Global Health Law

Lawrence O. Gostin

• Publisher: Harvard University Press
• Year: 2014
• ISBN:
  9780674369887
• Topic: Law
• Subtopic: Medical Law
• Index: Law

The international community has made great progress in improving global health. But staggering health inequalities between rich and poor still remain, raising fundamental questions of social justice. In a book that systematically defines the burgeoning field of global health law, Lawrence Gostin drives home the need for effective global governance for health and offers a blueprint for reform, based on the principle that the opportunity to live a healthy life is a basic human right.Gostin shows how critical it is for institutions and international agreements to focus not only on illness but also on the essential conditions that enable people to stay healthy throughout their lifespan: nutrition, clean water, mosquito control, and tobacco reduction. Policies that shape agriculture, trade, and the environment have long-term impacts on health, and Gostin proposes major reforms of global health institutions and governments to ensure better coordination, more transparency, and accountability. He illustrates the power of global health law with case studies on AIDS, influenza, tobacco, and health worker migration.Today's pressing health needs worldwide are a problem not only for the medical profession but also for all concerned citizens. Designed with the beginning student, advanced researcher, and informed public in mind, Global Health Law will be a foundational resource for teaching, advocacy, and public discourse in global health.

PART I

Failures in Global Health and Their Consequences

Health Inequities in Today’s Globalized World

THIS FIRST PART OF THE BOOK lays the foundation for themes that will permeate throughout—particularly global health with justice, in which all people live and work in conditions that allow them to lead healthy, productive lives. Chapter 1 considers four fundamental issues, which are among the most pressing in global health today: (1) the services universally guaranteed under the right to health, (2) states’ duties to safeguard the health of their own populations, (3) international responsibilities to contribute to improved health in lower-income countries, and (4) the governance needed to ensure that all states live up to their mutual responsibilities.

Chapter 2 examines the forces of globalization, looking for explanations of why health hazards change form and migrate everywhere on the earth. The global movement of goods, services, and ideas enables the rapid dissemination of pathogens and unhealthy lifestyles—behavioral risk factors, such as diet, tobacco use, and physical activity—across the world. Globalization demonstrates the interconnectedness among all countries, and all people, so that no state can insulate itself from transnational health threats. This chapter will deepen readers’ understanding of the urgent need for collective global action to safeguard the population’s health.

Collective action, however, will remain out of reach without the norms, processes, and institutions formed through international law in the broader currents of global governance for health. As explained in Chapter 3, the boundaries between law and governance are indistinct, with elements of law bleeding into governance, and vice versa. This chapter categorizes and explains three major sources of global health law: international health law (principally WHO normative instruments, discussed in Chapters 6 and 7), the human right to health (Chapter 8), and interconnecting legal regimes that have an impact on health. Part I concludes with six “grand challenges” in global health: (1) global leadership, (2) international collaboration, (3) harnessing creativity, (4) sustainable financing, (5) setting priorities, and (6) influencing multiple sectors.

CHAPTER 1

Global Health Justice

Toward a Transformative Agenda for Health Equity

CONSIDER TWO CHILDREN—one born in sub-Saharan Africa and the other in Europe, North America, or another developed region. The African child is almost eighteen times more likely to die in her first five years of life. If she lives to childbearing age, she is nearly 100 times more likely to die in labor. Overall, she can expect to die twenty-four years earlier than the child born into a wealthy part of the world.¹ Collectively, such vast inequalities between richer and poorer countries translate into nearly 20 million deaths every year—about one in every three global deaths—and have done so for at least the past two decades.² Put simply, the health gap between the rich and the poor is pervasive and unjust, with few signs of improvement.

The basic human needs of the world’s poorest people continue to go unmet. In 2010, 780 million people lacked access to clean water and 2.5 billion people were without proper sanitation facilities, while approximately 870 million people faced chronic hunger.³ Deteriorating infrastructure (e.g., electricity and roads) and worsening environmental conditions have compounded these threats to health in impoverished areas of the world. The health challenges that are the focus of the Millennium Development Goals (MDGs)—child and maternal mortality, HIV/AIDS, and malaria—persist as major health threats, as do neglected tropical diseases. Emerging infectious diseases (EIDs) continue to threaten the world’s population, while the tremendous burden of noncommunicable diseases (NCDs) and the devastation of severe injuries continue to grow.

Yet these vast health disparities are not even fully captured by contrasting rich countries with poor ones: profound inequalities are found within countries, as marginalized populations trail far behind national averages. In Nairobi, Kenya, for example, the child death rate in impoverished slums is many times the rate in the wealthiest neighborhoods. These deprivations arise amid splendor for a lucky few, with one-third of the world’s largest fortunes held by people in low- and middle-income countries. Even within wealthy states, dramatic health differences are tied to social disadvantage, with the poorest people often having life expectancies similar to those inhabiting the least developed countries. A black, unemployed youth in Baltimore, for example, can expect to live thirty-two years less than a white professional in the same city.⁴ With the happenstance of one’s birth still the greatest determinant of health, the current state of world health is one of deep injustice.

