Trade challenges at the World Trade Organization to national noncommunicable disease prevention policies: A thematic document analysis of trade and health policy space

Lessons for strengthening policymaking for obesity and diet-related noncommunicable disease prevention: A narrative synthesis of policy literature from the Western Pacific Region

Obesity and diet-related noncommunicable diseases (NCDs) have a profound impact on individuals, households, health care systems, and economies in low- and middle- income countries (LMICs), with the Western Pacific Region experiencing some of the highest impacts. Governments have committed to improving population diets; however, implementation challenges limit effective policy action. We undertook meta-narrative synthesis of the academic literature and used theories of policymaking and implementation to synthesize current knowledge of issues affecting the adoption and implementation of policies to prevent obesity and diet-related NCDs in LMICs in the Western Pacific Region. We found that political leadership and management of food and nutrition policies often diluted following policy adoption, and that nutrition and health advocates find it difficult to enforce policy compliance from actors outside their sectors. Opportunities for strengthening implementation of food and nutrition policies in the Western Pacific include (1) improved and earlier engagement between health policymakers and implementing agencies; (2) focusing on the need for increased accountability from governments, including through effective engagement and organization of actor networks, knowledge sharing, and in highlighting where stronger action is required; and (3) identifying and building the strategic capacities of policy actors in framing, advocacy, coalition-building, knowledge translation, and leadership.

Stakeholder arguments during the adoption of a sugar sweetened beverage tax in South Africa and their influence: a content analysis

BACKGROUND

Sugar-sweetened beverage (SSB) taxes are recognised as an effective intervention to prevent obesity. More countries are adopting SSB taxes, but the process of the adoption is politically complex.

OBJECTIVE

This study aimed to analyse how public participation processes influenced the South African tax.

METHODS

We conducted a content analysis of documents associated with the process of adopting the tax. Records were identified utilising the Parliamentary Monitoring Group database, including draft bills, meeting minutes and written submissions. The records were categorised and then inductively coded to identify themes and arguments.

RESULTS

We identified six cross-cutting themes advanced by stakeholders: economic considerations, impact on the vulnerable, responsiveness of an SSB tax to the problem of obesity, appropriateness of an SSB tax in South Africa, procedural concerns, and structure of the tax. Stakeholder views and arguments about the tax diverged based on their vested interests. The primary policymaker was most responsive to arguments concerning the economic impact of a tax, procedural concerns and the structure of the tax, reducing the effective rate to address industry concerns.

CONCLUSION

Both supportive and opposing stakeholders influenced the tax. Economic arguments had a significant impact. Arguments in South Africa broadly echoed arguments advanced in many other jurisdictions.

Public health advocacy strategies to influence policy agendas: lessons from a narrative review of success in trade policy

BACKGROUND

Despite accumulating evidence of the implications of trade policy for public health, trade and health sectors continue to operate largely in silos. Numerous barriers to advancing health have been identified, including the dominance of a neoliberal paradigm, powerful private sector interests, and constraints associated with policymaking processes. Scholars and policy actors have recommended improved governance practices for trade policy, including: greater transparency and accountability; intersectoral collaboration; the use of health impact assessments; South-South networking; and mechanisms for civil society participation. These policy prescriptions have been generated from specific cases, such as the World Trade Organization's Doha Declaration on TRIPS and Public Health or specific instances of trade-related policymaking at the national level. There has not yet been a comprehensive analysis of what enables the elevation of health goals on trade policy agendas. This narrative review seeks to address this gap by collating and analysing known studies across different levels of policymaking and different health issues.

RESULTS

Sixty-five studies met the inclusion criteria and were included in the review. Health issues that received attention on trade policy agendas included: access to medicines, food nutrition and food security, tobacco control, non-communicable diseases, access to knowledge, and asbestos harm. This has occurred in instances of domestic and regional policymaking, and in bilateral, regional and global trade negotiations, as well as in trade disputes and challenges. We identified four enabling conditions for elevation of health in trade-related policymaking: favourable media attention; leadership by trade and health ministers; public support; and political party support. We identified six strategies successfully used by advocates to influence these conditions: using and translating multiple forms of evidence, acting in coalitions, strategic framing, leveraging exogenous factors, legal strategy, and shifting forums.

CONCLUSION

The analysis demonstrates that while technical evidence is important, political strategy is necessary for elevating health on trade agendas. The analysis provides lessons that can be explored in the wider commercial determinants of health where economic and health interests often collide.

US and EU Free Trade Agreements and implementation of policies to control tobacco, alcohol, and unhealthy food and drinks: A quasi-experimental analysis

BACKGROUND

Identifying and tackling the factors that undermine regulation of unhealthy commodities is an essential component of effective noncommunicable disease (NCD) prevention. Unhealthy commodity producers may use rules in US and EU Free Trade Agreements (FTAs) to challenge policies targeting their products. We aimed to test whether there was a statistical relationship between US and EU FTA participation and reduced implementation of WHO-recommended policies.

