Is Globalization Still Good for Health?

Tuesday, April 16, 2019
Is Globalization Still Good for Health?

The symposium held on April 16, 2019 explored the changing relationship of trade and health. The event convened experts to discuss the incidence of heart disease, diabetes, and other noncommunicable diseases rising in poor nations, as well as the overuse of existing antibiotics and underinvestment in new ones threatening to bring about a post-antibiotic era. The panels examined the deep tensions between health, trade, and commercial interests generated by efforts to confront these health concerns.

The event was sponsored by CFR's Global Health Program with support from Bloomberg Philanthropies.

Session I: Trade, Agriculture, and Antimicrobial Resistance
This session will assess the role of trade in addressing the overuse and misuse of, and excessive access to, antibiotics.
Aik Hoe Lim, Anthony D. So, Kathy Talkington

BOLLYKY: Good morning, everyone. Thanks so much for coming. I’m Tom Bollyky. I’m the director of the Global Health Program here at the Council on Foreign Relations.

It is my great pleasure to welcome you to our first Symposium on Health and International Economics entitled Is Globalization Still Good for You? Twenty years ago from this year, large and violent protests filled the streets outside of leaders’ meetings of the World Trade Organization, the World Bank, the International Monetary Fund, and the G7 meetings of the world’s richest countries.

There was a fierce debate as to whether or not global and economic and social integration served to benefit only the rich and powerful or whether it also advanced the interests of the poor and underprivileged. These concerns were accompanied by or spurred, rather, by a dramatic increase in the global trade in goods and services and increases in the volumes of capital flows. And also there was an HIV epidemic that exposed the global inequities around access to medicines.

Twenty years later, concerns in globalization and health are on the rise, not quite reaching the level of the protests that we saw in 1999, but disrupting global health partnerships and initiatives and dominating many global health and development meetings. These concerns are again being spurred by changes in trade, increase in the global integration of consumer products, the industrialization and internationalization of agriculture. These developments have helped reduce poverty and increase food production, but also transformed the health risks that confront low- and middle-income countries.

Cases of heart disease, diabetes, cancers, other noncommunicable diseases, are surging in poor countries and arising in much younger people with much worse outcomes than we’ve seen in wealthy nations. Tobacco, alcohol, the food-and-beverage industry, are increasingly targeting the rising young-adult populations in low- and middle-income countries. And there are new threats emerging in developing countries, like resistance to antibiotics, spurred in part from that global industrialization and integration of agriculture and aquaculture.

Increasingly, the policy levers that we seek to address these global-health challenges and threats fall in the fiscal and tax space, the non-health space.

So what are the roles—what are the appropriate responses to these emerging health challenges? What’s the appropriate role of trade law and trade governance and the private sector in that response? These are the questions we are here to discuss today. And we have an all-star cast of speakers to do so. You’re in for a treat.

I will leave the moderators for each panel to make the introductions, but the first session this morning, which I will moderate, is on “Trade, Agriculture, and Antimicrobial Resistance.” The second panel, which will follow that, will be around the changing dynamics of health and trade in an era of noncommunicable diseases—cardiovascular disease, cancer, diabetes, and the like. That will be moderated by John Monahan.

And then we will have a keynote lunch discussion moderated by Vanessa Kerry that will focus on the question of whether globalization remains good for health as a launching pad for our broader discussion of trade, investment, and the changing global-health environment.

A couple of notes before we proceed. First I want to start by thanking Bloomberg Philanthropies for their generous support and making this symposium possible. I would also like to thank Kayla Ermanni, Morgan Singer, Stacey LaFollette from our meetings team, who did all the hard work organizing today’s event, making the rest of us look good who did very little.

Today’s event is on the record, which means you are welcome to make use of the information and the comments you hear today and to blame the person by name who made them. If you haven’t already, please silence your cell phones and electronic devices.

And with that, I would ask the first set of panelists to come up to the stage.

Great. Well, it’s me again. I’ve already spoken a fair bit, so I will endeavor to be brief in introducing this panel.

The combination of overuse of existing antibiotics and or underinvestment in new ones has put us at the precipice of what the U.S. Centers for Disease Control and Prevention has described as a potential post-antibiotic era. According to the CDC, there are at least 2 million illnesses and 23,000 deaths in the United States that are caused by antibiotic-resistant bacteria alone, roughly 700,000 globally. Estimates are that by 2050 these diseases could kill tens of millions more, change the practice of modern medicine and agriculture and food and development, as well as shift or start to affect financial growth.

We have a great panel today to focus on this emerging health issue that has trade implications. With that, I want to introduce each of them.

Kathy Talkington, who is the director of the Antibiotic Resistance Project at Pew Charitable Trust.

You have their bios in your programs, so I’m just going to introduce them by name and title.

Anthony So, who is the professor of practice and the founding director of the IDEA, or I-D-E-A—

SO: IDEA Initiative, Innovation + Design for Enabling Access.

BOLLYKY: The IDEA Initiative at Johns Hopkins Bloomberg School of Public Health; and Hoe Lim, who is the director of Trade and Environment at the World Trade Organization.

And with that, let me start by asking Anthony to explain why are we using antibiotics in agriculture, in aquaculture in the first place? And how does that use of antibiotics in animals affect antibiotic resistance in people?

SO: Sure. Well, thank you, Tom, and for the Council on Foreign Relations, for the opportunity to kick off this set of discussions on “Trade, Agriculture, and Antimicrobial Resistance.” And importantly, let me also say the interdisciplinary dimensions that you’re bringing to this intersectoral problem are just absolutely critical. And so I’m so glad to see the Council actually working.

Just as a disclaimer at the outset, I am speaking today in my personal capacity and not in my role as co-convener or as member of the U.N. Interagency Coordination Group on Antimicrobial Resistance.

Let me first help try to connect the dots, really, between agriculture and antimicrobial resistance before adding the element of trade. Antimicrobials, or particularly antibiotics, or drugs (treating ?) bacterial infections, have really important roles in agriculture, as well as in human medicine, as all of you know. You know, now, treating disease in animal husbandry and aquaculture helps ensure, of course, food productivity as well as, of course, safety in our food system. And that’s critical. It’s also an important part of just treating animals humanely in our food-production system.

But our food-production system actually uses antibiotics for a wide range of purposes, and I’ll name four of them. One is growth promotion, which is actually to improve productivity by reducing the losses, really, from non-hygienic, actually, growing conditions for livestock, or to put weight on food animals. So antibiotics actually increase the feed efficiency, so you can have less input for essentially greater weight gain. And the more weight gain, the more profit, actually, when you bring it to market.

Now, preventive use, which is where you use low sub-therapeutic doses of antibiotics, and often for periods of time longer than the treatment course, but there’s no diagnosis of disease present in that use of antibiotics.

A third indication is metaphylaxis. So some, say, parts of the herd or flock actually are diagnosed with disease, and then you treat the whole herd or flock, actually, with antibiotics.

And the fourth indication, of course, is treatment, which we all recognize is absolutely critical, actually, in ensuring, actually, the food safety and also productivity of our food system.

Now, the consensus is that growth promotion should not be done with antibiotics. I think there’s pretty broad, actually, consensus now on that. There is a little bit of divided consensus as to where you draw the line to, actually, of course, to reduce the use of antimicrobials in some of the other indications—preventative use particularly, where actually you don’t have any diagnosis of disease and where the relabeling of growth promotion as actually preventive use might just be a matter of intent. And so we have a lot of difficulty drawing that line; it’s fuzzy. And even metaphylaxis, where sometimes actually that tipping point to having a diagnosis of disease in a few members of the herd or flock tips actually people to instead resort to antibiotics as a way to offset non-hygienic conditions.

Now, many in public health believe, as I do, that we need to actually reduce the use of antimicrobials overall in the growing, actually, of our food animals. And there are other ways of doing this, of course.

Now, so how does this connect the two? Well, the use of more antibiotics drives essentially drug resistance and essentially makes, then, our drugs less effective for continued use. And the majority of antibiotics by volume, up to 70 percent perhaps in the United States, actually, in fact, are used to raise food animals, not actually to treat human beings in medicine.

And also—we also spray these, of course, on plant crops, and sometimes in amounts that are vastly greater than the amount we use in human medicine. So for streptomycin and oxytetracycline being used—for example, being sprayed on our citrus groves in Florida are perhaps used in greater amounts than we use in human medicine in the country.

And the class of antibiotics used in agriculture, except perhaps for ionophores, are the same as in humans. And so the mechanisms of genetic determinants of resistance, in fact, cross over between the boundaries of health-care delivery, the food-production system, and the environment—the one health perspective, if you will, of antimicrobial resistance.

The precise magnitude of this contribution is not known, but we actually—and may never be precisely knowable. But given the frequency of foodborne infections—I’m sure all of us have had our moments— the pathway from agriculture to health care is clear. And we can now even genetically fingerprint, actually, its transmission from food systems to actually health-care delivery systems.

So there is no doubt, actually, that these are porous boundaries. But importantly—and we’ll discuss it here—food crosses borders, as do people who consume these products. And so, of course, that brings us, of course, to the subject of this panel.

So, with that, maybe I can then delve—

BOLLYKY: Please.

SO: —really deep into the trade issues.

So in November of 2015, investigators in China announced that a new form of resistance to colistin had been discovered. Now, colistin is an antibiotic that is one of our last-line defenses against drug-resistant infections in human medicine. And because of its known toxicity, we very seldom use it in human medicine but as a drug of last resort.

By contrast, it had been widely used, actually, in food-animal production, because they thought that human medicine no longer needed that antibiotic; so not surprising that this drug-resistant strain, which we call MCR-1, was found in food animals, in retail meat products, and in humans.

This finding sent shockwaves through the global medical community, because—and not long after that study, this form of resistance to colistin was reported in more than 30 countries. And lest we point our fingers too quickly at China, only a few years ago colistin was the fifth most widely sold antimicrobial in food-animal production in Europe.

The spread of such drug resistance can occur through the movement of livestock or, more likely, food-animal products or human beings. That’s right. We carry this actually across borders just as readily as tourists crossing borders do. So the $1.1 trillion in agricultural trade that connects our globe and ensures our greater food security is also a superhighway for distributing the next superbug.

Now, globalization involves, of course, the movement of goods or people across borders. And to be clear, drug-resistant pathogens actually do not respect borders, nor do they have to apply for visas. And in recent years we have seen this story repeatedly, from NDM-1, the New Delhi metallo-beta-lactamase 1, actually a genetic determinant of drug resistance, to, of course, what you probably saw in the New York Times pages recently, for Candida auris, a drug-resistant fungal infection.

So if you ask me, is globalization still good for health, of course. But when diseases cross borders but life-saving drugs lag behind, we begin to see an asymmetry of globalization that can lead to health inequity. And the key challenge is whether we are committed to globalizing the capacity to respond to these globalizing threats across health.

Do we have surveillance systems to stand sentinel over our health-care and food systems, second-line drugs, affordable and available to treat resistant infections, or even veterinarians to prescribe antimicrobials appropriate for food-production purposes? This asymmetry, of course, plays out into economic projections done by the World Bank in its 2017 report, Drug-Resistant Infections: A Threat to Our Economic Future.

So, if unchecked, antimicrobial resistance projected by the Bank would disproportionately affect low-income countries more than wealthy countries—the greatest drops in economic growth, the greatest losses in livestock production, and most of the additional 24 million people who will be pushed into extreme poverty by 2030.

And the asymmetry cuts also in the other way too. The Bank projects if we do invest to contain AMR, antimicrobial resistance, low-income countries will see substantial economic payoffs. But the greatest absolute per capita gains—absolute and per capita gains—will flow to upper-middle-income and high-income countries.

The overuse of antibiotics is clearly a global problem. And we still use antibiotics for growth promotion; that is, to treat disease in—not to treat disease in animals but help them gain weight or offset unsanitary hygienic conditions. But now moving 190 or so member states is daunting. But let me suggest there is reason to hope that trade in agriculture can play an important role, actually, as we take the next steps to tackle AMR.

The latest report from OIE, or the World Organization for Animal Health, shows progress. But 45 countries still use antimicrobials for growth promotion. And the WHO suggests we should go further, that we should have to curb the use of medically important antibiotics for preventative use in food production.

While there may not be consensus between all the intergovernmental agencies on that, there is consensus that we should actually curb and phase out the use of antimicrobials for growth promotion, and we should bring an immediate end to the use of these antibiotics classified as highest priority by the WHO unless they’re critically important antimicrobials in human medicine.

Now, perhaps our strategy to responding to AMR can find priority by looking at the patterns of international trade. The trade in food-animal products is highly concentrated, and so is the use of food—antimicrobials in food-animal production. Five countries in 2010—China, the United States, Brazil, India, and Germany—comprised over 50 percent of the use of antimicrobials in food-animal production—just five countries.

Anyone like salmon here? Well, 95 percent of the world’s actual use of antibiotics used in salmon aquaculture production is just one country—Chile. It’s for treatment of the salmon there, not prevention.

So it’s clear that much of the responsibility for curbing the use of antimicrobials in traded meat and fish products are in the hands of just a few countries. And for the exporting countries, those countries are taking—taking in their imports may also be concentrated. So just a few years back, the analysis by actually the U.S. Congressional Research Service showed just how concentrated it is. At the time for the United States, nearly 40 percent of farm-pork exports went to Japan, 35 percent of the poultry exports went to Russia and China, and over 60 percent of our beef exports went to Mexico and Canada.

The Congressional Research Service also flagged our potential vulnerability as key trading partners and competitors of the United States have begun to place restrictions on importing livestock and poultry products raised with antimicrobial drugs. And these countries who are placing these restrictions include New Zealand, South Korea, and the European Union.

By 2022, the European Commission would require food-animal products imported into the European Union not to be raised with antibiotic growth promoters. And there also may be a list of antibiotics critical to human medicine that they will simply not allow at all to be used in livestock production.

Now, not waiting for governments to act, for the past few years we’ve seen consumers forcing changes in how we bring food to our tables. Members of the Antibiotic Working Coalition, the U.S.-based group, have successfully targeted those procuring food. You might have heard this in the newspapers—restaurant chains with public-facing brands. You know, and through the Chain Reaction scorecard, they’ve actually tried to document the progress of McDonald’s, KFC, and others to commit to sourcing food-animal products raised without the routine use of antibiotics. And I’m sure Kathy will discuss this further in just a moment.

And we have witnessed, of course, the expectations of the supply chain globalized. Not long after—not long ago, we actually brought together civil-society groups for the United States and Asia to discuss the lessons on globalizing food campaigns. And not long after that, the Center for Science and Environment, based in India, released a report called Double Standards: Antibiotic Misuse by Fast-Food Companies, calling out multinational companies for their failure to commit for similar timelines to phasing out antibiotic use in their meat products in India.

So today we face a critical window of opportunity to act. Globally, antimicrobial consumption in food-animal production will climb by two thirds between 2010 and 2013. And so, particularly for those countries with large export economies in food-animal products, the choice is clear. We can either pay now to make the transition to agricultural practices less reliant on antimicrobial products—antimicrobial use—or we can pay more later. But we will have to mitigate some of the challenges that can come from trade in agriculture by investing and globalizing our ability to respond to the challenge of antimicrobial resistance.

BOLLYKY: Great. Fantastic set of comments. And you even provided your own segue to the next speaker, so I appreciate that. (Laughter.)

Kathy, tell me a little bit about what is this happening through your consumer-driven initiatives as well as industry networks? How do you see the role of the private sector in addressing the challenge of antibiotic resistance?

TALKINGTON: Sure. And thank you. Thank you for the opportunity to be here. And thanks to the Council for the invitation.

I work for the Pew Charitable Trust, and we have an Antibiotic Resistance Project. As you’ve heard, there is a sense of urgency around this issue. We talk about antibiotics as underpinning modern medicine as we know it. We rely on these valuable tools for so many things. So what are some of the solutions?

I think it is important—I think Anthony laid out the challenges we face. And then the question becomes, now what? What can we do? And what is the role of private sector potentially in this challenging era?

So one of the things that we’ve been working on at Pew is trying to figure out how do we take advantage of the pressure, the consumer interest in this issue? There is an opportunity sort of building on the work that has been done, and I should say, my focus has been in domestic arena but I think there are lessons that can be learned here in a global arena. How do we build on the progress that has been generated by consumer interest? As you all may know, the FDA eliminated the use of growth promotion in animal agriculture.

They require veterinary oversight for food and water, drugs, and that’s all good and we’re starting to see some benefits of that—those initiatives—sort of the federal policy lever. But then the question was what—how can we build on that—what can we do now in lieu of—well, we haven’t seen another federal initiative, necessarily. So what else can be done?

So we started talking to folks along the food chain, from the production side to the buyers to the meat packers in between, to better understand what are the opportunities and challenges there. They are motivated. So, first, you have to have folks interested in the topic and the motivation is the consumer demand. I think companies are interested in meeting that demand and how do they demonstrate that what they’re doing is using antibiotics appropriately.

