Global Health in the News: A Series (II) - Global Health is Everywhere. Even Over Here.

​GLOBAL HEALTH IS EVERYWHERE. EVEN OVER HERE: A summary of the leaked US-UK trade deal documents and what these could mean for the NHS.

When one thinks of Global Health, it is very easy to fall into the trap of imagining malnourished Somali and tearful Syrian refugee children. Although these are incredibly important and serious issues, the image of Global Health seems to be one that, unbeknownst to itself even, breeds a saviour complex, perpetuated by race, class, geography, culture and socioeconomics. I begin this post with the above semi-disclaimer to highlight the fact that Global Health is all around us. That we are all Global Health - this is in essence a plea for an open mind as I talk about the upcoming issue.  When I told the president of SfGH that I wanted to write something in the upcoming weeks (this was weeks ago) for the blog, he was very happy and very encouraging. Though he made sure to ‘remind’ me to ensure that its Global Health related. This is given my track record of discussing, at length, race, gender (my role is Gender Secretary), politics and other seemingly ‘unrelated’ topics, that if brought up in Global Health conversations, are easily dismissed. And when they are discussed, they are only discussed in a distancing-of-the-problem kind of way such as Sexual Violence in war zones or Maternal Health in South Africa. Again this is not to dismiss the legitimacy or immediacy of these global problems, but it begs the question of why we as students at western institutions, almost always immediately exclude ourselves and our communities from Global Health discussions? Why do we behave as though the issues of Global Health always belong to other communities who are usually poorer, darker and not as “educated” [1] as we are?  So given all the above, for today’s Global Health in the news: A series, I would like to talk about the UK and the NHS. 4 days ago Jeremy Corbyn, the head of the Labour party, released a 451 page, uncensored dossier titled UK-US Trade and Investment Working group. Read the full document here (click-link and scroll down).  One of the most commonly used catch-phrase slogans recently, has been Labour’s “NHS is not for sale”. This leaked document, containing “secret talks”, is claimed by some to be “proof” that the NHS is “on-the-table”. Given all the drama surrounding this document and all the smoke and mirrors, with Boris Johnson calling the claims “conspiracy theory-fuelled nonsense” and denying vehemently that the NHS is “on the table,'' I decided to set out in search for the truth (and this table). Or as close as I could get. What does this document tell us about the future of the NHS based off of the trajectory of these trade talks?

​​ ​Is the NHS on the table? ​Yes and no. The documents show that the US wants “full market access” (the term “negative listing” being used by US trade officials) as part of any future trade deal with the UK. What this means is that total market access is the baseline assumption and the onus is on the UK to identify exemptions. The term “negative listing” therefore means that ‘everything’ is technically on the table unless it is explicitly stated to not be. The leaked documents do not show the NHS to be exempt from trade discussions (and in fact suggest that it may be discussed “further down the line”) thereby creating a legitimate cause for alarm.

