Global Health Law

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Global Health Law

• Meeting Basic Survival Needs of the World's Least
  Healthy People Toward a Framework Convention on
  Global Health
• Lawrence O. Gostin
• Linda and Timothy ONeill Professor of Global
  Health Law Georgetown University Law Center

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The Challenge of Protecting Global Health
Health problems have serious economic,
political, and security ramifications for millions
Major health hazards cross State borders
Protection of global health requires cooperation
global governance
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Future Expectations If No Changes Take Place

• Most affected States
• Least capable of effecting change

• States with resources to protect global health
• Lack political will to act outside their borders
• Act out of narrow self interest or humanitarian
  instinct
• Ethical/Legal obligation is not acknowledged
• Assistance driven by public sympathy in
  catastrophic events, not long term health
  problems.

• Result
• Spiraling deterioration of health in poorest
  regions with global consequences for disease
  transmission, trade, international relations, and
  security.

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Meeting Basic Survival Needs

• A focus on these major
• determinants of health would enable the
  international community to have a dramatic effect
  on global health prospects.

Sanitation Sewage
Pest Control
Well Functioning Health System
Essential Medicines Vaccines
Clean Air Water

• Less dramatic and glamorous than emergency
  response measures, this approach would have
  lasting effects on common health problems.

Tobacco Reduction
Diet Nutrition
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Role of International Law I

• Shortcomings of Current Legal Solutions
• Diverse state non-state actors influencing
  health outcomes.
• Difficulty in setting normative standards and
  assuring follow-through especially in health.
• International law is ineffective at creating
  obligations or even incentives for better
  funding, services, or protection in health of
  poor populations.

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Role of International Law II FCGH as a Starting
Point
The arena of global health law is in need of an
innovative mechanism to structure international
obligations.

• Framework Convention on Global Health (FCGH)
• Commit States to economic and logistic targets
• Remove barriers to engagement of private and
  charitable sectors
• Set realistic goals for global health spending as
  GNP
• Specify optimal areas of investment for basic
  survival needs
• Build sustainable health systems
• Create incentives for scientific innovation

WHO or new institution created for this purpose
would set standards, monitor progress, mediate
disputes.
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Detailed Lecture Outline

• Why should governments care about serious health
  threats outside their borders?
• Global equity and disproportionate burden of
  disease.
• The international communitys choice to target a
  few high profile issues instead of deeper
  systemic problems in global health what is the
  significance of basic survival needs?
• The value of international law and the proposal
  for a Framework Convention on Global Health.

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I. Global Health A Matter of National Interest?

• Human activities promote the
• spread of disease across national borders

CYCLE OF Congregation, Consumption, and Movement
Members of the world community must rely on
one another for health security State
Instability Poor Health
Environment Pollution
Overtaxed Health Systems
Proximity to Animals
Bioterrorism
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I. Global Health A Matter of National Interest?
a. National Interests in the Health of the
Populace

• More reasons to pay attention
• Emerging and re-emerging diseases increasingly
  affect developed nations, with resistance to
  front line drugs.
• Domestic costs of response can disrupt social
  life and infringe on individual rights.

• Primary obligations of a State
• Defense
• Security
• Welfare Domestic Health

includes
affects

• Health of Other Populations Beyond National
  Borders
• DNA fingerprinting confirms pathogen migration
• More than 30 infectious diseases emerged in past
  2-3 decades. (Haemorrhagic fevers, Leginnaires
  disease, Hantavirus, West Nile virus, monkeypox,
  etc.)
• Vast growth in global trade of fruits,
  vegetables, meats, and eggs brings forth
  outbreaks of foodborne infections (Salmonella, E.
  coli, Norwalk).

