http://ijhpm.com Int J Health Policy Manag 2017, 6(7), 419–421 http://ijhpm.com http://ijhpm.com Int JJ Health Int Health Policy Policy Manag Manag 2016, 2016, 5(2), 5(2), 117–119 117–119
doi 10.15171/ijhpm.2016.145
Commentary
doi 10.15171/ijhpm.2015.188 doi 10.15171/ijhpm.2015.188
Commentary
Just Say No to the TPP: A Democratic Setback for American PoliticsPublic and Power in Global Health: The Constituting Role and Asian Health Comment on “The Trans-Pacific Partnership: Is It Everything We Feared for Health?” of Conflicts
1,2,3*on “Navigating Between Comment Stealth Advocacy and Unconscious Dogmatism: The Carles Muntaner , Deb Finn Mahabir1
Challenge of Researching the Norms, Politics and Power of Global Health”
AbstractClemet Askheim, Kristin Heggen, Eivind Engebretsen** Article History: The article by Labonté, Schram, and Ruckert is a significant and timely analysis of the Trans-Pacific Partnership Received: 24 August 2016 (TPP) policy and the severe threats to public health that it implies for 12 Pacific Rim populations from the Accepted: 31 October 2016 Article History: Americas Abstract and Asia (Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, Article History:6 November 2016 ePublished: In a and recent article, Gorik Ooms has attention to the underpinnings of themany politics of Received: Received: 55 September September 2015 2015 United States, Vietnam). With careful anddrawn analytic precision the normative authors convincingly unearth aspects global health. Wethat claim that Oomsthe is public indirectly submitting to a liberal conception of politics Accepted: Accepted: 13 13 October October 2015 2015 of this piece of legislation undermine health achievements of most countries involvedbyinframing the TTP. ePublished: the politics of globaltheir health as a question of individual Drawing on theheuristic theoretical works of ePublished: 15 15 October October 2015 2015 Our comments complement policy analysis with the aim morality. of providing a positive tool to assist Chantal Mouffe, we introduce a conflictual concept of the political as an alternative to Ooms’ conception. in the understanding of the TPP, and other upcoming treaties like the even more encompassing Transatlantic Using controversies surrounding medical treatment of AIDS patients in developing countries as a case we Trade and Investment Partnership (TTIP), and in so doing motivate the public health community to oppose underline the opportunity for political changes, through political articulation of an issue, and collective the implementation of the relevant provisions of the agreements. The aims of this commentary on the study of mobilization based on such an articulation. View View Video Video Summary Summary Labonté et al are to show that an understanding of the health effects of the TPP is incomplete without a political Keywords: Global Health, Liberal Politics, Chantal Mouffe, Conflict, AIDS, Antiretroviral (ARV) analysis ofTreatment policy formation, and that realist methods can be useful to uncover the mechanisms underlying TPP’s political and policy processes. Copyright: © 2016 by Kerman University of Medical Sciences Keywords:Citation: Scientific Realism, Health Policy, Politics,E.Epistemology, Causality, Social Mechanisms Askheim C, Heggen K, Engebretsen Politics and power in global health: the constituting role of Copyright: © 2017 Comment The Author(s); Publishedbetween by Kerman University Medical Sciences. This is an conflicts: on “Navigating stealth advocacy of and unconscious dogmatism: theopen-access challenge *Correspondence *Correspondence to: to: of researching and power of global Attribution health.” Int JLicense Health Policy Manag. 2016;5(2):117– article distributed underthe thenorms, terms politics of the Creative Commons (http://creativecommons.org/ Eivind Eivind Engebretsen Engebretsen 119. doi:10.15171/ijhpm.2015.188 licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the Email: Email: [email protected] [email protected] original work is properly cited. Citation: Muntaner C, Mahabir DF. Just say no to the TPP: a democratic setback for American and Asian public to: health: Comment on “The Trans-PacifictoPartnership: Is itdebate everything feared for health?” Int J Health Policy take the political as the primary *Correspondence level and the normative as n a recent contribution the ongoing aboutwethe Carles Muntaner Manag. 2017;6(7):419–421. doi:10.15171/ijhpm.2016.145 secondary, or derived from the political? role of power in global health, Gorik Ooms emphasizes
I
role of power in global health, Gorik Ooms emphasizes the normative underpinnings of global health politics. He identifies three related problems: (1) a lack of agreement among global health scholars about their normative premises, he article by Labonté, Schram, and Ruckert1 (this issue), (2) a lack of agreement between global health scholars and henceforth LSR,regarding is a significant and timely analysis of policy-makers the normative premises underlying the Trans-Pacific Partnership (TPP) policy and the policy, and (3) a lack of willingness among scholars to severe threats public health that itpremises implies for Pacific This clearlytostate their normative andtwelve assumptions. Rim populations from the Americas and Asia (Australia, confusion is for Ooms one of the explanations “why global Brunei, Canada, Chile, Japan, Malaysia, Mexico, Newthe Zealand, health’s policy-makers are not implementing knowledge Peru, Singapore, States, and Vietnam). With