Contents   Abstract 1. Prologue: Of Globalized Epidemics, North-South Divide and the Challenge of Governance 2. The Microbial Superhighway: Does Disease Pose a Globalized Governance Challenge ? 3. The G8 and Global Health Governance: innovation or Rhetoric ? 4. Epilogue: The Relevance of Self-Interest in the Global Governance of Globalized Health Challenges  Download

Obijifor Aginam
Professor of Law,
Carleton University,
Ottawa, Canada

oaginam@cs.carleton.ca

Abstract

The transnational spread of infectious and non-communicable diseases in an interdependent world has constantly challenged the governance structures of the Westphalian international system. The phenomenon of globalisation is fast eroding the geo-political boundaries of nation states. As globalisation intensifies, so do globalisation of infectious diseases. Globalisation of public health threats also means globalisation of the governance strategies to fight them. Using the concept of global health governance involving non-state actors, this article assesses the contributions of the G8 Summit to the global governance of HIV/AIDS, tuberculosis and malaria in an interdependent world. While a commendable initiative, the article argues that the G8 countries should do more by committing sufficient resources to the Geneva-based Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria. Self-interest should be at the centre of evolving structures of global health governance in a paradoxically inter-dependent and divided world. Globalisation has altered the traditional distinction between domestic and international health threats and all of humankind is now immersed in a single microbial sea.

Keywords: G8 Summit, Global Burdens of Disease, Global Fund to Fund Fight HIV/AIDS, Tuberculosis and Malaria, Global Governance Deficits, Globalisation of Public Health, Global Health Law, Global Health Governance, Global Microbial Superhighway, Global Village, North-South Health Divide, WHO Commission Macroeconomics and Health and World Health Organisation

Author’s Note

An earlier version of this paper was presented at the Annual Meeting of the Association of American Law Schools, 4 January 2003 in Washington DC on a Panel ‘Towards a Globalized Theory of Public Health Law’. I should like to thank Prof Dayna B Matthew, University of Boulder School of Law, for inviting me to participate in the meeting and Prof Lawrence Gostin, Georgetown University, a co-panelist at the AALS meeting whose seminal writings on law and public health have inspired me over the years. I should like to thank Stephen Jones of Carleton University, Ottawa, for his excellent research assistance towards the writing of this paper. All shortcomings and errors are mine.

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This is a refereed article published on 4 June 2004.

Citation: Aginam, O, 'Salvaging Our Global Neighbourhood: Critical Reflections on the G8 Summit and Global Health Governance in an Interdepedent World', Law, Social Justice & Global Development Journal (LGD) 2004 (1), <http://elj.warwick.ac.uk/global/04-1/aginam.html>. New citation as at 15/07/04: <http://www2.warwick.ac.uk/fac/soc/law/elj/lgd/2004_1/aginam/>.

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‘We meet as we fight to defeat SARS, the first new epidemic of the twenty-first century … Globalization of disease and threats to health mean globalization of the fight against them …The events of the last few weeks also prompt us to look closely at the instruments of national and international law. Are they keeping up with our rapidly changing world?’– Gro Harlem Brundtland, Address to the Fifty-Sixth World Health Assembly, Geneva, 18 May 2003