So we decided to get a group together to talk about what does stewardship mean in animal agriculture. It had never been clearly defined across the species from chickens to pork to beef and along the food chain from the producers all the way to the buyers. Some of the challenges we were trying to address is the buyers want to meet consumer interest but they’re not sure what it means to raise animals responsibly with antibiotics. It’s a complicated topic.

You can’t just say no antibiotics necessarily. There are options in poultry now with no antibiotics ever. But there is also a need to treat animals from time to time when they are ill and there’s a variation on what that means. So how does a McDonald’s, for example, or a Walmart say to their customers, we are raising animals responsibly? So we wanted to see if we could help define what that means—what is antibiotic stewardship on the farm. So bringing this group together we have now come up with a framework of defining what antibiotic stewardship is and it parallels what’s happened on the human side.

As you may know, the U.S. Centers for Disease Control created core components of human stewardship programs and that was an important step because once you had the criteria in place of what a meaningful program looks like, then there was opportunities for, in the human side, policy interventions to require stewardship in health care settings.

Some of those policies aren’t finalized, which is unfortunate, but the criteria of having those stewardship-defined programs was critical. There is also, on the human side, a joint commission that regulates or accredits hospitals and they have required the core components that CDC put in place.

So the thinking was if we can define core components of stewardship in animal agriculture that creates a scenario where you can start to evaluate progress in responsible use of antibiotics in animal agriculture. So that was the thinking, and there was agreement on these principles, again, across the species and up and down the food chain, and I think the—sort of the question then in an international setting, and some of the groups—some of the organizations that were part of this conversation are global companies—the McDonald’s, Walmarts, Hormel, Tysons.

So is there an opportunity to utilize these components in a more global conversation, and we had talked a little bit about standard setting and if you’re having a trade conversation, you know, setting the standards of what that looks like. Perhaps this could be the—sort of a starting framework for what some of those core components could look like. It was a complicated conversation. It’s very technical.

But I think we were able to distill it into some critical pieces of understanding what stewardship is, getting buy-in from the—both the producer and the farmer, having veterinary oversight, having records, demonstrating that you’re continuously reducing the need for antibiotics through alternatives, vaccines, management practices on the farm is to constantly push and integrate new information, new research, new opportunities. How does biosecurity play into that?

So it’s sort of making the focus to pay attention to your use of antibiotics and reducing the need for that use going forward. So, again, I guess the other point would be that it is a continuous quality improvement design. It is not a one—there is no one clear definition because there’s a lot of research yet to be done and that needs to be constantly reintegrated into the system.

So that’s the work that we did with the private sector. It’s still ongoing. But the first step was getting those components agreed upon so that everyone has a clear understanding of what the expectations are in a meaningful program.

BOLLYKY: Great. Great. Thank you. So Hoe: what is the role for the trade folks in the room here? Are we a just brake—and I say this as a former trade negotiator myself—are we just a brake on achieving public health here? Or, does trade law and governance have a more positive role to play in addressing this set of challenges? How do you see it?

LIM: OK. Well, thanks very much, Thomas, and thanks to the Council on Foreign Relations for the invitation to join you. Maybe before I begin just two disclaimers. Firstly, I’m speaking here in a personal capacity, and secondly, I am not an agricultural specialist nor really an AMR specialist. So that may lead you to ask the reasonable question, why am I here.

Now, I think why I’m here is essentially because WTO is paying a lot of attention to this issue. It’s a very urgent global issue and we are participating in different processes, namely those created under the U.N. through interagency task forces and consultative groups, looking at what sort of response could there be to AMR leading to its recommendations to the General Assembly in one fora.

But it’s not just one fora. There are many different foras talking about AMR, and we are participating in this often either in an observer capacity or in the technical capacity, providing views from the trade agreement perspective. And we have also been quite involved with WIPO—the World Intellectual Property Organization—as well as the World Health Organization, in hosting symposiums and discussions on antimicrobial resistance and stewardship in world trade policy.

I moderated a session of this type two years ago at WIPO at which we had stakeholders who were involved from the standard-setting community to the actual countries—in this case, it was Brazil—and we also had an academic contribution from Europe about AMR. And I think many of the issues we discussed in that forum are relevant and relevant to this particular discussion. So maybe if I could run through a little bit the sort of issues that we were talking about from a trade perspective.

I think, firstly, the panel essentially recognized that trade has played an important role in supporting food security, in supporting food trade, on the one hand, and has played an important role in development and in growth. since many developing countries are relying on agricultural trade.

And in the area of health, traditionally, the discussion has been about access to medicines and about how do we ensure better access to essential medicines. And here, trade has, you know, certain roles that it has played in terms of trade instruments, reducing tariffs, burdensome customs facilities, discriminatory product requirements, or more directly through the amendment of the TRIPS agreement on access to essential medicines.

And today if you look at tariffs on health products, the trade-weighted average tariff is something below 5 percent. But such instruments and such approaches do not seem to be sufficient when we talk about AMR, and access alone is not really the solution. Some might say that perhaps the problem is access and how do we have more responsible use after access.

So this was really the set of discussions that we had, and another part of the discussion was—actually I haven’t spoken about this yet—is about apart from responsible use, what are the market incentives to support the development of new antibiotics and how do we create these market incentives, which do not lead to more, let’s say, irresponsible use. So this was another challenge that came to the discussion.

Another point that I thought was quite interesting, and this relates a bit more to me in the trade and environment area, which is some interesting parallels between the challenge of AMR and global environmental challenges. In a way, we’re dealing with a global externality problem and with environmental pollution, for instance. Many of these externalities are undervalued, and, as Anthony and Cathy has already said, they’re not easily contained within borders, and unilateral actions, you know, will have difficulty in succeeding. So you need a sort of joined coordinated global response to AMR.

So here, try to move from there to trade, OK, because I think since we need a global response and global cooperation is required, that’s required both for the effectiveness of dealing with AMR. It is also required to avoid trade tensions and, certainly, trade tensions will arise if countries start to adopt unilateral measures using diverging standards and if there is no agreement on the science behind those standards.

So and we know today that, you know, there is already divergences in terms of how countries look at the use of antimicrobial products. Where it cuts or connects most concretely to WTO is when we talk about two agreements. One if the agreement on sanitary and phytosanitary measures and the other is the agreement on technical barriers to trade. But since we’re talking here about agriculture—

BOLLYKY: Would you just say a word what those agreements cover, broadly?

LIM: Yeah. Sure. I’ll talk a bit about SPS because that’s directly relevant to the conversation here on agriculture. That agreement, basically, covers measures taken for animal health, food safety, and plant health. OK. WTO agreement creates that space, you know. Members can take measures in response to animal health, food safety, plant health.

But in taking these measures, they have to do a few things and one which is that they should not introduce discrimination. I think that’s one big part of the agreement is on discrimination. And the other is reliance on international standards. The agreement, essentially, basically has a strong encouragement on members to harmonize on the basis of international standards and linked to that is a use of science—assessments based on science.

So these are the sort of parameters in which this discussion will interact with the WTO agreements. We look—we are not standards developers but we look very much towards where these standards come from, and when we look at international standards for measures related to sanitary and phytosanitary measures such as animal health and food safety, three specific organizations are mentioned.

The first one on animal health is the International Organization for Epizooties, or OIE; food safety codex and plant health—a organization called IPPC. So if a WTO member bases its regulations—technical regulations on those standards, it would be presumed as being not more trade restrictive than necessary. So it provides a sort of—a way to deal with this sort of divergence between different countries.

There is, of course, also flexibilities provided. Sometimes countries may feel that the international standards are not sufficient or they may need to go beyond international standards, and this is allowed under the SPS agreement but they need to be scientifically justified. So these are, essentially, some instruments in the agreements that would allow—try to move countries towards more cooperation on international standards and, hopefully, reducing divergences.

Now, the other sort of challenge that comes up a lot when we talk about AMR resistance—and this came up in the panel that I moderated—was the sort of developing country perspective, and this came up quite strongly in that panel where food producers from developing countries basically feel that there is not sufficient recognition of the challenges that they face in food production nor the measures that they are taking—at least, this was what was said in my panel—to deal with responsible use of antimicrobial products.

And at the same time, there was a concern with what was called extraterritoriality—that if certain standards are established elsewhere and that they are forced to conform to those standards and that is not an international standard they could potentially seek to challenge this in the WTO. So these are sort of tensions that are out there, which is where the trade part comes in, and I think nobody wants to have a big trade dispute over AMR.

So that will not be effective for what we’re trying to do to curb antimicrobial resistance. It will not be good for trade nor, would I argue, would it be good for food security or development. So the emphasis would be it’s not easy. I think Anthony already mentioned that. It would be how do you get those bodies that are responsible for setting these international standards to come towards an agreement on what should be the international standard. I believe that Codex and OIE already have some standards and they are in the process of developing further standards and, you know, and that’s one way which the WTO agreements could help. It’s to put pressure on the development of these standards, essentially.

BOLLYKY: Great. Great. Thank you so much. So I’m going to ask a couple questions but then I will turn it over to you in the audience so you should start thinking about your tough questions now. So I think having a background in trade and environment is, in fact, actually the perfect background for this panel discussion. I would say that the issue of developing new antibiotics is a global public goods problem, which are the types of problems with which global health is very familiar.

Doesn’t mean we in global health always do it right? Of course not, but we understand the need for addressing challenges where a market solution doesn’t exist and the range of options for how to address that circumstance. Not all of those global health solutions are popular with some countries and some industries, but it’s a very familiar space.

So the problem of antibiotic resistance, to me, is a lot like climate change. We need every country to take action in order for this to be successful in addressing this challenge. As Hoe mentioned, the use of antibiotics in food production is shifting to low- and middle-income countries, which is also true for greenhouse gas emissions. Like climate, we also have some scientific uncertainty about the exact contribution of the use of antimicrobials in agriculture to resistance—which makes it hard to impose trade restrictions under WTO rules when we have unscientific uncertainty about what is necessary and what is least trade restrictive as possible.

So the last thing I’ll mention on the trade front is the incentive that trade agreements provide to adopt international standards because adopting the international standard protects you from being sued. But that only helps if you’re adopting health-promoting restrictive measures. If you’re not adopting such standards, you are not likely to be sued anyways. So trade agreements don’t necessarily provide an incentive for governments to ratchet up their protection they might not otherwise.

So with that long preamble, here’s my question. My question is, do we need some form of international agreement either in the trade realm like the environmental goods agreement that provides a market incentive for people to adopt more AMR-addressing practices? Or, do we need a new WHO framework convention on AMR or some international instrument like the international health regulations? Or, do we need to see just need to make better use of these networks of private sector actors to try to move this forward? Maybe we’ll start with Anthony since he’s been sitting the longest.

SO: I think that the need for, actually, perhaps stronger international agreement on how we actually move forward is probably a bridge we will have to cross, and we have a number of processes underway already that provide some initial frameworks. So there is a global development stewardship framework that was called for in the global action plan on antimicrobial resistance a few years ago which does involve actually tripartite collaboration among, you know, WHO, FAO and OIE, as well as U.N. Environment as well. So that is an initial framework. We also have a monitoring and evaluation framework that is tripartite with U.N. environment action participation as well to begin to put in some framework of accountability.

What we are clearly missing is really the magnitude, actually, of mobilization of resources, and actually the speed with which we probably will need to actually address this issue before actually we face a critical actually point where we actually will cross over and be unable, actually, to abate some of the consequences for antimicrobial resistance, which is really quite considerable. We’re talking about ten million lives per year by year 2050 will be lost to drug-resistant infections if unchecked. And that’s more than the number of deaths actually from cancer today, to give you some sense of the magnitude. You know we’re talking about—in the U.K., you hear estimates up to $100 trillion in losses actually in, of course, economic losses by—cumulatively by that year as well.

So we do have some starting framework but I think what we may need to think about, actually, is if we do not meet certain benchmarks in the near future, and hold our global community to those, then we may need to actually have a trigger—a policy trigger whereby actually, in fact, we then commit, as member states, to in fact engage in actually discussion where we need something like we have seen in other areas—climate change, and certainly things like the Montreal Protocol to reduce ozone-depleting chemicals to actually more aggressively provide the infrastructure we’re going to need to address AMR.

BOLLYKY: So who’s the leading this effort? Who will be the leaders on concluding an international agreement? Which member states are most likely to insist on something? There have been a few in the climate space, not that those efforts have gone spectacularly. But we have at least had these leaders on climate. Who is it on AMR?

SO: Yeah, I mean I think that it is, obviously—it’s going to have to take an entire community of nations, but there are obviously some who are putting really money behind this. We can point to certainly I would say, across both sides of the Atlantic, efforts certainly from the U.S. NIH and BARDA, as well as the U.K. AMR Centre and Wellcome Trust, and joint efforts, for example, on the innovation of novel antimicrobials through CARB-X. We are seeing, of course, commitments by a number of European countries. Sweden has been a remarkable leader actually in this space, or the United Kingdom, the Netherlands, Germany—all have stepped up, I would say, to actually, in various ways, contribute to both multilateral funding vehicles, sometimes bilateral approaches, and similarly to help start building capacity.

We are, unfortunately, just very short of the mark, however. I mean, when you think about the economic losses, this should be an easy cost-benefit calculus, even for my beginning students in public health school. (Laughter.) That this is an investment that returns amazingly. You know, this has been, of course, said actually by the World Bank as well, if anyone needs, actually, more clear, actually, economic analysis of this . But this should be a no-brainer. (Laughter.)

BOLLYKY: So, Kathy, help me out. Do we need networks of regulators working together in sort of an Anne-Marie Slaughter idea of technical experts working together in networks? Is it industry? If it’s not going to be a big, global agreement—either through the WHO and leaving aside the trade issue for a second—who is it? Where are these networks of private sector actors and regulators that are going to move this?

TALKINGTON: I think they’re part of the solution. I think the challenge is there’s no easy answer. I think we’ve all recognized that, that it’s going to take effort from the global community. It’s going to take effort on the country side. I think, as Anthony pointed out, what the challenge we’re, I think, looking at now is how do you mobilize the interest and the resources? How do you prioritize this issue among so many other things? I think even in the United States we are challenged with how do get momentum in the human sector as well as in animal. Part of that is, you know, we’re sort of waiting for the other shoe to fall into the, you know, post-antibiotic world. Do we have to wait until that happens before significant action takes place? I hope not.

But, you know, I think some of the countries—and you all are better—more knowledgeable than I—the, you know, WHO required national action plans for antibiotics. And a number of countries have put those into place. But the challenge now is how do you get the resources to do what the action plans say? And I don’t know if there are good examples in the international arena of how—what are the incentives, what are the motivating factors? I think the—on the industry side, they can certainly—and maybe that’s a short-term way to start to make progress as there’s more consumer interest, getting international companies to talk about this, to set expectations and set standards. Whether that’s the long-term solution, you all, again, in the international arena know whether that’s sustainable. It seems like that’s maybe an initial component, a little bit faster while these international questions get answered.

I do think the scientific question is interesting. As was pointed out, in order to set some of these international standards, you have to base it on scientific information. There are gaps in the antibiotic arena that could limit the ability to set some of these international standards. So, you know, maybe I’m asking more questions than answer, but it’s difficult.

BOLLYKY: No, that’s great. That’s great. There are a lot of questions in this space. So, Hoe, speaking from your experience on the environmental side, can trade get out the way of solving these issues? Can they also be part of the solution? Are there market incentives that may be leveraged? Are there are agreements? Are there ways of driving people to higher standards of production that could be used in this space? What do you see as the lessons from how trade as a community have tried to grapple with environment issues?

LIM: Not an obvious one, because although the challenges are the same—in the sense of global collective action—the instruments of how you address it, at least so far in the trade world—in the trade world on environment, the main attempts have been to try to reduce the cost of environmental goods. So to allow more dissemination of environmental technologies, like solar panels, wind turbines, and so on. So that has been the main sort of attempt. Has not yet succeeded, but I hope it will succeed. And to reduce non-tariff barriers on environmental goods would be another part of this sort of—sort of effort.

But when you come to antibiotics, you know, I’m not sure whether that’s the solution you’re seeking, to reduce the costs and to disseminate further, because it seems that the problem is maybe the externalities are not well taken into account in the actual cost of the product. So—

BOLLYKY: But if, for instance, if antibiotics increased the costtt of agricultural production, there might be an advantage to using trade liberalization to lower the cost of those antibiotic-free or-reduced agricultural products, right?

LIM: But then you would be trying to curb the availability of antibiotics essentially, if I understood where you were going. And that would not—it’s not a sort of, let’s say, the sort of instrument that WTO is best placed to put forward. You know, it’s more about improving excess rather than reducing excess, which is why I said that for me the key part to this is how do you bring about more regulatory cooperation? And that regulatory cooperation in the WTO setting is framed by international standards. So if you have the international standards, then a trade agreement can be quite effective in pushing people to harmonize on the basis of the international standard.

And that harmonization on the basis of the international standard would then be the basis for technical regulations. I mean, something to maybe just clarify with is that in the trade context we treat technical regulations and standards differently. Technical regulations are mandatory measures that must be complied with and standards are voluntary. But the main point in the agreement is that if you are establishing a technical regulation, you are strongly encouraged to harmonize based on the international standard. So I think what we provide in trade is one forum—it’s not the only one—it’s one forum to try to bring about more regulatory cooperation.