METHODS AND FINDINGS

We performed a statistical analysis assessing the probability of at least partially implementing 10 tobacco, alcohol, and unhealthy food and drink policies in 127 countries in 2014, 2016, and 2019. We assessed differences in implementation of these policies in countries with and without US/EU FTAs. We used matching to conduct 48 covariate-adjusted quasi-experimental comparisons across 27 matched US/EU FTA members (87 country-years) and performed additional analyses and robustness checks to assess alternative explanations for our results. Out of our 48 tests, 19% (9/48) identified a statistically significant decrease in the predicted probability of at least partially implementing the unhealthy commodity policy in question, while 2% (1/48) showed an increase. However, there was marked heterogeneity across policies. At the level of individual policies, US FTA participation was associated with a 37% reduction (95%CI: -0.51 to -0.22) in the probability of fully implementing graphic tobacco warning policies, and a 53% reduction (95%CI: -0.63 to -0.43) in the probability of at least partially implementing smoke-free place policies. EU FTA participation was associated with a 28% reduction (95%CI: -0.45 to -0.10) in the probability of fully implementing graphic tobacco warning policies, and a 25% reduction (95%CI: -0.47 to -0.03) in the probability of fully implementing restrictions on child marketing of unhealthy food and drinks. There was a positive association with implementing fat limits and bans, but this was not robust. Associations with other outcomes were not significant. The main limitations included residual confounding, limited ability to discern precise mechanisms of influence, and potentially limited generalisability to other FTAs.

CONCLUSIONS

US and EU FTA participation may reduce the probability of implementing WHO-recommended tobacco and child food marketing policies by between a quarter and a half-depending on the FTA and outcome in question. Governments negotiating or participating in US/EU FTAs may need to establish robust health protections and mitigation strategies to achieve their NCD mortality reduction targets.

The Politics of Regulating Foods for Infants and Young Children: A Case Study on the Framing and Contestation of Codex Standard-Setting Processes on Breast-Milk Substitutes

BACKGROUND

Breastfeeding is important for the health and development of the child, and for maternal health, in all country contexts. However, global sales of breast-milk substitutes (BMS), including infant, follow-up and toddler formulas, have 'boomed' in recent decades. This raises the importance of international food standards established by the Codex Alimentarius Commission (Codex) on the safety, composition and labelling of BMS. Such standards appear to be strongly contested by governments, industry and civil society groups, yet few studies have investigated the politics of Codex standard-setting processes. The aim of this paper is to understand who participates in decision-making, and how actors frame and contest proposals to revise the Codex Standard on Follow-up Formula (FUF).

METHODS

We adopted a case study design involving two steps. First, we enumerated government, industry, civil society, and international organization stakeholders participating in standard-setting processes of the Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU). Second, we conducted a framing analysis of stakeholder inputs during the FUF standard revision in CCNFSDU meetings. Publicly available online meeting reports (2015-2019) were retrieved, analyzed using a theoretical framework, and organized thematically.

RESULTS

High-income country (HIC) delegates greatly outnumbered those from other country income categories. Industry representation was higher compared with other observer categories. Member state delegations included more industry representation than civil society representation, and were occasionally the only member state delegates. Industry stakeholders framed arguments in terms of trade implications, science, and flexible standards. Civil society groups used public health, science, and pro-breastfeeding frames.

CONCLUSION

Codex BMS standard-setting procedures are dominated by HICs and industry groups. Limited representation of civil society, and of low- and middle-income countries (LMICs), suggest actions are needed to substantially increase support for their involvement at Codex. Such representation may help to counteract power asymmetries and commercial influences on food standards for infants and young children.

Reassessing the health impacts of trade and investment agreements: a systematic review of quantitative studies, 2016-20

To ensure a high level of health protection, governments must ensure that health and trade policy objectives are aligned. We conducted a systematic review of the health impacts of trade policies, including trade and investment agreements (TIAs), to provide a timely overview of this field. We systematically reviewed studies evaluating the health impacts of trade policies published between Jan 19, 2016, and July 10, 2020. Included studies were quantitative studies evaluating the impact of TIAs and trade policies on health determinants or outcomes. We evaluated methodological quality and performed a narrative synthesis. 21 of 28 067 articles identified via searches met our criteria. Methodologically strong studies found reduced child mortality, deteriorating worker health, rising supplies of sugar, ultra-processed food, tobacco, and alcohol supplies, and increased drug overdoses following trade reforms, compared with the time periods before trade reform. However, associations varied substantially across contexts and socioeconomic characteristics. Our findings show that trade policies, including TIAs, have diverse effects on health and health determinants. These effects vary substantially across contexts and socioeconomic groups. Governments seeking to adopt healthy trade policies should consider these updated findings to ensure that opportunities for health improvement are leveraged and widely shared, while harms are avoided, especially among vulnerable groups.

