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Am J Public Health. 2005 January; 95(1): 23–34.
PMCID: PMC1449846
Ethics in Public Health Research

Global Trade and Public Health

Abstract

Global trade and international trade agreements have transformed the capacity of governments to monitor and to protect public health, to regulate occupational and environmental health conditions and food products, and to ensure affordable access to medications. Proposals under negotiation for the World Trade Organization’s General Agreement on Trade in Services (GATS) and the regional Free Trade Area of the Americas (FTAA) agreement cover a wide range of health services, health facilities, clinician licensing, water and sanitation services, and tobacco and alcohol distribution services.

Public health professionals and organizations rarely participate in trade negotiations or in resolution of trade disputes. The linkages among global trade, international trade agreements, and public health deserve more attention than they have received to date.

GLOBAL TRADE AND international trade agreements have transformed governments’ ability to monitor and to protect public health (box p24). They have also restricted the capacity of government agencies to regulate occupational and environmental health conditions and food products and to ensure affordable access to medications and water. Pending proposals cover a wide range of health services, health facilities, clinician licensing, and distribution of tobacco and alcohol. Public health organizations are only beginning to grapple with trade-related threats to global health, including emerging infectious diseases and bioterrorism. Although economic globalization has attracted wide attention, its implications for public health remain poorly understood.

In this article, we analyze key global trade issues that affect public health, briefly tracing the history of international trade agreements and describing the forces shaping agreements such as the North American Free Trade Agreement (NAFTA). The recent shift to treating services as tradable commodities is of particular importance; we analyze the General Agreement on Trade in Services (GATS) as a case in point. We also discuss the implications for public health of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and the proposed Free Trade Area of the Americas (FTAA) agreement. Although many agreements contain implications for public health, as we summarize in Table 1 [triangle] and the box on page 26, we emphasize those features of agreements currently under negotiation that warrant attention by public health practitioners and organizations.

TABLE 1
Summary of International Trade Agreements and Trade Organizations Pertinent to Public Health and Their Principal Implications for Public Health

EMERGENCE OF INTERNATIONAL TRADE AGREEMENTS

Historical Origins

Although trade across nations and continents dates back centuries, the framework for current international trade agreements began after World War II with the “Bretton Woods” accords. These accords sought to generate economic growth in the reconstruction of Europe and Japan after World War II, in part by stabilizing currency rates and trade rules. Between 1944 and 1947, the Bretton Woods negotiations led to the creation of the International Monetary Fund and the World Bank and to the establishment of the General Agreement on Tariffs and Trade (GATT). GATT aimed to reduce tariffs and quotas for trade among its 23 participating nations and also established such general principles as “most favored nation treatment” (according to which the same trade rules were applied to all participating nations) and “national treatment” (which required no discrimination in taxes and regulations between domestic and foreign goods).1 GATT also established ongoing rounds of negotiations concerning trade agreements.

During the 1980s and 1990s, these international financial institutions embraced a set of economic policies known as “the Washington consensus.” Advocated primarily by the United States and the United Kingdom, these policies involved deregulation, privatization of public services, measures designed to achieve low inflation rates and stable currencies, and mechanisms enhancing the operations of multinational corporations. As the pace of international economic transactions intensified, facilitated by technological advances in communications and transportation, the World Trade Organization (WTO) in 1994 replaced the loose collection of agreements subsumed under GATT.

Trade Rules

The WTO and regional trade agreements have sought to remove both tariff and nontariff barriers to trade. Tariff barriers involve financial methods (e.g., taxes on imports) of protecting national industries from competition by foreign corporations. Nontariff barriers refer to laws and regulations affecting trade, including those that governments use to ensure accountability and quality. In more than 900 pages of rules, the WTO set criteria for permissible and impermissible nontariff barriers, for example domestic policies governing environmental protection, food safety, and health services. These rules aim to increase cross-border trade under the assumption that increased trade may enhance nations’ wealth or well-being. While aiming to achieve “free” trade across borders, the rules in trade agreements limit governments’ regulatory authority over trade and enhance the authority of international financial institutions and trade organizations.2

Examples of Actions Under International Trade Agreements That Affect Public Health

