By the early twenty-fi rst century, trade and international trade agreements transformed governments’ ability to monitor and protect public health. Trade agreements restricted the capacity of government agencies to regulate occupational and environmental health conditions and food products and to ensure affordable access to medications and water. Such agreements covered a wide range of health services, health facilities, clinician licensing, and the distribution of tobacco and alcohol. To some extent, public health organizations began to grapple with trade-related threats to global health, including emerging infectious diseases and bioterrorism. However, these organizations did not consistently call attention to the potentially deleterious effects of trade agreements on public health and medical services.1 Partly as a result, during the fi nal years of what I have called empire present, trade agreements profoundly shaped policies that impacted health throughout the world.