careful generatedUnited by global health’s empirical scholars. ” He calls for greater unitythe between scholars and between scholars and analytic precision authors convincingly unearth and policy-makers, many aspects of this piece ofconcerning legislationthe thatunderlying underminenormative the 11 premises and greaterofopenness when it involved comes to in advocacy. public health achievements most countries the We commend the effort to reinstate power and politics in TTP. Our comments will complement their policy analysis and agree that “a purely empirical evidence-based with the global aim ofhealth providing a positive heuristic tool to assist in approach is a fiction, ” and that such a view risks covering up the understanding of the TPP, and other upcoming treaties “the role of politics and power.” But by contrasting this fiction like the even more encompassing Transatlantic Trade and with global health research “driven by crises, hot issues, and Investment Partnership (TTIP), and in so doing motivate the concerns of organized interest groups,” as a “path we are the public health community to oppose implementation trying to move away from, ” Oomsthe is submitting to a liberal of the relevant provisions of the agreements. The the aims of conception of politics he implicitly criticizes outcomes 11 this commentary on LSL’s study are twofold: to argue that an of. A liberal view of politics evades the constituting role of analysis of the health is incomplete without conflicts and effects reducesofitthe to TPP either a rationalistic, economic 2,3 a political analysis of formation and thatnorms. realist This calculation, or its an policy individual question of moral methodsiscan be useful to uncover thestates mechanisms echoed in Ooms when he that “it isunderlying not possible to discuss and the policy politics processes. of global 4health without discussing the TPP’s political But agreed what if we premises behind theTPP politics. ”11 the LSR startnormative their policy analysis of the with
T
secondary, or derived from the political? Email: [email protected] That is what we will try to do here, by introducing an alternative conceptualization of the political and hence free us from the “false dilemma” Ooms also wants to escape. agreement are crucial to understanding its putative public “Although constructivists have emphasized how underlying health consequences, including whether the policy shouldand be normative structures constitute actors’ identities 5 6 implemented or not. Such a task might require new methods interests, they have rarely treated these normative structures (see themselves section below). In theand meantime, preliminary analysis as defined infused our by power, or emphasized of actors and strategies during the TPP’s agenda setting and how constitutive effects also are expressions of power.”22 This 7 policy formulation processes revealstheorist the central that is the starting point for the political Chantalrole Mouffe, political power playsisintothe agreement. and her response develop an ontological conception of political, where belongs to ontological The the agenda setting of “the the political TPP agreement (orour those of the 33 condition. According to Mouffe, society instituted TTIP, World ”Trade Organization (WTO), Northis American conflict. “[B]y ‘the political’ I mean the dimension of Freethrough Trade Agreement [NAFTA], Central America Free Trade antagonism which I take to be constitutive of human societies, Agreement [CAFTA], and US treaties with China and South while ‘politics’ I mean set of practices Korea) arebybuilt around thethe assumption that and “freeinstitutions trade” is through which an order is created, organizing human a beneficial “win-win” strategy for the countries involved coexistence in the context of conflictuality provided by the in terms of 33economic development and quality of life for political.” An issue or a topic needs to be contested to become their population.8 Yet, the evidence from economic history political, and such a contestation concerns public action and for example, points major successes fueled creates a ‘we’ and to ‘they’ formdevelopment of collective identification. But 8-10 by trade protectionism. Indeed, trade protectionism has the fixation of social relations is partial and precarious, since enabled social is and health progress in countries likeanSouth antagonism an ever present possibility. To politicize issue Korea, Japan.8-10 Conversely, tradetoliberalization andTaiwan, be able and to mobilize support, one needs represent the has world been associated with manner health hazards such ascamps increased in a conflictual “with opposed with consumption of tobacco, alcohol, which people can identify. ”33 and foods high in salt, fat, and 11 Ooms uses the caseabout of “increasing aidprimarily spending sugar. In spite of talk free tradeinternational the TPP is not on reducing AIDS treatment” to one illustrate hisexpect, point.11 since He frames the about tariffs, as would they are
upon policy document. Yet, the policy process and its already low5,12-15 but rather about investor’s rights, including underlying political struggles thatFaculty lead of toMedicine, this multilateral the right to challenge democratically elected governments Institute University Institute of of Health Health and and Society, Society, Faculty of Medicine, University of of Oslo, Oslo, Oslo, Oslo, Norway Norway Full list of authors’ affiliations is available at the end of the article.
