Lawrence O. Gostin, Global Health Law (2014)

Lawrence gostin's excellent book Global Health Law1 was published in March 2014, the same month the World Health Organization (WHO) announced that a worrying new batch of cases of Ebola hemorrhagic fever had been detected in West Africa. Reading the book from the vantage point of the unfolding outbreak added a surreal dimension. It was a reminder of how rapid and unpredictable shocks to global health can be. (Gostin mentions Ebola, but only as one of several emerging infectious diseases that threaten public health and security.) The book also provided an historical lens on the daily media accounts of the international response to the outbreak. But most uncanny of all was how well the twists and turns in the response to the Ebola outbreak mapped to Gostin's diagnosis of the tensions and dysfunctionalities that afflict global health governance. Gostin predicts that the path of the disease will follow the fault lines of a developing country's failing public health system. He expects a lack of international coordination and shows of both strength and weakness by the World Health Organization. The book also presages how the developed countries of the global North will respond—late, espousing a mix of altruistic and self-interested motivations. Even though Global Health Law was written before the 2014 Ebola outbreak, it knows the script that the international community's response will follow; it also explains how this script came to be, where it fails, and how it should be rewritten. Global Health Law lays out 3 objectives: (1) defining the field of global health law; (2) systematically describing and analyzing the major sources of this body of law and their institutional frameworks; and (3) articulating a kind of manifesto to guide global health governance in the 21st century. Its overarching goal is “to reveal in vivid detail the yet untapped potential of global health law to redress the dire state of global health today.”1(p.31) Global Health Law is divided into 4 parts. Part I introduces the book's central themes and reviews the major threats facing global health in the 21st century. Gostin describes the injuries, infectious diseases, and noncommunicable diseases that pose the greatest burden to public health, as well as upstream determinants like global trade, poverty, and government corruption. Part II presents the key institutions, starting with the WHO and the World Bank, and then tracks the rise of the Young Turks of global health, led by the Global Fund, the GAVI Alliance, and the Gates Foundation. Part III examines the sources of law most relevant to global health—their history, content, strengths, and weaknesses—and covers in detail the 2 main treaties: the International Health Regulations and the Framework Convention on Tobacco Control. Other chapters deal with branches of law that intersect in important ways with global health: human rights law, international trade law, and intellectual property law. Part IV looks ahead to the major challenges facing global health and its governance; it includes case studies of the AIDS pandemic, noncommunicable diseases in the developing world, pandemic influenza, and the migration of health workers. As should be evident from this description of its content, Global Health Law does not suffer from a lack of ambition. Three aspects of the book set its very broad scope. First, Gostin defines global health law expansively. It includes the “mission, sources of law, key participants, and ethical foundations.” The sources encompass both “hard law” (eg, binding treaties) and “soft law” (eg, codes of practice, informal arrangements), which may be located either inside or outside the health sector. The concept of “global governance for health” turns out to be a more accurate encapsulation than global health law of the terrain Gostin covers. Consequently, readers expecting a typical legal treatise will be disappointed. In part, Gostin's hand is forced here because there are few formal sources of international health law. The World Health Assembly (WHO's rule-making arm) has enacted only 3 treaties in its 65-year history, and 2 of them predate the WHO! Understanding what constrains the behavior of actors in global health therefore necessitates a more nuanced understanding of the forces at work. Gostin's approach resembles that of the eminent regulatory theorist John Braithwaite, whose sweeping analysis of regulation considers the full array of influences that “steer the flow of events.”2 Second, because Gostin perceives legal rules as inextricably tied to the myriad factors that shape population health, he glides easily between legal rules and social and political determinants, sometimes scarcely bothering to distinguish them. This conflation stems from a conviction that Gostin has long championed in the domestic setting, that public health law cannot be understood without considering its interconnectedness with the wider public health movement.3 Thanks to his encyclopedic knowledge of the field, he does this successfully. The result is a book that could hold its own under the title Global Health. Third, the book is both descriptive and prescriptive. On the descriptive side is a wealth of information on topics ranging from biosecurity to trade and investment law litigation. The sections on the political history of the major global health institutions are a highlight, a lucid account of peaks and troughs in the influence of the main actors during the last 50 years. On the prescriptive side, Gostin sketches his vision of what needs to be done to improve global health, and how the international community might accomplish this. Much of this vision appears in the final chapter of the book, in which Gostin elaborates his idea of “global health with justice,” although normative observations and arguments appear throughout the book. In format, the book is somewhere between a scholarly treatise and a nonfiction work written for the lay reader. It is not an easy book to read cover to cover. The information is dense in places and there is some repetition and overlap across chapters. This serves selective reading better than a sustained beginning-to-end approach. But the book's detail, breadth, and clear organization make it a fine choice as a primary text for a survey course on global health or global health law, or as a primer for more specialized courses. Global health practitioners and advocates, too, will find much in Global Health Law to hold their attention. Gostin's detailed treatment of topics such as noncommunicable diseases and the role of nongovernment organizations sets the book apart from conventional accounts of global health and enhances its relevance to a broad readership. Global Health Law's most important contribution lies not in any of the descriptive or normative information it conveys but in the argument that the book as a whole makes: global health law has arrived as a field and demands attention. Gostin is not the first to make this case; David Fiddler and Allyn Taylor have toiled in these trenches for more than a decade.4,5 But the sweep of Gostin's narrative and his unmatched talent for integrating law with the wider public health enterprise set a new mark in defining the field. The counter to the book's central premise is that global health law is merely a motley collection of snippets from other, better-established, fields—international law, international human rights law, health law, public health, international relations, and political science—and when unmoored from their disciplinary homes, these snippets lose force and rigor. In other words, the returns to conceiving of global health law as a unified field are small. Global Health Law succeeds in refuting that argument. It provides an angle on what ails global health with the potential to make a measurable difference to the international community's pursuit of “the highest attainable standard of physical and mental health” for all.6 Around the time I finished the book, Thomas Duncan, the first US Ebola patient, died. A couple of week later, Governors Chris Christie and Andrew Cuomo of New Jersey and New York, respectively, announced mandatory quarantine measures. The nagging question for me was not whether the field of global health law matters but how governments and civil society could consider themselves equipped to tackle global health without it.