Global Health Governance and the Challenge of Chronic,Non-Communicable Disease

Beaglehole R. Ebrahim S. Reddy S. Voûte J. , on behalf of the Chronic Disease Action Group, “Prevention of Chronic Diseases: A Call to Action,” The Lancet 370, no. 9605 (2007): 2152–2157.

World Health Organization, Preventing Chronic Disease: A Vital Investment , Geneva, 2005, at 2, available at <http://www.who.int/chp/chronic_disease_report/en/> (last visited June 11, 2010) (hereinafter WHO).

Id., at 57 (rising from 35 million to 41 million).

Mathers C. Loncar D. , “Projections of Global Mortality and Burden of Disease from 2002 to 2030,” PLoS Medicine 3, no. 11 (2006): 2011–2030, at 2022. By 2001, however, non-communicable diseases accounted for 59% of global mortality; nearly 54% of deaths in low-and middle-income countries, and 87% of deaths in high-income countries.

WHO, World Health Statistics 2008, Geneva, 2008, at 29, available at <http://www.who.int/whosis/whostat/2008/en/index.html> (last visited June 11, 2010).

Id., at 29.

Id., at 18. See also Yach D. Wipfli H. Hammond R. Glantz S. , “Globalization and Tobacco,” in Kawachi I. Wamala S. , eds., Globalization and Health (Oxford: Oxford University Press, 2007): At 39–67.

Mathers C. Loncar D. , “Projections of Global Mortality and Burden of Disease from 2002 to 2030,” PLoS Medicine 3, no. 11 (2006): 2011–2030.

Hossain P. Kawar B. Nahas M. , “Obesity and Diabetes in the Developing World -A Growing Challenge,” New England Journal of Medicine 356, no. 3 (2007): 213–215.

Wild S. Roglic G. Green A. Sicree R. King H. , “Global Prevalence of Diabetes: Estimates for the Year 2000 and Projections for 2030,” Diabetes Care 27, no. 5 (2004): 1047–1053.

Res G.A. , 61/225, World. Diabetes Day, U.N. Doc. A/RES/61/225 (January 18, 2007), available at <http://www.worlddiabetes-day.org/files/docs/U4D/UNR_mediakit_0407.pdf> (last visited June 11, 2010).

Whitlock G. , Prospective Studies Collaboration, “Body-Mass Index and Cause-Specific Mortality in 900 000 Adults: Collaborative Analyses of 57 Prospective Studies,” The Lancet 373, no. 9669 (2009): 1083–1096.

See WHO, supra note 2, at 6.

Id., at 18.

See McKinlay J. Marceau L. , “To Boldly Go…,” American Journal of Public Health 90, no. 1 (2000): 25–33, at 28–29.

See WHO, supra note 2; Boutayeb A. , “The Double Burden of Communicable and Non-communicable Diseases in Developing Count ries,” Transactions of the Royal Society of Tropical Medicine and Hygiene 100, no. 3 (2006): 191–199; Daar A. Singer P. A. Persad D. Pramming S. Matthews D. Beaglehole R. , “Grand Challenges in Chronic, Non-communicable Diseases,” Nature 450, no. 7169 (2007): 494–496.

See Popkin B. Mendez M. , “The Rapid Shifts in Stages of the Nutrition Transition: The Global Obesity Epidemic,” in Kawachi I. Wamala S. , eds., Globalization and Health (Oxford: Oxford University Press, 2007): At 68–80; Stamoulis K. Pingali P. Shetty P. , “Emerging Challenges for Food and Nutrition Policy in Developing Countries,” The Electronic Journal of Agricultural and Development Economics 1, no. 2 (2004): 154–167.

Lopez A. Mathers C. Ezzati M. Jamison D. Murray C. , eds., Global Burden of Disease and Risk Factors (New York: Oxford University Press, 2006): At 9–10, 24lff. Tobacco use, unhealthy diet and physical inactivity result in physiological risk factors (high blood pressure, high cholesterol, high blood glucose level, and overweight/obesity), which in turn contribute to heart disease, cancer, diabetes, and chronic respiratory disease. See WHO, supra note 2, at 48.

