There are few aspects of legislation that don’t impact on the public’s health, whether through the opportunity and nature of employment, regulatory frameworks for services and products, or protection of the natural environment. The UK’s departure from the EU will have significant and wide-ranging implications for national laws and regulation, trade relationships, the movement of people and the distribution of resources. The process will require a great many agreements between parliamentarians in the four nations of the UK, as well as with those in Europe.

It has been described as ‘arguably the greatest peacetime challenge the UK has ever faced’. But it also represents an opportunity to work towards a more ambitious vision for future policy, legislation and regulation. Promoting a health-in-all-policies approach to post-Brexit arrangements could put centre stage the protection and promotion of the public’s health.

Brexit means a lot is up for grabs

Viewed through the lens of health determinants, the potential for change to the social, political, environmental and economic landscape in the UK could have significant and far-reaching implications for the future health prospects of people in the UK. The disruptive nature of the separation process offers scope to take a more holistic approach to policymaking – one that places greater priority on human and environmental health. But in doing so, there are significant opportunities and risks that policymakers must consider.

In September 2016, the Health Select Committee launched an inquiry into the priorities for health and social care in the negotiations on the UK’s withdrawal from the EU. The inquiry was cut short by the general election in June 2017. But when the committee reported in April 2017 on workforce issues for the NHS and reciprocal health arrangements for UK and EU citizens, it noted that further important considerations – including how Brexit might affect the protection of public health – remained ‘outstanding issues for a successor committee’.

What is the focus of this essay collection?

This series of essays explores some of these outstanding issues. The Health Foundation invited contributors with expertise in public health, employment standards, local government, consumer rights and food policy to share their insights on the potential risks and opportunities ahead. We asked them to comment on:

• the public health protections that currently flow from EU treaties, policies and institutions that would need to be secured through alternative mechanisms or approaches
• whether future independence from EU institutions and European regulation presents opportunities for improving the health of people in the UK
• the implications for the protection of health of new trade relationships between the UK and other countries.

Each essay explores different, and perhaps not immediately obvious, ways in which the UK’s relationship with the EU influences people’s health. These cover:

• setting the current policy framework for food, farming and fishing
• setting regulations and mechanisms that uphold employment and consumer protections
• determining international trade agreements
• providing structural support to disadvantaged regions
• influencing the shape of the labour market.

It is not possible in this short essay collection to examine all the potential implications for the public’s health of leaving the EU. It does not include, for example, the issues already considered by the Health Select Committee, the potential issues for public health workforce capacity or population health research. Nor the potential broader effects of Brexit on the general economic climate, public finances and household incomes and how these in turn could affect health prospects. Air pollution and the many considerations of Brexit for health services in the UK are also not covered, but have been explored in detail elsewhere.,

How do the essays identify opportunities for a health-in-all-policies approach?

This collection of essays underlines the value of taking a health-in-all-policies approach to the legislative programme that will follow the UK’s departure from the EU. It highlights the opportunity this provides to rethink the wide range of departmental policies that have a major influence on people’s health.

The contributors have identified some of the ways in which leaving the EU will require the UK to set new policy frameworks, transpose or introduce regulations, form new trade relationships and replace support funds. But they have raised questions too. For example, how might replacing the Common Agricultural Policy allow for improvements to the nature and regulation of the UK’s food supply? What are the implications for putting health considerations at the heart of new international trade deals? Could Brexit be an opportunity to strengthen employment standards and therefore support good work as a determinant of health?

This collection surfaces just some of the ways health is influenced by policymaking outside of the health care sector. It demonstrates how leaving the EU – and the resultant profound shift in the policy landscape – presents risks that need to be mitigated. But it also indicates the opportunity facing policymakers across all sectors for a major rethink of the UK’s approach to improving the health of its population.

Kath Dalmeny, Chief Executive and Brexit Lead for Sustain: the alliance for better food and farming

The UK needs a safe, secure, healthy and sustainable supply of good food, equitably distributed, which enables everyone to eat well while not compromising the needs of future generations. Following Brexit, sensible food, farming and fishing policies could deliver this vision, and help food production reduce its significant contribution to greenhouse gas emissions. These matters will be profoundly shaped by the UK’s adoption or adaption of new and existing EU standards – whether of its own design or dictated by new international trade deals.

The EU (Withdrawal) Bill promises to transpose all EU law into UK law. The aim is for a smooth transition to the new era, with no damaging cliff edge for businesses, policymakers or newspaper headline writers. Though the aim is worthy, the execution will raise many challenging questions. Transposing laws is one thing; transposing institutions, data, science and enforcement mechanisms is quite another. What relationship will the UK have, for example, with the European Chemicals Agency, the European Food Safety Authority or with assessments of pesticides, international food fraud and water quality? Who will undertake the scientific data gathering, monitoring and product testing? Who will pay for this? Will the UK have access to EU-wide data and scientific assessments? What protection will there be against commercial influence on policy decisions that affect public health?

Colleagues in the food movement, among others, are calling the combination of these questions the ‘governance gap’. While EU processes have sometimes been inadequate, bureaucratic or opaque, the UK’s domestic institutions that will need to replace them, such as the Food Standards Agency, and local authority food safety inspectors, have been greatly diminished in capacity over recent years. Half of UK trading standards officer posts have been lost since 2009. The government must leverage the country’s public health expertise to help design institutions and processes that meet health priorities, with full independence and accountability, adequate resources and no compromise.

Accountability for health

Control of the unnecessary use of antibiotics in farming illustrates the impact of health accountability. To be part of the EU, the UK recognises the authority of the European Court of Justice and the European Commission. These bodies can hold member states to account for their failure to meet democratically agreed statutory targets. On farm antibiotics, the EU has now passed rules – through a process that involved the UK at every stage – to say that routine preventative use of antibiotics in farm animals must end, to protect their efficacy for treating human disease. However, the UK government has no plans to implement a ban in the UK – it has instead asked the farming and pharmaceutical industries to come up with voluntary targets.

Currently, the EU can hold the UK to account for failure to act, demonstrated by the European Commission recently warning the UK of heavy fines for persistently contravening agreed nitrogen dioxide levels. How will policymakers and regulators be held to account when links with the European Court of Justice and European Commission are severed? Secretary of State for Environment, Food and Rural Affairs Michael Gove has recently made some useful comments on the possibilities of a new UK environmental body that could hold the government to account, but its remit, powers and likelihood of establishment are not clear. There is also the risk of future international trade deals undermining policy commitments. For example, figures suggest that the use of farm antibiotics is more than twice as high per animal in the US as it is in the UK.