Muntaner and Mahabir
in regulations that protect the health of populations via the investor-state dispute settlement (ISDS).5,12,15 In its essence, the TPP is a way of “harmonizing down” to the benefit of the private sector over and above democratically sanctioned regulations that protect the health of the public.12-16 A policy formation7 analysis is needed to understand the secrecy of the meetings behind the publics’ back, without civil society participation, yet with hundreds of lawyers and lobbyists representing corporate interests devoted to scrutinizing every single page of the agreement.12,13 Simply stated, these strategies reveal an unfair power imbalance in the TPP’s policy formation stage. First, the TPP serves to get rid of (democratically elected) government regulations that stand in the way of corporate profits.12,15 Second, the TPP undermines countries in their ability to challenge large multinational corporations. For example, using the ISDS panels (whose staff are selected by corporations), a tobacco company could sue a country if its tobacco regulations would threaten its profitability prospects. While in wealthy countries such as Australia, Canada, and the United Kingdom, states have won trials against tobacco companies,16 the TPP’s ISDS would substantially shift the power balance in favor of corporations.12,13,15 In examining the LSR adaptation of the health impact assessment (HIA) approach, several methodological innovations could have contributed to a better understanding of the health implications of the TPP.17-24 Although, a HIA analysis is typically conducted using quantitative methods (a reproducible transparent method), at issue is that in order to achieve a deeper political and policy analysis of the policy formation process of the TPP (and other similar trade agreements) we need qualitative methods that remain reproducible and transparent.4,25,26 This means that an adaptation of the HIA to a qualitative approach requires that, several core tenets (to be discussed in later paragraphs) must be observed in order to maintain the reproducibility (and thus validity) of findings. The current adaption of the HIA tool in LSL amounts to a pragmatic approach which is useful yet has some limitations with regard to explaining the TPP. Specifically, the knowledge derived from LSL’s textual analysis is developed without a model, hypotheses or explicit procedure to test them. Such an approach, thus, limits the ability to systematically identify social causal mechanisms (eg, a common activity of policy actors involved in the TPP is to rewrite the rules of the economy that can undermine democratically established government regulations).15 This lack of social causal mechanisms reduces the potential for recommendations leading to policy interventions18-27 (eg, reforms to protect democratic government regulations from the interference of private actors in trade agreements). In brief, a mere reading of the TPP final draft without political theory does not permit one to systematically uncover the underlying explanatory social causal mechanisms at play during its policy formation stages. Furthermore, the pragmatic approach used in LSL’s analysis is less heuristic than a realist approach,4,5,25,26 since it inhibits the development and testing of hypothesis from which to then refine theory or draw policy recommendations. We maintain that a systematic theory-based analysis4 of policy formation7 and a testing of hypothesis or models, is needed 420
to reveal the distribution of power relations in the crafting of the TPP and its important consequences for the social determinants of health (SDOH). The approach used in LSL’s paper to understand the TPP’s consequences for population health, limits the analysis to the examination of the text of the agreement. We should avoid this danger of “textualism” whereby the analysis of society is limited to a textual analysis.17 For example, this approach to the TPP fails to capture political processes that maintain the status quo for the wealthy. Based on the experience from previous trade agreements,13 the TPP most likely will result in an increase in economic inequality since its gains will only benefit the wealthiest.5,12-15 In addition, environmental, food, occupational, and healthcare regulations could be challenged if they are perceived as a threat to profitability via the ISDS instrument, whose composition is predisposed towards investor interests.5,12,15 Essentially, there is potential in the TPP for negatively impacting the SDOH. We propose a set of alternative methods.4,6,18-27 Specifically, we assert that a scientific realist (SR) approach20 offers several critical advantages that need to be considered to effectively analysis the HIA using qualitative methods. Epistemologically, a SR analysis asserts that an objective truth exists and, thus, a real world exists that is independent of the observer. Moreover, this reality is stratified into the empirical (experienced and perceived), the actual (events and outcomes occur but may not be perceived), and the real (where underlying structures as emergent properties and mechanisms can cause changes and outcomes).18 Additionally, real objects are considered intransitive, which means that these objects exist independent of our knowledge or perception of them.22 In other words, this SR approach seeks to identify causal social mechanisms that are hidden, such as power relations. Therefore, a SR approach supports our understanding of society by making