Health

Michael Whaites

Public Health Service

Michael is a registered nurse and midwife, an active unionist for 20 years and is now working as an organiser for the Australian Nurses and Midwives Federation, and is sub-secretary of the Oceania region for Public Services International.

The problems with the free trade agreements is this standstill and ratchet approach to regulation. If the unions in Australia were successful in getting the safe staffing levels into legislation, if we can do that before a free trade agreement that involves Bupa, then we’re OK. We won’t get it afterwards. … So you can see the way that free trade agreements are impacting on this, the way they protect companies for maintaining their tax avoidance, the way they can smash trade union rights, the way they hamper what we say is decent regulation is deeply problematic. The experience in Australia is the same as happening in NZ. I really like the model we have heard outlined that are based on Maori principles. The underlying principle of using indigenous environment-based philosophies can be really helpful because of that holistic approach they tend to take. As a long-term goal that’s really positive. As a middle term goal for our movement, we should be looking at getting governments to do whole of government impact assessments of free trade agreements, not narrowly focused impact assessments. … Focusing on health care provision and what that means for societies is a good way to tap in and get engagement from broader communities.

Micheals presentation starts at 2mins 45secs into the video.

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Marilyn Head: Michael, you have been tireless in working against the big four agreements in this area: PACER+, the TPPA, TiSA and RCEP, fighting to get better world service agreements for people. The World Bank recently issued a report which suggested the respective labour problems for Pacific Island nations in Aotearoa – not enough work in one country and skills shortages in another – could be magically fixed by moving young people to Aotearoa to work in aged care facilities. That got short shrift from New Zealand Nurses Organisation and the Pacific nurses section. Some people would think that’s a win-win situation and it has been included in a number of trade agreements. Why is that not healthy trade?

Michael: One of the key campaign goals for Public Services International is to achieve a minimum safe staffing levels in health care, whether aged care or acute care, and maintaining adequate qualifications of staff providing that care, wherever that may be. An example of that is minimum carer ratios in aged care. That’s a campaign running in Australia at the moment.

One of the big players there is Bupa, which is also active in NZ. Aged care in Australia is coming under the spotlight in many ways. There’s been exposure of resident abuse and massive understaffing, but also tax avoidance by the aged care for-profit providers. The way aged care is funded in Australia is 75% of funding comes from government providing the cash for them to provide care. So taxpayers are providing cash and the government is paying that money to aged care providers, who are cutting staffing levels and cutting qualifications, to the point where a carer is required on average to get a resident up out of bed, showered and dressed in 6 minutes. Impossible. When that was put to the providers they said it’s just an average. These are some of the lowest paid workers in Australia. This exploitation and abuse involves poor working conditions, poor agreements, workers put in untenable positions. It has got so bad there is now a royal commission into aged care in Australia and a Senate inquiry into the tax avoidance practice of these for-profits.

The staffing crisis in aged care in Australia is not because there’s not enough people to work. People don’t want to be subjected to those sorts of working conditions. People leave because economically, morally, physically they can’t stand it. Into this the industry and government want to say the answer is to bring people in from the Pacific Islands. It’s really quite a racist view that people from another country should be brought in to do the work that no one in Australia is prepared to do. You might cop that when you are thinking about fruit picking. But when you are talking about the care of a person in a care facility, the moral outrage has many avenues to run down.

Beyond aged case, there is a major risk of what happens once you have surrendered your health services to the market and the market fails. There was a case in one of the Nordic countries where an aged care provider company collapsed and something like 150,000 residents were having to be re-homed. One of the pervasive things about free trade agreements is that it undermines our public health system. Once you see the privatisation and shift to health care being something that is you obtain for profit rather than a human right it is deeply problematic. We have a banking royal commission in Australia at the moment that is showing that the financial sector was charging dead people for fees, it’s absolutely appalling. You don’t have companies like AMP coming to aged care because they care deeply about elderly residents. They care deeply about a profit and they’ll get it however they can. The risk to our human right to health when we surrender it to the market through free trade agreements can be catastrophic.

The problems with the free trade agreements is this standstill and ratchet approach to regulation. If the unions in Australia were successful in getting the safe staffing levels into legislation, if we can do that before a free trade agreement that involves Bupa, then we’re OK. We won’t get it afterwards. We won’t be able to say to these private employers that actually you have a minimum staffing level that you need to apply. So you can see the way that free trade agreements are impacting on this, the way they protect companies for maintaining their tax avoidance, the way they can smash trade union rights, the way they hamper what we say is decent regulation is deeply problematic. The experience in Australia is the same as happening in NZ.

