analysisBy Eric A. Friedman, Lawrence O. Gostin, Mayowa Joel and Rotimi Sankore
Lagos — Few events remind us more of humanity’s shared health vulnerability than the outbreak of an untreatable, highly lethal disease that is resisting efforts to contain it, spreading from community to community, and across borders from country to country – like the current Ebola outbreak in West Africa.
The human suffering, fear and even panic, impact on families and communities, and the economic hardships are immense. The greatest burdens are felt in Guinea, Liberia, Sierra Leone, with cases and fatalities confirmed in Lagos, Nigeria - one of Africa’s two most populous cities, along with Cairo, with a population of over 12 million – more than the population of Guinea, Liberia, or Sierra Leone.
There are also reports that cases are emerging in Senegal, and that Ebola has returned to the Democratic Republic of Congo.
The international community is now scrambling to deal with a crisis, having failed for so long to take sustainable proactive measures needed to respond to global health hazards and pandemics, including the current Ebola outbreak. Where was a governing framework for global health – the spark to ignite the right to health for all – that could have built national and regional capacities to effectively prevent and contain such an uncontrolled outbreak in the first place?
The Case for a Framework Convention for Global Health
Binding international legal frameworks exist for everything from global threats like nuclear arms and climate change to economic concerns including trade and investment. Only several narrow treaties exist to safeguard world health, on tobacco and on cooperation to protect against the international spread of disease, though the latter has proven deeply inadequate for the Ebola outbreak or similar pandemics. As the current and past outbreaks so clearly demonstrate, Ebola and other diseases are global threats. It seems self-evident and logical that an international legal framework is required for non-episodic and sustainable promotion of global health that guarantees the health of every individual, and communities.
International law could establish such a framework, the legal infrastructure for the resilient, responsive, equitable health systems and the community trust that are now so badly needed. While too late to stem the present unfolding tragedy of Ebola in West Africa – there will be further threats to global health . And it is not too late to use the power of global law and solidarity to create a sustainable healthier future. The world’s poorest people must not be subjected to out of control disease’s when a sound health infrastructure could easily prevent it. We do not have to tolerate high burdens of disease and early death that falls heaviest on the world’s poorest people, whether in Sierra Leone (life expectancy: 46) or South Dakota in the USA (life expectancy of American Indians on the state’s Pine Ridge Reservation: upper 40s).
What if countries could come together to agree to a Framework Convention on Global Health (FCGH)? This global health treaty would be based on the human right to health and aimed at closing unconscionable national and global health inequalities. The treaty would improve the health and lives of people everywhere, with particular attention to the most vulnerable and disadvantaged.
Improved Governance, Disease Prevention and Stronger Health Systems Are Crucial Globally, Regionally, and Nationally – Global Health Is Only As Strong As Its Weakest Link
The FCGH would establish standards to ensure and sustain for everyone health care and underlying determinants of health, along with a global and domestic financing framework to ensure sufficient, sustained funds. It would be designed to better empower people to hold their governments to account, and participate in decisions that affect their health. The treaty would incorporate measures to increase health equity and support health for marginalized people and populations, including responding to various forms of violence against women.
Further, the FCGH would elevate the status of the right to health in other international regimes (such as trade and investment) – and as health based threats do not recognize borders – it would further clarify governments’ collective obligations to health across national borders. Its key principles can be found at: http://www.globalhealthtreaty.org/docs/platform-for-an-fcgh-full.pdf.
Global health is only as strong as its weakest link. Achieving comprehensive universal health coverage will require sufficient investment for training of more, and the right mix of, health workers, reaching every community. It will require health workers based in communities, able to quickly detect unusual occurrences of disease and building a bridge between people and the health systems meant to serve them. It will require well-functioning primary health facilities to competently treat and care for patients, ensuring high quality services in safe, hygienic conditions.
This includes protecting patients and health workers with infection control supplies and protocols now lethally lacking. In other words, it would require having precisely the strong disease prevention policies and health systems that are now lacking in many countries including those affected by the current Ebola outbreak and many others that might be—making the people vulnerable not only to disease outbreaks, but also to the more ordinary, and often deadly, daily drumbeat of avoidable and treatable infectious and non-infectious diseases, injuries, and maternal and child mortality.
Community Trust, Participation, Ownership, and Accountability
The FCGH would ensure that people could participate in health-related decision-making and establish health accountability at all levels. This will increase people’s sense of ownership over health policies and practices. It will mean implementing such community-level approaches to participation as village health committees, village health teams, and community scorecards. It will also enhance and ensure community support and solidarity during outbreaks, especially for case finding and treatment support.
These are all forums for community-health worker engagement. Along with the higher quality of care that comes from better governance and health systems – so that people associate health facilities with good quality, caring providers, and better health – this engagement will enable health systems to earn public trust. People would turn towards the health system rather than shun it, or even attack it as painfully demonstrated by recent armed attacks on an Ebola health facility by fearful members of a community in Liberia and Nigeria.
