When evidence isn’t enough: Ideological,institutional,and interest-based constraints on achieving trade and health policy coherence

Neoliberalism

Neoliberalism has been shaped by the fundamental values of classical liberalism. For classical liberalists, there is no collective ‘public interest’ beyond the interests of the individuals who comprise that community – and achieving the central goal of maximising individual liberty and freedom requires a constitutional government with limited powers, rule of law, private property rights and the free movement of people, goods, services, capital and ideas (Freeman, 2017). While classical liberalism is conceptually well developed in the literature, neoliberalism has been described as a term that is ‘… oft-invoked but ill-defined …’ (Mudge, 2008: 703) and has ranged from being a ‘… conceptual trash heap capable of accommodating multiple distasteful phenomena’ (Boas and Gans-Morse, 2009: 156) to a more carefully explored construct positioned as a dominant or hegemonic ideology (Flew, 2014; Harvey, 2005).

Neoliberalism’s roots lie in a series of debt crises in the 1970s, which created opportunistic conditions for a re-emergence of 19th-century economic liberalism, which advocated that freedom from state intervention in markets is necessary to promote economic growth and full employment (Gilbert, 2013). A key moment was the election of Margaret Thatcher in the United Kingdom in 1979 and Ronald Reagan in the United States in 1980, as a result of which conservative politicians sympathetic to neoliberal ideas gained power in two of the world’s most dominant market economies (Peck and Tickell, 2007). The 1990s saw the systematic spread of a set of neoliberal policy preferences throughout the developing world as conditionalities for loan and debt relief provided by the International Monetary Fund (IMF) and the World Bank (Ruckert, 2008). These neoliberal policy preferences are referred to as the Washington Consensus, ¹ and include (1) increased fiscal discipline to limit budget deficits; (2) reduced public expenditure, moving away from subsidies and administration towards fields with high economic returns; (3) tax reform, broadening the tax base and moderate marginal tax rates; (4) financial liberalisation, allowing interest rates to be market-determined; (5) competitive exchange rates, either undervalued or correctly valued; (6) trade liberalisation; (7) increased foreign direct investment through reduced barriers; (8) privatisation of state enterprises; (9) deregulation, the abolition of regulations that impede the entry and exit of goods, services and capital, not in the areas of safety, environment and finance; and (10) secure intellectual property rights (Williamson, 2008).

Although neoliberalism began as a North Atlantic ideological movement, it has evolved through conflicts with the external social world and local articulations by states invited, seduced and compelled to take part over the past 40 years (Clarke, 2008; Peck, 2004). Harvey (2005) describes it as an ideological project of a class seeking to expand the reach of corporate capital and create new means of capital accumulation, including through the ‘economisation’ of social and political life. While neoliberalism remains both an elusive and expansive construct, it can be summarised as follows:

Neoliberalism sees competition as the defining characteristic of human relations. It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling, a process that rewards merit and punishes inefficiency. It maintains that ‘the market’ delivers benefits that could never be achieved by planning. Attempts to limit competition are treated as inimical to liberty. Tax and regulation should be minimised, public services should be privatised. The organisation of labour and collective bargaining by trade unions are portrayed as market distortions that impede the formation of a natural hierarchy of winners and losers. The greater the failure, the more extreme the ideology becomes. Governments use neoliberal crises as both excuse and opportunity to cut taxes, privatise remaining public services, rip holes in the social safety net, deregulate corporations and re-regulate citizens. The self-hating state now sinks its teeth into every organ of the public sector. (Monbiot, 2016)

Neoliberalism as a constraint on public health values

Neoliberalism has played an important role in shaping the dynamic between states, society and the market. It presents markets as the morally neutral and depoliticised counterpart to the state. The state, by contrast, is a political space appropriated by the self-interests of politicians and bureaucrats, prone to illegitimacy and abuse of power, where even promising policy is ultimately subverted by individual interests to retain political power (Reis, 2012). As suggested by Dugger (1992), this bifurcation of the state and the market has been used as a way of making the market appear to be a source of productivity and economic growth, and the state a source of interference in the otherwise self-regulating system of free markets.

