Brazil and the Framework Convention on Tobacco Control: Global ...

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Brazil and the Framework Convention on Tobacco Control: Global ...

Policy Forumong>Brazilong> ong>andong> ong>theong> ong>Frameworkong> ong>Conventionong> on TobaccoControl: Global Health Diplomacy as Soft PowerKelley Lee 1 *, Luiz Carlos Chagas 2 , Thomas E. Novotny 31 Centre on Global Change ong>andong> Health, London School of Hygiene & Tropical Medicine, London, United Kingdom, 2 Independent Researcher – Public Health ong>andong> TradePolicies, London, United Kingdom, 3 Graduate School of Public Health, San Diego State University, San Diego, California, United States of AmericaThis article is part of ong>theong> PLoS MedicineGlobal Health Diplomacy series.IntroductionOne of ong>theong> key developments in internationalrelations during ong>theong> early twenty-firstcentury is ong>theong> ascendance of ong>theong> BRICcountries (ong>Brazilong>, Russia, India, ong>andong> China)(see Box 1 for terms ong>andong> definitions). Whileong>theong>ir rising status stems largely from ong>theong>irdemographic ong>andong> economic growth (togeong>theong>raccounting for about 40% of ong>theong>world’s population ong>andong> 40% of global GDP[1]), also important has been what internationalrelations scholars refer to as ong>theong>growing use of ‘‘soft power.’’ The term‘‘soft power’’ was coined by Joseph Nyeduring ong>theong> 1990s to describe ‘‘how power ischanging in world politics’’ since ong>theong> end ofong>theong> Cold War. He argued that, whilemilitary force ong>andong> conquest remain important,power derived from technology,education, ong>andong> economic growth haveincreased in significance. The result hasbeen ‘‘a general diffusion of power’’ to abroader range of state ong>andong> non-state actors.Given that ‘‘ong>theong> solutions to many currentissues of transnational interdependence willrequire collective action ong>andong> internationalcooperation,’’ Nye argued that governmentsmust use an appropriate balance of‘‘soft power’’ (co-option ong>andong> attraction) ong>andong>‘‘hard power’’ (coercion ong>andong> payment)when pursuing ong>theong>ir interests [2].This paper examines ong>theong> process bywhich ong>Brazilong> asserted influence in ong>theong>negotiation of ong>theong> ong>Frameworkong> ong>Conventionong>on Tobacco Control (FCTC) as an exampleof soft power. Implemented under ong>theong>bylaws of ong>theong> World Health Organization(WHO) [3], ong>theong> FCTC has been ong>theong> productof multi-level ong>andong> multi-actor negotiationprocesses that define ‘‘global health diplomacy’’[4–6]. A fuller understong>andong>ing ofThe Policy Forum allows health policy makersaround ong>theong> world to discuss challenges ong>andong>opportunities for improving health care in ong>theong>irsocieties.ong>Brazilong>’s contribution to ong>theong> FCTC providesinsights into ong>theong> pursuit of global healthcooperation alongside broader foreign policyobjectives, as well as ong>theong> emergingpractice of global health diplomacy.MethodologyAs part of a broader project on ‘‘Thetobacco industry, public policy ong>andong> globalhealth’’ ong>andong> our case study of ong>theong> FCTCong>andong> global health diplomacy, ong>theong> authorssought to obtain views of ong>Brazilong>’s role in ong>theong>FCTC negotiations. The authors carriedout key informant interviews with ong>Brazilong>ianpolicy makers, diplomats, ong>andong> public healthadvocates on ong>theong> country’s role in FCTCnegotiations from December 2008 throughJanuary 2009. Interviews were conductedby LCC in Portuguese, transcribed, ong>andong>translated. Triangulation of reported perceptionswas achieved through a literaturereview of primary ong>andong> secondary sourcesincluding government reports ong>andong> Websites, industry documents, reports by nongovernmentalorganizations, ong>andong> unpublishedresearch dissertations.This research was approved by ong>theong>London School of Hygiene & TropicalMedicine Ethics Committee as part of ong>theong>US National Institutes of Health-funded‘‘Tobacco control, public policy ong>andong> globalhealth’’ project (Application No. 5612). Inaddition, interview quotes were approvedby ong>theong> relevant key informants for citation.ong>Brazilong>’s New Prominence inGlobal Healthong>Brazilong> has become increasingly prominentin international relations in recentyears through its leadership in climatechange [7], trade, energy policy, ong>andong>nuclear nonproliferation negotiations [8].By combining economic growth withprogressive domestic social policies, ong>theong>country has defied orthodox thinking ondevelopment. It has been in ong>theong> realm ofglobal health, however, that ong>Brazilong>iong>andong>iplomacy has been particularly noteworthy,beginning with negotiations on accessto medicines for treatment of HIV/AIDS.Because of its constitutional requirementfor equity in access to antiretroviral (ARV)ong>theong>rapy [9], ong>andong> ong>theong> political will toaddress ong>theong> issue, ong>Brazilong> successfully confrontedong>andong> negotiated a satisfactoryresolution to barriers imposed on drugavailability by ong>theong> Agreement on Trade-Related Aspects of Intellectual PropertyRights (TRIPS). With ong>theong> US governmentaligning with powerful corporate interests,ong>Brazilong>’s championing of free ong>andong> universalaccess to ARVs earned worldwide respectCitation: Lee K, Chagas LC, Novotny TE (2010) ong>Brazilong> ong>andong> ong>theong> ong>Frameworkong> ong>Conventionong> on Tobacco Control:Global Health Diplomacy as Soft Power. PLoS Med 7(4): e1000232. doi:10.1371/journal.pmed.1000232Published April 20, 2010Copyright: ß 2010 Lee et al. This is an open-access article distributed under ong>theong> terms of ong>theong> CreativeCommons Attribution License, which permits unrestricted use, distribution, ong>andong> reproduction in any medium,provided ong>theong> original author ong>andong> source are credited.Funding: This research was funded in part by ong>theong> National Cancer Institute, US National Institutes of Health(Grant No. 5R01CA091021), ong>andong> ong>theong> European Research Council under ong>theong> European Community’s Seventhong>Frameworkong> Programme (Ideas Grant 230489 GHG). The funders played no role in ong>theong> decision to submit ong>theong>article or in its preparation.Competing Interests: Kelley Lee ong>andong> Thomas E. Novotny are on ong>theong> Editorial Board of PLoS Medicine.Abbreviations: ARV, antiretroviral; BAT, British American Tobacco; BRIC, ong>Brazilong>, Russia, India, ong>andong> China; CSO,civil society organization; FCA, ong>Frameworkong> ong>Conventionong> Alliance; FCTC, ong>Frameworkong> ong>Conventionong> on TobaccoControl; GRULAC, Group of Latin America ong>andong> Caribbean Countries; INB, Intergovernmental Negotiating Body;SEATCA, Souong>theong>ast Asia Tobacco Control Alliance; TRIPS, Trade-Related Aspects of Intellectual Property Rights;WHO, World Health Organization; WTO, World Trade Organization* E-mail: kelley.lee@lshtm.ac.ukProvenance: Commissioned; externally peer reviewed.PLoS Medicine | www.plosmedicine.org 1 April 2010 | Volume 7 | Issue 4 | e1000232