The UK government has already signalled that the EU Charter of Fundamental Rights will not be transposed into UK law when the country leaves the EU. With it, a foundation stone of public health and consumer protection will be lost. The ‘enhanced rights’ under the charter have been acknowledged by a UK court as a legitimate defence, in a case on constituents’ rights to privacy when corresponding with MPs, for example. The ‘unfrozen moment’ of Brexit should not be used to remove safety nets. Instead, it should be used to enshrine the rights of the UK population – one of which should be access to good food. This will need the political will and vision to do so, as well as a groundswell of public support.

Important European treaty principles are more than likely to be lost, such as the precautionary principle, the principle that the polluter pays, the right of access to environmental information and the right to justice. In future, if your family is affected by pesticide drift from the field next to your house, your ability to discover pesticide information or to take legal action will be greatly dependent on whether such principles are instated in UK law – or perhaps in the terms of reference of Michael Gove’s proposed environmental body. The fate of such legal principles is not yet fully clear but the signs are not encouraging.

During 2018, the UK will also need to start devising new agriculture and fisheries legislation to replace the structures, rules and funding provided by the Common Agricultural Policy (CAP) and the Common Fisheries Policy (CFP). At a profound ecological level, these are (or could become) core public health policies. The population’s long-term sustainable nutrition is inextricably bound up with the health of the UK’s soil, pollinators and marine ecosystems. Intergenerational health and equalities rely on the resilience and yield of the country’s fish stocks. To secure future nutrition and a sustainable source of heart-healthy omega-3s, the new fisheries bill must keep fishing efforts within scientifically agreed limits, allowing fish stocks to replenish. Of course, this has huge implications on the short-term profitability of the fishing fleet, even though recovered fish stocks could mean much greater profitability in the future. It will be a matter of political will whether long-term ecological thinking wins out over short-term economic gain.

Financial incentives to promote healthy production

Farmers provide much more than just food – flood management, soil and pollinator protection, landscape and carbon sequestration, to name but a few – yet struggle to be profitable, as these services are not factored into the price of food. If farmers are to thrive and be capable of looking after the UK’s precious natural assets, including people’s health, then there are some challenging choices ahead.

Will consumers accept higher food prices, to return more value to farmers? If so, how can the state help people on a low income to be able to afford this – a better ‘national living wage’, free school meals, vouchers for fresh fruit and vegetables, and more? Will supermarkets and big food manufacturers be required to adhere to higher standards and help farmers with the costs of making the transition? Will farmers be paid through public subsidy to be stewards of nature? Or indeed, should the UK adopt a far-sighted and balanced combination of all three of these approaches?

Some declare subsidies a market distortion, but markets need to be skewed in the right way if the UK is to collectively achieve the public benefits of antibiotic reduction, pollinator conservation, greenhouse gas emission reductions and much more. It is difficult to see how farmers may address these challenges on their own, as they face squeezed profit margins in supermarket supply chains.

The UK can move beyond the CAP and CFP systems, and design its own in which public money is earned for delivering public goods. These may include healthy food, soils and pollinators, as well as a beautiful landscape in which the population can enjoy the mental wellbeing associated with being in contact with nature. EU rules have been stringent in limiting government intervention to support agriculture, seeking to create a level playing field between EU farmers. Arguably, post-Brexit agreements could be used to steer our food production system in a more beneficial direction. Outside of EU constraints, the UK could provide greater investment in local food infrastructure, such as abattoirs and marketing hubs, and in skills and training to prepare farmers for the climate, soil, antibiotics and pollinator challenges ahead.

Investment in UK farming

The UK’s home-grown farming strategy and post-EU funding priorities could also see the country invest in domestic horticulture to supply the copious, colourful and delicious fruits and vegetables that would help turn the tide on diet-related ill health. The country falls woefully short of producing enough of its population’s recommended five-a-day. The UK’s commitment to a sugary drinks levy is welcomed – however, the UK still subsidises the production of sugary food and drinks that are known to cause diseases. These subsidies must also be stopped.

The UK could also choose to invest money (including revenue from the sugary drinks levy) into both children’s health and decent farm livelihoods by buying more UK-grown fruit and vegetables to supply school meals. What if every school, hospital, prison and barracks in this country used decent food, produced in decent ways, and promoted the health of consumers as well as the health of the environment? That is a vision worth championing.

Trading with the EU and beyond

There are two large challenges to this approach. The first being that the other 27 EU states have a big say in all of this: any Brexit deal must be signed off by them. There is an argument that they will not wish to see a potential future trading partner operating to lower standards than required in the EU, which could put EU producers at a competitive disadvantage. Ultimately, the EU-27 will have great influence on which standards must be retained to enable the ‘deep and special relationship’ option to endure. It is possible that the EU will require the UK simply to demonstrate equivalency with EU standards and to cooperate with the EU institutions that uphold those standards.

The second challenge is international trade with countries outside the EU. As soon as the UK has left Europe, there is likely to be a rush to secure new international trade deals, at which point the UK’s food, hygiene, quality, farming and fishing standards will almost inevitably be challenged. Indeed, US Commerce Secretary Wilbur Ross has already indicated, in a speech to the CBI in November 2017, that the UK would be expected to drop restrictive EU product standards if it wants a free trade deal with the US. Many have already commented on the possibility of chlorine-dipped chicken, hormone-reared beef, irradiated meat and meat grown with high levels of antibiotics all entering the UK market if the US becomes its favoured trading partner. Have no doubt that the politics of food, regulation and public health will be lived out in the meat supply chain – it always is. Campaigners have already highlighted the need for future UK trade deals to be open to public and parliamentary scrutiny in order to manage such conflicts.

In response to such concerns, the Sustain alliance is bringing people and organisations together to campaign for a new Food Act. This would set the legal framework for a Better Food Britain. The alliance is also developing proposals – through consultation – for new systems to replace EU farm subsidies and fishery policies and exploring the possibility of introducing a right to food into UK law. It is the task of our generation to ensure that public health, social justice and the environment are kept firmly centre stage – throughout Brexit and beyond.

Richard Kemp, councillor and leader of the Liberal Democrats, Liverpool City Council

Any review of the external determinants of health shows there are three key factors that contribute to a person’s wellbeing, which in turn contributes to their health. These are a good job, good pay and a good home (in a good neighbourhood).

