The linkage between public health and international trade is increasingly recognised as an area of great significance for health. Here, we outline the areas covered, and issues involved, in a study that has been undertaken by the secretariats of two international organisations most involved.
The World Health Organization (WHO) and the World Trade Organization Secretariat (WTO) have published a joint study of the relationship between trade rules and public health. The 171-page study entitled "Agreements and Public Health - a joint WHO/WTO study" explains how the Agreements relate to different aspects of health policies. It is meant to give a better insight into key issues for those who develop, communicate or debate policy issues related to trade and health.
Principle of non-discrimination
The study begins by explaining the basic WTO principle of "non-discrimination": WTO Members cannot discriminate between their trading partners nor between imported and locally-produced goods that are otherwise similar. However, Article XX of GATT, from which WTO was created, guarantees members’ right to take measures to restrict imports and export of products when those measures are necessary to protect the health of humans, animals and plants (Article XX (b)). Members may wish to subordinate trade-related considerations to other legitimate policy objectives and constraints, such as health, the report says. WTO jurisprudence, on several occasions, has confirmed that WTO Members have the right to determine the level of health protection they deem appropriate. Human health has been recognised by the WTO as "important in the highest degree".
Relevant agreements
The report describes the two WTO Agreements that allow countries to restrain trade for legitimate reasons, including health. They are the Agreements on Technical Barriers to Trade (TBT) and Sanitary and Phytosanitary Measures (SPS). They both also require that such measures should not unnecessarily restrict trade.
Two other WTO Agreements related to health and health policies are Trade-Related Intellectual Property Rights (TRIPS) and Trade in Services (GATS). TRIPS covers patent protection for pharmaceutical products and GATS relates to trade in services, including health services.
Health issues
The specific health issues dealt with in the report are:
- Infectious disease control, which may require trade or travel restrictions in exceptional circumstances.
- Food safety - new sources of food-born illness, such as dioxin residues in animal feed and BSE, are of increasing relevance to international trade. The SPS Agreement formally recognises the food safety standards, guidelines and recommendations established by the FAO/WHO Codex Alimentarius Commission.
- Tobacco control - some measures taken by governments to reduce tobacco consumption are not consistent with WTO rules. The challenges to comprehensive tobacco control policies led WHO to propose the development of a Framework Convention on Tobacco Control (FCTC), which is currently being debated.
- Environment - removing trade barriers to green technologies and to suppliers of environmental goods and services can potentially benefit both the environment and health. However, trade in dangerous materials, such as hazardous wastes and unsafe chemicals, may also increase environmental health hazards. Multilateral environment agreements (MEAs) represent an important multilateral course of action to address specific environmental issues which may also be relevant to health, such as, for example, limiting the use of ozone-depleting substances. No disputes have thus far come to the WTO regarding the trade provisions contained in any MEA. At least 20 (out of some 200) MEAs contain trade provisions that may violate the principle of non-discrimination.
- Access to drugs and vaccines - WTO negotiations may lead to the elimination or reduction of import duties on drugs, vaccines or other medical supplies, which may lower prices. The TRIPS Agreement should enhance incentives for R & D into new drugs, but there is also concern that it may lead to drug price increases due to more stringent patent protection. In this regard, the TRIPS Agreement allows WTO Members, under certain circumstances, to use safeguards, such as compulsory licensing and parallel imports. The Doha Declaration on the TRIPS Agreement and Public Health helps clarify the conditions under which flexibility could be used.
- Health services - there have been notable increases in foreign investment by hospital operators and health insurance companies in search of new markets. Depending on appropriate regulatory conditions, trade liberalisation can contribute to enhancing quality and efficiency of supplies and/or increasing foreign exchange earnings. However, trade in services, in some cases, has exacerbated existing problems of access and equity of health services and financing, especially for poor people in developing countries. For example, an increase in the "brain drain" of health professionals leaving low-income countries can worsen health personnel shortages in developing countries. There are also fears that the benefits of opening markets will be concentrated among the wealthy.
- Food security and nutrition - these issues are being addressed in several ways in current negotiations. For example, a wide range of countries have called for the elimination of export subsidies and other forms of agricultural support so as to put an end to their adverse impact on the production systems of developing countries. In general, increased market access is important for many, especially low-income developing countries for which export agriculture remains the principal source of foreign exchange.
- Emerging issues - biotechnology, information technology, and herbal medicines and traditional knowledge for treating illnesses. Biotechnology: as the scope of its application grows wider, the TRIPS Council has debated whether some biotechnological innovations are patentable. Information technology has already stimulated changes in health care delivery, and has the potential to foster greater cross-border supply of health services. Its use in cross-border trade to serve the poor, however, could be constrained by high cost and lack of infrastructure. Traditional medicine: as the economic and trade value of the knowledge of traditional medicine and medicinal plants increases, there is increasing concern about protecting it adequately and ensuring that the ensuing benefits are fairly and equitably shared.
Finally, the report deals with "coherence" in health and trade policy. Some observers have expressed the view that WTO rules could constitute a threat to sound public health policies. The report suggests that a constructive way to address such concerns is to view them as opportunities for finding common ground. Minimising possible conflicts between trade and health, and maximising their mutual benefits, is an example of policy coherence.
In their foreword, the Directors-General of the two organisations, Gro Harlem Brundtland and Mike Moore, send a clear message "there is much common ground between trade and health" but "health and trade policy-makers can benefit from closer co-operation to ensure coherence between their different areas of responsibilities."
The study, which was launched in August 2002, is available as a pdf on the WHO website at www.who.int