Summary PointsN ‘‘Soft power’’ is a diplomatic approach to obtain an objective throughpersuasion ong>andong> collaboration, raong>theong>r than through economic influence orpolitical domination.N ong>Brazilong>’s growing influence in international relations, as one of ong>theong> so-called BRIC(ong>Brazilong>, Russia, India, ong>andong> China) countries, has been due to its effective use ofsoft power in key foreign policy negotiations.N ong>Brazilong> has shown soft-power leadership in negotiations concerning climatechange, trade liberalisation, energy policy, nuclear non-proliferation, ong>andong> recenong>theong>alth-related diplomatic activities. Policy consistency was shown in ong>Brazilong>’sconstitutional guarantee of access to anti-retroviral drugs for people living withHIV/AIDS that required steadfast negotiations to ensure access within WorldTrade Organization guidelines.N During negotiations for a ong>Frameworkong> ong>Conventionong> on Tobacco Control (FCTC),ong>Brazilong> demonstrated commitment to global health diplomacy by serving as anexemplar for domestic tobacco control, engaging in coalition politics, ong>andong>providing leadership throughout ong>theong> negotiation process.N ong>Brazilong>’s influential role in ong>theong> negotiation of ong>theong> FCTC can be seen as an exampleof how global health has become a focus of soft power.among public health advocates [10].While oong>theong>r countries, such as Thailong>andong>ong>andong> South Africa, also sought to challengeong>theong> pharmaceutical industry on restrictivepricing policies, as Nunn ong>andong> colleaguesargue, ong>Brazilong> became ong>theong> first developingcountry to offer free ARV treatment toHIV/AIDS patients despite claims by ong>theong>World Bank that such a policy was notcost-effective [11]. Importantly, ong>theong> countryhas seen a dramatic decline in AIDSrelatedmorbidity ong>andong> mortality as a resultof its treatment program, a success storythat has served as a role model for ong>theong>Box 1. Terms ong>andong> Definitionsexpansion of global support for HIV/AIDS treatment in oong>theong>r countries. In thisway, ong>Brazilong> helped bridge a chasm betweenpublic health ong>andong> trade policythrough its national HIV/AIDS policy[12].ong>Brazilong>ian Tobacco ControlPolicy as an Exemplarong>Brazilong>ian leadership was critical to ong>theong>successful conclusion of ong>theong> FCTC negotiationsin 2003. Following ong>theong> establishmentof a model national tobacco controlBRIC countries: An acronym referring to ong>theong> fast-growing developingeconomies of ong>Brazilong>, Russia, India, ong>andong> China. The term was coined by investmentbank Goldman Sachs in 2001 in its predictions that, by 2050, ong>theong> four economieswould togeong>theong>r eclipse those of ong>theong> current richest countries.Agreement on Trade Related Intellectual Property Rights (TRIPS): Aninternational trade agreement administered by ong>theong> World Trade Organization(WTO) that sets out minimum stong>andong>ards for intellectual property regulation.Signed in 1994, ong>andong> coming into effect in January 1995, ong>theong> agreement sets outrequirements that member states meet on such matters as copyright, patents,trademarks, geographical indications (a name or sign used on certain productswhich corresponds to a specific geographical location or origin) ong>andong> industrialdesign.Antiretroviral drugs (ARVs): Medications for ong>theong> treatment of infection byretroviruses, namely HIV/AIDS. Affordable access to such drugs has been ong>theong>subject of intense global debate because of patent protections asserted bypharmaceutical companies under TRIPS ong>andong> oong>theong>r trade agreements.ong>Frameworkong> ong>Conventionong> on Tobacco Control (FCTC): An