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


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.

Global Health Working Group Promotes Ebola Open Letter

Last week a Workshop was held at the Centre for Global Health Policy at the University of Sussex which brought together a number of scholars, primarily UK-based International Relations scholars, to discuss the current Ebola crisis and the international response to it.

From this workshop arose an open letter on what the field of International Relations offers in terms of learning the lessons from the Ebola response:

The Ebola outbreak in West Africa has brought to light some important issues and tensions in global health, ranging from the institutions that have been created to service the international community – such as the World Health Organization (WHO) – to the role of governments, politics and ideas in determining how, where and what health issues are addressed. Failings in the management of and response to the Ebola outbreak have sparked a debate about the efficacy of the system of global health governance. This is a necessary debate for the global health community to engage in. When the time comes, we believe that analysts of global health politics and international relations have several valuable insights to help ‘learn the lessons’ from the 2014 Ebola outbreak.

First, on institutional reform: The Ebola outbreak has been an exceptional event. It should not be assumed that lessons drawn from this single event can provide a template for redesigning the everyday workings and agenda of an institution such as the WHO. The WHO has certainly made mistakes in the Ebola response, and these need to be recognized and addressed. However, the efficacy of its Ebola response is not the only metric by which this institution should be judged, nor should Ebola be used politically as an opportunity to further undermine the WHO.

Second, on institutional innovation: We have observed recent calls for the creation of a new international ‘rapid response’ agency for health emergencies. Clearly in some cases rapid response is of the utmost importance, and enhanced rapid response coordination and capacity is needed. However, emphasising rapid response to the detriment of other solutions is problematic, inasmuch as the former is by its very nature ill-suited to building long-term solutions to deep-seated problems. The international community must also be careful that creatingsuch a body may be counterproductive, by shifting attention away from the important task of strengthening in-country health systems which are best-placed to be first line responders to health emergencies.

Third, on the relationship between global health governance and national health systems: Any investigation into institutional failings in the response to Ebola in 2014 must be cognizant of the wider system of global health governance that has dominated questions of African health reform since 2000. A knee-jerk “blame game” of “who did not do what when they should” will only provide a veneer of accountability. Instead, we need a systematic unravelling of why health systems were so poorly developed in Guinea, Liberia and Sierra Leone. Here, reflecting on the impact of the goal-oriented mentality underpinning the Millennium Development Goals agenda cannot be avoided. We must also consider the roles of the actors (state and non-state) that have supposedly been responsible for supporting these health systems, and what they could have done better. The results of such analyses could go some way to providing the basis for thinking about how to build a more sustainable model of global health governance.

Fourth, on the centrality of politics to all institutions: Attempting to separate politics from the technical workings of institutions is a useless exercise – and a potentially dangerous one. All global health institutions are engaged in the management of resources, expectations and the interests of a myriad of state and non-state actors. They have to engage in political brokering, negotiation, leadership and policy design and implementation. The idea that international institutions can or should be “apolitical” has only contributed to limiting their agency, whilst obscuring the real politicking that occurs within and between these institutions. ‘Politics’ is not the problem, and it must be part of the solution.

Fifth, on power and inequalities: Contrary to a much-repeated refrain, disease does know borders. These borders may be those that separate nation-states from one another, but they can also be cultural, racial, economic, or gendered. Access to information and adequate healthcare, as well as exposure to health risk, are not equally shared but rather are dependent on a multitude of local, national and international divisions – not least inequalities in power and wealth. These need to be acknowledged, understood and deconstructed if we are to finally make good on the promise of delivering ‘health for all’.

The recent Ebola outbreak in West Africa – the latest in a depressing series of outbreaks in this region in recent decades – has highlighted the extent to which global health policy has become reactive rather than proactive. A failure to take bold political action in addressing the concerns we have highlighted in this letter will mean that the global health community will remain ill-equipped to respond to future outbreaks, still less to prevent them occurring.

Should you or any of your colleagues wish to sign this open letter please email Sophie Harman (s.harman@qmul.ac.uk) by Midday UK time on Monday 8th December with: ‘Please add my name to the open letter, *name and *institution’.

Global Trade and Health: Rana Plaza, One Year On

Last Thursday marked the one year anniversary of the Rana Plaza tragedy in Bangladesh, which left more than 1100 dead and many more injured. The disaster has been described as one of the worst industrial accidents in modern history.