the “black box” of policy formulation transparent through the identification of causal mechanisms that are linked to specific contexts.23 This search for causal mechanisms in turn supports the needed explanation of how, why, for whom, and under what circumstances specific outcomes occur,6 such as how and why the power of private actors influence the policy process and policy outcomes of HIA. This realist epistemology is currently adopted in the social sciences24 and public health.18 For example, realist methods have been previously used to systematically reveal social mechanisms involved in the implementation of Health in all Polices (HiAP).4,25 In using a social conflict theoretical approach, the evidence from these studies demonstrates that outcomes of HiAP policy implementation are linked to hypotheses and social mechanisms involving ideology, resistance, and political power, something that would be important to uncover in a critique of the TPP. In terms of transparency and reproducibility, realist methods start with a theory from which testable hypothesis are developed with the aim of re-fining a specific theory. Next, the search for mechanisms using realist methods are used for theory testing in order to advance the understanding of policy formation, implementation, or evaluation.18,26,27 Realist methods use data from multiples sources (for example, from key informant interviews, grey and empirical literature) to increase validity. Ultimately, these processes specific to a SR analysis could provide trade agreement scholars with
International Journal of Health Policy and Management, 2017, 6(7), 419–421
Muntaner and Mahabir
a transparent and reproducible method. Moreover, the SR approach provides a methodology to systematically identify mechanisms during the process of policy formulation which can inform a critical analysis of public polices and interventions. The realist approach can also be used in conjunction with qualitative methods such as quantitative comparative analysis (QCA), which has been proved useful in policy research.28 The above theoretical and methodological suggestions do not detract from the important contribution of LSL to expose the consequences of the TPP for the public health of American and Asian countries. The complement of a political analysis with realist methods might reveal an additional understanding of trade agreements to inform actions in health and social policy. In that sense, the TPP itself is not a finished policy since the two candidates for the presidency of the United States have pledged to stop it, and is quite unpopular among US citizens.29 Ultimately, the TPP might be less understood as a policy document (that can be amended with technical changes in its provisions) than as a political process with major implications for global public health.
10.
11.
12. 13. 14. 15. 16.
17.
18.
Ethical issues Not applicable.
19.
Competing interests Authors declare that they have no competing interests.
20.
Authors’ contributions
Both authors planned the commentary. CM wrote the first draft. DFM provided comments.
21. 22.
Authors’ affiliations
Bloomberg Faculty of Nursing University of Toronto, Toronto, ON, Canada. 2 Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. 3School of Medicine, University of Toronto, Toronto, ON, Canada. 1
References 1. Labonté R, Schram A, Ruckert A. The Trans-Pacific Partnership: Is it everything we feared for health? Int J Health Policy Manag. 2016;5(8):487-496. doi:10.15171/ijhpm.2016.41 2. Muntaner C, Borrell C, Espelt A, et al. Politics or policies vs politics and policies: a comment on Lundberg. Int J Epidemiol. 2010;39(5):1396-1397. doi:10.1093/ije/dyp220 3. Muntaner C, Sridharan S, Solar O, Benach J. Against unjust global distribution of power and money: the report of the WHO Commission on the social determinants of health: global inequality and the future of public health policy. J Public Health Policy. 2009;30(2):163-175. doi:10.1057/jphp.2009.15 4. Shankardass K, Renahy E, Muntaner C, O’Campo P. Strengthening the implementation of Health in All Policies: a methodology for realist explanatory case studies. Health Policy Plan. 2015;30(4):462-473. doi:10.1093/heapol/czu021 5. Navarro V. Attacking Democracy and Wellbeing. Anagrama; 2015. 6. Pawson R. Evidence-Based Policy: A Realist Perspective. Sage publications; 2006. 7. Howlett M, Ramesh M, Perl A. Studying Public Policy: Policy Cycles and Policy Subsystems. Toronto: Oxford University Press; 2009. 8. Chang HJ. Bad Samaritans: The Myth of Free Trade and the Secret History of Capitalism. USA: Bloomsbury Publishing; 2007. 9. Amsden A. Escape From Empire: The Developing World’s
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Journey Through Heaven. Cambridge, Mass: The MIT Press; 2007. Wade R. Governing the Market: Economic Theory and the Role of Government in East Asian Industrialization. Princeton: Princeton University Press; 1990. Stuckler D, McKee M, Ebrahim S, Basu S. Manufacturing epidemics: the role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco. PLoS Med. 2012 26;9(6):e1001235. doi:10.1371/ journal.pmed.1001235 Chomsky N. Who Rules the World? Macmillan; 2016. Stiglitz J. The Great Divide: Unequal Societies and What We Can Do About Them. New York: Norton; 2015. Stiglitz J. Making Globalization Work. Norton; 2007. Stiglitz J. The Euro and its Threat to the Future of Europe. Penguin Books; 2016. Steele SL, Gilmore AB, McKee M, Stuckler D. The role of public law-based litigation in tobacco companies’ strategies in highincome, FCTC ratifying countries, 2004–14. J Public Health. 