149 , 150 •, 151 – 153 , 155 ••] in suggesting that proactive environmental measures to decrease exposure to palatable food cues, particularly in the form of targeted marketing to our vulnerable populations, is a necessary strategy for slowing the obesity epidemic.…”

“…Compared with middle-income neighborhoods and White neighborhoods, low-income as well as Black and Hispanic neighborhoods are less likely to have access to large supermarkets offering high-quality affordable foods [ 23 , 24 ]. A recent study examining the effect of SSB affordability on consumers’ purchasing behavior and weight-related health outcomes found that SSB affordability is a major influence of purchasing behavior and is significantly associated with the prevalence of both overweight and obesity [ 150 •].…”

Harnessing trade and investment agreements to promote public health

“…Although flexibilities within trade rules could allow carefully crafted public health regulations to minimise the risk of a potential challenge, whether trade rules should place such a burden on governments remains a question of political economy [55]. Creating stronger and more legally defensible general health exceptions within FTAs and IIAs is an important public health target and should be of the highest priority.…”

Health equity and health system strengthening – Time for a WHO re-think

“…And yet, the blanket assumption that UHC programmes will lead to more equity is highly contested. First, as others have pointed out, truly universal healthcare access remains an elusive goal: even in countries purported to already have 'universal' healthcare systems, specific services (such as expensive treatments for cancer) tend to be excluded and certain groups (such as refugees) systematically disadvantaged (Birn & Nervi, 2019). And since UHC is typically conceived in terms of coverage with a circumscribed range of services, many healthcare services are likely to remain inaccessible for poorer population (Giovanella et al, 2019).…”

“…In recent years, both the strengthening of health systems and the achievement of equity have become increasingly tethered to the over-arching goal of UHC (Astana Declaration, 2018). And yet, many critics point to this prioritisation of UHC as a reflection of the abandonment of a more ambitious social justice agenda that treats the achievement of health and health equity as preconditioned on addressing the wider social, economic and political inequalities that fuel it (Birn & Nervi, 2019;Giovanella et al, 2019;Sanders et al, 2019). It is to this discussion we hope to contribute by broadening the equity lens as it may apply to health system strengthening and providing some new avenues of linking equity to global health practice.…”