Examination of Witnesses (Questions 962
- 979)
MONDAY 12 MAY 2008
Professor David Fidler and Dr Kelley Lee
Q962 Chairman:
Good afternoon. Thank you both very much for coming. The format,
as you know, is that we will ask you questions along the lines
of the reforms needed in the intergovernmental organisations to
deal with infectious diseases. We are primarily interested in
the changes needed in the intergovernmental organisations or the
architecture by which we deal with infectious diseases and not
the diseases themselves—although obviously we need to have
some knowledge or information about the diseases when necessary.
I would like to invite both of you to come in on a question whenever
you feel you have something to say. Perhaps I could begin with
the fairly clear question to you, Dr Fidler, but do remember what
I said, Dr Lee: if you want to come in on it, please feel free
to do so. You are, in a way, Professor Fidler, recognising what
I think some of us have been struggling with, that nation states
are not always the best way of dealing with the problems in the
modern world. The structure of health care is becoming very, very
important in that, because of the changes that have taken place
in the global economy generally and otherwise, the nation state
bit is no longer sufficient, in a way. Do you have a solution
to this? I read your paper with some care. There was a lot of
very interesting constructive criticism in it. I am not quite
sure what you would like to see as the alternative and I particularly
want to know if you think it is a case of reforming the existing
system or whether we need something absolutely new in some way.
Professor Fidler: I would start by saying you
need a bit of both. There are elements of the existing system
that are simply going to have to be kept because that is the nature
of the structure of the international system, but I do think that
we need to move way from that State-centric model and think about
different alternative strategies and approaches. We are seeing
a lot of that taking place now, with different types of innovative
governance strategies with regards to different threats that are
faced from infectious diseases. I do not find the term "architecture"
very useful for the purposes of thinking about this in the future;
that is, looking forward as opposed to criticising what we have
today. I think a more apt analogy is "networked governance".
We are going to have to build networks of State, intergovernmental,
and non-state actors, in order to deal with these types of problems.
You are already starting to see that happening. If you think about,
for example, the International Health Regulations, the way they
build non-State actors directly into a global surveillance system
is a very different model of global governance from what we saw
before. That is an innovative way of trying to integrate the new
actors (non-State actors) and new technology (global information
technology) with regards to global surveillance for these diseases.
You see this in other examples as well; whether that is the International
Finance Facility for Immunisation, or even the (PRODUCT)RED campaign,
or the Global Fund, many of these are reaching out to non-State
actors and building them into these global networks. That is really
the way the future is going to be, rather an attempt to centralise,
harmonise and rationalise, within a single governance architecture,
the way we approach these problems.
Q963 Chairman:
I understand that. You are not arguing for a single organisation?
We have had indicated to us that that probably would not be a
good idea—and certainly it would not be my ideal solution.
You are saying build on what we have with new examples? The IHR—which
we will come to a bit later in the session—is the type of
approach that you would like to see. Is that correct?
Professor Fidler: Yes. This is being done in
all the innovative governance areas. There is an attempt to try
to integrate these networks across issue areas. It is not just
the IHR; there are lots of examples of this. This is moving away
from that State-centric approach. It is also, to some extent—although
not in all cases—moving away from formal treaty-based mechanisms.
The IHR is treaty-based but many of these other examples are not
based on treaties, they are set up in more informal partnership
contexts—which is also a different type of development going
forward. I think these are going to have to develop with regards
to specific issue areas, as opposed to being one overarching structure.
I can talk in more detail about some specific examples of that,
or ideas that I have tried to develop in my writing. But, again,
that is a combination of existing mechanisms/processes but building
in some of these innovative features, particularly to harness
and take advantage of what non-State actors could bring to the
table.
Q964 Lord Howarth of Newport:
Evidently it is extremely important to bring the non-State actors
into the system as coherently as possible and take advantage of
the resources that they can mobilise. On this networked model
that you have been postulating, would we be better placed to achieve
rational and decent priorities? Or would the effort tend to go
where resources happen to be concentrated according to the predilections
of the organisations that were the biggest players? If we resort
increasingly to the informal relationships that you have been
sketching, does that mean that the system would become even more
ad hoc and that we have to say goodbye to any prospect of an evolution,
for example, of international law which would fortify these international
efforts and help over time to establish a better and more reliable
capacity to address these problems?
