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


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


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.

Canada and the post-2015 world: Part I

In this post, guest blogger Ronald Labonté introduces a two-part blog series about post-2015 development goals. Discussed are their relationship to health and specific steps Canada could take to encourage a healthy and progressive transition. 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.

In 2000 the world committed to health and a paternalistic egalitarianism, as the Millennium Development Goals (MDGs) promised reductions in extreme poverty and hunger, and measurable progress in water and sanitation, education and a host of specific health targets. There was lots to criticize in the MDGs: lack of ambition in the targets (especially for poverty), failure to consider the already surging pandemic of noncommunicable diseases, lack of equity stratifiers for the targets, huge holes in the data used to measure progress, and a resounding silence on any of the economic and political systems that were fuelling global financial speculation, transnational corporate power and gross inequities in income and wealth. Still, the MDGs galvanized some important initiatives and have chocked up some successes.

As the 2015 clock on the MDGs ticks down, there’s been a flurry of intergovernmental, civil society and social mediated consultations on what the world’s nations should commit to next. If the 2000 MDGs were a bureaucratic exercise in synthesizing what states had already more or less agreed upon during the 1990s, the post-2015 has opened the floodgates to consultation processes to such an extent that one becomes either exhausted with keeping up with the opportunities to input, or cynical about why bothering to.

Bracketing an excess of cynicism to strike a balance between realism and defeatism, this two-part blog series offers a few reflections on the competing post-2015 goal streams and Canada’s potential role within them. The first post will reflect on sustainable development goals, the UN high-level panel, and health goals in the post-2015 context. The second post will discuss aid-for-trade and aid-for-taxation strategies, and summarize how Canada can prepare for the post-2015 world.

Sustainable Development Goals

No one outside of the US Tea Party any longer insists that climate change is a left-wing environmentalist plot. (Although it would be nice if there were more left-wing environmentalists at the political and economic levels where they are needed.) The problem with these goals, an output of the Rio+10 initiative, rests with the term itself, a throwback to the late 1980s Bruntland Commission (Our Common Future) (1) and the first wave of efforts to harness economic development to environmental sustainability. Back then Canada was a leader, jumping enthusiastically on the ‘roundtables on economy and environment’ governance ideal promoted by the Commission. I recall an environmental lawyer leaving one of such meeting, complaining that the business folks around the table ‘Just don’t get it!’ To which a senior government official gently chided, ‘Oh, but they do. You see, they got the noun and you got the adjective.’

We continue to live under the illusion that, with claims of a slowly greening economy, we can consume our way out of a problem of over-consumption. We can even invest our savings on the Dow Jones Sustainability Index, feeling better that our retirement returns derive from companies deemed to be operating in a ‘sustainable’ way. We just have to pretend that there is consensus on how to measure good corporate environmentalism so that we aren’t fooled by such as Pepsi-Cola’s claim that in India it is replacing more water than it takes to supply the sub-continent with its sugary beverages (2). As for our greening economy: Why should the USA use trade rules to challenge China’s heavy subsidization of its solar and wind turbine industries? Yes, it puts the US-based industries at a competitive disadvantage, but it drives up global prices and slows diffusion of possibly important climate change reducers. Why not exclude from trade rules subsidies on all new products that reduce the human environmental footprint, a race to the top rather than a slide to the bottom?

Canada scores very poorly on this account. Our exit from the Kyoto Accord in 2011 and our drive to become a fossil-fuel superpower have transformed Canada from a once-upon-a-time eco-leader (we were, after all, the birthplace of Greenpeace and home of the increasingly pessimistic David Suzuki) to one of the bottom-placing eco-destroyers. The potentially healthy challenge for Canada is that if the post-2015 goals achieve their mooted intent of applying to all countries, alongside the increasing anger of developing countries at the rich club reneging on its climate change commitments, we may be dragged back into accountable commitments to a greener future.

But the gravest challenge for a post-2015 sustainably developed future lies in the fallout of the Great Financial Crisis, which became the Great Recession and persists as the Great Austerity. Most domestic political attention has drifted back to conventional economics of spurring growth by re-energizing the real economy of production and consumption (jobs, jobs, jobs). This is saleable in the short-term, although the quality of new employment with respect to pay, benefits, security, and health and safety remain vexing complications under neoliberalism’s labour market ‘flexibilization’. But it grates against the reality that we cannot use conventional economics to grow incomes for a world of soon to be 9 billion producers and consumers (3). We don’t have enough of a planet to do so. Add to that our oft-proclaimed ‘time bomb’ – an aging population living longer, with demographers and politicians concerned with increasing the size of the active labour force (those aged 20 – 65 or 70) to sustain the social contract (health care, pensions and benefits) for the swelling cohort of elders. This continuous priming of the base of the demographic pyramid is simply an environmental ponzi scheme, one that only radical redistribution and economic regulation might prevent from imploding.

