Specific health issues and WTO agreements
As noted in PART I most of the WTO agreements are taking into concern a lot of health issues and they allow governments, in pursuing national health and other policy objectives, to take measures to restrict trade in order to protect health. This is legitimate as a matter of principle. This part refers to the eight important health issues that the national policy makers are facing and which relate to one or more of the WTO agreements.
1. Infectious disease control
A cross-border movement not only of people but also of goods through trade is a phenomenon that keeps increasing year after year. At the same time this increases the challenges for infectious disease control. The risk of infectious disease rises with increased mobility of people, growth in international trade in food and biological products, and social and environmental changes. These developments affect all elements in the infectious disease chain: hosts (people), agents (microbes causing disease), and vectors (means by which microbes come into contact with people). The variety of transmission methods and the increase in volume of trade of all kinds means that to control disease outbreaks in an effective way in today's world, public health officials need to collect and disseminate information quickly. Another important issue is that trade officials who negotiate and implement trade agreements need to be aware of health risks so that they can avoid them effectively. In most cases, sound public health practice will focus on the mode of transmission-for example, sexual behaviour and drug use in the case of HIV/AIDS - rather than restrict the mobility of people or goods. There are a lot of ways to avoid health risks and protect the public health system, some of them recommended to be used only in exceptional circumstances such as quarantines, trade embargoes and isolation. However though,in the recent years a combination of sensitive early warning surveillance systems, rapid verification procedures and international response networks, epidemic preparedness plans and stockpiles of essential medicines has reduced the need to employ trade embargoes or travel restrictions. In any case, specific measures used to control infectious disease may be subject to the WTO rules if they affect trade in goods or services. Infectious Disease Control can be found in WTO’s agreement and more specific in the SPS, TBT, and the GATT agreement.
2. Food Safety
According to the WHO world wide almost 2 million children die every year due to diarrhoea and most of this is caused by microbiologically contaminated food and water. Industrialized countries are also part of this phenomenon. It is estimated that one third of the population suffers from food-borne disease every year and out of these up to 20 per million die. These cases are related to microbiological problems but nowadays there are more sources that are dangerous and may cause the same results. The addition of chemical contamination in food and the new context in international trade in which borders, tariffs and other classical barriers to trade are either limited or vanished makes the situation more and more difficult to solve and extremely serious. Several new sources of food-borne illness are of increasing relevance to international trade. In the past few years, chemical hazards in food-related products have been the source of several limited, but highly publicized health crises. Changing patterns of farming and animal husbandry can also affect food safety, illustrated by the spread of mad cow disease (BSE) and its onward transmission to people which manifests as vCJD, a fatal neurological disease. The widespread use of antibiotics in animal husbandry has contributed to increased levels of antibiotic-resistant bacteria in humans. Furthermore that past 10 years the context of international trade has grown substantially. Exports and imports of more and more processed foods are easy enough due to the fact that boarders and tariffs are limited and this situation is increasing the importance of sanitary and phytosanitary measures and the SPS Agreement. Food safety is an issue of great importance and this is why the WTO has an agreement that applies to it. As mentioned before the SPS agreement replies to any trade-related measure taken to protect human life or health from risks arising from additives, contaminants, toxins or other disease-causing organisms in foods or beverages. This agreement clearly gives governments the right to restrict trade to protect public health, but any measure taken must be based on scientific evidence. Moreover, on the international food safety agenda another significant challenge must be concerned and this has to do with the new foods that are derived from genetic modification. There are not only advantages but also disadvantages. It is clear enough that the application of biotechnology on foods has made it more efficient and also has contributed to increase harvest. Most important is the fact that it holds promises for the improvement of public health. However though there are some facts that are not that promising and are related to the longterm health effects of genetically-modified (GM) foods, such as: the potential for gene transfer from GM plants to microbial or mammalian cells; the transfer and expression of a functional antibiotic resistance gene to recipient cells in people or animals; and allergenic effect. Lastly, other challenges lie ahead, particularly the need to develop global standards for pre-market approval systems of genetically modified food to ensure that these new products are not only safe, but also beneficial for consumers. On the trade side, arguments are brewing over the feasibility of regulations that would place "traceability" and labelling requirements on bio-engineered foods, and their consistency with WTO trade rules.