There is a burgeoning literature that establishes the importance of social position -factors such as occupational class, income inequality, education level, residential area, gender, and race –upon population risk profiles and health outcomes. These social and economic factors impact differentially upon groups within society, generating health inequalities. In the famous Whitehall study of 17,500 London civil servants, unskilled manual workers were found to have mortality rates three times as high as men in the executive ranks of employment over a ten year period. Marmot M. Shipley M. Rose G. , “Inequalities in Death –Specific Explanations of a General Pattern?” The Lancet 1 (1984): 1003–1006. Twenty years later, the Whitehall II study found that the lower the grade of employment, the more likely participants were to have symptoms of cardiovascular disease, chronic bronchitis, to have been diagnosed with diabetes or hypertension, to smoke, to be overweight, and to perceive themselves to be in poor health. Marmot M. , “Health Inequalities Among British Civil Servants: The Whitehall II Study,” The Lancet 337, no. 8754 (1991): 1387–1393. It is now recognized that “[t]he social gradient in health is apparent for both males and females and across all age groups and countries where data exist, no matter how socioeconomic disadvantage is measured. Magnus P. , ed., Australia's Health 2006: The Tenth Biennial Health Report of the Australian Institute of Health and Welfare, AIHW no. AUS 73 (Canberra, 2006): At 232, available at <http://www.aihw.gov.au/publications/index.cfm/title/10321> (last visited June 11, 2010) (hereinafter AIHW). See also Kunst A. , “Trends in Socioeconomic Inequalities in Self-Assessed Health in 10 European Countries,” International Journal of Epidemiology 34, no. 2 (2005): 295–305. In Britain, data from the 2001 census illustrates the gap in both life expectancy and healthy life expectancy between the richest and poorest groups of electoral wards, as divided into twenty categories of deprivation. There was a 7.6 year difference in male life expectancy at birth between the most deprived and least deprived twentieth of electoral wards (79.1 versus 71.5 years), but a gaping 14.1 year difference in disability-free life expectancy between the richest and poorest wards. For women, the gap in life expectancy at birth was 4.8 years (82.4 versus 77.5), but extended to 12.8 years for disability-free life expectancy. Rasulo D. Bajekal M. Yar M. , “Inequalities in Health Expectancies in England and Wales –Small Area Analysis from the 2001 Census,” Health Statistics Quarterly, no. 34 (2007): 35–44; see also Stringhini S. , “Association of Socioeconomic Position with Health Behaviors and Mortality,” Journal of the American Medical Association 303, no. 12 (2010): 1159–1166. In the United States, although race has tended to overshadow class as evidence for socioeconomic inequality, studies suggest a similar picture. Isaacs S. Schroeder S. , “Class –The Ignored Determinant of the Nation's Health,” New England Journal of Medicine 351, no. 11 (2004): 1137–1142; Krieger N. Chen J. Waterman P. Rehkopf D. Subramanian S. , “Painting a Truer Picture of US Socioeconomic and Racial/Ethnic Health Inequalities: The Public Health Disparities Geocoding Project,” American Journal of Public Health 95, no. 2 (2005): 312–323.

The temptation for policy makers to focus narrowly on individuals and their lifestyle decisions, rather than on the factors that influence patterns of decision making, is seductive. After all, marketing behavioral change to individuals does not impose responsibility on tobacco and food manufacturers for the impacts of the products they sell. Nor does it impose responsibility on governments to secure the conditions under which their population can live healthy lives. Still less does it hold governments accountable for the off-shore health effects of domestic policies, such as the subsidization of commodity crop production. For a discussion of how the persistent use of subsidies by the United States and the European Union have altered the food economies of developing countries, encouraged diet substitution and growing demand for cheap, imported commodity foods, see Lloyd-Williams F. O'Flaherty M. Mwatsama M. Birt C. Ireland R. Capewell S. , “Estimating the Cardiovascular Mortality Burden Attributable to the European Common Agricultural Policy on Dietary Saturated Fats,” Bulletin of the World. Health Organization 86, no. 7 (July 2008): 535–541, available at <http://www.who.int/bulletin/volumes/86/7/08–053728/en/index.html> (last visited June 11, 2010); Schäfer Elinder L. , “Obesity, Hunger, and Agriculture: The Damaging Role of Subsidies,” BMJ 331, no. 7528 (2005): 1333–1336; Sealing K. , “Attack of the Balloon People: How America's Food Culture and Agricultural Policies Threaten the Food Security of the Poor, Farmers, and Indigenous Peoples of the World,” Vanderbilt Journal of Transnational Law 40 (2007): 1015–1037.

Rose G. , “Sick Individuals and Sick Populations,” International Journal of Epidemiology 30, no. 3 (2001): 427–432, at 428.

For a review of conceptual models for understanding power relationships and governance in global health, see Hein W. Burris S. Shearing C. , “Conceptual Models for Global Health Governance,” in Buse K. Hein W. Drager N. , eds., Making Sense of Global Health Governance: A Policy Perspective (Houndmills: Palgrave Macmillan, 2009): At 72–98.

In the context of health systems improvement, Bryan Mercurio argues, “[w]ithout a government willing to devote significant time and resources into improving its own health service (and the health of its citizens), no international effort will be successful. Thus, if a government is not willing to provide a framework conducive to promoting improved health services, even a steady supply of donated drugs, foreign doctors and aid workers will not make a long term difference to the state of the nation.” Mercurio B. , “Health in the Developing World: The Case for a New International Funding and Support Agency,” Asian Journal of WTO and International Health Law and Policy 4, no. 1 (2009): 27–64, at 33.