Protecting noncommunicable disease prevention policy in trade and investment agreements

Preventing noncommunicable diseases is a global priority, for which the World Health Organization has recommended policies to reduce the consumption of tobacco products, alcohol and unhealthy foods. However, regulation has been strongly opposed by affected industries, who have invoked the provisions of legally binding trade and investment agreements. The aim of this analysis of the legal, economic and public health literature was to present a short primer on the relationship between noncommunicable disease prevention policy and trade and investment agreements to help public health policy-makers safeguard public health policies. The analysis identified opportunities for protecting, and even promoting, public health in trade and investment agreements, including: (i) ensuring exceptions for public health measures are included in agreements; (ii) committing to good regulatory practice that balances transparency and cooperation with the need for governments to limit the influence of vested interests; (iii) ensuring trade and investment agreement preambles acknowledge the importance of public health; (iv) excluding investor-state dispute settlement mechanisms from agreements; and (v) limiting the scope and definition of key provisions on investor protection to reduce the risk of investment disputes. This synthesis of the multidisciplinary literature also provides support for greater strategic and informed engagement between the health and trade policy sectors. In addition, ensuring a high level of health protection in trade and investment agreements requires cooperation between disciplines, engagement with experts in law, economics and public health policy, and fully transparent policy processes and governance structures.

COVID-19, Trade, and Health: This Changes Everything? Comment on "What Generates Attention to Health in Trade Policy-Making? Lessons From Success in Tobacco Control and Access to Medicines: A Qualitative Study of Australia and the (Comprehensive and Progressive) Trans-Pacific Partnership"

Townsend and colleagues highlighted the myriad political forces which fostered attention to health issues during negotiations to establish a new trans-pacific trade deal in Australia (the CP-TPP [Comprehensive and Progressive Agreement for Trans-Pacific Partnership], formerly known as TPP). Among the factors they identify, exporter interests and exogenous events helped to generate attention to trade-related concerns about tobacco and access medicines, and limited attention to nutrition and alcohol. These are important considerations as the United Kingdom negotiates a trade deal with the United States in haste, whilst at the same time attempting to manage the ongoing coronavirus disease 2019 (COVID-19) pandemic. In this commentary, I reflect on changing attention to trade and nutrition during the COVID-19 pandemic in light of Townsend and colleagues' analysis. I explore scope for greater attention to nutrition in US-UK trade negotiations, and the challenges created by the vested interests of major UK and US processed food exporters. I further discuss the utility of the theoretical tools employed by Townsend and colleagues for wider debates in the political economy of health.

Non-communicable disease policy implementation in Libya: A mixed methods assessment

The Libyan Ministry of Health is keen to understand how it can introduce policies to protect its population from non-communicable diseases (NCDs). We aimed to perform an implementation research assessment of the current situation, including challenges and opportunities. We used an explanatory sequential mixed methods design. We started with a quantitative assessment of NCD policy performance based on review of the WHO NCD Progress Monitor Reports. Once we had identified Libya's NCD policy gaps we performed a systematic review to identify international lessons around barriers and successful strategies for the policies Libya has not yet implemented. Finally, we performed a series of key stakeholder interviews with senior policymakers to explore their perspectives around promising policy actions. We used a realist paradigm, methods triangulation, and a joint display to synthesise the interpretation of our findings and develop recommendations. Libya has not fully implemented any of the recommended policies for diet, physical activity, primary care guidelines & therapeutics, or data collection, targets & surveillance. It does not have robust tobacco policies in place. Evidence from the international literature and policymaker interviews emphasised the centrality of according strong political leadership, governance structures, multisectoral engagement, and adequate financing to policy development activities. Libya's complex political and security situation are major barriers for policy implementation. Whilst some policies will be very challenging to develop and deploy, there are a number of simple policy actions that could be implemented with minimum effort; from inviting WHO to conduct a second STEPS survey, to signing the international code on breast-milk substitutes. Like many other fragile and conflict-affected states, Libya has not accorded NCDs the policy attention they demand. Whilst strong high-level leadership is the ultimate key to providing adequate protections, there are a range of simple measures that can be implemented with relative ease.