Although the global health gap remains unacceptably large, the international community has taken major steps to improve health and advance development. The United Nations adopted the MDGs to lift disadvantaged people out of poverty and disease (see Box 1.1). The Paris Declaration on Aid Effectiveness and the Accra Agenda for Action call for clearer targets and indicators of success, harmonization among partners, alignment with country strategies, and mutual accountability for results. The Global Fund to Fight AIDS, Tuberculosis and Malaria has emerged as a major international financier, pooling billions of dollars for health programs in more than 150 developing countries.⁵

Meanwhile, both domestic and international health investments have increased. For example, from 2000 to 2010 governments in sub-Saharan Africa more than doubled their per capita health spending, from an average of fifteen dollars to forty-three dollars (in nominal dollars and including on-budget external assistance).⁶ International health assistance increased from less than $6 billion annually in the early 1990s to $10.5 billion in 2001, and then climbed to $26.9 billion in 2010.⁷

But despite unprecedented engagement, the international community has not fundamentally changed the reality for the world’s least advantaged people. Will progress be achieved for poor and marginalized populations? Or will they come to form a permanent global health underclass? The fight against the most endemic and intractable diseases, such as AIDS and tuberculosis (TB), is at risk of slowing, or even reversing. Health inequities within many countries are growing. New global health challenges are arriving in force, particularly the rapid growth of NCDs and the impact of climate change, especially on water and food supplies (see Chapter 2, Box 2.3). Will countries mitigate these new, complex health threats, or will inequities be further compounded? Now is a pivotal time for global health—a moment of both promise and peril.

BOX 1.1 The Millennium Development Goals and Beyond: Toward a Post-2015 Sustainable Development Agenda

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Recognizing the failure to meet the needs of the world’s poor, the UN General Assembly, on September 8, 2000, unanimously adopted the Millennium Declaration.¹ The Millennium Development Goals (MDGs), which followed the Declaration, are the world’s most broadly supported and comprehensive development targets, creating numerical benchmarks for tackling poverty and hunger, ill health, gender inequality, lack of education, lack of access to clean water, and environmental degradation by 2015.²

Child health MDG 4 calls for a two-thirds reduction in the mortality rate of children younger than five years old between 1990 and 2015. Globally, child mortality has fallen from twelve million deaths in 1990 to 6.9 million deaths in 2011. There are, however, gaping inequalities: 33.9 percent of child mortality occurs in South Asia and 48.7 percent occurs in sub-Saharan Africa, whereas 1.4 percent occurs in high-income countries.³ Health inequalities among children are actually growing.⁴

Maternal health MDG 5 calls for a three-quarters reduction in the maternal mortality ratio between 1990 and 2015, together with universal access to reproductive health services. Maternal mortality is dropping, from 543,000 deaths in 1990 to 287,000 in 2010. The improvements, which mask extreme variations, are largely attributable to better care during pregnancy and skilled childbirth attendants.⁵ To mobilize action, the 2010 MDG Summit launched the Global Strategy for Women’s and Children’s Health.⁶

HIV/AIDS, malaria, and other diseases MDG 6 aims to halt and reverse the spread of HIV and the incidence of malaria and other diseases. Even with historic global engagement to prevent AIDS-related deaths and nearly 10 million people on treatment by the end of 2012, under 2013 WHO treatment guidelines a further 16 million people in resource-poor settings will require treatment.⁷ Malaria remains a major killer. Despite significant progress in some countries over the past decade, malaria deaths climbed from about one million in 1990 to nearly 1.2 million in 2010. Climate change and growing resistance to antimalarial medications pose major threats. In 2010, roughly 1.2 million people died of tuberculosis, with 85 percent of new cases occurring in Asia and Africa. Multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB pose deep challenges.⁸

Food, water, and sanitation MDG 1 aims to halve extreme poverty and hunger by 2015, compared with 1990. The environmental sustainability goal, MDG 7, calls for halving the proportion of people who lack basic sanitation and safe drinking water by 2015, relative to 1990. The world has already met the water target, but this still leaves 11 percent of people without this necessity. The sanitation target is severely off track. At the current pace, 33 percent of the population—2.4 billion people—still will not have access to basic sanitation by 2015.⁹ The hunger target is off-track as well, though in 2013 the United Nations reported that it was within reach with accelerated progress. Yet even achieving the target could leave more than 11 percent of the world’s population without enough to eat, and far more people still suffering nutritional deficiencies.¹⁰

Most MDG targets have not been met, partially as a result of four global crises: finance, food, energy, and climate change.¹¹ In 2008 WHO Director-General Margaret Chan observed that even though “the health sector had no say when the policies responsible for these crises were made … health bears the brunt.”¹²

In 2012 the UN launched a process to formulate post-2015 sustainable development goals, including a focus on health systems. As of 2013 the UN was considering the following health-related sustainable development goals: universal health coverage, healthy life expectancy, and enhancing MDGs 4–6 while reducing the burden of noncommunicable diseases (NCDs). The UN High-Level Panel of Eminent Persons on the Post-2015 Development Agenda offered “ensure healthy lives” as an illustrative health sector goal, with targets focused on women and children, along with reducing the burden of infectious diseases and NCDs. Separate High-Level Panel illustrative goals addressed food security and universal access to water and sanitation.¹³

NOTES

1. United Nations General Assembly (UNGA), Resolution 55/2, “Millennium Declaration,” September 18, 2000.

2. United Nations (UN), The Millennium Development Goals Repo...