At the broader level of wellbeing and alternatives, the zika virus outbreak in South America is a really good example of lessons that we’ve failed to learn. Zika wasn’t just about the vaccination and where you might go to get it and who might administer it. It was about the importance of good waste removal so there was no water lying in the streets where the mosquitoes could breed. It was about good personal protective equipment. It was about community education. So you can see that the Zika virus is really about a holistic approach to health care and a whole of government approach to health care.

I really like the model we have heard outlined that are based on Maori principles. The underlying principle of using indigenous environment-based philosophies can be really helpful because of that holistic approach they tend to take. As a long-term goal that’s really positive. As a middle term goal for our movement, we should be looking at getting governments to do whole of government impact assessments of free trade agreements, not narrowly focused impact assessments. They don’t do any now. The impact assessments need to be broad and our understanding of health needs to be broad. Focusing on health care provision and what that means for societies is a good way to tap in and get engagement from broader communities.

But I want to pick up on a point George made. I don’t think it’s useful to see corporations as alien automons that make their own programmes – people make decisions, people at the top of corporations make decisions. We need to name and shame them. Because it’s people who can make the decisions to reverse that. Whether it’s politicians or the corporates. We need to name the people who have failed and make right decisions on behalf of communities.

Leena Menghany, Médecins Sans Frontières

Medicines And Treatments

Lena is coordinates the access campaign for affordable medicines in India for Médecins Sans Frontières/Doctors Without Borders.

If you don’t challenge these trade agreements, they play into Big Pharma’s hands. And big pharmaceutical companies love monopolies. They prescribe these monopolies through the free trade agreements. So you’ll see Pfizer’s hand on the TRIPS agreement, but you will also see Big Pharma’s hand in the TPP. And now you see the pharmaceutical industry’s hand in the Regional Comprehensive Economic Partnership (RCEP), repeating the very same prescriptions for monopolies to keep medicine prices very high. … We’re not commies, we’re not left, we’re not right. But this just seems completely wrong, the way the free trade agreements are trying to take away the ability of governments to protect life. On labour, they are creating problems. On farming and agriculture they are creating problems. On environment there’s no question. ISDS has totally ensured that corporations can take over our land and exploit them in ways that are not in line with environmental purposes. You have medicines out there. Show me one area where these free trade agreements would benefit people, then we should talk about them. From a perspective as an Indian they don’t offer any of that.

Leenas presentation starts at 2mins 45secs.

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Marilyn Head: The access campaign in India is a big campaign launched in the more recent stages of the Regional Comprehensive Economic Partnership (RCEP) negotiations to try and oppose proposals that would undermine access to medicines. Can you tell us a bit more about the campaign and explain how trade agreements, that are meant to free up products so poor countries can get them, why doesn’t it work that way for medicines?

Lena: Trade agreements do the opposite to making affordable medicines more available. They put up obstacles to affordable medicines. Some developing countries have been fighting to make medicines themselves, to develop the technology. India is one of those few countries. Ghandi said we should make our own medicines and start developing generic medicines to address the shortages of medicines. Some of the first facilities to make medicines in India were set up post WWII so India could make the medicines it needed. Subsequently, the level of organic chemistry and other technical knowledge in India was quite high and the education system helped develop that.

We went on to develop the technology to make almost any medicines we want – injectables, biologics, small molecules. The aim in the 1970s was basically to meet the needs of India. By the 1990s it had grown into a situation where countries that couldn’t access Big Pharma’s medicines due to prices started to look towards India to try to buy the same medicines. That’s how Médecins Sans Frontières (MSF) came to India. We started to talk to the generic companies there during the Aids crisis where about 600 people were dying in South Africa from Aids every day and 8000 people were dying across developing countries due to Aids. We found that Indian companies had the capacity to make good quality medicines at very low cost. They were very competitive. They could make pediatric formulations, they could make fixed dose combinations of Aids medicines. Since then many developing countries have started to buy medicines from India. This is starting to become a developing country phenomenon where you see Thailand, Brazil, Bangladesh and others trying to make medicines.

Then come the free trade agreements. The first one was the TRIPS agreement at the World Trade Organisation trying to put up the barriers so countries can’t trade in legitimate generic medicines. That’s the problem. If you don’t challenge these trade agreements, they play into Big Pharma’s hands. And big pharmaceutical companies love monopolies. They prescribe these monopolies through the free trade agreements. So you’ll see Pfizer’s hand on the TRIPS agreement, but you will also see Big Pharma’s hand in the TPP. And now you see the pharmaceutical industry’s hand in the Regional Comprehensive Economic Partnership (RCEP), repeating the very same prescriptions for monopolies to keep medicine prices very high.