UN High Level Panel

The UN High Level Panel on the post-2015 goals (is there ever one called ‘low-level’?) came up with a number of useful suggestions that could partly forestall such a dystopian ponzi pyramid. These include a call for governments to regulate private finance, reform trade, crack down on illicit capital flows, stem transnational tax evasion, return stolen assets and promote sustainable patterns of production and consumption (4). Such recommendations are meatier than the Panel’s obligatory nudge to donor countries to honour their aid commitments. Been there, done that and, in Canada’s case, we don’t seem to care much. Despite our acknowledged if initially botched leadership on the ‘Muskoka Initiative’ for Maternal/Child Health, we are losing ground on our aid commitments, freezing the level of our disbursements, and restricting contributions to a smaller number of countries. Apart from issues of quantity, there are issues of quality. The 2012 Centre for Global Development’s Quality of ODA Index ranks Canada in the lower half of donors on efficiency and reducing the burdens or transaction costs of aid. We do better on fostering institutions, and are smack in the middle on transparency and learning; a middling assessment at best (5).

Returning to the Panel’s higher-level goals: Good as they are in intent, there is no operational guidance in the report. There is also too much emphasis on corporate social responsibility and partnerships between states and businesses to make global markets more just and equitable, rather than recognizing the pressing need for mandatory and enforceable market rules. It is in how we must move on the Panel’s goals that is of prime importance, which then requires an analysis of why we have these problems in the first place. As a People’s Health Movement commentary laments, none of the prevailing models for post-2015 priorities question, much less challenge, the prevailing paradigm of economic growth (6).

There is even the risk that the UN High Level Panel could reinforce some of the more egregious qualities of the prevailing paradigm. For one, it criticizes the core labour rights of the ILO-led initiative on social protection and ‘decent work’ (7) as too much of a ‘one size fits all.’ It calls, instead, for ‘good jobs’ and for ‘flexibly regulated labour markets’, an invitation to a continual reduction in labour’s power against that of capital. In sync with the World Bank and other economic development agencies, its poverty goal of ‘leave no one behind’ (commendable, depending on where one draws the poverty line) is based on the norm of ‘equality of opportunity.’ While the procedural justice inherent in this norm is important (all should be treated alike), in the game of economics it only becomes fair when all are alike when they start playing. This is patently not the case, not when fewer than 1500 people have more wealth than the combined populations of the continent of Africa and the sub-continent of India (8). Equality of opportunity only becomes fair when it is joined with a parallel commitment to equality of outcome – an ideal but measurable target – that relies on progressive tax/transfer programs within and between governments. Such a norm is unlikely to have much political traction in Canada at the moment, however, where reduced and regressive taxation have been the norm for the past decade or more. The same may be true for most of the austerity-addicted high-income countries and many of the recession-stuck middle-income ones.

What of health?

No one knows exactly how health goals in the post-2015 final list will be defined. Several of the goals from the sustainable development agenda and the high-level panel already deal with key health determinants, albeit imperfectly. The World Health Organization (WHO) is calling for completion of the 2000 health MDG’s unfinished agenda, and a ‘healthy life expectancy’ goal perhaps allowing some broader measurable target. But it seems most keen to bank on a post-2015 health goal of universal health coverage (UHC), a re-born concept still in search of consensus. The WHO defines it as “ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need” (a nod in the direction of the heady days of the Alma Ata Declaration on Primary Health Care), with services “of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship” (9). This sounds reasonable enough, but it ducks the contentious issue of the relationship between public and private sectors in health care financing and provision. With private insurers and providers eager to carve out a larger piece of the annual $6.5 trillion health care ‘market,’ the risk is that the costly chaos now passing for Obamacare in the USA will come to define the global default position.

This is a debate in which Canada could aggressively insert its own comparatively positive experience with a universal, single-payer and mixed provider system. Canada’s national health insurance risk-pool and legislated public administration creates one of the fairest, most efficient and most accessible health care models on record (excepting Cuba). Sure, it has warts: wait-times, gaps in coverage, encroaching privatization. But compared to the American model, and to the dual public/private models dominating Latin America (which most countries in that region are trying to transform into a more public system), the warts on Canada’s system become mere cosmetic pimples.


1. Our Common Future, Report of the World Commission on Environment and Development, World Commission on Environment and Development, 1987. Published as Annex to General Assembly document A/42/427, Development and International Co-operation: Environment August 2, 1987.

2. See: http://www.indiaresource.org/news/2011/pepsipositivewater.html

3. Sustainable Development Commission, 2009. Prosperity without growth: the transition to a sustainable economy? London: UK Sustainable Development Commission.

4. High Level Panel on the Post-2015 Development Agenda, May, 2013. http://www.post2015hlp.org/wp-content/uploads/2013/05/UN-Report.pdf

5. See: http://www.cgdev.org/page/quality-oda-quoda

6. See:

7. International Labour Organization (ILO), 2011. Social protection floor for a fair and inclusive globalization [online]. Report of the Advisory Group chaired by Michelle Bachelet convened by the ILO with the collaboration of the WHO. Geneva: ILO. Available from: http://www.ilo.org/wcmsp5/groups/public/—dgreports/—dcomm/—publ/documents/publication/wcms_165750.pdf

8. See my last blog: http://www.healthypolicies.com/2013/11/canadas-austerity-agenda-its-about-the-taxes/

9.  See: http://www.who.int/universal_health_coverage/en/


Based on two plenary presentations at the 2013 Canadian Conference on Global Health, Ottawa, Canada, October 28-29.



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.