We see that sort of discussion through different processes. One is simply the committee meetings, where a member may challenge another member on a technical regulation that they have taken. And through that process, actually, it leads to more transparency on what that measure actually is about. It establishes sometimes actually even what might be considered good practices in regulating for a particular objective. And—you know, and that is one way to try to get more regulatory cooperation that would be good for the objective, as well as lessening trade tensions. But it’s not—it’s not automatic. This is a process of lots of dialogue, essentially.

And maybe the other point is dialogue between whom. And I think that these sorts of issues from the environment side, as we are asking, the main thing is that we need coherence—you know, coherence nationally, because, you know, it cannot be assumed that there is a coherent national position on any of these issues. If you speak to one ministry, they may have one view. Another, they may have another position. So national coherence would be quite important. And that national coherence will eventually affect whatever international coordination one is trying to do.

So like in trade, we would expect that when the member comes and speaks about these issues at WTO, they have one position that is already determined at home what that position is. But in practice, we may not always see that. We may see that one member or government may have one position in WTO and may have a different position, say, in WHO, or somewhere else. So it’s really hard for an international organization to bring about coherence if our members themselves are not being coherent. (Laughter.) So I think that national coherence will really need to be worked upon.


TALKINGTON: I was going to raise, if I may, just another issue which I think would be interesting to know if there’s any precedence for this is around alternatives to antibiotics. So instead of focusing on the antibiotics and reducing access necessarily, because you have different countries with different requirements. But there’s been some talk about, you know, what are the alternatives to antibiotics, and making those tools available to agriculture as an incentive to use those instead of antibiotics. And just wondering—and what I mean by alternatives is whether that’s vaccines or management practices, there’s research on probiotics and feed—different types of feed. There’s a lot of research that needs to be done, yet again, the scientific challenges are there, whether they work in a developing country scenario, different climates, et cetera. But there is—I think there is potential there. And whether or not there is a way to provide incentives for that type of innovation and uptake in countries—do you think there would be an appetite for that type of focus?

LIM: So sort of incentives to build capacity to improve practices, essentially?


LIM: Yes, I would think so, you know? And I think that would be a very positive way if one can demonstrate that, you know, better practices also means better trade, and therefore better access, you know? That has a sort of parallel to environment, if you like. You know, there has been some interesting research that shows that more stringency on environmental regulation at home actually helps domestic companies to export more environmental goods abroad. So that sort of research or that sort of capacity or awareness raising could be quite interesting.

TALKINGTON: Thank you.

BOLLYKY: Yeah. And I will say, and to put a plug for OIE, I think they are trying to do some of this capacity building on the veterinary side.

TALKINGTON: They are. They are. Yeah.

SO: I think importantly, though, resource are not following as quickly or in the magnitude that they should. If we look at innovations really of both technologies and of practice, you can see on the human side we particularly focus actually on especially the technologies. So we’re talking about billion dollar, actually, market entry rewards to pharmaceutical companies that bring novel antibiotics to market. But when we come actually to the practice side, we’re not doing so well on the human side. But on the animal side, we’re talking about really very little resources going in. And there, we need both the innovation—we don’t have the product of partnerships as numerous. We have one like (of med ?) on the animal side, as opposed to the dozens we actually have on the human side.

And if we could simply support, like the development of, for example, of a vaccine for salmon aquaculture in Chile. Why is there not a global effort to do that, and eliminate that 95 percent of the use of antimicrobials in salmon aquaculture so we can eat Chilean salmon alongside Norwegian salmon? I mean, Norwegian salmon actually had a vaccine program that actually contributed significantly to a 90—over 90 percent reduction in antimicrobials used in Norwegian aquaculture. Now, it’s a tougher problem, actually, in Chilean aquaculture. So it’s not like they’re sitting on their hands. You know, these are multinational companies also that have operations in Norway, and Chile, and Canada, for example.

So the question is, why aren’t we actually revving up the effort to actually develop a private-public partnership to do just that? Where is, of course, the transition funds, particularly to lift up, you know, the livelihoods of our small-scale farmers. Not just, you know, the factory farm-level agribusinesses, but what about actually trying to actually enable the transition to more sustainable agricultural practices in resource-limited settings? If we really want to have this, actually, done, we’re going to have to actually reach all those levels of the agricultural system. We can’t just simply talk about just the McDonalds and KFCs doing their big buys. It’s a great starting point, but we’re going to have to do more. And so that’s going to require investment. And I think a transition fund, a leapfrog fund, to enable that kind of transition is something we should do today.

BOLLYKY: Great. Great.

So we’ve gone on for a while. I would love to call on the members of the audience. If you have questions, raise your hand. I will call on you. If you could just state your name and your affiliation before you ask your question. And please make your question sound like a question. (Laughter.)


Q: Peggy Hamburg, U.S. National Academy of Medicine.

Just following up on your last comment—is this on—I know nothing about salmon vaccines. But it seems to me if there’s already a salmon vaccine that is being used in Norway, there’s a huge demand for Chilean salmon, because you said 95 percent from salmon comes from there. What—of farm sales?

SO: Ninety-five percent of the antimicrobials used globally in salmon aquaculture are used in Chile.

Q: Oh, oh, oh, I’m sorry. Oh, well, that may change my question a bit, because I did mishear that, and I was surprised. But anyway, what—is it just a problem of getting the vaccine paid for in Chile? Or is it not approve in Chile and can’t be used in there?

SO: It’s a different set of diseases. So the one in particular in Chile is what we call SRS. It’s a rickettsial disease, which turns out to be quite intractable. And so they have to use a lot of antibiotics in their, actually, salmon aquaculture there. And we—they have not been able to find yet a suitable vaccine that can actually tackle this particular disease.

Q: So it’s a new vaccine that has to be developed?

SO: Right, yeah.

Q: So that brings me to the question I actually originally was going to ask, which was to—if any of you wanted to speak a little bit to the role of vaccines in AMR? I think, you know, it wasn’t initially an area of much focus. People were more focused on developing new antibiotics and responsible stewardship of existing antibiotics. But there’s an increasing push now in the vaccine arena which, you know, has clear application for some infectious disease agents than others. But just wondering if you could give your perspective on how that is going, what are the real prospects for impact, and, you know, what kinds of additional programs, policies, and incentives would be needed.

SO: Yeah. That is a great question, because in many ways the costs involved in bringing a new drug to market are in many—are often as many times fold what it would take to, say, bring other complementary technologies to market—like diagnostics and vaccines. The role of both of those complementary technologies is really critical. For example, projections suggest that if we actually achieve nearly universal pneumococcal vaccination among children under age five across the whole spectrum of low- and middle-income countries that do not yet have 80 percent or greater, actually, vaccination levels, we could literally halve the number of antibiotic treatment days of children under five globally, because they would not have—be presenting with pneumococcal disease. As a result, we would avert a huge number of antibiotic doses that unnecessarily—that otherwise would have been prescribed.

And, you know, similarly, we actually would—this is similar when it comes to the vaccinations for, like, diarrheal disease. You would have fewer presenting cases. And even though inappropriate treatment is sometimes is done with antibiotics obviously for diarrheal disease, just reducing that baseline obviously level of infection averts the unnecessary use, or even sometimes the necessary use, of antibiotics. All that, of course, would be a major contribution from vaccines to actually, of course, decreasing the burden of AMR, the driving force of selection from the use of those antibiotics.

The other piece, of course, is the complementary technology diagnostics. And I believe the finding of a point of care diagnostic that would enable us even in the remote parts of our health care delivery system to know when we have a bacterial infection or a viral infection—bacterial infections, of course, we treat with antibiotics, viral we do not. If we could have actually health care workers equipped with that, that would make an incredible difference, obviously, in decreasing the necessary use of antibiotics in those settings.

That also has another very interesting cross-sectoral possibility. If we found actually a diagnostic that could, in fact, at point of care, reveal, actually, whether or not there’s a bacterial or drug-resistant bacterial infection, even better, imagine if we could use that in the food supply chain, and detect actually at points of trade. You know, in my Whole Foods—or not—or—(inaudible)—Whole Foods—(inaudible)—(laughter)—you know, but, you know, at a grocery store actually purchase of your chicken. If you could tell, actually, your drug was in salmonella, can you imagine what a policy signal that would be, you know, revealing all of a sudden in the food chain that we have this problem. And think of the public awareness that would come with that, and then, of course, the important public support to take these measures that we must do.

BOLLYKY: So, Anthony, let me ask you a follow-up question on that.

On leaving aside the consumer use of, point-of-consumption or point-of-purchase diagnostics, how much investment is going in the veterinary space for diagnostics? So you broke out the various uses of antimicrobials in agriculture.

SO: Yeah. Mmm hmm.

BOLLYKY: With more accurate diagnostics, you could potentially limit some of the unnecessary veterinary uses of antibiotic that aren’t just about growth promotion. Is that happening?

SO: I’m sure—there are obviously—there’s a whole diagnostic industry for, of course, veterinary use. I’m not probably the best one to tell you exactly the market sort of level of that. I can tell you even on the human side is not an easy go. You know, we are still having challenges to create multiplex platform, actually diagnostic technologies, point of care use technologies for the human health care delivery side, and that’s where the money is, you know. (Laughs.) And so—

BOLLYKY: Yeah. And the cows can’t tell you what’s wrong with them, I assume? (Laughter.)

SO: Indeed. So I think we have to do a lot more in both, actually, healthcare and the food system.

I think where we could, actually, do, obviously, efforts of making sure the same platforms are accessible in terms of, actually—that we can build upon, in terms of innovation ecosystems, for both, actually, healthcare delivery and food systems—and even environmental monitoring, you know, because we, actually—we haven’t even talked much about, actually, exactly how much these antibiotics, actually, enter our environment. I mean, let’s face it, most of it, actually, enters the environment eventually because most antibiotics when consumed 30 to 70 percent probably cross a range of species and other conditions, and antibiotics, actually, end up in the fecal waste—you know, if I might actually be so bold, actually, before lunch—(laughter)—to actually raise this, you know, and that actually means it ends up in our environment. The manure run-off from agriculture, actually, factory farms all ends up in our environment, and the amazing thing about that is we’re seeing also now worrisome studies emerging in the literature, actually, about how these antibiotics might be affecting things that are even more problematic than we thought.

For example, methane gas emissions, there’s a study—it’s incomplete literature—but there’s a study suggesting that 40 percent more methane gas emissions in cattle treated with, actually, antibiotics versus cattle not treated with antibiotics; glyphosate, one of the most widely used herbicides mixed, actually, in test tubes, actually, with, actually, low—it actually enhances, antibiotic, actually, resistance, actually, in bacteria. And so again, we have concerns like that.

Antibiotics flowing into the ecosystem. Dung beetles that, actually, clear all the manure, actually, in our ecosystem, their, actually, life cycle may be, actually, affected; we don’t know yet. Ivermectin in our anti-parasitic area clearly, actually, has some effects on the dung beetle, actually, ecosystem behavior. These are things we do not have fully explored. Where is the researcher’s end on this? I would be worried. If the methane gas emissions alone, actually, hypothesis is correct, and actually is confirmed, that—agriculture is a tipping point for climate change. Where is, actually, our thinking about this?

BOLLYKY: Great. Great.


Q: Yes, Ilona Kickbusch from Geneva, the Graduate Institute.

I’d like to ask a little bit about politics, geopolitics in all of this, because I was part of the G-20 health negotiations. And as we know, you know, western companies are moving out of antibiotics production; a major part of the generic antibiotics are produced in India. The final declaration from the Hamburg Summit was nearly not possible because India did not want to sign up in terms of some of the more restrictive aspects that the western G-20 members wanted around AMR. We are faced with, you know, on the one hand, the overuse globally but still large pockets of non-access to antibiotics as well. This was not yet mentioned. And then, so, you know, you have a major part of the necessary production in one part of the world and a rising geopolitical power. At the same time, that geopolitical power is increasingly dependent on China for the active pharmaceutical ingredients which, you know, are then—could also be used in a variety of ways.

So, if you could just comment on some of the politics around this? Because you asked, Tom, you know, about international agreements and of course there’s a whole variety of interests that are there, and particularly if this were to explode in a certain area, then extraordinary dependencies as to who produces this stuff and who has control over the ingredients. You might remember a couple of years ago there was an explosion in a factory in China that produced some active pharmaceutical ingredients, and suddenly that endangered pharmaceutical production around the world because this was the only place that did this.

So could you say some things about that since we’re in this political environment here? Thank you.


TALKINGTON: That’s not my—(laughs)—

SO: I’m happy to take this (off ?) on that discussion.

So, you know, Ilona, I think that obviously underuse, not just overuse—access but not just excess—has to be, of course, a key focus of our efforts in tackling AMR. You know, when a country like India, of course, actually steps into the forum, in diplomatic circles, you often hear, matter of fact, more people are killed—actually, die from the lack of access to antibiotics than from the overuse today. Now that picture will change over time, obviously, but I think, importantly, we have to, actually, address underuse problem. It’s absolutely critical.

But more to your question, really, that followed, which really has to do with, you know, how do we actually see this fit into the pharmaceutical supply chain and where do we, actually, then afford responsibility? We have been—particularly in the antibiotic resistance coalition for which our program actually serves as secretariat for—I mean—I was—it’s been, really, a fascinating discussion amongst civil society groups. There was a study a few years ago by changing markets—the changing markets group that documented, in fact, the effluence from antibiotic manufacturing, actually, in India and China. And clearly—you know, when you look at the waterways in—around places like Hyderabad, you find concentrations of antibiotics that are, actually, above, actually, clinical levels, actually, in the blood stream when treating therapeutically, which is really, of course, concerning. That being said, most pharmaceutical plants, actually, do not try to, of course, put most of their antibiotics into the waste water stream; they’re trying to, actually, sell the antibiotics, so they try to put it into the pills that go into, actually, human or, actually, veterinary use. And unfortunately, much of that results, of course, in either point source pollution from hospitals, municipal waste, actually, of course, or, actually, in run-off from agricultural operations.

So if you were to look at, actually, the percentage across the pharmaceutical value chain, it’s probably going to be—and I grant you, the only figures we have are probably from the European industry, suggesting that two percent may be in that. But there’s a lot of reason to believe it’s not as high as one might otherwise magnify, actually, in discussions of this, you know, and much of it, of course—pollution, particularly—into the environment is downstream. So it means, of course, that we’re going to have to have very different, actually, points of intervention than just that.

There are solutions, however, to, actually, trying to correct pharmaceutical manufacturing problems. Can have, as you’ve pointed out, significant problems, as we have also shortages of antibiotics. We still don’t, actually, source regularly, actually, and effectively Benzathine Penicillin G, a generic drug used to treat, actually, pregnant women with syphilis, and secondary prophylaxis for rheumatic heart disease for 33 million people around the world. It’s amazing. That’s because a manufacturing plant in China failed GMP standards and UNICEF was left without a key supplier. That was a huge problem, as you well know.

These kinds of, actually, antibiotic shortages could be induced if we, actually, choose the wrong measures to correct this problem. That’s why civil society’s been very concerned because we have groups that work on innovation access, and we have groups working, of course, on the food and environment issues. But in our discussions, we understand that the fragility of the supply system—we have to understand that underuse is a serious problem and that people need those drugs today. So we’re going to have to make sure that, actually, we do it in a way that incentivize—provides, actually, the support necessary to reduce those sources of pollution by, actually, investing, providing higher, perhaps, actually, unit costs support, whatever it might be—various incentives—not just punishing, actually, some of these firms so they would leave an exit, leaving us without a supply of essential antibiotics.

BOLLYKY: Great. One quick follow-up question, and then I want to turn it over to Sir George, so you’ll come next.

In terms of the—the antimicrobial resistance movement has been very upfront about wanting to pursue an innovation model that isn’t dependent on intellectual property. So the U.K.’s review on this topic really took a strong stance on that issue, a lot of the other initiatives as well. Where are we now four, five years into this process? Are we seeing a similar level of funding go into that space, or do you think that position on intellectual property and patents has hurt the mobilization of funding?

SO: That’s a complicated question. (Laughter.) There are several layers to this. So there is, of course—I would say over the past decade-plus, even before we, actually, entered discussions of antimicrobial resistance, there was a concept called de-linkage, which actually surfaced in WHO intergovernmental discussions, whereby, actually, one would divorce the return on investment for a company from essentially the price of the drug, and the thought was, of course, that generic competition would then lower the price of the drug to close to marginal cost making it more affordable.

In the area of antibiotic resistance, of course, the issue got a little more complicated. So groups like ours actually start asking, so, if—but—should we divorce, really, just from price or divorce from also quantity. Price times quantity, obviously, equals revenue, and quantity, of course, matters in antibiotic resistance because the more drug you sell, the more you’re incentivized to sell based on volume-based sales, the more you drive resistance. So that is clearly the wrong economic model, actually, to incentivize companies when you’re trying to curb, actually, the volume of antibiotics sold so that, in fact, one is able to actually ensure effective stewardship and longer effectiveness of the antibiotic in the marketplace and for—in healthcare delivery and food systems. So they have talked about de-linkage in a broader context for that.

