I think to some extent we are seeing it already with the rise of institutional responses to health threats that serve this region. Bodies like the Global Fund and WHO act within international public health law.

Yes, and I am sure you are aware that WHO, IDLO and others have met in Rome and Cairo to begin drafting a public health law drafting manual for developing nations. If adopted and used, then it would encourage countries to adopt similar laws, right? You may wish to check the report link, which deals with further work in the region. I am curious about whether future efforts with AEC will lead to more "harmonization."

I have not studied this issue in depth (outside the field of Union law), but in a way EU social policy can be an example on how complicate is to agree on common legal standards. It would be relatively easy to reach the same level of protection in Sweden-Denmark-Germany, but impossible to reach the same level across the Union. The integration worked as a charm in the field of commercial policies, but not for social & tax policies. To give a simplified example (statistics equals simplification for me) in Sweden and Denmark more than 30% of the state budget is involved in social policies, while in Romania the figure is around 17% even if at least apparently Romanians would need more social assistance.

As I see it, the global health policy is closely related to environmental law, but also indirectly with tourism and free movement. The protection of environment means to protect the human health ultimately, but one can see how difficult is to globally agree on these issues, or better said, we agree in principle, but we do not want to set a price on these 'principles'. The risks are global, while the financing policies are municipal as dimension. Very interesting indeed for the legal scientist to explore this area indeed!

My final question in this set of thoughts is whether we can separate the issue of health from the social policies, as long as health is social, meaning supported by state subventions and social fees and taxes, connected with social insurance etc?

The philosophical problem is that when we say 'social' in terms of health we think (99,99%) state and municipal money. We don't mean EU-social, but national state-social or maybe county-social. By analogy to have a genuine and actually effective global policy (health or environmental) we must start to think global-social, what it's still difficult to imagine for most of the people (unfortunately).

I agree global health policy may be akin to environmental policy and the laws meant to operationalize them. We know environmental effects may not respect sovereigns, borders, or laws at the sub-national, national or international levels, and we also appreciate the visa versa may be true. Based on current practices, tourism and free movement may be more directly than indirectly related to human health. For example, Thailand, Singapore, Malaysia did over 3 billion US dollars worth of medical tourism business in 2006.Even though this may not be the “tourism” of consideration, medical tourism can boost economies, but it may also affect the health insurance system of the participating country.

Case in point may be Thailand's experiencing a 0.4% rise in its GDP while also incurring a rise in its health expenditures on health worker salaries and wait-times in its public system. Pandemics, especially those related to atypical flu, are occurring because of the international movement of people, animals, and products. Old and new diseases are occurring in new places. Environmental resources are becoming scarce. All of these affect health and wealth at multiple levels. These exchanges, as part of globalization, can transform nations by altering the patterns of human behavior, travel, trade, or lifestyles of the nations involved. They may collectively serve as a positive transformative force capable of improving the health and wealth of all nations, but globalization can be a destabilizing force. Societies and their economies flourish best when they are stable and one way societies can achieve stability is through the “rule of law.”

The problem may be deciding whose law applies given the different legal systems and societies, with their varying beliefs, values, and cultures. I am not sure we can separate social policies from fiscal policies since health relies on access to care which then relies on financing, payment, and insurance schemes to support them. If exchanges flourish, then it bring us to a global-social situation and the potential global society. But if legal structures are meant to promote social relationships, then whose law will apply at sub-national, national, or international levels given there is no “global health law” per se. There are treaties, conventions, and international laws, but agreement and enforcement are not always achievable and there is a “price.” Regardless of the impact of AEC, I do believe globalization will challenge the health, wealth, and stability of Asia. It must, because Asia contains almost 4 billion people or over half of our world’s population. Are our social and legal systems prepared? Who pays?

I've used the attribute 'indirect', because when it comes to tourism and free movement, the person in question might still have a choice (to buy or not a holiday or to move or not the residence to a certain country and there are often some alternatives available for the named destination). The crucial right for this point is the access to accurate and timely information, in the meaning that if I had the information that in the country of destination an epidemic disease had recently out-broken and I still decided to travel for holidays there, it would mean that I am prepared to assume the risks.

