Second Pan-American Conference on Obesity - PACO II
Oranjestad, Aruba, 15 – 16 June, 2012
Foreign Policy, International Trade and the Prevention of Childhood Obesity1
1. Health/Childhood Obesity as a Foreign Policy Issue

The focus of my presentation is the use of an international relations or foreign policy
framework, which embraces international trade policy, to address the problem of childhood
obesity. According to Wang and Lobstein (2006)2 childhood obesity is rising worldwide. This is
of particular concern since childhood obesity raises the risk of an early onset of heart disease,
hypertension, type II diabetes, liver diseases and a number of other chronic diseases (Lobstein &
Jackson-Leach, 2006)3. In spite of this, historically, international co-operation on matters of
health has focused largely on pandemics associated to infectious diseases, with far less
attention paid to chronic non-communicable diseases (NCDs) which do have equally debilitating
effects on people and economies, particularly in the developing world.

It may be worth noting that the much acclaimed Millennium Development Goals made specific
reference to certain infectious diseases without any direct reference to non-communicable
diseases (NCDs). There is no doubt that attention must be paid to addressing the diseases
identified in the MDGs. However, in my view, no less effort should be spared in addressing the
rise in chronic NCDs. The use of diplomatic efforts, and foreign policy in general, as a framework
to address childhood obesity should be pursued more vigourously.

David Fidler, who has conducted substantial research on the relationship between health and
foreign policy, observes that the profile of health as an issue in global politics has grown
significantly in the past 10 -15 years and the political prominence of health is a new
phenomenon for those working in foreign policy and global health in the early 21st century4. In
2005, Fidler noted that ‘the nature and extent of foreign policy attention devoted to health
today is historically unprecedented5’. The term ‘global health diplomacy’ has gained widespread
1
Presenter: Vincent J. Atkins, Trade Policy and Technical Advisor, Office of Trade Negotiations, Caribbean
Community Secretariat. The views expressed in this presentation are the personal views of the presenter and are
not intended to reflect the position of CARICOM on the subject.
2
Y. Wang & T. Lobstein (2006) Worldwide Trends in Childhood Obesity. International Journal of Pediatric Obesity 1,
11 – 25.
3
T. Lobstein and R. Jackson-Leach (2006). Estimated burden of Paediatric Obesity and co-morbidities in Europe.
Part 2. Number of Children with indicators of obesity-related disease. International Journal of Pediatric Obesity 1,
33-41.
4
D. Fidler (2008). Navigating the Health Terrain: preliminary considerations on mapping global health policy. World
Health Organization, Geneva.
5
D. Fidler, (2005).“Health as foreign power: Between principle and power,” Whitehead Journal of Diplomacy and
International Relations 6/2, p. 179
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use to describe the process by which state and non-state actors engage to position health
issues more prominently in foreign policy decision making.6

It must be admitted however, that the exact nature of the relationship between health and
diplomacy or international relations is not always quite clear. In fact, Drager and Fidler7 (2007)
describe the relationship between health and foreign policy as being ‘vital, complex and
contested’. On the one hand health may be perceived as one of the issue areas in international
relations similar to national security, economics and development, the traditional elements of
the national interest. From that perspective co-operation in addressing health issues serves as
a tool to pursue the foreign policy goals of co-operation and progress among states.

On the other hand, there are those who contend that health as an issue area in foreign policy
may simply be a mechanism through which states exercise ‘soft power’ to achieve other
strategic global political objectives – including the acquisition of power and influence . From that
perspective health is not an imperative of foreign policy, but rather viewed as a means to other
ends8.

Labonte and Gagnon (2010)9 observe that in the past decade several governments have issued
specific foreign policy statements on global health. They were able to catalogue nine such
statements with titles such as: - Swiss Health Foreign Policy: Agreement on Health Foreign Policy
Objectives (Switzerland, 2006); Oslo Ministerial Declaration – Global Health: A pressing foreign
policy issue of our times (Norway, France, Brazil, Indonesia, Senegal, South Africa and Thailand,
2007); Meeting Global Challenges: international co-operation in the national interest (Norway,
2006). Bustreo and Doebbler (2010)10 state however, that most of these policy statements, do
not view health as an essential inclusion of foreign policy.