Evaluating the Impact of COVID-19 on Society, Environment, Economy, and Education

The COVID-19 pandemic has caused drastic changes across the globe, affecting all areas of life. This paper provides a comprehensive study on the influence of COVID-19 in various fields such as the economy, education, society, the environment, and globalization. In this study, both the positive and negative consequences of the COVID-19 pandemic on education are studied. Modern technologies are combined with conventional teaching to improve the communication between instructors and learners. COVID-19 also greatly affected people with disabilities and those who are older, with these persons experiencing more complications in their normal routine activities. Additionally, COVID-19 provided negative impacts on world economies, greatly affecting the business, agriculture, entertainment, tourism, and service sectors. The impact of COVID-19 on these sectors is also investigated in this study, and this study provides some meaningful insights and suggestions for revitalizing the tourism sector. The association between globalization and travel restrictions is studied. In addition to economic and human health concerns, the influence of a lockdown on environmental health is also investigated. During periods of lockdown, the amount of pollutants in the air, soil, and water was significantly reduced. This study motivates researchers to investigate the positive and negative consequences of the COVID-19 pandemic in various unexplored areas.

Policy-makers' perspectives on implementation of cross-sectoral nutrition policies, Western Pacific Region

Implementation of effective cross-sectoral nutrition policies remains a challenge worldwide. By reviewing reports from World Health Organization meetings and consultations - convened for policy-makers representing Member States of the Western Pacific Region - we provide an insight into how national policy-makers and external actors can support different dimensions of nutrition policy implementation. Key insights of policy-makers attending food and nutrition-centred meetings include that country-level implementation of nutrition policy relies on strong policy design, organizational planning and governance mechanisms that promote collective responsibility across multiple sectors. Policy-makers responsible for implementing nutrition policies face major challenges resulting from limited capacity, both within and external to government, particularly in relation to monitoring and enforcement activities. Successful implementation of nutrition policy measures will require greater political will to provide the requisite resources and institutional structures to ensure sustained policy effectiveness. Nongovernmental partners, including international agencies and researchers, have an opportunity to support policy implementation by providing technical support to Member States to frame action on nutrition in a more compelling way. They can also help policy-makers to build the organizational and structural capacity to coordinate cross-sectoral policy. Improved policy design, planning and governance and strategic capacity-building, supported by external partners, can strengthen the sustained implementation of cross-sectoral nutrition policy and improve nutrition outcomes.

Who influences nutrition policy space using international trade and investment agreements? A global stakeholder analysis

Background

Regulation of food environments is needed to address the global challenge of poor nutrition, yet policy inertia has been a problem. A common argument against regulation is potential conflict with binding commitments under international trade and investment agreements (TIAs). This study aimed to identify which actors and institutions, in different contexts, influence how TIAs are used to constrain policy space for improving food environments, and to describe their core beliefs, interests, resources and strategies, with the objective of informing strategic global action to preserve nutrition policy space.

Methods

We conducted a global stakeholder analysis applying the Advocacy Coalition Framework, based on existing academic literature and key informant interviews with international experts in trade and investment law and public health nutrition policy.

Results

We identified 12 types of actors who influence policy space in the food environment policy subsystem, relevant to TIAs. These actors hold various beliefs regarding the economic policy paradigm, the nature of obesity and dietary diseases as health problems, the role of government, and the role of industry in solving the health problem. We identified two primary competing coalitions: 1) a ‘public health nutrition’ coalition, which is overall supportive of and actively working to enact comprehensive food environment regulation; and 2) an ‘industry and economic growth’ focussed coalition, which places a higher priority on deregulation and is overall not supportive of comprehensive food environment regulation. The industry and economic growth coalition appears to be dominant, based on its relative power, resources and coordination. However, the public health nutrition coalition maintains influence through individual activism, collective lobbying and government pressure (e.g. by civil society), and expert knowledge generation.

Conclusions

Our analysis suggests that industry and economic growth-focussed coalitions are highly capable of leveraging networks, institutional structures and ideologies to their advantage, and are a formidable source of opposition acting to constrain nutrition policy space globally, including through TIAs. Opportunities for global public health nutrition coalitions to strengthen their influence in the support of nutrition policy space include strategic evidence generation and coalition-building through broader engagement and capacity-building.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00764-7.

Do international trade and investment agreements generate regulatory chill in public health policymaking? A case study of nutrition and alcohol policy in South Africa

BACKGROUND

Trade and health scholars have raised concern that international trade and particularly investment disputes may be used by transnational health harmful commodity corporations (THCCs) to effectively generate public health regulatory chill. The purpose of this study was to contribute to the limited evidence base of trade or investment dispute-related regulatory chill using a case study of nutrition and alcohol policy in South Africa.

METHODS

We conducted 35 semi-structured interviews with 36 key stakeholders involved in nutrition, alcohol and/or trade/investment policymaking in South Africa. Interview transcripts were analyzed using thematic analysis. We used Schram et al's theory on three forms of regulatory chill (anticipatory, response and precedential) to guide the analysis. We report evidence on each form of regulatory chill as well as specific contextual factors that may influence the risk of regulatory chill.