We are, actually, at the point where I think we still have in some ways, I would say, a constructive ambiguity, where I think that the—like the European industry, I think, has been fairly consistent since about 2010 when, actually, ReAct had a meeting with the support of the Swedish government to introduce this concept, actually, of de-linkage to industry, and they, actually, very much supported, actually, this notion of de-linkage. It has appeared in multiple policy reports since then. I think we need to go beyond even de-linkage, though, because the reality is that no one wants, actually, the pharmaceutical companies saying, actually, in your doctor-patient relationship saying, well, I have to ensure, actually, stewardship of my, actually, product therefore, I, actually—I’m going, actually, to intervene here, you know? That’s not anything that a public health professional or a medical professional or the drug companies want. They aren’t in a position to do that; they don’t want to do that.

The question is, how do we then create an end-to-end approach? And so we are starting to discuss, actually, how can we ensure new approaches that involve end-to-end approaches, and we’re seeing a lot of creative approaches there. Some of it has to do with financing, like, you know, paying up front for some of these things, more push incentives. Some of it has to change—changing the way in which we actually structure, of course, the pharmaceutical R&D system. You know, I think there is a lot to be done yet in this space. We’re just at the beginning.


We only have two minutes, so I’m going to call—I’ve seen two hands for some time, so I’m going to call Sir George. Please make it brief so we can try to get an answer, and then, you, who have also been raising for a long time.

Q: Thanks so much. I am impressed with your comment on diagnostics. So my quick question is, what is a relative level of investment in new antibiotics, vaccines and new diagnostics? What is a relative level of investment in those three?


We’re going to take this second question at the same time, so Ms. Wu.

Q: Thank you. Patricia Wu, C&M International.

My question goes back to, Thomas, what you were raising about a potential agreement. It sounds like we’re on the verge, hopefully, of a tipping point. We’ve got great economic studies. We’ve got some political leadership. But what will it take, in your view, to kind of get over this hump? Is it political leadership? If you look at, for example, the FCTC or the Montreal Protocol, were there certain commonalities that you can draw from in terms of what’s necessary to just get us over the finish line here?


I’m going to—given that we only have basically a minute, I’m going to ask Anthony to briefly respond to Sir George, and then, for the two of you to just give, you know, a sentence on where you really see the issue of leadership in terms of moving an agreement forward.

SO: Unfortunately, we really do not know the answer to your question because R&D costs are, actually, largely non-transparent. We do not have disclosure, unfortunately. This is, of course—this can be subject of a resolution and discussion at the World Health Assembly this year, but even in the United States we have remarkable non-transparency of the R&D costs. You can only, actually, figure this out, actually, indirectly if you have a firm that is only involved in a single product, and you look at their, actually, returns so you know the R&D is, actually, for that particular product line, and you don’t even know sometimes if, actually, they’re doing other product lines. So it’s almost impossible for us, actually, to truly asses the level.

You can look at the relative market sizes, but, actually, that’s the best we can do. But unfortunately, I’m sorry, we don’t really have the answer to that.


Kathy, Hoe, anything very quickly on—

TALKINGTON: Yeah. So I—political will, obviously, is key. What does it take to get that political will? I think we need better information. We need better data, better surveillance on what the magnitude of the problem is, and I think the other piece is we need the voice of the problem. It is difficult to find the victims of antibiotic resistance, and finding those people and amplifying the challenge, to me, would be critical.

BOLLYKY: So is the lesson of international trade negotiations: persistence and patience? What do you have to offer on this?

LIM: You have to be very patient if you deal with international trade negotiations, but—(laughter)—you know, I think a lot has really been said that really touches on your question on what’s needed, and I think the challenge in moving AMR today is that you need a multilateral solution. Yet we are seeing today, if I can say, multilateralism is not very popular in many places, so it’s very hard to come back to finding an AMR solution which is multilateral unless we also reinforce the need for multilateral—multilateralism, basically, in all spheres, not just in AMR. So they’re, like, connected, in my view.

And how do you do that? Well, I don’t think there’s one answer. It’s both top-down and bottom-up. I mean, I think you do need political leaders to push the issue, but you also need bottom-up from what we’ve really been saying, from all stakeholders to make it sort of attractive for political leaders to push on the issue.


So we will have a ten-minute coffee break, and we will come back at 10:30. Do not go anywhere. The hits keep coming. Our next panels are great, too. So—but please join me in welcoming our speakers—or thanking our speakers. (Applause.)


Session II: Trade and Health in the Era of Noncommunicable Diseases
This session will explore how trade and public health oversight can reach a better balance.
Sally Grooms Cowal, Jimmy Kolker
John Monahan

MONAHAN: I’m John Monahan. I’m a senior fellow at Georgetown University and I’ll be presiding over this session today.

And we have—this should be a really interesting discussion. We have two terrific speakers, who I’ll introduce in just a second. But just to get us started, just—and I know most everybody in the room here is quite expert in global healthy, but just a—just a couple sort of definitional and background points to get us set, mostly about what we’re talking about, which is noncommunicable diseases, trade, the private sector, their interrelationship.

Just as a matter of definition, NCDs, noncommunicable diseases, are noninfectious, nontransmissible diseases, such as cardiovascular disease, cancer, chronic respiratory illnesses, diabetes. NCDs are really important. They are the leading causes of global death and mortality, killing three out of five in the world today and are basically responsible for the bulk of the global burden of disease.

And while the incidence and prevalence of NCDs are pretty common in the high-income world, as we know, because of life here in the United States and our challenges with obesity and similar diseases, the burden of NCDs is rapidly growing in low and middle-income countries. In fact, it’s growing more rapidly than we experienced in the disease transition here in high-income countries. In fact, many low and middle-income countries are facing a double burden of both continuing infectious disease crises around HIV, TB, other diseases, as well as this emerging set of issues around NCDs.

Thankfully, our friend Tom Bollyky from the Council on Foreign Relations has written a terrific book. So if you want to know more about that double burden and the challenges the world faces, you’ve got one place to look.

But let me talk a little bit about I think why we want to focus on this set of issues. NCDs have several risk factors, many of them are related to things like unhealthy diets, a lack of physical activity, harmful use of alcohol, tobacco. In other words, NCDs basically relate to how we live, work, play, how we—and how we operate in the world. And really, most importantly to this conversation about trade, it’s also how we consume and buy products in global marketplaces.

And so this has been a discussion in many U.N.-WHO meetings over the last several years. I suspect we’ll be hearing quite a bit about that from our speakers.

And I guess I would just say a couple of things. Because so much of this is about consumption of products and services, this gets to questions of trade and how markets work or they don’t. The earlier conversation today I thought was really interesting when we talked about challenges of over and underconsumption. That’s certainly true around healthy foods throughout the world.

At the same time, obviously, because we’re talking about markets, we’re talking about private sector actors. And a big part of the questions we’ll be discussing today is, how do you engage and how—and what’s the proper way to engage private sector actors in these questions around the public health response to NCDs?

And also, these same industries, they’re—they could potentially be part of the solution. There are also other industries, like the pharmaceutical industry and others, that are going to be involved in products that may be helpful in addressing some of these NCDs. So this is—this is a complicated question and it—and we are really lucky because we’ve got two terrific colleagues and experts here today to help us sort this out. And they are people who have deep experience with the U.S. government and deep experience working in health diplomacy in this area.

And so I want to take just a chance to introduce our colleagues here. First, I want to introduce Ambassador Sally Grooms Cowal. She is the senior vice president at the American Cancer Society. She had a long and distinguished career, as you can see in your biographies, in the—in the U.S. Foreign Service. She has worked on—she was involved in the creation of UNAIDS. She was an ambassador of Trinidad and Tobago during her career. And so she’ll come and talk to us about the substantial work she’s been doing at ACS.

And then my colleague Ambassador Jimmy Kolker, a former assistant secretary of global affairs at HHS, a colleague of mine now at Georgetown at our Center for Global Health, Science, and Security. He also has appointments with the Center for Strategic and International Studies and the American Academy for the Advancement of Sciences.

So the way we’re going to do this is Sally will start us off for about ten minutes and talk about her perspective and her experience; Jimmy will do the same. We’ll have a little bit of an exchange and then we’ll open the discussion up to the audience.

So with that, Sally, would you like to kick us off?

COWAL: Great, I would. Thank you very much, John.

And again, thanks to the Council on Foreign Relations and Tom’s work in putting this—Tom and his team’s work in putting this session together this morning.

John has already told you about why you should care about NCDs, and yet most of us don’t. And that’s really because, of course, I look at it particularly from the cancer perspective as I work for the American Cancer Society. But I can tell you that in cancer alone there’s sort of a tsunami of cancer and other noncommunicable diseases impacting lives and livelihoods across the globe. And yet, the world is largely unaware and unprepared.

So NCDs, as he said, causing almost 75 percent, more than 70 percent of all deaths in the world globally. One in every six deaths is now—cancer is responsible for one in six deaths in the world. And it’s particularly disproportionate in low and middle-income countries because 85 percent of the deaths from noncommunicable diseases in those countries are among people ages thirty to sixty-nine. So they’re really premature deaths; they’re not just deaths, but they’re deaths as we saw in HIV, for instance, of people in the—in mid-career, in what should be the full bloom of health, dying.

And, of course, the morbidity is also tremendous. Even if you don’t die immediately, your ability to contribute to your family and your society much reduced by diabetes, cardiovascular diseases, lung diseases, and cancer. And this continues to grow so that by 2030, five times as many deaths as from HIV, malaria, tuberculosis combined will be attributable to noncommunicable diseases.

And we know that tobacco use, physical inactivity, harmful use of alcohol, and unhealthy diets are also on the rise and increasing. That’s why we’re seeing such a rapid increase.

So then we get into the topic of today, which is really how these noncommunicable diseases and economics relate. And the rise in noncommunicable diseases in low and middle-income countries is predicted to impede efforts to reduce poverty in low and middle-income countries because it’s increasing the cost of health care. And most of the cost of care in these low and middle-income countries falls on individuals and their families and communities. We see in Africa whole communities will mobilize around funding one person to be able to get to cancer treatment in the capital city.

And there’s also virtually no development funding going into this and small budgets of the countries themselves. So just of the United States, for instance, less than 1 percent of our global health funding is how directed toward noncommunicable diseases, although, as we’ve heard, they are 70 percent of the burden of disease in low and middle-income countries. So we’ve got a disproportionality going on here.

And society’s most vulnerable people—so it’s not only the vulnerable countries, but it’s the vulnerable people within the vulnerable countries who are disproportionately impacted because they’re at greater risk of harmful products, such as tobacco or unhealthy dietary practices, and they have the most limited access to health services. And, of course, we know that this is as true in the United States as it is abroad.

Who’s the most affected? People living in marginalized communities or rural communities far away from the services, but where the fast food industry has spread the most rapidly.

The high costs associated with health care for NCDs drains household resources and pushes millions of people into poverty every year. So I guess you could say that healthy is wealthy, even if you’re living on a dollar a day.

But the question is, how do we stay healthy? How can we keep populations healthy when trade liberalization, as you indicated, may play a role in increasing the supply of risk factors. This is very new and we’re still at the incipient stages of talking about this, but we do know that as countries liberalize trade, the consumption of unhealthy commodities increases. That’s a fact.

So I think trade agreements should now be considered as social determinants of health at a global scale. And I can cite you only one thing that should bring this fact home, and that’s—and I say this with some reluctance as a person who was very involved as deputy assistant secretary of state in working on the first NAFTA negotiations—but the Mexican obesity rates have tripled since the bringing into force of NAFTA. So trade obviously plays a role.

Let me for a moment talk a bit more about tobacco, which is a particularly lethal risk factor. So tobacco kills approximately six million people globally every year. So think of it as a holocaust every year. And at least 20 percent of cancer deaths could be eliminated if there were no exposure to tobacco smoke or to tobacco. So unless countries take some significant steps on tobacco, it will kill one billion people in this century; that’s one-seventh of the world’s population.

And this is not just happening by chance. It’s happening because the tobacco industry works tirelessly and with very deep financial pockets to preserve its established markets in developed countries—think e-cigarettes, Juul is now owned by Philip Morris—while viewing and treating low-income countries as great potential markets for increasing tobacco consumption.

So, many countries around the world have begun to adopt meaningful tobacco control policies, taxation among them. The tobacco industry works to block and delay and dilute these policies and they do that within countries and they do it within global agreements also.

So trade and investment agreements have provided the tobacco industry international litigation tools to attempt to undercut groundbreaking tobacco control measures. The two most well-known cases are Australia’s plain packaging and Uruguay’s single-product restrictions, which were challenged in lawsuits by the tobacco industry. And it proved extremely costly, time-consuming for those countries, although they both prevailed. It has an absolutely chilling effect on other poorer countries who have contemplated adoption of tough tobacco control measures.

So as I said, fortunately Australia and Uruguay were successful in fending off the litigation tactics. And the twelve countries, now eleven with the withdrawal of the U.S., negotiators of the Trans-Pacific Partnership, the TPP, exempted tobacco control measures from litigation rights of investors in countries party to the agreement. That’s extremely important. So they ruled out the ability to sue over tobacco restrictions.

And at the time the U.S. was still actively involved in TPP negotiations, we did some polling on the topic with the American—with American publics across the country, a randomly sampled poll, showing that there was absolutely tremendous support for this kind of restriction, for restricting the tobacco companies from being able to freely market their product on vulnerable populations in other countries. And that was among Republicans, Democrats, and independents. And was even—the support for doing this was even higher than the support for, for instance, measures on free trade or environmental standards, which first came into trade negotiations in the NAFTA round.

So there is public support. It gets us back to the first conversation a little bit about talking, is there consumer support for restrictions on the U.S. of antibiotics? And yes, there is. How do we mobilize that?

So we know from this polling data that, as we go into new trade agreements, there will be support from the public for having such restrictions. So these efforts to protect public health through trade agreements have been supported. And what we’ve learned about how to do something to exempt tobacco control measures from trade agreements should serve as a model, I think, in inserting measures to protect public health and safety from other threats such as from packaged foods, alcohol, and the promotion of unhealthy fast food franchises globally.

Kentucky Fried Chicken is not the largest of those, but I can tell you that there are two hundred and thirty-three thousand Kentucky Fried Chicken outlets around the world in a hundred and nineteen different countries, eight hundred and eighty-four in South Africa. A few years ago, I was in Kenya and saw a large demonstration on the street, which I assumed was political, and it turned out to be the opening of the first Kentucky Fried franchise—Kentucky Fried Chicken franchise in Nairobi and many people were lined up around the block to be among its first consumers.

So, again, as we heard on the earlier panel, tobacco is the only WHO treaty ever enacted, the Framework Convention on Tobacco Control. But given the growing evidence and belief that food and beverages are the new tobacco in terms of their effect on obesity and obesity on the growth of noncommunicable diseases, I think future trade agreements will allow some kind of leeway to limit the rights of investors in countries who are parties to the agreement. So this will not come without a struggle.

In the current NAFTA talks, which are still going on now, U.S. negotiators, Trump administration negotiators are trying to limit the ability of all three of the countries, Canada, Mexico, and the United States, to warn consumers about the dangers of junk food. And this was according to a New York Timesarticle that appeared a couple of weeks ago.

So we’re just at the beginning of something new and something terrifically, I think, as relevant to public health as all of the things that are more often discussed. So thank you.

MONAHAN: Thank you, Sally.

I told you this would be a great—this would be a great conversation.


KOLKER: Thanks very much. And it’s a pleasure to be here. Thanks to the organizers.

Just as the U.S. and other bilateral development aid emphasizes contagious communicable diseases, multilateral organizations, such as WHO, were established in the last century to prevent and treat communicable diseases. And so the 2011 World Health Organization ministerial on NCDs really was the first time that they had, in an organized way, stepped up measures, guidance to control individual risk behaviors and put the noncommunicable diseases on a part with other global health concerns.

And as Sally has outlined, the international community has long paid attention to tobacco, but the move now to look at sugar and salts and fats and the nutrition products that you’re talking about meant that the WHO expanded existing guidelines, established new guidance and recommendations, and requires countries now to collect and report on new indicators, mostly concerning obesity, but the whole range of risk factors for noncommunicable diseases.

And I think we heard a lot in the previous discussion about standards, which are the way in which trade functions, but it’s important to recognize that WHO functions on the basis of guidance. And guidance is, by WHO rules, developed by experts in a nontransparent process. They meet privately. The private sector is specifically excluded from the discussions of guidance development, which is understandable in one way, you certainly don’t want the industry to say yes, you should drink more coffee. But on the other hand, it does mean that some of the information that may be available to the private sector, their comparative advantages in looking at how products are used, is not necessarily in the room. NGOs can be, if they have an expert who’s nominated, and sometimes that process also is not very transparent. There might be an interest group that has an expert in the room, is actually charged with writing the guidance when the organization itself is an advocacy group for certain positions.

But furthermore, member states don’t vote on the guidance. You read a lot about World Health Assembly resolutions that endorse or welcome or take note of guidance, but the guidance specifically is not supposed to be a political process.

