Convention on Global Health

8/14/2019 Convention on Global Health

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Global Health Law

Meeting Basic Survival Needs of the World'sLeast Healthy People: Toward a Framework

Convention on Global Health

Lawrence O. GostinLinda and Timothy ONeill Professor of Global Health Law

Georgetown University Law Center


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The Challenge of Protecting Global Health

Health problems haveserious economic,political, and securityramifications for millions

Major health hazardscross State borders

Protection of global health requirescooperation & 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 bordersAct out of narrow self interest or humanitarian instinctEthical/Legal obligation is not acknowledgedAssistance driven by public sympathy in catastrophic events, not long termhealth problems.

Result:Spiraling deterioration of health in poorest regions with global consequencesfor disease transmission, trade, international relations, and security.


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Meeting Basic Survival Needs

Sanitation& Sewage

PestControl

Clean Air & Water

TobaccoReduction

Diet& Nutrition

WellFunctioning

Health System

EssentialMedicines &

Vaccines

A focus on these major determinants of health would enable the

international community to have adramatic effect on global healthprospects.

Less dramatic and glamorous than

emergency response measures, thisapproach would have lasting effects oncommon health problems.


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Role of International Law I

Shortcomings of Current Legal Solutions: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 healthof 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 targetsRemove barriers to engagement of private and charitable sectorsSet realistic goals for global health spending as % GNPSpecify optimal areas of investment for basic survival needsBuild sustainable health systemsCreate incentives for scientific innovation

WHO or new institution created for this purpose wouldset standards, monitor progress, mediate disputes.


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Detailed Lecture Outline

I. Why should governments care about serious healththreats outside their borders?

II. Global equity and disproportionate burden of disease.

III. The international communitys choice to target a fewhigh profile issues instead of deeper systemic

problems in global health: what is the significance of basic survival needs?

IV. The value of international law and the proposal for aFramework Convention on Global Health.


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CYCLE OFCongregation,Consumption,and Movement

I. Global Health: A Matter of National Interest?

Human activities promote thespread of disease across national borders:

OvertaxedHealth

Systems

EnvironmentPollution

Proximityto Animals

Bioterrorism

Members of the

world communitymust rely on one

another for healthsecurity:

State Instability

Poor Health


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Primary obligations of a State: Defense Security Welfare Domestic Health

I. Global Health: A Matter of National Interest?a. National Interests in the Health of the Populace

includes

affectsHealth of Other Populations Beyond National Borders:

DNA fingerprinting confirms pathogen migration

More than 30 infectious diseases emerged in past 2-3 decades. (Haemorrhagic fevers, Leginnairesdisease, Hantavirus, West Nile virus, monkeypox,etc.)

Vast growth in global trade of fruits, vegetables,meats, and eggs brings forth outbreaks of foodborneinfections (Salmonella, E. coli, Norwalk).

More reasons topay attention:

Emerging and re-emerging diseasesincreasingly affectdeveloped nations,with resistance tofront line drugs.

Domestic costs of response candisrupt social lifeand infringe onindividual rights.


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

Massive loss of life expectancy, with negative impacton entrepreneurs, skilled workforce, parents, andpolitical leaders. Estimated GDP loss in hardest hitcountries is almost 20% (World Bank).

HIV/AIDS

Projected loss of global GDP 6%)Pandemic human influenza?

Mass culling of flocks and herds, trade bans on beef,lamb, poultry.

FMD, BSE, and Avianinfluenza

Travel bansSARS in 2003

Effect on Trade and CommerceDisease

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

Human

RightsAbuses

Mass

Migrations

CivilUnrest

More likelyto harbor terrorisms

More likelyto join inarmed

struggles

PoliticalInstability

States inPoor

Health

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 arepaired with numerous political and militaryentanglements.

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 militaryprowess make it strategically important; regionalinstability will have dire ramifications for the world.


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BUT

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-

OECD countries: increaseddevelopment assistance for global health from nearly $2

billion to $12 billion (1994-2004).

Gates Foundation willdonate up to $3 billion per year for global healthdevelopment.

Global health development assistance is dwarfedby annual military spending ($1 trillion) andagricultural 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 termcommitment.

Even with new investments most OECD stateshave not fulfilled their pledges (0.7% of GNP) andwould need $100 billion to close the gap.

National security assessments and internationalagreements only narrowly justify state action onglobal health.

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 arevast:

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 aslong as a child in Japan.

A child born in Angola is 73 times more likely to die than a child born inNorway.

As life expectancy steadily climbs in developed states, less developed andtransitional countries (Russia) are witnessing a drop in LE.

In one year, 14 million of the poorest people in the world died. If their lifeexpectancy 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.

Lelmi Malik, a 32-year-old mother of three, writhes in pain as SolomonOlukade massages a guinea wormfrom her ankle in the village of Dunkure, Nigeria. (March 22, 2001)Credit: Mike Urban/Seattle Post-Intelligencer

Filarial Worms: the second-leading cause of permanentand long-term disability in theworld. Filariasis causesdisfiguring enlargement(elephantiasis) of the arms,

legs, breasts, genitals.

