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A couple of weeks ago I wrote a quick diary reflecting on the upcoming trade negotiations between the EU and US. It reflected on the fact that proponents praise the forthcoming trade agreement for its potential to breathe life into recession-torn economies (via export-related job growth), but cautioned that export gains are responsible for creating a decreasing number of new jobs, and that other rosy predictions for trade-related job growth haven’t exactly panned out.

The diary didn't get much traffic in way of comments, but nonetheless I was surprised by the undisturbed nature of the small number of replies that were made. In short, commenters noted that because the EU and US have similarly advanced economies, wages, and regulatory protections, we shouldn't worry too much about jobs being outsourced or about imports causing significant job losses. Unfortunately, things are not so straightforward.

I should mention that I'm by no means an international trade expert. My interest in trade stems from my work as a public health researcher. The connection might seem bizarre, but as a public health researcher I am interested in the social factors that contribute to people’s health. Social factors like peoples’ income, education, employment---essentially, the types of resources which allow us to exert some sort of control over our life: where we live, what kind of employment we can take up, how much time we can spend with our families, the type of food we can afford. In other words, rather than being interested in things like healthcare and medicine (factors that help us when we’re sick), I am interested in the types of factors which help us from becoming sick in the first place.

This is where trade enters into the equation. If trade has an impact on these important social factors, like employment and income, we need to know what that impact is. It is true, generally speaking, that the US and EU are both advanced economies, but the EU is not a homogeneous market. The EU is an economic and political union made up of 27 very different countries. As such, there are a handful of countries in the EU where labour costs in the manufacturing sector are significantly lower than they are in the US. Below is a graph from the US Department of Labor. It shows that in the US, manufacturing costs are $35.53 per hour. This is lower than costs in some EU countries like Norway, Belgium or Denmark, which might fare well for the US when it comes to the US/EU trade agreement. But take a look at some of the EU countries on the right hand side of the chart, where labour costs are much less than they are in the US – for example in Estonia, Hungary, and Poland. In Poland manufacturing costs are 75% lower than they are in the US; workers in the manufacturing sector in Poland receive only slightly higher wages than manufacturing workers in Mexico.  

Again, I'm not a trade expert, but I am interested in what a trade agreement between the US and EU would mean, both for American and European workers. And while it may seem we have a lot in common with our counterparts across the pond, perhaps we have less in common than we think. If so, we should be very careful in assuming that this agreement doesn't have the potential to make very significant impacts both on our respective economies and our levels of health.  

Wed Mar 20, 2013 at 05:32 PM PDT

More Trade, More Jobs?

by healthypolicies

Today the Obama Administration notified Congress of its plans to enter into negotiations with the European Union over the Transatlantic Trade and Investment Partnership (TPIP). Actually Obama announced plans to negotiate the pact in his speech to Congress back in February, but it's US practice for the administration to send lawmakers a formal notification at least 90 days before beginning trade talks.

Proponents on both sides of the Atlantic will praise the pact for its potential to breathe life into recession-torn economies via export-related job growth. However, two caveats to this enthusiasm are worth noting.

First, figures from the government's own International Trade Administration show that export growth is responsible for increasingly less job growth. Whereas in 2009 one billion dollars in export growth was noted to be worth 5,998 jobs, in 2012 it was estimated to be worth only 4,926. That's an approximately 18% decline in 3 years. Since the TPPP is likely to take at least a couple years to iron out, its value in terms of job creation should be carefully considered. Especially in light of arguments which relate freer trade to depressed wages and greater income inequality.

Second, just because a free trade agreement has potential to increase export growth, doesn't mean it will. Last Friday marked the one-year anniversary of the U.S.-Korea Free Trade Agreement. Data released from the government show that in the year since its implementation, US exports to Korea decreased by 9%, all while imports from Korea are on the rise. In other words, what’s happened is the exact opposite of what the Obama administration promised: export growth and more jobs.


According to the Centers for Disease Control, the US is in the midst of the worst flu season it’s seen in a decade. In Boston, a state of emergency has been declared, where at least 18 people have died because of the flu. The CDC recommends that people with flu-like symptoms stay home and avoid contact with others, except to receive medical care. But as Think Progress reports,

“for a huge number of American workers, that option doesn’t exist due to a lack of paid sick days. 40 percent of private sector workers and a whopping 80 percent of low-income workers do not have a single paid sick day. One in five workers reports losing their job or being threatened with dismissal for wanting to take time off while sick”
So what’s a country to do?

One idea is to avoid restaurants that don’t provide paid sick leave—in the food industry the potential for spreading disease is high, especially with 79% of workers reporting that they are unable able to take a paid sick day.