RESULTS

Trade obligations were found to generate a significantly greater anticipatory-type chilling effect on nutrition and alcohol regulation than South Africa's investment treaty obligations. Response chill was reported to have occurred in relation to South Africa's proposed tobacco plain packaging regulation while awaiting the outcome of both Australia's investor-state and WTO state-state disputes. No cases were reported of THCCs threatening an investor-state dispute over nutrition or food regulations, but there were reported cases of THCCs using arguments related to South Africa's trade obligations to oppose policy action in these areas. No evidence of nutrition or alcohol policy precedential chill were identified. Factors affecting the risk of policy chill include legitimacy and perceived bias of the dispute system, costs involved in pursuing a regulation/defending a dispute and capacity to pay, social acceptability of the industry, a product's perceived risk to health and confidence in a successful dispute outcome e.g. through cross-border policy learning.

CONCLUSIONS

Our findings indicate that currently, South Africa's trade obligations have a more prominent role in inhibiting nutrition and alcohol action than investment treaty-related concerns. However, given the potential for wider use of the ISDS mechanism by THCCs in the future, strategies to protect public health policy space in the context of both international trade and investment treaty and dispute settlement contexts remain important.

When actions do not match aspirations - comparison of the European Union policy claims against what has been negotiated for health services, trade and investment

Background

Obligations arising from trade and investment agreements can affect how governments can regulate and organise health systems. The European Union has made explicit statements of safeguarding policy space for health systems. We assessed to what extent health systems were safeguarded in trade negotiations using the European Union (EU) negotiation proposals for the Transatlantic Trade and Investment Partnership (TTIP) and the negotiated agreement for the EU-Canada Comprehensive Economic and Trade Agreement (CETA).

Methods

We assessed if and to what extent the European Union policy assurances were upheld in trade negotiations. Our assessment was made using three process tracing informed tests. The tests examined: i) what was covered in negotiation proposals of services and investment chapters, ii) if treatment of health services differed from treatment of another category of services (audiovisual services) with similar EU Treaty considerations, and iii) if other means of general exceptions, declarations or emphases on right to regulate could have resulted in the same outcome.

Results

Our analysis shows that the European Union had sought to secure policy space for publicly funded health services for services chapter, but not for investment and investment protection chapters. In comparison to audiovisual services, exceptions for health services fall short from those on audiovisual services. There is little evidence that the same outcome could have been achieved using other avenues.

Conclusions

The European Union has not achieved its own assurances of protection of regulatory policy space for health services in trade negotiations. The European Union trade negotiation priorities need to change to ensure that its negotiation practices comply with its own assurances for health services and sustainable financing of health systems.

Corporate power and the international trade regime preventing progressive policy action on non-communicable diseases: a realist review

Transnational tobacco, alcohol and ultra-processed food corporations use the international trade regime to prevent policy action on non-communicable diseases (NCDs); i.e. to promote policy 'non-decisions'. Understanding policy non-decisions can be assisted by identifying power operating in relevant decision-making spaces, but trade and health research rarely explicitly engages with theories of power. This realist review aimed to synthesize evidence of different forms and mechanisms of power active in trade and health decision-making spaces to understand better why NCD policy non-decisions persist and the implications for future transformative action. We iteratively developed power-based theories explaining how transnational health-harmful commodity corporations (THCCs) utilize the international trade regime to encourage NCD policy non-decisions. To support theory development, we also developed a conceptual framework for analysing power in public health policymaking. We searched six databases and relevant grey literature and extracted, synthesized and mapped the evidence against the proposed theories. One hundred and four studies were included. Findings were presented for three key forms of power. Evidence indicates THCCs attempt to exercise instrumental power by extensive lobbying often via privileged access to trade and health decision-making spaces. When their legitimacy declines, THCCs have attempted to shift decision-making to more favourable international trade legal venues. THCCs benefit from structural power through the institutionalization of their involvement in health and trade agenda-setting processes. In terms of discursive power, THCCs effectively frame trade and health issues in ways that echo and amplify dominant neoliberal ideas. These processes may further entrench the individualization of NCDs, restrict conceivable policy solutions and perpetuate policymaking norms that privilege economic/trade interests over health. This review identifies different forms and mechanisms of power active in trade and health policy spaces that enable THCCs to prevent progressive action on NCDs. It also points to potential strategies for challenging these power dynamics and relations.

How does globalization affect COVID-19 responses?

BACKGROUND

The ongoing COVID-19 pandemic has highlighted the vast differences in approaches to the control and containment of coronavirus across the world and has demonstrated the varied success of such approaches in minimizing the transmission of coronavirus. While previous studies have demonstrated high predictive power of incorporating air travel data and governmental policy responses in global disease transmission modelling, factors influencing the decision to implement travel and border restriction policies have attracted relatively less attention. This paper examines the role of globalization on the pace of adoption of international travel-related non-pharmaceutical interventions (NPIs) during the coronavirus pandemic. This study aims to offer advice on how to improve the global planning, preparation, and coordination of actions and policy responses during future infectious disease outbreaks with empirical evidence.