Below: Antoinette St. Fab, leftand her mother, Marie DeniseBernard, in Logane, Haiti.Their Swollen legs are asymptom of lymphatic filariasisImage Credit: NY Times

Guinea Worms: In 2003 the threemost endemic countries, i.e., Sudan,Ghana, and Nigeria reported 20,299cases of the disease. (CDC)

River Blindness/Onchocerciasis: The diseaseis most intensely transmitted inremote African rural agriculturalvillages, located near rapidly

flowing streams. Presently, it isestimated that 37 million peoplecarry O. volvulus , with 90 millionat risk in Africa. - AfricanProgramme for OnchocerciasisControl [APOC] (2005)

Image Credit: BBC International


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II. Global Health Disparities: Are Profound Health Inequalities Fair? b. Who is Responsible for Addressing Global Health Disparities?

Causal Pathwaysto Disadvantage Include:

PovertyPoor EducationUnhygienic Environments

PollutionSocial Disintegration

Systemic Disadvantagesin health and other aspectsof social, economic, andpolitical life :

Existing InequalitiesBeget Other Inequalities. :

C OMP

O UND

, S U S T AI N

,RE P R

OD

U C E

Almost everyonebelieves this is

unfair, but there is no

consensus on theethical or legalobligation to help

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


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II. Global Health Disparities: Are Profound HealthInequalities Fair? b. Who is Responsible for Addressing Global Health Disparities?

Are Disparities Ethically Wrong?

Right to Health focuses on Stateobligations to their own populations.

Inequalities specifically violate the right tohealth.

Rights discourse is more rhetorical thantruly explanatory.

Inequalities violate human rights.

Needs elaboration.Inequalities are self evidently wrong and unfair.

Problem:Argument:Disparities are Ethically Wrong Because

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 criticalto public welfare.


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Existing claims (Nagel, Rawls, Walzer) are narrowlyframed around the state:citizen relationship.

Positing such a relationship between countries is achallenge.

Arguments for a non-statist view of the globalcommunity that focuses on interdependenceare rare outside activist circles.

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?

WhoseDutyIs It?

What is theScope of Such Duty?

WhatCreates

Such Duty?

DUTY TORESPOND

Lack of a principled ethical argumentmay 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 thesame or worse position as before.

Solution:

Mobilization of public and private sectors tomeet basic survival needs. (e.g. Marshall Plan)

Marshall Plan poster,circa 1949


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III. Basic Survival Needs: Ameliorating Suffering and Early Deatha. Reframing the Approach to Development Assistance

Emphasis on high-visibility crises diverts resources

from long-term projects that focus on everydayneeds.

A small number of wealthy donors are setting theglobal development agenda with littleunderstanding of local needs and capacities. (seeright)

Assistance is fragmented and uncoordinated:programs compete with each other and with localefforts.

Many projects have narrow, short-term goalspreferring quick, observable, and quantifiable results.

Massive infusion of assistance can produceproblematic over-reliance and dependency.

Host countries also carry some responsibility for thefailures 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

Immunizations

NutritionalFoods

PotableWater

PublicHealth

Infrastruct.

Sanitation

HealthEducation

Primary

Health CareEssentialMedicines

Assistance should beredirected to supportBasic Survival Needs.

Nigerian woman receives asmallpox vaccination in 1969during the World HealthOrganization's effort to wipeout smallpox. By 1979 the

virus had been eradicated.

Something as simple as avaccine, generic drug, basicengineering, or sanitation canresult in significant healthimprovements among the worlds

poorest populations.

PestAbatement


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III. Basic Survival Needs: Ameliorating Suffering and Early Death b. Health Systems: Basic Infrastructure & Capacity Building

Poor countriesin need of adequate

health care

Foreign aid workers

Foreign runstate-of-the-art

facilities

Capacity-buildingassistance

Health System Needs:

Public health agencies

Primary health care services

Human resources skilled workers(HCW)

Public health education facilities (tominimize brain drain).

Area of Concern:

Even when developing countriestrain HCWs, they are pushed tomigrate by depressed workingconditions at home and pulled byaggressive recruiting from OECDstates.


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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:

1. Set goals

2. Ensure coordination

3. Monitor results

Existing tools are inadequate a NEW approach is needed.


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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 narrowlyscientific/technical agency, yet is still has the responsibility to contribute itsexpertise.

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:1. Legal obligation falls on the state to protect its own population other populations cannot take precedence.

2. Since the right to health is progressively realizable, potential violationsrequire subjective judgment.

3. Even if some obligation can be read, there is no systematic method of

implementation and enforcement.
http://www.wto.org/index.htmhttp://www.unep.org/


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IV. Global Governance for Health: Proposing a Framework Conventionc. Framework Convention: Details

The Framework Convention Format

Framework Convention

on Global Health

Structural inadequacies ininternational health law:Vague standardsIneffective monitoringWeak enforcementStatist approach

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 actorsEvaluates 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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Broad Principles of the Framework Convention

Guidance for SubsequentLaw-making

Process

OngoingScientificAnalysis

EnforcementMechanisms

EmpiricalMonitoring

InstitutionalStructures

Stakeholder Obligations

Engagement &Coordination

Objectives

Mission

FCGH


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Advantages of the Framework Convention

Incremental process and ability to evolve in the long term: helps avoid politicalbottlenecks.

Creation of international norms and institutions provides an ongoing andstructured 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 evidenceleaves 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

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Convention on Global Health

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