Since about 1950 more than 70,000 studies have proven that smoking causes disease, disability and death. WHO estimates that tobacco products kill about 4.2 million people per year. Empirical evidence confirms that trade openness leads to increased tobacco consumption, and this is why the promotion of tobacco and its trade have become a major global public health threat. Tobacco market is characterized by several failures and inefficiencies which the governments need to take in advantage so that they can protect their people. These failures include first of all the lack of information about the health ricks of smoking, second the acknowledgment about the risk of addiction and last the physical and financial costs imposed on non-smokers. It is clear that if the consumer knows all the risks he is putting himself into then he would bear all the costs of his choices. Therefore, a tobacco control policy could be the continuously increase of tobacco products prices through excise taxes or duty tariffs.This policy could lead to a lower level of consumption and a lower prevalence of smoking among youth. As the years pass more and more countries are tending to adopt tobacco control programs additionally to the price increase. These programs include restrict of tobacco advertisements, expand public health information campaigns, restrict sales through vending machines, ban smoking in public places and support for tobacco control coalitions. In accordance to the WTO agreements there are a number of them that come into play when we talk about tobacco control such as the GATT  agreement. Other WTO agreements that may be applicable are the TBT agreement in relation to product requirements such as packaging and labelling, the GATS in relation to restrictions on cigarette advertising and the TRIPS in relation to trademark protection and the disclosure of product information considered by producers to be confidential. These agreements may have measures for tobacco control but have not yet been involved in tobacco-related controversy among WTO Members.
To conclude, a proper cooperation between trade and health officials not only at national but also at international levels is crucial so that they manage to ban the use of tobacco.
Τhe link between environment and health is well established: everyone knows that most environmental hazards will affect human health in varying degrees. However though, the link between environment, health and trade is not that obvious. Economic growth is not sustainable in the long-term if it comes at the expense of environment, that is the air, land and water on which human life and public health depends. Removing trade barriers to green technologies and to suppliers of environmental goods and services can potentially benefit both the environment and health. For example in many developing countries, foreign investments can introduce modern equipment and production processes that are safer and less polluting than those used previously. It is more than obvious that, removing trade-distorting policies such as subsidies may both enhance trade as well as benefit the environment. However, trade in dangerous materials, such as hazardous wastes and unsafe chemicals, may also increase environmental health hazards. With the entry in force of the WTO in January 1995, the Committee on Trade and Environment (CTE) was established. Τhe CTE has a broad-based mandate covering all areas of the multilateral trading system - goods,services and intellectual property. It has brought environmental and sustainable development issues into the mainstream of WTO work. The CTE’s first report notes that the WTO Members’ wish to approach the issue of trade and environment in a constructive manner.Trade and environment are both important areas of policy-making and they should be mutually supportive in order to promote development. One important aspect of the trade and environment interface is the relationship between WTO rules and multilateral environmental agreements (MEAs). 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. To address shared environmental problems,national governments have signed over 200 MEAs. 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. Therefore, the dimension of the problem should not be exaggerated. Τo sum up, although there is potential, no disputes have thus far come to the WTO regarding the trade provisions contained in an MEA.
5. Access to drugs and vaccines
Modern medicine depends a lot on the use of drugs and vaccines to treat or prevent illness. WHO estimates that currently one third of the world’s population lacks access to essential drugs with this figure rising to over 50% in the poorest parts of Africa and Asia. Drugs that appear on WHO’s Model List of Essential Drugs are defined as those which satisfy the health care needs of the majority of the population. Access to essential medicines and vaccines depends on 4 critical elements which are : a) affordable prices b) rational selection and use c) sustainable financing and d) reliable supply systems. Although the latter 3 points are very important in order to place the problem of access to drugs in the right perspective, when it comes in health and trade discussions the focus is usually on drug prices. WTO negotiations may lead to the elimination or reduction of import duties on drugs, vaccines or other medical supplies, which may lower the prices. International conventions before TRIPS agreement did not specify most of the minimum standards for patents. Over 40 countries provided no product patent protection for pharmaceuticals prior to the launching of the negotiation of the TRIPS Agreement and some 20 WTO Members still did not do so by the time of the conclusion of the TRIPS negotiations. A few of these countries did not provide process protection in this area as well. The duration of patents was less than 20 years in many countries. One effect of patent protection is that it gives the patent owner the right to prevent the competition from using the information to produce the same products and the possibility to set prices higher than they could otherwise. For this reason, the price of patented drugs is often much higher than the price that would prevail if generic competition were allowed. Such differences lie behind the concern that TRIPS could result in substantial increases in the price of drugs once countries implement its rules. 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. Lastly the Declaration enshrines the principle that WHO has publicly advocated and advanced over the last four years, namely, the re-affirmation of the right of WTO Members to make full use of the safeguard provisions of the TRIPS Agreement in order to protect public health and promote access to medicines.
