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2005

The UN and the Responsibility to Practice Public Health

David P. Fidler
Indiana University Maurer School of Law, [email protected]

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The UN and the Responsibility to Practice Public Health
DAVID P. FIDLER"

INTRODUCTION
Analyses of, and proposals for, reform of the United Nations (UN) frequently
present the challenges facing the UN, its member states, and their respective
populations as interconnected problems that all must be addressed effectively for
progress to be made. For example, the UN Secretary-General's High-level Panel on
Threats, Challenges, and Change (High-level Panel) stated that "[p]overty,
infectious disease, environmental degradation and war feed one another in a deadly
cycle."' The argument that poverty, infectious disease, environmental degradation,
and war are interrelated problems of human governance can produce resignation
that the task is impossible. Mounting scepticism about the UN's potential to
contribute significantly to addressing these interdependent crises does little to
temper such resignation. The outcome of the World Summit in September 2005
perhaps has, for some, deepened this pessimism.2
If, as the UN and UN reform strategies argue, poverty, disease,
environmental degradation, and insecurity are intertwined, then a critical element of
any response must involve policies that produce synergistic benefits for each of these
areas of concern. This article focuses on public health as a critical synergistic
strategy on which the future role of the UN in world affairs may depend. As
analyzed below, overlaps between poverty, infectious disease, environmental
degradation, and security point to the improvement of public health nationally and
globally as a critical mission for governance in the twenty-first century. Public
health is at the heart of strategies designed to advance development, tackle
infectious diseases, mitigate environmental degradation, and support peace and
security. Reflecting on the High-level Panel's report, the UN Secretary-General
argued that "[w]e need to pay much closer attention to biological security", and he
supported the High-level Panel's call "for a major initiative to rebuild global public

Professor of Law and Harry T. Ice Faculty Fellow, Indiana University School of Law,
Bloomington, USA; Senior Scholar, Center for Law and the Public's Health, Georgetown
and Johns Hopkins Universities.
Report of the Secretary-General'sHigh-level Panel on Threats, Challenges and Change, A More Secure
World: Our Shared Responsibility, UN GAOR, 59th Sess., Supp. No. 565, UN Doc. A/59
(2004) at para 22, online: United Nations (http://www.un.org/secureworld/ report.pdf>
[A More Secure World]. For analysis of the High-level Panel's report, see Anne-Marie
Slaughter, "Security, Solidarity, and Sovereignty: The Grand Themes of UN Reform"
(2005) 99 A.J.L.L 619 and Marco Odello, "Commentary on the United Nations" High-
Level Panel on Threats, Challenges and Change," (2005) 10J. Conf. & Sec. L. 231.
2 UN General Assembly, 2005 World Summit Outcome, GA Res 60/1, UN GAOR, 60 t Sess.,
UN Doc. AIRES/60/1 (2005), online: United Nations <http://daccessdds.un.org/doc/
UNDOC/LTD/NO5/511/30/PDF/NO551130.plf?OpenElement. [World Summit Outcome].
 JownalofIno Law&ImationlRelationsVo( Vol. 2(1)

health."3 In many ways, the UN reform agenda has at its core the strategic objective
of achieving significant improvements in global public health.
The plausibility of imagining the UN dealing effectively with the
interlinked crises of development, disease, environmental degradation, and security
hinges, therefore, on the plausibility of the UN fostering significant improvements in
global public health. Whether such improvements occur depend on the extent to
which the UN can make what I call the responsibility to practice public health a major
feature of the individual and collective behaviour of states. By connecting the
strategic importance the UN and UN reform efforts have given public health in
addressing problems related to development, disease, environmental degradation,
and security with the attempts to promote a responsibilityto protect as a new norm for
international relations, I outline the component parts of the responsibility to
practice public health, provide examples that support the reality of its formation in
world politics, and consider questions that this responsibility raises. The article
argues that the fate of UN contributions to international relations in the first
decades of the twenty-first century will depend more on the responsibility to
practice public health than on more prominent issues, including Security Council
reform, international law on the use of force, peace building, and even the
responsibility to protect in connection with large-scale, violent atrocities.

PUBLIC HEALTH AT THE CORE OF UN REFORM STRATEGIES

The role of the UN and the need for UN reform are not new topics in international
relations; but never before has public health featured in UN reform proposals as
prominently as it did in the report of the High-level Panel (December 2004) 4 and in
the Secretary-General's own report In Larger Freedom (March 2005). Neither
document contains a section on "public health" because both integrate the need for
public health improvements across the range of problems confronting the UN and
its member states in the twenty-first century. The High-level Panel identified
development, disease, and environmental degradation as critical components of
what it called "comprehensive collective security",6 and the deterioration of public
health globally as a threat to comprehensive collective security and called for the
rebuilding of global public health. 7 The High-level Panel also argued that, in cases of
a suspicious or overwhelming outbreak of infectious disease, the Security Council
should become involved to support actions of the World Health Organization

3 A More Secure World, supra note 1 at viii.

4 Supra note 1.
5 United Nations Secretary-General, In Larger Freedom: Towards Development, Security and
Human Rights for All-Report of the Secretary-General, UN GAOR, 59th Sess., UN Doc.
A/59/2005 (2005), online: United Nations <http://daccessdds.un.org/doc/UNDOC/GEN/
N05/270/78/PDF/NO527078.pdf?OpenElement [In LargerFreedom].
6 A More Secure World, supra note 1 at 14.
7 Ibid. at paras. 66-70.
 The UN and the Responsibility to Practice Public Health

(WHO) and to mandate greater state compliance with multilateral efforts to control
the outbreak.8
In terms of In Larger Freedom, each of the Secretary-General's objectives for
UN reform-freedom from fear, freedom from want, and freedom to live in dignity-
depends on progress in the area of public health. To achieve freedom from want, the
Secretary-General emphasized fulfillment of the eight UN Millennium Development
Goals (MDGs), 9 three of which target specific health problems (child mortality;
maternal health; and the challenges of HIV/AIDS, malaria, and other diseases) and
four of which seek improvement in key social determinants of health (extreme
poverty and hunger; universal primary education; gender equality; and
environmental sustainability).' ° The eighth MDG (develop a global partnership for
development) seeks cooperation with pharmaceutical companies to provide access
to affordable, essential medicines in developing countries." In addition, eight of the
sixteen targets set for achieving the eight MDGs and eighteen of the forty-eight
indicators used to measure progress towards the MDG targets directly relate
to health. 2
The Secretary-General also asserted that ensuring access to sexual and
reproductive health services, providing safe drinking water and sanitation,
controlling pollution and waste disposal, assuring universal access to basic health
services (including services to promote child and maternal health, to support
reproductive health, and to control killer diseases), building national capacities in
science, technology, and innovation, and ensuring environmental sustainability are
national priorities for achieving freedom from want. 3 In addition, strengthening
global infectious disease surveillance and increasing research on the 4special health
needs of the poor are global priorities in realizing freedom from want."
In terms of freedom from fear, the Secretary-General's vision for collective
security included addressing threats presented by "poverty, deadly infectious disease
and environmental degradation", because these threats can have equally catastrophic
consequences as war, conflict, civil violence, organized crime, terrorism, and
weapons of mass destruction. 5 The Secretary-General expressed particular concerns
about security threats from biological weapons and biological terrorism, argumg
that "[o]ur best defence against this danger lies in strengthening public health."