1. Prologue: Of Globalized Epidemics, North-South Divide and the Challenge of Governance

It is now widely accepted that the Westphalian international system and its multilateral governance architecture are increasingly characterized by governance deficits and therefore incapable of effectively regulating most of the emerging global health issues of our time. The recent transnational spread of Severe Acute Respiratory Syndrome (SARS) (Brundtland, 2003) and other recorded cross-border epidemics in human history have formidably challenged the orthodox structures of multilateral health governance. The menace of disease in an interdependent world propelled by the phenomenon of globalization has transformed the world into a single germ pool where a single microbial sea washes all of humankind (Brundtland, 2001). Nation-states, non-state actors (NGOs and civil society organizations), and international organizations agree that the inherited models of international governance are becoming ineffective in the face of the global crisis of transnational spread of infectious and non-communicable diseases. Focusing on the gaps of the Westphalian system, global governance discourses (Fidler, D, 2002; Lee, K, Dodgson, R and Drager, N, 2002; Kickbusch, I, 2003) postulate that what distinguishes global governance from international governance is the involvement of non-state actors in the governance process. The vulnerability of humans to microbial threats in a web of global interdependence calls for a critical re-assessment of the contemporary governance approaches to globalized health threats. Quite worrisome in this endeavour are the stark realities of North-South health divide: the uneven distribution of global disease burdens between the industrialized and developing worlds (Aginam, O, 2000; Aginam, O, 2003; WHO, 1995; Murray, CJL, and Lopez, A, 1996).

This article discusses one recent global health governance initiative that is outside the normative boundaries of orthodox international health institutions – the G8 Summit. [1] The article focuses on the G8 Summits in Okinawa, Japan (2000), Genoa, Italy (2001), and Kananaskis, Canada (2002), and explores how the G8 catalyzed the establishment of the Geneva-based Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis (‘the Global Fund’). With the Global Fund as the subject of analysis, this article assesses the G8 Summit’s commitment to global health governance, its gaps, failures and potential to advance or diminish human vulnerability to disease in a paradoxically interdependent and divided world. Does the G8 offer any effective and innovative governance mechanism that could potentially alter the gap in mortality and morbidity burdens of infectious and non-communicable diseases between the rich and poor nations? Does the G8 Summit’s global health initiative advance global health law and governance capacity of multilateral health institutions like the World Health Organisation?

2. The Microbial Superhighway: Does Disease Pose A Globalized Governance Challenge?

The metaphorical conceptions of ‘global village’ (McLuhan, M and Powers, B R, 1992) and ‘global neighborhood’ (Commission on Global Governance, 1995) underscore the emerging interdependence of populations, markets and nation-states. Certain vicissitudes of global interdependence have metamorphosed into a new form of globalism, one that easily globalizes disease through transnational networks of travel, trade, and tourism. Scholars and policy-makers have coined the term ‘globalization of public health’ to explore the transnational or globalized nature of emerging and reemerging public health threats in an interdependent world (Lee, K and Dodgson, R, 2000; Fidler, D, 1997; Yach, D and Bettcher, D, 1998a; Yach, D and Bettcher, D, 1998b; Lee, K, 2003). Globalization of public health de-emphasises the ‘territorialisation’ of public health simply because the concept of state sovereignty is alien to the microbial world (Held, D and McGrew, A, 1999; Scholte J A, 2000) [2] . This form of globalism, premised on the ‘death of physical and geographical distance’, as Lee (1999) argues, conceives the world as a single place because of increased travel and other shared experiences that lead to more localised, nationalised, and regionalised feelings of spatial identity. The argument that globalization has led to the death of physical and geographical distance does not suggest that the nation state has been significantly weakened to become irrelevant in global governance. Contemporary world order is still predominantly founded on a coalition of nation states. Because, the onus of basic curative, preventive and promotional health care services still falls on governments within national jurisdictions, isolationism is now a characteristic hallmark of public health policies constructed in most of the industrialised global North. Isolationism is premised on the impression that the developing world is a reservoir of disease. It is a conscious effort to create a health sanctuary in the developed world that protects European and North American populations from exotic diseases imported from the global South. In this isolationist agenda, industrialised states construct immigration policies to exclude immigrants from the developing world who are ‘carriers’ of leading infectious diseases. Most industrialised states have imposed mandatory medical screening and testing for major diseases on African immigrants.

