摘要：Global trade and international trade agreements have transformed the capacity of governments to monitor and to protect public health, to regulate occupational and environmental health conditions and food products, and to ensure affordable access to medications. Proposals under negotiation for the World Trade Organization’s General Agreement on Trade in Services (GATS) and the regional Free Trade Area of the Americas (FTAA) agreement cover a wide range of health services, health facilities, clinician licensing, water and sanitation services, and tobacco and alcohol distribution services. Public health professionals and organizations rarely participate in trade negotiations or in resolution of trade disputes. The linkages among global trade, international trade agreements, and public health deserve more attention than they have received to date. GLOBAL TRADE AND international trade agreements have transformed governments’ ability to monitor and to protect public health (box p24). They have also restricted the capacity of government agencies to regulate occupational and environmental health conditions and food products and to ensure affordable access to medications and water. Pending proposals cover a wide range of health services, health facilities, clinician licensing, and distribution of tobacco and alcohol. Public health organizations are only beginning to grapple with trade-related threats to global health, including emerging infectious diseases and bioterrorism. Although economic globalization has attracted wide attention, its implications for public health remain poorly understood. In this article, we analyze key global trade issues that affect public health, briefly tracing the history of international trade agreements and describing the forces shaping agreements such as the North American Free Trade Agreement (NAFTA). The recent shift to treating services as tradable commodities is of particular importance; we analyze the General Agreement on Trade in Services (GATS) as a case in point. We also discuss the implications for public health of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and the proposed Free Trade Area of the Americas (FTAA) agreement. Although many agreements contain implications for public health, as we summarize in Table 1 ▶ and the box on page 26, we emphasize those features of agreements currently under negotiation that warrant attention by public health practitioners and organizations. TABLE 1— Summary of International Trade Agreements and Trade Organizations Pertinent to Public Health and Their Principal Implications for Public Health Treaty, Organization, or Law Focus and Implication Ratification or Negotiation Status Examples of Cases Relevant to Public Health Summary of key multilateral agreements General Agreement on Trade and Tariffs (GATT) Part of Bretton Woods accords at end of World War II; reduced tariffs as financial barrier to trade Applies to all 148 nations that now participate in WTO Venezuela won a challenge to the US Clean Air Act of 1990, weakening regulation of gasoline contaminants that contribute to pollution. World Trade Organization (WTO) Emerged in 1994 from the “Uruguay round” of GATT negotiations; created a stable organization with staff; aims to remove tariff and nontariff barriers to trade Includes all WTO member nations See below under separate trade agreements. General Agreement on Trade in Services (GATS)a Opens services to participation by foreign private corporations; services may include health care services, national health programs, public hospitals and clinics, professional licensure, water, and sanitation systems Applies to WTO member nations; commitments by countries currently under negotiation Country requests have targeted US professional licensing requirements and restrictions on corporate involvement in drinking water and wastewater systems. Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS)a Protects patents, copyrights, trademarks, and industrial designs across national boundaries; limits governments’ ability to introduce medication programs and to restrict the availability and reimbursement of medications under publicly funded programs Applies to WTO member nations; rules concerning medications for conditions such as AIDS under negotiation On behalf of pharmaceutical corporations, the United States has challenged attempts by South Africa, Thailand, Brazil, and India to produce low-cost antiretroviral medications effective against AIDS. Agreement on Technical Barriers to Trade (TBT)a Reduces barriers to trade that derive from technical standards and regulations applying to the safety and quality of products; covers tobacco and alcohol, toxic substances and waste, pharmaceuticals, biological agents, foodstuffs, and manufactured goods Applies to WTO member nations In its challenge of France’s ban on asbestos imports, Canada argued that international standards require the “least trade restrictive” regulations; a WTO tribunal approved the challenge, although an appeal tribunal rejected Canada’s claim after international pressure. Agreement on the Application of Sanitary and Phyto-Sanitary Standards (SPS)a Reduces barriers to trade that derive from governments’ regulations and laws designed to protect the health of humans, animals, and plants; covers food safety provisions Applies to WTO member nations On behalf of the beef and biotechnology industries, the United States successfully challenged the European Union’s ban on beef treated with artificial hormones. Summary of key US regional agreements North American Free Trade Agreement (NAFTA)b Removed most restrictions on trade among the United States, Canada, and Mexico Ratified and implemented in 1994 Under Chapter 11, the US Metalclad Corporation successfully sued Mexico in regard to toxic waste restrictions; the Methanex Corporation of Canada challenged the United States over California’s ban of a carcinogenic gasoline additive. Free Trade Area of the Americas (FTAA)b Extends NAFTA to all countries of the Western hemisphere except Cuba Under negotiation This agreement would open public sector health care services and institutions to corporate participation. Central American Free Trade Agreement (CAFTA)b Applies NAFTA-like trade rules to the United States, the 5 Central American countries and the Dominican Republic Agreed by trade negotiators, signed by US president, awaiting consideration by US Congress This agreement would interfere with the ability of Central American generic drug industry to produce and sell affordable prescription drugs. Open in a separate window aWTO trade agreement (applies to all WTO member nations). bRegional trade agreement (applies only to signatory nations).