8 Ibid at para. 144.

9 In LargerFreedom,supra note 5 at paras. 28-31.
10 UN Millennium Development Goals, online: <http://www.un.org/millenniumgoals/>.
" Ibid.
12 World Health Organization, Health inthe Millennium Development Goals, online: World
Health Organization <http://www.who.int/mdg/goals/en/>.
13 In LargerFreedom, supra note 5 at paras. 40-41, 43-44, 46, 57.
14 Ibid. at paras. 63-64, 67.
15 Ibid.at para. 78.
16 Ibid.at para. 93.
 Jowlof nwrnatnonalL lw&im RVlol.( Vol. 2(l)

Such strengthening should include bolstering WHO capabilities in the areas of

disease surveillance and response.17 The threat from infectious diseases is such that
the Secretary-General stated that he was ready to call to the attention of the UN
Security Council "any overwhelming outbreak of infectious disease that threatens
international peace and security". 18
The Secretary-General's conception of freedom to live in dignity also
connected with public health. The Secretary-General emphasized that protecting
human rights was important for fulfilling the objectives of development and
security. 9 He further declared that "[t]he right to choose how they are ruled, and
who rules them, must be the birthright of all people, and its universal achievement
must be a central objective of an Organization devoted to the cause of larger
freedom."2 ° Public health supports this right and attribute of human dignity because
"[e]ven if he can vote to choose his rulers, a young man with AIDS who cannot read
or write and lives on the brink of starvation is not truly free."2'
The prominence of public health in the UN reform strategies of the High-
level Panel and the Secretary-General parallels efforts made in other forums to
highlight public health's growing importance to development, security, human
rights, and environmental protection. Arguments about the centrality of public
health to the process of economic development, such as those made by the
Commission on Macroeconomics and Health,23 echo public health's profile in the
MDGs. The rise of infectious disease threats, both naturally occurring and
intentionally caused, has made public health a frequent topic in debates about
national and international security.24 The relationship between public health and

'7 Ibid.
18 Ibid.at para. 105.
19 Ibid. at para. 140.
20 Ibid.at para. 148.
21 Ibid. at para. 15.
22 See, e.g., Empowering People at Risk: Human Security Prioritiesfor the 21st Century (Working
Paper for the Helsinki Process on Globalization and Democracy Report of the Track on
"Human Security") (2005) (making health a priority for the human security agenda),
online: Human Security Gateway <http://www.humansecuritygateway.com/data/
item907994828/view>.
23 Commission on Macroeconomics and Health, Macroeconomicsand Health: Investing in Health
for Economic Development (Geneva: World Health Organization, 2001).
24 See, e.g., Chemical and Biological Arms Control Institute (CBACI) & Center for
Strategic and International Studies International Security Program, Contagion and Conflict:
Health as a Global Security Challenge (Washington, D.C.: CBACI, 2000); Jonathan Ban,
Health, Security, and U.S. Global Leadership (Washington, D.C.: CBACI, 2001); Andrew T.
Price-Smith, The Health of Nations: Infectious Disease, Environmental Change, and Their Effects on
National Security and Development (Cambridge, MA: MIT Press, 2002); Jennifer Brower and
 The UN and the Responsibility to Practice Public Health

human rights-both civil and political rights and economic, social, and cultural
rights-has been a feature of human rights and public health discourse over the past
decade. 25 Analyses of the emergence and re-emergence of infectious diseases identify
environmental degradation as an underlying cause of the appearance and spread of
pathogenic microbes.2 6 In addition, much of the body of international environmental
law was developed to protect, directly or indirectly, human health from the harmful
effects of pollution and other forms of environmental degradation.27
The argument that public health is a core element of leading UN reform
strategies does not claim that public health is the only element of such strategies or
constitutes the "magic bullet" for all global problems. UN reform and the issues it
attempts to address are too complex for reductionist analysis. The argument does
claim, however, that public health represents a critical public good that UN reform
proposals integrated into thinking about development, disease control, security,
human rights, and environmental degradation. Strategies that cut across these areas
are badly needed. The High-level Panel complained, for example, that
"[i]nternational institutions and States have not organized themselves to address the
problems of development in a coherent, integrated way, and instead continue to