The spatial dimension of globalization, although a postulation of a microbial superhighway that unifies the entire global village nonetheless does not suggest that globalization of public health is a new phenomenon. Seminal accounts of the transnational spread of infectious diseases aptly suggest that the spatial dimension of globalization was a conspicuous feature of the earliest recorded epidemics in history. In an account of the plague that ravaged Athens during the Peloponnesian War in 430BC, Thucydides (1954) observed that the plague first originated in Ethiopia, and then descended into Egypt and Libya and much of the Persian Empire before it was introduced into Athens by soldiers during the war. Medical historians suggest that the path of the Black Death (Bubonic Plague) in 14^th century Europe followed international travel and trading routes, and subsequently spread to Europe and North Africa (Hays, J N, 1998, p 39; Porter, D, 1999; Watts, S, 1997). In the 15^th century, the emergence of new diseases – smallpox, measles, mumps, chickenpox, scarlet fever – among the native populations in the Americas following their conquest by Europeans, marked what Berlinguer (1999) called the ‘microbial unification of the world’.

Apart from the phenomenon of globalization, a second factor that globalizes disease is the south-north health divide, the socio-economic inequalities between the industrialised and developing nations. The world is increasingly polarized by poverty and underdevelopment and less by geo-political boundaries (Aginam, O, 2000; Aginam, O, 2003). In a global policy universe, how does poverty or underdevelopment impact on the health of three quarters of humanity who live in the south? According to the World Health Organisation (1995), poverty is the world’s most ruthless killer and the greatest cause of ill health and suffering. Poverty is the main reason why babies are not vaccinated, clean water and sanitation are not provided, curative and other therapies are unavailable, and mothers die in childbirth. Poverty is the cause of reduced life expectancy, handicap, disability and starvation. Poverty is a major contributor to illness, stress, suicide, family disintegration and substance abuse. Poverty wields its destructive influence at every stage of human life from the moment of conception to the grave. It conspires with the most deadly and painful diseases to bring a wretched existence to all who suffer from it. One consequence of the north-south health divide is the unequal distribution of the global morbidity and mortality burdens of leading infectious and non-communicable diseases on populations in the industrialized and developing worlds (Murray, C J L and Lopez, A, 1996).

The cumulative effect of the erosion of geo-political boundaries as a result of the globalization of public health, and the impact of south-north health divide on populations within such boundaries has traditionally placed global health within the agenda of multilateral institutions. Public health poses global/transnational challenges that require innovative global governance approaches. Despite the enviable feat and successes by the orthodox multilateral health organizations – World Health Organisation, Food and Agriculture Organisation, UN Children’s Fund, and UN Joint Program on AIDS, [3] new evidence has emerged linking the pernicious poverty and underdevelopment in most of the developing world with the mortality and morbidity burdens of leading killer diseases – HIV/AIDS, Tuberculosis and Malaria. Within the normative boundaries of global health law founded on the Westphalian system, these new challenges serve as the catalysts for innovative global health governance approaches involving non-state actors in which the G8 Summit - a group of eight most industrialized nations – emerged as an important actor in recent years.

