Intended for healthcare professionals

Rapid response to:


The Transatlantic Trade and Investment Partnership and UK healthcare

BMJ 2014; 349 doi: (Published 04 November 2014) Cite this as: BMJ 2014;349:g6552

Rapid Response:

It is interesting and concerning to read about the TTIP negotiations taking place between the EU-US: many aspects of the negotiations and the content of the “agreement” appears to be remarkably similar to those of the Trans Pacific Partnership Agreement (TPPA). The TPPA is a Pacific Rim regional trade agreement involving 12 countries, including New Zealand, Australia and the US, which has the potential to significantly alter the domestic environment for health policy-making.

As in the TTIP, the TPPA discussions are held in strict secrecy and few details about the negotiations are publicly available. What is known is based on leaked documents. The TPPA is said to comprise approximately 29 chapters, which include legal rules covering issues such as investor protections, intellectual property rules and regulatory coherence along with more traditional trade issues such as the removal of tariffs. A number of recent reviews based on leaked negotiating documents conclude that there are legitimate concerns about the potential impact of the TPPA in relation to ensuring equitable access to medicines and public health regulation, including tobacco, food and alcohol regulation.1,2 Moreover, many of the impacts will be differentially distributed. People in low income countries and disadvantaged groups within participant countries including those of low socioeconomic status, Indigenous people and those with chronic illnesses and disabilities are likely to be disproportionately affected.2,3

Through the TPPA, the US is seeking to eliminate therapeutic reference pricing, introduce appeals processes for pharmaceutical companies to challenge formulary listing and pricing decisions, and introduce onerous disclosure and “transparency” provisions that facilitate industry involvement in decision-making around coverage and pricing of medicines (and medical devices), which will inevitably lead to a significant increase in the cost of medications and delay market entry of generic drugs.1,4

The highly controversial investor-state dispute settlement (ISDS) mechanism in the investment chapter of the TPPA allows foreign corporations to sue governments for compensation (for awards that often amount to hundreds of millions of dollars) in international tribunals. For example Eli Lilly and Company, is currently using ISDS provisions under the North American Free Trade Agreement (NAFTA) to seek compensation of $500 million dollars from the Canadian Government in response to a patent ruling made in a Canadian federal court.5 Philip Morris Asia is using a similar clause in an investment treaty between Hong Kong and Australia to sue the Australian Government over the introduction of tobacco plain packaging.3 The uncertainty and legal costs associated with ISDS provisions will have a “chilling effect” on governments considering health and environmental protection policies that industry vested interests are likely to contest. This may have already contributed to delays in the introduction of plain packaging tobacco laws in New Zealand.3

Increasing public concern with the TPPA has led to thousands of New Zealanders recently marching across the country in a national day of protest.6 In addition the New Zealand Medical Association and a number of other health sector organizations have called for an independent assessment of the impact of the TPPA on the NZ health system and the ability to achieve legitimate public policy objectives, such as the protection of public health, safety and the environment.7

In considering these new generation trade agreements it may be that we are standing at a crucial cross roads, where the wrong turn will affect not only access and cost of healthcare, but most crucially our Governments sovereignty to prioritise health care policy to protect and improve the health of citizens for generations to come. When the stakes are seemingly this high and negotiations so exclusive, action from the international medical community to express concern and to access information about the health implications in the negotiating documents needs to be urgent and prioritised.

1. Monasterio, E., & Gleeson, D. (2013). Pharmaceutical industry behaviour and the Trans Pacific Partnership Agreement. The New Zealand medical journal,127(1389), 6-12.
2. Monasterio, E., & Gleeson, D. (2014). The Trans Pacific Partnership Agreement: Exacerbation of inequality for patients with serious mental illness. Australian and New Zealand Journal of Psychiatry, 0004867414557679.
3. Hirono K, Gleeson D, Haigh F, et al. (2014) The Trans Pacific Partnership Agreement and the Health of Australians: A Policy Brief. Centre for Health Equity Training, Research and Evaluation, Centre for Primary Health Care and Equity, UNSW, Australia.
4. Gleeson D, Lopert R, Reid P. (2013) How the Trans Pacific Partnership Agreement could undermine PHARMAC and threaten access to affordable medicines and health equity in New Zealand. Health Policy 112: 227-233.
5. Baker BK. Threat of pharmaceutical-related IP investment rights in the Trans Pacific Partnership Agreement: An Eli Lilly v Canada case study. Investment Treaty News, 20 September 2013. rights-in-the-trans-pacific-partnership-agreement-an-eli-lilly-v-canada-case-study/
6. Marches against TPPA trade deal
7. NZMA supports call for TPPA assessment

Competing interests: EM has previously received honoraria presentation payments and travel and accommodation assistance from Janssen- Cilag, Eli Lilly and Sanofi Aventis, but not in the last 6 years.

17 November 2014
Erik Monasterio
Consultant in Forensic Psychiatry
University of Otago, Christchurch School of Medicine
Erik Monasterio, Hillmorton Hospital, Annex Road, Christchurch 8140, New Zealand.