2016;38(3):516-521. doi:10.1093/pubmed/fdv068 Reckwitz A. Toward a theory of social practices a development in culturalist theorizing. European Journal of Social Theory. 2002;5(2):243-263. doi:10.1177/13684310222225432 O’Campo P, Dunn JR, eds. Rethinking Social Epidemiology: Towards a Science of Change. Springer Science & Business Media; 2011. Ng E, Muntaner C. A critical approach to macrosocial determinants of population health: engaging scientific realism and incorporating social conflict. Curr Epidemiol Rep. 2014;1 (1):27-37. doi:10.1007/s40471-013-0002-0 Muntaner C. Invited commentary: on the future of social epidemiology—a case for scientific realism. Am J Epidemiol. 2013;178(6):852-857. doi:10.1093/aje/kwt143 Bhaskar R. A Realist Theory of Science. New York: Routledge; 1975. Bhaskar R. Philosophy and scientific realism. In: A Realist Theory of Science. New York: Routledge; 2008. Hedström P, Ylikoski P. Causal Mechanisms in the Social Sciences. Ann Rev Sociol. 2010;36(1):49-67. doi:10.1146/ annurev.soc.012809.102632 Sayer A. Realism and Social Science. Sage; 2000. Molnar A, Renahy E, O’Campo P, Muntaner C, Freiler A, Shankardass K. Using win-win strategies to implement health in all policies: a cross-case analysis. PloS One. 2016;11(2):e0147003. doi:10.1371/journal.pone.0147003 Molnar A, O’Campo P, Ng E, et al. Protocol: Realist synthesis of the impact of unemployment insurance policies on poverty and health. Eval Program Plann. 2015;48:1-9. doi:10.1016/j. evalprogplan.2014.09.002 O’Campo P, Kirst M, Tsamis C, Chambers C, Ahmad F. Implementing successful intimate partner violence screening programs in health care settings: evidence generated from a realist-informed systematic review. Soc Sci Med. 2011;72(6):855866. doi:10.1016/j.socscimed.2010.12.019 Shahidi FV. Welfare capitalism in crisis: a qualitative comparative analysis of labour market policy responses to the Great Recession. J Soc Policy. 2015;44(4):659-686. doi:10.1017/ s004727941500029x With time running out, Obama to make final push on Asia trade deal that Clinton opposes. Politics. The Washington Post. August 1, 2016. https://www.washingtonpost.com/politics/withtime-running-out-obama-to-make-final-push-on-asia-trade-dealthat-clinton-opposes/2016/08/01/2213464c-57f3-11e6-9767f6c947fd0cb8_story.html.
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421
doi 10.15171/ijhpm.2016.145
Commentary
doi 10.15171/ijhpm.2015.188 doi 10.15171/ijhpm.2015.188
Commentary
Just Say No to the TPP: A Democratic Setback for American PoliticsPublic and Power in Global Health: The Constituting Role and Asian Health Comment on “The Trans-Pacific Partnership: Is It Everything We Feared for Health?” of Conflicts
1,2,3*on “Navigating Between Comment Stealth Advocacy and Unconscious Dogmatism: The Carles Muntaner , Deb Finn Mahabir1
Challenge of Researching the Norms, Politics and Power of Global Health”
AbstractClemet Askheim, Kristin Heggen, Eivind Engebretsen** Article History: The article by Labonté, Schram, and Ruckert is a significant and timely analysis of the Trans-Pacific Partnership Received: 24 August 2016 (TPP) policy and the severe threats to public health that it implies for 12 Pacific Rim populations from the Accepted: 31 October 2016 Article History: Americas Abstract and Asia (Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, Article History:6 November 2016 ePublished: In a and recent article, Gorik Ooms has attention to the underpinnings of themany politics of Received: Received: 55 September September 2015 2015 United States, Vietnam). With careful anddrawn analytic precision the normative authors convincingly unearth aspects global health. Wethat claim that Oomsthe is public indirectly submitting to a liberal conception of politics Accepted: Accepted: 13 13 October October 2015 2015 of this piece of legislation undermine health achievements of most countries involvedbyinframing the TTP. ePublished: the politics of globaltheir health as a question of individual Drawing on theheuristic theoretical works of ePublished: 15 15 October October 2015 2015 Our comments complement policy analysis with the aim morality. of providing a positive tool to assist Chantal Mouffe, we introduce a conflictual concept of the political as an alternative to Ooms’ conception. in the understanding of the TPP, and other upcoming treaties like the even more encompassing Transatlantic Using controversies surrounding medical treatment of AIDS patients in developing countries as a case we Trade and Investment Partnership (TTIP), and in so doing motivate the public health community to oppose underline the opportunity for political changes, through political articulation of an issue, and collective the implementation of the relevant provisions of the agreements. The aims of this commentary on the study of mobilization based on such an articulation. View View Video Video Summary Summary Labonté et al are to show that an understanding of the health effects of the TPP is incomplete without a political Keywords: Global Health, Liberal Politics, Chantal Mouffe, Conflict, AIDS, Antiretroviral (ARV) analysis ofTreatment policy formation, and that realist methods can be useful to uncover the mechanisms underlying TPP’s political and policy processes. Copyright: © 2016 by Kerman University of Medical Sciences Keywords:Citation: Scientific Realism, Health Policy, Politics,E.Epistemology, Causality, Social Mechanisms Askheim C, Heggen K, Engebretsen Politics and power in global health: the constituting role of Copyright: © 2017 Comment The Author(s); Publishedbetween by Kerman University Medical Sciences. This is an conflicts: on “Navigating stealth advocacy of and unconscious dogmatism: theopen-access challenge *Correspondence *Correspondence to: to: of researching and power of global Attribution health.” Int JLicense Health Policy Manag. 