Neoliberalism thus discounts the complex range of state actions that shape the economy and society, including the implementation and enforcement of legal and regulatory instruments and investment incentives, as well as substantive policy formation that structures the education, health, social services, urban design, land use, mobility, science and development landscape within a country. States are thus in an ongoing position to shape the foundation from which markets grow and the workforce and consumer base to produce and reproduce them. Consequently, and contrary to neoliberal viewpoints, the state does not act as an obstacle to the market, the state enables and defines the market, and the larger economy within which markets operate (Reis, 2012). Equally, under neoliberalism, society is, in Harvey’s (2005) terms, ‘economised’ to individual consumers and market actors whose personhood is valuated through the lens of ‘hard working’ producers or ‘responsible’ consumers (Clarke, 2008). Neoliberalism has hence been described as ‘an articulation of state, market and citizenship that harnesses the first to impose the stamp of the second onto the third’ (Wacquant, 2012: 66).

This belief in a limited state, an omnipotent market and economised citizens underlying neoliberal trade and investment agreements produces conflicts with a public health belief in the state as the provider of public goods to all citizens in a fair and equitable manner that, in fact, corrects for systemic market failures. Consequently, when public health actors engage with trade and investment agreements as a structural driver of negative health externalities and inequities, many find themselves up against considerable opposition to their core values and beliefs. Public health priorities collide with competing national priorities for economic growth. Neoliberalism indicates that the best way to create that growth is through free markets, which trade and investment agreements are designed to provide. It is then claimed that these benefits will trickle down to the population at large subsequently improving health – in spite of a growing body of evidence to the contrary (Dabla-Norris et al., 2015; Tausch, 2015). Public health frameworks on the complex structural and social determinants of health also collide with a system that attributes success and failure to the character of the individual. Under a neoliberal model of individualism, poor health outcomes are privatised as personal failings not social problems (Giroux, 2015). Finally, public health collides against a system premised on privatising all aspects of social and political life, where essential medicines and health services become ordinary for-profit commodities delivered by the market.

Implications for action on NCDs

These collisions will impact the successful execution of the GAP-NCDs, including objectives such as raising the priority accorded to the prevention and control of NCDs in global, regional and national agendas and internationally agreed development goals, through strengthened international cooperation and advocacy. One of the policy recommendations under this objective is to encourage inclusion of NCD actions in economic development policies, which includes trade and investment agreements. Getting NCDs on the agenda for economic policy development would require addressing a number of ideological conflicts. First, the market logic of neoliberalism that treats all goods as ordinary commodities runs counter to the public health logic to frame some goods in relation to their health-promoting or health-harmful status. Moreover, so long as economic growth remains the primary objective of any economic policy, regardless of whether that growth is healthy or equitable, the public health agenda to slow or reduce growth in tobacco, alcohol and unhealthy food industries may threaten economic growth objectives in some countries.

Additionally, while some health agendas may be more disposed to alignment with economic policy, for example, antibiotic research and development which involves investment into a marketable product of importance to health, NCDs are more antagonistic to markets and neoliberal values. Action on NCDs generally requires less consumption of things like tobacco, alcohol and processed food and beverages, all highly profitable products – posing a direct threat to consumer markets. Likewise, action on NCDs challenges a number of neoliberal values in relation to individualism and limited government. Not only does public health socialise outcomes such as obesity – highlighting the role of obesogenic food environments over individual behaviour on the grounds that food choices are conditioned and constrained by availability, affordability and manipulative marketing techniques – it even portends that the state has a responsibility to regulate these environmental drivers for the public good. This is met by extreme opposition from a range of individuals, consumer groups and corporations operating on neoliberal values and resisting a paternalistic state. In order to put an international health agenda like the GAP-NCDs on the trade and investment policy agenda, public health actors will have to appreciate the constraining role of ideology and find ways to either work within it or work around it. While traditional public health disciplinary perspectives will dictate that producing robust evidence on the relationships between trade conditions, market conditions and health outcomes is the best way to drive change – such tactics will inevitably produce a slow battle with mixed results.

Constitutionalism

While ‘constitutions can be understood to depict simply any structure of governance’ (Cottier and Hertig, 2003: 279), a more nuanced understanding of constitutionalism views its core functions as ‘… both setting up and limiting the power of the polity, defining the fundamental boundaries between the private and the public, the state and the individual, mainly in terms of fundamental rights, and between the different branches of government’ (Cottier and Hertig, 2003: 280). Liberal constitutionalism, more specifically, has regarded the fundamental rights of individuals to be negative liberty rights, providing for the right not to be subjected to an action of another person or group. These have been described elsewhere as the first generation of human rights, centred on physical and civil security (e.g. right not to be subjected to arbitrary arrest) and civil-political liberties (e.g. freedom of assembly) (Vasak, 1977).