If you look at prices today – there is such a difference in different countries. It’s such a privilege to be here in NZ. I was talking to a cousin, we both grew up in India. I met him after years. He told me how he accesses his asthma medicines. He pays a very small amount and the rest of it comes from the health care system. If you look at the situation facing governments like NZ or Australia that pay for health care, you have prices as insane as $1000 a pill, which was what the Hepatitis C medicine was supposed to be when it first came out. New cancer remedies are $100,000 per patient per year. Our governments are expected to pay those kinds of prices to Big Pharma without questioning the kinds of monopolies they have and the prices they demand. This is where we need to start questioning why we are paying such high prices, when there’s competition out there and governments could choose to procure more affordably. Free trade agreements block that avenue completely.

Question: There is a question here about what power does little NZ have as a small power and a small purchaser of overseas products and services. Negotiations are founded on both parties having equal interest and influence, and we are in a situation where on the surface it seems we are very tiny. Yet India was in a position where is was perceived not as small, but as a developing nation. What can we learn from how India has developed itself.

Leena: We are talking about rights in a very different way. In India we think radically about land, about rights, about water. Movements are very vibrant in India and as access to treatment we are part of that. My experience of looking at pharmaceuticals is where I can speak from. The best thing that works for us is competition. We just fail to understand that, not in terms of services, but in terms of goods. If you look at pharmaceutical medicines, NZ may be small but it has an ability to pay for its medicines, and that’s a very important factor to remember. Negotiations work very well when you have competitors. When you’ve got the same drug from multiple suppliers you can get a good price for NZ. It doesn’t matter how small you are, if you’ve got an efficient procurement system, which NZ does have, you do have the ability to attract producers of medicines to give you good low prices. The problem is that the monopolies are increasing and blocking out competition. You cannot negotiate in a vacuum, which is the effect of the monopolies they are trying to create. This is very important to remember. You need to preserve that very efficient procurement system and negotiate what’s best for people here.

The value of Pharmac as a model for developing countries as drug purchasing agencies is really important. We tend to compare ourselves constantly to Australia and NZ. You shouldn’t do that as NZ. The US prices are inflated to such a point that if you start comparing with them, then any deal seems better than that. I think this is a mistake. Thailand has built a health care system where they are negotiating and bringing down prices, and they do something which NZ could utilise. They use compulsory licensing often – they try to get in the competitors through licensing. I think this is very important. If you compare the prices that NZ pays, MSF pays a fraction of that price. If you look at Hepatitis C medicines, we pay $120 a treatment, which is 3 months of treatment; I believe that NZ is paying about $10,000. Of course, if you compare to the US which is about $50-60,000 it seems like a really great price. But if you ask an MSF pharmacist they will say you got a really bad deal. We have to stop comparing to the US in terms of pricing and look at countries that are looking at generics as an option, and how you price generics is related to the cost of production and the quality. Building capacity on that level is very important.

The trade agreements are something that we need to oppose tooth and nail as hard as we can. That’s what MSF has been doing from day one, when the NAFTA and Central America trade agreements were being negotiated. Our job in India is to keep the free trade agreements out of pharmaceuticals. They just don’t work. There’s no transparency. This is an unequal relationship. It’s a very colonisers kind of attitude. You don’t know what’s good for you, we will tell you what’s good for you and you’ve got to adopt it because some people sat across the table and negotiated a deal. The free trade agreements have language which is very ambiguous. They are very smart. They put in the nice language and then they put in all the other crap out there that messes us up in terms of access to treatment. That’s why we are opposing them. We need to oppose them openly as movements, as people.

When the EU India agreement was being negotiated, thousands of people came to New Delhi to show their opposition. Unfortunately we are not mobilising at that level as people, as movements, to show our opposition to agreements like RCEP. They always say, oh you’ll get something in exchange. And that means what? NZ want’s the opening of the dairy market. India’s a very big dairy market for them. But India’s got small farmers running their own dairy cooperatives. So these are situations where people need to talk to each other. I’m sure people in NZ don’t want the small farmers to lose out in a free trade agreement over dairy. This is something that is very problematic. They are going after very fundamental areas. And medicine is unfortunately part of it.