2016;5(2):117– article distributed underthe thenorms, terms politics of the Creative Commons (http://creativecommons.org/ Eivind Eivind Engebretsen Engebretsen 119. doi:10.15171/ijhpm.2015.188 licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the Email: Email: [email protected] [email protected] original work is properly cited. Citation: Muntaner C, Mahabir DF. Just say no to the TPP: a democratic setback for American and Asian public to: health: Comment on “The Trans-PacifictoPartnership: Is itdebate everything feared for health?” Int J Health Policy take the political as the primary *Correspondence level and the normative as n a recent contribution the ongoing aboutwethe Carles Muntaner Manag. 2017;6(7):419–421. doi:10.15171/ijhpm.2016.145 secondary, or derived from the political? role of power in global health, Gorik Ooms emphasizes
I
role of power in global health, Gorik Ooms emphasizes the normative underpinnings of global health politics. He identifies three related problems: (1) a lack of agreement among global health scholars about their normative premises, he article by Labonté, Schram, and Ruckert1 (this issue), (2) a lack of agreement between global health scholars and henceforth LSR,regarding is a significant and timely analysis of policy-makers the normative premises underlying the Trans-Pacific Partnership (TPP) policy and the policy, and (3) a lack of willingness among scholars to severe threats public health that itpremises implies for Pacific This clearlytostate their normative andtwelve assumptions. Rim populations from the Americas and Asia (Australia, confusion is for Ooms one of the explanations “why global Brunei, Canada, Chile, Japan, Malaysia, Mexico, Newthe Zealand, health’s policy-makers are not implementing knowledge Peru, Singapore, States, and Vietnam). With careful generatedUnited by global health’s empirical scholars. ” He calls for greater unitythe between scholars and between scholars and analytic precision authors convincingly unearth and policy-makers, many aspects of this piece ofconcerning legislationthe thatunderlying underminenormative the 11 premises and greaterofopenness when it involved comes to in advocacy. public health achievements most countries the We commend the effort to reinstate power and politics in TTP. Our comments will complement their policy analysis and agree that “a purely empirical evidence-based with the global aim ofhealth providing a positive heuristic tool to assist in approach is a fiction, ” and that such a view risks covering up the understanding of the TPP, and other upcoming treaties “the role of politics and power.” But by contrasting this fiction like the even more encompassing Transatlantic Trade and with global health research “driven by crises, hot issues, and Investment Partnership (TTIP), and in so doing motivate the concerns of organized interest groups,” as a “path we are the public health community to oppose implementation trying to move away from, ” Oomsthe is submitting to a liberal of the relevant provisions of the agreements. The the aims of conception of politics he implicitly criticizes outcomes 11 this commentary on LSL’s study are twofold: to argue that an of. A liberal view of politics evades the constituting role of analysis of the health is incomplete without conflicts and effects reducesofitthe to TPP either a rationalistic, economic 2,3 a political analysis of formation and thatnorms. realist This calculation, or its an policy individual question of moral methodsiscan be useful to uncover thestates mechanisms echoed in Ooms when he that “it isunderlying not possible to discuss and the policy politics processes. of global 4health without discussing the TPP’s political But agreed what if we premises behind theTPP politics. ”11 the LSR startnormative their policy analysis of the with
T
secondary, or derived from the political? Email: [email protected] That is what we will try to do here, by introducing an alternative conceptualization of the political and hence free us from the “false dilemma” Ooms also wants to escape. agreement are crucial to understanding its putative public “Although constructivists have emphasized how underlying health consequences, including whether the policy shouldand be normative structures constitute actors’ identities 5 6 implemented or not. Such a task might require new methods interests, they have rarely treated these normative structures (see themselves section below). In theand meantime, preliminary analysis as defined infused our by power, or emphasized of actors and strategies during the TPP’s agenda setting and how constitutive effects also are expressions of power.”22 This 7 policy formulation processes revealstheorist the central that is the starting point for the political Chantalrole Mouffe, political power playsisintothe agreement. and her response develop an ontological conception of political, where belongs to ontological The the agenda setting of “the the political TPP agreement (orour those of the 33 condition. According to Mouffe, society instituted TTIP, World ”Trade Organization (WTO), Northis American