I see the connection more direct, when it comes to environmental law, because the choices to act on a preventive pursuit are limited. If the neighbour state has an undeveloped or ineffective water policy, the consequences are direct and inevitable for the health of humans and non-humans in the whole region. My argument is therefore that the concern is direct in this second example, since it is nothing the neighbour of a sovereign state (and bad policy maker) can do, in reality, to prevent the harm (first to the nature and then to the health). The information concerning the water pollution is important, but it's not the only important factor here. The problem is to rely on a common set of scientific facts and a common or at least convergent interpretation of the scientific data, that should be used in order to form and implement the environmental policies with a view on prevention.

The same problem rises in relation to vaccination/medication and the risks associated with them. I would say that concerning the risks and the side effects on one hand and lack of sufficient scientific assessment on the other even if we could solve the financial issue, we would still have to agree on what is the correct prediction of science to rely on, while applying the precautionary and the proportionality principle.

In this sense research networking is literally vital, since a common or at least converging understanding of the recent scientific findings used for harm/risk assessment is essential for an effective legal enforcement.

In the field of antitrust law the extra-judicial enforcement is a reality. A cartel agreement concluded by the producers in jurisdiction X, can bring about an impairment of the competition in jurisdiction Y and thus the competence of the Competition authorities of the latter to start an investigation and to bring an action for establishing an infringement of the antitrust law before the Court in jurisdiction Y. By analogy, similar procedures would improve the enforceability of environmental/health law.

Archie, could I have a link to the draft law please. I actually was not aware of it.

Emanuela, do you think social would include a duty to assist? I know there is a question of who assists especially in times of austerity but it is interesting to try and interrogate whether there is any consensus about the existence of this duty?

Sharifah, . A copy of the report along with PPT presentations from the workshop is posted on the International Development Law Organization (IDLO) at http://www.idlo.int/english/WhatWeDo/Programs/Health/Pages/DetailsEvent.aspx?IDEVENT=227. This report differs from other workshops because it contains the reflections of various speakers and work groups.

Sharifah, I checked the link and it takes you to the site where you can browse subjects on the left and materials' selections and their links on the right.

Thanks will have a look at it and let you know my thoughts.

Ref: 'Emanuela, do you think social would include a duty to assist?'

A very interesting question indeed. In the specific context I was referring to the EU law jurisprudence, where the friction between social assistance and health protection appears as evident. In EU law, the rights of the patient comprise the rights of obtaining health care services in another member state than the one of residence (where the taxes are paid). As known in the EU, most of the member states have a generous health care policy, meaning that a series of services are provided for free and most of them are heavily supported by state subventions. The social dimension of health care is a reality that can not be ignored in this context.

The link between the quality of tax payer and beneficiary of social assistance in a member state and the one of patient/recipient of medical care has been used to limit the freedom of the patient to obtain care in a different member state. These limits have been reduced as proportions by the Court jurisprudence. Therefore, from my perspective, I must add to the usual modalities of payment (direct payment, private insurance policy) also the social assistance benefits. They are relevant for all the states with a social market economy. As Archie Alexander has emphasized the question of 'Who pays?' can not be ignored.

A duty to assist on the international arena would be a good idea, though it is still an utopical one due to political, economic and the limitation of scientific evidence concerning the assessment of risk and benefits. However there might be some cases of blatant lack of care that could be used in some clever way to bring about the issue of duty to assist (I am not sufficiently knowledgeable in this area of law to propose what can be done, because I don't know what already has been done in more detail).

Emanuela, the issue of free movement of individuals across sovereign borders to obtain any service, whether it is a social service or health care raises issues related to financing of social services and legal and regulatory concerns with regard to protecting the health and safety of the individual as well as the sovereign. In the case of the Asian Economic Community, members have identified a variety of areas where they will allow across-the-border sharing of a variety of services. One service area is health services and health care workers. This means countries will have to decide how to supply and pay for services for any non-citizens choosing to avail themselves of these services as well as determining who is or is not qualified as a visiting health worker. All of these activities are globalizing in nature and they may deliver gains or extract costs from the recipient nation. These exchanges will affect the health and wealth of the nations involved.