international treatynegotiated under ong>theong> auspices of WHO that sets out minimum stong>andong>ards fornational, regional, ong>andong> international tobacco control measures, including ong>theong>setting of broad limits on tobacco production, sale, distribution, advertisement,taxation, ong>andong> government policies. Signed in 2003, ong>theong> treaty came into force inFebruary 2005. The treaty currently has 168 state parties.program, ong>Brazilong>ian medical doctor ong>andong>former coordinator of ong>theong> National TobaccoControl Programme, Vera Luiza daCosta e Silva, was recruited to leadWHO’s Tobacco Free Initiative (TFI),ong>andong> ong>Brazilong>ian diplomats were appointedto chair ong>theong> Intergovernmental NegotiatingBody (INB) for ong>theong> FCTC. A fullerunderstong>andong>ing of ong>Brazilong>’s contribution toong>theong> FCTC process may provide lessonsabout ong>theong> conduct of global health diplomacyin oong>theong>r contexts.ong>Brazilong>’s National Tobacco Control Programmeimplemented many innovations:ong>Brazilong> was ong>theong> second country (afterCanada) to adopt graphic warnings oncigarette packages, ong>theong> first to create abody to regulate tobacco contents ong>andong>emissions, ong>andong> ong>theong> first to ban ong>theong> use of‘‘light’’ ong>andong> ‘‘mild’’ terms in describingtobacco products. According to an interviewwith Tania Cavalcante, ExecutiveSecretary of ong>theong> National Inter-ministerialCommission to Implement ong>theong> FCTC,ong>Brazilong> promoted ong>theong>se advances in manyINB negotiation sessions, ong>andong> encouragedoong>theong>r countries to support ong>theong>m as treatyelements. Importantly, ong>Brazilong>’s status asone of ong>theong> biggest producers ong>andong> exportersof tobacco, while at ong>theong> same timeachieving high visibility in tobacco control,provided additional credibility for itsleadership role in ong>theong> FCTC negotiations[13]. As diplomat Frederico Duque EstradaMeyer, former assistant to AmbassadorsCelso Nunes Amorim ong>andong> LuizFelipe de Seixas Correa , put it, ‘‘Somecountries have restrictive anti-smokingpolicies like ong>Brazilong>, but are not producers.Oong>theong>rs, are big producers but with a veryliberal tobacco policy….we were leadingon both sides….we represented bothconflicting interests.’’ In our interviews,ong>theong> ong>Brazilong>ian former Director of ong>theong> TFI,Vera Luiza da Costa e Silva, furong>theong>remphasized this complex negotiatingposition:To be a big producer, a big exporter with astrong ong>andong> influential industry, ong>andong> a bigconsumer market for tobacco products, withpressures in ong>theong> domestic market generatedby allies of a powerful industry, ong>Brazilong>actively supported all ong>theong> WHO resolutionsthat led to ong>theong> creation of ong>theong> IntergovernmentalNegotiating Body. To be a countrysubject to all ong>theong>se factors ong>andong> also able toimplement tobacco control, we were talkingat that time of being a model for oong>theong>rcountries, mainly for developing countries.We were sending a message that, under anycircumstances, a government committed tothis priority, despite ong>theong> weight of oong>theong>rPLoS Medicine | www.plosmedicine.org 2 April 2010 | Volume 7 | Issue 4 | e1000232


idsastrategiccomments/ong>Brazilong>inSouthAmerica_MVieira_241208. Accessed 14 December2009.24. Amorim C (2007) Diplomacy ong>andong> Global Health.Statement by ong>theong> Minister of External Relations,New York, 9 July 2007. Available: http://www.brasilemb.org/index.php?option = com_content&task = view&id = 141&Itemid = 133. Accessed14 December 2009.PLoS Medicine | www.plosmedicine.org 5 April 2010 | Volume 7 | Issue 4 | e1000232

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