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Henry Greenberg, Stephanie Shiau, The vulnerability of being ill informed: the Trans-Pacific Partnership Agreement and Global Public Health, Journal of Public Health, Volume 36, Issue 3, September 2014, Pages 355–357, https://doi.org/10.1093/pubmed/fdu061
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ABSTRACT
The Trans Pacific Partnership Agreement (TPPA) is a regional trade agreement currently being negotiated by 11 Pacific Rim countries, excluding China. While the negotiations are being conducted under a veil of secrecy, substantive leaks over the past 4 years have revealed a broad view of the proposed contents. As it stands the TPPA poses serious risks to global public health, particularly chronic, non-communicable diseases. At greatest risk are national tobacco regulations, regulations governing the emergence of generic drugs and controls over food imports by transnational corporations. Aside from a small group of public health professionals from Australia, the academic public health community has missed these threats to the global community, although many other health-related entities, international lawyers and health-conscious politicians have voiced serious concerns. As of mid-2014 there has been no comment in the leading public health journals. This large lacuna in interest or recognition reflects the larger problem that the public health education community has all but ignored global non-communicable diseases. Without such a focus, the risks are unseen and the threats not perceived. This cautionary tale of the TPPA reflects the vulnerability of being ill informed of contemporary realities.
Introduction
The Trans-Pacific Partnership Agreement (TPPA) is a regional trade agreement currently being negotiated by the USA and 11 other Pacific Rim countries in North and South America and Asia, excluding China. These countries include 10% of the global population and account for 30% of its gross domestic product.1
The negotiations are now in their 10th year and are held in secret, although many senior corporate executives and their representatives are participants. The US Congress has only recently been given limited access to the interim proceedings.2 What is publicly available is derived primarily from leaks and a summary of these is available.3 As with prior regional trade agreements, the current administration wants ‘fast track’ authorization to approve the final version, thus limiting both scrutiny and modification
The goals of the TPPA are to improve the exchange of goods and services, enhance global industrial vertical integration and enlarge the scope of intellectual property protection. As it is significantly independent of the World Trade Organization, it is not bound by many of the previously established guidelines and regulations.4 The contents and thrust of the TPPA pose serious threats to public health goals, primarily for non-communicable diseases (NCDs). The key health issues are centered around the inhibitions of drivers of risk factors for NCDs such as tobacco regulations, restrained imports of highly processed foods, and access to generic drugs and exuberant patent protections.
Argument
It is our argument that academic public health has failed to appreciate the serious risks of the TPPA and has not responded to the threats. Even if the version of the TPPA that is eventually enacted embraces all the health promoting policies it should, the failure of academic public health to participate in the current debate reflects the weakness of its comprehension of twenty-first century priorities. It is, then, a cautionary tale for public health education.
A recent article by public health professionals from Australia highlighted for us the serious threats to global NCD prevention efforts posed by the TPPA.1 This startling revelation prompted an exploration of the issues surrounding the genesis and promulgation of the proposed agreement, and there was much to be concerned about. The dictates of the agreement, in all but name a treaty, could, for the most part, override national guidelines and regulations in the corporate arena that pertain to health. The regulatory structure embedded in the TPPA withdraws jurisdiction from national judicial systems and puts it in extraterritorial tribunals designed to favor trade/corporate interests. At the very least, processing a claim that selective taxes on tobacco or import controls on health-harmful processed foods are valid will delay policy implementation and will be extraordinarily expensive, especially for emerging economies.
The ‘enabling clause’ of the World Trade Organization which recognizes that emerging economies may need to protect some, or many, sections of their economy from open competition has been excluded in the TPPA.4 Drug or device patents can be ‘evergreened’, by which they can be extended up to 20 years by the introduction of a new indication, a new delivery system or even for a medicine by changing from tablet to capsule.5 The USA has backed off an insistence that tobacco be excluded from the agreement putting at risk the protections in the Framework Convention on Tobacco Control.6 The TPPA will place few or no barriers to importation for the large transnational food companies, so that they can invest, own, distribute, advertise, label and in every way possible control all aspects of the enterprise.2 For these corporations, a common set of rules simplifies and streamlines their processes. This capacity will trump the ‘enabling clause’ and hence will permit a set of uniform corporate policies and objectives to pertain to the entirety of the trade area.
