Urge the #USTR to consider public health impacts of #NAFTA renegotiation

The Trump Administration is planning to renegotiate the North American Free Trade Agreement (NAFTA). The first step in the process is soliciting public comment on the objectives of the renegotiation by Monday June 12, 2017.

Members of the Trade and Health Forum have prepared a comment for its members to submit which reflect the position of the American Public Health Association in its policy statements with regard to trade and health. We urge you to submit the comment below or one of your own using the instructions below.


1. Go to www.regulations.gov

2. Enter “2017-10603” in the “SEARCH for: Rules, Comments, Adjudications or Supporting Documents” search box and click “Search”.

3. Click on the “Comment Now!” button next to “Requests for Comments: Negotiating Objectives Regarding Modernization of North American Free Trade Agreement with Canada and Mexico.”

4. Submit your comment and complete other required fields.



Dear USTR Robert Lighthizer,

The impacts of trade agreements, like the North American Free Trade Agreement (NAFTA), on public health in the United States and partner countries are wide-ranging. While trade agreements can produce economic benefits as well as damages, the health effects of trade agreements must also be considered. Trade agreements can, and often do, limit access to essential medicines; increase the use of tobacco, alcohol, and obesogenic foods and beverages; reduce access to health services; and undermine environmental protections and labour rights. The American Public Health Association has detailed potential public health harms which may arise from trade agreements in its official policy statement, “Ensuring that trade agreements promote public health” (Policy Statement 201512) (https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/12/08/16/04/ensuring-that-trade-agreements-promote-public-health).

U.S. efforts to renegotiate NAFTA present an opportunity to reassess these risks and incorporate measures to ensure the highest attainable level of health for all Americans. I urge you to engage in a transparent renegotiating process that includes public input and accountability and prioritizes the health as well as the economic well-being of the American people.

Incorporating a public health perspective is critical as these concerns were largely excluded from the original NAFTA negotiations and continue to be neglected in the U.S.’s negotiations of more recent trade agreements. Of 28 Trade Advisory Committees (TACs) that advise the Office of the USTR, there is no committee focused on health and only a single member representing health or health care is included in two of the sixteen industry TACs. This absence of a public health perspective on trade is acknowledged by the Government Accountability Office[1] and measures to redress this have been included in proposed Congressional bills that have been the subject of substantial advocacy. In early 2014, President Obama pledged to establish a Public Interest Trade Advisory Committee, which included mention of health expertise in the call for nominations.[2] However, this has yet to be established.

In renegotiating NAFTA with Mexico and Canada, we urge the USTR to:

1.    – Eliminate any Investor-State Dispute Settlement (ISDS) system in order to protect national, state, and local government actions to protect public health from challenges by corporate entities;

2.     -Ensure that trade agreements protect, promote, and prioritize public health over commercial interests, when such commercial interests may undermine or threaten public health, and seek to ameliorate rather than exacerbate health disparities and inequities;

3.     -Support formal exemption of essential public services (e.g., health, education, social services, water, corrections) from NAFTA; and

4.     -Include policies which:

a.      carve out/exclude tobacco and alcohol control measures from all trade agreements,

b.     promote environmental protection and support efforts to curb climate change,

c.      do not undermine national and international labor rights and safe working conditions,

d.     do not promote the downward harmonization of environmental and occupational standards, labor rights, and working conditions.

This list should not be considered exhaustive, but highlights major public health protections that should be observed in the renegotiation of NAFTA. Incorporating such protections for public health will prevent NAFTA from undermining the health of Americans, thereby increasing the efficiency of U.S. health spending and improving policy coherence across different arms of the U.S. government.

Thank you for your consideration.



[1] http://www.gao.gov/new.items/d071198.pdf (page 49)
[2] http://www.regulations.gov/document?D=USTR-2014-0005-0001


Student Spotlight: Jillian Kowalchuk

With this guest contribution, we are initiating a new series on Healthy Policies which spotlights students who are exploring issues related to the political determinants of health. This first post comes from Jillian Kowalchuk who writes about Kingdon’s three streams model in relation to the Framework Convention in Tobacco Control, which  entered into force 11 years ago, today. 

Policy Entrepreneurs and Kingdon’s three streams model for agenda setting during the formation of the Framework Convention in Tobacco Control: a student applies theory to example

Jillian Kowalchuk

DL lunch-22

The creation of the Framework Convention in Tobacco Control (FCTC) in 2003 was the World Health Organization’s (WHO) first international treaty. Prior to the FCTC, there were no global regulations to combat tobacco use. Nor was there a structure in place to support countries that wished to enact policies.

Policies are made over time and are influenced by the interactions between people who have the power, ability and resources to get things done. Termed actors in academia, they drive the policy process and may include national, international, governmental, intergovernmental and local organizations and individuals (1). Hundreds of people were involved in the creation of the FCTC. This article will focus on a handful that paved the way for the FCTC to move from idea to reality. These ‘policy entrepreneurs” are key actors that create momentum and opportunities. They start the conversation, develop connections that support and guide the process so that a policy moves to the forefront of the agenda (2-4).

The idea of the FCTC began in the 1990’s with Ruth Roemer and Allyn Taylor. Ruth Roemer was a professor in law at UCLA and a formidable leader in public health law. Allyn Taylor is a global health law consultant whose PhD thesis in the 1990’s formed the partial basis for the FCTC. By the 1990s, the tobacco epidemic was becoming recognized as a monumental public health concern in most developed countries (2). Local, state and national tobacco control policies were intermittently emerging in various nations, however global statistics of the impact of tobacco use climbed. More than 3.5 million lives were lost to tobacco in 1998 alone (3).

The FCTC follows Kingdon’s theory of how policies get onto the agenda. Kingdon’s three streams model of agenda setting is the idea that it is the alignment of politics, the problem and the policy that creates a window of opportunity for a policy to move onto the agenda. The ‘policy stream’ involves the analyses of problem, debates and resolutions that reflect dominant social values that are feasible, and publically and politically acceptable. The ‘politics stream’ is the coming together of visible and hidden participants to advocate for a solution and create movement (5). Roemer and Taylor recognized the ‘problem stream’ of the tobacco epidemic; it would require international legislative agreements between countries in order to be successful. This was reiterated by Dr. Gro Harlem Brundtland, who was elected as Director General of the World Health Organization in 1998, and stated,

“Tobacco control cannot succeed solely through the efforts of individual governments, national non-governmental organizations and media advocates. We need an international response to an international problem” (3 p6).

The application of the ‘policy stream’ began with Roemer and Taylor networking through their spheres of influence in public health and law, to lobby that a tobacco control treaty was technically feasible and increasingly publically and politically necessary for the WHO to develop, negotiate and lead (3). Dr. Gro Brundland’s declaration was the ‘politics stream’ bridging together all three streams to place tobacco control on the global health agenda.

Visionaries with power of persuasion and resources used the political, problem and policy opportunities to create the FCTC. After 3 years of negotiating, the FCTC was adopted in 2003 and came into force in 2005. Today there are 180 signatory countries to the FCTC and the latest global progress report indicates that nearly 80% of these countries have adopted or strengthened tobacco control legislation after ratifying the Convention. Using the theoretical concept of ‘policy entrepreneurs’ and Kingdon’s ‘three streams model’ not only helps us to understand how the FCTC came to be, but also illustrates how policy solutions to major health problems can be achieved.


My deepest thanks to Dr. Sue Lawrence for her contributions to the structure, revision, overall support and encouragement in pursuing publishing this assignment as a blog submission.


1. Buse, K., Mays N., Walt G, editor. Making Health Policy. 2nd ed. Berkshire: Open Unversity Press; 2005.

2. Roemer R, Taylor A, Lariviere J. Origins of the WHO framework convention on tobacco control. American Journal of Public Health. 2005. p. 936–8.

3. World Health Organization. History of the WHO Framework Convention on Tobacco Control. Geneva; 2009 p. 1–58.

4. Jha P, Chaloupka FJ, editors. Tobacco control in developing countries. New York; 2000.

5. Kingdon J (2010) Agendas, Alternatives and Public Policies, updated 2nd edition. Harlow: Longman Classics.

Author Biography:

Jillian is a recent graduate from the MSc degree in Public Health from the London School of Hygiene and Tropical Medicine (LSHTM). She also holds a Bachelor of Arts degree in Psychology from the University of Alberta.

Jillian has consulted throughout her MSc at with the private public health consultancy Be the Change Group Inc. Jillian works nationally and internationally with high-risk and vulnerable populations, in creation of campaign designs, implementation research, monitoring and evaluation,  and technical writing. Jillian volunteers on various projects, including blogging for the University of London and currently sits on the Board of Directors for Does HIV Look Like Me? International.

Jillian currently is completing a research internship at The AIDS Service Organization (TASO) in Uganda before attending her graduation in March.

To explore future collaborations and to connect please find her at:

LinkedIn: Jillian Kowalchuk 

Twitter: @kowalchuk_jill

Email: jillian@bethechangegroup.com

Webpage: http://www.bethechangegroup.com/team/jill.html


Philip Morris v Australia: A crushing blow to Big Tobacco or a deferral of sentencing for plain packaging?

In this guest post, Ashley Schram, Ronald Labonté, and Arne Ruckert ask whether the recent decision in the legal battle between Australia and Phillip Morris is a victory for public health. 

