Global health justice, resenha do livro de Lawrence Gostin por Sofia Gruskin

UntitledGlobal Health Law
Lawrence O Gostin
Harvard University Press
The Lancet – This is a crucial time for global health. Negotiations for the post-2015 development agenda are moving towards conclusion, and sad to say political priorities and machinations have resulted in many contentious debates, with the inclusion of sexual and reproductive health and human rights within the Sustainable Development Goals (SDGs) remaining the most controversial. It is impossible to read Lawrence Gostin’s Global Health Law without this scenario in mind.
Global Health Law brings attention to critical aspects of law that anyone interested in global health needs to be concerned about: the major sources of law, and the institutions relevant to implementing them. Gostin makes clear he takes an expansive view of global health law, which he sees as inextricably linked with global governance. Noting their interconnectedness, Gostin sets out his wish to show the potential of law and global governance to dramatically improve health and wellbeing. Without taking issue with his thesis or approach, the book’s title led me to expect a focus on legal frameworks, perhaps the importance of law to delivering health services or achieving health outcomes, or specific ways in which global health law could ameliorate things going forward.
Had this book been called, as suggested in the final chapter, “Global Health with Justice”, I might have expected the wealth of topics and breadth of approach offered, ranging from exploration of many aspects of HIV/AIDS and non-communicable diseases to detailed histories of key global health institutions.
Gostin usefully clarifies the current state of play in some essential areas of global health and provides a handful of excellent detailed case studies.
With respect to the International Health Regulations, the Framework Convention on Tobacco Control, and certain topical subjects such as pandemic influenza the book is a welcome contribution to classroom teaching. Global Health Law is particularly interesting in the places where Gostin not only summarises what is known but provides acute analysis and suggests areas ripe for improvement—whether in calling out the lack of transparency in relation to some of the processes he describes or in articulating the limits of relevant legal frameworks. One might quibble with elements of his analysis or disagree with some of his conclusions, but this is when the book is most alive.
Gostin is not afraid to call out big business—the tobacco, pharmaceutical, food, and alcohol industries—as well as corruption in the myriad places he has seen it. Nor is he reluctant to name problems in the leadership and approach of many of the organisations he works and engages with. All of these are reasons to applaud Gostin’s book.
Gostin posits that the solution to major global health challenges lies in transforming global health law and global governance because of their potential to dramatically improve health and reduce inequalities. But law is a double-edged sword with the power to hurt as much as to heal. For law to have the transformative potential Gostin proposes requires agreement by all stakeholders that a framework grounded in theories of justice and based on human rights law is key to global health. The book ends with a call for a Framework Convention on Global Health, an innovative idea that Gostin has been championing for some time. However, even if a Framework Convention on Global Health gained needed traction, it remains unclear if governments would reach agreement on the rights framework needed for such a treaty to be effective.
As one sees only too clearly in the tenor of the negotiations happening around the SDGs, it has been startling to see the myriad ways the language of rights has been batted around by governments in the negotiation processes. Especially troubling are the issues at stake with the health goal, and in particular ensuring that universal access to sexual and reproductive health and rights make it explicitly into the post-2015 agenda.
This is of critical importance not just for the global health agenda but for people’s wellbeing over the next decades. I am particularly grateful, therefore, to Gostin for his clear articulation of human rights law and noting its central place within global health. There is need for clarity about what is included when anyone, from a commentator to a major institution, invokes the words human rights, and those involved in negotiating our future should be encouraged to adopt an explicit definition of human rights in their deliberations.
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Dennis M Sabangan/epa/Corbis
It is increasingly apparent that many government representatives think of human rights primarily in terms of violations. This aspect is important, one need only consider the history of family planning and the policies and programmes undertaken in the name of population control—including instances of people being coerced to accept contraceptive implants or intrauterine devices, or subjected to forced abortions or sterilisations. These are extreme and egregious violations of human rights and exposing violations wherever they occur must remain an important focus of how we think about human rights, even if they are not explicitly about the law or the legal aspects of rights per se. Although this approach to rights will be of critical importance to monitoring the post-2015 agenda, it has little relevance to setting it.
What is relevant to setting the post-2015 agenda is the way in which human rights law can prevent violations from occurring in the first place. This can happen, for example, at a national level, by ensuring that health services do not discriminate in the access to contraception afforded particular groups, such as people younger than 18 years, ethnic minorities, people living with HIV, sex workers, and transgender or intersex people. Clear articulation of human rights norms and standards can also be used to require improvements in the quality of health services that are provided.
When human rights are integrated into policy-making processes, they can help to ensure that health facilities and services are non-discriminatory and of good quality from the outset, as well as that accountability mechanisms are in place, and their inclusion in global monitoring frameworks can ensure targets are set with appropriate attention to marginalised or discriminated against populations.
Whether the focus is on the legal aspects of rights as articulated by Gostin, rights to prevent violations, or rights to promote health and wellbeing, all have a place in the post-2015 world. However, the differences in how one interprets a rights lens have important implications both globally and within specific country contexts, and have consequences for how people and governments who are not sensitive to rights will understand any global commitments going forward.
The politics within and between countries are crucial to every decision, large and small, that affects global health. The more constrained national spaces are becoming—let alone the larger geopolitical space within which the post-2015 agenda is being negotiated—the more concern there must be about reductionist approaches that threaten to overlook sexual and reproductive health, if not human rights more generally. While certainly the result of politics between countries, importantly donor institutions, including foundations and multilateral and bilateral agencies, have all been key players.
Although Gostin includes a section on the Bill & Melinda Gates Foundation and carefully raises concerns about its unchecked influence in the global health field, I think he misses an opportunity to bring specific attention to its unfettered forays into national and global health spaces, as well as the role of donor institutions more generally in narrowing the scope of the sexual and reproductive health and rights field away from so-called sensitive issues, such as the provision of safe abortion services.
Gostin’s focus on global health justice is key to delivering a post-2015 development agenda that will benefit the world’s poor. Who is vulnerable or disadvantaged clearly will vary between and within countries, but explicit articulation of human rights norms and standards can combat the risk that the new agenda will result in even less attention and support for the health of the most difficult to reach and most marginalised populations in our societies, and what needs to be done to support their ability to use whatever services are on offer.
The SDGs must build on what exists and ensure human rights are systematically and rigorously considered in relation to all components of the global health agenda, including reproductive health, sexual health, comprehensive sexuality education, and safe abortion. The post-2015 goals have the potential to institutionalise rights in global health work, and to transform how rights are understood and addressed. This is a tremendous opportunity, and one that we cannot squander. The stakes are too high. Aligning with Gostin’s view of global health with justice, every effort must be made to ensure that the post-2015 agenda improves a range of health outcomes, including those related to sexual and reproductive health, enhances and contributes to health and wellbeing, and ultimately assures the enjoyment of human rights for all.

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