Orthodox views on transitions to constitutionalism contend that it is the inevitable outcome of a state transitioning to democracy and the best approach to protecting individual rights by guaranteeing freedoms that no elected government can change (Hirschl, 2004; Limbach, 2001). For some, this explains the surge in constitutionalism following the wake of human rights violations in World War II (Dworkin, 1990). As constitutions cannot be amended by any ordinary legislation, thereby binding successive governments to its laws, they require an intermediary to equally enforce the rules of the game for all political actors (Hirschl, 2004). It is argued that such a role can only effectively be fulfilled by an apolitical body of independent arbiters of the law. In such a system, the state remains the highest authority of the social course of the nation, but is subject to the constraints imposed by the constitution and its traditions, as interpreted by the courts (McLachlin, 2003).

Alternatively, it has been argued that the primary purpose for transitioning to a constitutional system, particularly one modelled on the US constitution, was the promotion of broader liberal values such as the rule of law and limited government. More specifically, fostering economic growth by developing predictable laws for the marketplace, protection of property rights and capital accumulation, and legal recourse through independent courts if these laws and protections are violated (Weingast, 1993, 1997). Accordingly, constitutionalism enshrines these rights and protects them against future political regime changes that may result is a less-friendly investment climate, which would negatively impact economic growth (Hirschl, 2004). Critical historical investigations of US constitutionalism on the other hand suggest that this model secured a particular type of liberty and property rights for a particular class of people and entrenched the dynamics of master over slave, capital over labour and colonist over native (Di Muzio, 2014). The US constitution safeguarded the right to accumulate wealth beyond one’s needs and cemented those rights against future challenges from an increasingly radicalised and politically inspired majority (Di Muzio, 2014). Indeed, the transition to constitutionalism has been argued as a way to protect states against the tyranny of majority rule and to insulate policymaking from democratic, majoritarian politics shielded behind beliefs of an impartial judiciary (Dworkin, 1990).

The new constitutionalism

Roots of the modern trade and investment system lie in the post-World War II years and a period of expanding constitutionalism through supranational institutions, such as the IMF, the World Bank and the General Agreement on Tariffs and Trade (which would later evolve into the World Trade Organization [WTO]). These institutions and their formative treaties were promulgated as opportunities to mutually develop peace and prosperity for all nations, based largely on the premise that greater economic interdependence would serve as a deterrent to future conflict. They represented an evolution of public international law from a ‘law of coexistence’ to a ‘law of cooperation’ (Cottier and Hertig, 2003). This new cooperation necessarily demanded some level of transference of state sovereignty in traditionally domestic policy domains to supranational governance structures that could then be arbitrated on by some form of judicial body. This new generation of international agreements was made in the image of liberal constitutionalism, necessitating an abandonment of constitutionalism as conceptually bound to the nation state, and embracing it as a process ‘extending constitutional structures to fora and layers of governance other than nations’ (Cottier and Hertig, 2003: 264). International trade – a pivotal area for post-war economic development and integration – was a natural entry point for an emerging constitutionalism between states.

This new constitutionalism (Gill, 1998; Gill and Cutler, 2014) – inclusive of but not restricted to international trade and investment agreements – has been considered a part of the neoliberal project that seeks to transform macroeconomic and microeconomic policy in order to (1) expand and entrench private property rights as well as the privatisation of public assets, including land and water, and public services; (2) safeguard private property from state measures that may directly or indirectly expropriate such property, including ‘locking-in’ the above reforms with financial penalties for any violations; and (3) shelter such policy formation from democratic scrutiny and contestation from the masses, for example, presenting trade and investment agreements as purely economic matters to dissuade the general public from developing interest, alongside high levels of secrecy around negotiations (Gill and Cutler, 2014).