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I. Global Health A Matter of National Interest?
b. National Economic Interests Trade and
Commerce

• Countries with extremely poor health become
  unreliable trading partners that struggle to
• Develop and export products and natural resources
• Pay for essential vaccines and medicines
• Repay Debt

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I. Global Health A Matter of National Interest?
c. National Security
CIA Infant mortality is a leading predictor of
State failure. U.S. Dept of State AIDS is a
national security threat.

• Sub-Saharan Africa
• Overwhelming poverty and disease are
  paired with numerous political and
  military entanglements.
• The regions marginal strategic importance has
  allowed the world to ignore the health and
  security crises.

• Eurasia
• Burgeoning HIV/AIDS crises in India,
  Russia, and China mirror that of
  sub-Saharan
  Africa.
• Additional emerging health problems (infant
  mortality, womens health) exacerbate the
  HIV/AIDS crisis.
• Eurasias population, economic participation, and
  military prowess make it strategically important
  regional instability will have dire ramifications
  for the world.

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I. Global Health A Matter of National Interest?
d. How States Perceive Global Health
-Although States may understand the threat of
health hazards beyond their borders, actual
engagement is limited-

• Global health development assistance is dwarfed
  by annual military spending (1 trillion) and
  agricultural subsidies (300 billion).
• Increase in assistance is a response to a few
  high-profile problems (HIV/AIDS, Pandemic flu,
  Asian tsunami) not a strategic long term
  commitment.
• Even with new investments most OECD states have
  not fulfilled their pledges (0.7 of GNP) and
  would need 100 billion to close the gap.
• National security assessments and international
  agreements only narrowly justify state action on
  global health.

• OECD countries increased development assistance
  for global health from nearly 2 billion to 12
  billion (1994-2004).
• Gates Foundation will donate up to 3 billion per
  year for global health development.

BUT
Could states be correct that true global
engagement does not serve their interests?..
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II. Global Health Disparities Are Profound
Health Inequalities Fair?

• Poor populations burden of disease is not only
  higher than that of wealthier states, but also
  disproportionate.
• The degree to which the poor suffer unnecessarily
  is rarely considered.
• Disparities in life expectancy and likelihood of
  maternal death during labor are vast
• Average life exp in Africa is 30 years less than
  that in Americas or Europe.
• A child from Zimbabwe or Swaziland is expected to
  live less than half as long as a child in Japan.
• A child born in Angola is 73 times more likely to
  die than a child born in Norway.
• As life expectancy steadily climbs in developed
  states, less developed and transitional countries
  (Russia) are witnessing a drop in LE.

In one year, 14 million of the poorest people in
the world died. If their life expectancy matched
that of the worlds rich, that number
would have dropped to 4
million.
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II. Global Health Disparities Are Profound
Health Inequalities Fair?
a. Diseases of Poverty Preventable Suffering
Diseases of Poverty endemic in the worlds
poorest regions but unknown among the worlds
wealthy filarial worms, elephantiasis, guinea
worms, malaria, river blindness, schistosomiasis,
and trachoma.
Filarial Worms the second-leading cause of
permanent and long-term disability in the world.
Filariasis causes disfiguring enlargement
(elephantiasis) of the arms, legs, breasts,
genitals. Below Antoinette St. Fab, left and
her mother, Marie Denise Bernard, in Léogane,
Haiti. Their Swollen legs are a symptom of
lymphatic filariasis Image Credit NY Times
Guinea Worms In 2003 the three most endemic
countries, i.e., Sudan, Ghana, and Nigeria
reported 20,299 cases of the disease. (CDC)
River Blindness/ Onchocerciasis The disease is
most intensely transmitted in remote African
rural agricultural villages, located near rapidly
flowing streams. Presently, it is estimated that
37 million people carry O. volvulus, with 90
million at risk in Africa. - African Programme
for Onchocerciasis Control APOC (2005) Image
Credit BBC International
Lelmi Malik, a 32-year-old mother of three,
writhes in pain as Solomon Olukade massages a
guinea worm from her ankle in the village of
Dunkure, Nigeria. (March 22, 2001) Credit Mike
Urban/Seattle Post-Intelligencer
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II. Global Health Disparities Are Profound
Health Inequalities Fair?
b. Who is Responsible for Addressing Global
Health Disparities?
Almost everyone believes this is unfair, but
there is no consensus on the ethical or legal
obligation to help