Emanuela, if you have time and would like to look at what some are considering, take a look at the following reports. Internat'l Expert Consultation on Public Health Law at http://sydney.edu.au/law/news/docs_pdfs_images/2009/July%202009/Magnusson_IDLO_Rapporteur26062009.pdf or the workshop is posted on the International Development Law Organization (IDLO) at http://www.idlo.int/english/WhatWeDo/Programs/Health/Pages/DetailsEvent.aspx?IDEVENT=227. What I believe is interesting is how different nations approach health, health law, governance, and policies. Heatlh systems are impacted by across-the-border exchanges.

Thank you, Archie. I will take a look on your documents, definitely.

I don't know that there can be one answer to a question as all encompassing as this one, and would appear to me that before you can address a global health law or international law, the staffing would certainly include the WHO and the UN.

Also poverty needs to be addressed, and I am sure it would be difficult to tell people who have very little that they have to stop cutting down the virgin forests because they are destroying the land, especially when the industrial nations insist on buying the timber. Again the problem is not as easy as writing a health plan if the underlying cause is poverty.

I understand that nearly 1/2 million women die each year in childbirth for lack of appropriate health care, but malnourishment might be the greatest cause for these deaths. Western nations have worked for decades in Africa trying to solve these issues without success. Malnourishment, poverty, environmental damage to the land in order to find enough pennies to feed ones family, all route causes of health care issues.

In places such as Thailand, Indonesia, Malaysia, and the Philippines, sexual diseases are rampant because of the number of young girls that are sold into sex slavery, would your law consider trying to change this practice? The UN has been fighting human trafficking for decades without making so much as a dent in it. Even with a health law how can the world stop the drug and sex traffic that as created an AIDs epidemic that reaches throughout the Asia-Pacific region?

According to the last WHO report 500,000 people dies from AIDS in this region in the 2000 almost all of them attributed to mainline drug abuse and prostitution. Social evils that probably will not be affected by a global health plan, because these are marginalized people who remain outside the mainstream.

Mike, thank you for your insights. Your concerns about the scope of the "law" being sufficiently expansive to address the issues affecting health are warranted. If you would like to know more about these efforts here are links to a servies of reports sponsored by the WHO, IDLO, WTO, and the Rockefeller Foundation studying the concept of international public health as an instrument to promote health and access to health. Efforts began in Rome with discussions on legal mechanisms that led to a later meeting in Cairo that resulted in efforts to draft an international public health law drafting manual for governments. See Internat'l Expert Consultation on Public Health Law at http://sydney.edu.au/law/news/docs_pdfs_images/2009/July%202009/Magnusson_IDLO_Rapporteur26062009.pdf and see also International Expert Consultation on the Development of a Public Health Law Manual, http://www.law.georgetown.edu/oneillinstitute/documents/2010_CAIRO%20CONSULTATION%20-%20REPORT.pdf. These meetings assembled a variety of international legal and policy people from multiple nations. Part of the considerations were focused on how law might be a tool to help address many of the problems you identify. Law can be a tool to promote social relationships and support positive behaviors that foster both health and wealth while others may see it doing just the opposite, depending on a variety of factors. Globalization and its ability to use the behavior of people to change societies and their health and wealth may be catalyst for spreading health problems and vices from one nation to a neighboring nation for a variety reasons ranging from insufficient laws, regulatory controls, and policies to the opposite end of the spectrum.

Since Asia contains a significant portion of the world's population and many of the problems you mention here occur there, a workshop was held in Bangkok this past April to look at the issues, experiences, and gaps in the health laws, governance mechanisms, and policies arising from globalization of the region and beyond. International Development Law Organization (IDLO) at http://www.idlo.int/english/WhatWeDo/Programs/Health/Pages/DetailsEvent.aspx?IDEVENT=227. The gathering in Rome, Cairo, and Bangkok underscore the efforts of NGOs, legal and public heatlh experts, governments, and civil society to look at mechanisms for improving health by addrssing the above issues. These are not the only efforts to look at using law as a mechanism to improve health and access to health care. Several conferences and workshops have followed focusing on global health and the law. We both know that societies have utilized laws and regulations to alter human behavior for generations. The problem is the force and effect of laws may depend on a variety of factors at the subnational, national, and international levels. Who enforces what and when is always a problem. And I agree with your points, the laws must consider and address the above issues for success. As you suggest, this is a very complex, broad issue that is not easily addressed. Thank you for your comments, and I hope you will look at these reports, if you can take some time from your busy day.