See, e.g., Hawkes C. , “Uneven Dietary Development: Linking the Policies and Processes of Globalization with the Nutrition Transition, Obesity and Diet-Related Chronic Diseases,” Globalization and Health 2, no. 4 (2006), available at <http://www.globalizationandhealth.com/content/2/l/4> (last visited June 11, 2010); see Stamoulis Pingali Shetty , supra note 17.

Pingali P. , “Westernization of Asian Diets and the Transformation of Food Systems: Implications for Research and Policy,” Food Policy 32, no. 3 (2007): 281–298, at 282.

See Popkin Mendez , supra note 17; Stamoulis Pingali Shetty , supra note 17; Stuckler D. , “Population Causes and Consequences of Leading Chronic Diseases: A Comparative Analysis of Prevailing Explanations,” The Milbank Quarterly, 86, no. 2 (2008): 273–326.

See Elinder Schäfer , supra note 20; Sealing , supra note 20. Agricultural subsidies-leading to the overproduction of sources of saturated fat -can also impact adversely on health in the exporting countries. See Lloyd-Williams , supra note 20.

Lock K. Stuckler D. Charlesworth K. McKee M. , “Potential Causes and Health Effects of Rising Global Food Prices,” BMJ 339 (2009): b 2403. The authors briefly review the following processes to explain the average increase of 75% in global food prices between January 2006 and July 2008: Dietary changes in emerging economies; the impact of WTO rules and IMF-sponsored policies on domestic agricultural production and local food systems; the impact of E.U. and U.S. agricultural subsidies; and rising fuel costs, climate change, and speculative hedge fund investments in agricultural markets.

See Stuckler , supra note 26; Finkelstein E. Ruhm C. Kosa K. , “Economic Causes and Consequences of Obesity,” Annual Review of Public Health 26 (2005): 239–257; James W. , “The Fundamental Drivers of the Obesity Epidemic,” Obesity Reviews 9, supp. 1 (2007): 6–13.

Ludwig D. Pollack H. , “Obesity and the Economy: From Crisis to Opportunity,” JAMA 301, no. 5 (2009): 533–535. In developing countries, as GDP rises, obesity rapidly shifts towards lower socioeconomic groups, affecting women before men. See Monteiro C. Moura E. Conde W. Popkin B. , “Socioeconomic Status and Obesity in Adult Populations of Developing Countries: A Review,” Bulletin of the World. Health Organization 84, no. 12 (December 2004): 940–946. For a more comprehensive assessment of insecure employment upon health inequalities, see Employment Conditions Knowledge Network, Employment Conditions and Health Inequalities, Final Report to the WHO Commission on Social Determinants of Health (September 20, 2007), available at <http://www.who.int/social_determinants/resources/articles/emco-net_who_report.pdf> (last visited June 11, 2010) (hereinafter EMCONET); von Braun J. , “The Food Crisis Isn't Over,” Nature 456, no. 7223 (2008): 701.

See GATT Panel Report, Thailand –Restrictions on Importation of and Internal Taxes on Cigarettes, DS10/R, BISD 37S/200 (November 7, 1009). In this complaint, brought by the United States, the World Trade Organization Panel held that Thai tobacco control legislation, which prohibited the importation of cigarettes except under a license (which was granted to a Thai monopoly), went beyond what was necessary to protect public health. See Fidler D. , International Law and Public Health: Materials on and. Analysis of Global Health Jurisprudence (Ardsley, New York: Transnational Publishers, 2000): At 224–30. The World Bank has noted that “[t]he removal of trade barriers tends to introduce greater competition that results in lower prices, greater advertising and promotion, and other activities that stimulate demand. One study concluded that in four Asian economies that opened their markets in response to U.S. trade pressure during the 1980s –Japan, South Korea, Taiwan, and Thailand –consumption of cigarettes per person was almost 10 percent higher in 1991 than it would have been if these markets had remained closed.” The World Bank, Curbing the Epidemic: Govern ments and the Economics of Tobacco Control, Washington, D.C, 1999, at 14.

See Cassels S. , “Overweight in the Pacific: Links between Foreign Dependence, Global Food Trade, and Obesity in the Federated States of Micronesia,” Globalization & Health 2, no. 10 (2006), available at <http://www.globalizationandhealth.com/content/2/l/l0> (last visited June 23, 2010); Evans M. Sinclair R. C. Fusimalohi C. Liaiva'a V. , “Globalization, Diet, and Health: An Example from Tonga,” Bulletin of the World. Health Organization 79, no. 9 (Geneva: WHO, 2001): At 856–862. For discussion of the impact of globalization and trade liberalization on (poor) diet in Pacific Island countries, and prospects for national regulation to address this in ways consistent with WTO rules, see Hughes R. Lawrence M. , “Globalisation, Food and Health in Pacific Island Countries,” Asia Pacific Journal of Clinical. Nutrition 14, no. 4 (2005): 298–306; Thow A. Hawkes C. , “The Implications of Trade Liberalization for Diet and Health: A Case Study from Central America,” Globalization and Health 5, no. 5 (2009), available at <http://www.gl0balizati0nandhealth.c0m/c0ntent/5/l/5> (last visited June 11, 2010).