Peter Chalk, The Global Threat of New and Reemerging Infectious Diseases:Reconciling U.S. National
Security and Public Health Policy (Santa Monica: RAND, 2003).
25 The importance of civil and political rights to health has arisen with respect to strategies
to fight discrimination created by the HIV/AIDS pandemic (see L. 0. Gostin, The AIDS
Pandemic:Complacency, Injustice, and Unfulfilled Expectations (Chapel Hill: University of North
Carolina Press, 2004), at 61-87 (analyzing human rights and public health in the
HIV/AIDS pandemic)) and to the use of quarantine and isolation to deal with contagious
disease threats, whether intentionally caused or naturally occurring (see, e.g., M.A.
Rothstein et al., quarantine and Isolation: Lessons Learned from SARS (Report from the
Institute for Bioethics, Health Policy and Law, University of Louisville School of
Medicine to the Centers for Disease Control and Prevention, 2003)). In terms of
economic, social, and cultural rights, renewed attention has developed in the past five
years with respect to the right to health, as evidenced by the issuance of a General
Comment on the right to health (see Committee on Economic, Social, and Cultural
Rights, General Comment No. 14: The Right to the Highest Attainable Standard of Health, UN
CECSROR, 22 d Sess., UN Doc. E/C.12/2000/4 (2000)) and the appointment of a Special
Rapporteur on the Right to Health in 2002 by the Commission on Human Rights (see
Office of the UN High Commissioner for Human Rights, Special Rapporteur of the
Commission on Human Rights on the Right of Everyone to the Enjoyment of the Highest
Attainable Standard of Physical and Mental Health, online: Office of the UN High
Commissioner for Human Rights (http://www.ohchr.org/enghsh/issues/health/right/)).
26 Institute of Medicine Committee on Microbial Threats to Health in the 21st Century,
Microbial Threats to Health: Emergence, Detection and Response (Washington, D.C.: National
Academies Press, 2003), at 75-77.
27 D. P. Fidler, "Challenges to Humanity's Health: The Contributions of International
Environmental Law to National and Global Public Health" (2001) 31 Environmental Law
Reporter 10048.
 Jownal ofInen Law&IntmtonalRdahtions Vol. 2(l)
treat poverty,28 infectious disease and environmental degradation as stand-
alone threats.
Public health is a strategic "best buy" for national and UN policies because
it constitutes an integrated public good that benefits the fight against poverty,
diseases, environmental degradation, and insecurity. I have argued elsewhere that
the rise of public health's importance in national and international politics means
that public health itself is becoming an independent marker of good governance.29
The High-level Panel captured the essence of this argument when it concluded that
improving global disease monitoring capabilities was important for not only fighting
emerging infectious diseases and defending against biological terrorism but also
"building effective, responsible States".3" Public health's importance to development,
disease control, environmental protection, and security gives it governance
importance obscured by the traditional "stove piping" of policy areas and by
conventional categorization of public health as an activity belonging in the "low
politics" of international affairs.
This conclusion concerning the strategic importance of public health
necessitates coming to grips with the assertions in the reports of the High-level
Panel and the Secretary-General that the global public health system is, presently,
inadequate for the important role it must play in the areas of development, disease
control, security, human rights, and environmental protection. The High-level Panel
observed that many current infectious disease problems "signify a dramatic decay in
local and global public health capacity." 31 The Secretary-General argued that "[t]he
overall international response to evolving pandemics has been shockingly slow and
remains shamefully underresourced."32 Understanding this state of affairs requires
comprehending the historical relationship between the UN and public health.

THE UN AND PUBLIC HEALTH IN HISTORICAL PERSPECTIVE

Supporting international cooperation on health was one of the functions assigned to
the UN by its Charter.33 The WHO's establishment as the specialized UN agency
with responsibility for international health enhanced the UNs institutional
capabilities in this realm. The WHO Constitution's preamble expressed a vision for
health in the affairs of states and peoples that resonates with public health's central

28 A More Secure World, supra note 1 at para. 55.

29 D.P. Fidler, "Germs, Governance, and Global Public Health in the Wake of SARS,"
(2004) 113J. Clin. Invest. 799.
30 A More Secure World, supra note 1 at para. 69.
31 Ibid. at para. 47.
32 In Larger Freedom, supra note 5 at para. 63.
33 Charterof the United Nations, 26 June 1945, Article 55(b).
 The UN and the Responsibility to Practice Public Health

role in contemporary UN reform strategies.3 4 The preamble linked the enjoyment of

the highest attainable standard of health with international security, economic
development, and human rights.3" The WHO's main focus was on improving health
conditions in developing countries, and it provided support to such countries
through vertical programs (e.g. disease eradication initiatives) and horizontal
strategies (e.g. improving overall health system capacities). The WHO's influence
and prestige reached its peak in the late 1970s when it successfully eradicated
smallpox from the planet and launched its seminal Health for All by the Year 2000
campaign, which sought to ensure that everyone would have access to primary
health care services by 2000.
The 1980s and 1990s witnessed not the march towards health for all but
rather a "twenty years' crisis" for the WHO and the UN system with respect to
global health. Looming largest in this crisis was the emergence of HIV/AIDS into one
of the worst pandemics in human history.36 In addition to HIV/AIDS, the world
experienced the resurgence of new and old infectious diseases, fuelled by a diverse
array of social and economic phenomena, including globalization, antimicrobial
resistance, and environmental degradation.3" Public health experts also saw many
countries beginning to bear a "double burden of disease'-a burden arising from
continued infectious disease problems accompanied by growing rates of non-
communicable diseases associated with, among other things, tobacco
consumption. 38 The establishment of the World Trade Organization in 1995 left
many public health experts thinking that health and its importance to human rights
and social justice in developing nations had been subordinated to the trade and
corporate interests of developed countries.39 Making matters worse was the decline

34 Constitution of the World Health Organization, 22 July 1946, in World Health

Organization, Basic Documents, 40th ed. (Geneva: World Health Organization, 1994)
[WHO Constitution], at 1.
35 Ibid.
36 Joint United Nations Programme on HIV/AIDS (UNAIDS), Report on the Global HIV/AIDS
Epidemic2002 (Geneva: UNAIDS, 2002), at 44 ("Twenty years after the world first became
aware of AIDS, it is clear that humanity is facing one of the most devastating epidemics
in human history.").
37 World Health Organization, World Health Report 1996: Fighting Disease,FosteringDevelopment
(Geneva: World Health Organization, 1996), at v (WHO Director-General warning that
the world stands "on the brink of a global crisis in infectious diseases.").
38 World Health Organization, World Health Report 1997: Conquering Suffering, Enriching
Humanity (Geneva: World Health Organization, 1997), at v (The WHO Director-General
argues that "[i]n the battle for health in the 21st century, infectious diseases and chronic
diseases are twin enemies that have to be fought simultaneously on a global scale.").
39 For analyses of the relationship between trade and health, see World Health
Organization and World Trade Organization, WTO Agreements & Public Health:A JointStudy
by the WHO and the WTO Secretariat (Geneva: World Health Organization, 2002); E.R.
Shaffer, et al., "Global Trade and Public Health," (2005) 95 Amer. J. Publ. Hlth. 23.
 JournaloflniontLw Int aionaRations Vol. 2(l)
in the WHO's effectiveness and influence precipitated by a number of factors,
including leadership problems at its Geneva headquarters. 40 Topping off the twenty
years' crisis was the realization that nuclear, chemical, and especially biological
terrorism was a growing threat, which also highlighted the extent to which national
and international public health capabilities were inadequate.41
This potted history of the relationship between the UN and public health
until the end of the twentieth century provides some background on the
discrepancy between the critical function leading UN reform strategies have given
public health and the reality of public health on the ground. This discrepancy raises
questions about the plausibility of the UN contributing to the significant
improvements in global public health that UN reform proposals have argued are
necessary. If the twenty years' crisis tells the tale of UN intergovernmentalism on
public health being overwhelmed, what can we realistically expect from arguments
that the international community must elevate public health as an integrated public
good to support the achievement of security, development, disease control, human
rights, and environmental protection?

