The health impact of trade and investment agreements: a quantitative systematic review and network co-citation analysis

Abstract

Background: Regional trade agreements are major international policy instruments that shape macro-economic and political systems. There is widespread debate as to whether and how these agreements pose risks to public health. Here we perform a comprehensive systematic review of quantitative studies of the health impact of trade and investment agreements. We identified studies from searches in PubMed, Web of Science, EMBASE, and Global Health Online. Research articles were eligible for inclusion if they were quantitative studies of the health impacts of trade and investment agreements or policy. We systematically reviewed study findings, evaluated quality using the Quality Assessment Tool from the Effective Public Health Practice Project, and performed network citation analysis to study disciplinary siloes.

Results: Seventeen quantitative studies met our inclusion criteria. There was consistent evidence that implementing trade agreements was associated with increased consumption of processed foods and sugar-sweetened beverages. Granting import licenses for patented drugs was associated with increased access to pharmaceuticals. Implementing trade agreements and associated policies was also correlated with higher cardiovascular disease incidence and higher Body Mass Index (BMI), whilst correlations with tobacco consumption, under-five mortality, maternal mortality, and life expectancy were inconclusive. Overall, the quality of studies is weak or moderately weak, and co-citation analysis revealed a relative isolation of public health from economics.

Conclusion: We identified limitations in existing studies which preclude definitive conclusions of the health impacts of regional trade and investment agreements. Few address unobserved confounding, and many possible consequences and mechanisms linking trade and investment agreements to health remain poorly understood. Results from our co-citation analysis suggest scope for greater interdisciplinary collaboration. Notwithstanding these limitations, our results find evidence that trade agreements pose some significant health risks. Health protections in trade and investment treaties may mitigate these impacts.

Keywords: Co-citation analysis; Diets; Foreign investment policy; Health outcomes; Non-communicable diseases; Systematic review; Tobacco; Trade and investment agreements (RTAs); Trade policy.

Fig. 1

Number of RTAs, 1950–2010. Notes: Solid black line represents cumulative number of RTAs in force; grey bars show RTAs entered into force per year. Data extracted from the World Trade Organization’s Regional Trade Agreements Information System on 15 February 2016. See bibliography for full reference [57]

Fig. 2

Macro-social model outlining potential health effects of RTAs and associated mechanisms. Notes: Numbers 1–3 identify whether outcomes and pathways are linked indirectly via changes to (1) trade flows, (2) foreign direct investment flows (FDI), or (3) directly via RTA clauses. Relevant RTA provisions were identified from Dur and Baccini (2014)

Fig. 3

PRISMA diagram showing study identification, screening, and inclusion. Notes: flow diagram based on PRISMA guidelines set out in Moher et al. 2009

Fig. 4

Co-citation of studies. Notes: Created using VOSViewer Version 1.6.1. The network map shows co-citation patterns of the 117 journals cited at least 5 times within the studies we reviewed. Node size corresponds to the number of citations, lines correspond to the existence of a citation in either direction, and distance between nodes corresponds to the tendency for studies to be cited together by other studies

Fig. 5

Methodological quality assessment: distribution of studies between quality scores. Notes: Studies reviewed = 17. Studies were evaluated using an adapted version of the Quality Assessment Tool developed by the Effective Public Health Practice Project (Thomas et al. [31]). See Additional file 1: for full details