For a review of how tobacco companies attempted to discredit the World Bank's landmark study on the economics of tobacco control, see The World Bank, supra note 31; Mamudu H. Hammond R. Glantz S. , “Tobacco Industry Attempts to Counter the World Bank Report Curbing the Epidemic and Obstruct the WHO Framework Convention on Tobacco Control,” Social Science & Medicine 67, no. 11 (2008): 1690–1699.

WHO, Global Strategy on Diet, Physical Activity and Health, Res. WHA57.17 (2004), available at <http://www.who.int/dietphysicalactivity/strategy/ebll344/en/index.html> (last visited June 11, 2010). See Cannon G. , “Why the Bush Administration and the Global Sugar Industry are Determined to Demolish the 2004 WHO Global Strategy on Diet, Physical Activity and Health,” Public Health Nutrition 7, no. 3 (2004): 369–380. Kelly Brownell and Kenneth Warner write: “The Sugar Association simultaneously played its ultimate card. Expressing concern for ‘the hard working sugar growers and their families,’ its president again wrote to WHO, vowing to use ‘every avenue possible to expose the dubious nature’ of the report, ‘including asking Congressional appropriators to challenge future funding of the U.S.'s $406 million contributions… to the WHO.’ This is the WHO that deals with AIDS, malnutrition, infectious disease, bioterrorism, and more, threatened because of its stance on sugar.” Brownell K. Warner K. , “The Perils of Ignoring History: Big Tobacco Played Dirty and Millions Died –How Similar is Big Food?” The Milbank Quarterly 87, no. 1 (2009): 259–294, at 275.

World Economic Forum, The Global Agenda 2009, Geneva, 2009, at 69, available at <www.weforum.org/pdf/globalagenda.pdf> (last visited June 11, 2010).

General Agreement on Tariffs and Trade (GATT), 1994, available at <http://wwwwto.org/english/docs_e/legal_e/06-gatt_e.htm> (last visited June 11, 2010). Under GATT, WTO members are required not to adopt measures that discriminate between the imports of different countries, or between domestic goods and imports. These are the “Most Favored Nation” rule and the “National Treatment” rule in GATT Articles I and III, respectively.

In the United States, assuming that courts would accept that the state has a legitimate health interest in the quality of children's diets, state legislation restricting the advertising of certain foods to children would only be permissible if it directly advanced the interest in public health and was not “more extensive than is necessary to serve that interest.” See Cent. Hudson Gas & Elec. Corp. v Pub. Service Comm'n, 447 U.S. 557, 566 (1980); Pomeranz J. Teret S. Sugarman S. Rutkow L. Brownell K. , “Innovative Legal Approaches to Address Obesity,” The Milbank Quarterly 87, no. 1 (2009): 185–213, at 188–191.

In the EC Biotech Products case, the Panel distinguished between foods that posed a danger to the life or health of the customer, and foods that were nutritionally disadvantageous due to the quality or quantity of their nutrients, but without necessarily presenting a danger to the health of the consumer. The Panel made it clear that the SPS Agreement only applies to laws seeking to address a “danger for the consumer.” See WTO, European Communities –Measures Affecting the Approval and Marketing of Biotech Products , Disputes WT/DS291, WT/DS292 and WT/DS293, September 29, 2006, available at <http://www.wto.org/english/tratop_e/dispu_e/cases_e/ds293_e.htm> (last visited June 14, 2010), at ¶ ¶ 7.405–7.408, ¶ ¶ 7.414–7.415. The TBT Agreement would likely apply to technical regulations that were aimed at improving the diet of the population. Id.; see also the definition of “technical regulation” in Annex 1 of the WTO, Agreement on Technical Barriers to Trade, available at <http://www.wto.org/english/docs_e/legal_e/17-tbt_e.htm> (last visited June 14, 2010) (hereinafter TBT Agreement).

See TBT Agreement, supra note 38, at ¶ 2.2.

Id., at ¶ 2.3.

For discussion of country level laws supporting the prevention of obesity and non-communicable diseases, see, e.g., Perdue W. Mensah G. Goodman R. Moulton A. , A Legal Framework for Preventing Cardiovascular Diseases,” American Journal of Preventive Medicine 29, no. 5 (2005): 139–145; Magnusson R. , “What's Law Got to Do With It? Part 2: Legal Strategies for Healthier Nutrition and Obesity Prevention,” Australia and New Zealand Health Policy 5, no. 11 (2008): 139–145, available at <http://www.anzhealthp0licy.c0m/c0ntent/5/1/11>; Hodge J. Garcia A. Shah S. , “Legal Themes Concerning Obesity Regulation in the United States: Theory and Practice,” Australia and New Zealand Health Policy 5, no. 14 (2008), available at <http://www.anzhealthpolicy.com/content/5/l/l4>; Martin R. , “The Role of Law in the Control of Obesity in England: Looking at the Contribution of Law to a Healthy Food Culture,” Australia & New Zealand Health Policy 5, no. 21 (2008), available at <http://www.anzhealthp0licy.c0m/c0ntent/5/l/21> (last visited June 11, 2010).

