introduction

Global Health Challenges and the Role of Law

Colleen M. Flood and Trudo Lemmens

ealth rights have grown very popular. First appearing more than 60 years ago in the UN Universal Declaration on Human Rights, health rights, both general and specific, now appear in many other international agreements, as well as in domestic state constitutions and statutes. Despite the proliferation of health rights and the recognition of health-related components of other rights (and an accompanying rise in litigation), we still face staggering disparities in health and access to health care both within nation states and across the globe. Health care spending per capita for the top 5% of world population is nearly 4,500 times that for the lowest 20%. Each year 2.5 million people die annually from vaccine-preventable diseases1 and close to 7 million children under the age of 5 died in 2011 from malnutrition and mostly preventable diseases.2 In this special edition, we collectively explore to what extent law has and could make a difference in meeting global health challenges. Canadian and international scholars met at a conference on Global Health Challenges and the Role of Law in Toronto on May 4-5, 2012 and presented papers

in five different clusters: Global Health and Chronic Diseases; Global Health and Vulnerable Populations; Global Health and Human Rights; Globalization, Pharmaceuticals, and Free Trade; and Globalization and Global Trade in Bodies and Services. We asked participants to explore the various ways in which law3 functions (or malfunctions) as a tool for reform in global health, and more broadly, the interactions between law and other mechanisms of global health governance. Not all papers provide explicit answers to these questions. But they all reflect on either the value of legal intervention, or the limits of law in providing solutions, or the complex ways in which law interacts with other normative systems and socio-economic practices and transactions. The first and most important global challenge highlighted by contributors is the poor health of billions in the world, particularly in lower- and middle-income countries, and, related thereto, inadequate and inequitable access to care and essential medicines. Can law make a difference? Most contributors to this special edition focused on access to health care as opposed to health simpliciter likely because injustices of

Colleen M. Flood, LL.B., LL.M., S.J.D., is a Professor and Canada Research Chair at the Faculty of Law, University of Toronto and is cross-appointed to the School of Public Policy and the Institute of Health Policy, Management & Evaluation. From 20062011 she served as the Scientific Director of the Canadian Institute for Health Services and Policy Research. She holds a Bachelor of Arts and Bachelor of Laws (Honours) from the University of Auckland, New Zealand as well as a Master of Laws and Doctorate in Juridical Science from the University of Toronto, Canada. Her primary areas of scholarship are in administrative law, comparative health care law & policy, public/private financing of health care systems, health care reform, and accountability and governance issues more broadly. Trudo Lemmens, LL.M., D.C.L., is the Scholl Chair in Health Law and Policy at the Faculty of Law of the University of Toronto, where he also holds cross-appointments in the Faculty of Medicine and the Joint Centre for Bioethics. He has a Licentiate in Law from the K.U.Leuven, and a Master in Laws (specialization bioethics) and Doctorate in Civil Law from McGill University. During the academic year 2012-2013, he is a faculty member of the Centre for Transnational Legal Studies and an academic visitor at the Faculty of Law and the HeLEX Centre for Health, Law and Emerging Technologies of the University of Oxford. His research is primarily focused on the intersection of law, ethics, biomedical innovation, and medical research and practice. global health and the law spring 2013

INTRO D UCTION

the latter sort are more difficult to fit in a legal frame, given the diffusion of actors involved and the problem of establishing causation between an individuals poor health and larger social determinants of health. However, one contributor did explicitly tackle the issue of global health inequities. According to Solomon Benatar, law may help to challenge existing norms and reformulate them, but law alone will not be enough; closing the global health chasm requires a radical reconceptualization of the distribution of health and the sphere of health care. Benatar criticizes the legal

of the Supreme Court has been widely criticized from that perspective. At the conference, two presentations addressed this debate. In her contribution, Mariana Mota Prado discusses the case of Brazil frequently held up as an example of right to health litigation worsening inequality of access to health care, by diverting public funds to expensive novel treatments for affluent claimants. Prado does not reject these claims, but she adds complexity to this debate by suggesting that one has to look at the longer-run impacts of this form of litigation. She argues resulting policy changes