I won’t go into services, because in India everyone wants the private health care market. People like me, who have no access to health care from the government, want to buy from the private health care sector. We are just consumers for them. And India is a billion plus health care market for them. The opening up of the health care services market is huge for industries, huge for corporations. And they don’t want public health care systems to exist. They don’t want the UK’s NHS to survive. They don’t want Pharmac to survive because they want to take over the markets. This is the problem we have with these free trade agreements. There is no justification for them. You can’t justify them on any grounds. As a human rights lawyer you just can’t find any justification. We should say this as openly as we can.

You know I’m not left or right. The middle class in India is very money minded. We grew up in extremely difficult situations. I’m a post-partition kid, we came from Pakistan to India, the other side came from Burma, we had nothing. All we care about is getting the next two meals, putting our children in school. We’re not commies, we’re not left, we’re not right. But this just seems completely wrong, the way the free trade agreements are trying to take away the ability of governments to protect life. On labour, they are creating problems. On farming and agriculture they are creating problems. On environment there’s no question. ISDS has totally ensured that corporations can take over our land and exploit them in ways that are not in line with environmental purposes. You have medicines out there. Show me one area where these free trade agreements would benefit people, then we should talk about them. From a perspective as an Indian they don’t offer any of that.

Dr George Laking

Climate Change

George is a medical oncologist at Auckland District Health Board specialising in respiratory malignancy, and a very big advocate for Smokefree Aotearoa NZ, a former member of Pharmac’s Pharmaceutical and Therapeutics Advisory Committee and Te Ora the Maori medical association, President elect of the NZ College of Physicians, and an active member of Ora Taiao, the Climate and Health Council.

The invitation to this hui asked us to think about principles. Coming from the Maori side and reflecting on what the principles would be, we have to wind it back right to the beginning – te kore, te po, the separation of Rangi and Papa by the atua Tane. The creation of the world of light. … There’s a particular concept – tauutuutu – the word for reciprocity. It’s a very big thing in trading situations. Coming through from yesterday’s discussion, I think that’s what we’ve been missing a lot of in the trade agreements we have had. There’s not been a lot of reciprocity. There’s a lot out of balance. Some people are doing all the value adding and supply chains and other people are left with being mines for extraction of natural resources. There hasn’t really been a concept of reciprocity in those levels. To have a chance at solving the climate change problem, of surviving it and mitigating as much of the harm as possible, it’s my belief that we have to reset the principles along those lines.

George Laking’s talk starts at 20 minutes into the video

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Marilyn Head: Pharmac is the purchasing agency for the health system. Its special position changed quite a lot in 2009. Pharmac had always been off limits in trade treaties. Suddenly in 2009 John Key said pharmaceuticals were on the table, which was a catalyst for many health sector organisations to take an active interest in trade treaties. From your perspective, why was the health community up in arms and what has been the effect?

George: Personally, I’m not opposed to questioning and re-evaluating the value of our public institutions, and sometimes by doing that we realise how incredibly valuable they are to us. My interpretation of what the previous government did is they said they might put Pharmac on the table, it might be an institution they were willing to sacrifice if the exchange in their eyes was good enough. I think Pharmac weathered that period of uncertainty. They have had to change some of their processes around the heading in the TPPA called ‘Transparency’. But I feel their fundamental ability to negotiate on the price of medicines does remain intact.

The huge upswell of interest from the health sector was instrumental to ensure Pharmac could still use the levers to get the best price. That’s the phase of history we are in. Civil society has to fight for the preservation of our public institutions. That happened, thank goodness. I don’t view the activities of Pharmac as that different from private health care associations that negotiate a lot on the price of medicines that come into their schemes. My understanding is that in the US public agencies are forbidden to negotiate the price of drugs, so Medicaid can’t do so but Health Maintenance Organisations do that all the time. That’s normal commercial practice. For Pharmac to do what it does, it has to be able to walk away from deals, say no we’re not going to buy that because that’s not value for money. As Leena Manghaney says, the prices are outrageously high. That’s profiteering basically. Once you get into that sort of market situation you can walk away and the seller has to come back with a better price if they want to have a deal.

The other part of the negotiations is having more than one seller. If it’s a monopoly situation then Pharmac is in a more difficult situation. That’s where there’s been anxiety about changes to patent law, and increasingly the length of patents on drugs, to stop generic drugs and biosimilar drugs. So long as Pharmac can walk away from deals and there’s competition among vendors, then the fundamental is intact.

Question: There are public health issues beyond medical and clinical care, like junk food, smoking, pollution and the health of the planet. What prospects are there for binding international agreements to trump trade agreements.