See WTO Panel Report, European Communities –Trade Description of Sardines, ¶ 5.21, WT/DS231/R (May 29, 2009), available at <http://www.sice.oas.org/dispute/wto/ds23l/ds231el.asp> (last visited June 13, 2010). In this case, the WTO Panel upheld Peru's claim against an EC Regulation which provided that only fish from the species Sardina pilchardus could be marketed as “sardines” (and not fish from the species Sardinops sagax). The Panel found that the Codex Alimentarius Commission Standard for Canned Sardines and Sardine Type Products (Codex Stan 94) was a “relevant international standard” and that the European Communities had not shown that Codex Stan 94 was an “ineffective or inappropriate means for the fulfillment of the legitimate objectives pursued by the EC Regulation, i.e., consumer protection, market transparency and fair competition.” Id., at ¶ 7.138.

See TBT Agreement, supra note 38, at ¶ 2.5.

Magnusson R. , “Non-communicable Diseases and Global Health Governance: Enhancing Global Processes to Improve Health Development,” Globalization and Health 3, no. 2 (2007): 1–16, available at <http://www.globalizationandhealth.com/content/3/l/2> (last visited June 14, 2010); Magnusson R. , “Rethinking Global Health Challenges: Towards a ‘Global Compact’ for Reducing the Burden of Chronic Disease,” Public Health 123, no. 3 (2009): 265–274, at 270–271.

WHO, Framework Convention on Tobacco Control, WHA 56.1 (entered into force February 27, 2005), available at <http://www.who.int/fctc/text_download/en/index.html> (June 14, 2010).

A large number of international instruments do, nevertheless, have a connection with global health in the sense that they could potentially affect it. See Taylor A. Bettcher D. Fluss S. DeLand K. Yach D. , “International Health Instruments: An Overview,” in Detels R. McEwen J. Beaglehole R. Tanaka H. , eds., Oxford Textbook of Public Health, 4th ed. (Oxford: Oxford University Press, 2004): At 359–386.

See Lee K. Sridhar D. Mayur P. , “Bridging the Divide: Global Governance of Trade and Health,” The Lancet 373, no. 9661 (2009): 416–422, at 420.

WHO's Constitution states that the objective of the organization is “the attainment by all peoples of the highest possible level of health.” WHO, Constitution, at Art. 1, available at <http://www.who.int/governance/eb/constitution/en/index.html> (last visited June 14, 2010). The Constitution also states that it is the function of WHO to “take all necessary action to attain the objective of the Organization,” (id., at art. 2(v)), including proposing “conventions, agreements, and regulations”, and making “recommendations with respect to public health matters” (id., at art. 2(k)). Specific powers relevant to WHO's global normative role include the power to make treaties (id., at art. 19), regulations in specific areas (id., at art. 21), non-binding recommendations (id., at art. 23), and the obligation of member States to report to WHO annually on action taken with respect to recommendations, conventions, agreements and regulations (id., at art. 62).

For discussion of the tension between WHO's centralized, global, normative functions, and its more decentralized, country-focused, technical assistance functions, see Prah Ruger J. Yach D. , “The Global Role of the World Health Organization,” Global Health Governance 2, no. 2 (Fall 2008/Spring 2009), available at <http://www.ghgj.org/ruger2.2rolewho.htm> (last visited June 14, 2010).

See Stuckler D. Hawkes C. Yach D. , “Governance of Chronic Disease,” in Buse K. Hein W. Drager N. , eds., Making Sense of Global Health Governance: A Policy Perspective (Houndmills: Palgrave MacMillan, 2009): 268–293; see also Magnusson , supra note 44.

See WHO, supra note 34.

WHO, Prevention and Control of Noncommunicable Diseases: Implementation of the Global Strategy , WHA61.14, May 24, 2008,available at <http://www.who.int/gb/ebwha/pdf_files/A6l/A6l_Rl4-en.pdf> (last visited June 14, 2010), referring to WHO, Draft Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases , Report by the Secretariat, Provisional agenda item 11.5, A61/8 (Apr. 18, 2008), available at <http://www.who.int/gb/ebwha/pdf_files/A6l/A6l_8-en.pdf> (last visited June 14, 2010).

WHO, Global Strategy to Reduce the Harmful Use of Alcohol, WHA63/13 –Annex 2, March 25, 2010, available at <http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_13-en.pdf> (last visited June 24, 2010).