METHODS AND DATA

We analyzed data on international travel restrictions in response to COVID-19 of 185 countries from January to October 2020. We applied time-to-event analysis to examine the relationship between globalization and the timing of travel restrictions implementation.

RESULTS

The results of our survival analysis suggest that, in general, more globalized countries, accounting for the country-specific timing of the virus outbreak and other factors, are more likely to adopt international travel restrictions policies. However, countries with high government effectiveness and globalization were more cautious in implementing travel restrictions, particularly if through formal political and trade policy integration. This finding is supported by a placebo analysis of domestic NPIs, where such a relationship is absent. Additionally, we find that globalized countries with high state capacity are more likely to have higher numbers of confirmed cases by the time a first restriction policy measure was taken.

CONCLUSIONS

The findings highlight the dynamic relationship between globalization and protectionism when governments respond to significant global events such as a public health crisis. We suggest that the observed caution of policy implementation by countries with high government efficiency and globalization is a by-product of commitment to existing trade agreements, a greater desire to 'learn from others' and also perhaps of 'confidence' in a government's ability to deal with a pandemic through its health system and state capacity. Our results suggest further research is warranted to explore whether global infectious disease forecasting could be improved by including the globalization index and in particular, the de jure economic and political, and de facto social dimensions of globalization, while accounting for the mediating role of government effectiveness. By acting as proxies for a countries' likelihood and speed of implementation for international travel restriction policies, such measures may predict the likely time delays in disease emergence and transmission across national borders.

Neoliberal discourse, actor power, and the politics of nutrition policy: A qualitative analysis of informal challenges to nutrition labelling regulations at the World Trade Organization, 2007-2019

Unhealthy diets are increasing contributors to poor health and mortality in low- and middle-income countries (LMICs). Government interventions targeting the structural drivers of unhealthy diets are needed to prevent these illnesses, including nutrition labelling regulations that create healthier food environments. Yet, implementation remains slow and uneven. One explanation for slow implementation highlights the role of politics, including powerful ideological discourse and its strategic deployment by economically powerful actors. In this article, we advance research on the politics of nutrition policies by analysing political discourse on nutrition labelling regulations within an influential and under-studied global institution: the World Trade Organization (WTO). We identified WTO Technical Barriers to Trade (TBT) Committee meeting minutes with reference to nutrition labelling policies proposed by Thailand, Chile, Indonesia, Peru, Ecuador, Bolivia, and Uruguay (2007-2019; n = 47). We analysed the frames, narratives, and normative claims that feature in inter-country discourse within TBT meetings and examined how actors mobilize ideological and material sources of power via these statements. We find that informal government challenges to nutrition labelling proposals within the Committee featured a narrative that individualized the causes of and solutions to poor diet, downplayed harms from industrialised food products, and framed state regulation as harmful and unjust. These non-technical claims mobilised neoliberal ideology and rhetoric to contest the normative legitimacy of members' proposals and to de-socialize and de-politicize poor diets. Furthermore, high-income countries (HICs) re-framed policy goals to focus on individual determinants of poor nutrition whilst calling for their preferred policies to be adopted. Patterns of discourse within TBT meetings also had striking similarities with arguments raised by multi-national food corporations elsewhere. Our findings suggest that non-technical and ideological arguments raised during TBT meetings serve as inconspicuous tools through which nutrition labelling policies in LMICs are undermined by HICs, industry, and the powerful ideology of neoliberalism.

COVID-19 and the collapse of global trade: building an effective public health response

The scale of the COVID-19 pandemic is a consequence of international trade and globalisation, with the virus spreading along established trade and travel routes. However, the pandemic also affects international trade through reductions in both supply and demand. In this Viewpoint we describe the many implications for health and propose ways to mitigate them. Problems include reduced access to medical supplies (in particular, personal protective equipment and tests), budgetary shortfalls as a result of reduced tariffs and taxes, and a general decline in economic activity-leading, in many cases, to recessions, threats to social safety nets, and to increased precariousness of income, employment, and food security. However, in exceptional cases, the pandemic has also brought some transient benefits, including to the environment. Looking ahead, there will be great pressure to further liberalise rules on trade to encourage economic recovery, but it is essential that trade policy be informed by its many consequences for health to ensure that the benefits are maximised and threats are minimised through active identification and mitigation.