Given the magnitude of the threats, the response of the public health community has been paltry. Commentaries in the literature by public health professionals are rare. The effort, limited as it is, has been led by the Australian group.1,4 However, there is nothing from the American public health community. A review of the table of contents from January 2013 through February 2014 (last search 19 March 2014) for leading public health journals, including American Journal of Epidemiology, American Journal of Public Health, BMC Public Health, Epidemiology, International Journal of Epidemiology and Journal of Public Health finds no mention of the TPPA by either American or others. Reviewing all articles focused on TPPA in the New York Times since January 2013 finds rare mention of the health impacts, but no reporter has felt the need to ask for any public health official to comment on the treaty.
Commentary from nonpublic health professionals has been plentiful, although not robust. New York City's former mayor has castigated the Obama administration for its cave-in on maintaining an exclusion for tobacco;6 lawyers have been critical of the TPPAs authority to override national laws and regulations7–9 and the blogosphere reveals widespread commentary from health-related organizations such as the American Medical Association, American Association of Retired Persons, OxFam and Doctors without Borders.10–13
Why has the American public health community been absent? An argument that this is not an issue for public health is simply not valid. As a signatory nation, the US regulations would be as much at risk as others. While it is unlikely that the tobacco companies would have the temerity to try to strike downregulations in the USA, it is not impossible. True, the most potent impacts will be on foreign governments and their populations, but global health is a core component of the American public health academic enterprise and an important tool of US foreign policy.
Here are five factors that may contribute to the deafening silence of American Public Health.
The HIV/AIDS epidemic was a cataclysmic event that dominated the attention of the public health world, not inappropriately, although it may have compromised the capacity to focus on other important issues, including the threats of regional trade agreements.
Most schools of public health are ‘soft money’ schools such that the faculty are supported by grants rather than ‘hard money’ or clinical income. Infectious diseases, including HIV/AIDS, tuberculosis and malaria, have dominated global health grants to faculty, attracted excited interest by students and created a cocoon environment in the schools.
The realms impacted by regional trade agreements such as the TPPA are not those usually visited by public health professionals. The issues are not diseases or traditional public health concerns. Rather they are legal structures, trade and patent regulations, pharmaceutical pricing regulations and agricultural subsidies. Public health may be too insular and not encourage sufficiently academic cross fertilization to match public health with law, trade, urbanization or economics and hence better prepare a global-focused work force to deal with the new realities of the day.
In the current teaching environment, political and economic issues seem quite divorced from the traditional, and promulgated, view of public health that engages causes and causes of causes, usually only one step away. Restrictions on the sale of tobacco, banning sugary drinks from schools and building urban parks typify the usual upstream foci. A tilt toward the policies further upstream that actually create the political, economic and social environments that propagates NCD risk factors will be needed. Exploration of the role of public policy will need to assume a more prominent position in the preparation of the public health professional.
The TPPA threat is primarily focused on the risk factors for NCDs, themselves all but ignored in the global curriculum. The well-funded curriculum of the late twentieth century has obscured consideration of global NCDs.14,15 With the faculty not fully engaging global NCDs, the issues raised by such regional trade agreements are not seen, even though many health-related non-governmental organizations have begun to raise the issues.
Conclusions
The public health professional of the future will need a firmer grasp of public policy. Understanding the political genesis of policy and the forces that propel, alter or squelch policy needs to be more firmly embedded in the curriculum. The political globalization currently extant and exemplified by the TPPA is a window onto the future. Responding to fully developed policies is too late; academic public health must be able to recognize their genesis and actively engage in and shape their construction.
This concept merges with the need for public health professionals to travel much further upstream in the search for causes of disease, or ill health. For example, more attention should be given to trade policies and agricultural subsidies that make sugar sweetened beverages so profitable and ubiquitous. There will be a need for greater emphasis on policies that impinge on health but are themselves embedded in other governmental ministries. Trade agreements are one such example, but agriculture subsidies, water management, urban development, oversight of television content and industrial pollutions are others. The current and more concerted effort to promulgate the ‘heath in all policies’ approach to global health (and domestic, for that matter) reflects the recognition of these ideas but they do need to be worked into the curriculum.16
And, of course, NCDs need to occupy an important role in the global public health curriculum so that the next generation of professionals can be conversant with the dominant issues facing tomorrow's developing world.14,15 Academic public health has been slow to adapt to these realities and pays a high price for courting irrelevance. The price will go higher as new threats to the global community emerge.