In the year since the accident, we have witnessed a number of initiatives aimed at providing compensation to the victims and preventing similar catastrophes from occurring in the future. As recent analyses and commentaries point out however, these efforts have been largely insufficient. Victims for instance, have thus far received little compensation despite promised assistance. The two agreements meant to hold corporations accountable for working conditions, fall short on a variety of fronts. And the market for cheap, fast-fashion continues to swell.

However, there is a particularly important issue which seems to have been largely neglected in these discussions: that garment production in Bangladesh, and its accompanying impacts on workers’ well-being, cannot be considered in isolation from the broader global trading regime within which it is situated.

Production in the textile and clothing sector is characterized by global commodity chains whereby suppliers around the world compete for contracts. This creates an imperative for suppliers to remain competitive by way of low labour costs and more flexible employment conditions. Poor working conditions in the sector are thus not unique to Bangladesh, or even less developed countries. This past December, seven workers were killed in a garment factory fire in Italy, where thousands of Chinese immigrants are reported to produce garments under conditions of squalor.

Employment in the sector is also extremely vulnerable to the type of economic shifts that are inherent to an increasingly interconnected world. In 2001, an economic recession combined with a change in US foreign policy diverted a significant amount of garment orders from Bangladesh to African and Caribbean nations. In a matter of months, almost 1,300 firms closed and 400,000 workers (mostly women) were left jobless. Job insecurity, in addition to poor working conditions, is thus a defining feature of employment in the sector.

Together these considerations suggest the need for a broader, global approach to ensuring the well-being of textile and clothing workers. Towards this end, some have suggested linking trade agreements to respect of international labour standards. However, others worry this might raise labour costs to the point that poor countries will lose a significant proportion of their employment.

It has also been suggested that “the struggle for labor standards needs to be broadened and made more inclusive by transforming itself into a struggle for a universal ‘‘social floor,’’” which would guarantee provision of basic needs to all citizens. This would not only ensure that workers are able to collectively organize without fear of losing their employment, but also provide a safety net for workers in times of economic downtowns.

At a minimum, addressing the well-being of textile and clothing workers requires recognitions of the links between global trade and labour markets, discussions of the ultimate objectives of trade policies, and more comprehensive and fine-tuned assessments of how trade interacts through international labour markets to influence health.

Healthcare spending and health: looking beyond the money


This graph was posted on the Atlantic last week and illustrates the striking relationship between healthcare spending and life expectancy.  There are many important and interesting aspects to this relationship, which has been documented for some time, but there is one aspect which is seldom discussed when the topic surfaces in mainstream media outlets.

One of the most discussed features of this relationship, and the one covered by Atlantic author Matthew O’Brien, is the isolated position of the US (in the top right area of the graph). O’Brien notes that ‘[Americans] spend much more than any other rich country, but [they] certainly don’t get more for it. [They] get less. [They] get about the same health outcomes, but don’t cover everybody like other rich countries do.’

With US life expectancy clearly positioned below 80 years, and other countries approaching levels closer to 85, I can’t agree with O’Brien that Americans ‘get about the same health outcomes’, but let’s leave that aside for now.

The obvious questions prompted here are why does healthcare cost so much in the US, and relatedly, how can this wasteful spending be eliminated? O’Brien points his finger at culprits like high doctors’ pay and patients’ opposition to having their coverage change.

A  more extensive debate on this relationship is happening on the blog, The Incidental Economist, which is the original source of the graph used in the Atlantic piece. Nonetheless, the bottom line of many of these conversations is likely to be some form of O’Briens conclusion:  [Americans] can’t afford [their] healthcare exceptionalism’.  With an extreme and growing number of Americans underinsured, unemployed and underfed, this conclusion is hard to deny.

But there is another important conversation to be had.

This conversation emerges when we look at the cluster of countries spending more than $2000 per capita on healthcare. Here the data begins to flatten out and after this point, spending on healthcare appears to buy little in terms of health improvement. This particular feature of the graph prompts different sorts of questions than those outlined above. Questions like: if healthcare spending is not buying health improvements then what  is responsible for better health; and why does the US lag so far behind in international health comparisons? The bottom line of conversations centred on these questions point to a different sort of American exceptionalism.

There are several, well-documented, reasons why healthcare does not produce health. These reasons derive from population health research and generally speaking, relate health to societal structures that govern the amount of inequality in a society. In this field of work, American exceptionalism is found in graphs like this one:

infant mortality

In this graph, the US (again, at the top right) is isolated for its extremely high level of income inequality and high level of infant deaths.

Despite the fact that there are now over 170 studies which show that health is worse in more unequal societies, even  journalists hired to cover health stories neglect to identify inequality as a crucial determinant of health.

