Short-Interval Cortical Inhibition and Rhetoric and the Law, Or the Law of Rhetoric: How Countries Oppose Novel Tobacco Control Measures at The World Trade Organization

The tobacco industry has developed an extensive array of strategies and arguments to prevent or weaken government regulation. These strategies and arguments are well documented at the domestic level. However, there remains a need to examine how these arguments are reflected in the challenges waged by governments within the World Trade Organization (WTO). Decisions made at the WTO have the potential to shape how countries govern. Our analysis was conducted on two novel tobacco control measures: tobacco additives bans (Canada, United States and Brazil) and plain, standardized packaging of tobacco products (Australia, New Zealand, Ireland, EU and UK). We analyzed WTO documents (i.e. meeting minutes and submissions) (n = 62) in order to identify patterns of argumentation and compare these patterns with well-documented industry arguments. The pattern of these arguments reveal that despite the unique institutional structure of the WTO, country representatives opposing novel tobacco control measures use the same non-technical arguments as those that the tobacco industry continues to use to oppose these measures at the domestic level

Investment Incentives and The Implementation of the Framework Convention On Tobacco Control: Evidence from Zambia

Purpose: Policy misalignment across different sectors of government serves as one of the pivotal barriers to WHO Framework convention on Tobacco Control (FCTC) implementation. This paper examines the logic used by government officials to justify providing investment incentives to increase tobacco processing and manufacturing in the context of FCTC implementation in Zambia. Methods: We conducted qualitative semi-structured interviews with key informants from government, civil society and intergovernmental economic organizations (n=23). We supplemented the interview data with an analysis of public documents pertaining to economic development policy in Zambia. Results: We found gross misalignments between the policies of the economic sector and efforts to implement the provisions of the FCTC. Our interviews uncovered the rationale used by officials in the economic sector to justify providing economic incentives to bolster tobacco processing and manufacturing in Zambia: 1) tobacco is not consumed by Zambians/tobacco is an export commodity, 2) economic benefits outweigh health costs, and 3) tobacco consumption is a personal choice. Conclusions: Much of the struggle Zambia has experienced implementing the FCTC can be attributed to misalignments between the economic and health sectors. Zambia’s development agenda seeks to bolster agricultural processing and manufacturing. Tobacco control proponents must understand and work within this context of economic development in order to foster productive strategies with those working on tobacco supply issues. These findings are broadly applicable to the global analysis on the barriers and facilitators of FCTC implementation. It is important that the Ministry of Health monitors the tobacco policy of other sectors and engages with these sectors to find ways of harmonizing FCTC implementation across sectors

Measuring progess on diet-related NCD's: the need to address the causes of the causes

WHO has developed nine voluntary global monitoring targets and 25 indicators to assess progress in the implementation of national strategies to achieve the global political commitment to reduce the probability of dying from non-communicable diseases (NCDs) for people aged 30–70 years, by 25% by 2025.1,2 Robert Beaglehole and colleagues (Oct 13, p 1283)3 argue that it is better to focus on two of the population-wide targets: tobacco control and dietary salt reduction, and the treatment target, and that the targets should be reported according to socioeconomic status and gender.Department of HE and Training approved lis

Equity in Times of Austerity: Ontario’s Revenue Crisis in Historical Perspective

Concerns for health equity have found entry into social policy discussions in Canada at both the national and provincial levels of government. However, in the aftermath of the global financial crisis social programs improving the distribution of social determinants of health (SDHs), such as adequate housing and income, secure employment opportunities, affordable education and health care are increasingly under attack. In light of persistent deficits, historically high debt, and the precarious state of the global economy, there is a need to re-examine various revenue tools as, to date, there has been little historical analysis of the structural changes made to revenue sources or acknowledgment of the need to re-examine the revenue side of government activity in addressing fiscal imbalances. The article interrogates changes to the Ontario taxation system, especially during the deepening of neoliberal policies in the province (post 1990), to provide historical context to the current state of the provincial treasury. It focuses particularly on income, sales, and corporate income tax, which comprise the majority of revenue generated through taxation. The decline in government revenue is then linked to three key pathways affecting the distribution of social determinants of health: social assistance, labour market policy, and housing. The article finally probes the plausibility of alternative tax structure scenarios and their potential for financing social programs that address health equity.  Résumé Une préoccupation pour l’équité en matière de santé a été incorporée aux discussions de politiques sociales, tant au niveau provinciale que  fédérale. Cependant, suivant la crise financière globale, l’amélioration d’une distribution plus équitable des déterminants sociaux de la santé par des programmes d’aide sociale, comme un logement et un revenu approprié, la sécurité d’emploi, une éducation et des soins de santé accessibles, sont chaque jours plus menacés. Considérant les déficits constants, un historique de dette élevée, ainsi que l’état précaire de l’économie globale, il existe un réel besoin de réexaminer différents outils du revenu. À date, il n’y a eu que très peu d’analyses historiques des changements structuraux qui ont été apportés aux sources de revenus, et même, de la nécessité de réexaminer le côté revenu de l’activité gouvernementale lorsqu’ on aborde le déséquilibre budgétaire. Cet article interroge les changements apportés au système de taxation de l’Ontario, surtout lors de l’approfondissement des politiques néolibérales (après 1990), afin d’offrir une analyse historique de l’état actuel de la trésorerie provinciale. L’article examine plus particulièrement les taxes sur le revenu, les ventes, et sur la fiscalité des sociétés, ce qui comprend la vaste majorité des revenus obtenus à travers la taxation. La baisse de revenus gouvernementaux est reliée  avec trois voies majeures affectant la distribution des déterminants sociaux de la santé: l’assistance sociale, la politique du marché du travail, et le logement.  Finalement, des structures de taxes alternatives sont examinées, ainsi que leur plausibilité et leur potentiel pour financer des programmes d’assistance sociale qui traitera de l’équité en matière de santé.Mots-clefs: équité en matière de santé; austérit