Whichever perspective one may subscribe to regarding the place of health in foreign policy,
there is no doubt that health has become an important issue area in foreign policy. This may of
course present an opportunity for health activists to use foreign policy as a medium to address
both national and global health issues. To succeed in doing so, however, it is important that
health sector officials become familiar with and active participants in, the field of diplomacy and
foreign policy decision-making, much in the same way that trade officials have before major
players in the conduct of the trade-related foreign policy objective of their home states.
6
R. Labonte and M. Gagnon (2010). Framing Health and Foreign Policy : lessons for global health diplomacy.
Available at http//: www.globalisationandhealth.com/content/6/1/14. Retrieved 10 June 2012.
7
N. Drager and D. Fidler (2007). “Foreign Policy Trade and Health: At the cutting edge of global health diplomacy”,
Bulletin of the World health organization 85/3, p 162. Available athttp://www.who.int/bulletin/volumes/85/307041079/en/.
8
F. Bustreo and C.F. Doebbler (2010). “Making Health an Imperative of Foreign Policy: The value of a Human Rights
Approach”. Health and Human Rights Volume 12, No 1. P.47. Available at http//www.hhrjournal.org
9
Ibid.
10
Ibid.
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11

I do not wish to convey the impression that co-operation among states in the field of health is a
new phenomenon. Far from being so, states have been co-operating for decades in addressing
health issues and diplomatic activity among states to deal with the spread of communicable
diseases is very well known. What may be new, however, is the greater integration of health
issues in foreign policy considerations, that is health as a foreign policy issue and, perhaps more
pertinent to the PACO II Conference, the greater tendency for co-operation among states to
embrace the control of non-communicable diseases.

Fidler (2008)11 notes that recent developments find more non-communicable disease concerns,
such as control of tobacco and obesity and obesity related diseases, becoming the focus of
diplomatic attention. He states that “this diplomatization of some non-communicable disease
problems has, functionally, forced actors to formulate their interests, articulate and advance
them, and determine what to do, if anything, if interests converge on the need to address such
problems collectively”.

The recent advances by the World Health Organization in addressing the problems of tobacco
smoking through the Framework Convention on Tobacco Control (FCTC) and the Global Strategy
to reduce the harmful use of alcohol are examples of states acting collectively to address noncommunicable health issues in which their interests converge. The FCTC is the first international
treaty established under the Constitution of the WHO and the first dealing strictly with tobacco
control. The Global Strategy details voluntary policy options and interventions at the national
level and global priorities at the international level.

Unarguably, childhood obesity is another health problem which has assumed global dimension
and on which the interests of states in stemming the problem and its related diseases converge.
Of course the problem of childhood obesity differs from both tobacco and alcohol abuse in the
sense that both tobacco and alcohol are specific commodities for which there is irrefutable
evidence of their causal link with NCDs. In the case of childhood obesity it is not as easy to
identify specific products for which the causal link may be established in the same way that this
can be done for alcohol and tobacco related diseases although in this presentation I have taken
the liberty to refer to obesogenic foods almost as if this was a distinct class.

Notwithstanding that difficulty, there is little doubt that certain products contribute
substantially, if not solely, to the problem of childhood obesity. Whether one argues that the
causes of childhood obesity are rooted in behavioral or other factors, there appears to be to be
sufficient evidence that the consumption of certain foods is either directly contributable or
more conducive to childhood obesity than others.
Ibid.
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
The product classification systems used in international trade, the Harmonized System of
Product Classification, and in the national schedules of countries utilize a product coding and
description mechanism which makes it possible to classify products on the basis of their specific
characteristics, such as sugar, fat or sodium content, and to treat products differently in
international trade on the basis of these specific characteristics. For example, states could
discriminate in their application of duties and other taxes on products on a tariff line basis
depending on their levels of sugar or fat content, or between whole foods and refined foods or
between fresh fruits and vegetables and processed foods.

Where convincing evidence exists of a causal link between certain food characteristics and
childhood obesity states can discriminate in their treatment of these foods, particularly where
these obesogenic foods are popular with children, subject of course to international trade
principles such as the Most Favoured Nation (MFN) principle , which discourages discrimination
among sources of imports and the National Treatment principle, which discourages
discrimination between domestically produced goods and like imported goods.