We asked participants to explore the various ways in which law functions (or malfunctions) as a tool for reform in global health, and more broadly, the interactions between law and other mechanisms of global health governance. Not all papers provide explicit answers to these questions. But they all reflect on either the value of legal intervention, or the limits of law in providing solutions, or the complex ways in which law interacts with other normative systems and socioeconomic practices and transactions.
order underlying our current capitalist market system for colluding with the processes that contribute to huge wealth disparities by gravely misallocating the resources that influence the social determinants of health. He argues that our international legal order facilitates a shift towards hyper-individualism and super-capitalism and erosion of cooperation, solidarity, and mutual responsibility. These distortions have coincided with the commodification of health care and an emphasis on technical innovation over the effective deployment of existing knowledge and technologies. Developing sustainability and improving global population health, according to Benatar, will require changes in international law that incorporate a re-thinking of social priorities and a re-examination of the legal powers of corporations. One of the most obvious ways in which law impacts access to health care is through litigation of heath care rights (or related rights, such as the right to life). Many advocates of human rights believe as an article of faith that pursuing the realization of health rights will result in public welfare improvements and in particular will improve the plight of vulnerable populations. Others, however, express concern that court challenges will put undue pressure on public health care systems to expand access to, for example, highly expensive drugs of relatively low efficacy and/or result in human rights challenges that actually further a privatization agenda. In Canada, the Chaoulli decision that occur in multiple domains (e.g., institutional and governance shifts in the health care system, changes to the legal system) might be net beneficial, even if at first blush access to health care itself is worsened for the most vulnerable. She calls for further research to assess these effects and the long-term impact of rightto-health litigation. Aeyal Gross engages in a comparative analysis of Israel and Canada, exploring whether right to health litigation has been used to re-articulate claims to private health care as human rights claims, thus undermining rather than expanding equity. He contrasts a Canadian case (Chaoulli) which he claims co-opted a constitutional right to security of the person to create a right (for some) to private health insurance with an Israeli case (Kiryati) where an application to allow preferential treatment for those who could pay was denied. But Gross notes that the Kiryati case, although suggestive of judicial resistance to rights discourse being co-opted for non-progressive ends, has to be situated in a larger context. In other cases, the Israeli judiciary has so far been unwilling to challenge government policy that imposes significant out-of-pocket payments at point of service, effectively rationing care for the poor. Thus, in Israel the courts have been strong enough to resist attacks on existing equality-enhancing government policies (prohibitions on private payment for preferential access to specialists) but not sufficiently strong to strike down policy

10

journal of law, medicine & ethics

Flood and Lemmens

that undermines equality (the imposition of extensive co-payments). Other contributors are more optimistic about the role of the judiciary in advancing progressive rights to health care, particularly by drawing on international law, both hard and soft. In this regard, Oscar Cabrera and Juan Carballo argue that in the area of tobacco control, courts can play a very positive role. They explore standard criticisms of judicial enforcement of economic, social, and cultural rights and explain how, at least in the case of tobacco control, these arguments falter. Critics point to the limited technical capacity of the courts; that judicial interference may result in the redirection of public resources to those who can afford to litigate; and the problem that those most in need do not have access to the courts or appropriate legal representation. With respect to the technical capacity of courts, they discuss how the Framework Convention on Tobacco Control establishes scientific and medical determinations that compensate for any judicial limitations in this regard. With respect to inappropriate redirection of resources, they argue that courts are not required to substantially redirect public resources in the context of tobacco, because tobacco control measures are largely inexpensive and cost-effective. And finally, with respect to access to justice concerns, tobacco control decisions from Latin America have broadened the law of standing and justiciability and affirmed the non-retrogression component of progressive realization in ways that will bolster future health rights litigation. Thus, it seems that the tobacco control case (and the interplay of international law and litigation) provide important lessons for success in other arenas. One caveat remains, however, for in many of the cases referred to the right to health is used as a shield by government to resist industry challenges to tobacco control laws and so although it is certainly positive that law is protecting laudable public health action on the part of governments, it is not necessarily promoting it or demanding it. Rebecca Cook in her contribution discusses the case of Alyne da Silva Pimentel Teixeira (deceased) v. Brazil4 where the Committee on the Elimination of Discrimination Against Women (CEDAW) found, for the first time, that a nation state was responsible for the preventable death of a poor pregnant woman of AfroBrazilian descent. Cook paints a picture of the interplay between international law (the UN Convention on the Elimination of All Forms of Discrimination Against Women), international oversight and governance (CEDAW, which monitors compliance on the part of member states), constitutional law (CEDAW linked Brazils responsibilities to its own constitution
global health and the law spring 2013