PUBLIC HEALTH AND THE RESPONSIBILITY TO PROTECT

Assessing the prudence and feasibility of placing global public health at the heart of
UN acivities in the twenty-first century is a task far too complex for the space
allotted to this article, but a preliminary sketch of important issues can be
attempted. The prominence of public health in the leading UN reform proposals,
combined with public health's rise on the agenda of world politics more generally,
point conceptually to the need for a principle of individual and collective
responsibility to improve national and global public health-the responsibility to
practice public health. This responsibility advocates individual and collective
actions that derive from public health theory and practice.
The concept of the responsibility to practice public health brings to mind
the growing prominence of the emerging norm called the "responsibility to protect."
Both the High-level Panel and the Secretary-General argued that the UN and its
member states must embrace and act upon the responsibility to protect. 42 As
elaborated by the Secretary-General, the responsibility to protect
lies, first and foremost, with each individual State, whose primary
raison d'tre and duty is to protect its population. But if national

40 F. Godlee, "WHO in Crisis," (1994) 309 Br. Med. J. 1424, at 1427-1428 (arguing that
WHO "is suffering a crisis of confidence, both internally and internationally" and is
"entering a period of intense soul searching and internal upheaval.").
41 For example, the WHO responded to this growing threat by updating its 1970 report on
the health aspects of chemical and biological weapons. See World Health Organization,
Public Health Response to Biological and Chemical Weapons: WHO Guidance (Geneva: World
Health Organization, 2004).
42 A More Secure World, supra note 1 at para. 203; In LargerFreedom, supra note 5 at para. 135.
 The UN and the Responsibility to Practice Public Health

authorities are unable or unwilling to protect their citizens, then

the responsibility shifts to the international community to use
diplomatic, humanitarian and other methods to help protect the
human rights and well-being of civilian populations.
The support in the UN reform strategies for the responsibility to protect
continues the work done by others, most prominently the International Commission
on Intervention and State Sovereignty (ICISS). 4 4 As elaborated by ICISS, the
responsibility to protect is based on the premise that state sovereignty means that
the state itself has primary responsibility for the protection of the people living in its
territories.45 When a state is unwilling or unable to stop or avert serious harm from
affecting its population as a result of internal war, insurgency, repression, or state
failure, then the principle of non-intervention in international law yields to the
international responsibility to protect.46 This international responsibility embraces
three component responsibilities: to prevent crises that put populations at risk; to
react to situations of compelling human need with appropriate measures; and to
rebuild to ensure that the harms to the population do not arise again. 4' The
responsibility to protect provides the legitimacy for military intervention by the
international community in extreme cases when peaceful diplomatic or coercive
measures, such as sanctions, have failed to stop the suffering of the population in
question.4 8 Support for the responsibility to protect from the High-level Panel, the
Secretary-General, and the World Summit basically follows the ICISS formulation of
the responsibility to protect. 49
Neither the High-level Panel nor the Secretary-General connected the
emerging norm of the responsibility to protect with their respective arguments on
the critical importance of public health to twenty-first century humanity.
Consistent with the approach of the ICISS, they focused the responsibility to
protect on large-scale, violent atrocities, such as genocide, ethnic cleansing, and
crimes against humanity.5 0 The World Summit's outcome statement also focused the
responsibility to protect on such atrocities.5

43 In LargerFreedom,supra note 5 at para. 135.

44 International Commission on Intervention and State Sovereignty, The Responsibility to
Protect (Ottawa: International Development Research Centre, 2001) [ICISS].
45 Ibid. at paras. 2.14-2.15.
46 Ibid at para. 4.1.
47 Ibid. at para. 2.32.
48 Ibid. at para. 4.10.
49 A More Secure World, supra note 1 at para. 203; In Larger Freedom,supra note 5 at para. 135;
World Summit Outcome,supra note 2 at paras. 138-139.
50 A More Secure World, supra note 1at para. 203; In LargerFreedom,supra note 5 at paras.134-135.
51 World Summit Outcome, supra note 2 at para. 139.
 JournalofInternationalLaw egInternationalRelations Vol. 2(l)
The relevance of the concept of individual and collective responsibility to
protect to the massive human suffering associated with the global failures in public
health is, however, clear.12 The UN reform documents and other UN activities
communicate the enormity of the public health threats and harms populations in
both developed and developing countries face in the early twenty-first century-
HIV/AIDS, tuberculosis, malaria, malnutrition, unsafe water, lack of sanitation,
antimicrobial resistance, and emerging infectious diseases such as SARS and avian
influenza. Large-scale atrocities involving violence are a horrific problem requiring
the UN's attention; but such atrocities do not encompass all the severe suffering
populations endure because of the unwillingness or incapability of governments to
protect their populations from serious, foreseeable, and often preventable harms.
The depressing global morbidity and mortality statistics connected to HIV/AIDS,
tuberculosis, and malaria alone reveal a fundamental failure by states, individually
and collectively, to protect the well-being of human populations from pathogenic
threats. To these macabre statistics must be added the misery and death caused by
diseases related to poverty and environmental degradation. Reflecting on the grim
statistics connected with communicable diseases in connection with the High-level
Panel's emphasis on human security, Slaughter asked, "If human security is our aim,
why on earth should 53
we privilege the saving of lives from violence over the saving of
lives from disease?"

THE ELEMENTS OF THE RESPONSIBILITY TO PRACTICE PUBLIC HEALTH

Both the logic of the High-level Panel's and the Secretary-General's reasoning on the
strategic importance of global public health and the brutal realities of disease on the
ground in the world today point to the need to formulate a specific responsibility to
practice public health. Formulation of this responsibility borrows from thinking
developed with respect to the responsibility to protect and from the basic functions
of public health practice. These functions are (1) surveillance of disease and health
trends in populations; and (2) interventions to address the introduction or spread of
health risks in populations. Monitoring population health through surveillance
provides the data that allows interventions to be made. Surveillance is, thus, critical
to effective interventions. Similarly, surveillance without effective intervention does
not protect public health.
Interventions come in three forms. Prevention interventions prevent health
risks from reaching populations. Treatment of water supplies to eliminate pathogens
or contaminants and disease eradication campaigns are examples of prevention

