Trade and Public Health: What’s missing?

In a piece published in the Lancet last Friday, public health researchers warn of the negative public health impacts of the Trans Pacific Partnership Agreement (TPP), also known as ‘the biggest trade deal you’ve never heard of’.

The TPP is a large regional trade agreement being negotiated by 11 countries around the Pacific Rim—Australia, Brunei, Canada, Chile, Malaysia, Mexico, New Zealand, Peru, Singapore, USA, and Vietnam.

The authors draw attention to two major ways the Agreement is likely to negatively impact public health. First it is argued that the TPP will reduce access to medicines via strong protections on intellectual property rights. Second, the authors note that one of the Agreement’s major clauses (related to investor–state dispute settlement provisions) will limit the ability of governments to regulate important health impacting industries such as those related to the production of tobacco, alcohol and highly processed foods.

The outlined arguments are compelling and worth a read. They are also supported by similar warnings being cast across the public health sphere.

However, I wonder if there isn’t more to the picture. The identified pathways which link the TPP to health are largely about contextualizing risk factors. That is, they contextualize people’s exposure to individual-based risk factors. These risk factors are related to people’s access to medicines and unhealthy behaviours such as smoking, alcohol consumption and the consumption of unhealthy foods. In this way, these pathways can largely be characterized as operating within a bio-medical paradigm.

However as Link and Phelan importantly acknowledged, even if we change the contexts within which people are exposed to individual-based risk factors, fundamental determinants of health will continue to shape population health profiles. This is because fundamental determinants of health—things like income, power, knowledge, prestige—are associated with a range of diseases and health outcomes. Moreover, we live in a world where new diseases and risk factors are always presenting themselves, and those with greater resources will always be better positioned to protect themselves. This idea is similar to perspectives which highlight the health importance of factors outside the bio-medical domain, factors for instance related to people’s social position like income and employment, and the distribution of wealth across populations. The idea here is that these social determinants have impacts on health outside of their role in shaping individual health behaviours.

So while the pathways thus far identified as linking the TPP to health are important, are they the only ways through which the Agreement might impact health? Specifically, are there ways in which it may also impact these fundamental, social determinants of health?

In a Wall Street Journal piece, author Philip Stevens argues that lamenting over the TPP’s influence on access to medicines is short sighted since it ignores the historically important role trade has played in generating many of the negotiating countries’ wealth, such as Singapore, and thereby their subsequent gains in health via increased spending capacities on important health promoting policies like water and sanitation programs. However, this notion was forcefully rebuked in a piece by Pubic Citizen which among other arguments illustrates that during periods of increased trade liberalization economic growth contracted in Singapore, as it also did in other countries undergoing liberalization policies. Therefore free trade can neither be categorically credited for higher growth nor improvements in health outcomes.

But saying that trade liberalization does not uniformly lead to growth or that economic growth does not uniformly lead to improved health, does not mean that trade does not impact health through economic pathways.

The TPP for instance, is expected to have wide implications on the textile and clothing sector, which many middle and low income countries rely on as an important source of employment. For example, by removing tariffs on textile imports from much of Asia, the Agreement is likely to negatively impact textile producing countries in the Caribbean and Central America. El Salvador alone is expected to lose 22,000 jobs in its textile market (and another 15,000 indirectly). On the flip side, textile markets in Asia, and in Vietnam particularly, are expected to gain.

Employment, as a key factor shaping people’s social position, is a fundamental and social determinant of health. But how these shifts in employment will impact health will largely depend on countries’ labour market conditions as well as the level of protection offered by policies like unemployment insurance.

Current acknowledgements of the links between TPP and health call for the incorporation of health impact assessments within international agreements, strengthened representation of public health within economic negotiations and greater coherence between trade and health policy.  Expanding our understanding of the links between this agreement and health not only strengthens these calls, but is crucial to the success of these undertakings.


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