Professor Fidler: Let me address the priority
question first. I think you have to take into account that there
are two different rationalities that are at work here. One rationality
is when we talk about rational priority from a public health point
of view. The other rationality is a foreign policy rationality,
where you have to take into account the limits of what you are
able to achieve. There has been no problem with regard to identifying
what are major public health priorities, and where we need more
money, and where we need more governance capacity. But, when you
turn around and say "OK, US—or UK—please implement
this", the foreign policy people, who already have experience
in a development context of trying to do these sort of horizontal,
systemic, capacity-building reforms, push back, because from a
rational point of view there are limits to what even a powerful
country can do with regard to reforming the way in which another
government operates. If you are serious about that, you are talking
about regime change for public health or structural adjustment
for public health. The foreign policy people say, "We have
limits to what we can do here, so a more rational strategy is
to pursue more limited, technical vertical programmes that we
have more control over, so that we can see how our money is being
spent." That is a rational priority setting from a foreign
policy point of view as opposed to a public health point of view.
Even if you had a mechanism that you could set up—and to
some extent we have that mechanism in the WHO—that rationality
does not necessarily match up with the diplomatic and foreign
policy rationale of the countries which have to provide specifically
the resources for that. In terms of the informal partnerships
versus more formal mechanisms, I think we are in early stages
with regards to seeing how many of these informal partnerships
operate. Again, it is not entirely the case that informal partnerships
are all that is on offer at the moment. We have two big and very
important examples of the development of international law, the
IHR and the Framework Convention on Tobacco Control. But what
is interesting about the informal mechanisms is the extent to
which all of the players have avoided putting them in an international
legal framework. They have avoided treaties. They have avoided
even putting it inside the WHO. I think there is the sense, particularly
in this initial innovative stage of finding some new alternative
approaches, that a little bit more flexibility is better at the
moment than trying to work this into international law. It is
part of my scepticism about some of the proposals that have been
made about having more treaties in connection with global health.
I do not know if you have questions specific to some of those
proposals. To some extent, the informal partnering mechanism does
not detract from the development of international law. Many of
the norms on which these informal partnerships are drawing, are
already principles of international law; they just have not been
effectively implemented in the treaty formats in which they were
initially adopted. Here are efforts to try to influence some of
the norms and ideas and processes that are in international law.
That will feed back into the process of international law and
create a dynamic context which we did not have in the past, where
at least in public health, international law was stagnant.
Q965 Chairman:
The problem of enforcement comes into that in a very big way.
Professor Fidler: Give me any topic in international
relations and you have an enforcement problem in international
law. People get hung up on enforcement with international law,
and I think it is the wrong thing to get hung up on, particularly
as a first step. The only place you find effective enforcement
of rules of international law through independent third party
adjudication is the World Trade Organisation. That is it. There
is not anywhere else in international law that you find an effective
enforcement mechanism. People ask me, for example, "How do
you enforce International Health Regulations?" There is not
an enforcement provision, but look at the way in which the incentives
and the dynamics of the rules are set up and you start to see
that the enforcement of this starts to drive off the creation
of reciprocal self-interest that States have to comply. That is
what is more interesting about that development than an enforcement
mechanism. I would encourage you not to get hung up on enforcement
because that affects every single area of international law.
Q966 Chairman:
I understand that argument but, to use a current example, if you
had one of these infectious diseases coming out of a state like
Burma, I am not quite sure what you would do about it, and I am
not convinced that "Let's persuade the State" would
necessarily work. It would depend on which sections of the community
were being hurt as to whether or not the State did anything.
Professor Fidler: You then have to start thinking
of drawing on different types of rules of international law. For
example: Would this require humanitarian intervention? Would that
require the use of military force? There are rules of international
law that deal with that. Here the question is not so much one
of enforcement but one of relieving humanitarian suffering. So,
even in that context, it is not an enforcement question.
