Latin American public health is not for sale

Even in “progressive” countries like Ecuador, healthcare public policies are being strongly interfered with by corporate interests. Español. Português

Hugo Noboa Cruz
17 November 2015

A medical doctor examines a child at a riverside settlement in northern Ecuador. Flickr. Some rights reserved.

In recent years, the most successful public policies regulating industrial products harmful to health have been those related to the control of tobacco, thanks to the drawing up, implementation and overall effectiveness of the national laws developing the World Health Organization’s Framework Convention on Tobacco Control (FCTC).

The successful impact of these policies is such that its effects are quite evident in terms of decreasing sales and consumption of tobacco products, especially conventional cigarettes, in almost every country in the world. Some countries can even measure some decline in the incidence and mortality rate of some of the tobacco-related disorders.

Beyond their success, the effect of the tobacco-control policies can also be seen in their extension to other products, particularly the industrially processed foods and sugary drinks (taxes, labeling, advertising regulation). Today, a vast movement in Latin America (CLAS and the world at large is advocating for the drafting of a global Framework Agreement on a Healthy Diet, similar to that which has allowed a more effective regulation of tobacco.

According to the WHO, tobacco, ultra-processed food containing excess fat and salt, and sugary drinks (in addition to a sedentary lifestyle, excessive alcohol consumption, and stress), account for most of the cardiovascular diseases, diabetes, chronic respiratory conditions and certain malignant tumors in almost every country in the world. Treatment for these ailments entails high costs and, thus, the flourishing of the healthcare business.

The road to proper regulation of these industries, however, is a long and hard one. The role of civil society is essential (though quite often insufficient) to make sure that governments and legislative bodies do not falter when enacting and implementing public policies against distinct and constant interferences from (among others) the tobacco, food, and alcohol industries – or, rather, against the suitable arrangements between the power groups in government and these industries.

But there are still other industries which should be regulated effectively on public health grounds. These are not only the so-called "illegal" drugs cartels, but also the pharmaceutical, medical equipment, health supplies and medical infrastructure construction industries, which put commercial interests over and above people’s health.

Health-focused regulation should even be extended (with a "health-in-all-policy-areas" approach) to the arms industry, the natural resource extractive industries, and large energy projects (dams) which aggress nature, and therefore the human race, especially local communities self-isolated from this predatory civilization.

Despite progress in tobacco control through public policies, there are serious obstacles blocking the path of regulation. Regulation is not new: it started in the 1970s, when the first report of the US Surgeon General on well-documented hazards caused by tobacco was published, and the subsequent decoding of secret documents of the major tobacco companies indicating that they had been aware of the damage, including addiction, for decades.

The case of Ecuador

 In Ecuador, the first regulation dates back to the old Health Code (1971). Regulation of advertising for tobacco and alcohol was decreed in 1973. Tobacco industry interference in health policy is also not new here. The first legal framework drafted to suit industry interests dates back to 1940. In 1960 an Emergency Decree sanctioned “the free processing, distribution and sale of all types of tobacco products in the domestic market”. Industry interference and/or agreements with the political power have been especially important, however, since the regulation of tobacco was updated in 1994 and, particularly, since Ecuador ratified the FCTC in 2006, which did put the industry in an awkward position.

Tobacco legislation and regulatory policies in Ecuador are not an achievement attributable to the “citizens’ revolution” government. Rather, they have been achieved, despite the government and its interests, thanks to the country's international commitments as a result of its ratification of the FCTC, and to the persistent activity of anti-smoking activists, within and without government agencies, who have pushed for the passing of legislation and the adoption of regulations to the extent of their possibilities and overcoming many constraints.

In Latin America and the Caribbean, the so-called “progressive” governments are not the ones that have fared better on tobacco control. There is no link between the development of public policies targeting tobacco and the political tinge of the government. In fact, governments that are considered to be conservative, such as Colombia and Panama (along with Canada, Uruguay or Brazil) have taken the lead in this field.