Industry influence over global alcohol policies via the World Trade Organization: a qualitative analysis of discussions on alcohol health warning labelling, 2010–19

Background: Accelerating progress to implement effective alcohol policies is necessary to achieve multiple targets within the WHO global strategy to reduce the harmful use of alcohol and the Sustainable Development Goals. However, the alcohol industry's role in shaping alcohol policy through international avenues, such as trade fora, is poorly understood. We investigate whether the World Trade Organization (WTO) is a forum for alcohol industry influence over alcohol policy. Methods: In this qualitative analysis, we studied discussions on alcohol health warning labelling policies that occurred at the WTO's Technical Barriers to Trade (TBT) Committee meetings. Using the WTO Documents Online archive, we searched the written minutes of all TBT Committee meetings available from Jan 1, 1995, to Dec 31, 2019, to identify minutes and referenced documents pertaining to discussions on health warning labelling policies. We specifically sought WTO member statements on health warning labelling policies. We identified instances in which WTO member representatives indicated that their statements represented industry. We further developed and applied a taxonomy of industry rhetoric to identify whether WTO member statements advanced arguments made by industry in domestic forums. Findings: Among 83 documents, comprising TBT Committee minutes, notifications to the WTO of the policy proposal, and written comments by WTO members, WTO members made 212 statements (between March 24, 2010, and Nov 15, 2019) on ten alcohol labelling policies proposed by Thailand, Kenya, the Dominican Republic, Israel, Turkey, Mexico, India, South Africa, Ireland, and South Korea. WTO members stated that their claims represented industry in seven (3·3%) of 212 statements, and 117 (55·2%) statements featured industry arguments. Member statements featured many arguments used by industry in domestic policy forums to stall alcohol policy. Arguments focused on descaling and reframing the nature and causes of alcohol-related problems, promoting alternative policies such as information campaigns, promoting industry partnerships, questioning the evidence, and emphasising manufacturing and wider economic costs and harms. Interpretation: WTO discussions at TBT Committee meetings on alcohol health warnings advanced arguments used by the alcohol industry in domestic settings to prevent potentially effective alcohol policies. WTO members appeared to be influenced by alcohol industry interests, although only a minority of challenges explicitly referenced industry demands. Increased transparency about vested interests might be needed to overcome industry influence. Funding: None

WHO response to WTO member state challenges on tobacco, food and beverage policies.

In 2013, the World Health Assembly endorsed the World Health Organization’s (WHO) Global action plan for the prevention and control of noncommunicable diseases 2013–2020 to achieve a 25% reduction in mortality from noncommunicable diseases by 2025.1 Two years later, all of the world’s governments committed to reducing the global burden of noncommunicable diseases as part of the sustainable development goals. The rationale for these commitments is clear: in 2016, noncommunicable diseases caused almost threequarters of all deaths worldwide and this burden has significant economic costs.2 The World Economic Forum estimates that, without concerted action, cumulative economic losses from noncommunicable diseases will exceed 7 trillion United States dollars over the period 2011–2025 in low- and middleincome countries.3 WHO’s Global Action Plan is ambitious, as it aims to achieve a world free of the avoidable burden of noncommunicable diseases.1 The plan recognizes that this aim can only be achieved through determined action by Member States and international partners. The contribution of WHO is its ability to convene, set norms and standards, and offer technical support. For example, WHO has developed cost–effective interventions for preventing noncommunicable diseases that include labelling regulations for salt, fat and sugar, for soft drinks, for tobacco and for alcoholic beverages

Under the influence: is the World Trade Organization a forum for industry influence over global alcohol policies? A qualitative analysis of discussions on alcohol health warning labelling, 2010-2019