My basic argument is that although it may be difficult to link the causes of childhood obesity to
specific products in the same way that certain diseases can be linked to alcohol and tobacco
childhood obesity is sufficiently important to be considered a matter of national interest which
merits a collective approach to its solution, in ways similar to that taken on tobacco and alcohol.

In that regard, the Government of Aruba has to be commended for the prominence which it has
given to the control of childhood obesity both at the national level and in its contribution to
international efforts to deal with the scourge of non-communicable diseases. In effect, Aruba
has demonstrated a commitment to elevate childhood obesity as an issue area of national
interest. If other countries can be persuaded to do the same, the tools of global health
diplomacy and global collective strategies could be used in the efforts to control the problem.
2. International Trade and the control of Childhood Obesity

As in foreign policy, there are conflicting views between the relationship between health and
trade, which have implication for the effectiveness of using trade policy to address health issues,
including the control of childhood obesity. On one hand is the view that trade liberalization
increases growth and development, which reduces poverty, which leads to improved health that
in turn improves growth (Labonte and Gagnon, 2010)12. Bustreo and Doebbler (2010 )13
reference a study by Owen and Wu (2007)14 which suggested that there was a positive
correlation between trade and health which was due to trade openness increasing technology
and knowledge transfers that benefitted health care. The same study concludes that economic
12
Ibid.
Ibid.
14
A. L. Owens and S. Wu, (2007), “Is Trade Good for Health?” Review of International Economics 15/4, pp 660-682
13
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policy based on openness to trade may increase donors’ confidence and thus improve the level
of investment in health.

On the other hand, Labonte and Gagnon (2010)15 indicate that the evidence to suggest that
trade liberalisation leads to increased health through its contribution to growth and poverty
reduction is weak. They observed that while most econometric studies find liberalization on
average is associated with growth, this positive relationship is neither automatically guaranteed
nor universally observable. Lobstein (2010)16 states that ‘while trade liberalization may
contribute to global wealth and economic development, the process is not without its
drawbacks: in particular, the opening of markets facilitates the importation of foods and the
inward investment of capital in the manufacture and retail of foods that can undermine healthy
dietary patterns”. He notes that “the extra-ordinary rise in the prevalence of obesity witnessed
in the last two decades cannot be attributed simply to worldwide failures in personal
responsibility” and that “the context in which choices are made must be recognized”. He says
further that “the effects of trade liberalization on obesogenic foods popular with children form
an important part of that context”.

International trade policies may provide some scope, within a foreign policy framework, to treat
with public health issues generally and with the problem of childhood obesity, in particular.
International trade policy is constantly evolving and the World Trade Organization, which has
responsibility for oversight of the trade agreements which its Members have already concluded,
also serve as a forum for further negotiations among its Members.WTO Members, therefore,
have the facility to incorporate into their multilateral trade relations emerging concerns which
have implications for trade or which could be addressed through trading mechanisms. It is in
that context that concerns related to climate change and the environment constitute part of the
agenda of the WTO and the use of trade instruments to address these concerns are making their
way onto the agenda of the WTO.

In my view, there is no reason why childhood obesity which is impacted by global trade and
investment measures should not be considered in the context of further negotiations in the
WTO where it is evident that trade and investment policies contribute in a substantial way to
the incidence of childhood obesity. The concern which many WTO Members may have with
using the WTO as a forum to address health and other non-trade concerns is that health-related
measures may be used as disguised barriers to trade.

International trade in the goods is governed by a number of WTO agreements which specify the
major principles and rules to govern that trade. In general these rules pertain to the application
of tariffs and other duties on imports, the prohibition on quantitative restrictions on imports,
15
Ibid.
T. Lobstein in C. Hawkes, C.Blouin, S.Henson, N. Drager and L. Dube (eds.) 2010. Trade, Food, Diet and Health:
Perspectives and Policy Options. Wiley- Blackwell. P 195
16
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regulations on food safety measures and technical product standards. Two fundamental
principles underlying multilateral trade arrangements are the Most Favoured Nation Principle
referred to earlier, which prohibits discrimination according to source of imports and the
National Treatment principle which prohibits discrimination between locally produced goods
and imported products of a like nature with respect to domestic taxes and regulations.