While this would do little for sick workers this season, it does have the potential to reduce the spread of disease, and perhaps it could act as an incentive for employers to provide better benefits to their workers (although there are other reasons why providing paid sick leave is good for business).

Which restaurants don’t provide paid sick leave to their employees?

Each year the Restaurant Opportunities Centers (ROC) United publishes a guide on the working conditions in popular America restaurants. In their latest guide, the following restaurants are noted for not providing paid sick leave:

7-Eleven Logan’s Roadhouse
AppleBees Long John Silver’s
BJ’s Restaurants Longhorn Steakhouse
Bob Evan’s Restaurants Luby’s Cafeteria
Bojangle’s Famous Chick ‘N Biscuits Maggiano’s Little Italy
Bonefish Grill McCormick & Schmick’s
Boston Market McDonald’s
Buca Di  Beppo Moe’s Southwest Grill
Buffalo Wild Wings Morton’s, The Steakhouse
California, Pizza Kitchen Noodles & Company
Capital Grille O’Charley’s
Captain D’s Old Chicago
Carino’s Italian On the Border
Carl’s Jr Outback Steakhouse
Carrabba’s Italian Grill Papa Murphy’s
Cheddar’s Causual Café Perkin’s Restaurant Bakery
Chick-Fil-A Popeyes Louisiana Kitchen
Chili’s Grill Bar Portillo’s Hot Dogs
Church’s Chicken Pot Belly Sandwich Works
Coldstone Creamery Qdoba Mexican Grill
Coner Bakery Café Quizno’s
Cracker Barrel Old Country Store Rainforest Café
Dave & Buster’s Rally’s Hamburgers
Denny’s Red Robin Gourmet Burgers
Dunkin’ Donuts Ruby Tuesday
Famous Dave’s Ruth’s Chris Steak House
Firehouse Subs Sbarro Pizza
Five Guys Burgers & Fries Sheetz
Fleming’s Prime Steakhouse & Wine Bar Starbucks
Fuddruckers Steak N Shake
Godfather’s Pizza Subway
Golden Corral T.G.I Fridays
Hardee’s Taco Bell
Houlihan’s The Melting Pot
Huddle House Uno Chicago Grill/Pizzeria
Jason’s Deli Whataburger
Jersey Mike’s Subs Wienerschnitzel
Johnny Rockets Wingstop
Krystal Yard House
Little Ceasers Pizza
[This piece is cross posted at Healthy Policies]

Atleast 97. has partnered with anonymous Tweeter, @gundeaths, to keep an interactive, crowdsourced tally of gun related deaths since Dec 14. See Here


Mammoth retail giant, Walmart, announced last week that it will cover 100% of healthcare costs for its US employees needing specialty heart, spine and transplant surgeries. And that’s not all.  For those needing treatment in what it calls its ‘Centers of Excellence’ program, the company is also offering an all-expenses-paid trip to some of the nation’s most prestigious hospitals. Coincidentally (but perhaps not), this news comes amid the first strike ever launched against the retailer in its 50-year history, with protests currently spreading across 28 stores in 12 states.

What are the health implications of this program and what do they mean in the context of worker strife? Examining the initiative on its own suggests that any beneficial impact the program might have on worker health is severely limited.

Sally Welborn, senior vice president of the chain’s global benefits says, “We devoted extensive time developing Centers of Excellence in order to improve the quality of care our associates receive”.

But how many of Walmart’s associates will actually be able to benefit from this program? To benefit workers must first be covered under the retailer’s healthcare plan, comprising not only an elusive number of employees, but most likely a dwindling group as well. In 2009, the company claimed that 52% of its 1.4m employees were covered; however this was before it eliminated health benefits for its part-time employees and hiked premiums for its full-time workers. And since then, the retail giant has declined to give figures of those covered. A Walmart watch group called Making Change at Walmart, estimates that for an average employee who earns $8.81/hr and works 34 hours per week, some of Walmart’s 2012 healthcare plans would cost between 77% and 104% of the employee’s annual gross income. This perhaps explains studies which show that Walmart workers are more likely than others in the industry to rely on government benefits, as well as criticisms that taxpayers are subsidizing the company by paying the healthcare costs of workers who are not insured on the company’s plan.

If the fact that the Centers of Excellence program is problematic to the extent that its impact on worker health will be seriously limited, even more problematic is the fact that it conveys a false sense of consideration for the lives and health of its workers. For while the Centers of Excellence program certainly is a great initiative for those who can afford the company’s insurance, most likely its upper managers and executives, clearly the well-being of the majority of its workers is not the company’s primary concern.  Moreover, while the program’s stated aim is to improve the quality of care for its employees, Walmart consistently disregards workers’ quality of life. Adverse working conditions have become a hallmark of Walmart’s employment model, brought more sharply into the public’s focus by various corporate watch groups, journalistic first-hand accounts like Barbara Ehrenreich's Nickled and Dimed, and now by the growing display of Walmart workers walking off the job.