So standards are much different. For instance, Codex Alimentarius standards, the standard-setting is transparent, the industry is very much involved, they’re subject to appeal if there is an objection to them.

I see Peggy Hamburg in the audience.

On the U.S. side, the Department of Agriculture and the FDA lead the U.S. involvement in the Codex standards, not policy people like myself who are voting on WHO resolutions, World Health Assembly resolutions that talk about guidance.

And just to look—and I credit Peter Mamacos who’s in the audience with putting me onto this for this panel. I looked at one of the most recent Codex Alimentarius guidance, which is for frozen french fried potatoes. Now, all of us have probably consumed frozen French fried potatoes, if we haven’t bought them at home, surely in a restaurant. And if I say “frozen french fried potatoes,” a picture pops into your mind’s eye of what a frozen french fried potato is or looks like.

But in fact, there are seven single-spaced pages in the standard under Codex on what a frozen french fried potato is. And this—it includes some very, very specific language, but it also says that salt, sugar, spices, and seasonings may be added and the standard is that’s still a frozen french fried potato without telling you how much salt, sugar, seasonings, or spices are in that.

WHO guidance on the other hand is very short, although there are documents supporting the guidance. But on—current WHO guidance says don’t consume more than five grams of salt per day and less than 10 percent of our energy intake should be from added sugars. Now, again, that’s something we can deal with, we understand what that guidance is, it’s very short and sweet.

But what does that mean in practice? And the issue that came up during my time in the Department of Health and Human Services was Chile proposed putting hexagons, symbols, big symbols that looked like stop signs on the—on the packaging, the front label of packaged foods saying “high in sodium, high in sugar, high in fats, high in calories.” And these didn’t mean that you couldn’t buy the product, it didn’t mean that they couldn’t be marketed, it didn’t mean they couldn’t be imported. But this warning label certainly would be a warning to consumers. But again, how they judged how I was going to consume my daily proportion of sugars or salts or fats was kind of still up to me, these were just saying warning, this might be—this is about—this is about use, not just an ingredient label, but be aware how you use those.

And increasingly, trade rules have been allowing for use labeling. And so we have a health standard. And WHO contributes to Codex. In fact, FDA, to their credit, is the only international donor that subsidizes the WHO’s involvement, expertise that goes to the safety of food products through Codex. Only about 15 percent of WHO’s actual effort in that is funded by voluntary contributions and we’re the only ones who do it. So credit to us, but it means WHO is significantly underrepresented in the Codex world and that the industry is not represented at all in setting these guidelines of how—of what healthy use of these products is.

And so I’m just going to go through in the trade and health world NCDs, three examples from my time in the Obama administration, because you’ve got practitioners on the stage rather than the academics or theorists.

But the first is just about protectionism. There’s a long tradition, at least in theory, that products contributing to healthy shouldn’t be subject to protectionist measures. But we had the situation in India where the Indian national health service decided that the amount that they would reimburse for pacemakers to practitioners who prescribed these patients who were in need of them was not, coincidentally, exactly the cost of the Indian-manufactured pacemaker that was there. And that in addition, there were tariffs on imported medical devices, so not only were the costs of U.S. manufactured, for instance, pacemakers higher to begin with, but they were significantly increased by the fact that India was taking measures to restrict their market.

And we were able to argue, using guidance, that there were conditions which a more sophisticated or pacemakers with different characteristics than the more scaled-down version that India was manufacturing would be valuable, would be recommended for patients. And India did reverse that policy. So by talking about pacemaker standards—pacemaker not just standards, because the Indians met the standards, but use and recommendations, this became a bilateral issue.

We’re finding, however, that in the proposed U.S. retaliation to China under proposals were these to be implemented, the original list included even drugs from NCDs like insulin on which we were going to impose tariffs on that and still includes medical devices and simple global health security products, such as gloves and masks. So the issue of how do you use protectionist measures in the field of global health I think is something that we need still to talk through and engage in.

A second example was I was in the chair, for better or worse, in the World Health Assembly 2016 debate on breast milk substitutes. And many of you saw articles about the 2018 debate which was about reaffirming breast-feeding resolutions that passed. But the breast milk substitutes resolution was specifically called for in the 1981 original breast-feeding resolution of WHO that said that WHO needed to develop further guidance for children between six months and three years who would not necessarily be exclusively breast fed and would have supplementary or complementary foods.

And that young child nutrition debate, though it certainly got the infant formula industry and others very mobilized to be sure that what was written in the guidance—again, which we couldn’t vote on—but what was written in the guidance was something that was consistent with U.S. law and practice, something we could actually implement if this were happening, and was recognizing the interests of U.S. manufacturers as well as the public health value of this process.

And I have to say, the interagency process was intense, probably the most attention-filled negotiations we had among agencies during that time. But we engaged early and we looked at—the industry presented positions very clearly. We looked at those in terms of public health value and actually proposed twenty changes, without—not in public, but to WHO directly and said our analysis of the public health benefits are that these twenty things actually shouldn’t be in the guidance. And some of them were because U.S. law wouldn’t allow them, like restrictions on advertising. We have a—we protect commercial speech, many countries don’t, but that was an—that was an issue that we couldn’t live with in the guidance.

But a number of them were simply we thought there was better science and we proposed that better science saying here’s some evidence, have you considered this, and it’s this in the guidance. I think we got five out of those twenty were actually incorporated by WHO into the guidance before it ever was sent to the World Health Assembly for a decision.

And then there were very high-level contacts between, for instance, Secretary Burwell and U.S. Trade Representative Froman. She got calls from everybody in the world, including Speaker Ryan. And this—as we developed our position, I have to say as a negotiator, it was—she was—it was such a benefit because she said here are the three things that we have to have: You can’t endorse the guidance, you have to mention milk positively—you can imagine which call that might have come from—and you can’t—this guidance can’t, in a legal sense, overrule or be equal to standards developed by trade agreements. So this is guidance, but it doesn’t—this does not refute that the standards already established or trade agreements already established are still valid.

And we were able—and then she said, which I really appreciated—she said, other than those, get the best deal you can. And I think we were able to do that. And they were contentious negotiations. It wasn’t we didn’t get everything we wanted there that we actually thought would have been in the public health interest, but at the same time we got a deal that we could live with, we didn’t endorse the guidance, we welcomed with appreciation the guidance.

And the guidance in fact moved us ahead. This has been pending since 1981, so people needed, some countries needed some guidance about the issue. And I think that was successful.

I did—I was not directly involved and I think some of the publicity about the U.S. position for the 2018 guidance was in fact unfair, but it was based on a couple of assumptions that turned out not to be very helpful. One was that because there wasn’t a requirement or an expectation as there was with the breast milk, the young child feeding, this was just a reaffirmation and sort of updating of the breast-feeding guidance. And so—and it wasn’t to prove it was just a resolution talking about reaffirmation of what that was.

So the U.S. position was there’s no need to do this, let’s not put this in front of the World Health Assembly. And that, I think, was a justifiable position. However, no one else supported it and it meant that during the first two or three initial discussions in Geneva, when all of these questions about details could have been debated and resolved and we probably would have been successful on at least two or three of them, we weren’t in the room. We just said we’re not doing this. And that, I think, is a huge mistake if you’re looking at how the World Health Assembly and other multilateral organizations develop.

And then we came into the World Health Assembly with a maximalist position, positions that we knew in advance weren’t going to be popular, but we wanted to say this is what we think is right. And I’m not prejudging whether our positions were right or wrong. They did align more closely with industry than we had in 2016 because we hadn’t had the same, I think, robust interagency process to look at the public health equities. But at the same time, we had to accept in the final resolution a number of positions that were not on our original list and seemed to be redlines as we were going into the negotiations.

So just on that, the question of how the interagency process works to take into account the trade issues, to take into account the health issues, but then to present a position which is actually negotiable in the real world I think is an important lesson of this.

The third, Sally already referred to, the Trans-Pacific Partnership, in which the Obama administration got HHS in the room initially and we became more and more active as both the advocates saw health as the reason that TPP probably wasn’t going to be something that they could support. And as the issues developed, it turned out that health probably weighed on the side of yes, the health advocates think this is a good reason, for the reasons Sally said, not just that tobacco was excluded from the dispute resolution mechanism, but that that exclusivity for drugs, the protection of the patents, which the U.S. has as twelve years, Australia had five, and we had ended up saying we couldn’t accept less than eight, and the result was, as one could expect, somewhat ambiguous, allowing countries to have between five and eight. But that’s considerably different than the twelve years, which was our opening position, and much more reasonable in terms of what activists saw as the need for that exclusivity, although we have experts in the room who may have their own views about that.

And a shout out to Tom, because the question of the impact of trade agreements on access to medicines is really underappreciated.

And I think you’re the only one that’s tried to write on this to see if there are actually effects in practice of, for instance, the U.S.-Korea agreement that you worked on. So appreciate your contribution to this field. But it’s a very important thing to look at because we don’t know enough about how these restrictions work in practice on trade agreements.

So anyway, thanks very much.

By the way, the U.S.-Mexico trade agreement has ten years, so not as favorable to the consumer as the TPP would have been.

COWAL: And I should point out that we never signed—we signed, but never ratified the Framework Convention on Tobacco Control. So we’re one of about five or six, eight countries in the world, which has not ratified it. And in justification, we say, well, we follow all the rules, which perhaps we do, but it’s also an important signal and an important signal of industry influence on U.S. policy that we have never ratified that.

MONAHAN: Well, to use Jimmy’s words, I welcome with appreciation all these very thoughtful, specific comments.

So maybe a way to start this before—and it relates, Sally, I think, to your last point and, Jimmy, your points—come to a—from a public health standpoint, there is a profound ambivalence about the role and the interest and strategy of these—of the industries we’re talking about here, the food industry, tobacco, alcohol. And we’ve seen that recently there have been some—you know, the most recent example is the Global Fund having a partnership with Heineken and then withdrew that partnership. I guess I’d be interested in, you know, underlying a lot of your comments is to think about how we should engage with these industries. And so maybe if I could each of you—I know each of you have been thinking about this, not only from a U.S. government and trade perspective—but just as we look ahead, what should we be thinking about in this space?

And maybe, Jimmy, I know you’ve been thinking quite a bit about this.

KOLKER: Well, I’ve been thinking about it. And I have to declare an interest that after I retired from government I was asked to be a member of a board of a foundation created by the AB InBev company, Anheuser-Busch, the beer industry.

In 2015, before I—before they set up the foundation, joined the board, established something called smart drinking goals and pledged a billion dollars to implement this. The credibility of the company to do this in-house was widely questioned, so they set up a foundation with some independent advisers, including Jo Ivey Boufford and Bob Orr and other names that are well-known in this community, to oversee this foundation which would look at transparency, look at be sure we’re publishing evidence and other things.

So anyway, I have a connection to the beer industry, although the foundation is independent, but a chartered group.

But it did—I think what I told the CEO of the company when I started on the board, I said I sat in the U.S. chair and advocated that in order to solve problems with NCDs there was comparative advantage the industry had and that they needed to be inside the tent in the construction—in the discussion. And I said I’m calling my bet. Let’s see if you can be an industry leader and really do have comparative advantages in marketing and research and product design and knowledge of consumers and consumer behavior that will actually achieve these reductions in harmful drinking, binge drinking, underage drinking, and so on.

So when the Global Fund rejected the Heineken contribution, I thought this is a missed opportunity to look at what kind of partner would Heineken be? And why are we—why would this contribution make sense to achieve the goals of the Global Fund? Heineken is not a public interest organization, it’s not a public health organization, nor is AB InBev. On the other hand, it does seem as though the global health community can benefit from these comparative advantages that industry does have.

And one—just in 2016, the Framework for Engagement with Nonstate Actors was passed at the World Health Assembly. And it did—one of the key elements of that was that there are four kinds of nonstate actors: there are foundations, academic, academia, nongovernment organizations, and private sector. And in some ways, they’re treated differently by the resolution or the framework.

But one thing we’ve insisted on and it is in the final version is that evidence is evidence. That the evidence created—even if there’s a private sector sponsorship of some kind of study, that the evidence should be judged on its merits, not the merits of the presenter of the evidence. And it does seem as though that principle is one that would make sense in the public health world, the idea that the private sector does have interests, should be certainly up front, but also that it doesn’t mean that their contributions are negligible or necessarily negative to public health outcomes.


COWAL: Well, I think I’m a little harder than Jimmy on this issue. First of all, I do think you have to draw a line in the sand about tobacco and put that out all by itself, the only product which, when taken as directed, kills you. Can’t be said for beer or wine or other alcohol or most foods.

And the tobacco industry is sort of known way back into the 1950s and ’60s for falsifying evidence and, I mean, I think we all know all of these things. So they have an extremely negative track record which goes on until today when, about a year ago, Philip Morris, too, established its foundation called, sort of disingenuously, the Foundation for a Smoke-Free World and poured billions of dollars into it and hired an ex-WHO employee to run it. And this organization has gone out and tried to recruit many partners within the civil society community and I—and I think academia and others. And most of us have said and have advised just, you know, just say no to this one. There’s no point in working with the tobacco community.

On the, you know, on the alcohol side—and I also say this as a person who owns a winery, so full disclaimer there—(laughter)—I’m somewhat conflicted—

MONAHAN: The disclosures of our panels may be the most interesting part of all this today. (Laughter.)

COWAL: Yes. Although I do make the case for red wine, you know, it is a good antioxidant. (Laughter.)

KOLKER: There’s no safe level of consumption of alcohol.

COWAL: Right, including there was a recent study in the U.K. about breast cancer and alcohol and saying even one glass of wine increases your risk. I mean, we all as consumers have to take that into account.

I was also—full disclaimer, you know—part of UNAIDS at the very beginning when we were very anxious to work with Heineken in a lot of places, particularly in Sub-Saharan Africa where they were promoting the brand, the brand was widely popular. And we saw them as contributing, again, on responsible drinking and also on providing some of the last-mile distribution of things like condoms because, well, gosh, if a beer or a Coca-Cola truck can get to this village, which doesn’t have any access, can they carry along something that would be really good?

In some ways, with a twenty-five-year look back in the rearview mirror, I see that as somewhat disingenuous and somewhat naïve because we certainly have to say—I mean, Coca-Cola, as far as I know, has no particular impact on HIV, but alcohol, in terms of reduced inhibitions and leading to somewhat riskier behavior, certainly does.

So, you know, we’re in the early stages. I think the jury is still out. And I certainly—I think WHO moving to acknowledge that we do live in a real world and there are some nonstate actors in that world and they are diversified is something that’s long overdue in coming. So I’m very much in favor of that.

But I think I see with some of the food and beverage people exactly the same kind of tactics perhaps in a slightly less pejorative way, but to really promote their products to small children and essentially it’s not only the fact that obesity rates are so high in places like Mexico and the United States and Jamaica and other places in the Caribbean, it’s that childhood obesity rates are even higher. So we’re addicting, you know, a generation of young people. There is an effect of this, even in the—not even in the United States, including in the United States.

The American Cancer Society just put out a report a couple of months ago about the earlier age—earlier ages at which people are being diagnosed with cancers in the United States being related to the obesity epidemic. So things like colon cancer, for instance, which we used to begin screening at age fifty saying, well, virtually, you know, that’s a mark of passage, you get old enough to have your first colonoscopy, rah, rah. (Laughter.) But we promoted very heavily screenings, so a big national campaign of eighty by eighteen, 80 percent of the eligible population screened by 2018. It didn’t quite happen, but certainly screening rates are going up in the over-fifty age group.

But guess what? Just when you thought it was safe to go back in the water, now a lot of these colon cancers are being discovered and at very late stages because people haven’t been screened among thirty-year-olds and forty-year-olds. And that seems to be very closely related to an obesity epidemic.

MONAHAN: So what I think we’ll do is open up to questions. I’ve got—I’ve gotten several signals that we should get started on it. And there is, of course—I have to read a little bit of a—I would—I actually would ask everybody, just as Tom did, if you have questions to identify yourself and what organization you’re from. A reminder, this is all on the record. And try to, as best you can, think of your statement in the form of a question so that we can—we can take advantage of our panelists here.

And so I think why don’t I—I think I got—well, there’s one question in the back of the room there and then we’ll—we’ve got one up here. So why don’t we start with one back here and then we’ll go from—oh, please.

Q: Great. Thank you. My name is Amit Chandra. I’m an emergency physician and a consultant with the World Bank.

And my question is around the expanded definition of NCDs, that is NCDIs to include injuries. So directly to my question for the panelists, what do you think the role of trade and health policy specifically related to transport is in reducing the burden of injuries and specifically building the emergency care systems to address them and other NCDs?

MONAHAN: OK. Why don’t we—I’m wondering if we should take a couple of questions. There’s one down here in the front, I think.

Q: Yes, thank you. Ho Lin (ph) from WTO.

A sort of half question, half sort of observation. Life expectancy in China, from I gather from the data, has gone up from 69.3 years in 1990 to 76.3 years in 2016. And that’s an increase of seven years. I have been told that’s a phenomenal increase for any country to demonstrate. Over that time is an interesting time span because 1990 to 2016 is also when China started to embrace much more economic reform, much more trade openness, and joined the WTO in 2001. And there’s a relationship here I believe with growth of income. And growth of income is in turn related to trade.