Res G.A. , 55/2, United Nations Millennium Declaration , U.N. Doc. A/RES/55/2, September 18, 2000, available at <http://www.un.org/millennium/declaration/ares552e.htm> (last visited June 14, 2010). The MDGs contain three specific health goals: Reduce child mortality; improve maternal health; and combat human HIV/AIDS, malaria and other diseases.

Strong K. Mathers C. Leeder S. Beaglehole R. , “Preventing Chronic Diseases: How Many Lives Can We Save?” The Lancet 366, no. 9496 (2005): 1578–1582; Seffrin J. Hill D. Burkart W. Magrath I. Badwe R. Ngoma T. Mohar A. Grey N. , “It Is Time to Include Cancer and Other Noncommunicable Diseases in the Millennium Development Goals,” CA: A Cancer Journal for Clinicians 59, no. 5 (2009): 282–284; WHO, Preventing Chronic Disease: A Vital Perspective, WHO Global Report, 2005): At 26, available at <http://www.who.int/chp/chronic_disease_report/contents/en/index.html> (last visited June 14, 2010).

See WHO, supra note 2; Adeyi O. Smith O. Robles S. , Public Policy and the Challenge of Chronic Noncommunicable Diseases , The World Bank, Washington, D.C., 2007, available at <http://siteresources.worldbank.org/INTPH/Resources/PublicPolicyandNCDsWorldBank2007FullReport.pdf> (last visited June 23, 2010).

United Nations, “Millennium Development Goals,” available at http://www.un.org/millenniumgoals/> (last visited June 14, 2010).

See Adeyi Smith Robles , supra note 56, at 7. Making progress in this former area is one of the most difficult yet important challenges that developed countries including the United States, Britain, and Australia are facing in health systems reform. See Fielding J. Teutsch S. , “Integrating Clinical Care and Community Health: Delivering Health,” JAMA 302, no. 3 (2009): 317–319; Campbell S. Reeves D. Kontopantelis E. Sibbald B. Roland M. , “Effects of Pay for Performance on the Quality of Primary Care in England,” New England Journal of Medicine 361, no. 4 (2009): 368–378; Kidd M. , “What Impact Will the Australian Government's Proposed National Healthcare Reforms Have on Australian General Practice?” Medical Journal of Australia 191, no. 2 (2009): 55–57; Caciosek M. Coffield S. Edwards N. Flottemesch T. Solberg L. , “Prioritizing Clinical Preventive Services: A Review and Framework with Implications for Community Preventive Services,” Annual Review of Publie Health 30 (2009): 341–355.

Beaglehold R Yach D. , “Globalisation and the Prevention and Control of Non-communicable Disease: The Neglected Chronic Diseases of Adults,” The Lancet 362, no. 9387 (2003): 903–908; See Daar , supra note 16.

See Res G.A. , 55/2, supra note 54.

WHO, Health and the Millennium Development Goals, Geneva, 2005, at 7.

See United Nations, The Millennium Development Goals Report 2009, New York, 2009; WHO, Monitoring of the Achievement of the Health-Related Millennium Development Goals, EB124/10, November 27, 2008.

For a recent review, see Sridharr D. Khagram S. Pang T. , “Are Existing Governance Structures Equipped to Deal with Today's Global Health Challenges –Towards Systematic Coherence in Scaling Up,” Global Health Governance 2, no. 2 (Fall 2008/Spring 2009), available at <http://www.ghgj.org/sridhar2.2equippedtodeal.htm> (last visited June 14, 2010).

Silberschmidt G. Matheson D. Kickbush I. , “Creating a Committee C of the World Health Assembly,” The Lancet 371, no. 9623 (2008): 1483–1486.

Gostin L. , “Meeting the Basic Survival Needs of the World's Least Healthy People: Towards a Framework Convention on Global Health,” Georgetown Law Journal 96, no. 2 (2008): 331–392; Gostin L. , “A Proposal for a Framework Convention on Global Health,” Journal of International Economic Law 10, no. 4 (2007): 989–1008; Gostin L. , “Meeting the Survival Needs of the World's Least Healthy People: A Proposed Model for Global Health Governance,” JAMA 298, no. 2 (2007): 225–228.

See WHO, The World Health Report 2008: Primary Healthcare, Now More than Ever , Geneva, 2008, available at <http://www.who.int/whr/2008/en/index.html> (last visited June 14, 2010); WHO, Primary Health-care, Including Health System Strengthening: Report by the Secretariat , A62/8, April 9, 2009. The World Bank has also signaled health systems strengthening as its priority in the health sector. World Bank, Healthy Development: The World Bank Strategy for Health, Nutrition and. Population Results, Washington, D.C., 2007, at 25ff.

WHO, Primary Health-care, Including Health System Strengthening: Report by the Secretariat, A62/8, April 9, 2009, at §24.

The Global Fund to Fight AIDS, Tuberculosis and Malaria website, available at <http://www.theglobalfund.org/en/> (last visited June 14, 2010).