Dr Lee: Before we get into more specific things
around particular mechanisms, I'd like to return to the starting
point of this discussion around State versus non-State actors.
I think we are in a political and institutional transitional period.
It is an incredibly difficult challenge—a lot of ideas get
bounced about in the literature and the academic world. I conceptualise
it as a need to shift the paradigm from looking at health at the
border to beyond the border. At the moment, there is still an
state-based emphasis on trying to create stronger borders, whether
territorial or otherwise—perhaps through screening at ports
of entry; looking at testing immigrants prior to coming into a
country—trying to strengthen the fortress based on physical
territoriality. All that you have described, these global forces
at play, means that we have to recognise that such measures are
irrelevant increasingly, because we cannot control many of these
forces at the border. We have to think about, first of all, within
our borders and how we can build institutions that address how
effectively we can respond when a health risk comes into a country,
and then beyond borders when we look at not just developing countries
but all countries and how we strengthen institutions across countries—indeed,
this may be a kind of networked approach. We can all recognise
this when we say it, but doing it is really difficult. We still
keep coming back to state borders. I think that the 19th century
approach is still really well embedded in the way we see things.
I will stop there. There are lots of other things to say but that
is one of the key challenges. We have not all shifted our paradigms
yet.
Q967 Lord Avebury:
If you start thinking that borders are irrelevant, does it mean
that you have to treat communicable diseases in irregular migrants
in your territory? Would that be part of the package?
Dr Lee: It would be. It may not be politically
popular, but I think it would certainly be necessary. I will tell
you why. It sounds incredibly idealistic and imagine the cost—people
immediately say "Cost". But the problem is that we know
there are people coming in and out of many countries either documented
or undocumented. That is happening. We cannot—and we may
not want to—stem increased population mobility. That is
part of globalisation. The problem is that, when people are here
(and there are obviously practical challenges already to providing
health care for all), certain parts of the population, whether
they should be here or not, feeling they cannot access the healthcare
system. From an immigration point of view, this is a complete
nightmare, of course. Immigration policy would respond in a very
different way. From a public health perspective, it is in the
UK population's interests to offer people access to basic health
care, at whatever cost, because the implications are, if they
are suffering from drug-resistant TB for example, as a worst-case
scenario, and they do not feel they can access the health care
system, that the population as a whole is at risk. We are creating
incentives where these sorts of problems go underground. I am
not saying it is going to be politically very easy to sell that,
because at the moment it is about cost-savings, it is about keeping
NHS costs down, and so on. But in other countries, Canada, for
example, there are clinics where people can walk in, no questions
asked, and it is seeing the bigger picture really around public
health. It is a difficult one to sell, but from a public health
perspective it is a cost-effective way to deal with global health
issues.
Q968 Chairman:
Professor Fidler, you said in your evidence—and it is obviously
correct—that organisations like The Gates Foundation are
playing an increasingly central role; indeed, to some extent taking
over. I am not quite sure how we involve them in this process.
Is this what you see as part of the general drawing up of new
approaches?
Professor Fidler: Yes, it is. In terms of trying
to conceptualise how things are operating today, this is part
of how I see the very nature of the operation of international
relations changing fundamentally. The Gates Foundation is the
best example in the global health context of where you have a
non-State actor now who is able to influence global health, partly
and significantly because of the material influence—they
just have a lot of money and money talks—but, second, because
the material influence, the material power, if you will, that
the Gates Foundation possesses also allows it to have impact on
what priorities get set in global health. This is part of what
upsets people about the way in which non-State actors who are
not accountable to anybody come in and affect the way in which
global health is operating. First, that reaction assumes global
health is operating in a rational functional manner to begin with—which
I think is a problematic argument to make. Second—and I
struggle with this: this is the normative question and it is probably
what you are struggling with as well—as we look at States
and non-State actors and intergovernmental organisations, all
involved in this gigantic proliferation of initiatives, are we
undermining the capability to do something sustainable for public
health? That is a serious concern. As I think about that as a
governance matter, it is very hard for me to see a single solution—which
is why I think architecture is the wrong model, because I do not
think you are going to be able to control the behaviour of either
States or big powerful NGOs like the Gates Foundation. If you
think it is hard to get the United States and George Bush to toe
the line of the United Nations, try getting Bill Gates to toe
the line of the WHO. He does not have to. Increasingly, the Gates
Foundation is the first place people will pick up the phone to
call; not the WHO. In fact, someone told me—and I do not
know if this is true—that Bill Gates is now going to fly
to Indonesia to help intervene in that controversy over virus
sharing. Something has changed here. In an architectural model,
I do not know how to control or contain it. With a network model
you have a better chance. It is a serious problem.
