The sharp rise in food and energy prices, collapsing stock markets and the global financial crisis show that, now more than ever, health and trade are inexorably intertwined. In the first paper in The Lancet Series on Trade and Health, Dr Kelley Lee, London School of Hygiene and Tropical Medicine, UK, and Professor David Fidler, Indiana University, USA, and colleagues, look at how this relationship has mostly been dominated by trade and how global governance in the two spheres is markedly different.
The first signs of trade and health intertwining came with the quarantine measures imposed to prevent transmission of cholera, plague and other infectious diseases during early international trade. In this century, the General Agreement on Tariffs and Trade (GATT), adopted in 1947, and the International Sanitary Regulations (which later became the International Health Regulations [IHR]), adopted by the World Health Organization (WHO) in 1951, included provisions for balancing trade and health interests. However, although occasional controversies arose, GATT's development did not include substantial efforts to address policy linkages. Trade became caught up in the geopolitical struggle between the USA and the Soviet Union. The trade and health relationship was marginalised in the process.
In 1995, the World Trade Organization (WTO) incorporated GATT and established a much broader international trade institution. Today, the WTO boasts 153 member states, with another 29 countries seeking accession. WTO membership is extensive and expanding, because of the widely shared perception that economic growth and public welfare depend on participation in a robust system of international trade. WTO is the centre of authority for the governance of trade, more so than WHO is in health.
States becoming members of WTO must accept no less than 17 main multilateral agreements and 60 associated agreements. By contrast, membership of WHO does not require acceptance of multiple, extensive legal obligations, and WHO has rarely used its powers to negotiate and adopt legal instruments (e.g., the IHR and Framework Convention on Tobacco Control). In addition, global health governance is more fragmented because countries, other intergovernmental organisations (e.g, World Bank), and NGOs have challenged WHO's lead governance role. WTO governance has a strong dispute resolution procedure, and the absence of an equivalent dispute resolution process in WHO agreements means that countries could (and do) take WHO less seriously than WTO.
The authors say: "The above features of the WTO help explain why governance of the trade-health relationship is weighted toward international trade law."
The paper also looks at how direct and indirect links between trade and health make policy coherence between the two policy areas difficult. Challenges include developing clear evidence of how trade directly affects population health, and how to act when the trade-health links are indirect. For example, if tariff revenues decrease because of a WTO agreement, which leads to a country spending less on health, should this country restrict trade by increasing tariffs — or find alternative ways to finance its health plan, independent of tariff changes?
The authors conclude: "Trade and health have a long history that has seen these areas converge and diverge at different points in time. The current convergence, and the search for coherence, will define the trade and health relationship for decades to come. Whether those in both policy communities understand fully the trade and health imperative, and its technical and political challenges, will influence how these crucial objectives in global affairs will shape the future of states and their peoples."
Professor David Fidler, Director, Center on American and Global Security Indiana University School of Law, USA, T) +1 812-855-6403 E) dfidler@indiana.edu / cags@indiana.edu
Dr Kelley Lee, London School of Hygiene and Tropical Medicine (LSHTM), UK T) +44 (0)20 7927 2037 E) Kelley.Lee@lshtm.ac.uk
LSHTM Press Office T) +44 (0) 20 7927 2073 E) lindsay.wright@lshtm.ac.uk / gemma.howe@lshtm.ac.uk
For full first paper see: http://press.thelancet.com/tradeandhealth1.pdf
Journal
The Lancet