3. The G8 and Global Health Governance: Innovation or Rhetoric?

Since it was founded in 1975 as a Summit of the Heads of State and Governments of the major industrial democracies, the G8 meets annually to discuss social, economic and political issues facing domestic societies and the international community. The G8 countries control a considerable bulk of global capital in trade, finance and foreign direct investment. At the first G8 Summit held in Rambouillet, France, in November 1975, six countries, France, the United States, Great Britain, Germany, Japan and Italy were represented. Canada joined the Summit in 1976 Summit in Puerto Rico, and the European Community joined as an observer in 1977. Since 1991, the ‘G7’ has always held a post-Summit dialogue with the then USSR (later Russia). Since 1994, the G7 met with Russia after each Summit until the 1998 Birmingham Summit where Russia was admitted as a full member. The G8 Summit, as it is known today, has ‘consistently dealt with macroeconomic management, international trade, and relations with developing countries … The Summit also gives direction to the international community by setting priorities, defining guidance to established international organisations … Summit decisions often create and build international regimes to deal with new international challenges, and catalyze, revitalize and reform existing international institutions’. [4] The G8 consists of the eight most powerful countries in the world economically. Hodges, Kirton and Daniels (1999) refer to the G8 Summits as a think tank that includes ‘the individuals who matter most in the world’. The agenda of the G8 in successive summits since 1975 has included international trade, migration, debt, global digital divide, environment, crime and drug, transnational security issues and arms control, terrorism, hunger and food safety, poverty reduction and global infectious disease challenges. The Okinawa Summit of the G8 in 2000 marked a turning point in global governance of infectious diseases. The G8 leaders made a commitment to address the global challenges posed by leading infectious and parasitic diseases – HIV/AIDS, Tuberculosis and Malaria. The Summit recognised health as the key to posterity and economic development. Expressly recognising the link between health and development, the final Communique of the Okinawa Summit stated that, ‘good health contributes directly to economic growth whilst poor health drives poverty. Infectious and parasitic diseases, most notably HIV/AIDS, TB and Malaria, as well as childhood diseases and common infections, threaten to reverse decades of development and to rob an entire generation of hope for a better future. Only through sustained action and coherent international cooperation to fully mobilise new and existing medical, technical and financial resources, can we strengthen health delivery systems and reach beyond traditional approaches to break the vicious cycle of disease and poverty’. [5]

The G8 committed to working in strengthened partnerships with governments, the World Health Organisation (WHO), and other multilateral institutions, industry (especially pharmaceutical companies), academic institutions, NGOs and other civil society actors to deliver three critical United Nations targets (i) reducing the number of HIV/AIDS infected young people by 25 percent in 2010 pursuant to UN Secretary General’s Report to the General Assembly in March 2000 (ii) reducing Tuberculosis mortality rates and prevalence burdens by 50 percent in 2010 pursuant to the World Health Organization’s Stop TB Initiative, and (iii) reducing the burden of disease associated with malaria by 50 percent in 2010 pursuant to the World Health Organisation’s Roll-Back Malaria Campaign. [6] To achieve these targets, the G8 committed, inter alia, to support innovative partnerships, including the NGOs, private sector and multilateral organizations, and to explore the evolution of innovative governance strategy to accomplish these commitments. A post G8 Summit International Conference on Infectious Diseases held in Okinawa later in 2000 paved the way for the progress made by the 2001 G8 Summit in Genoa, Italy on the strategies for reducing the burdens on HIV/AIDS, TB and Malaria. The Okinawa conference attracted participants from the G8 and non-G8 countries, international organisations, civil society and pharmaceutical companies.

At the Genoa Summit in 2001, the G8 responded to an appeal by the UN General Assembly and the UN Secretary General, and pledged to commit USD 1.3 billion to the new Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria. As an innovation in global health governance, the Global Fund, according to the G8, will be a public-private partnership aimed at promoting an integrated approach that emphasizes prevention in a continuum of treatment and care. The Global Fund will operate according to principles of proven scientific and medical effectiveness, rapid resources transfer, low transaction costs, and light governance with a strong emphasis on outcomes. In the context of the Global Health Fund, the G8 pledged to work with the pharmaceutical industry together with the affected countries to facilitate the broadest possible provision of drugs in an affordable and medically effective manner. The Summit reaffirmed the commitment of the G8 towards balancing the intellectual property and public health imperatives of the World Trade Organization’s Agreement on Trade-Related Intellectual Property Rights (TRIPS). [7]

