Treating trade: the case for clinical engagement with regional trade agreements
Published Online: 10 May 2015
Article Info
The
global burden of non-communicable diseases (NCDs) continues to grow.
Although developing settings face the fastest growth in incidence, no
country is exempt from the medical, social, and economic harms of
dietary-associated disease. The food environment is a significant
determinant in the development of NCDs and is inexorably altered by
trade policy and practice.1
Historically
governed by the World Trade Organization (WTO), global trade is
increasingly shaped by a new generation of regional trade and investment
agreements.2
These agreements have the potential to push the food environment
further towards an abundance of cheap, highly processed products that
are detrimental to health.3
Clinicans treating obesity-related disease should engage with trade
policy decisions in the same way that respiratory specalists have
engaged as researchers and advocates for tobacco control.
Negotiations
for two mega-regional trade agreements are underway. The Transatlantic
Trade and Investment Partnership (TTIP; between the European Union and
the USA) completed the eighth round of formal negotiation in February,
2015. The Trans-Pacific Partnership (TPP; between the USA, Australia,
Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru,
Singapore, and Vietnam) has been under negotiation since 2010 and is
nearing the final stages. These agreements aim to set new global
standards and place new boundaries around the regulatory behaviour of
governments.2
Collectively, the TPP and TTIP have the potential to regulate a large
proportion of global trade, drive changes to the regulatory environment,
and produce clinically significant changes in food consumption.1
The
efforts of physicians to optimise medication regimens, encourage
physical activity, and moderate diets are clearly important, but they
might produce small-scale effects relative to measures directed at
regulating unhealthy food products. Regulation of labelling,
advertising, distribution, and sale of food can be constrained by
nations' obligations under international agreements.1 Trade agreements are therefore a significant determinant of the food environment.1, 4
The
dominant global norms for trade regulation are established by the WTO.
Underpinning the WTO agreements is a set of trade liberalisation
principles that facilitates the transfer of goods and services between
countries. These principles include the so-called most favoured nation
status (whereby imports from one trading partner must not be
discriminated against relative to imports from another WTO trading
partner) and national treatment (whereby domestic and imported products
must be treated equally).5
Exemptions to these principles are allowed when “those measures are
necessary to protect the health of humans, animals, and plants”.5
However, policies intended to protect health must be no more trade
restrictive than necessary, and no agreed systems exist for assessing
the evidence of health risk, measuring potential effects, or identifying
proportional responses to that risk. Disputes between WTO members are
settled through a system of slow, but transparent, state-to-state
arbitration. Although, in theory, countries have the scope to regulate
the food industry under this system, it can present barriers to
effective nutritional policies, including restrictions on low-nutrition
food. Indeed, overall, WTO membership is associated with increased
consumption of highly processed, health harming foods.1
The
experiences of small developing Pacific islands illustrate the
influence of WTO policy on the scope for food regulation in a setting of
extreme dietary disease. Imported high-fat meat offcuts, such as mutton
flaps and turkey tails, are popular in the region, and fatty meat
consumption has become a substantial contributor to dietary fat intake.6
This nutritional transition has parlayed into a catastrophic burden of
NCDs, prompting the Government of Samoa to ban imports of turkey tails
in 2007.7
However, to accede to the WTO in 2011, Samoa was required to drop the
ban, which was considered unnecessarily trade restrictive. Similarly,
Tonga's plans to apply quotas to fatty meat imports were abandoned over
concerns of WTO involvement. Contrastingly, Fiji has managed to maintain
its ban on mutton flap sales through WTO compliant language and
regional political influences.7
These vignettes from Pacific islands demonstrate the potential for
trade policy to place constraints on action to address public
health—even in small markets with a quantifiable NCD crisis. The WTO
agreements that have presented barriers to regulation of fatty meat
imports in the Pacific islands are regarded as a floor beyond which
newer trade agreements are expected to extend. Experience with the