These factors have been well quantified but also seem somewhat logical. If you have a good job, go home to a nice house and have a few bob in your pocket you are far less likely to resort to unhealthy behaviours, less likely to suffer from stress and anxiety about money, and also far more likely to have access to mental health services in times of need – all of which are vital for keeping you healthy.

If logic is not sufficient, then these figures should help to illustrate the link between work, salary and health. Table 1 is a comparison of my ward – Church Ward – in Liverpool (one of the wealthiest) with others and the national average in 2015. This shows that it is far more complicated than a simplistic view of a north–south divide. There are big differences inside both ‘rich’ and ‘poor’ areas.

How do EU funds make a difference to health?

The EU has invested in infrastructure in the past and the European Investment Bank still provides funding for health investment projects in the UK. However, in practice, the EU has nothing to do with day-to-day health funding in the UK. Overall, the EU has been and remains a relatively minor source of direct investment in health, but has invested extensively in factors affecting the wider determinants of health.

The EU gives no grants or support for housing, either public or private. What the EU has done for 3 decades is invest massively in employment and training schemes in poorer parts of the UK and throughout Europe. Between 2000 and 2006, there were six Objective 1 areas in the UK that received funding through the EU Structural Funds programme. These were mostly the big conurbations such as Newcastle/Gateshead, South Yorkshire and, of course, Greater Liverpool, but also included one less affluent county – Cornwall. Employment creation provides the money to fund other key health determinants and reduces illness by giving people a central purpose to their lives. It helps to pull them out of poverty, which Table 1 shows is a key determinant of health.

The people of Liverpool are more conscious of the need for job creation than many, but there are no regions in the UK where at least some areas or neighbourhoods have not been the recipient of one type of EU funding or another. These aren’t always the most obvious areas in terms of perceived need. As an example, sometimes the most scenic places like the Peak District and Lake District have been common recipients of specific EU funding programmes aimed at supporting hill-top farmers and their environments.

Employment and wealth figures did determine the need for funding though, and were so low in the UK’s six Objective 1 areas in comparison with the rest of Europe for between 10 and 15 years that they were granted such status. This was the top priority level for grant giving and the money flowed in. It is based on having a gross domestic product (GDP) per head less than 75% of the EU’s average. In Liverpool, the funding from the programme was used for capital and revenue activities that have transformed the city’s centre.

Without the matched funding from the EU there would not have been a major refurbishment of Liverpool’s museums and galleries and also the creation of a new one. There would have been no new canal, no conference and exhibition centre, no Liverpool ONE (the biggest new retail centre in Western Europe) and no growth of a myriad of hotels.

Above all, there would have been no European Capital of Culture in 2008, which turned around the image of the city and inspired confidence in other industries to surf in on the rising cultural tide to establish other businesses inside the Liverpool City Region. Although Liverpool no longer has Objective 1 status, it still has substantial amounts of funding coming into the City Region, and will have until the UK leaves the EU.

All that work and more has created jobs. Some of these jobs are not well paid (those in the service sector in hotels and bars, for example), but others are – giving employees disposable income and leading to a discernible spin-off of cash into other Liverpool businesses.

Risks if EU money is not replaced

Jobs, literally, can be the difference between life and death. EU programmes cannot deal with the total defects of the economy. But the fact is that the money from those programmes has been fundamental to regeneration programmes across the UK and will be extremely hard to replace.

Following the accession of many states to the EU since 2004, the amount of money available to regional funds in the UK has dropped considerably, but the EU still provides some chunky grants. Between 2013 and 2020 the two major European Funds – the European Social Fund (ESF) and the European Regional Development Fund (ERDF) – will have put almost £11bn into the economies of the poorest areas in the UK. The North West’s share of this is £1.1bn, and the Liverpool City Region’s share is about £150m.

But that is not all. This funding must be matched by the private or public sector. Currently, 30 major projects across both the public and private sectors in the Liverpool City Region are being financed by EU funding. Perhaps some of the ‘matching’ money will continue to flow without the European element. However, cross-government support will be needed to make sure equitable funding is made available across the UK, particularly in places where it isn’t at the moment (for example, transport spending per capita is four times higher in London and the South East than it is in the North West). Given the funding promises made to farmers, universities and other sectors in the UK, there simply will not be enough cash left for the wider uses to which EU money is currently put.

Priorities for the UK

The top three priorities in Liverpool (and similar cities) are jobs, jobs and jobs. Indirectly, a strong economy provides these regions with the taxes to pay for much-needed services. Directly, and in the context of health and social care, a much-improved health environment. There are so many ways places like Liverpool will not expand as quickly without the continued membership of the EU. The city’s port is dependent on breaking up big loads crossing the oceans and being split there for onward delivery to mainland Europe. This may not happen if the UK is outside the customs union and single market. The country’s universities depend on Europe-wide cooperation in research. If the UK is outside the EU, the money may not flow in the same way and the country’s universities could be excluded from cross-border research programmes. These losses of opportunity could have a direct and adverse effect on all health indicators.

There is disparity between spending on cultural organisations in London and the South East, and those in the North West. This disparity also occurs in infrastructure, research and many other sectors. The EU’s money has always been closely based on an objective assessment of need, whereas the UK government’s assessment under any political party has closer reflected political considerations. If EU funding is to be removed, it must be replaced using a transparent mechanism for ranking need and opportunity. The UK has a great opportunity to create national policies to address poverty, and perhaps to go even further by developing more aggressive policies to encourage the creation of wealth across the country, and with it improve the nation’s health.

Nina Renshaw, Secretary-General, the European Public Health Alliance

With the public debate around Brexit focusing mainly on its economic and legal consequences, public health concerns are in danger of falling by the wayside. There is a need to bring health to the forefront of the Brexit process.

The Article 50 negotiations to withdraw the UK from the EU may not be the toughest talks that the UK government must hold. As the Financial Times has pointed out, post-Brexit the UK will need to negotiate at least 759 treaties with 168 countries to maintain the UK’s current international relationships. Many of these concern ‘non-tariff barriers’ – such as safety or environmental standards – and clauses seeking to protect companies investing abroad. Indeed, 295 of these treaties are international trade deals struck by the EU on behalf of all member states. A further 202 determine the rules of regulatory cooperation between countries, for example mutual recognition of product standards. The rest are sectoral agreements, for example on movement of goods and cross-border services in agriculture, transport and nuclear energy.