What is the impact on Public Health strategies? (Read the 2020-2025 PHE strategy: Executive summary here) The US, as part of the trade deal, has requested for a system known as investor-state dispute settlements, mentioning the term 74 times in the trade talk documents. The intended purpose of ISDS inclusion in trade talks by companies is usually to settle disputes in a transparent way. The method of dispute settlements however, relies on arbitration rather than public courts.  ISDS was created in the 1960’s to protect former coloniser properties from the newly independent states. Coloniser companies appealed for ISDS because it was believed that the legal systems in foreign territories (usually ex-colonies) were lacking. The system was essentially created to protect against expropriation - the seizing of private property by governments in the supposed interest of the public. Given that the UK has a “strong rule of law and there is no indication of bias against foreign companies, you do not need this international mechanism.” [2] The likelihood of UK government unlawfully seizing the private property of US companies is close to zero. So why do companies need ISDS? What ISDS essentially means is that US companies, under an ISDS system, operating in the UK can challenge pending, new or future UK laws or regulations if they believe that said laws can affect their expected profits or investment potential. As a result they would have the right to seek compensation or “sue” the UK government, outside UK courts, for any strategies, policies or laws whose implementation can affect their profits or investments. This includes regulations designed to meet climate targets or protect the NHS and health. For example, the sugar tax, the traffic light food labelling system [3] and any newly detected threats to public health. Governments would therefore be unable to freely introduce public health strategies to protect the population from existant or newly detected threats, should these get in the way of the legal ISDS infrastructure of the trade deals.  This may all sound like apocalyptic fear mongering, but evidence for this in the near past is the 1993 Hong Kong-Australia trade deal, a free-trade deal containing ISDS provisions. In 2012 Phillip Morris Asia, a cigarette company, sued the Australian government over its plain-cigarette packaging laws. The litigation dispute lasted six years, with Phillip Morris Asia ultimately losing its multi-year dispute and being ordered to pay Australia’s legal costs in 2017. Despite this however, concerns over the launch of Phillip Morris’ legal case, led to a freedom of information request in 2016. The request was approved two years later with the information commissioner ultimately ordering the Austrlian government to disclose information on the true legal costs between 2016 and 2018. Documents say that the total figure is $38,984,942.97 which the government insists include the legal costs of other plain-packaging litigation issues . The Australian Government deliberately tried to keep this information a secret, given that the legal-costs of ISDS disputes, like this one, are settled using public funds (in most countries this means the tax-payer).  There are other cases to learn from. See Slovakia vs Achmea on how EU law protected Slovakia from a €22 million arbitration award in favour of Achmea BV, a dutch insurance company. ​ Will the NHS be forced by Big Pharma to pay more for drugs? ​(Was going to quote specific parts throughout this next section but you might as well read the whole thing - See page 48-51/64 of the document titled UK-US Trade & Investment Working Group 13-14 November 2017). The NHS is one of the world’s largest purchasers of drugs making the UK an important market for foreign access. Drug prices are regulated by the National Institute of Clinical Excellence (NICE), an independent regulatory body that makes judgements on the implementation and purchase of certain medical devices, drugs and surgical processes. Its analyses (called technology appraisals) are used by the NHS to decide on purchases. (See this article on how NICE decides which drugs to make available under the NHS).  The trade deal documents indicate the US’s desire for drug prices to be “competitive” and “market-derived” meaning that prices would be no doubt significantly higher than in NICE guidelines. NICE-like protections were removed in the US in the 1990s and drug prices have soared to extents where drugs in the US are now priced at three times the UK costs. Under a “market-derived” trade deal there would be a potential for NICE authority to be sidelined.  The US-UK trade deal documents also highlight the US’s desire for an extension on “Innovative Pharmaceutical Protections” (pg 47). The US highlighted that “there are patent vulnerabilities” stating that “12 years was a compromise. The initial proposal was 15 years with possibilities for extensions to protect orphan drugs.” The document explicitly shows US intentions to extend patents. Patents give drug companies exclusive rights to develop, sell and price any drugs they develop. The intention of this is to allow drug companies to recuperate development and research costs before other companies can reproduce the same drugs for lower prices. Therefore patents although positive in moderation, can give pharmaceutical companies a complete protected monopoly on life saving drugs. Extension of a patent protection (to say 15 years) means companies can control the price of the drugs they develop. This means that the NHS paying more for drugs is a very real possibility. It can also mean that certain drugs are simply not available any longer. Even more disturbing is the UK’s comments on (page 52/77 UK-US Trade & Investment Working Group 21-22 March 2018) the potential to “discuss particular health care entities” - aka the NHS - “further down the line when we come to consider what entities would count as ‘enterprises’.” 

Conclusions: What now? ​ A general election is coming up. Voters have the ability to not fall trap to politician soundbites and to research the information for themselves. We have the ability to overcome our apathy and to inform ourselves. To let that information empower us and give life to some sort of hope within us. A belief that we are more in control than we know and we are not slaves to our own apathy. Especially those of us within the medical field, whom, I believe, have a moral duty to be advocates for public health and to fight anything that may threaten it.  I didn’t write this to get you to vote for a specific political party. I wrote this “article” (if that’s what you wish to call it)  for two reasons. Firstly to inform and summarise a leaked document that some people may not have the privilege of time nor the mental or physical capacity and resources required to read (even in parts) and understand the original document. The second reason I wrote this article, is to make a point. That yes we can all go and volunteer in Kenya and pat ourselves on the back with a safari tour at the end. We can all go “build toilets in rural Indian villages” [4] and tell everyone about how it changed our lives when we get back, but Global Health is bigger than that. Global Health starts with us as individuals and our curiosities. It begins in what we are willing to deem acceptable in our own communities as well as others. For if we cannot protect the vulnerable at our doorstep how can we afflict sincere change anywhere else?

​[1] - “Educating the communities” is something that comes up a lot when you have Global Health students brain-storm ideas for solving health problems.  [2] James Harrison, associate professor of law at Warwick University in an article for the Independent.  [3] “The US view the introduction of warning labels as harmful rather than as a step to public health,” pg 41/64 of the document titled UK-US Trade & Investment Working Group 13-14 November 2017. Bullet point four under subheading “Key points to note” [4] The problem of voluntourism is a whole separate issue that I might write about in the future. To be continued….

Further reads: https://www.bmj.com/content/367/bmj.l6723.full https://www.independent.co.uk/news/business/news/brexit-us-uk-trade-deal-boris-johnson-tories-nhs-drug-prices-chlorine-chicken-a9221801.html https://www.reddit.com/r/ukpolitics/search/?q=UK%20US%20trade%20deal&restrict_sr=1&t=week https://isds.bilaterals.org/?-the-basics- Linked above but read the full leaked document here →  https://www.express.co.uk/news/politics/1209922/Labour-NHS-documents-Jeremy-Corbyn-unredacted-trade-NHS-USA-Brexit

For any further questions, feel free to email ​mimi_98@naver.com