George: I would hope this project would clarify the shape of an alternative and progressive approach to trade agreements that does protect health. Without having to depend on other international instruments without having to rely on other agreements as we currently have.

Question: Can you talk about the implications of trade agreements for climate and health?

George: Speaking on behalf of Ora Taiao, the Climate and Health Council I want to open the topic a bit wider. In much of my reading on the topic of trade and health, health has been conflated with health care. But fundamentally health runs through everything that we do in medicine and health, we understand the social and environmental determinants of health. That’s what we’re interested in. The health of people.

The economic settings we have and the international trade settings are major determinants of the health of people. And of course climate change is here and becoming worse. In my work in cancer medicine, I have to give prognoses. People are more often than not optimistic that “we’re going to beat this”. With climate change, as with cancer, we’re going to take harm. The best that we’ll be able to do is to try to deflect as much as possible of that harm. To achieve that deflection we’re going to have to make some very fundamental changes. And we will. But we can’t just tinker at the margins. That’s my worry with conversations like this, that we talk in the context of the current approaches and we are tinkering at the margins. That’s not what the future holds for us. It holds some fundamental change.

The invitation to this hui asked us to think about principles. Coming from the Maori side and reflecting on what the principles would be, we have to wind it back right to the beginning – te kore, te po, the separation of Rangi and Papa by the atua Tane. The creation of the world of light. So what I wanted to do in the few following comments is to build on that thought and hopefully bring an interpretation of the current crisis that we have. You know that Tane achieved the separation of Rangi and Papa but wasn’t able to sustain it. That was the problem. Tane on his own could not sustain that separation, what the atua had to do was to prop up the heavens with four poles. Once the heavens had been propped up that eventually created the space within which humanity can operate. I think that space – you can knock the poles out and the sky will fall down again. There are constraints on freedom of action in the space the atua created for us.

The economic concept we have been living under for the past 30-40 years of unfettered freedom of action of markets, is seriously damaging the stability of the pillars of heaven. Our economy is like a bull in the china shop that is holding up the world that we need to live in. So what we must do in designing the new approach is reinstate higher principles than simple freedom of economic action. In the Maori world we appeal to our wider values – wairuatanga, mana tangata, kaitiakitanga, whanaungatanga, – these are all there and known to us and really they are all the necessary preconditions for tino rangatiratanga, freedom of action.

There’s a particular concept – tauutuutu – the word for reciprocity. It’s a very big thing in trading situations. Coming through from yesterday’s discussion, I think that’s what we’ve been missing a lot of in the trade agreements we have had. There’s not been a lot of reciprocity. There’s a lot out of balance. Some people are doing all the value adding and supply chains and other people are left with being mines for extraction of natural resources. There hasn’t really been a concept of reciprocity in those levels. To have a chance at solving the climate change problem, of surviving it and mitigating as much of the harm as possible, it’s my belief that we have to reset the principles along those lines.

I’ve got two more thoughts that follow from this. Corporates and land. My personal view is that the corporations we have created are indeed the alien invaders that Russel Norman talked about. They are kind of autonomous machines with their own programming. I don’t think they are especially self-aware. But they do have programming and objectives that are different from the values I have tried to espouse. The corporations appear big compared to us. But one of the things that’s been overlooked is ‘who are we?’. We’re not just the individual people here and now. We have whakapapa. We exist in deep time. Those of us in the room now are expressions of our whakapapa that goes through deep time and is much bigger than the corporations ultimately. That is a major source of our mana and power to regain control of these things we have created.

The second thing is, drawing from Margaret Mutu’s comments yesterday, we must radically revise our relationship with the land. You don’t carve up your mother and sell her piece by piece, and that’s the fundamental problem with title. I think that relationship to land – Ngati Whatua said to us at the start, losing the land, losing the relationship like that has caused harm to the health of Ngati Whatua. This is objectively true from the medical side. So whatever policy we design must include a fundamental re-appraisal of the relationship with land. It is possible to change major settings like that in international relations. Our Islamic brothers and sisters won’t use interest, for example. So whole chunks of understanding of economies can be set aside and you can find ways. NZ has been really influential in changing the understandings of the land, with the personhood of Te Urewera and Whanganui te awa. Now I understand in India as well there has been some interest in what’s happened with NZ with the River Ganges. So initiatives like this in NZ can spread out around the world. This work we are doing now has to go towards the realisation of Matike Mai, we must take that on board as the end point of this project.