Both directly and indirectly, many of these treaties have an impact on the health of people in the UK. Some of these are in surprising fields, which the UK’s fledgling trade negotiators may not have yet considered.

Potential loss of protections without debate

An immediate danger for public health lies in the European Union (Withdrawal) Bill, under which the body of EU legislation – including valuable protections for health, consumers, the environment, workers and safety – is effectively being copied and pasted into the UK statute book. There is concern among civil society organisations across a number of sectors that EU protections could potentially be quietly dropped by the government without parliamentary debate – using the so-called ‘Henry VIII’ causes.

Many commentators in the UK, especially leading Brexiteers, are notorious for complaining about ‘red tape’ and over-regulation as a result of EU Council negotiations. Health and safety protections – not only those in the workplace but also safety standards for consumer goods and standards for clean air and water – may be under threat. Civil society groups will need to be especially vigilant and monitor the retention of these protections through the transition processes.

Harmful goods

More generally, huge effort will be needed when negotiating future international trade deals if public health is to become a ‘red line’ issue. It certainly has not been for the EU and was barely on the European Commission’s radar until the Transatlantic Trade and Investment Partnership (TTIP) negotiations with the US. In terms of the (relatively limited) body of current EU legislation that protects public health (eg the Tobacco Products Directive and REACH legislation on harmful chemicals or food safety standards), the UK may be more vulnerable to the power of industry lobbies when it is negotiating alone. It may even be tempted to shift to a low-regulation environment as a strategy for competitive advantage, as David Davis has publicly hinted.

During the EU’s international trade negotiations, health groups including the European Public Health Alliance (EPHA) felt the need to take EU trade negotiators back to basics, to explain how increased availability and cheaper prices for some categories of goods would have an overall negative economic impact through imposed health harm – tobacco and junk foods were the most obvious goods here.

In the context of the UK’s new trading relationships, the same awareness-raising effort will be needed among the untested UK negotiators to encourage different approaches to health-harmful and health-promoting goods. A look at the lobby groups most vocal in their support of the EU–Canada and EU–US trade deals reveals the sectors that think they have most to gain – spirits, meat, pesticides and chemicals – and should ring alarm bells for anyone concerned with public health.

Investment protection and dispute settlement procedures

One element of international trade deals that poses a very severe threat to public health is the inclusion of so-called ISDS clauses (investor–state dispute settlement). Public uproar over ISDS clauses and their potential for abuse by multinational corporations to block health-protecting legislation persuaded the EU to drop the proposal in trade negotiations with the US. The EU’s recent attempt to reform the system by rebranding it as an Investment Court System (and building on this via a Multilateral Investment Court) does not address the fundamental flaws of the arbitration system. But for the UK’s new deals, ISDS will likely be back on the table – unless the government has the foresight to propose an alternative.

These ISDS clauses have increasingly featured in trade negotiations, after previously being largely confined to more obscure bilateral investment treaties between developed and developing countries. They are also being used more and more around the world by corporations – including, notably, the big tobacco companies – to sue governments intending to introduce legislation that these corporations claim will harm their investments. Examples include Philip Morris claiming billions in compensation for lost revenues from the Uruguayan and Australian governments for the introduction of plain packaging. Both cases were lost and both countries went ahead with the schemes, but not until lengthy legal challenges had been resolved.

The real impact of the cases, though, was as a threat to other governments, to back off plans for smoke-free policies for fear of being sued. Given that the UK is home to many of the world’s biggest tobacco companies – as well as alcohol and chemicals companies – bet they’re already lobbying hard for ISDS to be included across the board. This is a strategy to undermine hard-won progress achieved under the UN Framework Convention on Tobacco Control, which strengthened governments’ hands against the might of large producers of health-harming products.

Medicines and medical devices

The Euratom Treaty, that the UK has announced it plans to leave, provides a small insight into the importance of international treaties to our daily lives and the potential negative impact on health of a ‘no deal’ Brexit. It regulates the trade and transport of nuclear fuel rods, as well as radioisotopes used in radiotherapy and materials used in diagnostics. All medical isotopes used in the UK are imported, mostly from the Netherlands, so new agreements need to be struck quickly to secure their continued supply. Despite some media attention during 2017, this issue has yet to be tackled by negotiators.

New trade deals will be needed in fields with the most obvious relevance for health and care, including medicines and medical devices. The UK currently has direct access to new medical innovations approved by the European Medicines Agency (EMA). But one of the few certainties of Brexit is that the EMA will have to vacate its current headquarters in London for a new EU home (in Amsterdam). How the UK will engage with the EMA approvals process going forward is a subject for the second phase of negotiations on the future relationship with the EU. The continuation of the relationship between the UK Medicines and Healthcare products Regulatory Agency (MHRA) and the EMA is of vital importance to patients on both sides of the channel, as the MHRA currently covers a disproportionate share of the EMA’s workload. In a ‘no deal’ scenario the EMA would need to seamlessly replace the expertise provided by the MHRA without any disruption to medicines approvals that would cause delays to patients in both the UK and the EU.

Any silver lining?

Admittedly, EU policy is far from being consistent in putting health first in many markets. Examples include the recent failure to limit advertising of health-harming food and drinks to children through the recently reviewed Audiovisual Media Services Directive, and alcohol, for which health measures are often challenged on the grounds they disrupt the flow of European trade or contradict agricultural subsidies. Indeed, the Scottish Government had to dramatically delay its plan to introduce minimum unit pricing for alcohol as a health protection measure. This was because the Scotch Whisky Association (supported by the European spirits and wine lobbies) challenged the decision all the way to the European Court of Justice, claiming it would disrupt the internal EU market. Similarly, the EU lacks a coordinated strategy on tackling non-communicable diseases such as cardiovascular disease, cancer, respiratory diseases and diabetes, as well as mental health conditions.

The UK remains a world leader in public health thanks to a strong tradition built over centuries in academia, research, the media (The Lancet and the BMJ) and civil society, which has given rise to a strong institutional framework in government. More recently, Edinburgh and Cardiff – empowered by devolution – have taken on a leading role, so it is essential to think beyond Whitehall and Westminster. This longstanding strength in the UK compares very favourably with other countries and could be converted into a competitive advantage: Brexit could be an opportunity to build further on this tradition of leadership.