• Causal Pathways
• to Disadvantage Include
• Poverty
• Poor Education
• Unhygienic Environments
• Pollution
• Social Disintegration

COMPOUND, SUSTAIN, REPRODUCE
Systemic Disadvantages in health and other
aspects of social, economic, and political
life

• Fundamental Questions
• WHY are inequalities unfair?
• WHO is responsible for change?
• What LEVEL of assistance is ethically justified?

Existing Inequalities Beget Other Inequalities.
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II. Global Health Disparities Are Profound
Health Inequalities Fair?
b. Who is Responsible for Addressing Global
Health Disparities?
Are Disparities Ethically Wrong?
Alternative Theory of human functioning Health
is an asset essential for adequate functioning of
individuals and communities. Population health is
a transcendent value because it enables a series
of activities critical to public welfare.
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II. Global Health Disparities Are Profound
Health Inequalities Fair?
b. Who is Responsible for Addressing Global
Health Disparities?
Is There a Duty to Rectify Disparities?

• Existing claims (Nagel, Rawls, Walzer) are
  narrowly framed around the statecitizen
  relationship.
• Positing such a relationship between countries is
  a challenge.
• Arguments for a non-statist view of the global
  community that focuses on interdependence
  are rare outside activist circles.

Lack of a principled ethical argument may show
the need for international law.
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III. Basic Survival Needs Ameliorating Suffering
and Early Death

• Most international aid is ineffective and even
  counterproductive
• The current level of support will surely wane.
• After the interest and/or resources have run out,
  the worlds poor will be in the same or worse
  position as before.

Solution Mobilization of public and private
sectors to meet basic survival needs. (e.g.
Marshall Plan)
Marshall Plan poster, circa 1949
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III. Basic Survival Needs Ameliorating Suffering
and Early Death
a. Reframing the Approach to Development
Assistance

• Emphasis on high-visibility crises diverts
  resources from long-term projects that focus on
  everyday needs.
• A small number of wealthy donors are setting the
  global development agenda with little
  understanding of local needs and capacities. (see
  right)
• Assistance is fragmented and uncoordinated
  programs compete with each other and with local
  efforts.
• Many projects have narrow, short-term goals
  preferring quick, observable, and quantifiable
  results.
• Massive infusion of assistance can produce
  problematic over-reliance and dependency.
• Host countries also carry some responsibility for
  the failures of international assistance
  preference for other needs over health, corrupt
  misappropriation of funds, incompetence, and
  bureaucracy.

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III. Basic Survival Needs Ameliorating Suffering
and Early Death
b. Basic Survival Needs as a Measure of Intl
Health Assistance
Assistance should be redirected to support
Basic Survival Needs.
Immunizations
Health Education
Primary Health Care
Essential Medicines
Nutritional Foods
Public Health Infrastruct.
Potable Water
Pest Abatement
Sanitation
Something as simple as a vaccine, generic drug,
basic engineering, or sanitation can result in
significant health improvements among the worlds
poorest populations.
Nigerian woman receives a smallpox vaccination in
1969 during the World Health Organization's
effort to wipe out smallpox. By 1979 the virus
had been eradicated.
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III. Basic Survival Needs Ameliorating Suffering
and Early Death
b. Health Systems Basic Infrastructure
Capacity Building

• Health System Needs
• Public health agencies
• Primary health care services
• Human resources skilled workers (HCW)
• Public health education facilities (to minimize
  brain drain).
• Area of Concern
• Even when developing countries train HCWs, they
  are pushed to migrate by depressed working
  conditions at home and pulled by aggressive
  recruiting from OECD states.