Louise Delany

An Agenda For Putting Health First

Louise is a lawyer, and a lecturer in public health law at the Department of Public Health, University of Otago, Wellington. Her interests and expertise extend beyond that to putting the common good first. She is the convenor of the newly formed Tax Justice Network Aotearoa NZ, which is allied to the UK network.

Several colleagues recently identified some rules that formed a kind of checklist. If proposed trade treaties did not conform reasonably with those ideas and those rules, then we should just not sign them. That should be the basis of our advocacy. … . A central rule is that the common good should be the overarching objective of all trade treaties, which includes environmental objectives, health ones, social justice and infrastructure, and economic functioning. … So we have a fairly holistic set of ideas for what actual words are in treaties and are underpinned by the values we were talking about yesterday. If we don’t have something like those rules, then NZ’s position should be not to sign.

Louise’s presentation starts at 14 minutes into the video.

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Marilyn Head: As an advocate for rules in trade agreements that put the common good first. Can you elaborate on this?

Louise: As a lawyer I am interested in the nitty gritty of what the words in treaties actually say and actually provide. Words are the basic platform that provides the means of expressing the values that underlie those words. I am interested in what treaties should actually say. Several colleagues spent some time getting ideas from people about what the rules should be. We distilled our ideas on those rules in an article on the subject that came out last year. It has its flaws – it was for an international audience – but identified some rules that formed a kind of checklist. If proposed trade treaties did not conform reasonably with those ideas and those rules, then we should just not sign them. That should be the basis of our advocacy.

Those rules consisted of principles. A central rule is that the common good should be the overarching objective of all trade treaties, which includes environmental objectives, health ones, social justice and infrastructure, and economic functioning. That should be the central goal. In addition, we had ideas on corporate responsibilities, and changes to corporate rights. All trade treaties should spell out investor and corporate obligations, as well as rights. That should be buttressed by other forms of international law, such as the proposed UN Business and Human Rights agreement mentioned yesterday. ISDS obviously has to go, and that rule should set out what alternative forms of dispute settlement should consist of. All trade and investment agreements should have concrete forms of enforcement and incentives to comply with internationally agreed obligations, such as those in the Paris Agreement, and disincentives for those who don’t. Investor rights certainly do not include the ability to sue in any form, whether ISDS or any other form, for loss of future profits as a result of the government’s right and obligation to govern for the common good. There should also be strong connections between international law, which trade agreements are a part of, and national agreements to spell out or put conditions around investor and corporate actions in a particular country.

Those are some of the rules. In addition, international law needs to spell out more concretely hierarchical issues. At the moment environment and international health commitments are basically trumped by trade and investment treaties that in practice take precedence over social justice provisions. That needs to change and be included in both environmental and trade treaties. Enforceability should not be the kind of issue that it is. Trade treaties are the most enforceable kind of treaties that we have. That can be changed if we are careful about the incentives and disincentives that we put in treaties.

So we have a fairly holistic set of ideas for what actual words are in treaties and are underpinned by the values we were talking about yesterday. If we don’t have something like those rules, then NZ’s position should be not to sign.

Question: Most of us understand about trading in drugs and medical devices, because they are goods. In the 21st century there’s a lot of trading in health services. What are some of the services being traded, aside from aged care that Michael Whaites talked about.

Louise: Services, of which we have a burgeoning amount, comes under the General Agreement on Trade in Services (GATS) at the WTO. The GATS is a tougher form of law than the older agreement on goods. It covers services you don’t think about as crossing the border, there are different categories, which include personnel (eg. people coming here to work in aged care). There’s medical tourism when people go overseas or overseas people come here. There’s also technological services, so when I have my CAT scan it may be read in another country than our own. Then there are investment issues – does a big overseas company like Bupa want to come in and set up their own hospital in NZ or do our investors want to do that overseas.

All those services are covered by the GATS. They all pose issues which we simply haven’t thought through. They involve quality issues – people in Australia or India are generally just as good or better than us in reading those CAT scans, but what if they aren’t? We have seen lots of issues and scandals inside NZ. We don’t know what happens with privacy of our data, who has access and under what conditions. What happens when things go wrong when we are talking about cross-border services? Those are some of the issues.

There are also foreign investment issues with chains of pharmacists, dentists, GP practices, which puts us at risk if change the conditions, so a multinational corporation decides to get out of the field and suddenly you are left high and dry. I think the district nursing service on Waiheke Island is owned by an Australian corporation, similarly in the South Island.

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