The relationship between spending on healthcare and health illustrates the limited returns of exorbitant US spending, but it also demonstrates the limitations of medical care in producing health: a story whose time is beyond ripe.


Readers of Healthy Policies will know that inequities in health are very much rooted in inequities of power. Recent posts by Ted Schrecker have outlined how political trajectories shape landscapes of health disparities. A defining feature of these trajectories is that in addition to being determined by unequal distributions of power, they also perpetuate the social structures responsible for these distributions. Because shifts in power have hugely increased social inequalities, including health inequities, power politics are health politics.

In this post I want to draw attention to a recent event in the scientific community. Its links to population health are by no means immediate, but it is a recent and striking example of how power dynamics can play out even in the context of a reputable scientific outlet.

Here is the short version of the story:

Danielle N. Lee, PhD is a postdoctoral research associate at Oklahoma State University. She is an African-American biologist who writes on her Scientific American blog, ‘The Urban Scientist’, about diversity issues in the scientific community. Dr. Lee was asked if she’d be willing to write for free for biology-online.org, a partner of Scientific American. She politely declined with the following:

Thank you very much for your reply.
But I will have to decline your offer.
Have a great day.

The editor of Biology Online came back with this:

“Are you an urban scientist or an urban whore?”

Dr. Lee posted a thoughtful response to the Biology Online editor on her blog, which was then removed without warning by Scientific American. Mariette DiChristina, editor-in-chief for Scientific American, said in a Twitter post that“@sciam [Scientific American] is a publication for discovering science. The post was not appropriate for this area & was therefore removed”.

It is worth noting that other Scientific American bloggers have protested that standards about what they can write have never been made explicit by the organization. Indeed many have pointed at examples of their own writing which are unlikely to fall under the remit of ‘discovering science’.

Bloggers in the scientific community have been rallying to Dr. Lee’s defence.  I encourage those of us in the social sciences and concerned with the public’s health to do the same.

To stay up-to-date with this story, follow the Twitter hashtag #standingwithdnlee.

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.


Curb the Spread of the Flu: don’t eat at restaurants that don’t provide paid sick leave

Photo by Flickr member Mcfarlandmo, available under a Creative Commons Attribution-Noncommercial license.

According to the Centers for Disease Control, the US is in the midst of the worst flu season it’s seen in a decade. In Boston, a state of emergency has been declared, where at least 18 people have died because of the flu. The CDC recommends that people with flu-like symptoms stay home and avoid contact with others, except to receive medical care. But as Think Progress reports,

“for a huge number of American workers, that option doesn’t exist due to a lack of paid sick days. 40 percent of private sector workers and a whopping 80 percent of low-income workers do not have a single paid sick day. One in five workers reports losing their job or being threatened with dismissal for wanting to take time off while sick”

So what’s a country to do?

One idea is to avoid restaurants that don’t provide paid sick leave—in the food industry the potential for spreading disease is high, especially with  79% of workers reporting that they are unable able to take a paid sick day.

While this would do little for sick workers this season, it does have the potential to reduce the spread of disease, and perhaps it could act as an incentive for employers to provide better benefits to their workers (although there are other reasons why providing paid sick leave is good for business).

Which restaurants don’t provide paid sick leave to their employees?

Each year the Restaurant Opportunities Centers (ROC) United publishes a guide on the working conditions in popular America restaurants. In their latest guide, the following restaurants are noted for not providing paid sick leave:

7-Eleven Logan’s Roadhouse
AppleBees Long John Silver’s
BJ’s Restaurants Longhorn Steakhouse
Bob Evan’s Restaurants Luby’s Cafeteria
Bojangle’s Famous Chick ‘N Biscuits Maggiano’s Little Italy
Bonefish Grill McCormick & Schmick’s
Boston Market McDonald’s
Buca Di  Beppo Moe’s Southwest Grill
Buffalo Wild Wings Morton’s, The Steakhouse
California, Pizza Kitchen Noodles & Company
Capital Grille O’Charley’s
Captain D’s Old Chicago
Carino’s Italian On the Border
Carl’s Jr Outback Steakhouse
Carrabba’s Italian Grill Papa Murphy’s
Cheddar’s Causual Café Perkin’s Restaurant Bakery
Chick-Fil-A Popeyes Louisiana Kitchen
Chili’s Grill Bar Portillo’s Hot Dogs
Church’s Chicken Pot Belly Sandwich Works
Coldstone Creamery Qdoba Mexican Grill
Coner Bakery Café Quizno’s
Cracker Barrel Old Country Store Rainforest Café
Dave & Buster’s Rally’s Hamburgers
Denny’s Red Robin Gourmet Burgers
Dunkin’ Donuts Ruby Tuesday
Famous Dave’s Ruth’s Chris Steak House
Firehouse Subs Sbarro Pizza
Five Guys Burgers & Fries Sheetz
Fleming’s Prime Steakhouse & Wine Bar Starbucks
Fuddruckers Steak N Shake
Godfather’s Pizza Subway
Golden Corral T.G.I Fridays
Hardee’s Taco Bell
Houlihan’s The Melting Pot
Huddle House Uno Chicago Grill/Pizzeria
Jason’s Deli Whataburger
Jersey Mike’s Subs Wienerschnitzel
Johnny Rockets Wingstop
Krystal Yard House
Little Ceasers Pizza