Central American–USA Free Trade Agreement (CAFTA) and the North American
Free Trade Agreement also suggests that these agreements have increased
the availability and reduced the price of processed and low-nutrition
foods.1
An example is the growth in both imports of snack foods and processed
food markets in Central America during a decade and a half of trade
liberalisation that culminated in the signing of the CAFTA.8
Foreign direct investment provisions in more recent trade agreements
can be expected to drive further increases in the market share of
transnational food corporations and their dominance in food supply
chains.1
Regional
trade agreements like the TPP and TTIP are intended to provide for yet
more liberalised trade. The full implications of the TPP are unknown at
this stage due to the secret nature of negotiations and lack of public
access to negotiating documents.3
Although the TTIP negotiations are more transparent than those of the
TPP in some respects, substantial concerns have been expressed about the
implications for health of proposed provisions of both the TPP and
TIPP.9
Contents of leaked drafts imply that the TPP might limit the scope for
governments to restrict the input of vested interests in policy making,
and reduce the range of interventions available to reduce diet-related
disease.3 For example, governments might be less able to introduce innovative nutritional labelling requirements.3, 4
Investor-state dispute settlement provisions, proposed for both the TPP
and TTIP, allow companies to litigate governments outside domestic
court systems.4
Pharmaceutical provisions under discussion in both forums also have
potential to constrain access to medicines that might otherwise have
been available to manage the metabolic and cardiovascular outcomes of
dietary harm.2, 4
By comparison with the WTO regime, the TPP and TTIP are likely to
contain fewer safeguards for the public and have more opaque dispute
resolution mechanisms. The TPP and TTIP have the potential to directly
affect the lives of millions of patients attending primary and
specialist care in all signatory nations.
Clinicians
should inform themselves about trade negotations in their countries and
consider whether proposals under discussion have the potential to harm
their patients and communities. When there is a risk that trade
consequences will affect patient health, physicians have a mandate to
advocate for broad health protection provisions. Collective professional
advocacy is exemplified by the UK Faculty of Public Health Policy
Report (which represents the three Royal Colleges of Physicians in the
UK), analysing proposals for the TTIP and warning of its potential
effects on health.9
RW
has received funds from the New Zealand–United States Council to attend
the 2013 Pacific Partnership Forum. DG receives funding from the
Australian Research Council for research on the Trans-Pacific
Partnership Agreement (TPPA), health, and nutrition. She has received
funding from various national and international non-government
organisations to attend speaking engagements related to trade agreements
and health, including the TPPA, and has represented the Public Health
Association of Australia on matters related to the TPPA. The views
expressed in this Comment are ours and not those of any organisation we
are affiliated with.
References
- Friel, S, Hattersley, L, Snowdon, W et al. Monitoring the impacts of trade agreements on food environments. Obes Rev. 2013; 14: 120–134
- Gleeson, D and Friel, S. Emerging threats to public health from regional trade agreements. Lancet. 2013; 381: 1507–1509
- Thow, AM, Snowdon, W, Labonté, R et al. Will the next generation of preferential trade and investment agreements undermine prevention of noncommunicable diseases? A prospective policy analysis of the Trans Pacific Partnership Agreement. Health Policy. 2015; 119: 88–96
- Friel, S, Gleeson, D, Thow, A-M et al. A new generation of trade policy: potential risk to diet-related health from the Trans-Pacific Partnership agreement. Global Health. 2013; 9: 46
- World Trade Organization and WHO. WTO agreements and public health. World Trade Organization and World Health Organization, Geneva; 2002
- Errington, F and Gewertz, D. Pacific Island gastrologies: following the flaps. J R Anthropol Inst. 2008; 3: 590–608
- Thow, AM, Swinburn, B, Colagiuri, S et al. Trade and food policy: case studies from three Pacific Island countries. Food Policy. 2010; 35: 556–564
- Thow, A-M and Hawkes, C. The implications of trade liberalization for diet and health: a case study from Central America. Global Health. 2009; 5: 5
- Weiss, M. Trading Health? UK Faculty of Public Health Policy Report on the Transatlantic Trade and Investment Partnership. UK Faculty of Public Health, London; 2015