Background Accelerating progress to implement effective alcohol policies is necessary to achieve multiple targets within the WHO’s Global Strategy to Reduce the Harmful Use of Alcohol and the Sustainable Development Goals. Yet, the alcohol industry’s role in shaping alcohol policy through international avenues, such as trade fora, is poorly understood. We investigate whether the World Trade Organization (WTO) is a forum for alcohol industry influence over alcohol policy. Methods We studied discussions on alcohol health-warning labelling policies at WTO’s Committee on Technical Barriers to Trade from 2010-2019 using written meeting minutes (n=83 documents). We identified instances where WTO members indicated that their statements represented industry. We further developed and applied a taxonomy of industry rhetoric to identify whether WTO member statements advanced arguments made by industry in domestic forums. Findings WTO members made 212 statements on ten alcohol labelling policy proposals. Statements featured many arguments used by industry to stall alcohol policy at the domestic level. They included de-scaling and re-framing the nature and causes of alcohol-related problems, promoting alternative policies such as information campaigns and industry partnerships. WTO members stated that their claims represented industry in 3.3% of statements, whereas 55.2% of statements featured industry arguments. Interpretation WTO discussions on alcohol health-warnings advance arguments used by the alcohol industry in domestic settings to undermine effective alcohol policy. WTO members appear to be influenced by alcohol industry interests, despite a minority of challenges explicitly referencing industry demands. Greater transparency about vested interests may be needed to overcome industry influenc

Trade and public health

As the number of new negotiations of regional trade and investment agreements has grown in recent years, evidence is mounting about their implications for population health.A linked CMAJ article by Barlow and colleagues is the latest to examine trade and investment policy as a plausible causal driver of diet-related health outcomes through high-sugar, high-fat and high-sodium food products. The authors found that even the minor reductions in tariff rates brought in by the North American Free Trade Agreement (NAFTA) on products such as high-fructose corn syrup, a common additive to sugar-sweetened beverages and other highly processed food products, were strongly associated with the increased supply of such commodities into Canada

Global Tobacco Control and Economic Norms: An Analysis of Normative Commitments in Kenya, Malawi And Zambia

Tobacco control norms have gained momentum over the past decade. To date 43 of 47 Sub-Saharan African countries are party to the Framework Convention on Tobacco Control (FCTC). The near universal adoption of the FCTC illustrates the increasing strength of these norms, although the level of commitment to implement the provisions varies widely. However, tobacco control is enmeshed in a web of international norms that has bearing on how governments implement and strengthen tobacco control measures. Given that economic arguments in favor of tobacco production remain a prominent barrier to tobacco control efforts, there is a continued need to examine how economic sectors frame and mobilize their policy commitments to tobacco production. This study explores the proposition that divergence of international norms fosters policy divergence within governments. This study was conducted in three African countries: Kenya, Malawi, and Zambia. These countries represent a continuum of tobacco control policy, whereby Kenya is one of the most advanced countries in Africa in this respect, whereas Malawi is one of the few countries that is not a party to the FCTC and has implemented few measures. We conducted 55 key informant interviews (Zambia = 23; Kenya = 17; Malawi = 15). Data analysis involved deductive coding of interview transcripts and notes to identify reference to international norms (i.e. commitments, agreements, institutions), coupled with an inductive analysis that sought to interpret the meaning participants ascribe to these norms. Our analysis suggests that commitments to tobacco control have yet to penetrate non-health sectors, who perceive tobacco control as largely in conflict with international economic norms. The reasons for this perceived conflict seems to include: (1) an entrenched and narrow conceptualization of economic development norms, (2) the power of economic interests to shape policy discourses, and (3) a structural divide between sectors in the form of bureaucratic silos

“That’s Enough Patients for Everyone!”: Local Stakeholders’ Views on Attracting Patients into Barbados and Guatemala’s Emerging Medical Tourism Sectors

Background Medical tourism has attracted considerable interest within the Latin American and Caribbean (LAC) region. Governments in the region tout the economic potential of treating foreign patients while several new private hospitals primarily target international patients. This analysis explores the perspectives of a range of medical tourism sector stakeholders in two LAC countries, Guatemala and Barbados, which are beginning to develop their medical tourism sectors. These perspectives provide insights into how beliefs about international patients are shaping the expanding regional interest in medical tourism. Methods Structured around the comparative case study methodology, semi-structured interviews were conducted with 50 medical tourism stakeholders in each of Guatemala and Barbados (n = 100). To capture a comprehensive range of perspectives, stakeholders were recruited to represent civil society (n = 5/country), health human resources (n = 15/country), public health care and tourism sectors (n = 15/country), and private health care and tourism sectors (n = 15/country). Interviews were transcribed verbatim, coded using a collaborative process of scheme development, and analyzed thematically following an iterative process of data review. Results Many Guatemalan stakeholders identified the Guatemalan-American diaspora as a significant source of existing international patients. Similarly, Barbadian participants identified their large recreational tourism sector as creating a ready source of foreign patients with existing ties to the country. While both Barbadian and Guatemalan medical tourism proponents share a common understanding that intra-regional patients are an existing supply of international patients that should be further developed, the dominant perception driving interest in medical tourism is the proximity of the American health care market. In the short term, this supplies a vision of a large number of Americans lacking adequate health insurance willing to travel for care, while in the long term, the Affordable Care Act is seen to be an enormous potential driver of future medical tourism as it is believed that private insurers will seek to control costs by outsourcing care to providers abroad. Conclusions Each country has some comparative advantage in medical tourism. Assumptions about a large North American patient base, however, are not supported by reliable evidence. Pursuing this market could incur costs borne by patients in their public health systems