Q969 Chairman:
Before I move on to surveillance, Dr Lee, would you like to add
any more on this?
Dr Lee: I agree with what Professor Fidler is
saying. For me I see the problem as this lack of an overall Master
Plan. There has been a market-based approach to health development
in a way, as in other areas of development, for various reasons—and
it is not just donors. There is a tendency to create another institution
and another mechanism rather than fix what is already there. We
have this proliferation, as we describe. It is a real problem.
This is the first thing anybody who looks at this area sees. Global
health, in particular, has a more crowded policy environment than
any other sector. There is this lack of a Master Plan—and
I do not have an answer. A lot of ideas are being put on the table
as to how co-ordination could be improved. Where should authority
lie and how should it be distributed? We may have disagreements
about the institutional mechanisms we need—and we can go
into some of the ideas that have been put forward—but without
an agreed vision, I just cannot see how we can move forward. Various
organisations are involved in special pleading, every disease
has its advocates, these silos, these vertical programmes, as
Professor Fidler has described. This is getting us nowhere, because
we are not sitting back and looking at the overall priorities.
Nobody is setting clear priorities overall; it is free-for-all.
Until we move beyond that, I see this as the key problem.
Q970 Chairman:
Having heard what you have said, I have to ask you another question
on this. Professor Rubin, the Director of the Institute for Strategic
Threat Analysis and Response, told us the other week that he favoured
a Global Compact approach to this. Are you aware of this proposal?
Professor Fidler: Yes.
Q971 Chairman:
We have found ourselves struggling with how it would deliver.
Do you have a view about it one way or the other?
Professor Fidler: I think I would have to join
your struggle. I have seen presentations on that Global Compact.
Even for someone who is as steeped in the machinations of global
politics as I am, it is a little hard to see exactly how the idea
would work. You can see what they are trying to do: they are avoiding
immediately the problems you get into by using formal or harder
international law. They want to have more of this flexible partnering
approach, issue linkage across four areas, to try to get people
moving together on a coherent integrated approach to that. You
can see they are picking up on these signals and these cues as
well. It is another idea that has been thrown out there with regards
to trying to move that agenda forward. I have some questions about
why they have chosen what they have chosen and how they have put
it together. I am not aware of how much traction that proposal
has in the policy world. There are all kinds of ideas that people
are throwing out here, and I have just tried to capture this transition
phase. To some extent, it is a competition of ideas. The survival
of the fittest is taking place right now. To some extent, that
is a necessary part of this transition.
Chairman: It is not necessarily
bad that we have that. I do think there is a bit of a struggle
between: Do we start from somewhere where we are not, in the hope
of starting again, so to speak? Or do we start from where we are?
Q972 Lord Howarth of Newport:
In your excellent, powerfully drafted evidence to us, Professor
Fidler, you said that you detect a growing sense in non-health
foreign policy circles that enough for the moment has been done
for global co-operation on communicable diseases, and that other
pressing issues, for example, global warming, deserve priority
attention. This is pretty pessimistic stuff. I do not know whether
it is an instance of what you were suggesting in our earlier exchange
that, from the point of view of practitioners of realpolitik
in foreign policy, it may be rational not to try very hard at
all. Is it the case, do you think, that countries are not particularly
interested in the diseases that are unlikely to communicate themselves
in large-scale and dangerous ways into their own societies? If
for the time being they are not particularly worried either about
Avian Flu and SARS, then they do not bother. It may be that the
conscience, in the sense of self-interest, of the world may be
pricked a bit by current events in Burma and that people will
start taking a livelier interest in these things again. But what
is to be done about this tendency to withdraw when there is not
an urgently perceived threat to our own insular interests?