The rights of individuals and private property once enshrined solely at the national level by constitutions were transformed to the protection of investor rights and intellectual property rights at the transnational level through a series of international trade and investment agreements (Gill and Cutler, 2014). One of the significant changes brought about by constitutionalism is the increased role of the judiciary in policymaking, a concept referred to as judicial empowerment (Hirschl, 2004; Woods and Hilbink, 2009). While constitutionalism within states empowers national judiciaries to protect citizen rights against violations from the state, the new constitutionalism empowers international arbitrators to protect foreign investor rights against actions of the state. The new constitutionalism has thus entrenched a type of transnational neoliberalism built on privatisation and liberalisation as structures for economic development, and the belief that national policies that inspire investor confidence and support capital accumulation will result in economic growth and wealth creation for all members of society (Gill and Cutler, 2014).

New constitutionalism as a constraint on public health legitimacy

The roots of trade and investment agreements in constitutionalism have implications for efforts to enhance coherence between trade and health policy. The first is the legitimation of certain actors, and not others, within this policy space. In essence, constitutions have been structured to have judicial bodies arbitrate on a set of rights for individuals, namely, foreign economic actors in the new constitutionalism, as guaranteed by the state. The consequence for the negotiation of trade and investment agreements has been a legitimised role for select bureaucratic and political actors as representatives of the state, generally from finance and trade ministries; economic and business actors as representatives of the market; and legal actors as necessary purveyors of the knowledge and processes required for judicial oversight and enforcement. Health and other public policy actors are arguably not viewed as legitimate actors within this space – even though the influence of international trade and investment agreements now extends well into the realm of shaping national law and domestic public policy (Cottier and Hertig, 2003; Labonté et al., 2016) – and are largely excluded from meaningful participation in the process. One of the challenges is that trade and investment negotiations occur in closed spaces (Gaventa, 2006), where elite actors operate behind closed doors to make decisions for the people with little to no meaningful public consultation or involvement, or pretence about broadening the boundaries for participation. The secrecy of trade and investment negotiations, rationalised on the need to protect state interests from negotiating partners, may have been defensible when these agreements were limited to tariff rate reductions; but with the ever-expanding content and societal implications of these agreements, this rationale no longer suffices.

The second, related, implication is that this absence of health policy actors can translate to an absence of the range of knowledge, values and agendas of health policy actors in these agreements. As noted earlier, liberal constitutionalism was designed to protect a set of negative civil-political human rights, and while fundamental, the values of the public health discipline commonly extend to the provision of positive rights that permit or oblige action. An equity framing, adopted by many in public health, advocates for what have been referred to by Vasak as the second generation of human rights, or socio-economic human rights. These can include the right to the provision of goods meeting social needs (e.g. nutrition, shelter, education) or economic needs (e.g. fair wages, social security) (Vasak, 1977). The largely impotent environment and labour protection chapters in the TPP agreement (Wilson, 2016) demonstrate that attempts to embed positive socio-economic human rights into a structure designed to enforce negative civil-political rights may be destined for failure.

Implications for action on NCDs

These constraints on the legitimacy of both public health actors and a public health agenda will have implications for implementation of the GAP-NCDs. For example, another objective of the plan is to strengthen national capacity, leadership, governance, multisectoral action and partnerships to accelerate country response for the prevention and control of NCDs. Within this objective, the action plan calls for the establishment of public health institutions to deal with the complexity of issues relating to NCDs, including trade. Development of such institutions has been executed within intergovernmental organisations, such as the WHO’s unit on Trade, Foreign Policy, Diplomacy and Health. The mandate of this unit is to work ‘to achieve greater policy coherence between trade and health policy so that international trade and trade rules maximise health benefits and minimise health risks, especially for poor and vulnerable populations’. Its efforts are focused on improving intersectoral collaboration between ministries of health and ministries of trade, commerce and finance by providing health actors with the capacities required to shape and manage the trade policy environment for health.

This type of capacity building has also occurred at the state level, with Thailand often cited as a leader in this space (Blouin, 2007; Smith et al., 2009). Thailand has followed the United Nations Development Programme (UNDP) Individual, Node, Network and Enabling environment (INNE) model of capacity development. Under the leadership of the Ministry of Public Health, Thailand, has taken numerous actions to develop individual and organisational capacity, and build formal and informal collaborative networks among health policymakers, health researchers, trade officers, trade negotiators, foreign policy officers, academic institutions, trade policy funding agencies, private sector and civil society. Such interdisciplinary networks provide opportunities for the exchange of different disciplinary values and interests. It has also taken steps towards an enabling environment for trade and health policy coherence, including revising its national constitution in 2007 to enshrine the government obligation to provide trade information to the public, have public consultations and parliamentary approval before engaging in trade negotiations. This has supported a wider degree of cross-sectoral participation, including from public health, in preparing for trade negotiations in an attempt to secure public health interests. Thailand has also applied its efforts in international fora, including Thai representatives successfully tabling a resolution on international trade and health at the World Health Assembly in 2006 (Thaiprayoon and Smith, 2015).