which affirms the right to health as a general human right) and the actions of various NGOs at the international and domestic level who were particularly influential in amassing the necessary evidence base to bring the case. All of these factors played a role in the success of this case. Cook examines how we can determine the effectiveness of the decision. One way is to assess whether the case will advance the sex and race equality norms in the health system, for example by narrowing the differential maternal mortality rates between poor Afro-Brazilian and other women in Brazil. It is too early to tell, according to Cook, but she argues that if the judicialization of health is going to be effective, then court decisions need to catalyze health systems to address health inequalities that poor pregnant women face in accessing maternity care. In so doing, courts will accelerate Brazils compliance with its human rights obligations and its commitment under the UN Millennium Development Goal of reducing its maternal mortality ratio by three-quarters, between 1990 and 2015. Both Cabrera/Carballo and Cook emphasize the importance of international law in promoting progressive judicial responses. This proved an important theme explored by a number of contributors; namely, the role of international law and international agreements in stimulating progressive change whether through the courts or political processes. Arthur Wilson and Abdallah Daar in their contribution to this special issue ambitiously tackle the question of what role, if any, international legal instruments have played in solving global health challenges. They assess a range of international instruments and related global challenges and with humility given the difficulties of establishing causation in such a complex arena suggest a number of factors that seem to be conditions precedent to success. Carrying on this theme, Constance MacIntosh focuses on the use of international instruments to promote health standards among aboriginal peoples. She shows in her paper how international legal instruments and international legal fora have promoted global dialogue about indigenous peoples health inequalities dialogue that was previously limited to the domestic sphere. MacIntosh emphasizes how the very active participation of aboriginal people at the international level has facilitated their recognition as legitimate contributors to domestic governance, thus contributing to enabling substantive engagement. Hard instruments, such as the International Covenant on Economic, Social and Cultural Rights and the Indigenous and Tribal Peoples Convention (ILO Convention 169) and soft instruments, such as the United Nations Declaration on the Rights of Indigenous Peoples, have provided 11