Professor Fidler: It is true and can be empirically
demonstrated that developed countries—and I would use the
United States as an example—are much more concerned about
direct disease threats than they are about indirect disease threats.
My perception, from watching the United States and also from talking
to people who are engaged with these issues and other global issues,
is that, when they see the new International Health Regulations
and they see PEPFAR. They see that there have been major responses
to these issues. Their concern is, "We've put together mechanisms;
now we are going to turn our attention to something else,"
because they also have on their plate climate change, the energy
crisis, the food crisis—and now we have the problem of this
humanitarian disaster in Burma. In relation to what they have
to do in terms of prioritising, most of those issues do not have
anything. It is not that there is a retreat or a lack of attention
to the health issue, but it tends to fall down the hierarchy of
what they are paying attention to now, because for some of these
other issues there is nothing in place. We have at least got things
going in the global health context, so their assumption is: "That's
been handled, and we'll let that operate." Where that risks
becoming complacency is that you now have to implement these things:
you cannot just have a new treaty and then it is done. This is
the problem with the IHR. How are these going to get implemented?
If there is not sustained foreign policy attention to that, we
are going to be back to Square One. I do notice that. I do not
think it is anything malevolent on the part of foreign policy
makers. Just look at everything else they have to handle—and
the foreign policy process is one of ruthless prioritisation.
Where is this going to fit in terms of political attention and
political resourcing with regards to these issues? Burma is interesting
because there has been, again as part of this transition, this
re-thinking of health as a global issue, a lot of attention in
the past 10 or 15 years on re-thinking humanitarian assistance
for disaster response and relief. As part of this, there has been
a lot of angst about not enough international law here to require
Burma to let in humanitarian assistance when a disaster happens.
What is interesting is over the past 10 or 15 years you have seen
the international community, both the UN as well as non-State
actors, develop the capacity to respond. If we look at what happened
in Indonesia or the earthquake in Pakistan or other big natural
disasters, we have not had these massive disease outbreaks. It
is very interesting. Without any development of international
law. The problem in Burma is unique to that regime. You cannot
say that there is a systemic problem because of what is happening
there. It does create the problem of how then do you respond with
regard to this particular type of regime, not just with the diseases
that are going to break out because of the cyclone, but, in Burma
Malaria is a huge issue, Tuberculosis, HIV/AIDS. Burma is a global
public health disaster. Again, how do you fix that problem? It
is regime change. I do not know how else to describe how you would
fix all those problems in a sustainable way. Are we willing to
take that on as a foreign policy objective? That is where people
start to hesitate.
Dr Lee: The starting point is that health is
always seen as a low-politics issue on the domestic front. Then
you move to the global level, global health has become a climber
on the international agenda, but only where it intersects these
key areas: security, trade, perhaps migration. When health intersects,
with these issue-areas those at the top tables of foreign policy
become interested. Of course, the problem then is that they interpret
public health priorities from their own policy lenses, so certain
diseases are given priority because they are seen, I suppose,
as a particular security threat in certain countries, or there
might be trade interests, where they intersect with health around
drugs and so on. There is, I guess, this partial and potentially
skewed view of what the global public health challenge really
is. What do we do about it? This situation is probably familiar
to anyone who has worked in policy. Our work at the London School
is constantly about banging the drum that: "Public health
is important because ... ", and then we try to break into
these influential policy circles. For a while, you start to use
this language of trying to scare people, saying, "If we don't
do something, then this many people will die." You fall into
this kind of language. It is a double-edged sword: you have to
play that game, but at the same time you distort what really is
your own agenda. I suppose I would say that we have tried to do
"joined-up government"- that horrible phrase—trying
to find ways to access those who have the policy influence and
trying to convince them. An alternative approach would be that,
given we do not know what the key threats will be we invest in
basic health systems that will be much more effective than picking
and choosing specific diseases. We do not know if a particular
disease is going to become a risk and cross borders, but we can
prepare for the types of changes that eventually will happen because
of globalisation and then shore up our institutional responses.