  • Under Chapter 11 of the North American Free Trade Agreement (NAFTA), the Metalclad Corporation of the United States successfully sued the government of Mexico for damages after the state of San Luis Potosí prohibited Metalclad from reopening a toxic waste dump. The Methanex Corporation of Canada sued the government of the United States in a challenge regarding environmental protections against a carcinogenic gasoline additive, methyl tertiary butyl ether (MTBE), banned by the state of California. The Free Trade Area of the Americas (FTAA), currently under negotiation, would extend such investor’s rights to all countries in the Western hemisphere except Cuba.
  • Acting on behalf of pharmaceutical corporations, the US government invoked the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) of the World Trade Organization (WTO) in working against attempts by South Africa, Thailand, Brazil, and India to produce low-cost antiretroviral medications effective against AIDS.
  • Canada challenged France’s ban on asbestos imports under WTO’s Agreement on Technical Barriers to Trade. Although a WTO tribunal initially approved Canada’s challenge, an appeal tribunal reversed the decision after international pressure.
  • On behalf of the beef and biotechnology industries, the United States successfully challenged the European Union’s ban of beef treated with artificial hormones under the WTO Agreement on the Application of Sanitary and Phyto-Sanitary Standards.
  • Currently under negotiation, the WTO General Agreement on Trade in Services (GATS) targets the removal of restrictions on corporate involvement in public hospitals, water, and sanitation systems. GATS could affect state and national licensing requirements for professionals and may raise challenges to national health programs that limit participation by for-profit corporations.
  • In the first trade dispute decided under GATS, a WTO tribunal rejected Mexico’s defense of its telecommunications regulations. The tribunal found that charges including a contribution to the development of Mexico’s telecommunications infrastructure were not “reasonable.” Mexico had argued that GATS provisions appeared to give flexibility to governments in achieving development objectives, including Mexico’s policy goal of promoting universal access to basic telecommunications services for its population.

Although the WTO (under general exceptions of GATT, Article XX) permits national and subnational “measures necessary to protect human, animal or plant life or health,” other provisions make this exception difficult to sustain in practice. For example, a country can be required to prove that its laws and regulations represent the alternatives that are least restrictive in regard to trade and that they are not disguised barriers to trade.3 Such rules also can restrict public subsidies, including those designated for domestic health programs and institutions, labeling them potentially “trade distortive.” Requiring that such subsidies apply equally to domestic and foreign companies that provide services under public contracts can preempt public policies directing subsidies to domestic corporations.

Of particular relevance to public health, 1 WTO provision requires “harmonization,” that is, reducing variations in nations’ regulatory standards for goods and services. Proponents have noted that harmonization can motivate less developed countries to initiate labor and environmental standards where none had previously existed.4 However, harmonization also can lead to erosion of existing standards, because it requires uniform global standards at the level least restrictive to trade.5 The WTO encourages national governments to harmonize standards on issues as diverse as truck safety, pesticides, worker safety, community right-to-know laws regarding toxic hazards, consumer rights regarding essential services, banking and accounting standards, informational labeling of products, and pharmaceutical testing standards.

Trade Enforcement and National Sovereignty

WTO and regional agreements such as NAFTA supersede member countries’ internal laws and regulations, including those governing public health. Under these agreements, governments at all levels are facing loss of sovereignty in policymaking pertinent to public health and health services. Technically, nations apply voluntarily to become WTO members. However, most less developed countries perceive that they will experience disadvantages in trade relations if they do not join.6 Traditionally, government agencies at the federal, state, county, and municipal levels have been responsible for protecting the public’s health, for example by ensuring safe water supplies, controlling environmental threats, and monitoring industries in regard to occupational health conditions. Trade agreements can reduce or eliminate such governmental activities to the extent that they represent barriers to trade.

In cases of dispute, an appointed 3-member WTO tribunal, rather than a local or national government, determines whether a challenged policy conforms to WTO rules. This tribunal includes experts in trade but not necessarily in the subject matter of the cases in question (e.g., cases involving health or safety) or in the laws of the contesting countries.3 Documents and hearings are closed to the public, the press, and state and local elected officials; the WTO considers only federal governments as members.

When a tribunal finds that a domestic law or regulation does not conform to WTO rules, the tribunal orders that the contested transaction in question must proceed. If a country fails to comply, the WTO can impose financial penalties and authorize the “winning” country to apply trade sanctions against the “losing” country in whatever sector the winner chooses until the other country complies. In challenges decided by WTO or NAFTA tribunals, corporations and investors have caused governments to suffer financial consequences and trade sanctions because of governments’ efforts to pursue traditional public health functions (box p24). Losing countries in these cases experience pressure to eliminate or to change the legislation in question and not to enact similar new laws.