52 Odello, supra note 1 at 241 (This "emerging rule" concerning the responsibility to protect
seems to be applicable in cases of genocide, ethnic cleansing and gross violations of
human rights, but there are no clear answers when we have to deal with pandemic
disease, famine, floods, etc....Owing to the fact that the [High-level Panel] Report deals
with a wide range of new "threats," it could be considered that the responsibility to
protect involves those situations as well.").
5 Slaughter, supra note 1at 624.
 The UN and the Responsibility to Practice Public Health

interventions. Protectioninterventions protect populations from health risks that will

reach human populations. The idea behind protection interventions is to "harden the
target"-strengthen a population's resilience against health risks. A classical
example of a protection intervention is vaccination, such as vaccination against
childhood diseases or seasonal influenza. Response interventions are actions taken to
control the impact on population health from risks that do affect people. Such
interventions can involve treating sick individuals (e.g. antiretrovirals for people
infected with HIV) or containing the sources of the health risks (e.g. isolation or
quarantine of contagious persons or addressing the source of toxic pollutants).
The public health functions of surveillance and intervention apply whether
the health context is entirely internal or affects more than one country. These
functions are transarchical because they apply whether the political context is
hierarchical, as prevails within states, or anarchical, as exists among states.
Surveillance and intervention have this transarchical quality because they are based
in epidemiology-the science of the study and control of diseases. The only
epidemiological path to better national and global public health leads through
surveillance and intervention.
Combining the basic principles of the responsibility to protect 54 with the
basic functions of public health produces the core features of the responsibility to
practice public health:
0 Basicprinciplesof the responsibilityto practicepublic health
1. State sovereignty implies responsibility, and the primary responsibility
for the protection and promotion of the health of the people lies with the
state itself.
2. Where population health is suffering serious chronic or acute harm and
the state in question is unable or unwilling to mitigate or eliminate the
harm, the principle of non-intervention in international law yields to the
international responsibility to practice public health.
3. The international responsibility to practice public health authorizes the
international community of states and non-state actors to take
extraordinary measures to address severe disease situations that involve the
cross-border movement and spread of disease organisms or agents.
e Foundationsof the responsibilityto practicepublic health
The foundations of the responsibility to practice public health, as a
requisite principle for the international community of states and non-state
actors, stem from:
1. The obligations to populations inherent in the concept of sovereignty.
2. The necessity for public health, as a "public good", to be the primary
responsibility of governments.

ICISS, supra note 44 at XI.

 JownlofIn LawIotatl Rekitions Vol. 2(1)

3. The obligations concerning international cooperation for health found in

the UN Charter.
4. The responsibilities linked to human health expressed by the WHO
Constitution.
5. Specific legal obligations related to the protection of human health found
in international legal instruments.
6. The developing practice of states, regional organizations, the UN
(especially WHO and including the Security Council), and international
non-governmental organizations with respect to health promotion and
protection.
0 Elements of the responsibilityto practicepublic health
The national and international responsibility to practice public health
encompasses four specific responsibilities:
1. The responsibility to monitor: to conduct surveillance of population
health and determinants of health to determine the sources of disease
threats and the nature of specific disease harms.
2. The responsibility to prevent: to intervene to prevent disease organisms
or agents from adversely affecting population health.
3. The responsibility to protect: to intervene to protect populations from
disease organisms or agents present in societies.
4. The responsibility to respond: to intervene to react to situations in which
disease organisms or agents cause outbreaks or epidemics of diseases in
populations.

RESPONSIBILITY PRINCIPLES AND THE SOCIAL CONTRACT CHALLENGE TO

WESTPHALIANISM

As with the responsibility to protect, the responsibility to practice public health is a

norm that overrides the principles of sovereignty and non-intervention when the
state fails to live up to its responsibilities. These "responsibility principles" reject
Westphalian assumptions and practices grounded in the idea of sovereignty as
supreme control over territory and the people and activities in it. As the ICISS
stated, the responsibility to protect involves re-characterizing sovereignty by
moving "from sovereignty as control to sovereignty as responsibility in both internal
functions and external duties."5 5 Westphalianism created two levels of society with
little interaction between them: (1) domestic society subject to sovereignty and off-
limits to other states under international law; and (2) international society, or the
society of states created by their interactions with each other in the context of
anarchy (including interactions in diplomacy, trade, and war). Responsibility
principles reject this bifurcation and conceive of world politics along the lines of a

55 ICISS, supra note 44 at para. 2.14.

 The UN and the Responsibility to Practice Public Health

social contract with dynamics more reminiscent of federal governance systems than
anarchical Westphahanism.
The social contract nature of the responsibility to practice public health
can be illustrated through an analogy to public health in federal systems, such as the
United States. Under the US Constitution, the states of the Union have primary
responsibility (that is, they have sovereignty) over public health.56 When health
threats escape the borders of a state, or the state is unwilling or unable to address a
serious health problem, the federal government's responsibility in the area of public
health is triggered. The federal government's role derives part of its scope from the
capabilities of the state governments on public health. The weaker or more
vulnerable those state-level capabilities are, the more involved the federal
government must become. Developments in the last twenty to thirty years have
produced a federalization of public health power in the United States because state-
level capabilities increasingly have to be supported and led by the federal
government exercising its constitutional authority. '
The same dynamic operates in international relations and helps explain the
rise of public health as a political issue in world politics in the last ten to fifteen
years. Globalization and other developments have increasingly stressed the ability of
individual states to handle threats to population health, especially in the area of
infectious diseases. The nature, speed, and scope of many health threats has placed
more demands on states' foreign policies, the capabilities of international
organizations, and the resources of NGOs and multinational corporations than ever
before in history.5 8 As an epidemiological matter, the basic functions of public health
cannot operate in this day and age under the old Westphalian framework,
particularly its strong principle of non-intervention, which rendered sovereignty
virtually sacrosanct. The world confronts the need to adjust to the globalization of
public health governance.
At the same time as the responsibility to practice public health pierces the
Westphalian veil of sovereignty, it demands that the "international community"
better organize itself to shoulder effectively the globalization of public health
governance. The twenty years' crisis revealed that the UN and its intergovernmental
public health capabilities proved a poor match for the challenges that emerged after
the halcyon days of the late 1970s, when WHO basked in the triumph of smallpox's
eradication and the launch of the Health for All campaign. The principle of the
responsibility to protect reflects exactly the same dynamic: the principle demands
that the international community be ready, willing, and able to intervene, by

56 L. 0. Gostin, Public Health Law: Power, Duty, Restraint (Berkeley: University of California
Press, 2001), at 25-59 (analyzing how federalism structures public health governance in
the United States).
57 D. P. Fidler, "Constitutional Outlines of Public Health's "New World Order" (2004) 77
Temple L. Rev. 247, at 250-257 (analyzing the federalization of public health in U.S.
constitutional governance).
58 Ibid at 257-272 (analyzing the globalization of public health governance).
 JoWnaloflnta-nationalLaw nenationalReations Vol. 2(l)

military force if necessary, to stop large-scale, violent atrocities. Social contract

politics in the context of anarchy is expensive, not only in terms of sovereignty costs
but also in the material capabilities that must be built nationally, internationally,
and globally to address globalized forces and threats effectively.