Based in Geneva, Switzerland, the Fund is a public-private collaborative financial instrument, and not an implementing agency. It is an alliance of partners from UN agencies, developing countries, donor governments, foundations, corporations and non-governmental organizations (Brugha, R and Walt, G, 2001). Some of the basic principles underlying the Fund include the creation, development, and expansion of government, private and civil society partnerships including the promotion of consistency with international law and agreements and respect for intellectual property rights. In April 2002, the Global Health Fund approved USD 616 million in its first round of funding to forty countries (Ramsay, S, 2002). The Fund is estimated to need USD 7-10 billion each year to combat HIV/AIDS alone, and would obviously need more resources for TB and malaria. The Fund has made funding commitments for full set of programmes over five years, which add up to USD 1.6 billion out of the USD 1.9 billion presently at its disposal. Where will the additional funds come from? Funding commitments by governments (including the G8) have decreased drastically in recent months. In a recent report, two non-governmental organisations – Health and Development Networks and Aidspan criticised the lukewarm attitude of countries towards the Global Fund (France, T, et al, 2002). Expressing the fear that voluntary contribution to the fund has failed, France et al (2002), proposed an ‘Equitable Contributions Framework’, which based on USD 10 billion per year ‘suggests that USD 1 billion a year should come from the private sector, as a minimum to justify the label ‘public-private partnership’ and the two seats it has out of the 18 voting seats on the Fund Board. The remaining USD 9 billion a year should come, in proportion to Gross Domestic Product (GDP), from the 48 countries that have ‘high’ Human Development Index, or HDI. (The UN’s HDI measures the overall quality of life based on standard of living, life expectancy, and literacy plus school enrolment). The proposed contribution comes to 0.035 percent of GDP for each country. Not one country has yet given at this level. Assuming, in the absence of better data, that every contribution made thus far is entirely for us this year, the Netherlands, (contributing at 97 percent of its proposed level), Sweden (73 percent), and Italy (57 percent) have done reasonably well. Seventeen countries have given between 1 percent and 50 percent of the proposed level, with Japan and the US at a very disappointing 12 percent and 13 percent, respectively. And 28 ‘high development’ countries have given nothing at all”.

In another report focusing on the compliance level of G8 countries Genoa Summit commitment of USD 1.3 billion, Yoon (2001) observed that pledges by Britain, Canada, France, Germany, Italy, and Russia yield appropriate equitable ratings relative to their GDPs while pledges by Japan and the US yield less equitable ratings given the size of their respective GDPs. Despite these facts, the 2002 G8 Summit in Kananaskis, Canada, paid little attention to the need to scale up resources for the Global Fund. The final communique issued at the end of the Kananaskis Summit has only one short paragraph on global infectious disease menace wherein the G8 leaders stated ‘we underlined the devastating consequences for Africa’s development of diseases such as malaria, tuberculosis, and HIV/AIDS. In addition to our ongoing commitments to combat these diseases, we committed to provide sufficient resources to eradicate polio by 2005’. [8] Even the ambitious New Partnership for Africa’s Development (NEPAD) adopted by the G8 at Kananaskis remains flawed exactly for the same reason of inaction and covert discontinuity with the Global Health Fund commitments. Is it possible to anchor African development initiatives on a sick and dying population? Malaria, HIV/AIDS and TB all have very heavy morbidity and mortality burdens on African populations, and therefore any socio-economic development African initiative must simultaneously or independently tackle the burdens of these diseases. NEPAD, according to Lewis (2002), talks of trade, investment, governance, corruption and matters relating to financial architecture. It is disturbingly startling that NEPAD hardly mentions HIV/AIDS. Can we talk about the future of sub-Saharan Africa without AIDS and Malaria at the centre of the analysis? If the G8 Summit takes NEPAD seriously, if it wishes to make development more than an ‘impossible hope’, if it adds to trade and investment a pledge to rescue the human condition in Africa, if it wants to redeem the Summit process, so tainted by previous posturing and irrelevance, then it will provide a guarantee, year by year, of the monies that Kofi Annan has requested for the Global Fund. In one fell swoop, the entire Summit would then be credible (Lewis, S, 2002).