Post-Brexit, the UK could move faster with a raft of public health policies, including minimum unit pricing right across the UK; banning trans fats, controversial and potentially carcinogenic herbicides and hormone-disrupting chemicals; and taking a much tougher approach to high-sugar products. But that, of course, depends on domestic political will. The potential post-Brexit policy vacuum has unleashed a wave of lobbying activity, especially among industry players, that the health community will need to match. It will be necessary to evidence why progress is needed on health promotion and disease prevention and which policies can effectively contribute, but a new level of public mobilisation will also be needed to counter the prevailing deregulatory agenda.

How should the UK approach trade policy?

Trade policy has recently and rapidly become an unavoidable focus of health-in-all-policies approaches to decision making. In trade, the largest markets set the rules: UK companies will still have to comply with EU standards if they want to export to the EU. Brexit means (for better or worse) that for the foreseeable future, new trade deals will need close attention from health campaigners and civil society in the UK and internationally. Health experts must act quickly to become valued interlocutors for trade negotiators on both sides of Brexit. The confluence of Brexit and trade policy is not only of vital importance for patients, the research community, health workers and employers but for the whole of society: health protections and with them the future sustainability of the NHS are at stake.

Karen Steadman, Policy and Research Manager (Health, Wellbeing and Work), the Work Foundation

The implications for businesses have been central to discussions on the UK’s departure from the EU. Changes in business rules and regulations aren’t just matters for shareholders – at the centre of all businesses are the people who work in them. Any rule changes will likely have complex implications for current (and future) UK workers. Given what is known about the relationship between work, work quality and health, should workers’ post-Brexit rights be seen as a public health issue?

Compared with other EU countries, the UK has a low rate of unemployment and an above average rate of employment., How much of that employment is ‘good work’ is debatable, but data from the European Working Conditions Survey suggest that the picture is not too bad. The UK looks comparatively good on many workforce measures including permanency of contracts, prospects for advancement, having the right skills and feeling recognised for doing a good job. Countries in the UK also compare well against many EU countries on the impact of work on health; although with 22% of the population saying their work negatively affects their health, there is clearly more progress to be made.

The EU’s role in UK workers’ rights

To what extent have EU provisions influenced UK workers’ protections and rights? The primary EU provision here is the European Social Charter, which, when adopted in 1961, set out a course of protections to improve the living and working conditions of EU citizens. When the UK signed up in 1997, it included directives on: equal pay; maternity rights; sex, disability and race discrimination; and health and safety. The charter precipitated many of the rights considered normal in the UK today. These are (for the most part) widely supported, while several, such as annual leave requirements, surpass the minimum level required by the EU.

What has been contentious is whether the EU should have a role in social and employment legislation. It is not possible to know whether a UK outside of the EU would have taken the same path on employee rights – the subsequent changes in policy and in society are so interwoven as to be barely distinguishable. There are exceptions though, as some EU-led provisions remain contested, and as such are ‘vulnerable to attack’ in the future. As outlined below, these could have implications for the health of the UK public.

Rights for agency workers: the Agency Workers Regulations 2010 (implementation of the 2008 European Temporary Agency Work Directive) provide agency workers who have been in place for 12 weeks with equal rights as directly employed staff at the same organisation, including in terms of pay and sickness absence. With agency workers often found in lower skilled occupations, they are potentially more vulnerable from a health perspective. There is some evidence indicating links between temporary work and poorer psychological health. Reducing workers’ access to core sickness benefits might be a source of stress, and may reduce the incentive for taking time off to recover when ill, or to seek timely medical support – actions that might allow for earlier intervention and prevent worsening health.

Limits on weekly working hours: the Working Time Directive guarantees terms such as a maximum 48-hour week and four weeks’ paid holiday per year, plus rules on the number of hours of rest for shift workers. After much debate, the UK opted into this in 1998, with the caveat that individuals could opt out. The rule has been particularly contentious in medicine, where it was argued that there should be more flexibility in what are counted as working hours during training. With longer working hours associated with poorer health outcomes, and particularly enhanced risk of coronary heart disease and stroke, the protective element of this directive for health is clear.

Promoting employee voice: the Information and Consultation of Employees Regulations (ICE), based on a 2002 EU industrial relations directive, promote the rights of workers to receive information and be consulted on changes in their organisation that could affect their jobs, or terms and conditions of employment. ICE was contentious with business groups, which argued that it would intrude on individual business policy. Though not clear cut, it has been suggested that there has been some impact on organisations’ consultation processes (whether new or modified existing provisions) since the directive came in. The regulations currently only apply to organisations with 50 or more employees, and require the support of 10% of employees. Having greater control over the nature of and decisions about work is associated with better health, wellbeing and job satisfaction and is a criterion of good work.,,

Racing to the top and the bottom

This leads us to what appears to be the biggest risk – polarisation. Though many employers have embraced and are striving for better quality work to enhance competitiveness, what about those who are seeking to be competitive through other means, particularly through doing the minimum and undercutting the competition? EU employment law sought to create a level playing field and provide safeguards to ensure that member states do not use workers’ rights and protections as bargaining tools. This reduces the risk that members of the single market compete by offering lower wages and fewer protections for workers.

Concerns about the potential for increasing polarisation of the UK labour market were highlighted in recent research by the Work Foundation for the TUC, which examined the potential impact of Brexit on the UK’s ability to attract foreign direct investment. The available information suggested that in the event of the UK leaving the single market, the risk of devaluing workers’ rights is greater at the lower end of the labour market, where there might be increased incentives for UK businesses to ‘undercut’ those in the EU in order to enhance their competitiveness. Could the weakening of safeguards allow some companies to engage in a ‘race to the bottom’ for employee rights, to reduce costs and offer contracts on the cheap?Again, concerns about workers’ rights post-Brexit are most pertinent for those in specific areas of the labour market, including low-skilled workers, agency workers and the self-employed.

Could shifts in the UK workforce encourage better working standards?

Is there potential that Brexit could offer opportunities to policymakers for improving work and health? One such area is the distribution of state aid. This is currently governed by the European Commission, which acts to prevent the funds being used to distort competition and create unfair national advantage. This provision has been a subject of long-term criticism from some charities that feel it doesn’t address the real issues with competition.

If EU restrictions on state aid were removed (although this is unlikely to be accepted by the EU under any future partnership agreement), the UK would be free to provide aid funding in a way that better fits local needs. This would potentially enhance opportunities for funding of charities and social enterprises working in deprived communities. It would, however, remain to be seen whether this would translate into significantly higher levels of public investment, given the UK has traditionally provided lower levels of state aid per capita than other European countries.