The world has been waiting for a decision in the legal battle between Australia and Philip Morris Asia (PMA) over tobacco plain packaging. On December 18th, 2015 the decision was finally in, and the verdict was: ‘no decision’. The arbitrators dismissed the case on jurisdiction, unanimously deciding they had no authority to rule. Headlines around the world heralded this as a defeat of Big Tobacco and a victory for Australia and public health [1–3], but was it actually? Does this ‘non-decision’ equate to a loss for Philip Morris?  As Marc Firestone, Senior Vice President and General Counsel for Philip Morris International (PMI) observed, “There is nothing in today’s outcome that addresses, let alone validates, plain packaging in Australia or anywhere else.” The case that many nations were waiting for to get the green light for tobacco plain packaging, is now permanently an amber light.

Back in 2010 the Australian government announced its plan to introduce tobacco plain packaging as a public health measure, legislation that mandates all aspects of cigarette packaging including the specified position, font, size, and colour of the brand name, and prohibits the use of any trademarks [4]. Less than one year after this announcement PMA purchased Philip Morris Australia in order to gain access to the investor-state dispute settlement (ISDS) procedures within the bilateral trade agreement signed between Hong Kong and Australia in 1993. Just four months after this acquisition, in June 2011, PMA notified Australia of its intention to sue over its plain packaging legislation in international arbitration [5].

Legal analyses suggested that PMA was unlikely to be successful in the merits-based stage of arbitration [6,7]. Presuming that such legal scholars were correct, having the case dismissed during the jurisdiction phase was arguably the best possible outcome for PMA by prolonging a process referred to as regulatory chill. This occurs when a government reduces the severity of, delays implementation of, or abandons a regulation altogether to avoid a possible trade or investment dispute, and its associated legal costs and potential financial penalties.

If we maintain the assumption that PMA would not have been able to win the decision on the merits of the case, the alternative scenario would have been for the tribunal to find that they had jurisdiction over the case, engage in multi-year proceedings on merits, only to ultimately decide in favour of Australia. In this alternative scenario Philip Morris would have, at best, gained a few more years of regulatory chill on tobacco plain packaging. Not to suggest that a few more years of regulatory chill is an insignificant thing; the threat of litigation is an exceedingly cost-effective tool for tobacco companies to dissuade new tobacco-control measures. PMI has initiated an ISDS challenge against related legislation in Uruguay [8,9]; and, alongside other transnational tobacco companies, has threatened Namibia, Togo and Uganda with similar lawsuits they argue would cost these governments millions of dollars to defend and lose [10]. While the Australian case hung in the balance, other states were less likely to introduce plain packaging [11]; the New Zealand government officially stating it was waiting for a decision in the case before proceeding with its own legislation [12]. A decision for PMA on jurisdiction would have bought a few more years of uncertainty and regulatory chill around plain packaging; but the loss at the merits stage would have rendered them ‘all bark and no bite’.

The decision of the tribunal not to decide on the merits of the case means a protracted period of regulatory chill until another country steps up to take Australia’s place. Canada’s recent announcement to pursue tobacco plain packaging [13] may indicate the entry of a new champion. However, it was reported that Australia’s legal bills as of 2015 had already totalled as much as 50 million AUD [14], meaning the Canadian government will require significant political will to go to ‘battle’ with Big Tobacco. Moreover, because the case was dismissed on jurisdiction the ‘non-decision’ offers nothing to Canada (or the rest of world) about the merits of tobacco plain packaging in international investment arbitration.

So did PMA lose? In Australia, yes, plain packaging legislation won’t be overturned and they won’t be compensated for loss of sales in that country. But did PMA lose on the world stage? No. They demonstrated that countries introducing such legislation would incur significant legal fees and avoided any substantive rulings that could be used as precedent in future cases.


1. Hurst D. Australia wins international legal battle with Philip Morris over plain packaging. The Guardian [Internet]. 2015 Dec 18 [cited 2016 Jan 29]; Available from: http://www.theguardian.com/australia-news/2015/dec/18/australia-wins-international-legal-battle-with-philip-morris-over-plain-packaging

2. Hutchens G. Australian government wins plain packaging case against Philip Morris Asia. Syd. Morning Her. [Internet]. 2015 Dec 18 [cited 2016 Jan 29]; Available from: http://www.smh.com.au/federal-politics/political-news/australian-government-wins-plain-packaging-case-against-philip-morris-20151218-glqo8s.html

3. Taylor R. Philip Morris Loses Latest Case Against Australia Cigarette-Pack Laws. Wall Str. J. [Internet]. 2015 Dec 18 [cited 2016 Jan 29]; Available from: http://www.wsj.com/articles/philip-morris-loses-latest-case-against-australia-cigarette-pack-laws-1450415295

4. Australian Government Department of Health. Tobacco plain packaging – Your guide [Internet]. Australian Government Department of Health and Ageing; 2014 [cited 2015 Apr 26]. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/tppbook

5. Chapman S. Australian government’s $50m investment in defending against Big Tobacco legal thuggery [Internet]. The Conversation. 2015 [cited 2016 Jan 29]. Available from: http://theconversation.com/australian-governments-50m-investment-in-defending-against-big-tobacco-legal-thuggery-45427

6. Voon T. Time to Quit? Assessing International Investment Claims against Plain Tobacco Packaging in Australia. J. Int. Econ. Law. 2011;14:515–52.

7. Voon TSL, Mitchell AD. Implications of International Investment Law for Plain Tobacco Packaging: Lessons from the Hong Kong–Australia BIT [Internet]. Rochester, NY: Social Science Research Network; 2012. Report No.: ID 2377919. Available from: http://papers.ssrn.com/abstract=2377919

8. Lencucha R. Philip Morris versus Uruguay: health governance challenged. The Lancet. 2010;376:852–3.

9. Levin M. Tobacco industry uses trade pacts to try to snuff out anti-smoking laws. NBC News [Internet]. 2012 Nov 29 [cited 2015 Apr 2]; Available from: http://investigations.nbcnews.com/_news/2012/11/29/15519194-tobacco-industry-uses-trade-pacts-to-try-to-snuff-out-anti-smoking-laws

10. Seccombe M. Big Tobacco’s plan to stub out plain packaging. Saturday Pap. [Internet]. 2014 Mar 8 [cited 2015 Apr 26]; Available from: http://www.thesaturdaypaper.com.au/opinion/topic/2014/03/08/big-tobaccos-plan-stub-out-plain-packaging/1394197200

11. New W. Australia Accuses Tobacco Industry Of “Regulatory Chill” In WTO Plain Packaging Case [Internet]. Intellect. Prop. Watch. 2014 [cited 2016 Jan 29]. Available from: http://www.ip-watch.org/2014/11/20/australia-accuses-tobacco-industry-of-regulatory-chill-in-wto-plain-packaging-case/

12. 3 News. Plain packaging court case paves way for NZ [Internet]. 3 News. 2015 [cited 2016 Jan 29]. Available from: http://www.3news.co.nz/politics/plain-packaging-court-case-paves-way-for-nz-2015122212#axzz3wTjBDC3y

13. Galloway G. Liberal pledge to demand plain cigarette packaging draws cheers. Globe Mail [Internet]. 2015 Oct 30 [cited 2016 Jan 29]; Available from: http://www.theglobeandmail.com/news/politics/liberal-pledge-to-demand-plain-cigarette-packaging-draws-cheers/article27054353/

14. Martin P. $50 million goes up in smoke defending plain packaging. Syd. Morning Her. [Internet]. 2015 Jul 28 [cited 2016 Jan 29]; Available from: http://www.smh.com.au/federal-politics/political-news/australia-faces-50m-legal-bill-in-cigarette-plain-packaging-fight-with-philip-morris-20150728-gim4xo.html



The TPP’s intellectual property provisions – a blow for global health and access to medicines

In this guest post, Dr. Deborah Gleeson discusses the final negotiations of the recently agreed trade accord, the Trans-Pacific Partnership, and resulting implications for access to medicines. Deborah is a lecturer in the School of Psychology and Public Health at La Trobe University in Melbourne, Australia. Her research focuses on the impact of international trade agreements on health.

Battles over medicine monopolies almost completely derailed the negotiations for the controversial Trans Pacific Partnership Agreement in the final days of negotiations in early October.

At issue was the United States’ efforts to use the TPP as a vehicle to extend market exclusivity for biologic products, an emerging class of cancer and immunotherapy treatments and vaccines. Extending monopolies on these very expensive products was expected to delay the market entry of more affordable medicines for hundreds of millions of people in TPP countries, placing them out of reach indefinitely for people in developing countries and adding significantly to pharmaceutical expenditure even in wealthy countries.

Transnational pharmaceutical companies headquartered in the US, and their industry association PhRMA, had been very clear about their key objective in the negotiations: to obtain 12 years of market exclusivity for biologics, matching the length of the monopoly in US law. And according to the Sunlight Foundation, the pharmaceutical industry was by far the industry most actively lobbying to influence the negotiations from 2009-2013.

That monopolies for biologic drugs became the final sticking point to be resolved in the TPP reflects just how out of step the US intellectual property settings are with the rest of the world, and how unpalatable the US pharmaceutical agenda was to the other TPP countries. While Japan and Canada provide eight years of exclusivity for biologics, most of the TPP countries currently provide either five years, or none.

The Australian Government, responding to pressure from health and community organisations, and fully aware of the degree of political opposition to anything that would increase the cost of medicines, refused to budge from its existing 5 years of data protection. The US had to make a humiliating retreat in order to conclude the agreement before the US election cycle made further negotiating progress impossible.