conflict. “[B]y ‘the political’ I mean the dimension of Freethrough Trade Agreement [NAFTA], Central America Free Trade antagonism which I take to be constitutive of human societies, Agreement [CAFTA], and US treaties with China and South while ‘politics’ I mean set of practices Korea) arebybuilt around thethe assumption that and “freeinstitutions trade” is through which an order is created, organizing human a beneficial “win-win” strategy for the countries involved coexistence in the context of conflictuality provided by the in terms of 33economic development and quality of life for political.” An issue or a topic needs to be contested to become their population.8 Yet, the evidence from economic history political, and such a contestation concerns public action and for example, points major successes fueled creates a ‘we’ and to ‘they’ formdevelopment of collective identification. But 8-10 by trade protectionism. Indeed, trade protectionism has the fixation of social relations is partial and precarious, since enabled social is and health progress in countries likeanSouth antagonism an ever present possibility. To politicize issue Korea, Japan.8-10 Conversely, tradetoliberalization andTaiwan, be able and to mobilize support, one needs represent the has world been associated with manner health hazards such ascamps increased in a conflictual “with opposed with consumption of tobacco, alcohol, which people can identify. ”33 and foods high in salt, fat, and 11 Ooms uses the caseabout of “increasing aidprimarily spending sugar. In spite of talk free tradeinternational the TPP is not on reducing AIDS treatment” to one illustrate hisexpect, point.11 since He frames the about tariffs, as would they are
upon policy document. Yet, the policy process and its already low5,12-15 but rather about investor’s rights, including underlying political struggles thatFaculty lead of toMedicine, this multilateral the right to challenge democratically elected governments Institute University Institute of of Health Health and and Society, Society, Faculty of Medicine, University of of Oslo, Oslo, Oslo, Oslo, Norway Norway Full list of authors’ affiliations is available at the end of the article.
Muntaner and Mahabir
in regulations that protect the health of populations via the investor-state dispute settlement (ISDS).5,12,15 In its essence, the TPP is a way of “harmonizing down” to the benefit of the private sector over and above democratically sanctioned regulations that protect the health of the public.12-16 A policy formation7 analysis is needed to understand the secrecy of the meetings behind the publics’ back, without civil society participation, yet with hundreds of lawyers and lobbyists representing corporate interests devoted to scrutinizing every single page of the agreement.12,13 Simply stated, these strategies reveal an unfair power imbalance in the TPP’s policy formation stage. First, the TPP serves to get rid of (democratically elected) government regulations that stand in the way of corporate profits.12,15 Second, the TPP undermines countries in their ability to challenge large multinational corporations. For example, using the ISDS panels (whose staff are selected by corporations), a tobacco company could sue a country if its tobacco regulations would threaten its profitability prospects. While in wealthy countries such as Australia, Canada, and the United Kingdom, states have won trials against tobacco companies,16 the TPP’s ISDS would substantially shift the power balance in favor of corporations.12,13,15 In examining the LSR adaptation of the health impact assessment (HIA) approach, several methodological innovations could have contributed to a better understanding of the health implications of the TPP.17-24 Although, a HIA analysis is typically conducted using quantitative methods (a reproducible transparent method), at issue is that in order to achieve a deeper political and policy analysis of the policy formation process of the TPP (and other similar trade agreements) we need qualitative methods that remain reproducible and transparent.4,25,26 This means that an adaptation of the HIA to a qualitative approach requires that, several core tenets (to be discussed in later paragraphs) must be observed in order to maintain the reproducibility (and thus validity) of findings. The current adaption of the HIA tool in LSL amounts to a pragmatic approach which is useful yet has some limitations with regard to explaining the TPP. Specifically, the knowledge derived from LSL’s textual analysis is developed without a model, hypotheses or explicit procedure to test them. Such an approach, thus, limits the ability to systematically identify social causal mechanisms (eg, a common activity of policy actors involved in the TPP is to rewrite the rules of the economy that can undermine democratically established government regulations).15 This lack of social causal mechanisms reduces the potential for recommendations leading to policy interventions18-27 (eg, reforms to protect democratic government regulations from the interference of private actors in trade agreements). In brief, a mere reading of the TPP final draft without political theory does not permit one to systematically uncover the underlying explanatory social causal mechanisms at play during its policy formation stages. Furthermore, the pragmatic approach used in LSL’s analysis is less heuristic than a realist approach,4,5,25,26 since it inhibits the development and testing of hypothesis from which to then refine theory or draw policy recommendations. We maintain that a systematic theory-based analysis4 of policy formation7 and a testing of hypothesis or models, is needed 420