TRADE AGREEMENTS AND PUBLIC HEALTH

A set of international trade agreements applies to all WTO member countries (currently 148). WTO agreements pertinent to public health include GATS, TRIPS, the Agreement on the Application of Sanitary and Phyto-Sanitary Standards, and the Agreement on Technical Barriers to Trade. In addition, regional agreements and nation-to-nation (bilateral) agreements are proliferating, with provisions based on the WTO and NAFTA.

North American Free Trade Agreement (NAFTA)

Initiated in 1994, NAFTA focuses on expanding opportunities for new investments, acquiring property, and opening services to competition by private corporations in the United States, Canada, and Mexico. NAFTA provisions have proven controversial, in that numerous US-based manufacturing industries have moved to Mexico, where environmental and occupational health standards are less strict and most companies pay lower wages. Unemployment and cuts in benefits for workers remaining employed in the United States have resulted in a growing number of uninsured workers and families.7 Overall, NAFTA did not create the new jobs in the United States that proponents predicted and has contributed to increasing inequality of wages.8

In Mexico, NAFTA’s impact has proven more dramatic. Jobs lost in agriculture owing to the increases in imports have far outweighed the jobs created by export manufacturing. Unemployment has increased most dramatically in rural areas.8 After NAFTA lowered tariffs on US agricultural products, crop prices dropped, and even Mexican subsistence farmers could not compete with US agribusiness, which receives large government subsidies. Between 1994 and 2003, 9.3 million workers entered Mexico’s labor market, but only 3 million new jobs were created during that period; in the same time span, real wages lost approximately 20% of their purchasing power.9 NAFTA also has led to widespread environmental damage as agriculture has seen a shift to large-scale, export-oriented farms that rely on water-polluting agrochemicals and more use of water for irrigation.8 Chronic public health problems along the border between the United States and Mexico persist.10

Chapter 11 of NAFTA, concerning investments, includes a unique “investor’s rights” mechanism by which individual foreign corporations (referred to as “investors”) can directly sue any of the 3 participating national governments. Before the establishment of NAFTA, trade agreements permitted only country-to-country enforcement by governments. However, companies can now sue for loss of current or future profits, even if the loss is caused by a government agency’s prohibiting the use of a toxic substance.11

Several landmark cases filed under Chapter 11 have dealt with environmental laws or regulations. For example, a NAFTA tribunal awarded the US-based Metalclad Company $16.7 million in its suit against Mexico. The state of San Luis Potosí had refused permission for Metalclad to reopen a waste disposal facility after a geological audit showed that the facility would contaminate the local water supply and after the local community opposed the reopening. Metalclad claimed that this local decision constituted an expropriation of its future potential profits and filed a successful suit against the country of Mexico.12,13

In addition, the Methanex Corporation of Canada initiated an approximately $1 billion suit against the United States after the state of California banned the use of methyl tertiary butyl ether (MTBE), a gasoline additive, because of its demonstrated carcinogenicity. Methanex produces methanol, a component of MTBE. This case remains under consideration by a closed appeal tribunal, while MTBE remains in use in California.

Such cases can exert a chilling effect on environmental protection efforts. For instance, several other states have deferred their planned bans on MTBE as a result of the threat posed by the pending Methanex case.14 Similar investor’s rights provisions have appeared in other regional and bilateral agreements, such as those recently negotiated by the United States with Singapore and Chile.

Free Trade Area of the Americas (FTAA)

The FTAA proposes that most provisions of NAFTA be extended to all 31 of the remaining nations in the Western hemisphere with the exception of Cuba.15 Ongoing negotiations include efforts to introduce an investor’s rights clause, similar to NAFTA’s, as well as to replicate features of GATS and other WTO agreements. If completed on schedule, negotiations will conclude in early 2005.