So now that the dust has settled, where do things stand? And to what extent does Australia’s victory over biologics in the final hours represent a real victory for global health?

The final text of the TPP has not yet been publicly released but in the interim, Wikileaks has released a leaked copy of the intellectual property chapter agreed between the parties at the conclusion of negotiations.

While there is no doubt that some of the worst elements of the initial US proposals for the TPP’s intellectual property chapter have been mitigated along the way, the final outcome is still no less than a disaster in global health terms.

Many of the initial harmful provisions proposed by the United States remain in the text. These include, among others: patents for new uses and new methods of using existing products, a low inventiveness threshold for issuing patents, patent term extensions for delays in granting patents or processing marketing approval applications, at least five years of data protection for new pharmaceutical products, and patent linkage provisions likely to result in delays in marketing approval for generics.

For the first time in a trade agreement, the TPP also includes a provision requiring countries to provide a minimum of five years’ market exclusivity for biologics. The wording of this provision is ambiguous, allowing considerable room for the US to pressure other countries to increase the length of the exclusivity period.

In some cases, the initial US proposals have been softened. For example, the first US IP proposal sought to make it mandatory for countries to provide patents for new forms, new uses and new methods of using existing products. The other TPP countries refused altogether to accept the requirement to provide patents for new forms, and the final TPP text requires countries to provide patents for “at least one of the following: new uses of a known product, new methods of using a known product, or new processes of using a known product.” The patent term extension and patent linkage provisions have also been made more flexible and less onerous than earlier drafts.

But there is still much in the IP chapter that will expand and extend monopolies and delay competition from more affordable follow on products in many countries. Even in wealthy countries like Australia, the TPP obligations will lock in current intellectual property standards, making it difficult or impossible to reform IP laws to improve access to affordable medicines in future.

The four poorest countries – Vietnam, Malaysia, Mexico and Peru – have been given transition periods, but at only three to ten years in length, these are far too short for the realities these countries face, and they apply to far too few of the TPP’s obligations. For example, Vietnam will only have three years to implement a patent linkage process and three to five years to introduce patent term extensions. When the TPP comes into force, Vietnam will be immediately locked into a low inventiveness threshold and will need to grant additional secondary patents.

Vietnam’s situation is of particular concern because, with the lowest GDP per capita of the TPP countries, it already struggles to provide affordable medicines for its population. A study based on the provisions in a 2014 leaked draft of the IP chapter indicated that, assuming its budget of 25.1 million USD for HIV treatment remained constant, Vietnam’s treatment coverage for eligible people living with HIV could fall from 68% to around 30%. Many of the provisions on which this analysis was based remain in the final text.

The pharmaceutical industry has expressed disappointment over the failure of the US to obtain 12 years of exclusivity for biologics, but in reality it has gained enormous concessions. If the TPP countries ratify the deal, Big Pharma will have succeeded in cementing intellectual property standards that will stymie access to medicines for up to 800 million people in the short term, and more if additional countries sign up in future. Furthermore, the TPP’s intellectual property chapter sets a new norm that is likely to become the template for future trade agreements: its implications are global as well as regional.

Civil society advocacy has blunted some of the most extreme US proposals for the TPP. But if ratified and enforced, it will still prevent untold numbers of people from gaining access to affordable medicines.

Health Impact Assessment of the Trans-Pacific Partnership

In this guest post, Krycia Cowling introduces a webinar organized by Katie Hirono and Fiona Haigh, from the Centre for Health Equity Training, Research, and Evaluation, at the University of New South Wales. The webinar, presented to the APHA Trade and Health Forum, discusses the health impact assessment their team conducted on the proposed Trans-Pacific Partnership. Krycia is a doctoral student in health policy at the Johns Hopkins Bloomberg School of Public Health.

Last week, negotiators agreed on a final draft of the Trans-Pacific Partnership, a twelve-nation trade agreement whose members collectively represent 40% of the global economy. In the coming months, the final draft has to be approved by all members’ governments; once in force, it will be the largest regional trade agreement to date.

Throughout negotiations, health advocates and researches have raised concerns about threats to public health posed by particular provisions in the agreement. In particular, attention has focused on the implications of extended intellectual property rights for the price of medicines and the power given to corporations to challenge health legislation through special forms of arbitration. But there are many other possible pathways through which an agreement this expansive may affect health.

Health Impact Assessment (HIA) is a tool to examine the likely health effects of a forthcoming policy or program and to develop recommendations to adapt the policy or program to maximize potential benefits and minimize potential harms for health. Many experts have suggested that HIAs be conducted on new trade agreements, and recently, a group of researchers in Australia conducted what may be the first HIA of a trade agreement while under negotiation.

In this presentation, Katie Hirono and Fiona Haigh, two members of the HIA research team at the Centre for Health Equity Training Research and Evaluation, at the University of New South Wales, describe the process for conducting an HIA of the TPP and their key findings. They focus on the implications for the health of the Australian population, through impacts on the cost of medicines, tobacco control, alcohol control, and food labeling. As Australia is only one of twelve countries set to join the TPP, and the agreement is now entering its final phases of approval, HIAs from the perspective of other potential member countries would be welcome inputs to debates around passing the TPP.

The Final Push: Canada and the Trans-Pacific Partnership (TPP) Trade Deal

In this guest post, authors Arne Ruckert, Ronald Labonté and Ashley Schram outline what’s at stake for Canada in the Trans-Pacific Partnership Trade Deal. This is an update of a piece originally posted at the Centre for International Policy’s Blog (updated 28/9/2015). Arne Ruckert is a Senior Research Associate in the Faculty of Medicine and a part-time Professor in the School of Political Studies at the University of Ottawa. Ronald Labonté is Canada Research Chair in Globalization & Health Equity, and Professor, School of Epidemiology, Public Health and Preventive Medicine at the University of Ottawa. Ashley Schram is a PhD candidate in Population Health at the University of Ottawa studying the health impacts of international trade and investment agreements. 

The Trans-Pacific Partnership is nearing the end game of negotiations, creating a market of 800 million people with a combined economic clout of US$28-trillion annually. After the US Congress granted fast-track authority to President Obama, a final agreement amongst the 12 Pacific-rim countries involved in the trade deal is now within reach. Reportedly ‘98% done’ trade ministers are meeting in Atlanta in early October to see if they can clinch an agreement. So what’s at stake for Canada?

Agricultural market access remains a sticking point for some of the TPP’s prospective members. Media coverage of the TPP in Canada has been dominated by Canadian supply management in dairy and poultry, which limits market access in these products for other countries. Canada is under pressure in the press and from some TPP countries to dismantle supply management if it wants to remain part of the final negotiations. Yet Canada has participated in past free trade deals without dismantling supply management, with Canada’s Minister of International Trade Ed Fast stating that “supply management has never prevented us from concluding trade agreements, and we have confidence that we will be able to do that with the TPP as well” (cited in Lu, 2015).

There are good (health and broader public policy) reasons for why Canada would want to continue with supply management, including guaranteeing a safe and stable stock of dairy and poultry products at affordable cost. A reasonable compromise for Canada would be maintaining its supply management but making some concessions in terms of increasing market access for other TPP countries in these products. However, latest reports indicate that Canada could provide sufficient market access to American dairy producers that it could tip the supply-management system into a fast (or slow) track to its end. The triangulated deal would have New Zealand dairy gain greater access to the US, the US gain greater access to Canada and Canada (perhaps) gain greater market access across the TPP for its beef exports. Health concerns or food security issues do not appear prominent in any of these compromises, and Canada’s dairy farmers are not amused. Similarly, rules of origin for the auto sector to which two TPP countries have already agreed (the US and Japan) could cost a large number of already rather beleaguered Canadian autoworkers.

There are other areas of the TPP overlooked in most media discussions that have potentially much stronger and lasting impacts. Foremost is Investor-State–Dispute Settlement (ISDS) provisions, which will grant multinational corporations the right to sue TPP governments over public policy decisions perceived as damaging to their investments and business operations (Hilary, 2014; Ruckert, Schram, Labonté, 2015). Canada is already the most sued developed country in the world because of NAFTA’s ISDS process, and the TPP will significantly increase the number of foreign investors eligible to sue (Sinclair and Trews, 2015). Strong civil society and academic critiques of ISDS have recently led to greater caution about how they should be included within new trade treaties. The Transatlantic Trade and Investment Partnership (TTIP) under negotiation between the US and the EU also contains an ISDS chapter, with concerns about its provisions voiced on both sides of the ocean. Rather than reject ISDS outright, European parliamentarians in July passed a compromise amendment which calls for replacing the ISDS system “with a new system…subject to democratic principles and scrutiny, where potential cases are treated in a transparent manner by publicly appointed, independent professional judges in public hearings and which includes an appellate mechanism, where…the jurisdiction of courts of the EU and of the member states is respected, and where private interests cannot undermine public policy objectives.” (Bridges Weekly, 2015: 4). The EU amendment appears to address many of the critics’ concerns with ISDS, and the Canadian government should push for the TPP to adopt a similar position. Investor protection would be strengthened, but so would government’s ability to pursue new public policy objectives without fear of an investor challenge.

