1.1 Overview of the Relationship Between Trade and Health
Trade, or the barter and exchange of goods between people, is as old as human societies. Once a practice between neighbours and adjoining communities, trade expanded over the centuries with the rise and reach of empires, the creation of nations and the development of new technologies. Advances in marine engineering saw Asian and European sailing fleets replace the Silk Road footpaths of Marco Polo. Industrialisation, trains, planes and trucks increased trade’s pace with more recent digital innovations creating wholly new venues for international commerce.
Trade brings with it the promise of prosperity and improved living standards, both of which can, directly and indirectly, benefit health. There is nothing inherent in such a relationship, however, and trade between nations has been marked as much by impoverishing exploitation as by enabling exchange. At the same time that Adam Smith was making the economic case for open markets and free trade in his classic text, ‘The Wealth of Nations’ [1], Britain’s rise to imperial dominance was based, in part, on its African slave trade and the expropriation of the wealth and resources of its occupied colonies. Disease, too, has long accompanied trade routes, from the Black Death of medieval times carried by stowaway rats on merchant ships to more recent pandemic waves of cholera that were swept along by maritime shipping to the post-millennial global diffusion of unhealthy commodities contributing to a worldwide rise in non-communicable diseases (NCDs).
Simply put, the relationship between trade and health has always been ambivalent, bringing both health opportunities and disease risks. Understanding this relationship to ensure the protection and promotion of public health has become more complex over the past half-century, as nations began creating international rules intended to govern an anarchic global economy that had proved as prone to conflict as to cooperation.
1.2 Purpose and Intended Audience of the Book
This short text is a primer on the complex web of modern trade and investment treaties that began with the birth of the World Trade Organization (WTO) in 1995 and which continued with the subsequent proliferation of bilateral and regional trade agreements. This book is intended for public health policy makers, researchers and advocates and focuses on specific trade agreements and how their provisions (trade rules) can affect the regulatory policy space for health, environmental and social protection. Trade has long existed, and much of it continues, outside of the formal rules in modern trade agreements; but increasingly these rules with their enforcement measures deepen and entrench the liberalisation principles that undergird all such agreements.
1.3 Structure and Content of the Book
In Chap. 2 we review the post-World War II expansion of trade liberalisation negotiations that led to the creation of the WTO. We describe key WTO principles and agreements and how these might impact health, and the WTO’s innovative dispute settlement process, providing several case examples. We then identify several new ‘WTO-Plus’ regional agreements, before concluding with a discussion of controversial investor-state dispute settlement rules. Chapter 3 begins to drill down into how trade rules affect specific health measures and outcomes, focusing on health services and on the effects of provisions protecting intellectual property rights (IPRs) on access to medicines, vaccines and medical devices. The role of IPRs, and their continual strengthening, in trade treaties, on access to affordable medicines continues to dominate public health concerns with trade policy. In Chap. 4 we describe how this focus has broadened in recent years to concerns with how trade and investment liberalisation treaties are increasing the global diffusion of ‘unhealthy commodities’ (tobacco, alcohol and ultra-processed foods) and how certain treaty rules are making it more challenging for governments to introduce measures aimed at reducing their consumption or minimising their health risks. We describe how public health policy makers might design new measures to avoid the risk of a trade challenge and introduce the concept of ‘policy coherence’, in this instance with respect to ensuring that trade rules do not conflict with national or intergovernmental commitments to reduce the prevalence of NCDs associated with consumption of unhealthy commodities.
Chapter 5 examines the recent trend in trade agreements to include chapters concerning labour rights and environmental protection measures. These chapters require governments that are ‘party’ to the agreement to respect their obligations under labour rights or environmental treaties but only become enforceable if a party lowers its existing standards specifically to gain a trade or investment advantage. Whether trade agreements are the appropriate place to improve or enforce labour or environmental standards remains a moot issue. Trade agreements do not simply arise ex nihilo but are the products of often intense and lengthy intergovernmental negotiations. Chapter 6 describes the negotiation processes, drawing on policy theory and using examples from public health engagements with, or post-hoc studies of, trade policy agenda-setting. Space for improving health issues within trade agenda-setting and negotiation processes exists, but at present, there remain concerns with the lack of transparency in trade negotiations and the excess influence of private economic interests over that of public health protection.
In Chap. 7 we discuss the strengths and limitations of the different research methods used to interrogate trade-related impacts on different health outcomes, the evidence from which public health relies upon in advocating for healthier trade policy. What healthier trade or investment policies should look like is the topic of the final Chap. 8, in which we identify different reform measures that should be incorporated in future agreements, as well as changes in the trade policy-making process to ensure that the resulting agreements reflect a judicious balancing between economic interests and health and broader public good protection. The importance of seeking to improve ‘policy coherence’ (or at least to reduce policy incoherence) between trade and other health, environmental and social development goals is evidenced in the 2030 Agenda for Sustainable Development, adopted by United Nations General Assembly in 2015 [2]. Goal 17 specifies, on the one hand, that countries ‘promote a universal, rules-based, open, non-discriminatory and equitable multilateral trading system under the World Trade Organization’ (17.10) (which calls into some question the use of bilateral or regional WTO-Plus negotiations in which many countries now participate); while on the other underscores the importance of ‘enhanc[ing] policy coherence for sustainable development’ (17.14) and ‘respect[ing] each country’s policy space and leadership to establish and implement policies for poverty eradication and sustainable development’(17.15) [3].
1.4 Overall Approach and Disciplinary Basis
Throughout this book, we have endeavoured to present a balanced representation of the trade and investment treaty environment. Our concern is foremost with protection of public health and its many social and environmental determinants. We recognise that governments invariably have multiple and often competing policy goals and that perfect policy coherence is never possible. Trade-offs are inevitable. Our analyses draw from disciplines ranging across epidemiology (e.g. what is the relationship between trade flows and population health?), sociology (e.g. how do power relations affect trade policy making?), political science (e.g. what are the arguments for or against trade liberalisation?), economics (what are the benefits or costs associated with trade liberalisation and who benefits most?) and law (what are the known or likely impacts of specific trade treaty rules on government regulatory policy space?). As such, it provides a ‘top-level’ interrogation of trade, trade treaties and health, sufficiently detailed to enable public health practitioners and policy makers to engage more knowledgeably with colleagues in the trade portfolios. We caution, however, that persons wanting a more in-depth understanding should avail themselves of some of our cited references, the useful online materials and archives of the World Trade Organization and the growing number of trade/health scholars and researchers within the universities worldwide. Our ‘take-home’ message is that too little attention has been given to known or potential health risks associated with trade and particularly trade that is governed by complex modern trade rules. Strengthening the capacity of public health actors to engage more effectively in trade policy-making and negotiating processes remains our acknowledged intent in producing this introductory text.
References
- 1.Smith A. An inquiry into the nature and causes of the wealth of nations. London: Strahan & Cadell; 1776. p. 1146.
- 2.United Nations General Assembly. Resolution adopted by the General Assembly on 25 September 2015: transforming our world: the 2030 agenda for sustainable development. A/RES/70/1 [Internet]. 2015, 21 October [cited 2019, May 27]. https://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E.
- 3.United Nations Sustainable Development Goals. Goal 17: revitalize the global partnership for sustainable development [Internet]. United Nations; n.d. [cited 2019, May 27]. https://www.un.org/sustainabledevelopment/globalpartnerships/.