Framing global discourses on non-communicable diseases: a scoping review

Background

The choices that policymakers make are shaped by how their problems are framed. At last, non-communicable diseases (NCDs) have risen high on the global policy agenda, but there are many disputed issues. First, what are they? Their name refers not to what they are but what they are not. Second, where do their boundaries lie? What diseases are included? Third, should we view their causes as mainly biomedical, behavioural, or social, or a combination? Our failure to resolve these issues has been invoked as a reason for our limited progress in developing and implementing effective remedies. In this scoping review, we ask “What is known from the existing literature about how NCDs are framed in the global policy discourses?” We answer it by reviewing the frames employed in policy and academic discourses.

Methods

We searched nine electronic databases for articles published since inception to 31 May 2019. We also reviewed websites of eight international organisations to identify global NCDs policies. We extracted data and synthesised findings to identify key thematic frames.

Results

We included 36 articles and nine policy documents on global NCDs policies. We identified five discursive domains that have been used and where there are differing perspectives. These are: “Expanding the NCDs frame to include mental health and air pollution”; “NCDs and their determinants”; “A rights-based approach to NCDs”; “Approaches to achieving policy coherence in NCDs globally”; and “NCDs as part of Sustainable Socio-economic Development”. We further identified 12 frames within the five discursive domains.

Conclusions

This scoping review identifies issues that remain unresolved and points to a need for alignment of perspectives among global health policy actors, as well as synergies with those working on mental health, maternal health, and child health. The current COVID-19 pandemic warrants greater consideration of its impact on global NCDs policies. Future global strategies for NCDs need to consider explicitly how NCDs are framed in a changing global health discourse and ensure adequate alignment with implementation and global health issues. There is a need for global strategies to recognise the pertinent role of actors in shaping policy discourses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05958-0.

Ultra-processed foods and the nutrition transition: Global, regional and national trends, food systems transformations and political economy drivers

Understanding the drivers and dynamics of global ultra-processed food (UPF) consumption is essential, given the evidence linking these foods with adverse health outcomes. In this synthesis review, we take two steps. First, we quantify per capita volumes and trends in UPF sales, and ingredients (sweeteners, fats, sodium and cosmetic additives) supplied by these foods, in countries classified by income and region. Second, we review the literature on food systems and political economy factors that likely explain the observed changes. We find evidence for a substantial expansion in the types and quantities of UPFs sold worldwide, representing a transition towards a more processed global diet but with wide variations between regions and countries. As countries grow richer, higher volumes and a wider variety of UPFs are sold. Sales are highest in Australasia, North America, Europe and Latin America but growing rapidly in Asia, the Middle East and Africa. These developments are closely linked with the industrialization of food systems, technological change and globalization, including growth in the market and political activities of transnational food corporations and inadequate policies to protect nutrition in these new contexts. The scale of dietary change underway, especially in highly populated middle-income countries, raises serious concern for global health.

Alcohol labelling rules in free trade agreements: Advancing the industry's interests at the expense of the public's health

INTRODUCTION AND AIMS

The Trans-Pacific Partnership Agreement (TPP) included novel rules for wine and spirits requiring parties to allow wine and spirits importers to display information required by the importing country on a supplementary label rather than on the standard label. Since the TPP negotiations concluded, alcohol-specific supplementary labelling rules have begun to appear in other trade agreements. The aim of this paper was to map the new instruments containing these rules and examine developments in the rules with implications for health information on alcohol containers.

DESIGN AND METHODS

Trade agreements signed after the TPP negotiations concluded were retrieved and searched for alcohol-specific labelling provisions. A legal analysis of these provisions and related exceptions was undertaken.

RESULTS

Supplementary labelling rules similar or identical to those in the TPP have been included in five subsequent trade agreements. The United States-Mexico-Canada Agreement also includes several additional provisions about alcohol labelling. Exceptions in the agreements provide some space for governments to defend labelling measure that might otherwise breach the rules, in the event of a dispute.

DISCUSSION AND CONCLUSIONS

By securing these rules, the alcohol industry is better positioned to claim the space on the standard label as industry 'real estate' and to oppose mandatory health information incorporated into the standard labelling. These risks can be mitigated by stemming the adoption of supplementary labelling rules in further trade agreements; clarifying the text of agreements and ensuring that regulators understand that the rules do not prevent the use of 'best-practice' warning labels.