Given how little is known about what Brexit and its implications will look like, we can perhaps be a bit more ambitious with conjecture. Is it possible, for example, that in the event of a flight of EU workers (as possibly seen already in new nursing registrants,) more opportunities will become available for UK workers in the medium term? Leaving aside economic arguments about lump of labour fallacy for the moment, is it possible that employers will fight harder to attract and retain employees, and therefore actively raise standards in order to appeal to a smaller pool of workers? Might this persuade employers to be more progressive in terms of job quality, support and flexibility – potentially enhancing opportunities for those with health barriers, older workers and those with caring responsibilities? Decisions yet to be made about freedom of movement for EU citizens and skilled immigration requirements will of course also impact here, as will how the UK will invest in education, training and skills for residents.

What the UK does to offset any harms is as important as discussions about the implications of the unknowns of Brexit. In terms of health, work and inequalities there has been a great deal of activity of late. Indeed, there is an increasingly coherent drive to sustain and promote good work to improve both health and productivity. The recent report of the Taylor review of modern working practices placed ‘good work’ at its centre, and set out a series of steps for how work quality can be improved in a changing UK labour market. The report called for the UK’s national strategy for work to be ‘explicitly directed toward the goal of good work for all’, thus securing a baseline of rights for all types of workers. Interestingly, it specifically included a call to extend ICE to all employees and workers, and for the support threshold to be reduced to 2%.

There are other promising signs. The recent Department for Work and Pensions and Department of Health’s joint strategy, Improving lives: the future of work, health and disability, makes explicit reference to ‘good work’ (rather than any work) as important for health. The recent industrial strategy, setting out the UK’s long-term vision for sustainable prosperity, also claimed that the government shares Mr Taylor’s ambition for good work. Time will tell whether these positive words translate into action.

What is known, is that uncertainty and insecurity in the labour market is unlikely to be good for businesses or for worker health. There must be a focus on what can be controlled: with recent policy changes indicating that a consensus is forming around the importance of good work, could this be a way of protecting workers from the perceived risks of Brexit? Being clear about what the UK wants from and for its workforce is the most important thing for negotiators to consider as talks progress.

Taking distinct perspectives on the implications of the UK leaving the EU for the public’s health, the essays in this collection have highlighted some common challenges.

• There will be a ‘governance gap’ as the UK’s relationship with EU institutions comes to an end. This could lead to increased pressure on national institutions to deliver the operational and enforcement functions currently provided at EU level, such as food, environmental, and trading standards monitoring and enforcement.
• It is possible that some social protections may be lost or weakened (eg for health, consumer safety and workers’ rights) if the government adopts a long-term deregulatory agenda – particularly if it is driven by pressure from other countries when reaching new trade agreements.
• In the process of negotiating trade agreements, the UK may take a less robust approach to risk assessments applied to goods and services if future frameworks do not incorporate the precautionary principle, as is the case in the EU.
• The replacement of EU funding with domestic funding could lead to less objective decisions about where the money is spent to support areas of investment need for regeneration, infrastructure and jobs, unless decisions are protected from political influence (at both national and local level).

The contributorss have also identified some opportunities to innovate, be progressive, put health at the heart of new policy frameworks for agriculture and employment, and make health a central consideration in international trade agreements. But all have pointed towards the conditions needed for better domestic policymaking for health to become a reality.

• Kath Dalmeny and Nina Renshaw emphasise the crucial role of parliamentary oversight of decisions on all aspects of post-Brexit arrangements. They argue this is needed to make sure that the impacts on health of new trade deals and policy frameworks are taken into full account during negotiations.
• Nina Renshaw says that trade negotiators and policymakers will need much better access to public health knowledge and impact assessment tools so that risks are fully understood and factored into any new trade agreements.
• Sue Davies and Kath Dalmeny both caution that, without access to EU institutions and structures, the UK will need to invest in domestic capacity to bridge the governance gap.
• Davies notes that strengthened trading standards services and the creation of a national arms’ length body with responsibility for consumer product safety will be needed at a time when trading patterns, supply chains and border controls become more complex. Dalmeny says that attention will need to be given to the increased pressures on environmental health services and the Food Standards Agency in protecting and promoting health.
• Richard Kemp argues that a new mechanism for distributing support funds will be needed when the UK leaves the EU. It must allow decision making to be made based on need and free of political considerations.
• Karen Steadman suggests that if policymakers establish a clear focus on what the UK wants from and for its workforce, it may be possible to capitalise on the positive, cross-department consensus on the value of good work that is developing and to better protect UK workers from the potentially disruptive effects of leaving the EU.

It is important to bear in mind there are major potential impacts on health that have not been discussed in this collection. The essays have not looked at the effects of leaving the EU on the wider economy, or on public finances and the likely impacts on jobs, earnings, investment in other public services, or on the cost of living. Recent estimates published by the Resolution Foundation and the UK Trade Policy Observatory suggest that poorer households are likely to be most affected by a ‘no deal’ in which trade tariffs and prices rise. These are all fundamental factors that shape people’s health and wellbeing.

Nor have the essays explored direct impacts on health and social care services in the UK. These include access to the EU’s health and care workforce, access to goods such as vaccines and radioisotopes for cancer treatments and scans, and future involvement with EU-wide collaborations for health-related research. Nor have they considered the proven health impacts of air pollution and the leading role played by the EU in setting and enforcing air quality standards – this has been analysed elsewhere. In addition to the challenges and opportunities identified by the essays, these factors must be addressed when the UK leaves the EU, to make sure all policies are developed with consideration of their impact on health.

Concluding thoughts

This essay collection has illustrated some of the less apparent ways in which the shift in the policy landscape on leaving the EU will have important implications for people’s opportunities to lead healthy lives. Good health is of value to the individual, and is also a societal asset – part of the foundations of a prosperous and flourishing society. It is therefore important that health considerations are placed at the heart of new policy frameworks, trade agreements, financial strategies and regulations after Brexit.

Leaving the EU has been described as an ‘unfrozen moment in which new possibilities occur’. It is also viewed as a point of immense risk and uncertainty that may harm economic prospects for people in the UK and overwhelm the governments in the four nations with vast amounts of legislative scrutiny for years to come.

Whether future challenges are perceived optimistically or pessimistically, leaving the EU will bring about change across all areas of policy. The potential scale and scope of this change present an opportunity to take a more ambitious, holistic approach to policymaking, with the goal of protecting and promoting the public’s health – as an economic investment and a social good. This will require strong political leadership, effective cross-government working and a shared understanding of how social policies can support better health.

