If we go back to the basics of epidemiology, it is abundantly clear that patterns of disease are converging globally, with NCDs emerging as the major threat to population health worldwide. Other threats of course remain – indeed low- and middle-income countries must now grapple with a potentially debilitating double burden of disease – but NCDs are ubiquitous. Tobacco smoking, alcohol consumption, unhealthy diet, physical inactivity and obesity are pervasive as risk factors globally. Last week’s launch of the Global Burden of Disease study confirmed this.
While it is clear in many cases that lifestyle behaviours associated with these risk factors are the immediate causes of disease, it is also clear that other underlying factors (or actors) must be driving this rapid convergence in behaviour and patterns of consumption. These changes have resulted in unprecedented levels of NCDs. Governments are indeed looking for solutions, but not always in the right place.
In this light, let’s explore the principle of ‘first, do no harm’, and examine it from a specifically global perspective – trade and globalisation.
The production line of (ill-) health
As many are aware, NCDs are largely preventable. In fact, the biggest opportunity (and challenge) is to reduce the contribution of risk factors such as tobacco smoking, alcohol consumption, unhealthy diet and physical inactivity to the rising burden of disease. In order to make meaningful progress in tackling NCDs, we need action that goes to the core of these risk factors by addressing supply-side factors and the environmental determinants. These are the push factors that drive trends towards increased consumption.
But what are supply-side factors and environmental determinants?
When we talk about supply-side factors and environmental determinants we immediately think about what is being produced (in what context and with which incentives); what is available; how much it costs; and, how it is marketed. An important factor in the obesity epidemic, for example, has been the availability, affordability and promotion of fast food, and the incentives along the food supply chain for its production and sale.
When faced with serious health challenges, government has a clear role to play in using these lever points for public benefit. But, as we will see, a government’s ability to take action to address this is sometimes limited by existing commitments to international trade.
Tobacco control policies are the most advanced in this field, and primarily aim to reduce demand by changing the environmental push factors. The Framework Convention on Tobacco Control (FCTC), the first and only global health treaty, sets out specific steps for governments to use taxation and pricing to reduce consumption; ban tobacco advertising, promotion and sponsorship; create smoke-free work and public spaces; use prominent health warnings on tobacco packages; and, curb illicit trade in tobacco products. This model has been hugely successful at empowering government and controlling the activity of tobacco corporations. Health advocates often look to the tobacco example to inspire policy action in other areas, including alcohol and food.
Trade, Globalisation and Health
Despite the many successes in tobacco control, it’s been far from plain sailing to this point. Since negotiations on the FCTC first opened, 63 million people (and counting) have died from tobacco-related diseases. Yet governments wishing to take regulatory action to tackle tobacco smoking still face an increasingly bitter fight from ‘Big Tobacco’ to protect their own interests. There has also been aggressive expansion to target new markets (women in established markets; new smokers in emerging low- and middle-income economies).
A recent high-profile example of this struggle against ‘Big Tobacco’ has been the introduction of plain packaging for cigarettes in Australia.
Congratulations to the Australian Government, who successfully defended their policy in the domestic courts. This was in spite of complaints from tobacco companies, working in unison, that the plain packaging infringed upon their brand ownership (intellectual property rights) and undermined trade investments. This month Australia rolled out its policy across the country, in a bid to further restrict the marketing activities of tobacco companies.
However, there are a number of international legal challenges that remain. These have been brought against the government by the tobacco industry, seeking new avenues to block regulatory action. As they lose clout with national governments, these companies increasingly tries to circumvent national policy through international trade law.
This new global dimension to public health policy reflects the structural dynamics that underpin both the supply side and the environmental determinants that affect demand – namely global integration of investment, trade and communication. Globalisation, to use a broader but more widely recognised term, has completely reshaped the policy playing field. The overhaul of the economic model, including trade liberalisation, has driven changes in the supply and promotion of consumer goods, with the emergence of transnational companies, retailers, foreign direct investment and global advertising. Global factors now stand right up there alongside national context in influencing the consumer environment.
But what does this new global playing field mean for health?
The World Trade Organization supervises the strict implementation of rules affecting global trade and commerce (chiefly international trade agreements), and provides a forum for complaints against countries considered to be ‘flouting the rules’.
One such legal challenge facing Australia over its bid to implement plain packaging comes via Ukraine, Honduras and the Dominican Republic (but financed significantly by the tobacco industry). The threat of such cases is a major disincentive for low- and middle-income countries looking to take policy action, as the legal costs to challenge such complaints can be astrononmical.
Another international legal challenge comes in the form of an investor-state dispute, whereby complaints can be made against a country deemed to be in contravention of bilateral trade agreements. Phillip Morris Asia claims that Australia is violating the terms of a 1993 trade pact between Hong Kong and Australia. In effect, they are seeking to block plain packaging as they frame it as a threat to trade.
The Australian government has since stated that, in addition to fighting this challenge, it will no longer support provisions in bilateral trade agreements that constrain its ability to implement national laws on social, environmental or economic matters. A clear sign that governments have concerns over the interplay between health policy and trade.
Other countries have faced down challenges and threats to national health policies from international trade agreements, including Norway when it introduced bans of retail display of cigarettes, and Denmark whose ban on trans fats in foods was scrutinised by the European Commission. The Scottish Government is currently awaiting an opinion from the European Commission as to whether its proposed policy on minimum unit pricing for alcohol contravenes EU trade rules.
Lessons for future health policy
The fact that a policy arena for NCDs is now operating at the global level means that policy-makers must consider the challenge of global trade when formulating national policy, but it also indicates that globalisation may be a significant factor (or amplifier) in the emergence and spread of the global NCD epidemic.
An expanding body of work suggests that the rate of increase in consumption of ‘unhealthy commodities’ (soft drinks, processed foods, tobacco and alcohol) is fastest in low- and middle-income countries, and that multinational companies have now penetrated these markets at similar levels to those seen in high-income countries.
Foreign-direct investment and free trade agreements are understood to be key factors behind this emerging trend, and that the heralded economic benefits of free trade are compromised by unexpected negative externalities (e.g. changing patterns of disease), and cost/benefits are not distributed evenly.
In 2002, the WHO and WTO prepared a joint report on the public health implications of trade. This found that trade agreements do take some account of health, permitting national measures that protect human health—but only those that are the least trade-restrictive relative to any other measure. The report emphasised the common ground between trade and health, but – recognising the potential for dispute – argued for health and trade policy ‘coherence’.
Certainly, trade policy continues to be one of the most contentious issues in global health.
Trade, globalisation & our new global health agenda
Global trade rules present genuine and substantial risk to health policies seeking to address supply side determinants and alter the consumer environment to reduce risk factors for NCDs. They affect what people eat and drink, and whether they smoke.
As it currently stands, when there are implications for trade, countries must construct a powerful case that demonstrates the relationship between the intervention and protection of public health – this requires capacity to construct a case and ability to participate fully in international policy-making to defend this case. Health policy can, and should, trump trade law, but this is not guaranteed and may come at very high cost to governments.
When faced with major global health challenges of a globalised nature, it seems counterintuitive that health policy is held hostage to trade policy (when we know that health is a pre-requisite to effective economic development…) and corporations are able to manipulate it to their own advantage. This is particularly frustrating when governments are trying to take upstream – pre-emptive – action on health, yet face barriers imposed by trade rules that seemingly serve the interests of big business.
Given these concerns, isn’t it time the health community tabled governance reforms to ensure this is no longer the case moving forwards?