Ecuador is not the most advanced country in Latin America as far as tobacco control policies are concerned. Its position is an intermediate one, definitely backward in areas such as: total ban on advertising (including cross-border advertising and displays at retail outlets) and on the sale of cigarettes by the unit (easily accessible for children and teenagers); effective regulation of electronic cigarettes; regulation of content and additives in cigarettes and other tobacco products; and regulation of brand presentations (prohibiting misleading brand extensions). The latter earned Uruguay a demand from Philip Morris International before the international trade courts, a fact which apparently influenced the authorities in Ecuador who refused to adopt this regulation demanded by antismoking activists since 2012.

If “progressivism” had anything to do with the best public health practices related to tobacco control, Cuba, the only government in the region that can be considered Socialist, should rank at the very top – but it does not. Revolutionary Cuba, along with Kirchnerist Argentina and imperialist US, have not even ratified the FCTC. They are among the few countries in the region that have not done so.

Earlier this year, the Ecuadorian cabinet discussed the alleged effects on the tobacco industry of a proposed very small tax to implement a tracking and tracing system for illicit goods, which had already been defined by the Internal Revenue System in 2014 as an additional tool of the FCTC, namely the Protocol to eliminate the illicit trade in tobacco products, signed by Ecuador in September 2013, ratified in June 2015 and presented to the UN on October 15, 2015. It should be borne in mind that the tobacco industry has been one of the main actors and beneficiaries of black marketeering. Considering this background, the Ecuadorian government may now regret having signed and ratified the Protocol, for it probably infringes its recent arrangements with national and transnational corporations included in the Organic Law of Incentives for Public-Private Partnerships and Foreign Investment which was passed in October 2015.

Not only tobacco

The tobacco industry has not been the only one to enjoy free access to the “citizens’ revolution” government and prevent stronger regulations. So have the alcoholic beverages (especially beer) industries, the processed food industries and the pharmaceutical drugs and medical equipment industries, among others.

The biased role of the Ecuadorian judiciary (linked to the government’s political movement) in the lengthy ruling by the Constitutional Court on the demand for utilities by former employees of the National Brewery is well known (see Chuchaqui seco: mucha ley y poca justicia para los ex-trabajadores de la cervecería nacional, by Gerard Coffey,, June 30, 2015).

The Communications Law passed in June 2013, besides its overall nefarious content, includes one article (#94) which, in its second paragraph, expressly prohibits any kind of publicity or advertising of alcoholic beverages. However, an Executive Decree of January 2014 (General Regulation of the Communications Law) includes article 59, which regulates advertising in breach of law and clearly at the brewing industry’s convenience, as shown in sections 3 and 4:

"3. Advertising of self-restraint alcoholic beverages is restricted to alternative channels only.
 4. Advertising of self-restraint alcoholic beverages through foreign TV channels, through audio and video systems by subscription is exempted from the general rule referred to in the previous paragraph."

It is therefore unsurprising that President Correa, a few days before the issuing of this rule by executive decree on Monday, December 2, 2013, in his usual change of the presidential guard and taking as a pretext the Guayaquil Emelec football team championship, appeared on the balcony of Carondelet presidential palace in Quito between Vice President Jorge Glas and former Vice Mayor Augusto Barrera wearing a shirt that did not say Emelec, but "Pilsener" (an alternative channel?), even though the Communications Law and Article 94 were fully in force. The President was contravening the law at a public event. Was the President being naïve, or careless? Both are hard to believe, considering how perfectly well-advised he always is.

It is also understandable that Luis Chiriboga is kept at the helm of the Ecuadorian Football Federation, a man who is fond of appearing at press conferences flanked not by Ecuador’s or the Ecuadorian Federation flag, but by Pilsener’s badges, logos and bottles (alternative channels?), he too contravening the law before everybody’s eyes and taking advantage of everybody’s goodwill.

Public health and the citizens’ revolution

The “citizens’ revolution” government has obviously invested in healthcare. There is no denying that. But what we should be asking is whether the investment has been efficient, effective and transparent. And what was it primarily invested in.