Thailand is a tremendous example of what needs to happen concurrently – developing actor capacity while building institutional support to foster legitimacy – however, the level of commitment demonstrated by Thailand has yet to materialise elsewhere to build legitimacy at the international level. The necessity of collective determinations of legitimacy has been emphasised, so while judgements of legitimacy are made subjectively at the individual level, these need to reach a critical mass to be aggregated and objectified at a collective level (Bitektine, 2011; Tost, 2011). Key to having legitimacy conferred is to have one’s actions or practices seen as desirable and appropriate (Johnson et al., 2006). As described in the first section on neoliberal ideology, public health will continue to struggle with legitimacy because of the ideological barriers that will constrain its practices as being desirable or appropriate within a neoliberal economic policy dominated environment.

Elite actor interests

Within the constitutionalised space of trade and investment agreement negotiations, some of the primary interests reflected are those of the economic, political and judicial elite (Hirschl, 2004). The dominant interest of economic actors within any policy-domain, including trade and investment policy, is promoting and protecting their capacity to maintain or increase wealth and profit (Frieden et al., 2010). It has been suggested that just as domestic economic elites once entrenched liberal values through national constitutionalism (Hirschl, 2004), transnational economic elites now entrench neoliberal values and policy preferences that support their interests through the new constitutionalism. The economic elite have been successful in using the current period of transnational neoliberalism to produce macroeconomic policy that has kept wages low or stagnant, trade unions and legislatures weak, inequality high, finance strong and mobile, and allowed capital’s share of gross domestic product to reach historic highs (Blyth and Matthijs, 2017).

In comparison to economic actors, political actors have a more varied set of potential motivations and interests in the policymaking process, including re-election or retention of office, ideology and achieving policy goals (Frieden et al., 2010). It is likely that some elite political actors are ‘true believers’ in the neoliberal ideology and see it as the path to economic prosperity for their country. It has been suggested that neoliberalism is ‘… now so deeply embedded in the reflexes of the world’s ruling elites and line managers that they have difficultly conceiving the world in any other way’ (Tribe, 2009: 69). It is also possible that some elite political actors believe that in a globally integrated economy, if they do not facilitate the flow of goods, services and capital across their border and provide a set of expansive rights for investors, they may lose economic growth and employment opportunities to more competitive countries. This is an extension of the ‘race-to-the-bottom’ theory that suggests that countries undercut each other, particularly in labour and environment standards, to attract investment from transnational companies (Davies and Vadlamannati, 2013; Mehmet and Tavakoli, 2003; Olney, 2013).

It may also be that in some cases, the distinction between the political elite and the economic elite is increasingly blurred. This possibility draws upon evidence of the ‘revolving-door’ between government and the private sector and the provision of political contributions that may fund special interests over public welfare (Draca, 2014; Luechinger and Moser, 2014). For example, during an important vote in the United States on the TPP, the US Business Coalition for the TPP contributed US$1,148,971 to political campaigns with an average contribution of US$19,673 to Republican candidates and US$9,689 to Democratic candidates (Gibson and Channing, 2015). Recent appointments in the Trump administration epitomise the revolving door and corporate political influence, such as former Goldman Sachs executives Gary Cohn, now director of the National Economic Council; Steven Mnuchin, now Secretary of the Treasury; Steve Bannon, now a special adviser to Trump; Rex Tillerson, former chairman of ExxonMobil, now the Secretary of State; and Betsy DeVos, billionaire investor in for-profit education companies, now Secretary of Education (Weissman, 2017). Discerning political interests from economic interests in such a cabinet will prove problematic, if not impossible.