In this context, the announcement of the new program, whether deliberate in its timing or not, has the potential to direct attention away from the concerns being voiced by striking workers. And not only does it initiate publicity which is distracting to legitimate calls for living-wages and better working conditions, it is an implicit challenge to valid attempts by workers to improve the conditions of their lives. This is because it covertly throws into question the basis on which workers are protesting. In other words, it provokes the question, “Why are workers striking if Walmart is so obviously concerned with worker well-being?”. However, any achievement in the improvement of workers’ health is much more likely to come from the demands being voiced in opposition to the company’s current modus operandi. Indeed if striking workers are able to secure higher wages and better working conditions, health improvements are likely to have ripple effects beyond that of individual workers to both the workers’ families as well as to their broader communities.

This piece is cross-posted at Healthy Policies




Last week the New York Times reported on a study which documents a reversing trend in life expectancy for the least educated whites in the US. The study shows that since 1990, life expectancy for white Americans without a high school diploma has fallen by five years for women and three years for men. Reading this article, one is likely to deduce that these declines are largely the result of individual health behaviours and life style choices.

Per the NYT,  reasons offered by researchers for this decline include “a spike in prescription drug overdoses among young whites, higher rates of smoking among less educated white women, rising obesity, and a steady increase in the number of the least educated Americans who lack health insurance”.

A range of public health experts are also quoted in the piece and offer roughly the same type of behavioural explanations. At the end of the article, Lisa Berkman, director of the Harvard Center for Population and Development studies, at least begins to shift the focus further up the causal chain and notes that the reversal in life expectancies “should be seen against the backdrop of sweeping changes in the American economy and in women’s lives”, highlighting the deleterious impact of low-wage jobs on women’s health.

Two days later it is Paul Krugman, an economist, not a public health expert, who highlights that worsening trends in life expectancies have taken place in the context of increasing income inequality (see also Katherine Greir’s  piece on Alternet, which Krugman cites).

Is this surprising? Not really. Krugman has noted the corrosive impacts of income inequality before; he’s even made direct references to the Spirit Level, a book which systematically outlines how income inequality is related to societies’ physical and mental health, as well as their levels of drug abuse, education, violence, and community life.

Unfortunately, Krugman’s easy receptivity to the political determinants of health is not mirrored in the work of national public health campaigns. In 2010, the US Department of Health and Human Services launched Healthy People 2020, a 10-year agenda for improving the health of Americans. However, despite its stated goal of achieving health equity by 2020, nowhere in its description of the social determinants of health is attention drawn to income inequality. Moreover, attention is scantily paid to the socio-political factors responsible for unequal distributions of resources important for health: resources like income, food, transportation options, social support, etc.

It is now well evidenced that in places where income inequality is greater, population health outcomes, like life expectancy and infant mortality, are worse. Unfortunately American public health professionals, and health journalists alike, continuously fail to acknowledge and translate the implications of this evidence.

[cross-posted at Healthy Policies]


Last year I wrote a piece about why Occupying Wall Street can make the US Healthier. In honour of the Movement's one year anniversary I offer a condensed version of that post here.

What does the Occupy Movement have to do with Public Health?

One of the movement’s fundamental concerns, excessive levels of income inequality, is a major determinant of health.

Protesters recognize that social ills, like income inequality, are a consequence of deliberate actions by individuals and groups who impart undue influence on the government. This is crucial. For it is ultimately this undue influence which threatens the quality, availability and distribution of resources important for health. Resources like income, employment, food, healthcare, housing, education, and the environment. By demanding sweeping reform of an entrenched system, protesters are thus taking aim at the ultimate determinants of health.

There are many reasons why the Occupy Wall Street movement should be supported.  For those concerned with the public's health the call to action should be answered without hesitation.



Last Friday a Wisconsin county Judge, Juan Colás, struck down much of Act 10, also known as the ‘budget repair bill’. The Act, which was proposed and vehemently defended by Republican Governor Scott Walker, passed in early 2011 and effectively eliminated the collective bargaining rights of public employees, setting ablaze an on-going saga of protests, recalls and court appeals.

In his 27 page ruling, Judge Colás declared the Act unconstitutional and while it was overturned only in regards to city, county and school district workers, not state employees, union leaders and public workers alike have hailed the decision.

What does this have to do with public health? Unions have long been advocates for health promoting conditions, from better working conditions and employee benefits, to higher wages and policies that benefit the middle and working class. Their ability to do this has in large part depended on their ability to collectively bargain.

In the context of sustained political attacks against workers’ rights, it is important public health professionals stand with the labor movement, both in celebrating its victories and in supporting its struggles.