A top 5 list of the best public health top 10 lists

Commemorating each New Year is an endless supply of top 10 lists. Typically these lists recount and rank some variety of preoccupation of the twelve months prior (books, movies, innovations, photos, you-name-it), while others offer predictions or resolutions for the year to come. In the world of public health, this phenomenon finds no exception.

Lists in general can tell us a lot about ourselves—our pursuits, anxieties, desires—when it comes to well-being, the majority of top ten lists portray very individualistic, very bio-medically skewed notions of health.  For this reason I’ve compiled a list of the top 5 public health top 10 lists which approach health with a greater consideration of the social determinants of health (SDOH). I’m only listing five because for all the top 10 health-related lists out there, I couldn’t find many that took this wider notion of health into account. If you know of any others please leave a note in the comments section.

Here goes:

5. The 2×2’s project’s “Public Health 2012: The Top 10 Stories of the Year”—This list discusses some of the major public health stories of the year, including US health reform, the NYC soda ban, and the health impacts of Hurricane Sandy. It made the cut for approaching these stories with a consideration of their political dimensions.

4. Surround Health’s “Public Health Top 10 List for 2013”—This is a list that looks into the future and presents a ranking of “public health milestones to look forward to in the coming year”. While the previous list highlights major public health stories and their political dimensions, I’ve included this list because it highlights a range of political issues and in turn discusses how they influence health. Examples include the health impacts of US immigration reform, gun control, and cuts to social security.

3. Croakey’s “Recommended reading for your summer holidays, from Croakey contributors”—Ok so I’ve bent the inclusion criteria a little bit for this one since it’s not technically a “top 10”, but like I said it was a struggle to find SDOH friendly lists, and you’ll thank me anyways because this has some really great reading recommendations from some very SDOH inclined public health folk.

2. Corporations & Health Watch’s “Books on Corporations and Health from 2012”—This book list comes from an organization concerned with how corporate industry practices influence health—if you didn’t find enough reading material for 2013 in the list prior, look no further.

1. Globalization and Health’s “Most viewed articles in the past year”—Ok, I bent the rules again. This unofficial list comes from Globalization and Health, an open access journal and a great resource for keeping up to date on SDOH research.

And don’t forget, Healthy Policies is in the running for its own “best of” list over at Healthline’s Best Health Blog of 2012 contest. We’re the only SDOH blog in the running and just barely keeping up with the current top 10 contenders—mostly lifestyle and weight-loss blogs—so make sure you vote every day until the 15th of February here!


Tackling Obesity: Should the UK take public health cues from the US?

A new report from the Royal College of Physicians (RCP) notes that nearly a quarter of the UK population is obese, a figure of expanding waistlines which trails only the US. Given the RCP’s objective of improving clinical conditions, it’s not surprising that the report focuses on the medical aspects of addressing obesity, concluding that “the healthcare system in Britain must adapt to the demands of an increasingly obese nation”.

However, in its recommendations for action, the report also directs attention beyond the boundaries of clinical care by calling for a national leader to spearhead obesity prevention efforts and to maintain a spotlight on the growing obesity crisis in the UK. According to Professor John Wass, chair of the working party that produced the report, this national leader should be someone like First Lady Michelle Obama, or New York City Mayor, Michael Bloomberg. Wass says,

“I think we could have a senior figure in London, rather like the mayor of New York, who has led on having smaller measures of Coca-Cola in cups and other things. Michelle Obama has had a huge effect on obesity and getting things labelled.”


Leadership is certainly a crucial aspect of achieving public health goals; but are US leaders focused on the right messages when it comes to addressing obesity?