Foreign run state-of-the-art facilities
Poor countries in need of adequate health care
Capacity-building assistance
Foreign aid workers
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IV. Global Governance for Health Proposing a
Framework Convention

• Investing in Infrastructure
• The amount of money is not more important than
  the strategy of investment and utilization of
  newly available resources.
• A structured approach would
• Set goals
• Ensure coordination
• Monitor results

Existing tools are inadequate a NEW approach is
needed.
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IV. Global Governance for Health Proposing a
Framework Convention
a. International Health Law WHOs Record

• WHOs Normative Powers
• Can adopt binding conventions that are stronger
  than normal treaties.
• Has quasi-legislative powers to adopt binding
  regulations. (opt-out system).

• WHOs Thin Record (in 60 years)
• Modern international health law has only 1
  significant regulation and 1 treaty
• The IHRs (revised in 2005 and addressing the
  same diseases as a 1851 conference) address the
  trans-migration of disease and not the health of
  poorest populations.
• FCTC (2003) regulates the only lawful product
  that is uniformly harmful and was only feasible
  because of industry villification.

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IV. Global Governance for Health Proposing a
Framework Convention
b. Influence of Trade and the Human Right to
Health

• Other agencies have developed international law
  that affects health...
• WHOs lack of participation can be blamed on
  their image as a narrowly scientific/technical
  agency, yet is still has the responsibility to
  contribute its expertise.
• WHOs definition of a right to health is so broad
  as to be unattainable.
• Recasting the problem of poor health as a human
  rights violation is unhelpful
• Legal obligation falls on the state to protect
  its own population other populations cannot
  take precedence.
• Since the right to health is progressively
  realizable, potential violations require
  subjective judgment.
• Even if some obligation can be read, there is no
  systematic method of implementation and
  enforcement.

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IV. Global Governance for Health Proposing a
Framework Convention
c. Framework Convention Details
The Framework Convention Format

• Structural inadequacies in international health
  law
• Vague standards
• Ineffective monitoring
• Weak enforcement
• Statist approach

Framework Convention on Global Health
Responds to

• Incorporates a bottom-up strategy
• Strives to build health system capacity
• Sets priorities to meet basic survival needs
• Engages stakeholders to contribute resources and
  expertise
• Works to harmonizes activities among world actors
• Evaluates and monitors progress towards set goals
  and priorities.

The Kyoto Protocol, UN Framework Convention on
Climate Change,
and Framework Convention on Tobacco Control


illustrate the developing and essential role of
the framework convention-protocol approach.
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IV. Global Governance for Health Proposing a
Framework Convention
c. Framework Convention Details
Broad Principles of the Framework Convention
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IV. Global Governance for Health Proposing a
Framework Convention
c. Framework Convention Details
Advantages of the Framework Convention

• Incremental process and ability to evolve in the
  long term helps avoid political bottlenecks.
• Creation of international norms and institutions
  provides an ongoing and structured forum for
  States and stakeholders to interact.
• A high profile forum can educate and influence
  actors to take decisive steps.
• Existence of a normative community helps build
  international consensus.
• Active engagement of stakeholders in
  negotiation, debate, information exchage, and
  capacity building.

• Challenging barriers to FCGH remain
• Domination of economically and politically
  powerful countries.
• Deep resistance to expend/transfer wealth.
• Little confidence in international legal regimes

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V. The Tipping Point

• Many Reasons to Act
• National interest
• Ethical obligation
• Legal obligation
• Although no one reason may be definitive, the
  cumulative weight of such evidence leaves no room
  for the status quo.

The complex and enduring problems in global
health require a
response that is COLLECTIVE COOPERATIVE
INNOVATIVE -- COMMITTED
Consequences of Inaction State political and
economic decisions to withhold a fair share of
assistance, major outbreaks of preventable
infectious disease, and a dangerous shift of
affluent actors to another cause.