Bozorgmehr Kayvan, San Sebastian Miguel
Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden. E-mail:
Health Policy Plan. 2014 May;29(3):328-51. doi: 10.1093/heapol/czt020. Epub 2013 Apr 16.
Trade liberalization is promoted by the World Trade Organization (WTO) through a complex architecture of binding trade agreements. This type of trade, however, has the potential to modify the upstream and proximate determinants of tuberculosis (TB) infection. We aimed to analyse the association between trade liberalization and TB incidence in 22 high-burden TB countries between 1990 and 2010.
and findings A longitudinal multi-level linear regression analysis was performed using five different measures of trade liberalization as exposure [WTO membership, duration of membership, trade as % of gross domestic product, and components of both the Economic Freedom of the World Index (EFI4) and the KOF Index of Globalization (KOF1)]. We adjusted for a wide range of factors, including differences in human development index (HDI), income inequality, debts, polity patterns, conflict, overcrowding, population stage transition, health system financing, case detection rates and HIV prevalence. None of the five trade indicators was significantly associated with TB incidence in the crude analysis. Any positive effect of EFI4 on (Log-) TB incidence over time was confounded by differences in socio-economic development (HDI), HIV prevalence and health financing indicators. The adjusted TB incidence rate ratio of WTO member countries was significantly higher [RR: 1.60; 95% confidence interval (CI): 1.12-2.29] when compared with non-member countries.
We found no association between specific aggregate indicators of trade liberalization and TB incidence. Our analyses provide evidence of a significant association between WTO membership and higher TB incidence, which suggests a possible conflict between the architecture of WTO agreements and TB-related Millennium Development Goals. Further research is needed, particularly on the relation between the aggregate trade indices used in this study and the hypothesized mediators and also on sector-specific indices, specific trade agreements and other (non-TB) health outcomes.
世界贸易组织（WTO）通过一系列具有约束力的贸易协定的复杂架构来推动贸易自由化。然而，这种贸易形式有可能改变结核病（TB）感染的上游和直接决定因素。我们旨在分析1990年至2010年间22个结核病高负担国家贸易自由化与结核病发病率之间的关联。
采用五种不同的贸易自由化衡量指标作为暴露因素，进行纵向多层次线性回归分析[WTO成员国身份、成员国持续时间、贸易占国内生产总值的百分比，以及世界经济自由度指数（EFI4）和全球化KOF指数（KOF1）的组成部分]。我们对一系列因素进行了调整，包括人类发展指数（HDI）差异、收入不平等、债务、政体模式、冲突、过度拥挤、人口阶段转变、卫生系统融资、病例发现率和艾滋病毒流行率。在粗分析中，五个贸易指标均与结核病发病率无显著关联。随着时间的推移，EFI4对（对数）结核病发病率的任何积极影响都被社会经济发展（HDI）、艾滋病毒流行率和卫生融资指标的差异所混淆。与非成员国相比，WTO成员国经调整后的结核病发病率比值显著更高[相对风险（RR）：1.60；95%置信区间（CI）：1.12 - 2.29]。
我们发现贸易自由化的特定总体指标与结核病发病率之间无关联。我们的分析提供了证据，表明WTO成员国身份与较高的结核病发病率之间存在显著关联，这表明WTO协定架构与结核病相关的千年发展目标之间可能存在冲突。需要进一步开展研究，特别是关于本研究中使用的总体贸易指数与假设的中介因素之间的关系，以及特定部门指数、具体贸易协定和其他（非结核病）健康结果的研究。
