We risk having a deeper public health emergency in 2021 in the aftermath of Brexit and new trade deals, warn Richard Smith, David J Hunter, Paul Kingston, and Heather Lodge

A potential “perfect storm” is on the horizon for non-communicable diseases (NCDs). Covid-19 has highlighted the importance of obesity as a risk factor for poor health outcomes; raised concerns over people’s alcohol and dietary habits; and in England alone is likely to result in an estimated 59 204 to 63 229 additional years of life lost due to breast, oesophageal, colorectal, and lung cancers. Covid-19 is associated with “highly significant levels of psychological distress that, in many cases, would meet the threshold for clinical relevance. Mitigating the hazardous effects of covid-19 on mental health is an international public health priority.” 

We are already seeing the impacts of the covid-induced recession; the inequalities that shape the UK’s social determinants of health are becoming increasingly starker, with the north of England especially hard hit. Yet, although covid-19 has monopolised the headlines during 2020, we are on the cusp of a far greater, longer, and deeper public health emergency in 2021: Brexit. While our departure from the EU dominated headlines before March this year, it is now clear that in a matter of weeks we will either have left the EU under a “hard Brexit” or with a “thin” deal, in the face of a largely resigned public and distracted policy and academic communities. 

At worst, from January 2021, we will be trading under the World Trade Organization system of trade rules and requirements, and the series of separate trade agreements required will take on even more prominence, especially in the consequences they will have for NCDs. At best, we will have in place a thin deal with the EU, which will bring significant disruption to supply chains and increased costs to consumers. Whatever the outcome, it is critical that our politicians and trade officials are held to account in their negotiations, in order to ensure that the potential risks to health are minimised, and opportunities for promoting health are seized, as trade discussions unfurl.

This is especially relevant to three major areas that affect public health and healthcare, including the longer term effects of covid-19. The first relates to three sectors: food, tobacco, and alcohol. Jamie Oliver and Joe Wicks have recently joined forces to try to raise the profile of the dangers of falling food standards post-Brexit. They highlighted the danger that trade deals could lead to foods which are higher in sugar, fat, and salt being imported into the UK, putting more children especially at risk of obesity. Although the Department for International Trade has indicated that it would not negotiate trade deals that harmed farmers or the public, it is less clear how this will be ensured.

The second concerns the environment and pollution. The connections between trade and investment and environmental quality is well recognised. Air pollution, for example, remains one of the leading causes of NCDs globally, with low and middle income countries especially affected. Transporting goods from their place of production to their place of consumption is a major contributor to air pollution. The impact of trade and investment on NCDs largely depends on whether appropriate environmental policies are in place. One of the few positives of the pandemic has been observing how the restrictions introduced due to covid-19 have improved air quality around the world. The UK government should not put such gains at risk by relaxing environmental regulations in a bid to boost economic growth. Trade, environmental, and public health policies need to be fully aligned with the broader aim of achieving sustainable development.

The third is the major concern of access to medicines. Long before covid-19, the UN General Assembly adopted a declaration from its Third High Level Meeting on NCDs in September 2018 that affirmed intellectual property rights should be “implemented in a manner that is supportive of public health and promotes access to medicines.” However, lessons from the battle over the provision of affordable, generic antiretrovirals to tackle the HIV/AIDS pandemic suggest that covid-19 presents a considerable risk of pharmaceutical companies once again adopting protectionist measures that will threaten the equitable provision of vaccines. This is a risk not just for covid-19 vaccines, but also cost effective access to medicines used to treat diabetes, cancer, and musculo-skeletal diseases.

Trade is, of course, a vital part of any country’s economic security, and we’re not suggesting that we lose sight of this. It is, however, important that we secure the benefits that trade brings while minimising the harms. Our concern is that the opacity of trade negotiations and the relative exclusion of health from debates creates a potentially dangerous imbalance. To redress, we need a concerted effort by the health community, assisted by legal and trade experts, to ensure that health is explicitly included in trade discussions and negotiations, and that parliamentary debate on trade agreements considers their health effects. We must also ensure that there’s support for research on areas where we currently lack evidence. We should know more, for example, about the potential for a framework for alcohol control equivalent to the Framework Convention on Tobacco Control, or which health protective domestic laws and public policies may be at risk in the UK’s new trade agreements.

At PETRA (the Prevention of Non-Communicable Disease Using Trade Agreements) we’re working to support evidence generation and dissemination on the links between trade and NCDs, engage public awareness, and provide expertise in health and law and fit for purpose trade negotiations. As a network, it is critical to have the support and engagement of our peers across the health community. We would invite all readers of The BMJ to visit our website and join our network. https://petranetwork.org

Richard Smith is deputy pro-vice chancellor and professor of health economics at the College of Medicine and Health, University of Exeter. He is a co-investigator with PETRA.

David J Hunter is emeritus professor of health policy and management, Population Health Sciences Institute, Newcastle University. He is a co-investigator with PETRA.

Paul Kingston is professor of ageing and mental health & co-director: Westminster Centre for Research on Ageing, Mental Health and Veterans, Faculty of Health and Social Care, University of Chester. He is principal investigator for PETRA.

Heather Lodge is acting coordinator for PETRA.

Competing interests: None declared.