The TPP also proposes to extend intellectual property rights (IPRs) with implications for drug costs, whether paid for publicly or privately (Hirono et al, 2015; Sinclair, 2013). This is of particular relevance for Canada, which already has the second highest drug prices in the world (Sinclair and Trew, 2015). A recent leak of the TPP IPR chapter shows that the major outstanding disagreements over IPR relate to “patent linkage” and expanded protection of biologics (Grunwald, 2015). Patent linkage prevents the registration and authorization of generic medicines until after the expiry of patents, considerably delaying generic market entry (Canadian Generic Pharmaceutical Association, 2012). Although Canada already has a patent linkage system in place, the TPP is the first time this system would be written into trade treaty obligations, interfering with future cost-saving reforms (Sinclair and Trew, 2015) and weakening the vibrant Canadian generic pharmaceuticals industry which is responsible for the production of two out of every three prescription drugs in Canada. A recent analysis of the draft intellectual property chapter of the TPP suggests that the US has been advocating for patent linkage to extend to biologics, along with a request for longer periods for data exclusivity. It also notes that many TPP member states have been opposed to extended IPRs (Grunwald, 2015), which would provide Canadian negotiators with a platform from which to  limit any extension of IPRs in pharmaceuticals beyond those already present in the World Trade Organizations TRIPS agreement.

Finally, TPP provisions for regulatory coherence and transparency have received relatively little mention. As with all recent free trade agreements, the TPP is only marginally about trade, and more about harmonizing regulations (financial, health, and safety standards, etc.) (Sinclair and Trew, 2015). The leaked regulatory coherence chapter outlines various expectations, including the obligation to encourage the use of regulatory impact assessments (RIAs) as practiced in the United States. The proposed regulatory model contains numerous pro-market factors that governments should consider when making domestic regulations. The obligations outlined in the regulatory coherence chapter are explicitly linked those in the transparency chapter (Kelsey, 2015). The transparency chapter (which has not been leaked) is expected to confer rights to affected commercial interests to participate in regulatory processes. The two chapters together will essentially impose: high-level behind the border disciplines on governments through market-centric norms; an ideologically driven commitment to light-touch regulations (whose detrimental effects are best seen in the global financial crisis of 2008); and a structured role for private and especially corporate interests to shape domestic regulations and policy-processes (Kelsey, 2015). Some TPP countries, especially those with developing country status, have raised concerns about these two chapters. Canada should align with these concerns and support their resolution within any final agreement.

Canada should be courageous enough to stand up to the United States (the main force behind these negotiations) and to form coalitions with TPP member countries that have similar concerns about these remaining TPP issues. It has precious little time left to do so. Ultimately, there is no point in signing on to a free trade agreement that represents very little economic benefit to the Canadian economy (and quite possibly economic loss), but which has major political and social implications, including the potential to hamper Canadian sovereignty and to undermine its regulatory autonomy.


Bridges Weekly (2015). TPP Countries Gear Up for High Stakes Ministerial Meeting. Retrieved from: http://www.ictsd.org/sites/default/files/review/bridgesweekly19-25.pdf

Canadian Generic Pharmaceutical Association (2012). Position on the Trans-Pacific Partnerships (TPP) Negotiations, Retrieved from: http://www.canadiangenerics.ca/en/advocacy/tradenegotiationi.asp

Gruwnald, M. (2015). Leaked: What’s in Obama’s Trade Deal? Retrieved from: http://www.politico.com/agenda/story/2015/06/tpp-deal-leaked-pharma-000126

Hilary, J (2014). The Transatlantic Trade and Investment Partnership and UK healthcare. BMJ 2014; 349: g6552.

Hirono, K. et al (2015). A Health Impact Assessment of the Proposed Trans-Pacific Partnership Agreement. Retrieved from: http://hiaconnect.edu.au/research-and-publications/tpphia/

Kelsey, J. (2015). How the Trans-Pacific Partnership Agreement Poses a Threat to National Sovereignty over Domestic Decision Making. Retrieved from: http://www.itsourfuture.org.nz/wp-content/uploads/2014/03/Regulatory-Coherence-paper.pdf

Lu, Seres (2015) Trade Minister Reassures Supply-managed Sectors ahead of TPP Talks, Retrieved from: http://www.theglobeandmail.com/report-on-business/trade-minister-reassures-supply-managed-sectors-ahead-of-tpp-talks/article25405222/

Ruckert, A., Schram, A. and Labonté, R. (2015). The Transpacific Partnership Agreement: Trading Away our Health? Canadian Journal of Public Health, accepted and forthcoming.

Sinclair, S. (2013, May). Opening remarks on Canada and the Trans-Pacific Partnership (TPP). Speech     presented at the House of Commons Standing Committee on International Trade, Ottawa Ontario. Retrieved from: https://www.policyalternatives.ca/sites/default/files/uploads/publications/National%20Office/2013/06/CanadaandtheTransPacificPartnership.pdf

Sinclair, S and Trew, S. (2015). The TPP and Canada. Fact Sheet, May 2015, Retrieved From: https://www.policyalternatives.ca/sites/default/files/uploads/publications/National%20Office/2015/05/TPPandCanada.pdf


Health and social justice: not all good things grow on the same tree*

In this guest post, Adina Preda and Kristin Voigt respond to a Healthy Policies piece which discusses their recent article ‘The Social Determinants of Health: Why Should We Care’.

We would like to thank Courtney for featuring our paper, ‘The Social Determinants of Health: Why Should we Care?’, on this blog and for offering a number of constructive criticisms of our argument. Part of the aspiration for our paper was to encourage more dialogue across disciplines about the normative questions surrounding health inequalities, and we are very pleased to have the opportunity to contribute to it here.

We identified two main concerns that Courtney raised about our argument: one to do with the grounds for advocating a redistribution of the social determinants of health and the other with our use of the evidence.

1. What should health professionals advocate for, and why?

One point of agreement between Courtney and us is that the current distribution of the social determinants of health is unfair and needs to be rectified. However, we think it is crucial that we think more critically about the grounds on which redistribution of the SDH is called for. Our AJOB paper expressed concern about the fact that much of the SDH literature argues for a more equal distribution as a means to reducing health inequalities. As we emphasised in the paper, economic redistribution and other (egalitarian) policies are required by social justice. For example, giving all children an equal start in life, as the SDH literature calls for, is required in and of itself, not because of any contribution it makes to health equity. Accordingly, we think it would be better if health professionals (and others) were to argue for egalitarian policies as a matter of social justice, regardless of any impact such policies might have on health inequalities.

This is important for a number of reasons. One reason is that, as a matter of principle, it remains important to emphasise that egalitarian policies are required as a matter of social justice, not just because of any effects they might have on other goals. Furthermore, as we already mentioned in the paper, if we argue for redistributive policies on the grounds that they will bring about more equal health outcomes but then they fail to do so, these policies might be conceived as having failed, even if they achieved a more equal distribution of the SDH. If, however, we argue for these policies as rectifying broader social injustices (and perhaps in addition offering some plausible possibility of bringing down health inequalities), they would still be considered a success to the extent that they achieve a fairer distribution, even if health inequalities remain unaffected. (We explain this in more detail in our rejoinder in AJOB.)

Courtney assumes that social justice and justice in health go hand in hand and asks in what context calls for social redistribution for the sake of health inequalities could detract from social justice more broadly. We agree that in general this should be the case but we think there are instances where these two goals might pull in different directions. One such instance is gender equality: Policies that seek to address inequalities between men and women – the pay gap, for example – might benefit women’s health and thus ‘exacerbate’ existing health inequalities between men and women. In such instances, it is plausible to argue that gender equality should take priority even though it might increase a health inequality that we don’t regard as fair.

If we could move to an ideally fair distribution right away, this would likely have positive effects on health (in)equality. For policy purposes, however, the decisions we have to make tend to be on a much smaller scale. We are not moving straight to a fully equal society but, rather, we may be considering different steps we could take towards such a society, such as early education programmes or policies addressing poor housing. The types of policies that most effectively contribute to the reduction of health inequalities may not be the ones that most effectively contribute to social justice, and vice versa. The way the connection between equality in health on the one hand and justice and equality on the other is framed in the SDH debate tends to obscure these possible difficulties.

To sum up, we are concerned that an undue emphasis on health and health inequalities may detract from the main reason for redressing existing inequalities including inequalities in health, which is justice.

2. Evidence

Courtney is also concerned that we are not paying sufficient attention to the literature showing that ‘countries with more redistributive social policies have better overall population health’. As such, she argues, redistributive policies seem to explain, in large part, the inequalities in health we see between countries. Since, in our AJOB paper, we ‘suggest that “the most dramatic figures cited in the SDH literature relate to differences in life expectancy across different countries”, we do not think we disregarded this important dimension of the literature although, as we explain below, this was not the most relevant issue for our argument.

We have a number of concerns about Courtney’s line of reasoning here. First, the ‘dramatic’ figures cited in the SDH literature relate to differences in life expectancy between rich and poor countries, not between countries with different levels of redistribution/economic inequality – though there are of course also significant differences in health outcomes across different countries with similar levels of wealth.

Second, Courtney switches here from talking about (reducing) social inequalities in health and improving overall health. As we emphasised in the paper, we think it is important to keep these two goals distinct. Improvements in overall population health are perfectly consistent with increased health inequality (as Courtney acknowledges as well). Our concern in the paper – and the claim we were examining – was that redistributive policies would not reduce health inequalities.

Third, as we pointed out, it is problematic to assume that the best way to redress a health inequality is to remove or alter its (ultimate) cause. Even if one of the causes of health inequalities is social or economic inequality, it does not follow that the best way to address health inequalities is greater social or economic equality.