The FTAA agreement would foster participation of multinational corporations in administering programs and institutions, such as public hospitals and community health centers, currently managed in the public sector. US-based insurance companies have expressed their interest in delivering services now provided by public sector social security systems throughout Latin America,16 as indicated in their testimony on the FTAA (Washington, DC, March 28, 2000): “public ownership of health care has made it difficult for U.S. private-sector health care providers to market in foreign countries. . . . Existing regulations . . . present serious barriers . . ., including restricting licensing of health care professionals, and excessive privacy and confidentiality regulations.”17

Proponents of privatization emphasize the inefficiencies and corruption that have occurred in some countries’ public sector programs. However, in many countries privatization and the participation of multinational corporations in public services have led to problematic effects. Such changes in Latin America have resulted in barriers to access stemming from copayments, private practitioners’ refusal to see patients because corporations have not paid professional fees, and bureaucratic confusion in the assignment of private providers; public sector expenditures increasingly have covered the higher administrative costs and profits of investors as clinical services have decreased for the poor at public hospitals and health centers.16,18,19 Similar trends have occurred in Africa and Asia.20,21

Although, at present, countries are free to privatize public services, the FTAA would impose the threat of a trade challenge against countries’ decisions to maintain or to expand public services, as well as costly trade sanctions if privatized services were to be returned to the public sector. FTAA chapters directly related to public health cover trade in services such as health care, water, education, and energy; intellectual property, which addresses access to affordable medications; standards for plant and food safety; and rules regarding governments’ allocation of subsidies and procurement of goods and services. Also important to public health, the FTAA’s language on financial investments adopts Chapter 11 of NAFTA as a model, and rules on trade in products could restrict governments’ regulation of product safety.

The FTAA process is entirely “top down”; all services are covered by all FTAA rules unless a country takes action affirmatively to exclude specific services. The Central American Free Trade Agreement (CAFTA), awaiting final review by Congress as of late 2004, and recently concluded US bilateral agreements with Chile, Singapore, Vietnam, and Jordan contain similar provisions.

General Agreement on Trade in Services (GATS)

Recognizing the increasing proportion of economic activities worldwide devoted to services, this WTO agreement encourages private investment and deregulation in terms of a wide spectrum of services. GATS treats human services such as health care, water and sanitation, energy, and education as commodities subject to trade rules. According to its stated aims, GATS will progressively cover an increasing number of services over time. The current round of GATS negotiations is scheduled to conclude in 2005.

A majority of GATS rules, including “most favored nation,” are “top down” (Table 2 [triangle]). That is, they already apply to all services in all WTO member countries. For example, according to the domestic regulation rule, government regulations regarding services should not be “more burdensome than necessary to ensure the quality of the service,” and qualification requirements and procedures for service providers, technical standards, and licensing requirements should not constitute unnecessary barriers to trade in services.1 When the process of minimizing trade restrictions comes into conflict with health standards, trade tribunals under WTO usually have decided that the former take priority.22 GATS sections on subsidies and government procurement, described subsequently, also apply to all services offered.

TABLE 2
Major Provisions and “Top-Down” Rules Relevant to Public Health in the General Agreement on Trade in Services (GATS)

Because many countries have opposed expanding WTO rules to the service sector, GATS operates, to some extent, according to a stepwise approach. Through a “bottom-up” process, nations negotiate with each other to “commit” to covering (or adding to the list of) services falling under 2 trade rules (Table 3 [triangle]). One of these rules, referred to as “market access,” prohibits governments from restricting numbers or types of service providers. As an example, this rule could undermine local laws restricting the number of liquor stores on a city block. Under the second rule, “national treatment” (described earlier), a country must treat foreign companies in the same manner as domestic companies.23 Programs designed to achieve social goals, such as measures aimed at ensuring accountability in regard to national privacy regulations by restricting medical transcription services to domestic companies, could violate this rule by “discriminating” against foreign corporations.

TABLE 3
Selected Health-Related Services Currently Covered by the United States Under the “Bottom-Up” Rules of the General Agreement on Trade in Services (GATS)

Within these 2 rules, GATS specifies 4 service modes to which a country can commit particular services24: (1) delivery of services based in 1 country to consumers based in another country (e.g., telemedicine), (2) delivery of services to foreign consumers within the provider’s country (e.g., “niche” specialty medical services that patients travel to receive), (3) investment in the services of another country, and (4) temporary migration by workers. For example, covering a service such as hospitals under Mode 3 can restrict nations’ or states’ ability to limit or control foreign investments in their health care systems. Covering nurses under Mode 4 can accelerate the migration of trained clinicians.