If we just focus on what we think specifically today is going
to be a threat, we do not know what is around the corner tomorrow.
So we need put our focus on basic health systems here in this
country as well as abroad.
Q973 Lord Howarth of Newport:
Might you take that approach a stage further? I suspect that,
historically, better sanitation and better education have done
more to promote good public health and to reduce and eliminate
diseases than the doctors have?
Dr Lee: Yes.
Q974 Lord Howarth of Newport:
If we are really trying to get to the roots of these problems,
then the whole thing becomes such a vast and amorphous policy
agenda that it is even harder to get focused and targeted and
prioritised in ways that might be useful.
Dr Lee: I do not know. If you think of 19th
century public health reforms in the UK, they were not just public
health reforms, they were social reforms. We were moving from
the Industrial Revolution, where we had cholera outbreaks, disease
was rife, there was large scale urbanisation. These are also things
that are happening today in the developing world, but at a much
more rapid rate, I suppose. What did the Government do? They adopted
broad social reforms: better housing and better sanitation. These
were do-able things. It did take a much longer period, and today
we have a bigger scale to deal with. But focusing our resources,
on developing the next vaccine or the next drug for whatever disease
we happen to think is going to come to our shores, is really a
short-sighted way of looking at it. Perhaps we need both but,
given limited resources, I think the shift in attention within
public health and health sector aid is really towards health systems
and realising that it is the institutional base within which we
can then mount effective responses that is important. It can be
a bottomless pit. It can sound like we are trying to create new
societies in developing countries. We are talking about huge resources
here. At the moment we do have resources that we are just mis-spending,
and not doing any of this. I keep coming back to sanitation, water,
clean water, basic health care—things we have known for
at least a century or a century and a half that work. Why can
we not apply those lessons to other countries?
Q975 Chairman:
When you say we do have resources that we are mis-spending, had
you anything particular in mind?
Dr Lee: I suppose that, if we add up all the
new resources for global health spending on the three Diseases
(HIV/AIDS, Tuberculosis, Malaria) by the Global Fund, UNAIDS,
Gates, on and on and on. A lot of this money is, first, totally
uncoordinated, but it is also going to quick fixes. It is looking
for that magic bullet. It would be fantastic if we found a vaccine
for AIDS or Malaria, but in the meantime there will be new diseases,
there will be emerging diseases. We know this is going to happen,
so do we then pour resources into the next disease? It is a very
short-term approach. Seeing the longer-term development of societies
is not very sexy or popular in terms of politics, but that is
ultimately where you get the most impact.
Professor Fidler: Foreign policy makers understand
this. They understand the importance of the social determinants
of health-education, gender issues, poverty. The problem is that,
unlike Britain doing this to itself in the 19th century, you are
asking another country to do this to another country. This is
where the "social determinants" approach, at least from
a foreign policy perspective, begins to look irrational: "How
do I do that, unless I impose a way of doing this and spend resources,
over which I have to maintain control—because, by the way,
I have 50, 60, 70 years of experience in developing countries
and I know many of these governments waste money." We have
tried education fixes, we have tried sanitation fixes. There is
a whole lot of development that has gone on which has not been
specifically connected to health, even though it deals with the
social determinants of health, and our effectiveness has, quite
frankly, not been very good. There are reasons for that and that
has to do with this international context of the limitations of
the ability of developed countries, donor countries, to leverage
their superior power over developing countries. This is a rational
calculation that cuts across all development areas, not just health.
Nobody has figured out how to get out of that trap.
Q976 Lord Avebury:
They have, to some extent, in the Millennium Development Goals.