Global Trust and Collaboration
The FCGH would also help build a trust between lower- and higher-income countries, avoiding situations as with Ebola, where the first three recipients of an experimental treatment were American and Spanish. The FCGH could establish the simple yet revolutionary principle that scarce medicines and vaccines will be produced and distributed on the basis of need and with criteria developed through inclusive participatory processes, rather than based on national wealth and power – or on no clear criteria at all. The FGCH could also form the basis of rights-based, comprehensive universal health coverage as part of the evolving post-2015 sustainable development agenda.
Securing the Future of Humanity
Historically, this outbreak of Ebola will not be the last of such sudden emergence of lethal disease – whether Ebola, a novel strain of influenza, or something more exotic still – where weak disease prevention and health systems hinder containment. We know from history that disease outbreaks can kill tens of thousands, even millions of people. And even all the advances of modern medicine do not guarantee availability of a treatment, especially as microbes demonstrate again and again their capacity to evolve to resist our best efforts at treatment.
The specter of a catastrophic influenza pandemic from a novel viral subtype, for instance, looms large. The worst, in 1918, killed 50 million people and infected 20-40% of the world’s population. The world has since experienced the Asian flu of 1957-1958, causing 2 million deaths worldwide, and the 1968-70 pandemic (or Hong Kong flu), which was relatively mild compared to the Spanish flu, affecting mainly the elderly and thought to have caused about one million deaths worldwide. More recently, a new H1N1 influenza virus derived from human, swine and avian strains was initially reported in April 2009 in Mexico and subsequently spread around the world. While today we have the benefit of modern medicine, we also have air travel to accelerate the global spread of disease, and health systems ill-equipped to take full advantage of medical technologies.
Meanwhile, Ebola ought not blind us to the daily realities of people in poorer countries and communities throughout the world, where the death toll thus far from Ebola pales in comparison to the avoidable death from other causes every day – much less the suffering caused by disease and disability, from AIDS, tuberculosis, malaria, child and maternal deaths to often overlooked mental disabilities and neglected tropical diseases. By one measure, more than one in three deaths globally, some 20 million deaths a year, are related to national and global health inequities.
No issue affects the prospects of every person on this planet more than health, a matter of life itself. Yet, immense inequities persist even with modern advances in global health. An FCGH would facilitate a clearer and more sustainable framework to catalyze both domestic and global funding, community participation, and accountability now so conspicuously absent—from adequate financing and health system strengthening to community and national mechanisms that create inclusive spaces for people to engage with health decision-making and hold their governments to account.
African Leadership is Crucial
No region of the world suffers more from disease outbreak and the daily toll of ill health than Africa. African leaders such as Nobel Prize Laureate Liberian President Ellen Johnson Sirleaf. presently facing the most serious of the Ebola outbreaks in her country, while leading Africa’s Common Position on the Post-2015 Development Goals could, alongside leaders in countries currently affected by Ebola (Nigeria, Sierra Leone, Guinea, Senegal, DRC) – and other governments of Africa – mobilize for an effort to establish an FCGH. This would echo African Heads of State action more than a decade ago at an Abuja special summit in 2001 to catalyze the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the AU Abuja commitments on health financing and investment.
The African Union Commission has taken important steps including: activating its Peace and Security mechanism to tackle Ebola; to replenish the African Union Special Emergency Fund and Public Health Emergency Fund, and will facilitate an emergency meeting of the Bureau of Conference of Ministers of Health in September, but longer term institutional and sustainable responses need to be put into place. The FCGH would be a major step in this direction. Preliminary discussions on the FCGH could commence at the Africa Regional Committee of the World Health Organization (composed of Health Ministers) in Benin Republic in early September. To ensure adequate domestic financing, African Ministers of Finance, Planning, and Economic Development must be part of the discussion - as well as Ministers responsible for International Affairs, Development, and Cooperation.
The Ebola outbreak demonstrates that economic growth and regional development can be brought to a shuddering halt if not based on sound investment in health and human and social development. The outbreak will no doubt be on the agenda of the African Union Summit in January and steps must be taken at the highest levels to demonstrate serious African domestic commitment to sustainable health policy and financing alongside global solidarity. Issuing a call for the FCGH would be one such step.
A global legal framework to ensure everyone the right to health would be a transformative step towards global justice. Nearly one hundred health workers have given their lives to protect their communities, growing numbers of ordinary people are suffering a particularly frightening and painful death, and entire communities and countries now live in fear and trepidation. What better way to honor these losses, these traumas, than to bequeath a legacy to secure the future health of humanity?
The authors are steering committee members of the Platform for a Framework Convention for Global Health (Rotimi Sankore and Mayowa Joel are also from the Africa Regional Secretariat of the FCGH Platform). For more about the Framework Convention on Global Health, please visit http://www.globalhealthtreaty.org.