So my question to the panel really is, do you see any health benefits from trade liberalization or none whatsoever?

One could have also similar statistics if you look at developing countries in terms of poverty and of income growth. And that data is fairly robust, so are the studies. I’m not suggesting causality as such, but to me they are important points here to keep in mind when we talk about trade liberalization.

Admittedly, I take the point that there are certain products where there is a need for strength and health measures, but, you know, it would seem to be not balanced to not take the other points into account as well.

MONAHAN: I think there’s two good questions. Who wants—anybody want to start? I think both the question about how injuries fit into NCDs and I think the other side of the story here. Obviously, the panel, in part we’ve been looking at health issues and concerns related to economic development and trade, but, again, sort of the broader frame I think is a—is a good point.

Jimmy, you want to start us?

KOLKER: Sure, I’ll start. Great questions. I think the emphasis in 2011 on noncommunicable diseases opened doors realizing that WHO and in fact the global health community had really been underemphasizing a huge number of conditions and activities that contribute to individual and global health that the multilateral system and aid and our attention hadn’t focused on. Injuries is one, mental health was the most, probably the most important, surgery and anesthesiology, injuries in emergency care, but also dental health, vision, hearing.

Peter will remember, we had intense lobby from the psoriasis interest group that we needed to get a WHO resolution on psoriasis.

So all of these things are valid. These are all health conditions that deserve attention. I think the question of the WHO, which is severely underfunded, has half the budget of PEPFAR annual budget, PEPFAR for just one disease and WHO for everything everywhere, half as much money per year, so the question of what can be done, how guidance can be developed, but how is that guidance then translated into country action, into individual facility best practices, the training of the workforce and so on, is an unanswered question. And while it’s on WHO’s agenda, we haven’t done this very well.

So I think the advocacy on those questions is important, but I don’t see an immediate solution in a multilateral or bilateral aid program. Setting up communities of practice in which we talk online or through some kind of mechanism as to how we solve these problems in the United States and what are the best practices that could be adapted in low and middle-income country settings is very much in demand. People want to know how do you solve this problem in the U.S., what are some best practices, not that we need contractors to come and run services in low and middle-income countries, but can we get your best technical experts to consult on that.

I’ll give one example of trade—what I see as a health benefit from trade liberalization. When I was ambassador to Uganda, Uganda decided after a couple of years of very successful PEPFAR money for treatment of HIV that they were going to set up a manufacturing facility in Uganda to produce antiretroviral drugs. And the result would have been that the drugs would have been more expensive than the entire Indian generic versions, that the safety and efficacy would have been hard to establish based on a kind of greenfield site that they were going to do this, and a sense of this was industrial policy, not health or trade policy. It was simply to try to get industry into a market that they knew was lucrative.

And so we were able to say at least PEPFAR was not predisposed to buy drugs from that facility or the facility would have to go through a lot of hoops to do that and that the free trade benefits of being able to get drugs from already established producers were easy to calculate. So that’s one example.


COWAL: I’m not at all an expert in China, but certainly much of what you say is factual. And I would have to say that by increased trade and increased wealth you’ve certainly seen a lot of malnutrition drop. And malnutrition is obviously the opposite side of the coin is overconsumption. So one caused a lot of health issues and the other is beginning to cause health issues.

Fifty percent of Chinese men are smoking as compared to 2 percent of Chinese women. So there’s a great pitch on by the tobacco companies, by the way, to get Chinese women to smoke because it’s clearly an under—an untapped market.

But I think we’ve also seen life expectancy rise because of the control of infectious diseases, HIV/AIDS, malaria, tuberculosis. Obviously by getting a better handle on those, that’s greatly helped life expectancy. So no question, your point is well taken. That’s why these things are so tricky and so difficult because it’s also true that the openness of the world, the globalization of the world is having rising living standards for many in the world and rising life expectancies. Life expectancy, we’ve done a lot in the area of maternal and child health, for instance, which have raised life expectancies. But we can’t forget about these other—about these other things.

And I think if, you know, if China continues to consume large quantities of food which is less healthy than a traditional diet and falls into having enough excess consumption to buy a totally unnecessary product like tobacco, we will see what could have been a continuing rise level out.

MONAHAN: And I would only add, I thought your comment on the first panel was really interesting about the challenge of managing externalities in the context of AMR. Putting aside tobacco, which I think rightfully is a product that has no—obviously, when used as designed, harms people.

I think with food and beverage, it really is, how do you—when you have a system where incentives may be sort of unilateral more in the case of trade, more is better and more products, how do you find that sort of Goldilocks moment where you’re—where the set of incentives are such that it’s not overuse, but you recognize underuse. And I would—that may be a way to think about, at least for products that have beneficial use, but can be used inappropriately.

So, Sir George, I think you were next.

Q: Thanks very much. Congratulations to the panel.

I’m very worried by the comment that Ambassador Kolker made and perhaps I got it wrong. Are you suggesting that the producers should be part of the guideline-making enterprise, that the producers should be in the room and help to prepare the guidelines?


Q: Because as Sally—thank God—(inaudible). Because as Sally pointed out, the experience of tobacco and now with sugar shows that in fact the chicken cannot be a friend with Colonel Sanders.

The other point, though—and I’m glad you didn’t say that. I just wish you would repeat what you said about making the guidelines, that’s very important.

The other point is you mentioned the expansion of what is—what are things that are considered as the NCDs. But I wish you would make some comment about the risk factor that has been introduced in the five by five is air pollution, because the impact of trade on air pollution or the use of fossil fuels is going to be a major concern. And I wish that you would make some comment about trade in relationship to air pollution.

MONAHAN: So maybe, Jimmy, do you want to start that?


MONAHAN: Sir George called me. I remember the first time I spoke to him was about ten years ago when he was calling about this set of issues, so I’m glad you’re still focused on it.

So, Jimmy, maybe talk about the guidelines and about air pollution.

KOLKER: No. I brought it up—and I’m sorry if I wasn’t clearer—in the context of the difference between standards and guidelines and that standards a judiciable, they are in the transparent process with the industry in the room, and they’re appealable. The guidelines are WHO’s expert process. And I think that is sacred and member states respect that.

And also, there have been moves to have guidelines subject to specific votes of, for instance, the World Health Assembly, which the U.S. has opposed. And I certainly spoke myself to that when Italy, for instance, proposed that the sugar guideline be voted on as a guideline by the World Health Assembly saying that this is really opening a Pandora’s box. We need the expert and disinterested views of experts in the guideline setting.

On the other hand, the WHO has been ineffective at figuring out, how do we integrate the views of the private sector, the comparative advantages that they may have in knowing about consumer behavior, knowing about how the guidelines can be applied or maximized at country level or in terms of publicity. And I think that there is a—there is some opportunity there. And the WHO is struggling through that.


COWAL: I don’t have an additional comment.


KOLKER: Air pollution, you’re right. But again, I—I mean, they’ve tried. There have been resolutions certainly at getting WHO to pay more attention, getting those climate and health connections made in our own society. But we haven’t gotten very far.

MONAHAN: So we’ve got about five minutes. I’ve got at least two questions. The gentleman in the back and then—oh, wait, oh, you’re right there—why don’t we—I’ve got—why don’t we take these two and then, unless there’s anybody else, then we’ll close.


Q: Thank you. Hi. I’m Allyson Bear from Lutheran World Relief.

I’m wondering if the panelists could speak to the role of agricultural subsidies in terms of their contribution to the cheapening of the food supply and the sort of resulting production of poor quality food inputs that are then used to contribute to these processed foods that are then sold inexpensively to consumers in other countries through these foreign direct investments that you were referring to earlier in your comments.

So what is the role of agricultural subsidies in relation to the obesity epidemic and the promotion of obesity across national boundaries?

MONAHAN: Thank you.

The gentleman at the back table there.

Q: Hi. Good morning. My name is Chen Yang (ph) with GW.

I think I have a little observation and maybe a quick question. I’m glad that we realize that trade can play such a critical role in the life and death of someone, especially those less fortunate. So my quick question is, do you think that Mr. Bill Gates is getting ahead of us since he’s investing so much in developing lots of vaccines especially for those poor people? Yeah, I know that his foundation is making lots of contributions doing that. Thank you.

MONAHAN: OK. Well, why don’t—I guess this is broadly about the role of Bill Gates and the Gates Foundation. So why don’t we just frame it that way.

So maybe I guess I’d ask, Sally, do you want to start first and then to Jimmy? Yeah, whoever wants to go first, commenting on the two questions or one if you prefer.

KOLKER: I mean, you have these two Foreign Service officers in remission talking about agricultural subsidies. I’m not sure it’s our area of expertise, but—(laughter).

COWAL: No, I mean, I certainly—

MONAHAN: But don’t restrain yourself.

COWAL: Well, why start now, you know? (Laughter.)

Certainly, I think we—I don’t think it’s entered, to my knowledge yet, and it’s sort of the secondary part of trade agreements, and I’m obviously talking not about Bill Gates, but about agricultural subsidies. But I think that it’s, as we peel back the layers of the onion, this will become ever more the case. I mean, I think about cheese is one of those things tremendously subsidized, promoted by the dairy industry. Cheese is almost free now and I think that’s why it gets put on every sandwich that you buy in a—in a fast food or other outlet. Almost by necessity they’re going to slap on a piece of cheese, most of which adds, you know, fat and calories to your diet that you don’t need since you already have a half-a-layer—a half-an-inch of meat on your sandwich.

But I truly, as Jimmy says, we’re probably out of our depth here in knowing how you would propose a regime that might take that into account.

I mean, one of the things that, you know, short of regulations and trade, again, that we’ve learned from the tobacco industry is, the single-most effective thing in retarding the use of tobacco products is taxation. I mean, we have smoke-free workplaces and everything else, but price does matter. So countries do retain the right to have their own tax policies and it seems to me they should try to tax unhealthier foods more heavily than they tax healthy foods. And that would somewhat restrict their use.

And in terms of, you know, the Gates Foundation, I mean, they have been sort of an enormous force, in my opinion, for good in the—in the global health space. Not only they—and I would say the Bloomberg Foundation is coming right up there and particularly has paid a lot of attention to noncommunicable diseases and they’re one of the leaders and first adopters in that area. But you can’t imagine organizations like the Global Fund, like Gavi for vaccines, and so many other things without the incredible not only generosity of the Gates Foundation, but I think really trying to think through what are the big problems in public health. They’ve been reluctant to come to the NCD table, not for want of trying. And I believe that they’re—


KOLKER: Great. I’ll comment on the question about vaccines. And it does—the reduction in mortality, the greater life expectancy is not—vaccines are a big contributor to that, along with other measures in maternal and child survival. And I give the Millennium Development Goals credit as countries really were trying to reduce their rates of maternal and child mortality and succeeded in doing that, along with availability of life-prolonging drugs, which are very important. We shouldn’t underestimate that.

But looking at it from a global, public health, governance perspective, foundations, like the Gates Foundation, which is the second-leading contributor to WHO’s budget after the United States, but has on role in the governing structure, and so many workarounds have been created, like the Global Fund, like the Gavi, in which foundations and, for that matter, the private sector have some role in the governance structure in order to get their input and also, one hopes, buy-in and some return for their contributions of being able to be sure that the product is of high quality.

So it does—like Sally, I have great admiration for the Bill and Melinda Gates Foundation for Bill and Melinda’s personal role in all this. And I do see them as contributors to good. But we, again, we haven’t really solved this problem: How do nonstate actors get involved in setting WHO priorities, for instance, other than giving essentially earmarked contributions for only what they want? And, you know, there are—the number of organizations giving voluntary earmarked contributions to WHO is approximately three thousand. I mean, this is not just a few foundations, but every organization every one of you is a member of for any reason is undoubtedly giving WHO some money to set some guidelines on something.

COWAL: And, John, we didn’t have time, but I wish we could have had time to talk more about the pharmaceutical industry because that is a whole other issue and also one that’s not uncomplicated, but where I think there is, you know, the possibility of some shared value propositions that we would be ill-served not to explore.

MONAHAN: Well, I’ll give you—any final, final words? Otherwise—other than establishing that our two experts here aren’t focused so much on agricultural subsidies, I think it was really a terrific tour de force. So thank you all very much. Join me in a round of applause. (Applause.)


Keynote Session: Is Globalization Still Good for Your Health?
This session will discuss whether the role of globalization in health is fundamentally good as health needs in poorer nations have shifted from infectious diseases and undernutrition to noncommunicable diseases, environmental concerns, and unhealthy habits.
David Dollar, Ilona Kickbusch
Vanessa B. Kerry

KERRY: Good morning, everyone. How are you? It’s nice to see you all. So this is your session: “Is Globalization Still Good For Health?” I’m Dr. Vanessa Kerry. I’m the co-founder and CEO of Seed Global Health and on faculty at Harvard Medical School.

And I’m very, very delighted to be joined here today by Ilona Kickbusch who is, as you know—you all have their bios, so I promised I’d keep that to a sentence. But she is the director of the Global Health Centre at the Graduate Institute of International Development Studies in Geneva. And David Dollar, who is a Brookings Institution Senior fellow and the host of the podcast Dollars and Sense.

So just some quick notes on this morning. We’re going to spend about half an hour asking some questions of our panelists, or I’ll be asking some questions of our panelists, and letting them really share a number of, I think, their extraordinary reflections, research and experience on what they’ve learned. And then at 12:15 I’m going to invite the members to be able to join the conversation and ask some questions directly. Please remember that this meeting is on the record. We will cover that again as we go into the questions.

So I actually want to start by asking you a question, please, David. You’ve done a lot of work and research on the impact of globalization on poverty, more recently started to think about the linkages to health. And, you know, it’s a good twenty-thirty years’ worth of thought and research that you’ve done. And I’d love to sort of hear how you—how that has evolved in maybe recent years in any way where you had sort of started, you know, twenty-thirty years ago. And what are the most sort of seminal things we should be thinking about globalization for the poor?

DOLLAR: OK, thank you very much. Really a great pleasure to be here. I learned so much from the morning discussion up until now. So I’m a relatively pro-globalization person. Part of pretty large group of people who twenty years ago were doing research on the impact of globalization on various outcomes. And I think some of the things we were arguing I think have been borne out. One of the important arguments were making is that integration between rich and poor countries would tend to raise the income of the poor countries, doesn’t have very large distributional effects within countries. So, in fact, poverty is reduced. And then there are a lot of health outcomes that are closely related to poverty, such as infant mortality, life expectancy.

So if you asked me kind of what have I been surprised by in the years that I did that research I would say in some ways I’m surprised that the strength of that turned out to be greater than we expected. So we’ve had this phenomenal growth of developing countries. A lot of it’s concentrated in China and India, Asia more broadly. But of course, that’s where most of the world’s population lives. So we’ve had this tremendous income surge in developing countries. We’ve had unprecedented poverty reduction. You know. We’ve had positive things like cutting infant mortality in half. Someone mentioned the dramatic increase in life expectancy in China. So I think a lot of that played out as we expected.

Now, I think to be fair to the pro-globalization group, you know, I went and reread a couple of my things for this session, we were also arguing that we needed stronger global governance in a lot of different dimensions. And I guess if I was thinking about things I’m surprised by, I would say that it’s turned out to be a lot harder to get improvements in global governance than we thought. So this rise of developing countries has created a whole new set of challenges for those countries and for the world.

Climate change is the most obvious. And China’s overwhelmingly the biggest emitter of carbon now, and India’s quickly heading up towards second place. We’re not going to be able to deal with climate change without strong contributions from China and India. And then I learned so much in the two sessions this morning that as these countries have gotten richer, they’re facing a whole new set of health challenges, noncommunicable diseases. First panel was about—I don’t even know the lingo. I kind of understand what the first panel was about, but I’m not going to—I’m not going to try to summarize.

But we’ve got a set of challenges within these countries and globally. And I don’t think we have a particularly strong global governance or improvements in global governance. In fact, I think it’s kind of a scary moment where we have these global challenges but if you look there’s really an anti-globalization movement that’s developed that’s reflected in things like Brexit, the election of Donald Trump, the rise of the old right in certain European countries. And I don’t want to only blame the West. I think within China you’ve got this renewed commitment to authoritarianism using the modern tools of the internet and artificial intelligence. So I think a lot of disturbing anti-globalization tends at a moment when, in fact, global challenges have never been greater. And we need the kind of global cooperation. We heard some very good examples about it in the first two panels.

KERRY: Could I ask you a little bit of a follow-up question on that, thought? Because if you think about sort of global public goods, right, and how we’re going to address climate change, or how we might address pandemics and pandemic preparedness and things cross-borders. And there has been—and you talk about this sort of anti-globalization movement. How are we going to manage kind of that balance between sort of some of the negative effects of globalization and sort of investing in global public goods, and having people sort of see the value in, you know, being united on that front?

