Globalization and health policy space: Introducing the WTOhealth dataset of trade challenges to national health regulations at World Trade Organization, 1995–2016

Brexit, trade and the governance of non-communicable diseases: a research agenda

BACKGROUND

The UK's post-Brexit trade strategy has potentially important implications for population health and equity. In particular, it will impact on the structural risk factors for non-communicable diseases (NCDs), including the consumption of health-harming commodities such as tobacco, alcohol and ultra-processed food and beverages. This article catalogues recent developments in UK trade policy. It then presents a narrative review of the existing research literature on trade and health and previous, prospective studies on the health impacts of Brexit. In so doing it identifies key questions and foci for a future research agenda on the implications of UK's emerging trade regime for NCD prevention.

MAIN TEXT

We identify five key areas for future research. (1) Additional scholarship to document the health effects of key trade agreements negotiated by the UK government; (2) The implications of these agreements for policy-making to address health impacts, including the potential for legal challenges under dispute settlement mechanisms; (3) The strategic objectives being pursued by the UK government and the extent to which they support or undermine public health; (4) The process of trade policy-making, its openness to public health interests and actors and the impact of the political and ideological legacy of Brexit on outcomes; (5) The impact of the UK's post-Brexit trade policy on partner countries and blocs and their cumulative impact on the global trade regime.

CONCLUSIONS

Further research is urgently need to understand the ways in which the UK's post-Brexit trade strategy will impact on NCDs and policy responses to address these, including the openness of the trade policy architecture to health issues. The outcomes of this process will have wider systemic effects on the global trade regime with implications for health. Researchers must be cognizant of the ideological components of the policy debate which have been absent from previous analysis of Brexit, trade and health.

Public health advocacy strategies to influence policy agendas: lessons from a narrative review of success in trade policy

BACKGROUND

Despite accumulating evidence of the implications of trade policy for public health, trade and health sectors continue to operate largely in silos. Numerous barriers to advancing health have been identified, including the dominance of a neoliberal paradigm, powerful private sector interests, and constraints associated with policymaking processes. Scholars and policy actors have recommended improved governance practices for trade policy, including: greater transparency and accountability; intersectoral collaboration; the use of health impact assessments; South-South networking; and mechanisms for civil society participation. These policy prescriptions have been generated from specific cases, such as the World Trade Organization's Doha Declaration on TRIPS and Public Health or specific instances of trade-related policymaking at the national level. There has not yet been a comprehensive analysis of what enables the elevation of health goals on trade policy agendas. This narrative review seeks to address this gap by collating and analysing known studies across different levels of policymaking and different health issues.

RESULTS

Sixty-five studies met the inclusion criteria and were included in the review. Health issues that received attention on trade policy agendas included: access to medicines, food nutrition and food security, tobacco control, non-communicable diseases, access to knowledge, and asbestos harm. This has occurred in instances of domestic and regional policymaking, and in bilateral, regional and global trade negotiations, as well as in trade disputes and challenges. We identified four enabling conditions for elevation of health in trade-related policymaking: favourable media attention; leadership by trade and health ministers; public support; and political party support. We identified six strategies successfully used by advocates to influence these conditions: using and translating multiple forms of evidence, acting in coalitions, strategic framing, leveraging exogenous factors, legal strategy, and shifting forums.

CONCLUSION

The analysis demonstrates that while technical evidence is important, political strategy is necessary for elevating health on trade agendas. The analysis provides lessons that can be explored in the wider commercial determinants of health where economic and health interests often collide.

Engaging with the Private Sector for Noncommunicable Disease Prevention and Control: Is it Possible to Create "Shared Value?"

Noncommunicable diseases (NCDs) are the leading cause of premature mortality worldwide. Corporate interests are sometimes well-aligned with public health, but profiteering from the consumption of products that are known to be the major contributors to the noncommunicable disease burden undermines public health. This paper describes the key industry actors shaping the NCD landscape; highlights the unhealthy commodities' impact on health and the growing burden of NCDs; and outlines challenges and opportunities to reduce exposure to those risk factors. Corporations deploy a wide array of strategies to maximize profits at the expense of health, including sophisticated marketing techniques, interference in the policy-making process, opposition and distortion of research and evidence, and whitewashing of health-harming activities through corporate social responsibility initiatives. There can be no shared value for industries that sell goods that harm health irrespective of consumption patterns (such as tobacco and likely alcohol), so government actions such as regulation and legislation are the only viable policy instruments. Where shared value is possible (for example, with the food industry), industry engagement can potentially realign corporate interests with the public health interest for mutual benefit. Deliberate, careful, and nuanced approaches to engagement are required.