Courtney also suggests that we are more concerned about the possibility that we could implement policies might fail to reduce health inequalities (a type I error) than we are about the possibility that we could fail to argue for policies that could, after all, reduce health inequalities (a type II error). Further Courtney claims that even if such policies will not have the desired effect, they are, as it were, ‘risk-free’ because ‘they will not harm anyone’s health’ (emphasis added). This, however, is precisely the kind of over-emphasis on health we caution against. We do not think that such policies should be evaluated only in terms of their effects on health. Thinking of risk purely as health risk obscures other important considerations. Health is, of course, valuable but it cannot be the only thing that matters. We are not concerned that redistributive policies have bad effects, we are concerned about advocating for them because of their effects and the opportunity costs involved in selecting one policy over another.

At this point, we think, it is just not sufficiently clear that what social justice requires is what justice in health requires: we do not as yet have a good understanding of what justice in health requires, and of the means through which it would be best achieved. This is precisely what this multi-disciplinary dialogue should aim to clarify.

*We borrow this expression from Gopal Sreenivasan. [http://www.thehastingscenter.org/Publications/HCR/Detail.aspx?id=842]

A response to ‘The Social Determinants of Health: Why Should We Care?’

In a provocative and recently published article, philosophers Adina Preda and Kristin Voigt question policy recommendations which call for more equal distributions of social factors as a means of reducing social inequalities in health. The article has already been commented on from a variety of angles. In this blog post, I’ll briefly outline the authors’ arguments and then highlight some areas of the authors’ analysis which I find additionally problematic. I conclude that public health professionals should continue to advocate for more equal distributions of social resources.

Broadly speaking, the authors first question the normative assumptions about the fairness of health inequalities as described in the social determinants of health (SDH) literature, particularly in high-profile publications such as the Marmot Review. The specific normative assumptions identified are that (1) only avoidable health inequalities are unfair and (2) only socially caused inequalities are avoidable. The authors move to illustrate why natural/biological inequalities might also be unfair, an argument which, to me, seems sound and which I’ll leave aside here. The authors then identify two possible reasons why health inequalities resulting from social inequalities are unfair either because (1) social inequalities are themselves unjust or (2) health inequalities themselves are unjust.

The authors, while conceding that they themselves believe inequalities in the distribution of SDH are unjust, dismiss those that would appeal to the first reason. They argue that if social inequalities are unjust, then “[they] ought to be redressed because (social) justice requires it, rather than because of their effects on health”. The authors “do not deny that showing the effects of social inequalities on health may strengthen the argument for redistribution” but argue that “this cannot be put forward as the main reason for such redistribution” (p30).

In a challenge to the second reason, the authors ask whether “there is any reason to claim that health inequalities are unfair when they result from a fair albeit unequal distribution of social goods” (p30). Here, two philosophical accounts of social justice are reviewed, Rawlsian and luck egalitarian, but neither are found to offer an adequate answer to this question.

Finally, the authors argue that “even if it is the case that health inequalities are unfair, it does not follow that they ought to be redressed by altering the distribution of SDH” (32). This is argued primarily on the basis of empirical uncertainties about the effectiveness of redistributive policy interventions. For example, the authors point to evidence that health inequalities have persisted in countries where the state has otherwise reduced inequalities in income and wealth. The authors also draw attention to evidence that shows that improvements in peoples’ socioeconomic conditions are unlikely to result in immediate improvements in health.

It is hard to argue with the authors’ concluding call for greater theoretical development about the ethics of health inequalities. This is something also called for in public health literature. Moreover, greater collaborative attention to these issues between philosophers and public health researchers is, as they suggest, much needed. Overall however, I find important shortcomings with the authors’ conclusion that we should be weary of public health calls for more equal distributions of social resources.

To begin with, I wonder whether claims about the unfairness of health inequalities, which are based on the recognition that social inequalities themselves are unjust, can be dismissed so easily. While the authors acknowledge that such claims can add strength to petitions for social justice (p30) they also argue that they can detract from such claims (p34). But in what scenario would we see appeals for social redistribution on the basis of health inequalities detract from social justice appeals? It seems to me, any effort which focuses on social injustices (regardless if it is through a lens of health equity) is strengthening attention to those issues.

Here the authors might reply that attention to social justice may be detracted if redistribution does not actually lead to more equal health outcomes. Indeed, they source evidence which questions the link between redistributive policies and health. However, their choice of evidence in this regard seems problematically selective. For example, the authors point to evidence which shows that social inequalities in health have persisted in Scandinavian countries, where social policies are typically more redistributive than in other countries. The authors fail to point out however, that the same literature base which has supported this finding has also shown that countries with more redistributive social policies have better overall population health. As such, redistributive policies seem to explain, in large part, the inequalities in health we see between countries. Since the authors themselves suggest that “the most dramatic figures cited in the SDH literature relate to differences in life expectancy across different countries”, it’s not clear why they would disregard this important dimension of the literature.

The authors also draw on evidence from the UK where they claim “there has been perhaps the most sustained effort to reduce social inequalities in health through large-scale social interventions” (p33). They note that such “efforts have had disappointingly small effects on social inequalities in health, with inequalities in some indicators not only stagnating but in fact widening” (p33). However, towards this end they cite work by Mackenbach (2010) who, in the very article they source, acknowledges that a potential reason why health inequalities have persisted in the UK is precisely because efforts were not aimed at broader redistributive policies. In other words, the large-scale social interventions the authors highlight were in fact not interventions involving broader redistributive policies. Mackenbach states: “One possible analysis of the causes of the failure of the English strategy to reduce health inequalities…then is that this failure is due to the fact that inequalities in income and wealth in England have remained unchanged or even widened” (p1252).

Preda and Voigt also flag evidence which shows that improvements in peoples’ socioeconomic position might not result in immediate improvements in health. But such evidence does not question the effectiveness of redistributive policies as the authors suggest; one could argue it rather highlights the pervasive damage poor socioeconomic position can have on health and the importance of using appropriate time-scales when evaluating interventions.

Even though the choice of evidence the authors focus on seems problematic for these outlined reasons, the authors do suggest that there may be more to the story. For instance, they recognize that “[o]ne possibility is that we simply have not yet seen large-scale social changes of the sort envisaged by proponents of the [health equity] model” (p33). In doing so, they leave room for uncertainty regarding the relationship between redistributive social policies and health. They also recognize that this relationship is complex and difficult to assess using standard medical standards of evidence. However, all these issues are framed problematically as well.

First, this uncertainty is used to argue against policy recommendations for a fairer distribution of social factors. However, how we treat uncertainty in public health is itself, a matter of public health ethics. As has been argued elsewhere, we need not rely on evidence of the sort generated by medical models of health. More importantly, the authors seem singularly concerned about the impacts of incorrectly advocating for redistributive policies (in the case that health inequalities will not improve as a result) but do not recognize the potential health dangers of not advocating for redistributive policies (in the case that such policies are necessary for reducing health inequalities). In epidemiological terms, the authors are more concerned about a type I error, a false positive, than a type II error, a false negative. This focus on type 1 errors, with little consideration of errors of the second kind, is often found in arguments claiming that more evidence is needed to take action on the social determinants of health.

If we consider the risks involved in each of these scenarios however, we find that what we risk in one case is worse than what we risk in the other. In the first case, if we advocate for redistributive policies, but are mistaken in our belief that health inequalities will be reduced, there is almost no evidence to suggest that a more equal distribution of social factors will harm anyone’s health. Health inequalities may indeed widen when everybody’s resources improve (since the better-off are often better able to take advantage of these resources), but again there is no evidence that makes us think that health would worsen for anyone because of a more equal distribution of social resources (it just may not improve as fast for everyone). Furthermore, if redistributive policies fail to reduce health inequalities, we are still left with greater social justice. This is an important consideration since, as the authors concede, current distributions of social resources are undeniably unjust.

In the second scenario however, if we fail to advocate for redistributive social policies (in the case that reducing health inequalities depends on this), not only is there the risk that social injustices persist, but here we have evidence which suggests that health inequalities may indeed widen and overall levels of health may decrease. Studies have for example, pointed to the damaging health impacts of current austerity agendas which serve to further increase unequal distributions of social factors.

Preda and Voigt are correct in that public health scholars do need to engage with philosophical debates surrounding health inequalities and the normative assumptions implicit in their work. For the reasons outlined above however, public health scholars should continue their calls for more equal social policies in the name of health equity.

Income Inequality and Health

In this guest post, Ronald Labonté moves from describing the impact of income inequality on health to the implications of this relationship for both the Canadian and global context. He presents two sets of policy reforms necessary for acting on these contexts and illustrates the scope for Canadian engagement with national and global policy options. This post is based on an invited presentation given to the Liberal Open Caucus, Senate of Canada, March 11, 2015. Labonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and is Professor in the Faculty of Medicine, University of Ottawa; and in the Faculty of Health Sciences, Flinders University of South Australia.

Concern about the health effects of income inequality are not new. Considerable attention was paid to the low life expectancies and deprived lives of the poor and the working class throughout the era of industrial capitalism, stretching from the late 18th through to the late 19th centuries. The reasons then were simple. The material contexts in which many of the non-rich lived during this period were the determining factors:

  • poor food
  • inadequate shelter
  • unsafe working conditions
  • lack of potable water or sanitation, and
  • little opportunity for social mobility to a better life apart from petty crime

The reasons today are more complicated, but derive from the basic findings that life expectancy across the income spectrum in countries such as Canada (and indeed, globally) follow a gradient. Those higher up the income ladder have longer, healthier lives; and the pattern holds for each step up the gradient. This pattern has led to contentious efforts to explain these findings, especially since many of those slightly lower on the income ladder are not living in materially deprived circumstances, nor are they necessarily leading unhealthier lifestyles.