Has public health (not only the image of some healthcare services) improved or, at least, have some historic achievements been maintained? Have child malnutrition and maternal mortality rates significantly decreased, as the government has been touting, and, above all, have the social gaps shown by these indicators diminished (thus putting a real face to the decline in the Gini index)? From what we know, at least in maternal mortality, or cervical cancer, these indicators have improved under the “citizens’ revolution” only for women in better economic situation, whereas for poorer women nothing much has happened: the maternal mortality rate of black and indigenous women is five times higher than white or mestizo women (the National Institute of Statistics and Census - INEC databases are available here:

Pablo José Iturralde’s essential report “Concentration of capital in the health system” published by the Centro de Derechos Económicos y Sociales (CDES) ends up with the following conclusion:

"While increased public spending helped the domestic market grow, it failed to change the highly concentrated income structure in the national markets. To the hyper concentrated markets that the Ecuadorian economy inherited from the neoliberal period, new markets linked to domestic consumption are added, and are being monopolized by a few business groups, the fastest growing of which are in the healthcare sector.

The increased public spending in the healthcare sector has generated an expansion of new private healthcare facilities. There is a relation between private investment and increased public spending.

Additionally, the central government makes financial contributions to social security institutes that are financed mainly by contributions from workers and employers. In turn, through the social security system, it funds private purveyors who hold contracts with the Instituto Ecuatoriano de Seguridad Social (Ecuadorian Social Security Institute – IESS), the Instituto de Seguridad Social de las Fuerzas Armadas (Armed Forces Social Security Institute – ISSFA), and the Instituto de Seguridad Social de la Policía Nacional (National Police Social Security Institute – ISSPOL).

All the healthcare activities considered in this study show high levels of concentration in the enterprise structure, but also, especially, concentration of assets and wealth. "

Several new studies point to the conformation of economic groups, offering another perspective to the concentration of capital in the healthcare sector.

One of the latest blows dealt by the “citizens’ revolution” government to the public health system in its effort to benefit its capitalist allies is the Basic Law on Incentives for Public-Private Partnerships and Foreign Investment, passed on October 27, 2015. A letter by the Ecuadorian chapter of the Latin American Association for Social Medicine addressed to the President of the National Assembly on October 28, 2015, sums up its concern:

 "We are deeply concerned about the approval, by 96 votes, of the draft “Basic Law on Incentives for Public-Private Partnerships and Foreign Investment”. This decision reveals a profound misunderstanding of the concept of medicine as a social good, as well as a very poor debate on the impact of this decision on public health.

This legal corpus aims at reforming the Basic Law of Health, in its relevant parts, so that "No sanitary registration or operating permit will be required to those who have been granted a good practice certificate or higher”. To consider that "sanitary registration" and "good practice" are interchangeable values is a misconception that can have profound implications for the safety and access to essential drugs. Production conditions and pharmaceutical-therapeutic pertinence are being confused.

The repeal of subsection 4 of Article 94 of the Communications Law - "Advertising of food and healthcare products must have the prior authorization of the Ministry of Health"-  signals a steep regression in healthcare policy by opening up the possibility of stimulating the inappropriate use of drugs in society, and further weaken the leadership role of the Health Authorities.

What does the Ministry of Health have to say about this new law? Will it remain silent, as it did when facing the Free Maternity Law, the Integrated Penal Code and the eventual ratification of the Commercial Agreement with the European Union?

Madam President, with yesterday’s vote the Assembly members of Alianza País (the governing party) have turned their backs on public health and the Constitution, which determines (Article 363) that "As for access to medicines, the interests of public health prevail over economic and trade interests." The impact on the health system and the population will be dire.

The few examples mentioned here show that the problem is not only the interference of some industries with public policies, but that public policies are often hammered out hand in hand with these powerful commercial interests.

The long neoliberal night is definitely in good health in Ecuador!



This article was published previously by La línea de fuego.

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