to reveal the distribution of power relations in the crafting of the TPP and its important consequences for the social determinants of health (SDOH). The approach used in LSL’s paper to understand the TPP’s consequences for population health, limits the analysis to the examination of the text of the agreement. We should avoid this danger of “textualism” whereby the analysis of society is limited to a textual analysis.17 For example, this approach to the TPP fails to capture political processes that maintain the status quo for the wealthy. Based on the experience from previous trade agreements,13 the TPP most likely will result in an increase in economic inequality since its gains will only benefit the wealthiest.5,12-15 In addition, environmental, food, occupational, and healthcare regulations could be challenged if they are perceived as a threat to profitability via the ISDS instrument, whose composition is predisposed towards investor interests.5,12,15 Essentially, there is potential in the TPP for negatively impacting the SDOH. We propose a set of alternative methods.4,6,18-27 Specifically, we assert that a scientific realist (SR) approach20 offers several critical advantages that need to be considered to effectively analysis the HIA using qualitative methods. Epistemologically, a SR analysis asserts that an objective truth exists and, thus, a real world exists that is independent of the observer. Moreover, this reality is stratified into the empirical (experienced and perceived), the actual (events and outcomes occur but may not be perceived), and the real (where underlying structures as emergent properties and mechanisms can cause changes and outcomes).18 Additionally, real objects are considered intransitive, which means that these objects exist independent of our knowledge or perception of them.22 In other words, this SR approach seeks to identify causal social mechanisms that are hidden, such as power relations. Therefore, a SR approach supports our understanding of society by making the “black box” of policy formulation transparent through the identification of causal mechanisms that are linked to specific contexts.23 This search for causal mechanisms in turn supports the needed explanation of how, why, for whom, and under what circumstances specific outcomes occur,6 such as how and why the power of private actors influence the policy process and policy outcomes of HIA. This realist epistemology is currently adopted in the social sciences24 and public health.18 For example, realist methods have been previously used to systematically reveal social mechanisms involved in the implementation of Health in all Polices (HiAP).4,25 In using a social conflict theoretical approach, the evidence from these studies demonstrates that outcomes of HiAP policy implementation are linked to hypotheses and social mechanisms involving ideology, resistance, and political power, something that would be important to uncover in a critique of the TPP. In terms of transparency and reproducibility, realist methods start with a theory from which testable hypothesis are developed with the aim of re-fining a specific theory. Next, the search for mechanisms using realist methods are used for theory testing in order to advance the understanding of policy formation, implementation, or evaluation.18,26,27 Realist methods use data from multiples sources (for example, from key informant interviews, grey and empirical literature) to increase validity. Ultimately, these processes specific to a SR analysis could provide trade agreement scholars with
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a transparent and reproducible method. Moreover, the SR approach provides a methodology to systematically identify mechanisms during the process of policy formulation which can inform a critical analysis of public polices and interventions. The realist approach can also be used in conjunction with qualitative methods such as quantitative comparative analysis (QCA), which has been proved useful in policy research.28 The above theoretical and methodological suggestions do not detract from the important contribution of LSL to expose the consequences of the TPP for the public health of American and Asian countries. The complement of a political analysis with realist methods might reveal an additional understanding of trade agreements to inform actions in health and social policy. In that sense, the TPP itself is not a finished policy since the two candidates for the presidency of the United States have pledged to stop it, and is quite unpopular among US citizens.29 Ultimately, the TPP might be less understood as a policy document (that can be amended with technical changes in its provisions) than as a political process with major implications for global public health.
10.
11.
12. 13. 14. 15. 16.
17.
18.
Ethical issues Not applicable.
19.
Competing interests Authors declare that they have no competing interests.
20.
Authors’ contributions
Both authors planned the commentary. CM wrote the first draft. DFM provided comments.
21. 22.
Authors’ affiliations
Bloomberg Faculty of Nursing University of Toronto, Toronto, ON, Canada. 2 Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. 3School of Medicine, University of Toronto, Toronto, ON, Canada. 1
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