There is no formal process for public debate in GATS decisions about committing services; countries make confidential requests regarding services that they would like other countries to commit, and the respondents can agree or disagree. Regarding public health, the European Union has requested that the United States drop restrictions on private corporate involvement in water and sanitation systems, as well as in the retail distribution of alcohol products.25 While the European Union has announced that it will not commit further any of its own human services, both the EU and the United States seek removal of barriers to trade in other countries covering health services, energy services, higher education, and environmental services.26

Several countries have submitted GATS requests with important implications for US health services (Table 4 [triangle]). For instance, India has asked that the United States recognize foreign licensing and other certified qualifications of medical, nursing, and dental professionals. Mexico has requested that the United States no longer limit foreign direct investment in hospitals and health facilities. Both Mexico and Paraguay have asked the United States to eliminate the “restriction of federal and state reimbursement to licensed, certified [health] facilities in the United States or a U.S. state.”25

TABLE 4
US Services for Which Other Countries Have Requested Future Coverage Under the “Bottom-Up” Rules of the General Agreement on Trade in Services (GATS)

Although the technical language of GATS has generated controversy about the extent of its eventual effects,27 GATS will probably affect public sector health programs in several ways. First, GATS will facilitate greater participation by private corporations within public health care institutions. For instance, the United States currently includes hospitals and health insurance coverage (within GATS, the latter falls under financial services rather than health services) in its commitments. Under GATS rules on public subsidies and government procurement, subsidies awarded to institutions for treatment of the underserved, graduate medical education, or research may be discontinued if challenged by other countries, or they could be directed to foreign private corporations that offer competing services. Municipal and county governments that reject bids or attempt to discontinue contracts with foreign companies could become liable to challenge. Although GATS proponents emphasize that countries’ commitments remain voluntary, policy analysts have expressed concern that WTO rules will permit a variety of challenges to countries with national health programs.28–30

Nations’ commitments under GATS so far have varied.4,31 The European Union has committed to including medical, dental, nursing, and hospital services, but not health insurance coverage, which therefore would remain in the public sector. Canada has not committed in regard to any health services. Although the United States has committed for hospital services, health facility services, and health insurance coverage and proposes to expand its commitment under “environmental services” to include wastewater, it has not made commitments in regard to professional licensing, alcohol and tobacco distribution, or drinking water. If the GATS objective of eventually including all services is achieved, however, these limits will prove temporary.32–34 Tables 2 [triangle]–4 [triangle] presents health-related services in the United States now covered by GATS, and those that could be covered in the future.

Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS)

The TRIPS agreement protects patents, copyrights, trademarks, and industrial designs across national boundaries. On the basis of the argument that such protections enhance economic incentives for creativity and invention, this agreement covers patented medications and equipment, textbooks and journals, and engineering and architectural innovations for health institutions, as well as computer technologies and entertainment products. TRIPS rules mandate that all WTO member countries implement intellectual property protections that provide 20-year monopoly control over patentable items. Entry into the WTO required that the United States extend patents from 17-year terms to the WTO’s 20-year standard.

TRIPS can limit governments’ ability to provide generic medications under publicly funded programs. For instance, federal and state government health programs such as Medicare and Medicaid have paid substantially higher drug prices as a result of these patent extensions. Overall, TRIPS has adversely affected US health care cost containment efforts by extending the period during which purchasers have had to pay higher prices for medications covered by patents.3,35

Provisions of TRIPS also could block proposals to reimport affordable prescription drugs from Canada into the United States.36 Similar provisions have appeared in bilateral agreements such as the Australia Free Trade Agreement.37

TRIPS especially affects access to medications for life-threatening conditions in low-income countries. TRIPS rules required most developing countries to change their rules by 2001, while the “least developed countries” must do so by 2016. One policy tool designed to deal with this problem in low-income countries, permissible under TRIPS rules, involves “compulsory licensing.” Under this provision, a country may require that a pharmaceutical company obtain a government license to market a needed medication under patent at a lower price than the company could charge under usual market conditions. The US government has supported efforts under TRIPS to prevent the governments of South Africa, Thailand, and Brazil from initiating compulsory licenses for production of generic alternatives to patented AIDS medications.38–40

As a result of concerns among professionals, legislators, and advocates, the Doha round of WTO negotiations in 2001 involved a proposal to relax some of TRIPS’s most severe rules regarding patent protection for medications useful in treating AIDS.41,42 Partly by threatening to impose compulsory licensing, Brazil’s government obtained low prices from pharmaceutical companies; this change has facilitated improvements in the country’s AIDS morbidity and mortality outcomes.43 In August 2003, the US pharmaceutical industry abandoned its insistence that the relaxed rules apply only to medications for AIDS, tuberculosis, and malaria.44 The resulting agreement has led to WTO control over a complex process for approving lowered medication prices under limited circumstances and leaves the issue of accessible medications in less developed countries unresolved.45–47