Economic interests in this system also extend to the judicial elite that have built and maintained the investor–state dispute settlement system. The international system of arbitration provided for in international trade and investment agreements, while generating considerable expenses for governments and tax-payers, has been a windfall for the legal industry. The legal industry has been the second largest profiteer of the system, earning over US$1.7b to date or US$8m per case (Van Harten and Malysheuski, 2016). An elite group of judicial actors have built and secured a multimillion-dollar industry that they have promoted as necessary to attracting foreign investment, about which they have controlled the academic discourse and lobbied against reforms, and within which they have acted as negotiator, litigator and arbitrator (Eberhardt and Olivet, 2012). In short, the interests of the dominant actors in this policy space boil down to money, power and resources – how to secure what they already have and how to find opportunities to potentially gain more.

Interest-based constraints on public health influence

Trade and investment negotiations have a range of power dynamics at play. From the asymmetrical trade-negotiating capacity, resources for participation and inequalities in bargaining power between high-income and low-income countries, to the disparity in access between financial ministries and public policy ministries within state actors, to the disproportionate capacity to influence negotiations between private corporate actors and private civil society actors. In a commanding display of the financial power of elite economic actors of transnational corporations, it was revealed that the combined capital of the five largest tobacco corporations, over US$400b; the five largest food and beverage corporations, over US$600b; and the five largest pharmaceutical corporations, over US$800b dwarfs 124 states with a gross domestic products of less than US$100b (Ottersen et al., 2014). This market power readily translates into political power, as demonstrated by the approximately 600 corporate lobbyists appointed as official advisers by the United States during the negotiation of the TPP agreement (Bowie, 2015; Swenson, 2014), while actors with mandates and expertise relevant to public health seldom participate in trade negotiations (WHO Commission on Social Determinants of Health, 2008).

The discrepancy in influence between corporate and civil society actors in the trade and investment space is also illustrated in committees and groups associated with the trade and investment policy space. The Codex Alimentarious Commission, a joint body of the Food and Agriculture Organization (FAO) and the WHO, has a mandate to develop and promote international food standards and guidelines that protect consumer health and ensure fair practice in food trade. The body gained prominence when under the WTO the Codex became the referent international standard in the event of a trade dispute. While objectively derived guidelines are essential to ensuring that these baselines are in the best interest of consumer health, as far back as 1993, this committee has been disproportionately influenced by private economic actors, with 662 representatives from industry and only 26 from public interest groups (Friel et al., 2007), a trend which has continued over time (Duquet and Geraets, 2012). Public health simply does not have the money, power or resources to compete with elite economic actors in this space, including their ability to secure the support of elite political or judicial actors profiting handsomely from this system.

Implications for action on NCDs

The interests of powerful economic actors will have implications for the feasibility of implementing the GAP-NCDs. For example, the objective to reduce modifiable risk factors for NCDs and underlying social determinants through creation of health-promoting environments includes recommendations for policy measures to reduce the level of sodium, saturated fat, trans-fats and sugars in prepared or processed food products as well as to limit excess calorie intake and portion sizes. These types of policy measures represent a threat to the profits of multi-billion dollar industries and the role of consumption in neoliberalism more generally. Of all of the issues discussed in this article, the formidable opposition from powerful market actors is the most recognised within public health. Former director-general of the WHO, Margaret Chan, has explicitly acknowledged that action on NCDs challenges the business interests of Big Tobacco, Big Food, Big Soda and Big Alcohol. She went on to highlight that these industries have a wealth of tactics to influence policy, including

front groups, lobbies, promises of self-regulation, lawsuits, and industry-funded research that confuses the evidence and keeps the public in doubt … contributions to worthy causes that cast these industries as respectable corporate citizens in the eyes of politicians and the public [and] arguments that place the responsibility for harm to health on individuals, and portray government actions as interference in personal liberties and free choice. (Chan, 2013)

Industry interference in public health policy is neither novel nor unexpected. Policy measures within this objective, such as a ban on trans-fats for example, will be executed within traditional public health policy space, where regulatory reform will continue to face industry opposition as it has for decades. Where coherence with trade policy is required is to ensure that agreements do not undermine policy measures at the domestic level, including protection of policy space, resistance to enhanced access for private industry, and protection from investor-state dispute settlement (Labonté et al., 2016). The exclusion of the tobacco industry as a direct participant in the TPP negotiations, due in part to the success of the Framework Convention on Tobacco Control, may have been a contributing factor in the inclusion of a tobacco carve-out mechanism in the final agreement. Moreover, it may indicate the type of progress that can be made when big industry, and not public health, is denied a seat at the table.