Dear

Monday, December 17, 2012

Dear Archie Alexander,

Please consider 'cross-posting' your question on ResearchGate on the "GlobalOccHyg List" with a regional sub-group for Asia - Pacific Rim.

Sincerely yours,

Andrew Cutz

Andrew Cutz, CIH | Moderator, GlobalOccHyg List | http://health.groups.yahoo.com/group/globalocchyg-list/ (on Yahoo Groups) |

RSS Feed http://rss.groups.yahoo.com/group/globalocchyg-list/rss | http://tinyurl.com/GlobalOccHyg-List (on LinkedIn) NEW!

Sure, Andrew. I am happy to do it. I am curious to know what others have to say.

I was thinking that there are so many social issues that lead to medical issues, which comes first the chicken or the egg? Do you attempt to change the argument and make the discussion how do we turn off the human trafficking and allow 12 year old girls to be children, or are they doomed to a life of whoring in the cat houses of Thailand. If this problem cannot be changed, perhaps the trade needs to be changed, as they did in the US and Holland - through licensing, medical exams, mandatory use of condoms and so forth.

And in the Philippines were poverty and filth force little children to work the garbage dump looking for anything that can be sold to put food on the table. A whole new group of families has been created herein, a lower caste of dump workers - lower than the poor, who are so infected with diseases esp TB that the traffickers won't take the girls for prostitution - they are tainted beyond belief. Again, do you attempt to change the social conditions, improve the quality of life or tackle the health issues.

That was really the point I was trying to make. Thanks. And good luck with your project, it is a mammoth undertaking.

Thank you, Mike. Mike, it is not a project of mine. There is no formal body of law called "global health law." It is a concept envisioned by a law professor at Georgetown Law. The more formal "body of law" would be international law as it would be applied to public health or international public health law. This application of law may address health issues that affect nations such as pandemics (IHR 5) or commodities. As I mentioned above there are subnational, national, and international issues that may or may not permit the formation, adoption, or implentation of a global health law, if one existed.

As far as the point, I was not changing the point because some believe the "law" may be a way to change human behavior, and with it, improve social conditions, if possible. Laws can be proscriptive or prescriptive, and they can be drafted to achieve changes in human behavior to improve social responsibility. For example, antismoking laws may be adopted to stop smoking to reduce health risks and improve health outcomes. Some would see the law as a mechanism for promoting social justice which would lead to a fairer distribution of resources such as capital, health care, etc. In turn, the law would be a way to promote healthy conditions that would raise the health and wealth of individuals and societies. So, the law would not be isolated from the social issues. It would be a mechanism to address them, and how it did so would be up to the policymakers and society. For some reason, mike, I believe you know this.

I simply wanted to know whether people were aware of the concept and whether there is a potential for law to becoming a "gloval" force for health. After all, globalization is a process that can be transformative. It can lead to positive changes as well as disruptive ones. The sex trade would be a globalizing force since women can be transported across borders taking their health conditions with them. Countries use criminal and immigration laws to check this with mixed success. There are plenty of examples including your garbage dump workers who may get a variety of health problems from the imported products they come into contact with. For example, workers salvaging heavy metals from discared electronics in China.

pharmaceutical patent and access to medicine by the poor in SEA got my attention and it is really a major problem.

Hi, Wanwipar. I did not see your response until I did some cross checking. The issue of essential medicine access is a major issue in SEA. Not only is it a major issue regarding patents and IP, it is a major issue for IHR (5) and access to viral isolates for pandemics. I am not sure if you looked inside the Report but there was a whole day featuring pharmaceutical access, CUTs, and other topics that may interest you. I wish I had seen your post much sooner. I hope you pursue this topic.