The Income Inequality Debate

Sir Michael Marmot, who designed the British Whitehall Studies that first brought international attention to the gradient effect, argued that these life expectancy differences, apart from those explained by proximal behavioural risks, were caused at least in part by negative social comparison, leading to a loss of self-esteem, psychosocial stress and poor health. This later became known as the ‘relative income’ or ‘income inequality’ hypothesis, which essentially stated that health inequalities were worse where income inequalities were greatest. Richard Wilkinson and Kate Pickett in their book, The Spirit Level1 became the most famous proponents of this argument, finding that for each of eleven different health and social problems outcomes are significantly worse in more unequal rich countries:

  • The Spirit Level by Richard Wilkinson and Kate Pickett
    The Spirit Level by Richard Wilkinson and Kate Pickett

    physical health

  • mental health
  • drug abuse
  • education
  • imprisonment
  • obesity
  • social mobility
  • trust and community life
  • violence
  • teenage pregnancies
  • child well-being

Many epidemiologists, however, were and remain skeptical of their use of co-relational data. An earlier 2004 systematic review of the literature concluded that there was little evidence that the size of income inequalities in itself explained differences in health within and between affluent countries, at least so far as the social comparison explanation is concerned.2 These findings are consistent with a larger literature that finds that it is not the scale of income inequality per se that is responsible for these health differences, but rather that those with different levels of income experience different levels of advantage and deprivation and psychosocial stress which is tightly related to their actual conditions or material conditions of life. As the authors of this 2004 study conclude:

“Although we found little evidence to support a direct effect of income inequality on health, this should not be interpreted to mean that factors that drive unequal income distribution at the system level are not important to individual and population health. Reducing income inequality by raising the incomes of more disadvantaged people will improve the health of poor individuals, health reduce health inequalities, and increase average population health (p.83)2.”

Why the Income Gap Still Matters

In other words, it is not so much the size of the gap between top and bottom income groups that accounts for health inequalities, but the fact that there is a gap in the first place. Reducing that gap remains a public health imperative. Moreover, one of the reasons why income inequalities in some countries do not lead to the same health inequalities as in others has to do with how that gap is reduced through the tax-funded provision of public goods (such as accessible quality education and health care, income transfers, even public transportation and active labour market policies).

This finding is similar to an argument made by the Princeton health economist, Angus Deaton3, whose own reading of the literature on income inequalities as a health determinant concluded that “childhood inequalities are the key to understanding much of the evidence, and that public interventions would do well to focus on breaking or weakening the injustice of parental circumstances determining child outcomes.” A more recent study, however, suggests that the income inequality and health hypothesis is still not entirely resolved. Using 31 years of panel data (1975 – 2006) from 21 OECD countries, the analysis found that, as income inequality increased, life expectancy decreased for both men and women, largely the result of excess mortality for children (aged 1 – 14).4

The study could not disentangle the reasons, but suggested that this was probably the result of under-investments in services for low-income parents, working poverty, long work hours and high household debt burdens, all leading to poorer living conditions and diets and high familial stress. Although the study used mortality data only, where there is high childhood mortality there is almost certain to be high childhood morbidity, creating an unhealthy start that accumulates over a lifetime; and demanding a focus on “on breaking or weakening the injustice of parental circumstances determining child outcomes,” as Angus Deaton expressed it.

These findings were underscored further by a comparison in changes in child well-being between 2007 and 2013 in the same 21 wealthy OECD countries5, a period during which income inequalities had risen in many of these countries subsequent to the 2007/2008 financial crisis. Child well-being (an index comprised of measures of health, education, behaviours, housing and environment and safety) improved in some countries but declined in others, including Canada. The declines were greatest in those countries that had experienced the largest increase in income inequality. The causal pathways, once again, were linked to a decline in material resources, maternal stresses creating epigenetic impacts in pregnancy and early childhood, precarious employment and reduced access to health and other public goods and services.

What Can We Conclude from This?

  • Income inequalities in themselves are likely not the best explanation for health inequalities
  • Within and between countries, however, there are stark health differences between people at different income levels
  • Part of this difference can be explained by different lifestyles (e.g. smoking rates, poor diets, lack of physical exercise), but not all of the difference
  • Lifestyle differences themselves are socially constructed and relate in many ways to affordability of healthier foods, more secure housing, opportunities for recreation and other ‘social determinants of health’
  • Psychosocial stresses associated with income inequality may account for some of the differences in health outcomes, but are more likely the result of material deprivations or shortfalls, and changes in employment or economic conditions that create greater precariousness and insecurity
  • Early childhood experiences (from pregnancy onwards) set the table for later life inequalities: both in income, and in health
  • Children are not born poor; they are born into poor families, and supports to reduce poverty by raising income levels of the bottom 40 percent of households become one of the most important policy levers that governments can use to create greater health equity over the lifespan

It is finally important to emphasize that it is generally the same economic policies and public policy responses that give rise to income differentials between people, and to the widening income inequalities that still appear to have an influence on the material conditions affecting peoples’ health opportunities.

How Well Is Canada Faring?

Since 1991, at least, Canada hasn’t made much progress in shrinking this income and health gap. Differences in the remaining years of life expectancy at age 25 for men in highest compared to the lowest income quintile was 7.1 in 1991. In 2006 it was still 7.1. For women the differences were 4.9 in 1991 and, well, in 2006: still 4.9.

How do these average individual differences stack up when the whole population is considered?

In 2013, Statistics Canada published the most comprehensive look at income differentials in mortality. The study examined cause-specific mortality rates by income adequacy among Canadian adults, using data from the 1991 to 2006 Canadian census mortality and cancer follow-up study. This study followed 2.7 million people aged 25 or older at baseline, 426,979 of whom died during the 16-year period. Age-standardized mortality rates (ASMRs), rate ratios, rate differences and excess mortality were calculated by income adequacy quintile for various causes of death.6 The result:

“If all cohort members had experienced the age-specific mortality rates of those in the highest quintile, the all-cause ASMRs would have been 19% lower for men and 17% lower for women. Extrapolated to the total non-institutional adult population, that amounts to an estimated 40,000 fewer deaths per year (25,000 fewer among men and 15,000 fewer among women)—the equivalent of eliminating all ischemic heart disease deaths (p.17)6.”

Two colleagues of mine, Dennis Raphael and Toba Bryant rather sensationally described these findings in this way:

“The health effects of income inequality in Canada are like 110 passenger jet falling out of the sky every day, 365 days a year.” 7

This led to some ridicule in a Financial Post blog 8, for which I have some sympathy. Describing the airplane analogy as “junk science,” the author, Peter Taylor, correctly points out that these figures are not about income inequality, which would require a measure of the size of the gap between rich and poor. Rather, it is about the fact “that people at the bottom of the income ladder tend to die earlier than those at the top.” As Taylor goes on:

“Why this is so is cause for vigorous debate. It could be a simple lack of resources. Low income Canadians might lack the ability to successfully navigate the complexities of Medicare. It might also reflect the fact lifestyle risk factors such as smoking, drinking and lack of exercise are more prevalent among lower incomes. Whatever the reasons, however, there’s a world of difference between acknowledging a link between poverty and health, and indicting income inequality as the cause of 40,000 deaths a year.” 8 plane

Fair enough, and Taylor is pretty correct in identifying the proximal causes of some of these gradient differences in health as they relate to one’s level of income. But we seem to be much more complacent in making similar claims that compare the mortality risks of smokers vs. non-smokers. Is it so misleading to describe the life expectancy differences between the richest 1/5th and the rest of Canadians as an inequality? More to the point: Taylor is wrong to ridicule public health’s concerns with these differences as “junk science”, arguing that public health should stick to vaccinations and steer clear of economics. The causes of these income differences in Canadian deaths are located within the economic and political policy choices that affect income distributions, and the social and environmental contexts that in turn affect poorer lifestyles, poorer living conditions and poorer opportunities for health.

That makes them a public health concern, just as the impoverished circumstances of early European industrial capitalism were the incubator of modern public health and its concerns with the conditions that create infectious and other diseases.

The Global Context

To put these findings into a larger global frame, since that is where most of my work is now focused:

  1. Income inequalities are at the highest level amongst OECD nations since 1985 – incidentally a period not only of economic recession, but also of the global diffusion of neoliberal economic models and market de-regulation.
  2. These inequalities are not just in relative income, but also in absolute income, including Canada.
  3. There is a negative and statistically significant impact between the scale of income inequalities and economic growth9. Income inequalities thus have a bearing on health due to any of the health-positive ‘trickle down’ effects of economic growth.
  4. The negative effect of income inequalities on growth is greatest when the gap between lower and median income households rises. Although the ‘breakaway’ wealth of the 1% is unrelated to economic growth (whether positive or negative), this breakaway wealth nonetheless correlates with decreases in the share of economic product going to labour (vs. to capital) and to a disproportionate control over politics and policy by a very small economic elite.
  5. Globally, wealth inequalities are even more extreme, as groups like OXFAM have been challenging much of the world on. Just 67 individuals (some estimate 72, but what’s another 5?) now have more wealth than the bottom 3.5 billion of the world’s population.10 10 individuals in Africa have more wealth than bottom 50% of that still impoverished continent.11labonte2
  6. Why wealth inequalities matter: globally we cannot eliminate life-threatening poverty without shifting economic policies to greater redistribution, both pre- and post-market. And certainly not if we are concerned with the ecological limits of growth, since as the 2009 UK Sustainability Commission noted, “there is as yet no credible, socially just, ecologically sustainable scenario of continually growing incomes for a world of nine billion people.”12

Acting on these global contexts and the national level requires two interrelated sets of policy reforms:

  1. Pre-market: elimination of low pay and precarious employment conditions through strengthened core labour rights, high minimum wages and strengthened collective bargaining to establish or re-establish a social contract between capital and labour; and changes in working hours and remuneration allowing employment opportunities to be more equitably shared.
  2. Post-market: redistribution through progressive taxation of incomes, inheritance, and rents; improved royalties on resources especially in low-income countries; capital controls to prevent legal or illicit capital flight; closure of tax havens; and a financial transaction tax or other systems of global taxation.