EVIDENCE OF THE EMERGING RESPONSIBILITY TO PRACTICE PUBLIC HEALTH

The responsibility to protect remains dogged by scepticism about the reality behind
the rhetoric. No doubt some readers understood the conceptual framing of the
responsibility to practice public health but wondered whether, in light of what
happened to the UN and the WHO during the twenty years' crisis, this
responsibility is merely a figment of my imagination. In this section, I argue that
evidence exists to support the claim that the responsibility to practice public health
is an emerging feature of twenty-first century international relations.

The Millennium Development Goals

As already indicated, the MDGs comprise a central objective in UN thinking about
global politics in the early twenty-first century; but they also embody more
specifically key aspects of the responsibility to practice public health. The MDGs
operate on the basis of population surveillance that provides the epidemiological
data necessary to assess the adequacy of prevention, protection, and response
interventions. Progress towards each of the MDGs' health-related goals, targets, and
indicators can only be assessed by empirically monitoring the health of populations
around the world. The health-related targets of the MDGs are assessed by collecting
information on specific health indicators. The data collected allows experts to
develop a picture for what kind of interventions are needed and what interventions
may not be working. As the WHO commented, "MDG monitoring has for the first
time made available a reliable and comparable set of country health statistics-
information which is useful for both policy-making and advocacy purposes."59 The
MDG process is, in fact, a grand epidemiological project both horizontally across the
world's regions and vertically within individual countries for both direct public
health problems (for example, child mortality, maternal health, and infectious
diseases) and key social determinants of health (for example, poverty, hunger,
education, gender equality, and environmental sustainability).

Revitalization of WHO
Part of the twenty years' crisis for UN activities on global public health related to
problems the WHO experienced during the 1980s and 1990s that limited its
effectiveness and lessened its influence. The last ten years have seen, however, efforts
made to revitalize the WHO so that it can better fulfill its mandate as the
specialized agency of the UN for public health. This revitalization process is too

59 World Health Organization, Health and the Millennium Development Goals (Geneva: World
Health Organization, 2005), at 14.
 The UN and the Responsibility to Practice Public Health

complex to try to capture comprehensively here, but it involves strategies to make

the WHO more responsive to the problems the globalization of public health
presents to its member states concerning both communicable and non-
communicable diseases. Indications of this revitalization can be found, for example,
in the manner in which the WHO (1) supported the MDGs; 60 (2) reshaped its
approach to global surveillance and response to infectious diseases, the potential of
which was demonstrated in the successful WHO-led effort to control the dangerous
global outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003; 61 (3)
provided leadership on combating the globalization of non-communicable diseases,
especially the WHO-led efforts to adopt the Framework Convention on Tobacco
Control62 and to develop a global strategy for fighting the spread of obesity-related
diseases; 63 and (4) recognized the need to create partnerships with other
international organizations (e.g. World Bank) 64 and non-state actors (e.g. Gates
Foundation) on a range of global health problems.

The New International Health Regulations

The new International Health Regulations adopted in May 2005 by the WHO (IHR
2005)65 constitute particularly compelling evidence of the emergence of the
responsibility to practice public health. For many reasons, the IHR 2005 constitute a
historic development in the use of international law for public health purposes; and I
explore this seminal international legal regime in detail elsewhere. 66 In terms of this
article, the IHR 2005 are important because they embody, in an international legal
agreement that will become binding on consenting states parties in 2007, the
responsibility to practice public health in a manner never before seen in the long
history of public health's relationship with international law.

60 Supra note 12.

61 See D. P. Fidler, SARS, Governance, and the Globalization of Disease (Basingstoke: Palgrave
Macmillan, 2004).
62 World Health Organization, Framework Convention on Tobacco Control (2005) online: World
Health Organization <http://www.who.int/tobacco/framework/fctcen.pdf).
63 World Health Organization, Global Strategy on Diet,Physical Activity, and Health: Obesity and
Overweight (2004) online: World Health Organization <http://www.who.int/
dietphysicalactivity/publications/facts/obesity/en!).
64 See e.g. World Health Organization, The Civil Society Initiative, online: World Health
Organization <http://www.who.int/civilsociety/en/index.html>.
65 World Health Assembly, Revision of the InternationalHealth Regulations, W1HA58.3, 23 (2005)
[IHR 2005].
66 D. P. Fidler, "From International Sanitary Conventions to Global Health Security: The
New International Health Regulations" (2005) 4 Chinese J.I.L. 325.
 JouraloflntanabnalLaw C IntenanalRelatn Vol. 2(l)

Starting in the latter half of the nineteenth century, states began to use
international law to facilitate cooperation on infectious disease control.67 The
approach crafted for the early international sanitary conventions of the late
nineteenth and first half of the twentieth century was, however, very limited in
terms of the diseases to which the treaties applied and the positive obligations of
states within their own territories. This Westphalian approach prevailed because
the major purpose of these treaties was to minimize the impact of national
quarantine regulations on flows of international trade. The international sanitary
conventions were as much or more trade agreements as they were instruments
focused on public health. The WHO continued this approach when it adopted the
International Sanitary Regulations in 1951,68 which the WHO later renamed the
International Health Regulations in 1969 (IHR 1969).69
The twenty years' crisis demonstrated, beyond any doubt, how bankrupt
the approach embodied in the IHR 1969 was in the context of global public health in
the last decades of the twentieth century. State parties routinely violated the IHR
1969, and the IHR 1969 did not even apply to the emergence and re-emergence of
many infectious diseases worrying global public health experts in the 1980s and
1990s.70 The WHO began the process of revising and updating the IHR 1969 in
1995;71 and the outbreak and containment of SARS accelerated the revision process,
eventually producing a radically different international legal regime for global public
health in the form of the IHR 2005.
The IHR 2005 contain a host of provisions that connect directly to the
responsibility to practice public health. First, the scope of the IHR 2005 covers both
communicable and non-communicable diseases regardless of origin or source.7 2 The
IHR 1969 and its predecessor regimes never ventured beyond a short list of naturally
occurring communicable diseases, the spread of which was associated with
international trade and travel. The IHR 2005's comprehensive disease scope means
that the obligations on surveillance and intervention in this regime are now driven
by global public health needs, not the trade interests of the great powers.