This piece is cross-posted at Healthy Policies


While reactions to Bloomberg’s soda ban continue to effervesce, those truly concerned with the public’s health would be well advised to hold their praise.

Continue Reading

The Occupy Wall Street Movement has opened up many opportunities to make clear the links between economic inequalities and inequalities in health. A growing number of doctors, nurses, patient advocates, and public health professionals are taking advantage of these opportunities and drawing attention to a range of health concerns. However, conversations and actions so far have largely focused on issues of access to healthcare, medical debt, cuts to healthcare budgets, and the pitfalls of for-profit medical systems.

One of the biggest health related actions of the Movement took place on October 26th when Healthcare for the 99% (a coalition of physician unions, nurses unions, and various healthcare campaign groups) organized a march in New York City against the for-profit health insurance industry. Just yesterday, a group of health advocates in Boston organized a Health Justice Day of Action where in addition to a variety of health focused events, a team of volunteers dispensed free flu shots. In the UK, protesters in Cambridge occupied the offices of the Healthcare firm Atos, and on Twitter, the hashtags  #occupyhealthcare and #occupyhealth document  that more and more people are making the link between economic inequalities and healthcare related concerns.

Less visible in the Movement are messages about the social determinants of health (SDOH). The need for better integration of SDOH messages have been noted by blogger Nate Osit, who emphasizes the need for a more global SDOH outlook in occupying efforts, and blogger Vinu Ilakkuvan, who has written about the need to move ‘beyond healthcare’ and highlighted examples of successful efforts toward this end. However, SDOH concerns aren’t completely absent from the Movement. The People’s Health Movement has stepped up to endorse the Occupy Wall Street Movement, directing attention to the importance of SDOH and urging its affiliates to “participate in this movement to overcome ill-health caused by social, political and economic systems that reproduce inequality and social injustice”. Moreover, “a group of (mostly) San Francisco Bay Area health professionals, providers, students, and advocates” have developed an Occupy Public Health site which includes, among other great resources, a lesson plan for teaching occupiers about the SDOH.

In an effort to support occupying actions directed at the social determinants of health, Healthy Policies will be hosting a Twitter chat tomorrow (Monday November 14th) on how SDOH messages can be better integrated into the Occupy Healthcare movement.  This chat is part of a larger effort organized by the IMAXI group, who are coordinating a series of social media events to bring people together to discuss the state of the world's health every Monday, from the 14th of November until Human Rights Day a month later.

The Twitter chat will begin at 3PMEST/20hGMT and last for 30 minutes. To view the chat search Twitter for #SDOHchat; to participate, tweet your thoughts, adding  ‘#SDOHchat’ to your tweet.  A transcript of the chat will be made available shortly afterwards.

[This piece is cross posted at Healthy Policies]


Growing commentary has covered much ground on the causes, faults, and promise of the Occupy Wall Street movement. However, a stone that has yet to be overturned is one that should have public health professionals, as well as anyone who cares about the health of their community, taking to the streets. While protesters are no doubt occupying Wall Street for a variety of reasons, in the process they are also confronting some of the most important determinants of health.

One of the movement’s fundamental concerns, excessive levels of income inequality, is a major determinant of health. In 2007, the top 1% of U.S. earners owned 34.6% of the wealth. In 2009, CEOs of major U.S. corporations took home 263 times the average compensation of American workers. It is now well established (see here, here, and here) that in places where income inequality is greater, population health is worse. It has recently been reported that the combined impact of poverty and income inequality was responsible for 291,000 US deaths in the year 2000 alone.

States with the highest income inequality are also less likely to invest in human capital and provide far less generous social safety nets. This is because income inequality also undermines civil society, erodes political participation and in turn, determines the type of policies government chooses to (and not to) pursue—all with important implications for the opportunities people have to lead a healthy life.

But the Occupy Wall Street protesters aren't just demanding a redistribution of income--there is a far superior recognition within the movement. Protesters recognize that social ills, like income inequality, are a consequence of deliberate actions by individuals and groups who impart undue influence on the government. This is important because it is ultimately this undue influence which threatens the quality, availability and distribution of resources important for health. Resources like income, employment, food, healthcare, housing, education, and the environment. By demanding sweeping reform of an entrenched system, protesters are thus taking aim at the ultimate determinants of health. Take a look at the Declaration of the Occupation of New York City for an idea of how protesters have related corporate influence to a range of these resources. Moreover, see this report by the World Health Organization which outlines how these resources in turn influence health.

There are many reasons why the Occupy Wall Street movement should be supported.  For those concerned with the public's health the call to action should be answered without hesitation.

 [This Diary is cross-posted at Healthy Policies]


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