Most of the OECD nations, however, have been going in the opposite direction in both of these policy areas. Respecting taxation and globally, the picture is even more pronounced, with net global taxation in the past 10 years (2002 – 2012) on a steady decline, resulting in USD 30 trillion more in untaxed wealth floating around the world now than just a decade ago (author calculations based on the World Bank data set). Yet OECD and IMF studies generally conclude that low income inequality is robustly associated with better economic growth, and that redistribution through progressive taxation that lowers income inequality “is benign in terms of its impact on growth (p.4).”13 Several recent studies have affirmed this:

  • A US review of econometric studies that concluded that raising the marginal tax rate from its present low 35% to its historic high of 68% would have no impact on factors driving economic growth, but would reduce poverty, inequality and stimulate growth through public spending.14
  • An IMF study that more cautiously suggest that capping the marginal rate at 60% would have little or no effect on growth rates.15
  • Emmanuel Saez and Thomas Piketty, although never believing this would be achieved, have argued that there is no economically justifiable reason why the marginal rate shouldn’t be at 80%.16
  • More recently, a paper drawing on the concept of economic optimality concluded that a 90% marginal rate tax on incomes > $300,000 may lead to some declines in GDP and aggregate wealth, but would also lead to greater overall well-being and happiness.17

This leaves unchallenged the fact, from an environmental vantage, we need to abandon the concept of growth as a measure of prosperity and develop other metrics that capture the capabilities and social interactions that are the bases of health and happiness.12

Not a Crisis of Scarcity, but a Deficit of Fairness

But what these bases nonetheless tells us is that, in Canada, and in much of the rest of the rich world, we do not have a problem of scarcity; we have a severe deficit of fairness, whether we frame our social justice remedies as increasing equal opportunity or improving equal outcome. This deficit, in turn, still diffuses globally, characterizing differences within and between nations.

With respect to the pre-market reforms mentioned above, and in the words of Henry Ford a century ago:

“I have to pay workers enough that they can afford to buy my cars.”

With respect to post-market conditions we need to enhance, and in the words of the American jurist, Oliver Wendell Holmes, expressed at another time when income and wealth inequalities were racing out of control:

“Taxes are the price we pay for a civilized society.”

Repeated opinion polls find that the majority of Canadians would agree to paying higher taxes, if such revenues went into the health and education, environmental protection, and other public good programs that most Canadians value – all investments that would lower market inequalities perhaps even better than income transfers or tax credits alone (the market has a way of stealing new dollars from the pockets of the poor, through higher food, housing or other commodity or service prices).

For Canadians, we should heed the caution of an OECD cross-national study that suggests that once a nation’s Gini income co-efficient rises above 0.3 there will be as much as a 9.6% increase in adult mortality (15-60 age group).18 In Canada, we are now considerably above the 0.3 Gini threshold, even after taking account of our (now slightly less generous) post-tax and transfers.

As a country, Canada is unlikely to proceed alone in making dramatic policy shifts in our taxation, minimum wage or social protection policies. To do so would put us in a competitive disadvantage with our Anglo-American economic neighbours and, with open global financial markets, risk capital flight (licit or otherwise) by corporations and high-income earners. Compared to many northern European countries, however, we could embrace much higher marginal taxes than we levy at present. But we would also need to engage in changing the rules of the global economy such that the growing gap between the tops, bottoms and most of the in-betweens is stopped, and then shrunk. Reducing inequalities, and not just eliminating absolute poverty, is now on the global Sustainable Development Goals agenda, which will be normatively binding on all nations if approved at a special UN General Assembly this September. There is renewed global discussion of global financial taxes of one form or another; and on the need to levy a social protection pool based on countries’ abilities to pay, to be drawn upon based on needs.

Indeed, there is no shortage of potential policy initiatives that can address income inequalities and remedy the negative health externalities these create, if not by their scale so much as simply by their existence. It is unlikely that the present Canadian government will embrace these new global policy discussions with any earnest, since it has had a long-standing political platform of going in the opposite direction.

But at the very least these policy options need national debate and a healthy re-kindling.

Can the Canadian Senate add more fuel to this important policy fire?


1. Wilkinson, R. and Pickett, K. (2010) The Spirit Level: Why More Equal Societies Almost Always Do Better, London: Penguin.

2. Lynch, J., Smith, G.D., Harper, S., et al. (2004) “Is Income Inequality a Determinant of Population Health? Part 1: A Systematic Review,” Milbank Quarterly, 82(1):5-99.

3. Deaton, A. (2011) What does the empirical evidence tell us about the injustice of health inequalities? Mimeo: Centre for Health and Wellbeing, Princeton University. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1746951

4. Torre, R. and Myrskylä, M. (2014) “Income inequality and population health: An analysis of panel data for 21 developed countries, 1975–2006,” Population Studies, 68:1-13.

5. Pickett, K., and Wilkinson, R. (2015) “The Ethical and Policy Implications of Research on Income Inequality and Child Well-Being,” Pediatrics, 135 (Supplement 2):S39-S47.

6. Tjepkema, M., Wilkins, R. and Long, A. (2013) “Cause-specific mortality by income adequacy in Canada: A 16-year follow-up study,” Health Reports, 24(7):14-22.

7. Raphael, D. and Bryant, T. (2014) “The Health Effects of Income Inequality: A Jet with 110 Canadians Falling Out of the Sky Each Day, Every Day, 365 Days a Year,” http://www.thinkupstream.net/health_effects_of_income_inequality

8. Taylor, P.S. (2015) “Junk Science Week: Death by One Percenter,” FP Comment, March 3. http://business.financialpost.com/2015/03/03/junk-science-week-public-health-officials-are-blaming-income-inequality-for-poor-health-so-they-can-exercise-control-over-the-economy/

9. Cingano, F. (2014), “Trends in Income Inequality and its Impact on Economic Growth”, OECD Social, Employment and Migration Working Papers, No. 163, OECD Publishing. http://dx.doi.org/10.1787/5jxrjncwxv6j-en

10. Moreno K. (2014) The 67 People As Wealthy As The World’s Poorest 3.5 Billion. Forbes March 25. http://www.forbes.com/sites/forbesinsights/2014/03/25/the-67-people-as-wealthy-as-the-worlds-poorest-3-5-billion/

11. Lakner, C. (2015) “The ten richest Africans own as much as the poorest half of the continent,” Let’s Talk Development World Bank blog, March 11. http://blogs.worldbank.org/developmenttalk/ten-richest-africans-own-much-poorest-half-continent

12. Jackson T. (2009) Prosperity without growth: The transition to a sustainable economy?  London: UK Sustainable Development Commission.

13. Ostry, J., Berg, A. and Tsangarides, C. (2014) Redistribution, Inequality and Growth, Washington: International Monetary Fund. http://www.imf.org/external/pubs/ft/sdn/2014/sdn1402.pdf   

14. Fieldhouse, A. (2013) A review of the economic research on the effects of raising ordinary income tax rates, Economic Policy Institute, New York. http://www.epi.org/publication/raising-income-taxes/

15. Elliot, L. (2013) IMF eyes tax potential of the world’s super-rich, The Guardian: http://www.theguardian.com/business/2013/oct/13/imf-meeting-united-states-debt-ceiling.

16. Saez, E. and Picketty, T. (2013) “Why the 1% should pay tax at 80%,” The Guardian, October 24. http://www.theguardian.com/commentisfree/2013/oct/24/1percent-pay-tax-rate-80percent

17. Kindermann, F. and Krueger, D. (2014) “High marginal tax rates on the 1%,”, CEPR’s Policy Portal, November 15. http://www.voxeu.org/article/high-marginal-tax-rates-top-1

18.  Kondo, N., Sembajwe, G., Kawachi, I., van Dam, R., Subramanian, S. and Yamagata, Z. (2009). “Income Inequality, Mortality and Self-Rated Health,” British Medical Journal, 339, b4471.

‘But they just can’t kill the beast’: the ongoing neoliberal plague

In this guest post, Ronald Labonté traces the history of neoliberalism through structural adjustment programs, the Great Recession and into current Austerity Agendas. Labonté examines why neoliberalism continues to dominate economic agendas and what types of policy messages are needed to combat the resulting health plagues. This post is cross-posted at Global Health Watch in support of the latest alternative world health reportLabonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and is Professor in the Faculty of Medicine, University of Ottawa; and in the Faculty of Health Sciences, Flinders University of South Australia.

The opening line comes from a classic 1977 song by The Eagles, ‘Hotel California.’ It’s a prescient line, since it was crafted just before the dawn of the neoliberal era (1980 and ever onwards), and emanated from the American heartland that helped spread the gospel of neoliberal economics around the world.