That is telling the developing countries that this is a standard
at which you should aim, and if you do take these goals on, then
the developed world will help you. A reduction in infant mortality,
for example. You can get a lot of money if you are prepared to
do things that will approach that particular goal.
Professor Fidler: There are conditionalities
to the use of donor and development assistance with regard to
what you do. To some extent, there is controversy about whether
or not the Millennium Development Goals are anywhere close to
being where they should be at halfway to 2015 at the present time.
Q977 Lord Avebury:
Except in sub-Saharan Africa, they are getting there.
Professor Fidler: There are controversies around
even other parts of the world with regard to some of the health-related
indicators.
Q978 Lord Jay of Ewelme:
There certainly are questions, but I myself feel fairly confident
that there has been more progress made than would have been made
otherwise because there are Millennium Development Goals. To that
extent, I would see them, personally, as an advance and as a policy
step. I want to go back just a moment to this governance question
and this rather difficult area between the present rather anarchic
state of institutions which we all agree is unsatisfactory and,
at the other end of the scale, the centralised directed system,
which I think we all agree would not work. To be honest, I like
the concept of networked governance, informal partnerships, but
I am not quite clear whether that just happens or whether it is
the survival of the fittest and there is a jungle mentality or
whether somebody tries to encourage us all to go in that sort
of direction, and, if so, who. I would welcome your thoughts on
that Then there is a specific question. Professor Gostin has talked
about a possible Framework Convention representing "a unique
opportunity to build normative consensus around the most pressing
problems in world health". Do you think there might be something
in that? Do you have the same scepticism about that as you would
do about Professor Rubin's ideas of a Global Compact? Who pushes
us in the right direction here? That is what I am trying to get
at.
Professor Fidler: Let me give you an analogy
which is going to be different from architecture.
Q979 Lord Jay of Ewelme:
I deliberately did not use the word "architecture!"
Professor Fidler: Right, but I want to contrast
that with the way I think about these issues, in terms of what
are we doing and why we are doing it. I make an analogy to the
world of software. You have a source code that runs the software/runs
the programmes for global health. That source code is now accessible
and influenced by all range of actors. Via people in this networked
context, they are following what is going on. The source code
is open source, it gets iteratively defined by the participation
of the various actors. Much of this is driven by the basic, fundamental
principles of public health. What do you need to do? Surveillance.
Then you need to have intervention with regard to disease problems
in transitory populations. That has to be based on evidence and
scientific principles, et cetera. That is part of what is driving
the development of the source code and finding then effective
policy and governance mechanisms and political mechanisms to put
that into place. That is where we see a lot of competition now
with regard to different ideas being floated. At the moment, I
do not know how you could avoid that, given this transition. I
think we are sort of in that framework at the moment. Some things
will fall by the wayside; other things, we will find out, perhaps
to our surprise, actually work. We can then build on that with
a further iteration. You will then start to see the nodes of the
network governance become a little bit smaller, so you begin to
get more coherency and you begin to get more consensus of what
you are doing and where you are going in connection with those
ideas. I think that is part of what Professor Gostin has in mind
with a Framework Convention on Global Health. Where I have a little
bit of scepticism with regard to that proposal is that we already
have a framework convention on global health: it is the WHO Constitution.
I have not yet seen, even in Professor Gostin's writings, a convincing
case that having another large treaty framework would get us any
farther than the ones we already have in connection with this.
Keep in mind the Framework-Protocol approach is a specific process
and dynamic. The Framework Convention means you sign up to not
do anything and then the substantive obligations come later—at
least, that is the classic way of setting up a Framework-Protocol
Strategy. Many of the things that would be needed, the obligations
in international law and a Framework-Protocol approach that Professor
Gostin has in mind, we already have in international law. There
are already international legal obligations with regards to basic
survival needs: a human right to health, other forms of human
rights. How well have we been implementing those existing rules?
Is adopting them in yet another treaty going to be effective with
regard to that proposal versus something else which may not be
in a treaty format but for which you might get some more traction
with regard to the implementation of capacity building?
|