The debate on the efficacy of the use of economic measures such as maintaining high duties or
tariffs on food imports with a greater propensity to cause childhood obesity and lowering taxes
on healthier alternatives calls into question the use of these measures to address childhood
obesity. However, the WTO Agreements does not prohibit a country from lowering such tariffs
or from increasing them, provided that the increase in tariff does not surpass the maximum
levels which the WTO Member has agreed to maintain on that product and providing that the
same tariff is applied universally without discrimination among sources of imports, except in the
instances which the WTO Agreements allow. The difficulty with this approach is that where a
country produces the same or similar products domestically an increase in import duties would
not increase the price of the locally produced products. A country which raises import duties on
products which it produces domestically may also run the risk of facing higher duties on its own
products when these are exported.

Lowering import duties on healthy foods, such as fruits and vegetables, however, may provide
an incentive to consumers to purchase them particularly since there is evidence that fresh fruits
and vegetables generally cost higher than processed foods. Moreover, the product classification
system and customs schedules used by countries allow them to apply different rates of duty and
other taxes on products depending on particular characteristics of these products. For example,
imports of products with a sugar or fat content below a particular threshold can be exempted
from the payment of duty or could be charged a lower rate of duty than a similar product
containing higher levels of fat or sugar. Energy dense foods and obesogenic products can
therefore be treated distinctly in a country’s customs schedule without violating existing
international trade rules. Moreover, negotiations on trade in goods can also take into account
strategies to control childhood obesity and cater for that objective in the revision or formulation
of trade rules.

Existing international trade policy permits the grant of subsidies to agriculture under specified
conditions. Domestic support (subsidies) in favour of the production of healthy foods could be
one measure used by governments to encourage the production of these foods, thereby making
them more affordable and accessible. Developing, countries in particular have additional
flexibility to grant subsides to resource poor and low income farmers. The weakness of such a
measure is that it assumes the availability of budgetary resources to provide the levels of
support which would create the incentive to grow the targeted commodities and it also has the
potential to distort the market giving rise to inefficiencies in resource allocation and use and
gives domestic production an advantage of imports. If subsidies give rise to protectionism
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retaliatory measures could also be adopted by trading partners. However, in the context of a
strategy to reduce childhood obesity exemption for the grant of subsidies that facilitate healthy
food choices is an option which could be explored in international trade negotiations.

The WTO Agreement on Sanitary and Phyto-sanitary Measures (SPS) seeks to regulate the use of
such measures by WTO Members. SPS measures are used to protect consumers from risks
arising from additives, contaminants, toxins or disease causing organisms in food, beverages or
feedstuff. Fidler(2010)17 states that measures to counteract obesity that restrict fats, sugars or
salts in foods may qualify as SPS measures because they seek to protect consumers from risks
these additives pose when consumed. However, the food safety rules under the SPS agreement
only address additives that directly harm health. Added fats and sugars may be considered as
only contributory factors to obesity and therefore may not directly harm health. Strategies to
counteract childhood obesity that qualify as SPS measures would have to comply with WTO
disciplines which seek to ensure that these strategies are non-discriminatory, not disguised
restrictions on trade and are the least restrictive strategies reasonably available to achieve the
objectives sought.

The WTO Agreement on Technical Barriers to Trade (TBT) in Article 2,2 recognizes that health is
a legitimate reason for enacting regulations and standards (Fidler, 201018). The TBT agreement
regulates the use of technical regulations which lays down product characteristics or their
related processes and production methods with which compliance is mandatory and technical
standards, for which compliance is non-binding. Restrictions on the levels of fats, sugars and salt
or labeling requirements may be considered as falling within the ambit of the TBT agreement
and would therefore have to comply with the rules governing the application of technical
regulations and standards. A strategy to counteract obesity that involve restricting fat, sugar and
salt content, applied on an MFN basis and consistent with the national treatment principle, may
be acceptable under the TBT Agreement and is yet another avenue through which states can
seek to control childhood obesity through the use of international trade policy.

I have not attempted to exhaust the list of possibilities for using international trade policy to
address childhood obesity. The examples I have provided should suffice however to
demonstrate that there is flexibility within international trade policy for states to adopt a global
strategy to address the problem through the trade component of their foreign policy.
***
17
D. Fidler “ The Impact of International Trade and Investment Rules on the Ability of Governments to implement
Interventions to Address Obesity: A case Study of the European charter on Counteracting Obesity” in C. Hawkes et
al. (eds.) 2010. Trade Food Diet and Health. Wiley-Blackwell.
18
Ibid.
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