Increasing the public health voice in global decision-making on nutrition labelling

To respond to the global noncommunicable disease (NCD) crisis, the Codex Alimentarius Commission (Codex), a multilateral United Nations body responsible for work on food standards, is developing global guidance for front of pack (FoP) nutrition labelling. Guidance from Codex regarding FoP nutrition labelling at the global level will almost certainly influence national policy making. This shift in Codex’s activities towards standards to address NCDs presents new risks for achievement of public health goals, as a result of the high level of industry involvement in this forum; there is a potential commercial conflict of interest held by manufacturers of products whose consumption could be discouraged by such guidance. In this Commentary, we examine the implications of Codex processes for developing robust global guidance on FoP nutrition labelling and identify opportunities to increase consideration of public health objectives. To date, there has been significantly higher representation of food industry compared to public health actors in Codex discussions on FoP nutrition labelling. Without a strong public health voice in Codex, the industry voice could dominate discussions on FoP nutrition labelling, such that subsequent global guidance prioritises future trade and profits over potential risks to public health. There is currently a critical window of opportunity for public health interests to be prioritised in this multisectoral international forum. The key public health priority for global guidance on FoP nutrition labelling is to ensure protection of policy space for national governments to implement strong and effective regulation, and allow scope for innovation. Public health actors can engage directly with Codex processes, at both the national and global level, and also need to raise awareness among domestic policy makers – including with Ministries of Agriculture and Industry, which often represent countries at Codex – regarding the importance and effectiveness of FoP labelling in NCD prevention. Increased engagement with Codex processes represents a tangible new opportunity to strengthen global governance for public health, and move towards improved coherence between trade policy and health protection goals.

The global fight against trans-fat: the potential role of international trade and law

Non-communicable diseases in general and cardiovascular diseases in particular are a leading cause of death globally. Trans-fat consumption is a significant risk factor for cardiovascular diseases. The World Health Organization's 'REPLACE' action package of 2018 aims to eliminate it completely in the global food supply by 2023. Legislative and other regulatory actions (i.e., banning trans-fat) are considered as effective means to achieve such a goal. Both wealthier and poorer countries are taking or considering action, as shown by the United States food regulations and Cambodian draft food legislation discussed in this paper. This paper reviews these actions and examines public and private stakeholders' incentives to increase health-protecting or health-promoting standards and regulations at home and abroad, setting the ground for further research on the topic. It focuses on the potential of trade incentives as a potential driver of a 'race to the top'. While it has been documented that powerful countries use international trade instruments to weaken other countries' national regulations, at times these powerful countries may also be interested in more stringent regulations abroad to protect their exports from competition from third countries with less stringent regulations. This article explores practical and principled considerations on how such a dynamic may spread trans-fat restrictions globally. It argues that trade dynamics and public health considerations within powerful countries may help to promote anti-trans-fat regulation globally but will not be sufficient and is ethically questionable. True international regulatory cooperation is needed and could be facilitated by the World Health Organization. Nevertheless, the paper highlights that international trade and investment law offers opportunities for anti-trans-fat policy diffusion globally.

Economic globalization, nutrition and health: a review of quantitative evidence

Background

Unhealthy dietary patterns have in recent decades contributed to an endemic-level burden from non-communicable disease (NCDs) in high-income countries. In low- and middle-income countries rapid changes in diets are also increasingly linked to malnutrition in all its forms as persistent undernutrition and micronutrient deficiencies continue to coexist with a rising prevalence of obesity and associated NCDs. Economic globalization and trade liberalization have been identified as potentially important factors driving these trends, but the mechanisms, pathways and actual impact are subject to continued debate.

Methods

We use a ‘rigorous review’ to synthesize evidence from empirical quantitative studies analysing the links between economic globalization processes and nutritional outcomes, with a focus on impact as well as improving the understanding of the main underlying mechanisms and their interactions.

Findings

While the literature remains mixed regarding the impacts of overall globalization, trade liberalization or economic globalization on nutritional outcomes, it is possible to identify different patterns of association and impact across specific sub-components of globalization processes. Although results depend on the context and methods of analysis, foreign direct investment (FDI) appears to be more clearly associated with increases in overnutrition and NCD prevalence than to changes in undernutrition. Existing evidence does not clearly show associations between trade liberalization and NCD prevalence, but there is some evidence of a broad association with improved dietary quality and reductions in undernutrition. Socio-cultural aspects of globalization appear to play an important yet under-studied role, with potential associations with increased prevalence of overweight and obesity. The limited evidence available also suggests that the association between trade liberalization or globalization and nutritional outcomes might differ substantially across population sub-groups.

Overall, our findings suggest that policymakers do not necessarily face a trade-off when considering the implications of trade or economic liberalization for malnutrition in all its forms. On the contrary, a combination of nutrition-sensitive trade policy and adequate regulation of FDI could help reduce all forms of malnutrition. In the context of trade negotiations and agreements it is fundamental, therefore, to protect the policy space for governments to adopt nutrition-sensitive interventions.

Electronic supplementary material

The online version of this article (10.1186/s12992-019-0456-z) contains supplementary material, which is available to authorized users.

Breastfeeding in low-resource settings: Not a "small matter"

Despite its clear biological benefits, many infants globally do not receive exclusive breastfeeding. In a Guest Editorial, Lars Åke Persson discusses what is needed to make breastfeeding the social norm.