## Introduction Here, we outline a conceptual framework of links between trade liberalisation and health outcomes, and review existing evidence for these by focusing on four key factors: income, inequality, economic insecurity, and unhealthy diets. The effect of trade and trade policy on health has come under increasing attention, esp. related to [[Intellectual Property Rights (IPR)]] and trade in health services. However, the effect of trade and trade liberalisation on social determinants of health have not received as much attention. ## Conceptual Framework WHO Commission on Social Determinants of Health - studied the effects of globalisation on social determinants of health. Associations between income and [[health is]] not linear, as income is more important for health in poor countries than in rich countries, where life expectancy is less sensitive to variations in income. [[Understanding the effect of trade liberalisation on the income of poor househoulds is especially important]] Whether or not trade liberalisation increases aggregate income, eg, a country’s gross domestic product (GDP), not everybody will gain from this new wealth. In view of the non-linear relation between income and health, to understand the effect of trade liberalisation on the income of poor households is especially important. [[High level of income inequality can have negative health implications, be it because of effects on material conditions or on psychosocial well-being]] [[Economic insecurity are associated with enhanced psychosocial stress and thus, affects health and life expectancy]] For example in Russia early 1990s, life expectancy of men declined because of the level of psychosocial stress, indicated particularly by the rise in alcohol consumption, alcohol-related illness, and violent mortality (suicide, homicide). [[Trade liberalisation boosts adoption of behaviours such as smoking and unhealthy diets]] ## Income and its distribution [[Great trade openness was suggested to be good for health (linearly) but turns out, the reevaluation of that widely cited studies that suggested that, the studies were only good to evaluate medium term]] In widely cited studies published during the 1990s, researchers argued that countries that removed their barriers to international trade—ie, showed great trade openness—saw augmented economic growth and poverty reduction. On that basis, openness to trade was suggested to be good for health. However, subsequent analysis has led to a re-evaluation. ==In a review of economic data, researchers concluded that: “the evidence suggests that openness enhances growth, at least over the medium term, but the methodological problems preclude our being wholly certain==.” [[Question]] So, what is needed to ensure the 'goodness' of trade liberalisation? The answer is complementary policies to ensure that trade liberalisation translated into high level of growth, such as stable macroeconomic environment, competitive exchange rate, solid fiscal policies, well functioning agricultural and labour markets, and physical infrastructure (port, roads, and telecommunications). [[Insights]] I would agree that this is currently happening in Indonesia. The CoG was seen as "selling" our country in the name of trade liberalisation. However, at the same time, we are seeing TKDN policy, and probably many other policies are in place to protect the domestic industries. [[Health policymakers must see, that liberalisation that may resulted in aggregated increase in GDP, but it doesn't guarantee the distribution outcomes of trade]] Country reducing or removing its barriers to imports and foreign investment must also consider the subsequent outcomes on the poverty level of its own population. Therefore, policymakers should be concerned with the outcomes for different regions of the country, for urban versus rural households, and for other relevant groups (eg, sex, types of rural households, age). [[Trade reforms create winners and losers. Some sectors of the economy might not be able to compete with new imported goods whereas others get access to new markets and opportunities]]. Moreover, individual incomes can alter because jobs can be created or lost and prices of and external demand for goods produced can rise or fall. Therefore, some losers from trade liberalisation might be poor households whose income will further fall. ## Income inequality If trade liberalisation favors production of goods produced by unskilled labors, then the country will benefit from trade liberalisation. However, if the liberalisation fall in the skills premium industry, the wage gap will widen even more, and the unskilled labor will remain engaged in informal activities rather than being in regular employment. ## Economic insecurity Trade liberalisation is *usually* accompanied by enhanced openness to foreign capital and liberalisation of financial markets and services, but is not always. Moreover, combination of trade and financial liberalisation is often associated with heightened economic insecurity. During trade reforms, job created is accompanied by employment losses because labour moves from one sector or industry to another: [[churning]]. This process needs social safety nets and smooth employment transition mechanisms to lessen material and psychological stress to workers and their families. Findings of study by the [[International Labour Organization (ILO)]], of manufacturing jobs in 77 countries, showed that high levels of international trade in a national economy were associated with increased movement of workers between sectors. Intersectoral movement makes finding new employment difficult and costly for displaced workers, because moving into a different sector usually needs a change in skillset. ## Diet and nutrition Reductions in prices of unhealthy foods—ie, calorie-rich, nutrient-poor, high in saturated fats and salt—compared with healthy foods, increased desirability and availability of unhealthy foods, worsening asymmetry between consumers and suppliers of foodstuffs, and growing urbanisation and changes in lifestyle are all possible means by which [[trade liberalisation could affect popular diets]], especially those of poor populations. We should also note that poor households are most sensitive to food price changes and, thus, are likely to change their diet accordingly.” Trade liberalisation also can affect availability of certain foods by removal barriers to foreign investment in food distribution. Evidence suggests penertration of supermarkets into various food retail markets of souther Africa, Latin America, and China. It resulted in pronounced shift to consumption of processed food. Trade liberalisation also enable foreign investment in multinational fast-food outlets. Trade liberalisation has enabled greater availability of highly processed, calorie-rich, nutrient-poor food in developing countries, but further research needs to be done to better understand the relation between trade policy and diets. We have some information about the growth of processed food sales; we note 29% annual growth in developing countries versus 7% in nations with high incomes. We also have seen a doubling in food import bills as a share of GDP in the 30 years up to 2004, mostly made up of processed foods. However, ==evidence for consumption patterns of processed foods and its determinants in developing countries are still very much needed==. ## Conclusion Trade policies adopted by national government can affect health outcomes and health systems via a very diverse set of channels and intermediate variables; these causal linkages can be difficult to track and monitor. Moreover, in many political systems, health authorities are not in a position to influence directly trade policy decisions at the national level. Nevertheless, their existing knowledge on the determinants of population health and their jurisdiction over social and health policies place policymakers in a privileged position to ensure that, in a increasingly global economic environment, domestic policies and regulations are designed to enhance social protection and to harness economic benefits of trade through redistributive policies. > Indeed, in the context of open economies, in which vulnerability to sudden change and increased economic insecurity is greater than in protected national markets, systems of social protection become more important than ever to reduce health risks related to psychosocial stress and material conditions. Social protection should stabilise incomes, distribute gains of globalisation to groups that would otherwise be excluded, and support development of new capabilities. To protect the effect on diet and nutrition, several policy options can be considered. In Japan, Norway, and South Korea they provided major support for local agriculture and maintained high import tariffs, and so they have relatively low levels of obesity compared with more liberal countries such as the USA and Australia. Another area of intervention: information asymmetries between food companies and consumers is another potential area for intervention. Greater regulation of marketing and advertising of food, esp. to children, is receiving much more attention. Beyond individual education, collective response is also needed - food labelling on nutritional value esp on processed food. The current financial crisis is a clear reminder of the urgency to deal with volatility associated with open economies and to build and strengthen the types of social protection discussed here. The work and recommendations of the WHO Commission on Social Determinants of Health3 on universal social-protection systems can contribute to build global political momentum to this end. Health-impact monitoring of trade reforms also becomes more relevant than ever, as the leaders of the G20 agreed to re-energise trade negotiations at the World Trade Organization, when they met in Washington, DC, USA, on Nov 14–15, 2008, to discuss the financial crisis.