6. Food security and Nutrition
The Rome Declaration on World Food Security states that : "Food security exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life." Food security is considered at two levels : National food security and Household food security. When it comes to the first one we are talking about the ability of a country to secure an adequate total supply of food to meet the nutritional needs of its populations at all times,through domestic production,food imports etc. Talking about the second one, it is concerned as the ability of a household to secure reliable access to enough food for its members at all times,through its own production, market purchases,use of its own stock or public provision. The issue of food security is complex and has many components.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. Food aid also in a another aspect and it is important in limiting the effects of national food insecurity,especially in emergency situations. Lastly a group of developing countries has emphasized the need to give developing countries additional flexibilities to address their food security concerns. To sum up, proposals have been made for developed countries to make more specific commitments in respect of food aid.
7. Health Services
The equitable and efficient delivery of quality health services in response to the health needs of a population depends on many factors, including the appropriate combination of resources available on domestic as well as international markets. International trade in health services is growing in many areas. Phenomenons such as the movement of health professionals to other countries, whether on a temporary or permanent basis, usually in search of higher wages and better working conditions is something that keeps increasing year after year. There have also been notable increases in foreign investment by hospital operators and health insurance companies in search of new markets. In addition, growing numbers of countries are seeking to attract health consumers from other countries.
Depending on appropriate regulatory conditions, trade liberalisation can contribute to enhancing quality and efficiency of supplies and increasing foreign exchange earnings. The possible benefits resulting from health care internationalization and trade liberalization can be directed toward public health objectives in various ways. While these trends are very promising and hold the development of the economy,not all countries may be well-positioned to turn the potential gains into health benefits for the majority of the people. In some cases, trade in services 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. The GATS agreement leaves countries the flexibility to manage trade in health services in ways that are consistent with national health policy objectives.The overall effect of GATS on trade in health services is thus likely to have remained negligible to date. Measuring the effect of GATS commitments measures in individual countries is also complicated by the lack of systematic data collection over time and the difficulty of isolating the effect of trade policy on health services and systems from other changes in health care markets and in national health regulations that may occur simultaneously. In conclusion, the commitment to progressive liberalization presents a potential for negotiating expanded commitments on trade in health services and, at the same time an opportunity to attract foreign direct investment and make it responsive to national health priorities. In many developing countries, this offers opportunities to acquire health services unavailable domestically or export health services and human resources to a larger world market. At the same time, there are risks of exacerbating existing problems of access and equity of health services and financing. The challenge as always is to maximize the opportunities and minimize the risks.
8. Emerging Issues
Ιn the health area there are two important technological advances that have the potential to revolutionize health care and these are : a) biotechnology, and b) information technology. A third emerging health issue is related to the centuries-old use of c) herbal medicines and traditional knowledge for treating illnesses. All three issues represent the next wave of policy issues involving health and trade. To understand them it’s important to describe them.
To begin with, biotechnology can be generally defined as «the application of scientific and engineering principles to the processing of materials by biological agents to provide goods and services». Nowadays as the scope of its application grows wider the TRIPS Council has debated whether some biotechnological innovations are patentable or not. Second 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, it could be constrained by high cost and lack of infrastructure. And last something about the 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.
These three issues, are among several emerging health and trade issues. As the world becomes more and more integrated the health issues of today can quickly become the trade issues of tomorrow.
As this study has shown, yes, there is common ground between health and especially public health and trade and therefore between the two big organisations the WHO and the WTO. Good health is one important building block for sustainable economic development. Τhe rules and provisions of the WTO agreements most relevant to health generally permit countries to manage trade in goods and services in order to achieve their national health objectives, as long as health measures respect basic trade principles such as non-discrimination. Even these provisions may be waived under exceptions for public health reasons as provided in many WTO Agreements. There are increasing opportunities for taking advantage of a collaboration between trade and health policies not only at national but also at international level. 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.» Effective policy making depends on awareness, coordination and engagement of all those concerned.
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