The Global Alliance for Vaccines and Immunisation website, available at <http://www.gavialliance.org/> (last visited June 14, 2010) (hereinafter VAGI).

Cometto G. Ooms G. Starrs A. Zeitz P. , “A Global Fund for the Health MDGs?” The Lancet 373, no. 9674 (2009): 1500–1502. Similarly, Reich and colleagues have called for the allocation of a fixed percentage of funding from vertical, disease-specific initiatives to support health systems strengthening, with an international research organization to monitor accountability and outcomes. Reich M. Takemi K. Roberts M. Hsiao W. , “Global Action on Health Systems: A Proposal for the Toyako G8 Summit,” The Lancet 371, no. 9615 (2008): 865–869.

Horton R. , “Venice Statement: Global Health Initiatives and Health Systems,” The Lancet 374, no. 9683 (2009): 10–12; WHO Maximising Positive Synergies Collaborative Group, “An Assessment of Interactions between Global Health Initiatives and Country Health Systems,” The Lancet 373, no. 9681 (2009): 2137–2169.

See Adeyi Smith Robles , supra note 56, at 7.

See Ridby N. Baillie K. , “Challenging the Future: The Global Prevention Alliance,” The Lancet 368, no. 9548 (2006): 1629–30. The five international NGOs are the World Heart Federation, the International Diabetes Federation, the International Pediatric Association, the International Union of Nutritional Sciences, and the International Association for the Study of Obesity. See Global Alliance or the Prevention of Obesity and Related Chronic Disease, available at <http://www.prevention-alliance.net> (last visited June 14, 2010).

The Oxford Health Alliance website, available at <http://www.oxlia.org/> (last visited June 14, 2010).

See McCoy D. Hilson M. , “Civil Society, Its Organizations, and Global Health Governance,” in Buse K. Hein W. Drager N. , eds., Making Sense of Global Health Governance: A Policy Perspective (Houndmills: Palgrave MacMillan, 2009): At 209–231.

See Alliance for Chronic Disease, Six of the World's Foremost Health Research Agencies Form Alliance to Curb Humanity's Most Fatal Diseases , Press Release, June 15, 2009, available at <http://www.oxha.org/knowledge/publications/Final%20news%20release%20200906ll.pdf>. The charter members of the Alliance are Australia's National Health & Medical Research Council; the Canadian Institutes of Health Research; China's Ministry of Health in association with the Chinese Academy of Medical Sciences; the UK Medical Research Council and the US National Institutes of Health (the National Heart, Lung and Blood Institute, and the Fogarty International Center).

See World Economic Forum, Network of Global Agenda Councils website, available at <http://www.weforum.org/en/about/GlobalAgendaCouncils/index.htm> (last visited June 14, 2010).

World Economic Forum, The Global Agenda 2010, Geneva, 2010.

See, e.g., McMichael A. Powles J. Butler C. Uauy R. , “Food, Livestock Production, Energy, Climate Change, and Health,” The Lancet 370, no. 9594 (2007): 1253–1263; Friel S. , “Global Health Equity and Climate Stabilisation: A Common Agenda,” The Lancet 372, no. 9650 (2008): 1677–1683; Higgins P. Higgins M. , “A Healthy Reduction in Oil Consumption and Carbon Emissions,” Energy Policy 33, no. 1 (2005): 1–4; Egger G. , “Personal Carbon Trading: A Potential ‘Stealth Intervention’ for Obesity Reduction?” Medical Journal of Australia 187, no. 3 (2007): 185–187; Adshead F. Thorpe A. Rutter J. , “Sustainable Development and Public Health: A National Perspective,” Public Health 120, no. 12 (2006): 1102–1105; Younger M. Morrow-Almeida H. Vindigni S. Dannenberg A. , “The Built Environment, Climate Change, and Health: Opportunities for Co-Benefits,” American Journal of Preventive Medicine 35, no. 5 (2008): 517–526.

WHO, New Network to Combat Noncommunicable Diseases, Press Release, July 8, 2009, available at <http://www.who.int/mediacentre/news/releases/2009/noncommunicable_diseases_20090708/en/index.html (last visited June 14, 2010).

For discussion of WHO's leadership role in global health, see Bonita R. Irwin A. Beaglehole R. , “Promoting Public Health in the Twenty-First Century: The Role of the World Health Organization,” in Kawachi I. Wamala S. , eds., Globalization and Health (New York: Oxford University Press, 2007): At 268–83; see Ruger Prah Yach , supra note 49.

See WHO Maximising Positive Synergies Collaborative Group, supra note 71; Nugent R Yach D. Feigl A. , “Non-commu-nicable Diseases and the Paris Declaration,” The Lancet 374, no. 9692 (2009): 784–785 (letter).