67 For an overview of the use of international law on infectious disease control during this
historical period, see D. P. Fidler, International Law and Infectious Diseases (Oxford:
Clarendon Press, 1999), at 21-57.
68 International Sanitary Regulations, 25 May 1951, 175 UNTS 214.
69 World Health Organization, InternationalHealth Regulations (1969) (3rd ann. ed.) (Geneva:
World Health Organization, 1983) [IHR 1969].
70 For analysis of the failure of the IHR 1969, see Fidler, supra note 67 at 65-71.
n World Health Assembly, Revision and Updating of the International Health Regulations,
WHA48.7 (1995).
72 IHR 2005, supra note 65 at Article 1.1 (defining "disease" to mean "an illness or medical
condition, irrespective of origin or source, that presents or could present significant
harm to humans").
 The UN and the Responsibility to Practice Public Health

Second, the IHR 2005 require all state parties to develop core public health
capacities within their respective territories within a set period of time in order to
engage in surveillance and to undertake appropriate interventions with respect to
serious disease events within their own territories or the territories of other states.73
Nothing in the long history of international law on public health approaches these
obligations to build and maintain core surveillance and intervention capabilities at
the state level. The IHR 1969 only mandated, for example, the maintenance of
minimal public health capabilities at ports of entry and exit for trade and travel.
Third, the IHR 2005 require state parties to notify the WHO of all disease
events that may constitute a public health emergency of international concern.74
This notification duty functions as part of the global surveillance system the IHR
2005 supports, and the duty goes far beyond the IHR 1969's requirement for state
parties to report outbreaks of less than a handful of infectious diseases. The IHR
2005 also breaks significantly with the IHR 1969 by empowering the WHO to
collect and utilize surveillance information obtained from NGOs and other non-
state sources, such as the media.75 This provision feeds into the WHO's Global
Outbreak Alert and Response Network (GOARN),76 through which WHO
harnesses the power of information technologies to state and non-state actor
participation in global public health to create a more comprehensive, rapid, and
effective surveillance system than anything seen before in the history of
international health cooperation. The IHR 2005 also permits the WHO to seek
verification from a state party about information it has received from sources other
the state party in question, and the IHR 2005 requires state parties to respond to
WHO verification requests.77 This surveillance system drastically reduces the
incentives and the possibilities states formerly had to cover-up serious outbreaks of
diseases in their territories.
Fourth, the IHR 2005 grant the WHO the authority to declare whether a
disease event actually constitutes a public health emergency of international
concern. 78 This important decision, which could carry serious political and economic
consequences for states, is not left in the hands of sovereign states. If the WHO
declares a public health emergency of international concern, it is empowered to
promulgate tempora7 recommendations on how state parties should respond to
such an emergency. 7 These recommendations would pinpoint what constitute
sound public health interventions vis-a-vis the public health emergency of

73 Ibid at Articles 5.1,13.1, and Annex 1.

74 Ibid. at Article 6.1.
75 Ibid at Article 9.1.
76 World Health Organization, Global Outbreak Alert and Response Network, online: World
Health Organization <http://www.who.int/csr/outbreaknetwork/en/>.
7 IHR 2005, supra note 65 at Articles 10.1-10.2.
78 Ibid. at Article 12.
79 Ibid. at Article 15.
 JowaofInn n ia
tInwonalRlationsVo.() Vol. 2(1)

international concern. State parties deviating from WHO recommendations or other

provisions in the IHR 2005 on appropriate interventions must justify their actions
by providing relevant information to the WHO.80 Each of these new WHO
authorities reflects the logic of the globalization of public health governance because
they acknowledge the need to shift some governance authority and responsibilities
from the national to the international level.
Fifth, the IHR 2005 requires that all public health interventions taken to
deal with disease events and public health emergencies of international concern be
not more restrictive of trade and not more intrusive for individuals than is necessary
to achieve the level of health protection sought.8 These obligations seek to ensure
that trade interests and human rights are respected as much as possible when states
and the WHO address serious international disease threats and mirror the principle
in the responsibility to protect that action "should always involve less intrusive and
coercive measures being considered before more coercive and intrusive ones
are applied."82
This description of the IHR 2005 should help make clear why the
Secretary-General and the World Summit supported either the revision of the IHR
or the IHR 2005 itself.8 3 The IHR 2005 expresses the necessity for the individual and
collective responsibility to practice public health as clearly as the MDGs. The new
Regulations represent a milestone for the UN system in advancing global public
health in international law. The acceptance by states of the IHR 2005's (1) much
more demanding surveillance and intervention obligations at the national level; (2)
empowerment of the WHO in terms of surveillance and intervention; and (3)
involvement of non-state actors in governance of global public health, all in binding
international law, reveals a level of consensus about the importance of collective
action on global public health that surpasses any previous treaty or non-binding
instrument concerning public health.

Security Council Involvement in Global Public Health

Another indicator of the emergence of a responsibility to practice public health can
be found in the Security Council's involvement in global public health issues. The
Security Council has, twice in the past five years (2000 and 2005), convened to
address the threat HIV/AIDS poses to international peace and security.8 4 Before the
first Security Council meeting on HIV/AIDS in 2000, the Council had never before

8o Ibid. at Article 43.

81 Ibid at Articles 17(d), 31.2, and 43.1.
82 ICISS, supra note 44 at XI.
83 In LargerFreedom, supra note 5 at para. 64; World Summit Outcome,supra note 2 at para. 57.
84 See UNSC Res 1308 (2000), UN Doc. S/Res/1308 (2000); and Security Council Presidential
Statement Recognizes "Significant Progress" Addressing HIV/AIDS Among Peacekeepers, But Says
Many Challenges Remain, SC/8450 Press Release, 18 July 2005, online: United Nations
<http://www.un.org/News/Press/docs/2005/sc8450.doc.htm>.
 The UN and the Responsibility to Practice Public Health

become seized of a matter pertaining to the threat diseases pose to international

peace and security. These meetings have set a precedent that the Security Council's
mandate to maintain international peace and security encompasses severe disease
threats that appear to be escaping the control of sovereign states to the serious
detriment of international relations.
Both the High-level Panel and the Secretary-General took this precedent
one step further by advocating for Security Council involvement in situations
involving overwhelming outbreaks of infectious diseases.85 These proposals are the
public health equivalent of the arguments under the responsibility to protect that
the Security Council should intervene in connection with large-scale, violent
atrocities relevant states appear unable or unwilling to address. The proposals also
complete the logic of the globalization of public health governance by invoking the
power of the international body with the most comprehensive governance authority
found in international law.

