key: cord-009160-e2qh3xd8
authors: Unger, Jean-Pierre; De Paepe, Pierre; Ghilbert, Patricia; De Groote, Tony
title: Public health implications of world trade negotiations
date: 2004-01-03
journal: Lancet
DOI: 10.1016/s0140-6736(03)15191-4
sha: 
doc_id: 9160
cord_uid: e2qh3xd8

nan

For personal use. Only reproduce with permission from The Lancet publishing Group.

THE LANCET • Vol 363 • January 3, 2004 • www.thelancet.com 83 CORRESPONDENCE licensing requirements". Claims that "the negotiations could reduce governmental discretion under GATS by introducing international standards for the organisation of services industries" are completely unfounded. Further, the authors' reference to the European Community hormone ban in this context is largely irrelevant, given the distinct structure of the relevant Sanitary and Phytosanitary (SPS) Agreement. Had Pollock and Price been interested in the potential outcome of the Article VI:4negotiations, they could have referred to a possible precedent in services, the Disciplines on Domestic Regulation in the Accountancy Sector. 2 Assertions that "the WTO's sole mandate is trade liberalisation" are mistaken. Tellingly, the Marrakesh Declaration of 1994 starts by welcoming "the stronger and clearer legal framework . . . adopted for the conduct of international trade, including a more effective and reliable dispute settlement mechanism". Impartial dispute settlement or, more generally, the rule of law in international trade might not be regarded as an important achievement for powerful members that have other-although less politically convincing-policy options. Small countries might hold different views, however. Of the complaints brought to the WTO since 2000, 60% were from developing countries.

In conclusion, Pollock and Price refer to a process in which "governments lose rights to regulate and to protect economic values and the principles that shape provision of public services". Although the GATS has now been applied for almost 9 years, Pollock and Price fail to describe any actual case in which governments would have deprived themselves of their sovereign right to regulate and to determine the scope of public service. These rights have never been questioned in a WTO forum. Since 1990, the aid policies of industrialised countries has tended to restrict the public sector's functions to mere disease control. On the grounds of the private sector's supposed higher efficiency, this policy recommends marketing of curative care together with prioritisation of disease control within the public sector. 2 GATS article 1.3.c. makes this recommendation compulsory: "a service supplied in the exercise of governmental authority means any service which is supplied neither on a commercial basis, nor in competition with one or more service suppliers". It could be invoked by powerful health services companies in countries with a weak bargaining position, to prevent publicly oriented services from receiving government subsidies or oblige subsidised public services to limit their activities to disease control.

As a consequence, access to general care will further suffer in areas where private providers are scarce (60% of the population of low-income developing countries live in rural areas), or will become too expensive for most (82·6% of south Asians live on less than US$2 per day 3 ). Article 1.3.c. could also hamper disease control-the paradigm of contemporary international aid in health. It provides the legal basis to preclude integration of disease control with general practice. Nevertheless, many commentators stress the convenience of integrating programmes into health facilities to achieve a reasonable prospect of successful disease control. 4 Such integration requires structures with patients, as journalists noticed while analysing causes of the severe acute respiratory syndrome (SARS) epidemic in China. 5 These patients, consulting for various symptoms, represent a pool of users that disease control programmes need for early case detection and sufficient coverage.

Subsidies to publicly oriented services owned by ministries of health, city councils, and non-governmental organisations could be barred on the ground of GATS article 1.3.c. Politicians who endorse it carry a heavy moral responsibility. 

Sir-In their Seminar (Nov 8, p 1561), 1 Andrew Kingsnorth and Karl LeBlanc discuss the prevention of incisional hernias, but overlook the most important way of avoiding incisional hernias-ie, by use of the lateral paramedian incision and the avoidance of midline incisions. There is clear evidence from randomised controlled trials 2-5 that the lateral paramedium incision is far superior to the midline incision, reducing the incidence of incisional hernia to as low as 0·33% at 1 year without a single dehiscence. The additional 10-20 min required by the lateral paramedian incision is far less expensive than the cost of repairing (often unsuccessfully) the roughly 10% or more hernias occurring in midline incisions. It is incredible in this age of emphasis on evidence-based medicine that the midline incision, with its attendant morbidity, is the most commonly employed means of access for this operation.

Harvard Medical School, 710 Wellesley Street, Weston, MA 02493, USA (e-mail: silenw@aol.com)

Peritoneal closure after lateral paramedian incision

Vertical abdominal incisions-a choice?