Magnusson R. , “Rethinking Global Health Challenges,” supra note 44; Nishtar S. , “Time for a Global Partnership on Noncommunicable Diseases,” The Lancet 370, no. 9603 (2007): 1887–1888.

Ravishankar N. Gubbins P. Cooley R. Leach-Kemon K. Michaud C. Jamison D. Murray C. , “Financing of Global Health: Tracking Development Assistance for health from 1990 to 2007,” The Lancet 373, no. 9681 (2009): 2113–2124, at 2117.

See Fidler D. Drager N. Lee K. , “Managing the Pursuit of Health and Wealth: The Key Challenges,” The Lancet 373, no. 9660 (2009): 325–331, at 327–328.

Id., at 329.

See Sridharr Khagram Pang , supra note 63.

International Health Partnership, A global ‘Compact’ for achieving the Health Millennium Development Goals , September 5, 2007, available at <http://www.internationalhealthpartnership.net/en/documents> (last visited June 14, 2010). The International Health Partnership was signed in September 2007 by a coalition of donor and recipient countries, international agencies and other funders. It seeks to put into operation the Pans Declaration on Aid Effectiveness: Ownership, Harmonization, Alignment, Results, and Mutual Accountability , High Level Forum, Paris, February 28-March 2, 2005, available at <http://www.internationalhealthpartnership.net/en/documents> (last visited June 14, 2010).

See WHO, supra note 45.

For further discussion of “global processes,” including an evaluation of WHO's initiatives in the area of Non-communicable diseases in terms of these processes, see Magnusson , supra note 44.

Thus, for example, the WHO Maximizing Positive Synergies Collaborative Group evaluates the relationships between global health initiatives, and country health systems, in terms of the impact of the former upon core “building blocks” for health system improvement: Service delivery, financing, governance, health workforce, health information systems, and supply management systems. See WHO Maximising Positive Synergies Collaborative Group, supra note 71.

The core functions of public health have been described in a variety of ways. See, e.g., Institute of Medicine, The Future of Public Health (Washington, D.C.: National Academy Press, 1988): At 43–46; Institute of Medicine, The Future of the Public's Health in the 21st Century (Washington, D.C.: National Academy Press, 2003): At 32–33,103–104 (herinafter IOM). See also Jorm L. Gruszin S. Churches T. , “A Multidimensional Classification of Public Health Activity in Australia,” Australia and New Zealand Health Policy 6, no. 9 (2009), available at <http://www.anzhealthpolicy.com/content/6/l/9> (last visited June 14, 2010).

See IOM, The Future of Public Health, supra, note 93, at 45. 95. Buse K. Drager N. Hein W. Dal B. Lee K. , “Global Health Governance: The Emerging Agenda,” in Buse K. Hein W. Drager N. , eds., Making Sense of Global Health Governance: A Policy Perspective (Houndmills: Palgrave MacMillan, 2009): 1–27, at 9–10; see also Ruger Prah Yach , supra note 49, at 2; Sridhar Khagram Pang , supra note 63, at 2–3.

For global health information initiatives, see WHO Health Metrics Network website, available at <http://www.who.int/health-metrics/en/> (last visited June 14, 2010); see also the Institute for Health Metrics and Evaluation website, available at <http://www.healthmetricsandevaluation.org/> (last visited June 14, 2010).

See supra note 41.

See Public Health Agency of Canada, WHO Collaborating Centre on Non Communicable Disease Policy, 2009, available at <http://www.phac-aspc.gc.ca/about_apropos/whocc-ccoms/index-eng.php> (last visited June 14, 2010); see also Public Health Agency of Canada, The Canadian Best Practices Portal for Health Promotion and Chronic Disease Prevention, 2010, available at <http://cbpp-pcpe.phac-aspc.gc.ca/> (last visited June 14, 2010).

Although the distinction between health protection and assurance, and health promotion, is clear enough at the national level, at the global level these functions overlap significantly. At the national level, health promotion refers to strategies that aim to influence the behaviors of individuals and communities. At the global level, however, health promotion and education includes seeking to catalyze action by national governments and policy-makers, not to mention other international agencies. This kind of leadership role, however, is precisely what is also needed to discharge the health protection and assurance function at the global level.

See TBT Agreement, supra note 39, at ¶ 2.5; WTO, The WTO Agreement on the Application of Sanitary and Phytosanitary Measures, at ¶ 3.2, available at <http://www.wto.org/english/tratop_E/sps_e/spsagr_e.htm> (last visited June 14, 2010) (hereinafter SPS Agreement).

See supra note 55.

Draft Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases, supra, note 52, at ¶ 29.

See Stuckler Hawkes Yach , supra note 50, at 270.

United Nations General Assembly, Prevention and Control of Non-communicable Diseases, U.N Doc. A/64/L.52, 28 April 2010, available at <http://www.un.org/ga/search/view_doc.asp?symbol=A%2F64%2FL.52&Submit=Search&Lang=E> (last visited June 23, 2010).