Global Health Equity Requires Global Equity

Many global health challenges are characterized by the inequitable patterning of their health and economic consequences, which are etched along the lines of pre-existing inequalities in resources, power, and opportunity. These links require us to reconsider how we define global health equity, and what we consider as most consequential in its pursuit. In this article, we discuss the extent to which improving underlying global equity is an essential prerequisite to global health equity. We conclude that if we are to improve global health equity, there is a need to focus more on foundational—rather than proximal—causes of ill health and propose ways in which this can be achieved.

Changes in apparent consumption of staple food in Mexico associated with the gradual implementation of the NAFTA

In 1994, the United States, Canada, and Mexico signed the North American Free Trade Agreement (NAFTA) to remove trade barriers and facilitate cross-border trade in goods and services. Worldwide, trade agreements, urbanization and economic development have shaped significant changes in dietary habits. This study aims to evaluate the association between the gradual implementation of NAFTA and changes in apparent consumption of staple foods in Mexico. We analyzed national apparent consumption of animal- and vegetable-source foods, using data from the Food and Agriculture Organization of the United Nations (FAO) from 1970 to 2018. Association between NAFTA and apparent consumption was estimated using interrupted time series analysis (ITSA) with synthetic controls and included two inflection points based on the implementation of NAFTA: 1994, when the agreement began, and 2008 when it was fully implemented. As a result, comparing Mexico with the synthetic control, we found a significant decrease in apparent consumption of pulses, -3.22 and -1.92 kcal/capita/day in the post-1994 and post-2008 periods, respectively. The vegetable-source foods showed an increase of 5.79 kcal/capita/day after 2008. The trends of apparent consumption of animal-source foods, eggs, and milk had significant increases after 1994 and 2008. The apparent consumption of meat increased only after 2008. The implementation of NAFTA was associated with an increase in apparent consumption of food from animal-source and a decrease in consumption of pulses. After 2008, an increase in apparent consumption of vegetable-source foods was observed.

Do international trade and investment agreements generate regulatory chill in public health policymaking? A case study of nutrition and alcohol policy in South Africa

BACKGROUND

Trade and health scholars have raised concern that international trade and particularly investment disputes may be used by transnational health harmful commodity corporations (THCCs) to effectively generate public health regulatory chill. The purpose of this study was to contribute to the limited evidence base of trade or investment dispute-related regulatory chill using a case study of nutrition and alcohol policy in South Africa.

METHODS

We conducted 35 semi-structured interviews with 36 key stakeholders involved in nutrition, alcohol and/or trade/investment policymaking in South Africa. Interview transcripts were analyzed using thematic analysis. We used Schram et al's theory on three forms of regulatory chill (anticipatory, response and precedential) to guide the analysis. We report evidence on each form of regulatory chill as well as specific contextual factors that may influence the risk of regulatory chill.

RESULTS

Trade obligations were found to generate a significantly greater anticipatory-type chilling effect on nutrition and alcohol regulation than South Africa's investment treaty obligations. Response chill was reported to have occurred in relation to South Africa's proposed tobacco plain packaging regulation while awaiting the outcome of both Australia's investor-state and WTO state-state disputes. No cases were reported of THCCs threatening an investor-state dispute over nutrition or food regulations, but there were reported cases of THCCs using arguments related to South Africa's trade obligations to oppose policy action in these areas. No evidence of nutrition or alcohol policy precedential chill were identified. Factors affecting the risk of policy chill include legitimacy and perceived bias of the dispute system, costs involved in pursuing a regulation/defending a dispute and capacity to pay, social acceptability of the industry, a product's perceived risk to health and confidence in a successful dispute outcome e.g. through cross-border policy learning.

CONCLUSIONS

Our findings indicate that currently, South Africa's trade obligations have a more prominent role in inhibiting nutrition and alcohol action than investment treaty-related concerns. However, given the potential for wider use of the ISDS mechanism by THCCs in the future, strategies to protect public health policy space in the context of both international trade and investment treaty and dispute settlement contexts remain important.