QUESTIONS ABOUT THE RESPONSIBILITY TO PRACTICE PUBLIC HEALTH

Identifying the responsibility to practice public health as a strategic principle

conceptually in UN reform analyses and developments in global public health
underscores the importance of this responsibility to the UN, its member states, and
non-state actors in contemporary world politics. The strategic importance of global
public health to the future of the UN and its role in world politics invites closer
scrutiny of the responsibility to practice public health. A comprehensive critique is
beyond the scope of this article, but a few words are needed to emphasize that this
responsibility confronts conceptual, political, and practical challenges that render it
suspect, fragile, and incomplete. This section briefly mentions critical questions the
emergence of the responsibility to practice public health raises.
To begin, one could ask whether the responsibility to practice public health
adds anything conceptually to the generally recognized (but often ignored)
responsibilities already connected with development, disease control, and
environmental degradation. The Secretary-General observed that "[e]ach developing
country has primary responsibility for its own development," which responsibility
developed countries support with undertakings on "development assistance, a more
development-oriented trade system and wider and deeper debt relief."86 The
preamble of the WHO Constitution contains propositions on the responsibilities of
states for the health of their peoples.8" No end of documents support the principle
that states must be environmentally responsible and make progress toward
sustainable development.

85 A More Secure World, supra note 1 at para. 144; In LargerFreedom, supra note 5 at para. 105.
86 In LargerFreedom, supra note 5 at para. 32.
87 WHO Constitution, supra note 34 at 1 ("Governments have a responsibility for the health
of their peoples, which can be fulfilled only by the provision of adequate health and
social measures.").
 JounaloflntenationalLaw9-InternatonalRelaions Vol. 2(1)
More sharply, questions could be raised about the traction such general
responsibilities concerning development, public health, and environmental
protection create in international relations. The Secretary-General followed his
description of the development responsibilities of developing and developed
countries by soberly stating that, "All of this has been promised but not delivered.
That failure is measured in the rolls of the dead-and on it are written millions of
new names each year."88 The need for UN reform plans to identify public health as a
strategic, cross-cutting approach suggests that the WHO Constitution's sentiments
on public health responsibilities have not historically taken deep root in the
international system. In terms of responsibilities associated with sustainable
development, the Secretary-General expressed his concerns for development efforts
"if environmental degradation and natural resource depletion continue unabated.""
Scepticism about the responsibility to practice public health may also
underscore the continuing failure of national governments and the "international
community" to allocate the resources needed to facilitate the kind of surveillance
and intervention capabilities required by the globalization of public health
governance. The UN reform strategies" emphasis on development, disease control,
and environmental degradation produced no new commitments of resources at the
World Summit to fund a cross-cutting approach based on global public health (or
any other approach for that matter). Even the remarkable governance changes made
in the IHR 2005 are tarnished because the Regulations provide neither resources nor
even a strategy for funding the building and maintenance of the national and
international surveillance and response capabilities at the heart of this new regime.
The manner in which the responsibility to practice public health is
unfolding may also draw concerns from public health theory and practice. From a
public health perspective, the contrast between the global governance breakthrough
in the new IHR and the perceived insufficient progress made on health-related
MDGs reveals dynamics that may privilege reactive policies concerning mobile and
dangerous cross-border disease events to which developed countries are vulnerable
(for example, SARS, avian influenza, pandemic influenza) over preventive and
protective governance for threats that kill millions in developing countries but do not
necessarily threaten the territories or interests of the rich countries (for example,
childhood mortality from malnutrition, diarrhoeal diseases, and lack of access to
vaccines for childhood diseases; maternal mortality caused by inadequate access to
reproductive health services; and sickness and death related to local water and
air pollution).
This kind of skewed trajectory for global health governance is not
sustainable because continued failure to prevent and protect (as the MDGs attempt
to do) feeds the deadly cycle that exists between poverty, disease, environmental
degradation, and insecurity. Governance mechanisms that are merely reactive and

88 In LargerFreedom, supra note 5 at para. 32.

89 Ibid. at para. 57.
 The UN and the Responsibility to Practice Public Health

attempt only to manage crisis after crisis spawned by this deadly cycle are not
resilient. The globalization of public health governance needs the responsibility to
practice public health to generate as much governance resiliency as possible
nationally and globally.

CONCLUSION

The plausibility of the UN contributing to the interlinked crises of development,

disease, environmental degradation, and insecurity depends on the effectiveness of
the UN's future efforts to strengthen global public health. The UN's challenge is to
embed the emerging principle of the responsibility to practice public health more
deeply into the individual and collective behaviour of states, international
organizations, and non-state actors. The UN has a better chance focusing on this
challenge than on many other, more high-profile features of UN reform debate, such
as increasing the size and composition of the Security Council, the need to change
the international law on the use of force, and the responsibility to protect triggered
by large-scale, violent atrocities. 90 Each of these reform areas derives from the UN's
mission to help save present and succeeding generations from the scourge of war;
but the prospects for increasing the UN's contributions to international relations in
the twenty-first century are dimmest with respect to making the Security Council
both more legitimate and effective by increasing its size, achieving genuine
consensus on the international law on the use of force, and advancing a consistent
application of the responsibility to protect.
The World Summit basically, if in a rather uninspiring way, accepted the
vision of the UN reform documents that makes global public health improvements
critical to mitigating and perhaps reversing the deadly cycle produced by the
interdependence of poverty, disease, environmental degradation, and insecurity.
Underpinning this vision is the emerging norm of the responsibility to practice
public health. Visions and norms are necessary but not sufficient to achieve the
governance resiliency required in the face of these mutually reinforcing threats to
human well-being. Despite stressing how critical improving global public health
will be for advancing humanity's values and interests in the twenty-first century,
oddly neither the High-level Panel nor the Secretary-General made any
recommendations or proposals for making the existing institutions that work on
global public health more effective. The closest proposal was the Secretary-General's
argument that an initiative on streamlining governance of the global environment
was needed. 91 Along the lines of a Peacebuilding Commission or integrating global
environmental governance, an important contribution could have been made by
establishing a Healthbuilding Commission or a global health governance initiative to
transform the responsibility to practice public health from a fragile, emerging norm

90 Slaughter, supra note 1 at 624 (comparing the task of preventing threats from violence
and threats from disease and arguing that "preventing disease is likely to be the easier
challenge").
InLargerFreedom,supra note 5 at para. 212.
62 JournaloflternanionalLaw&IntmationalRdations Vol. 2(1)

into a living principle of human governance. This transformation remains the UN's
burden and opportunity.