ACTIONS TAKEN BY PUBLIC HEALTH PRACTITIONERS

Concern about trade policies that cause adverse effects on public health has increased worldwide.48,49 Specific instances of organized resistance have shown that such policies can be blocked or reversed. For instance, as already described, the coordinated international efforts to expand the availability of AIDS medications in Africa despite TRIPS restrictions led to major changes in trade policies, and, partly by threatening to impose compulsory licensing, Brazil’s government helped improve AIDS outcomes through low medication prices.41 In addition, the campaign to eliminate users’ fees in public sector health services and education led to a major change in the World Bank’s policies in regard to enhancing privatization and corporate trade in services. Communities in Bolivia have succeeded in reversing the privatization of water supplies. Finally, through a series of protests, a coalition of health professionals, nonprofessional health workers, and patients in El Salvador has repeatedly blocked the privatization of public hospitals.

Alternative projects favoring international collaboration have countered some of the adverse effects of global trade on public health. For instance, the Brazilian Workers Party, which won the country’s presidency in late 2002, has emphasized expansion of public hospitals and clinics at the municipal level. Adopting the principle of community participation in municipal budgets, the new government has encouraged strengthening municipal public services and has attempted to limit the participation of multinational corporations in the area of public health. Such efforts have occurred in the context of a growing network of organizations that emphasize a strengthened public sector, critically assess the corporatization in health care that international trade agreements encourage, and express concern about the impact of global trade on public health, health services, and democracy.50,51

Because critical trade negotiations are taking place now and in the near future, we recommend that public health practitioners engage in several actions to address the growing challenges of global trade:

  • Participate in national and international networks that conduct research, surveillance, and advocacy concerning global trade and public health.
  • Engage in educational outreach to encourage more informed decisions about the relationships between global trade and public health and to influence the direction of international trade agreements; outreach activities should target (1) professional associations in the areas of public health, clinical medicine, health policy, and allied health professions; (2) state, county, and local health departments; (3) local communities and civic organizations; and (4) elected officials at the federal, state, county, and municipal levels.
  • Engage in efforts to introduce the themes just mentioned into the public media.
  • Conduct further research on the public health implications of existing and pending trade agreements.
  • Gain public health representation on advisory committees to the US Congress and the US Trade Representative.

The Center for Policy Analysis on Trade and Health maintains a listserve on globalization and health and also has posted on its Web site (available at: http://www.cpath.org) brief descriptions and contact information for key organizations attempting to address the public health effects of global trade.

CHALLENGES FOR PUBLIC HEALTH

The changing conditions of global trade have raised important challenges for public health, including privatization and reduction of public services; reduced sovereignty of governments in regulating services, medications, equipment, and economic activities that affect occupational and environmental health; and enhanced power of multinational corporations and international financial institutions in policy decisions. Processes that link global trade and health often occur silently, with little attention or representation by legislators, the public media, and health professionals.18

Linkages between global trade and public health deserve more critical attention. A growing number of advocacy organizations and professional associations have drawn attention to such linkages.52–56 Those concerned with health and security worldwide cannot afford to ignore the profound changes generated by global trade.

Table t5
Glossary of Key Terms

Acknowledgments

This research was supported in part by grants from the National Library of Medicine (grant 1G08 LM06688), the New Century Scholars Program of the US Fulbright Commission, the John Simon Guggenheim Memorial Foundation, the Roothbert Fund, the US Agency for Healthcare Research and Quality (grant 1R03 HS13251), the National Institute of Mental Health (grants 1R03 MH067012 and 1 R25 MH60288), the United Nations Research Institute for Social Development, and the Unitarian Universalist Veatch Program at Shelter Rock.

Ellen R. Shaffer and Joseph Brenner thank Alicia Yamin, Erica Frank, and Kristen Smith for their contributions to this work. Howard Waitzkin and Rebeca Jasso-Aguilar are grateful to Ron Voorhees, Carolyn Mountain, Celia Iriart, Angela Landwehr, Francisco Mercado, and Lori Wallach for their contributions to this project.

Note. The views expressed in this article do not necessarily represent those of the funding agencies.

Notes

Contributors
E.R. Shaffer and H. Waitzkin originated and designed the research and drafted the article. All of the authors participated in data acquisition and interpretation, provided administrative and technical contributions, and contributed to revising the article for content. E.R. Shaffer and H. Waitzkin obtained funding for the study.

Peer Reviewed

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