DOLLAR: Right. So I don’t want to be too negative, because we can also point to some positive developments. You know, we did get the Paris Climate Accord. You know, China is willing to sign on to try to have peak emissions by 2030. It’s not a terribly ambitious commitment from China, but it’s a commitment. And I think that’s important. And we heard some good examples this morning in areas of public health. So I think we have some discrete successes. And, you know, the best I can suggest is we need to build on those, publicize them, and counteract this kind of anti-globalization feeling that’s mostly taking us in a different direction.

KERRY: So you talk about a lot of the benefits of globalization. I actually want to switch to you, Ilona, for a moment to speak. You’ve done a lot of work on looking at the commercial determinants of health specifically and talked a lot about how globalization has shifted that or created some of the new issues we need to encounter. I was wondering if you could just share that a little bit with our members.

KICKBUSCH: Yes, I’d love to do that, and to echo some of the things that were said in the earlier panels, that in this process of globalization—of course, which was also a certain economic model that was put forward. There was enormous liberalization not just of trade but also the possibilities for private companies and investors to be much less regulated than they had been before. Remember, there was a banking crisis and a couple of things like that, which also affected the world. The fact was that, yes, we had significant gains in life expectancy on average. Absolutely extraordinary. But at the same time, in both the countries that you mentioned but in others, significant inequalities. And actually, as the SDG says, leaving many people behind. And a difficulty to address those inequalities.

And of course we’ve had—in the consequence also we’ve had a power shift which is partly leading to the populist movements that—and the anti-globalization ideas that we are confronted with now, because given the fact that there is more global power in China and more inequality, let’s say, in the U.K., that does mean something. And in an era of digitalization, of twenty-four-hour news, that has significant impact. So I think that’s one part of it, that we’ve got to sort of—really looking at the whole spectrum of those thirty years of, you know, the state moving back, the private sector moving in. At the same time, an increasing power of civil society also. We must recognize that.

And that leads to some of the issues that Jimmy Coca (ph) has referred to—you know, who should be part of the global governance game? In that period, we had two attempts to address global public goods. They were successful. The Framework Convention on Tobacco Control was already mentioned is regularly seen as a model for all kinds of other things. Let’s have one on alcohol. Let’s have one on food. Let’s have on one AMR. And the other, of course, the International Health Regulations.

Now, it’s interesting see that the International Health Regulations that basically started in 1851 stating that, you know, efforts at health security should not impede trade, and this kind of thinking is being repeated in the NCDs and everywhere else. You know, let’s just do something, but let’s not impinge on, point one, trade, point two, you know, the profits of companies. Then that has been interesting. And of course, the IHR, they could only change that in view of a major crises. Someone asked in the AMR panel, when are we going to get action on AMR? My thing is, only when a crisis comes. I think it’s going to be just like with the International Health Regulations. And even after making the international agreements, countries have not been willing to really invest in the implementation.

That sort of takes us to the commercial determinant. In that move of the state moving back, the companies moving in, we’ve started to look in a different way also at the actors that lead and contribute significantly to noncommunicable diseases. Now, nobody is saying it’s only these companies, you know, these evildoers. I mean, our ways of life are changing. There’s urbanization. There is a lot of factors that we need to take into account. But we have seen that a group of global industries has moved into the developing countries, has moved into these countries particularly towards vulnerable populations. And if you read the recent book that’s been published on Heineken and Africa, then I don’t think any global health organization can afford to partner with this company.


KERRY: How many people—can I just ask a quick show of hands? Anybody read that book yet? Do you want to give the two-sentence summary?

KICKBUSCH: It’s just been translated. Well, it’s a story because Heineken, you know, has been in Africa for a long time. And, you know, sort of buying influence, ensuring that, you know, vulnerable people, through certain strategies, buy beer. The buying up of smaller beer companies. I mean, it’s a very standard progress. But I think the most scary thing is the amount of involvement in political processes. And that’s something that’s not to be forgotten, that there’s this strong interface of commercial determinants and political determinants.

The thing I’d just like to highlight, because global health is about global flows, what we’ve seen as we started looking at this is that we’ve got to look beyond companies, because the thing that has happened is that we’re talking about major investors and major investments. What has happened in the consumer goods industry is that the global consumers goods industry—and that includes fast foods, you know, alcohol, soft drinks, you name it—is one of the few areas in global health—in sort of global markets where you can pull in tremendous profits. And therefore, we have seen major investment firms and private equity firms actually enter this market.

And you can see that these firms—and that now relates, you know, to those couple of companies that are actually trying to be responsible, are being, in quotes, bought up or bought into as shareholders by these private equity companies who try, and have literally already, destroyed much of that. And if you follow the story of the attempted takeover by Procter & Gamble, you can get—

KERRY: Takeover?

KICKBUSCH: By private equity firms. And one of the examples we can maybe come back to, to which Anheuser-Busch belongs to, is the G3 Capital investment firm, which has invested in Heinz, Kraft, Burger King—you name it—some major pizza thing. And Anheuser-Busch has bought up, you know, very consecutively. This has turned it into capital-producing machines. They’re no longer companies. They’re capital-producing machines without corporate social responsibility. That’s sort of move into the vulnerable parts of the world, mainly Africa, which has been left out of much of the globalization.

So I’ll stop there, but we’re trying to take global health literally and say: Global health is about global flows. It’s about global capital flows, knowledge flows, people flows, et cetera. And then see, you know, what is the driving force of this thing that’s happening globally.

KERRY: So a question I’d like to actually ask both of you, sort of in follow up to that, because I would agree, much of my work is based on the African continent. And it has been left behind. Vast swaths of that continent are being left behind. So when we talk about globalization benefitting, you know, from a growth perspective, the poor, or where markets are being most exploited. So the question that I want to ask both of you is: Is globalization good for all? And if it is not, or we’re not seeing that, how do we rectify where maybe it’s having a better benefit? And how do we bring places that have been left behind into some of the benefits that we’ve been seeing, and access it better?

KICKBUSCH: Well, obviously, globalization is not good for all. It’s not been good for the farmers who have, you know, been partly disenfranchised. It’s not been good for mining workers in the United States. It’s not been good for, you know, a whole range of populations. But that’s not the fault of globalization, per se. It’s also a question of how has the state taken on its responsibilities? And we see that at the same time many states, many governments, have rescinded on social responsibilities or have not put in place measures that have balanced out these processes that come through globalization. And of course, again, one of the really, really critical points in time was the financial crisis, which also, at least in Europe where I live, came across to people: You’re paying banks, but you’re not helping us.

And so I think that interface between, you know here are enormous processes going on that actually leave people a little bit disoriented, where frequently governments have said, oh, this is globalization. We can’t do anything about it. There’s no alternative, you know? And then you sort of do not get the response that governments should be giving in terms of social protection, in terms of health services, or whatever. And I’ll leave Africa to David. (Laughter.)

DOLLAR: Well, I was going to start—I was going to start with Europe, because, you know, I think there’s a lot we agree with. Globalization is basically making every country better off. There’s probably a couple of small exceptions, but certainly all of the G-20 countries are better off. Then there’s the question of what does the society do with that? So Germany’s a good example. If you look at the GINI coefficient for Germany after tax and transfer, it’s been very stable throughout this whole period of globalization.

KERRY: Is everybody familiar with the GINI coefficient? You probably are, just like to always make sure. All right, yeah.

DOLLAR: So, I mean, there is a trend from market outcomes to become more unequal, but I’m just citing Germany as an example that counteracts that through tax and transfer policies. And I think it’s quite successful. You have other examples—

KICKBUSCH: But stagnant wages. Totally stagnant.

DOLLAR: No, no, no, no. You have real living standard going up. It depends—I’m looking at, say, twenty years, OK?


DOLLAR: So you definitely—you know, governments can deal with the adjustment issues more effectively or less effectively. You know, Africa, as a couple of us have said, has largely been left out of the process of globalization. This most recent wave has been primarily about Asian countries. Most of the foreign investment that goes from rich countries to poor countries is going to China, India, Southeast Asia, et cetera. So I see Africa as largely being left out of this. But I think African societies would like to be more involved. An interesting recent development is China is making a big effort in Africa to finance infrastructure and help African countries connect. And when I travel around Africa I find that that’s largely welcomed by different types of countries in Africa.

KICKBUSCH: Can I just jump in here? And to say exactly what you’ve indicated. Too frequently when we talk about globalization people sort of see this globalization is from the north to the south. It’s no longer. It’s, you know, given the geopolitical changes. Think of the Chinese investments. But also think of Indian investments in their neighbor countries, et cetera. It’s a much more complicated interface of investment that is driven globally, including, you know, China buying up German middle-sized companies, and the fear that the European Union now has around G5 (sic; 5G) and Huawei investments, et cetera.

So also the story of globalization is changing, where there is a nervousness about globalization when it comes, like we say, to the East, and actually starts to affect the West in a variety of ways, in terms of ownership of companies, in terms of in equities, in terms, you know, of where also the East now is—actually has been more progressive. I mean, German car industries have been asleep. Meanwhile, you know, China has built the electric busses that most of the European urbanized cities are now buying because they want to address climate change. You know, Germany could have done that if it hadn’t slept. And so we’re seeing totally new processes that are making at least people in the West very, very nervous.

And where also, you know, the West didn’t see Africa as an area of investment, they saw it as an area for foreign aid. And so I think there’s a wake-up call there also to some—you know, to some extent, some of the previous imperialists were investing, but—I mean, Germany was not looking at Africa as an area of investment. It’s only waking up now as well as, you know, there are—there’s Nigeria, there’s South Africa. I mean, there’s countries that are moving very, very rapidly. And one has to look at it. And if you look at the psychological impact, when Europe has the crisis and young Portuguese people went to Angola because there were jobs and went to Brazil because there were jobs, you know, so something’s really changing.

KERRY: So this brings me, though, to my next question that I want to ask you both is: With globalization there’s movement of people as well, both in a proactive sense of seeking new jobs and, you know, being able to, you know, increase one’s personal standing either through income or through safety or better schools for their children. There’s also the sort of less-proactive, more reactive, of migration flows and people. And so—but specifically to the issues of brain drain, especially, you know, again, with my work being in sub-Saharan Africa, and I think about the loss over the last sort of thirty years of talent. We talk about the importance of state to regulate some of these processes. And you need capacity to be able to put some of that into place.

I was wondering if you could sort of talk about—a little bit about the impact of the flow of people, and how that is—affects human health today with sort of some of the—with the flows of people in today’s era of globalization.

DOLLAR: Well, I would—I’m someone who’s been relatively positive about migration, going back a long time. It’s an important part of globalization. It has potentially very large benefits. I know more about the migration into the United States than into Europe. You know, there are a lot of myths about migration into the United States. If you look over the last ten to fifteen years, you know, we’ve obviously had very, very solid job creation in the U.S. We have historically low unemployment. But we have what I call job polarization, so that most the job creation in the U.S. is at the high end—meaning, demand from people with college-educated or advanced degrees. But then there’s also a lot of job creation at the low end. Not so much for people with middle skills. And that’s a real issue in the U.S.

If you look at our migration, it tends to meet those job market demands. So a lot of our immigration is at the high end. In fact, I think—I think on average the immigrants have more education than native-born Americans. But that’s just a slight difference. They’re pretty similar to native-born Americans. Point I want to emphasize here is that the U.S. does—at least up until recently—the U.S. has accepted a lot of low-skilled workers. And I would argue that this is important, the U.S. is not just cherry-picking the high-skilled workers, contributing to brain drain. But a lot of developing countries have still rapid population growth, rapid labor force growth. They can’t create enough jobs. So I would argue that it’s basically a positive for people to migrate to more advanced economies. Lots of evidence that they send remittances back home.

But then you get into issues, like how is their education paid for? You know, the worst system is to have a totally publicly funded higher education system and then have a lot of brain drain. So I’m in favor of, you know, reasonable tuition for grants for poor people, for example. So there are ways that countries can address this. The last thing I’ll say on this is lots of evidence that migrants who come to the United States, only a fraction of them—a pretty good fraction—stay. But a very significant fraction go back to their country after five years. So they come to the United States, they earn some money, they build up some capital, perhaps they develop some skills, and then lots of them go back to their countries. And that actually can be a very positive force—

KERRY: Are there certain industries you see that in more often, thought? Because I think in medicine, for example, there are policies that come out of the United States and out of Europe that actually are recruiting to fill in our vacancies, and are directly—

DOLLAR: Right, but you’d be surprised how many people go back. I just saw—we just had a very good research paper on this presented at Brookings, using very detailed U.S. data, including tax records. And sort of roughly speaking—this is among the college-educated-plus cohort—you know, roughly speaking about half of them do not really catch on and actually go home pretty quickly, within one to two years. Now, they may not have gotten so many skills, et cetera, et cetera, you know, but there’s not—there’s a pretty good fraction who go back relatively quickly. And then there’s, you know, roughly half that ends up staying in the U.S. for five years or more.

KICKBUSCH: Well, there’s a significant problem, of course, with workforce migration and health. And that is doctors, but to an even larger extent it’s nurses. And given the area of remittances, of course there are countries that are producing people for export. So the Philippine consciously trains more nurses than they need in order for them to go abroad and the remittances to come back. At the same time, you have the problem, of course particularly again in a number of African countries, that these people are trained within the African context, or even in some of the developed countries, particularly then they would go and train in, you know, the former sort of colonial countries—like in the U.K., or in France, et cetera, and not go back.

So there is, you know, that tremendous gap of workforce that is really impeding the development then of universal health coverage and other developments that we would like to see in many of the developing countries. At the same time, of course, that’s a phenomenon—you get this domino effect. In Europe, for example, German doctors go to Switzerland. About 20 percent of the doctors in Switzerland are from Germany. About 30 percent, I think, of the nurses, something along those lines. They were trained, as you indicated, with German money. Switzerland consciousness does not increase the number of physicians they are training, because they get them, in quotes, “for cheap,” from abroad.

If you do a calculation then, it takes around, I think, I don’t know, I’ve forgotten the figure, of at least half a million to train a doctor because in Germany, of course, that is paid by the public. You don’t do what you do here in the United States of getting people to pay for it themselves. But then, you know, to Germany, then they come from Poland. Poland loses its doctors. They come from the Ukraine to Poland. So, you know, you get that domino story of workforce migration, which at least disrupts the system back home. And to some extent, even though, of course, it helps in the country that has these people, also disrupts interaction with patients. A big problem in mental health. If you can’t speak in your own language with the person that’s treating you, you know, all those kind of things happen.

But, you know, the enormous pull. There are now the WHO workforce codes on workforce migration. It’s very interesting, Germany, for example, that’s desperate for more nurses and carers is now building a system together with WHO trying to say: How can we attract people? But based on, you know, the code that WHO has developed so as not to be attacked along the lines, you know, like the U.K. did for a long time. You know, come to us, come to us. Also with wrong promises. And so I think looking at workforce migration and the millions—first of all, we are missing so many millions of health workers. And, secondly, those that we have, you know, we try and gobble up, at least the richer countries.

Also, of course, in Asia and elsewhere, you know, Japan has to ask itself for this question, for the first time letting people in. Saudi Arabia and all those countries there are gobbling up health professionals from everywhere. So, again, you know, it’s not only the old West that’s misbehaving, but there’s a lot of other actors out there that are also grabbing people away from where they are most needed. And for individuals, you can’t stop them. They have a right to move. It’s a human right to work elsewhere.

DOLLAR: And it’s going to be driven by economics, you know. Without migration, Europe, Japan are going to have rapid decline of the labor force. You’re still going to have a population. You’re going to need people to take care of you. Meanwhile, Africa needs to create twenty million jobs per year. And very soon it will need to create thirty million jobs per year. So there’s a lot of things we could do to help with that, but you’re almost certainly going to have economic pressure for Africans to move to Europe, also to the United States. Without immigration, the United States is actually in a similar situation—slightly higher fertility, but basically, you know, we’re facing labor force decline unless we have immigration. And this’ll be quite beneficial all around if it’s managed properly.

KERRY: I think this is actually a great discussion because when you think about the fact that the population is growing and we are going to be under increasing pressure to create jobs, and that—and opportunities, and to manage much of the populations under the age of eighteen, you know, I think that this crisis is only growing.

So with that, actually, I would love to open the discussion to members and to ask questions. A reminder, this is on the record. We will be passing around microphones. We’ll ask that you please stand. Just state your name and your affiliation so that we know who you are and where you’re from. And, as always, please, if you can, keep your questions concise so that there’s an opportunity for as many members as possible to speak. And if there are no questions—yes.

Q: Thank you all for your comments. My name is Dominique Carter. I’m from the National Science Foundation.

 And I wanted to know if you all would be willing to comment on the opportunities for investment from other countries? For example, you all stated China. And the engagement with the local workforce? So providing opportunities for local communities to build the workforce because some countries that have received investment have not seen that benefit, in that there has not been an engagement of local workforce. And so some countries are beginning to decline investment. For example, Sierra Leone rejected the 400 million (dollar) airport deal. So I wanted to know if you all can comment on that.

KERRY: That’s a great question.