The public health system cannot alone secure the protections and opportunities the UK’s departure from the EU presents. This will instead require broader coalitions with charities, academic institutions and think tanks working in health and non-health sectors.

There are already examples of concerted activities to raise issues, make the case to protect existing institutions, and propose new relationships for the future that will have an impact on the public’s health. Kath Dalmeny described how food and farming organisations have called for a new Food Act. The NHS Confederation instigated a Brexit Health Alliance of health care users, providers, commissioners and researchers to ensure health and care considerations are represented in Brexit negotiations. Another group – the Cavendish Coalition, a collaboration of 37 health and social care organisations – is working to make sure the UK still has a strong supply of domestic and international health and care staff and trainees after leaving the EU.

Addressing the breadth of the issues and opportunities identified in this collection of essays will demand a shared, confident vision for the future and more effective collaborations between organisations working in diverse policy areas, from trade and employment to planning and the environment. Public health campaigners have long called for a health-in-all-policies approach to policymaking. The changes in the regulatory and political landscape over the coming years will make this approach all the more necessary.

Jane Landon is a strategy adviser in the healthy lives team at the Health Foundation. Jane has worked in public health policy development and advocacy for nearly 20 years with charities and public health agencies. She is on a 22-month secondment from the UK Health Forum where she is Deputy Chief Executive and Director of Policy. Jane is also Director of the Eating Better charity, a fellow of the Faculty of Public Health and an adjunct research fellow at the Faculty of Health Sciences at Curtin University, Western Australia.

Kath Dalmeny is Chief Executive of Sustain, an alliance of around 100 organisations working to achieve a healthy, fair, humane and sustainable system for food, farming and fishing. Since 2016, Kath has been the alliance’s Brexit Lead, convening third sector organisations in the Sustain Brexit Forum to discuss the implications of fundamental changes to the UK’s governance of food, farming and fishing. She is also a commissioner for the new Food, Farming and Countryside Commission hosted by the RSA, and a member of the Repeal Bill working group convened by Unlock Democracy. Kath is a convenor of Sustain’s Campaign for a Better Food Britain, which will include the call for a fundamental right to food, instating UN sustainable development goals in UK law.

Sue Davies, strategic policy adviser at Which?, is leading Which?’s policy work on Brexit. She is also responsible for food policy at Which? and has represented consumer interests on a range of national and international committees. She was the chair of the European Food Safety Authority from 2012 to 2016. She has been awarded an MBE by the Queen in recognition of her work on food safety. 

Nina Renshaw is Secretary-General of the European Public Health Alliance (EPHA). EPHA is a member-led organisation of public health non-governmental organisations, patient groups, health professionals and disease groups working together to improve health and strengthen the voice of public health in Europe. Nina represents EPHA on the Civil Society Contact Group, the Social Platform, the Better Regulation Watchdog and the Executive Committee of the Health and Environment Alliance. She is also a member of the European Commission’s Advisory Group on the EU–US TTIP trade negotiations.

Richard Kemp is the leader of the Liberal Democrats on Liverpool City Council and a former leader of the Liberal Democrats in local government and vice chair of the Local Government Association (LGA). Richard was LGA spokesperson on international affairs for 9 years and represented the UK at a global level for local government. He is currently the Liberal Democrat spokesperson at the LGA on social care and health. Before becoming a full-time councillor in 2001 he worked as an adviser on regeneration projects throughout the UK.

Karen Steadman leads the health, wellbeing and work research and policy programme at the Work Foundation, part of Lancaster University. Karen’s research focuses on job quality and health – improving access to good quality, health-promoting work for more people, particularly those who experience health-related barriers to work. Karen leads Fit for Work UK, a coalition of expert stakeholders looking at the relationship between chronic conditions and musculoskeletal disorders and employment. She also leads the Health at Work Policy Unit, a programme of work designed to influence and improve workplace and working age health policy at national, local and organisational level.

Introduction

1. Fahy N, Hervey T, Greer S, et al. How will Brexit affect health and health services in the UK? Evaluating three possible scenarios. Health Policy. 2017;390(10,107):2,110–8. Available from: http://dx.doi.org/10.1016/S0140-6736(17)31926-8
2. World Health Organization. Contributing to social and economic development: sustainable action across sectors to improve health and health equity. 2014. Available from: http://apps.who.int/gb/ebwha/pdf_files/wha67/a67_r12-en.pdf
3. House of Commons Health Committee. Brexit and health and social care – people & process: Eighth report of session 2016–17. 2017. Available from: https://publications.parliament.uk/pa/cm201617/cmselect/cmhealth/640/640.pdf
4. Royal College of Physicians. Brexit: What does it mean for air quality? 2017. Available from: www.rcplondon.ac.uk/projects/outputs/brexit-what-does-it-mean-air-quality

Putting consumers at the heart of policymaking

1. Regulation (EC) No 178/2002 of 28 January 2002 laying down the general principles and requirements of food law, establishing the European Food Safety Authority and laying down procedures in matters of food safety
2. Which? and Government Office for Science. Food system challenges – public dialogue on food system challenges and possible solutions. 2015. Available from: www.which.co.uk/documents/pdf/food-system-challenges---public-dialogue-on-food-system-challenges-and-possible-solutions-445299.pdf
3. Regulation (EU) No 1169/2011 of 25 October 2011 on the provision of food information to consumers
4. Department of Health, Food Standards Agency, Welsh Government, Food Standards Scotland. Guide to creating a front of pack (FoP) nutrition label for pre-packed products sold through retail outlets. 2016. Available from: www.food.gov.uk/sites/default/files/multimedia/pdfs/pdf-ni/fop-guidance.pdf
5. Regulation (EC) No 1223/2009 of 30 November 2009 on cosmetic products
6. Regulation (EC) No 1907/2006 of 18 December 2006 on the Registration, Evaluation, Authorisation and Restriction of Chemicals (REACH)