The G8 Summit’s commitment on development would remain lopsided if public health remains at the margins of these initiatives. The recent Report of the WHO Commission on Macroeconomics and Health chaired by Jeffrey Sachs is replete with convincing and infallible evidence of the linkages between poverty, development and disease, and how these problems could easily be fixed. According to the Report:

the linkages of health to poverty reduction and to long-term economic growth are powerful, much stronger than is generally understood. The burden of disease in some low-income regions, especially sub-Saharan Africa, stands as a stark barrier to economic growth and therefore must be addressed frontally and centrally in any comprehensive development strategy. The AIDS pandemic represents a unique challenge of unprecedented urgency and intensity. This single epidemic can undermine Africa’s development over the next generation (WHO, 2002).

The Global Health Fund must not be allowed to become an orphan in less than three years of its life. There are many other reasons why the G8 and other industrialised countries should take emerging global health challenges seriously, especially what I have explored as ‘mutual vulnerability’ in the discourse of global health challenges and governance (Aginam, O, 2001).

4. Epilogue: The Relevance of Self-Interest in the Global Governance of Globalized Health Challenges

In the emerging global village, geo-political boundaries are irrelevant to public health threats, and populations within such boundaries are mutually vulnerable to the traditional and re-emerging powers of microbial forces. Hays (1998 p 8) rightly observed that ‘since the 16^th century the world has shrunk, with greater opportunities for the rapid movement of microbes to new populations’. As aptly observed by Brundtland (2001) ‘in the modern world, bacteria and viruses travel almost as fast as money. With globalization, a single microbial sea washes all of humankind’. If one inevitable consequence of globalized public health is vulnerability of all of humanity to microbial threats in an interdependent world, then the challenge of global governance of transnational infectious and non-communicable threats must be founded on enlightened self-interest. To paraphrase Yach and Bettcher (1998b), why then must industrialised countries such as the United States look beyond their own narrow self-interests with regard to transnational public health policy? Promoting public health abroad is promoting public health at home because the microbial superhighway provides opportunities for microbes to travel from an area thought to be a reservoir to a purported ‘safe haven’. In partnership with other countries, the industrialised countries can provide leadership and guidance in such areas as research, surveillance, regulation and governance, training, education and provision of preventive and curative therapies (Yach, D and Bettcher, D, 1998a).

Globalized public health requires a global policy universe and humane global health governance framework involving a multiplicity of actors – international organisations, private and corporate actors, and civil society. Rosenau’s concept of the ‘Frontier’, which renders the distinction between domestic and foreign affairs obsolete in an interdependent world, is the locus of the governance framework that I foresee for globalized public health (Rosenau, J, 1997). According to Rosenau (1997), ‘the ‘Frontier’ is dynamic and rugged. Thus the complexities of the new conditions that have shaped the ‘Frontier’ cannot be explained by a single source’. Fashioning an effective and humane global health governance framework will be difficult, but as Rosenau (1997) put it, ‘global governance is not so much a label for high degree of integration and order’. Governance of globalized public health in the ‘Frontier’ involves critical choices. What is most important is for evolving global health governance structures to focus on the ‘world’ as its primary constituency, and humanity (human life) as the endangered specie that it seeks to conserve. The G8 countries must be commended for their Okinawa initiative to establish the Global Health Fund, an innovative private-public global health governance mechanism. They, nevertheless, owe a duty to billions of people in our global neighbourhood that are vulnerable to AIDS, TB and Malaria to devote sufficient resources to the Global Fund. For the G8 Summit, the road from Okinawa to Genoa to Kananiskis on global governance of AIDS, TB and malaria has been marked by governance deficits and segmented approaches to one of the most complex serious issues confronting the international community today – transnational menace of pathogenic microbes. Enlightened self-interest, as Brundtland (2001) observed, ‘compels industrialized countries and private corporations to do what it takes to drastically reduce the current burden of disease in the developing world. To do this will be good for economic growth, be good for health and be good for the environment. Not only for the three billion people who have yet to benefit from the technological and economic revolution of the past fifty years - but for us all’. To salvage our global neighbourhood, international law, especially global health law, must align with the self-interest paradigm and strive to champion the tenets of human dignity long enshrined in human rights discourses as a way to humanise the evolving structures of global health governance in a divided world.

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