DOLLAR: I’ll just start off quickly. I think—you know, there’s a quite a bit of evidence that direct investment is beneficial for developing countries. You know, accelerates their growth, helps with exports, et cetera. But I would quickly add a caveat that we find examples where there’s very strong backward linkages. You know, Vietnam—I’m involved in a big global project on global value chains, that we just issued a report. And Vietnam has this very powerful backward linkage. So there are about—if I remember correctly—about seven million people in Vietnam working directly in manufactured export companies, which sounds pretty good but it’s a country of 100 million people.

But the backward linkage is more powerful. There are about ten million people working in forms that don’t export, but which sell all—essentially all their output to exporting firms. And a lot of those are medium-sized Vietnamese firms. So where you get the powerful poverty impact is when you get those backward linkages. And then, you’re right, there are lots of examples, particularly if it’s a mining investment or some kind of big infrastructure project. You can have kind of enclave investment that provides a little benefit for the country, but it doesn’t provide those powerful backwards linkages. And, you know, I’m afraid it would be a long discussion to go into what are some of the factors that lead into that. But that was my reaction.

KERRY: Do you want to talk about—

KICKBUSCH: No, I think I can only agree. And it’s one of the big criticisms right now of the investments along the Belt and Road. And of course, it reflects the power of the country respectively to set conditionalities also in terms of the investment. And of course, many of the countries have not done that. But that’s not only, you know, sort of the countries with weaker governance along the Belt and Road. If you look at, you know, the Greek and Italian ports, et cetera, I don’t think they have protected their own workers enough either. So it always comes back, you know, to the extent to which a government wants to act, feels it can act, and protects its own people in the process of such investment schemes.

KERRY: We have a question in back.

KICKBUSCH: Sorry, Sir George (sp)—

KERRY: Oh, I’m sorry. I’m sorry. What happened?

KICKBUSCH: No, no. Go ahead. Sir George (sp) also wanted to—

KERRY: Oh, yes. Thank you. Sorry.

KICKBUSCH: Go ahead. Go ahead.

Q: (Inaudible)—a retired member of Congress.

Could you talk a bit about the effort of the European Union and the United States to suppress the movement of people in North Africa and Central America, and whether that’s a good thing or a bad thing?

KICKBUSCH: Well, I’m not an expert in this, I must say. So it’s—I’ve not done research in this area. I do know that, you know, there have been significant attempts to have agreements with rather unsavory states, particularly in North Africa, to contain migration to Europe. That is now becoming very difficult as a new war looms in that area. There have been attempts and a logic that—and I turn to David here—that I don’t think applies, to say, you know, let’s put more development assistance into these African countries to keep people there. But actually, it’s not the poorest of people that actually migrate. So I’m not quite sure that, you know, it’s this strategy that’s going to work.

The major problem is that Africa is such a young continent, both North and South. And there’s going to be an enormous need for jobs for all these young people. And might I say, you know, culturally also a tremendous need to have jobs for young men. And that if that cannot be resolved over the next decade or so, there’s going to be a real major destabilization. And either, you know, people will just—will just come. And the conflicts that emerge from that have been hinted at, I would say, in the present crises in European countries. But if that happens, you ain’t seen nothing yet. (Laughter.)

DOLLAR: In the case of the migrants from Central America, I think a lot of them are refugees fleeing repressive situations. I personally feel the United States is treating these people very badly. We have an international protocol for how we should deal with refugees. There are also economic migrants. And I already indicated, I’m in favor of both low-end and high-end migration into the U.S. But it can’t be—we’re not going have open borders. I’m not naïve. But we could have a more rational and welcoming migration policy.

KERRY: Thank you. I believe there’s a question in the front, Sir George (sp).

Q: Thanks very much. Interesting discussion.

I like very much Ilona’s thesis of globalization being the global movement or flows—flows of money, flows of information, flows of—et cetera, et cetera—human resources. If you accept that thesis, then we can’t really say that Africa has been left out, because the flow of information has resulted in a tremendous change in disease pattern in these countries, much (of it in cities ?), as a result of a global flow of information, a global flow of resources. If that is the case, and you posit a certain weakness of the state, how would you envisage then the international intergovernmental organization’s role in controlling or ameliorating these global flows?

KERRY: This is a question I was going to ask you as well. So thank you.

KICKBUSCH: Well, we all want more global governance. Or, many of us, at least, do. And, you know, more effective international organizations. And of course, some of us here are particularly involved with the World Health Organization. The fact is, you know, some of the new organizations that were founded, particularly at the beginning of the century, the multi-stakeholder organizations we’ve heard about, have been very effective in addressing specific problems and issues—vaccines, HIV/AIDS, et cetera. They were not set up to govern. And but while this was going on, there was, you know, the parallel weakening of those institutions that were set up to govern internationally. That is, the World Health Organization.

And I was intrigued, because some of you asked about the role of the Bill and Melinda Gates Foundation in the earlier panel. And just last week, I was at a new thing that has been created by WHO, with the support of the government of Sweden, a so-called partners forum. John (sp) was there as well. And there was a talk about, you know, how do we strengthen the international organizations to do their job, and particularly WHO? And would you believe the person that sat there and said: My—he was asked by the moderator, you know, what would your dream be? What would your wish be if you were able to do something tomorrow?

And he said, you know, that member states agree to a 50 percent increase in assessed contribution to the World Health Organization, that it can do its job in governing global public goods. And we’ve heard the problems today. We need, you know, agreements on antimicrobial resistance. We need agreements on air pollution. We need agreements on noncommunicable diseases. We need cooperation and health security. So, you know, you’ve got about five major issues that you can only resolve if you treat them as a global public good and you agree to govern them jointly, and that you share responsibility.

And one of the things that we do have to address is that those countries that, you know, are part of this major geopolitical shift also start to come in. And, you know, the increase of assessed contributions of WHO has mainly been opposed by the BRICs countries. Actually, a whole number of Western countries were willing to go up—not much, but a 10 percent increase. The BRICs countries said no, zilch, zero. Now, interestingly enough some of the BRICs countries were the countries that more or less founded the World Health Organization. So I think, you know, this sharing also of political responsibility—which is starting to emerge in the G-20, if you look at the fact that, you know, more and more health issues are being discussed there, are being moved forward there.

Not that they’ve led to revolutionary results, but they have put health on a different part of the global agenda. They have led to, you know, really a different type, also, of foreign relations discussion of global health. And it’s these kind of things that we move forward. But, again, I say usually countries tend to wake up around crises. And one doesn’t want to sit here and say I want another crisis, but that’s how it goes.

DOLLAR: Can I just—I just think this point is so important. I think, you know, traditionally we look to the advanced economies to carry the burden on a lot of global public goods. And I think you’ve got—you’ve got the decline of the West, frankly, happening more rapidly than we expected. And you’ve got a diminished appetite for supporting global public goods. And as I see it, the emerging markets have really been the major beneficiaries of globalization. And there are some examples of them stepping up and playing more of a role in global public goods. But I take Ilona’s point that there’s a reluctance on the part of the emerging markets to step forward. So if nobody major is supporting these global institutions, then naturally they’re going to decline.

KERRY: I think it’s—no, these are really helpful points. And I think obviously there’s not just the question around the political aspects of governance here, but there’s got to be the private side and the private sector regulation that goes into it, to the points you were making.

Other questions we have? OK. Don’t want to bias to the left of the room, so. (Laughs.)

Q: Hi. Obviously, Tom Bollyky at the Council.

So it’s not surprising, per se, that globalization has resulted in these inequities. It’s always been part of the idea that winners would compensate the losers, whether it’s globalization writ large or trade in particular. Both of you were a little bit down on how aid has benefitted sub-Saharan Africa. It’s led to big health gains but not necessarily the same level of increases in formal jobs, or income, or infrastructure that you saw accompanying those health gains in the past. What is the obligation for other states, the winners of globalization to compensate the losers, in this case, on a country level? And what form does that compensation take?

So if it is the BRIC nations, there have been criticisms about Belt and Road and how it’s designed. What is a different way that those investments should be moving forward to, again, address the imbalanced development that’s happened, and in sub-Saharan Africa in particular?

DOLLAR: Right. So I’ve already indicated I think the biggest winners are the middle income emerging markets like China, and India, Vietnam. There are lots of examples. I think, to be fair, you know, the big ones there, China, India, they are making a lot of investment into Africa. They’re trading more with Africa. I think there are fifty African countries that have more trade with China than with the United States. So, you know, China’s becoming more presence. The Chinese attitude is that this is not aid. This is win-win south-south cooperation. They lend at commercial rates. They lend mostly in dollars at variable interest rates. I think that’s not widely understood.

And, you know, there’s a lot of Chinese direct investment. It’s not foreign aid. Now, when I visited Chinese projects in East Africa not too long ago, and projects were going well. And the officials I talked to, they were—found it kind of refreshing. It was expressed to me that you Westerners treat Africa like a basket case that needs aid. The Chinese see us as a profit opportunity. That’s refreshing for someone to see us as a profit opportunity. That’s just one view, but I’ve run into that.

Now, I think the problem is that China’s going to find that some of this infrastructure it’s financing—probably some of it’s not going to be very good, but I think a lot of it is going to be good. But the countries may still have problems serving the debt at commercial interest rates. And I think China’s going to be pressure to reschedule, forgive a lot of these debts. Ex post, it will turn out that it will have been foreign aid. And, you know, hopefully this will be part of an evolution of China to see that just sticking to that, you know, it’s win-win, it’s not aid—increasingly there’s going to be demand on China to be a major provider of aid in different areas. And that would be a very positive step.

KICKBUSCH: Of course, China has created an aid agency now. Just—it’s about one or two years old, very new development. All of these supports of even what was called aid, even in China, that cooperation was in the ministry of commerce. And, you know, so they are readjusting. They have just approached the United Kingdom to advise them on how to best implement aid, because they see DFID as one of the most prestigious and successful such agencies. So they are reaching out. We had to talk to them, for example, after the Ebola outbreak, where China’s CDC for the very first time engaged in, you know, foreign support enterprise. And they came back very, very reflective. And they said there were two things they did not know how to do. They did not know how to talk to the community, and they did not know how to interact with nongovernmental organizations.

And they were trying to cope with this. They knew—you know, they had all the medical skills and everything that was needed, but they themselves realized, you know, something was missing. So there’s a big learning process going on there that’ll be very interesting to watch. And that’s also why China is so interested in having tripartite projects with experienced partners in the whole ODA arena, to be able to—to learn from them and to implement better. So that’s one side. I think the other side, though, we must see how important it will be for Africa to have functioning health systems in order to move forward. And here is the question: How will the international community help Africa set up sustainable at least primary health care systems. And that is the big move right now, to sort of reconsider how—where it is a—but also where it can be investment, how that is taken forward, how that relates to an insurance industry, what kinds of new insurance models could be introduced, also for poor people, issues of that nature.

WHO has just published a very interesting analyses on public investment in universal health coverage. And realistically it turns out, you know, the majority of this is of course country based, 1 percent of the investment is through ODA. So also—you know, all these efforts we constantly undertake to analyze ODA from left to right to center to the middle, how effective it is, and if really everybody is doing everything. You know, you’re looking at 1 percent. So the question is really: How do you help countries build the financing—the public financing for their systems. And your point, of course, comes in again. You know, what role does taxation play? And in many of these countries, the taxation is actually then on consumer products, because so much of the work is still informal. And it’s very, very difficult to gather enough taxation to build a system. That’s why you need innovative types of insurances, like the 30-Baht system in Thailand, and other such models.

So I think, you know, we need quite a shift there on how one should invest, and particularly, you know, starting out from your book, you know, it’s all very well to say, well, these children and mothers and everyone else, and then there’s no health system they have for the rest of their lives. So, you know, we need to start moving to a model of sustainable investment in global health, and particularly in the fragile states. As Paul Collier has said, we need to look at that group of forty to fifty countries probably as a global public good, where we need to come together to invest significantly that they get their act together, definitely through health systems, which will enable much of the other involvement and investment that we’ve spoken about.

KERRY: And I think it’s worth noting, just to flag the importance of the health system, is that countries that have made meaningful investment in health prior to sort of other investment end up actually having massive economic growth. If you look at Vietnam, a lot of Southeast Asian countries. And so the links between health investments and economic growth are very significant.


KERRY: Rwanda is a great example. They made a very intentional investment in health and have had the fastest decline in TB in the history of the world, and the fastest decline over a decade, and the fastest decline in HIV on the African continent in a decade. And that was very linked to the investments in primary care and decentralization.


KICKBUSCH: Yeah. And it attracts the other investments that then address workforce and other things.

KERRY: Fully agree.

Questions? I’ve not had a chance to look over here as much. Yes, please.

Q: Hello. Allyson Bear from Lutheran World Relief.

So I think the panel has spoken about the diversifying of sort of the political and economic dynamics that have come with the rise of the BRICs and the relative flattening and decline of the West through the ear of globalization. Something very similar, I think, is happening at the—at the national level, where you see a great differentiation of income strata and relative winners and losers in many countries as a result of globalization. And I’m wondering what the panel feels the expectation should be of the sort of global—of sort of the society, but also at the global level of, within countries, addressing the inequality and what the expectations of the relative winners, the elite class that are emerging in many of these emerging middle-income countries, should be to addressing the health needs of those countries? Thank you.

KERRY: Thank you.

KICKBUSCH: Well, I think in terms of the WHO, there has, of course, been a very strong focus, point one, on social determinants of health to address that, and to look at the health inequities, particularly over the last ten years. And that—you know, in all regions of WHO. We mustn’t forget, we have the situation, at least for the U.S. and for the United States, these are two countries where life expectancy is actually declining. So, you know, there are some very serious issues that need to be looked at.

But I think in this case, one also has to look at particularly, for example, what the international labor organization is doing, which is looking very seriously at, you know, what does a fairer globalization mean? What does it mean—and I’ve touched upon that before—what individual states need to do in terms of redistribution? And the taxation issue is continuously raised there in terms of job creation, of course. And that’s a big challenge for the European Union, job creation in that context. But in a sense, you know, the whole discussion always comes back to how are these benefits that are so uneven in many of our countries—how are they better redistributed? And definitely it’s at the front of discussions in the United Kingdom, in France, in Germany.

And there also seems to be one thing which, you know, relates back to our little thing around Germany, that even where the evidence actually shows that there hasn’t been an extreme inequality developing, et cetera, there is a feeling within society that something is not going right. And I think, you know, those political moods are incredibly important. And the need to have good data—you don’t only need good evidence in health. You need good evidence in relation to your employment data, to your inequality data, et cetera. So, you know, you get data about child poverty in the U.K. that is just—you know, makes your mind blow. If, I don’t know, six out of ten children in the U.K. live in poverty.

So it’s those kind of things that give people a feeling also that their government are not delivering. And this feeling about injustice is one that is becoming very strong, at least. And the gilets jaunes in France, et cetera. And this is irrespective about being right or wrong. These are political climates that also then the governments really have to deal with, and where you need to be able to have some answers in democracies. Otherwise, we’re going to be in deep trouble.

DOLLAR: Yeah, I’m worried that we get a very bad dynamic—I see it already happening in the United States . A lot of people unhappy with the outcomes. We have relatively little redistribution in the United States compared to Northern Europe. And I see the Northern Europe redistribution as relatively successful and, ideally, evidence-based, right? We don’t really have much redistribution here in the U.S. We have a lot of unhappy people in the middle of the job spectrum. And I think that’s fueling an anti-globalization movement that’s leading to cutting off the borders and putting import protection against Chinese products. All of that is going to make the United States poorer, and it’s going to make it harder for the United States to actually address legitimate issues of people who are left behind. So that’s the kind of bad dynamic I’m worried about.

KICKBUSCH: It’s interesting, one of the leading German dailies just had a big article saying: People want more state. They want more regulation. They want more things done. And you know, they have a feeling, and maybe that’s Europe where, you know, also all the heads of state have usually said: It’s the fault of the European Union, you know, rather than there’s a couple of things we, ourselves, haven’t done. But something is happening in terms of what the expectations are towards government. And I think we’re going to see much more of that. If you see, you know, one of the most established welfare states in the European Union, Finland, and you look at their election results from this weekend, you have a hard time understanding it. And so there are fears at present in society. There’s a psychology going on that I believe we need to spend much more time on trying to understand.

KERRY: Well, thank you.

KICKBUSCH: On this positive note.

KERRY: Well, no. (Laughter.) Because I think as we conclude, you know, it’s interesting because I—when we first started this discussion, I am grateful, actually, for what I think you’ve outlined very importantly some of the key things we have to be thinking about and held accountable to as we discuss how to make sure that the positive effects of globalization are sort of felt by all, or that we create a system of balance or responsibility to course correct where we need to. But to have that discussion on a global level, it certainly has to happen at a national and structural level, without question. And states need to take accountability, and not just kind of point the blame. When I think globalization often has taken the hit or been the scapegoat for what has been a failure of the state to step in.

So you know, I think that—but what I’ve been grateful for, actually, is really understanding where the positives of this kind of integration and flow can exist, but making sure that the effects of that flow—that we’re cognizant about where it works, and where the failures are, and how we might be able to step in and take ownership for those. So with that, thank you very, very much for joining today.

KICKBUSCH: Thank you. (Applause.)


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