The Eagles were not singing about the 2008 Global Financial Crisis and its subsequent Great Recession and Global Austerity Agenda, but they may as well have been. The 2008 crisis was thought by many at the time to herald the final disgrace of a beastly neoliberal orthodoxy that deserved to die. But, in testament to capitalism’s resilience and the capture of the state by global elites (the 1%), the Occupy and other progressive social movements worldwide have so far been unable to kill the beast.

The Austrian-born economist, Von Hayek, is credited with first defining the essential contours of neoliberal economics in the 1940s: free markets, strong property rights, sovereign individuals and minimal government interference. It was not until the elections of Reagan (US), Thatcher (UK) and Kohl (Germany) in the 1980s that this marginal economic theory came to dominate what were then the world’s leading economic powers. Keynesian economists writing at the same time as Von Hayek summarily dismissed his ideas as ‘the belief that the nastiest of men for the nastiest of motives would somehow work for the benefit of all.’

The impetus for neoliberalism’s ascendency can be traced to the episodic crises of modern capitalism, where overproduction and under-consumption lead to declining rates of profit. These ups and downs in the business cycle were aggravated in the 1970s by the oil price shocks, which led to ‘stagflation’ in advanced economies and large international debts in developing nations having to front the rapidly rising costs of oil imports. The corresponding shift to the right in politics in the US and UK, and the threat of developing world debt defaults, gave neoliberal apostles a massive window of opportunity. This was seized upon in the first neoliberal wave, the structural adjustment programs (SAPs) imposed by the IMF and World Bank on indebted developing countries as the price for loan guarantees and bailouts. SAPs may have helped to keep the global financial system afloat, but did little for the economic recovery of those regions most under their yolk (Latin America, Africa). The health plague SAPs engendered was quickly evident, as structurally adjusted states spent less on health, education, social protection or other measures, imperiling the health of the poor, and particularly women and children. By the 1990s, income inequalities and health inequalities, after decades of shrinking, began a reverse trajectory. SAPs generally failed to achieve the economic growth their privatization, liberalization, de-/re-regulation and state minimalism agenda had promised. Although the term fell out of favour, its neoliberal economic platform did not.

That platform also led to neoliberalism’s second major iteration: the financialization of the economy. Stated simply, investors found it was easier and faster to make money from money than to build the ‘real economy’ of production and consumption. Aided by the repeal of banking regulations, central bankers’ belief in the beneficence of unfettered global capital and new digital technologies capable of creating a potpourri of new gambling ‘instruments’, the growth in what some have called ‘funny money’ speculation began in the 1990s and soared to stratospheric heights in the early 2000s. The global value of ‘derivatives’ (highly leveraged gambles in underlying assets such as stocks, bonds, currencies, and market indexes) still outstrips the value of the global economy by a factor of 10, despite the travesty of the 2008 Global Financial Crisis they helped to create.

The proximate causes of the 2008 crisis are now well known, explained in large measure by real estate sub-prime mortgages, the diffusion of ‘toxic debts’ marketed as sound investments throughout a globally integrated financial system, and the collapse of the real estate bubble on which the sub-prime debt-financed consumption of America’s declining middle-class was based. The rapid ripple effect in global supply chains led to the Great Recession (statistically now over for many countries though even most mainstream economists consider another one just around the corner) and the highest worldwide unemployment numbers on record. Recessions can sometimes bring health benefits; people use their cars less, and have less discretionary money to spend on tobacco or alcohol. But recessions can also lead to consumption of cheaper, unhealthier foods and bouts of binge drinking. Rising unemployment that is recession’s inevitable wake is strongly associated with negative health impacts. What employment that remains (or is newly created) in the wake of the 2008 crisis is often insecure, part-time and impoverishing in pay, creating considerable mental (and hence physical) distress. That’s for the rich world. For the poorer world, and as before with SAPs, women, children, rural populations, and informal workers are hit the hardest. Even in regions claimed to be growing rapidly despite the crisis and global recession (i.e. Africa), most of that growth is jobless and based upon the exploitation of that continent’s mineral, oil or ‘land-grabbing’ wealth.

Neoliberalism’s modern plague persists most perniciously in the Austerity Agenda. Wealthy countries around the world, faced with the imminent and chaotic demise of global finance and (hence) global capitalism in 2008, magically came up with trillions of dollars to bailout, shore up and/or socialize the debts of the egregious greed of a handful of the 1%. Rediscovering the ameliorative wisdom of Keynesian economics – that when private markets fail, governments should intervene – those countries that could pumped billions more into countercyclical public spending in an effort to jumpstart the sluggish global economy. It worked, at least a little bit and for a very little while. But within 18 months of public life support to their economies, governments were under pressure to rein in their spending to avoid debts that were believed by some economists (incorrectly, it later turned out) to dampen economic growth. Austerity became the catch phrase for a return of the same package of discredited neoliberal ideas as SAPs, but now on a global scale and in rich countries as well as poor. As with SAPs, the disease-generating fallout is becoming more manifest: from cuts to health, education and social protection; to user fees creating barriers to entitlements; to a slow down in poverty reduction or in the great achievements in reducing infant mortality and increasing life expectancies that the world’s governments committed to continuing in the 2000 Millennium Development Goals.

Of course, not all have had to tighten their belts. Indeed, as neoliberal globalization weakened labor rights, freed capital of most border constraints and turned a blind eye to tax evasion or avoidance schemes available only to transnational corporations and economic elites, the rich got obscenely richer and everyone else started sliding down the income and wealth gradients. These dramatic shifts in wealth, power and inequality may not show up immediately in health inequalities, but the evidence on what we now call the ‘social determinants of health’ portends for a rather sickly and dismal future for much of the world’s population.

Why has such an empirically vacuous set of economic practices continued to hold sway over most of the world’s governments? (Note ‘most,’ not ‘all’).

There are several potential answers, but the most compelling is the simplest: That many governments actively want to shrink the state. Their political leaders (or campaign financiers) are committed neoliberals, but their voting publics may actually like some of the programs that public revenues make universally accessible. There’s nothing like a claimed (and in most cases faked) fiscal crisis to sell citizens on the need for deeper cuts and more privatization, echoing Thatcher’s famous comment when first implementing such measures in the 1980s: There Is No Alternative. Almost forty years of this domineering message has indeed made it difficult for alternatives to gain a credible, media-prominent place in the economic playbooks of most political parties – a challenge that progressives must confront head on and which, more optimistically, does seem to be gaining a bit more space in public discourse. Social media helps here but so, too, do the organized mobilizations of resistance that have sparked around the world since 2008. Although not yet a singularly coherent political voice (and some might argue that a globalized world confronting multiple crises demands a politics of multiple voices driven issue by issue), the worrying decline in formal political participation in many countries is counter-balanced by a surge in the space for participatory democracy afforded (at least for now) in the digital world.

The policy messages that must occupy this participatory space, and to begin crowding out the neoliberal refrain across more conventional media, are fairly simple.

We need to put global finance back on a tight regulatory leash. There are little steps being taken to do so, but nothing as yet substantive enough to fundamentally alter the rules of the funny money game, or to prevent another financial collapse from occurring. (For those disappointed that 2008 didn’t kill the beast, don’t get too depressed. There will be more crisis opportunities.)

We need to rebuild the progressive and redistributive tax systems that wealthier nations enjoyed in the post-WWII era, and that shrunk the disparities that precipitated the 1930s Depression and, indeed, WWII itself. And we need to build such tax systems in today’s low- and middle-income countries saddled with decades of advice to keep their taxes low to attract foreign investment. (I set aside for now the further challenge of reducing institutional corruption – both public and private – that requires strong civil societies, greater financial transparency and justice systems free of elite capture.)

We need progressive and redistributive taxation to become global, since a globally integrated economy needs globally integrated means of redistribution. Two such measures would include a financial transaction tax (which could raise for the public good as much as $8 trillion annually), and the effective closure of tax havens and end to transfer pricing by which the rich keep most of their riches to themselves (bugger the public good!).

But we also need to change how incomes are earned in the first place. There are too many people competing for too few jobs in a highly unequal and bifurcated labor market. We need jobs to be shared more equitably, pay to be substantially more equalized and unions/labor rights to be strengthened, not ‘flexibilized’ in the name of global competitive advantage. Rather than governments negotiating more ‘free’ trade and investment treaties that lock in the privileges of investors and the oligopolies of transnational corporations (the same privileges that has led to the greatest wealth inequalities the world has likely ever seen), our governments should be creating more democratic and participatory forms of global governance in which the survival demands of creating a new economic order and a new way of sharing the diminishing natural resources of our planetary commons are the focal concerns. High on their issues list has to be the survivability of our planet, and a clean break with our fossil fuel, growth driven economic irrationality that is rational only if long-term human wellbeing is excluded from conventional economic equations.

In the immediate term, we need to refute the Austerity Agenda – now holding almost 80% of the world’s population in its grip – for what it is: an ideology devoid of theoretical or empirical support, that dampens rather than promotes economic growth, and that only fills the coffers of those already so rich that, as Oxfam reminds us, the wealth of the richest 85 people alone is more than that of the bottom 3 billion half of humanity.

If the scale of that inequality isn’t the single most outrageous global health issue of the day (well, alongside climate change, and they’re not unrelated) I don’t what is.

So let’s get on with shouting out the alternatives. After all, that is what Global Health Watch 4 and its three predecessors are all about anyway.