It is now widely acknowledged among public health professionals that efforts aimed at addressing obesity must account for the broader context within which personal choices are made. As Professor Lindsey Davies, president of the Faculty of Public Health, notes

“Obesity is not only caused by how much we each eat or drink: if tackling it were as simple as telling people to eat less and move more, we would have solved it by now. Our chances of being obese are also affected by factors like whether we have easy access to affordable fruit, veg and other healthy foods, and if it is safe to let our kids play outside.

More fundamentally, obesity is also influenced by the broader structural determinants of health that create socio-economic inequities. The structural determinants of health can be thought of as the policies which create unequal distributions of resources important for health, resources which influence people’s social position like, income, employment, education, knowledge, and power.  In rich countries for example, compelling evidence links obesity to the distribution of income across populations. In countries where the gap between the rich and the poor is wider, we find higher rates of obesity.

Authors, Gore and Khotari (2012) differentiate between three types of policy initiatives when the aim is to improve nutrition and increase physical activity. Initiatives can either be:

  1. Lifestyle-based: where the focus is on changing people’s behaviour, for example through advocacy campaigns to encourage healthier eating habits.
  2. Environmental-based: where efforts are aimed at influencing the environment in which personal choices are made for example, by banning the sales of unhealthy foods at schools; or
  3. Structural-based: where the aim is to improve the structural determinants of health directly for example by, broadening “the distribution of power, income, goods and services across the population”.

The authors argue that the most effective initiatives are those which are based at the structural-level and that public health “should not settle for programs that bring about changes in lifestyle and the immediate environment”.  In fact, it is noted that individual and environment-based initiatives may have potentially negative impacts on health equity by differentially benefiting those who are better positioned to take advantage of the initiatives. This has been the case with many smoking cessation campaigns which target services at the individual level. For example, in a smoking cessation program run by the NHS, the quit rate for the most disadvantaged smokers was only half of that achieved in the highest socio-economic group, despite equal access to the services. A potential explanation for this is higher nicotine dependence among the most socially disadvantaged. Other studies have similarly shown that “anti-smoking messages have been more successful with better off people”.

So where do Michelle Obama and Mayor Bloomberg’s obesity initiatives fall among Gore and Khotari (2012) characterization of healthy living initiatives?

Michelle Obama gained her leadership role in the US with the creation of Let’s Move: a campaign that aims to endchildhood obesity through better nutrition and increased physical activity. Let’s Move conceptually recognizes obesity as a multi-faceted socio-economic issue but is exceedingly an environment-based initiative which aims to improve the contexts in which personal choices surrounding nutrition and physical activity are made, for example, by improving the quality of food within schools and building playgrounds to promote greater physical activity among children.

Mayor Bloomberg poses with different sizes of soft drink containers. Photo: Chad Rachman/New York Post

Mayor Bloomberg is famed in certain public health circles for instituting a ban on large-sized sugary drinks in New York City. This initiative is also, categorically, environment-based since it aims to alter the context in which people make their decisions about what they drink.

While both Michelle Obama and Mayor Bloomberg’s initiatives are sensitive to the fact that people’s choices are shaped by their environments, neither tackle the fundamental, structural determinants of health. It is also worth noting, as discussed in a previous Healthy Policies post, that the Mayor’s initiative should be considered within a broader health agenda, one in which he is noted to have denied the links between income inequality and health.

Indeed if leadership is sought to improve obesity rates, the UK should not be taking cues from the US but from health and nutrition proponents within its own borders.

The UK is much more advanced in terms of the attention that is given to the structural determinants of health. This is especially true when compared to the US where public health efforts continue to compensate for the negative impacts of public policies rather than identify them as the sources of health problems. For example, Sir Michael Marmot is professor of epidemiology at the University College of London, and a well-recognized leader in the structural determinants of health;  UK-based academics Kate Pickett and Richard Wilkinson authored the widely discussed Spirit Level, a book which very much directs attention to the structural determinants of health.  In terms of nutrition, UK food campaigners and experts have drawn attention to the role of rising food prices and shrinking incomes in both increasing people’s consumption of fatty foods and in reducing their intake of fruit and vegetables; especially for those with the lowest incomes.

Therefore while the call by the RCP for an obesity-focused figurehead seems appropriate, the UK would be better suited to find leaders whose messages are more closely aligned with health proponents found within its own borders rather than those across the pond.

On a semi-related note:

Healthy Policies is in the running for Best Health Blog of the year, but we need your votes! In addition to bragging rights, there are monetary prizes involved which would help cover the annual costs of maintaining the website. While we held the lead for a few days, life-style and coincidently, weight-loss blogs are bringing in a lot of votes. We are the only Social Determinants of Health blog in the running! You can vote once every 24 hours here until the 15th of February.

best health blogs 2012