Protecting health in new trade agreements

1. European Public Health Alliance. Trade for health. Available from: https://epha.org/trade-and-health
2. McClean P. After Brexit: the UK will need to renegotiate at least 759 treaties. Financial Times. 30 May 2017. Available from: www.ft.com/content/f1435a8e-372b-11e7-bce4-9023f8c0fd2e
3. David D. Trade deals. Tax cuts. And taking time before triggering Article 50. A Brexit economic strategy for Britain. 14 July 2016. Available from: www.conservativehome.com/platform/2016/07/david-davis-trade-deals-tax-cuts-and-taking-time-before-triggering-article-50-a-brexit-economic-strategy-for-britain.html
4. See for example: Taylor NP. European regulatory roundup: EMA tasks working groups with redistributing workloads in run up to Brexit. Regulatory Focus. 22 June 2017. Available from: www.raps.org/Regulatory-Focus/News/2017/06/22/27957/European-Regulatory-Roundup-EMA-Tasks-Working-Groups-With-Redistributing-Workloads-in-Run-Up-to-Brexit-22-June-2017
5. European Public Health Alliance. AVMSD vote fails to ensure a healthier, future-proof marketing environment. Available from: https://epha.org/avmsd-vote-fails-to-ensure-a-healthier-future-proof-marketing-environment
6. World Health Organization. Global action plan for the prevention and control of NCDs 2013–2020. 2013. Available from: www.who.int/nmh/publications/ncd-action-plan/en

Securing jobs and working conditions after Brexit

1. Eurostat. Statistics explained: Unemployment rates, seasonally adjusted, June 2017 (%) F2.png. Available from: http://ec.europa.eu/eurostat/statistics-explained/index.php/File:Unemployment_rates,_seasonally_adjusted,_June_2017_(%25)_F2.png
2. Eurostat. Statistics explained: Employment statistics. Available from: http://ec.europa.eu/eurostat/statistics-explained/index.php/Employment_statistics
3. Eurofound. European working conditions survey – Data visualisation. 2015. Available from: www.eurofound.europa.eu/surveys/data-visualisation/sixth-european-working-conditions-survey-2015
4. TUC. UK employment rights and the EU: Assessment of the impact of membership of the European Union on employment rights in the UK. 2016. Available from: www.tuc.org.uk/sites/default/files/UK%20employment%20rights%20and%20the%20EU.pdf
5. Judge L, Tomlinson D. Secret agents: agency workers in the new world of work. Resolution Foundation; 2016. Available from: www.resolution foundation.org/app/uploads/2016/12/Secret-Agents.pdf
6. Virtanen M, Kivimäki M, Joensuu M, et al. Temporary employment and health: a review. International Journal of Epidemiology. 2005;34(3):610–22. Available from: http://dx.doi.org/10.1093/ije/dyi024
7. Kivimäki M, Jokela M, Nyberg ST, et al. Long working hours and risk of coronary heart disease and stroke: a systematic review and meta-analysis of published and unpublished data for 603,838 individuals. The Lancet. 2015;386(10,005):1739–46. Available from: http://dx.doi.org/10.1016/S0140-6736(15)60295-1
8. Eurofound. UK: The impact of the information and consultation directive on industrial relations. 2009. Available from: www.eurofound.europa.eu/observatories/eurwork/comparative-information/national-contributions/united-kingdom/uk-the-impact-of-the-information-and-consultation-directive-on-industrial-relations
9. Wheatley D. Autonomy in paid work and employee subjective well-being. Work and Occupations. 2017;44(3):296–328. Available from: http://dx.doi.org/10.1177/0730888417697232
10. Marmot M, Wilkinson R, Siegrist J, et al. Health and the psychosocial environment at work. In: Marmot M, Wilkinson R (eds). Social determinants of health. Oxford University Press; 1999.
11. Andriescu M, Giles J. Could a bad Brexit deal reduce workers’ rights across Europe? Estimating the risks of a ‘race to the bottom’. Work Foundation; 2017. Available from: www.theworkfoundation.com/wp-content/uploads/2017/05/415_BrexitWorkersRights.pdf
12. Oxera. Brexit: implications for state aid rules. 2016. Available from: www.oxera.com/Latest-Thinking/Agenda/2016/Brexit-implications-for-state-aid-rules.aspx
13. Nursing & Midwifery Council. New figures show an increase in numbers of nurses and midwives leaving the professions. 3 July 2017. Available from: www.nmc.org.uk/news/press-releases/new-figures-show-an-increase-in-numbers-of-nurses-and-midwives-leaving-the-professions
14. Buchan J, Charlesworth A, Gershlick B, Seccombe I. Rising pressure: the NHS workforce challenge. Workforce profile and trends of the NHS in England. Health Foundation; 2017. Available from: www.health.org.uk/publication/rising-pressure-nhs-workforce-challenge
15. Taylor M. Good work: The Taylor review of modern working practices. 2017. Available from: www.gov.uk/government/uploads/system/uploads/attachment_data/file/627671/good-work-taylor-review-modern-working-practices-rg.pdf
16. HM Government. Building our industrial strategy. 2017. Available from: https://beisgovuk.citizenspace.com/strategy/industrial-strategy/supporting_documents/buildingourindustrialstrategygreenpaper.pdf

Emerging issues: considerations for policymakers

1. Clarke S, Serwicka I, Winters A. Changing lanes: The impact of different post-Brexit trading policies on the cost of living. Resolution Foundation and UK Trade Policy Observatory; 2017. Available from: www.resolution foundation.org/app/uploads/2017/10/Changing-Lanes.pdf
2. Dayan M. How will our future relationship with the EU shape the NHS? Nuffield Trust; 2017. Available from: www.nuffieldtrust.org.uk/files/2017-11/1509990492_nt-future-relationship-with-eu-after-brexit -web.pdf
3. Royal College of Physicians. Brexit: What does it mean for air quality? 2017. Available from: www.rcplondon.ac.uk/projects/outputs/brexit-what-does -it-mean-air-quality
4. Gove M. The Unfrozen Moment – delivering a green Brexit. 21 July 2017. Available from: www.gov.uk/government/speeches/the-unfrozen-moment-delivering-a-green-brexit

A number of people contributed to the development of this collection and we would like to thank them for their comments and advice.

The essays in this collection have been produced independently by the contributing authors and do not necessarily represent the views of the Health Foundation. Errors and omissions remain the responsibility of the authors alone.

There is a pressing need to step up global and national action on non-communicable diseases, and the factors that put so many people at risk of illness and death from these conditions worldwide... action that is led by the highest levels of government and that inserts health concerns into all policy making – from trade and finance to education, environment, and urban planning.

Tabaré Ramón Vázquez, President of Uruguay

Tedros Adhanom Ghebreyesus, Director-General, the World Health Organization