INTRO D UCTION

the impetus for reform at the domestic level through negotiation, legislation, and litigation. MacIntosh provides examples of how internationally articulated norms found their way into domestic legal and policy initiatives related to health in New Zealand/Aotearoa and Canada. While MacIntosh focuses on aboriginal communities rendered vulnerable in the context of historically situated political and socio-cultural oppression, Sheila Wildeman, for her part, addresses the role of international human rights in stimulating more inclusive processes of deliberation concerning the political and socio-cultural determinants of disability. Her paper concentrates on the impact of the International Convention on the Rights of Persons with Disabilities; in particular, on how this convention has become a powerful tool in positioning mental health as a human rights issue. As Wildeman explains, the Convention was negotiated with the extensive involvement of NGOs, particularly disabled persons organizations. It not only combines civil and political rights with economic, social, and cultural rights, but also includes both rights of and state responsibilities for political participation. However, controversies remain over the Conventions implications for domestic laws on involuntary psychiatric treatment, including involuntary hospitalization and substitute decision-making. Wildeman concludes that the global prominence attained by the perspectives of disabled persons organizations during the negotiation and implementation of the Convention illustrates the potential transformative power of human rights law vis-a-vis ongoing mutual education and debate about the meaning and implications of fundamental norms. International human rights conventions and associated litigation are credited by a number of contributors with galvanizing (or potentially galvanizing) positive change, but another theme explored was the role of international trade agreements. Many commentators express concern that such agreements have exacerbated and perpetuated global chasms in access to health and health care. Reflecting this concern, in their contribution, Ruth Lopert and Deborah Gleeson emphasize the impact of American interests in bilateral and regional trade agreements on access to medicines. They emphasize how in addition to the socalled TRIPS-plus intellectual property protections, American trade negotiators have attempted to restrict other countries domestic policies on the pricing and provision of pharmaceuticals as well as the regulation of direct-to-consumer advertising.Lopert and Gleeson discuss how these provisions reflect the growing influence of trade objectives and industry interests on pharmaceutical policies worldwide. They warn that 12

these aspects of trade agreements, as exemplified in the current negotiations for the Trans Pacific Partnership Agreement, can seriously constrain advances made in the context of public health. Lopert and Gleeson argue that it is critical for Trans Pacific Partnership countries to recognize the potential costs to society of the U.S. agenda so that a better balance between economic and health objectives can be found. Patent protections are part and parcel of most international trade agreements, and Richard Gold, in his contribution, takes issue with the dominant discourses in the literature surrounding patents and human rights. He distinguishes three traditional positions in the debate: one position is that in the inherent clash between patents and human rights, the latter should prevail. A second view is that that patent rights are themselves a species of human right. And according to a third view, patent rights and human rights are different but compatible.Gold argues that the traditional approaches are incomplete and fail to recognize that human rights and patent rights are fundamentally different at the normative level and therefore incommensurable. Human rights, he suggests, are moral rights, whereas patent rights are contingent rights. In addition, human rights operate in his view primarily at the international level, whereas patent rights are primarily domestic. Picking up on the normative role of human rights law whether at the international or domestic level Trudo Lemmens argues it can be employed to strengthen the governance of pharmaceutical knowledge and to address the existing knowledge deficit resulting from industry-controlled scientific practice. He first discusses how the right to health is intrinsically linked to other human rights concepts (e.g., the right to information, the right to life, and the protection of private and family life). The human rights dimensions of access to reliable risk information can be invoked not only to reject data secrecy claims made in the context of international trade agreements, but also to impose a positive obligation upon states to actively support reliable knowledge production. Lemmens then goes on to advocate for a more conceptual use of human rights, as a methodology which requires a comprehensive analysis of the different interwoven historical, economic, cultural, and social factors that contribute to the current knowledge deficit. The claim that historically grown drug regulations have directly contributed to industry control over knowledge production is in this context particularly important for future law reform. The paper ends with the suggestion that strict transparency obligations should be integrated in the Framework Convention on Global Health, and that the WHO should reinvigorate its

journal of law, medicine & ethics

Flood and Lemmens

global leadership in the promotion and coordination of transparency measures. Contributors also explored how our quest for greater health care equity and better access is complicated by ever-increasing challenges posed by increasing global migration, both temporarily and permanently, of people, diseases, ideas, culture(s), services and commodities. North-American patients travel to Europe for new hips and knees, or go south to obtain experimental treatments in Mexico or Brazil, while desperately ill European patients pay fortunes to participate in controversial stem cell trials in Russia or Turkey. Patients from many industrialized countries flock to India and China to get around long organ wait lists in their home country. Meanwhile, U.S. surrogates may enter into contracts with Australian couples to be impregnated in Canadian clinics with Scandinavian sperm. Can the law intervene effectively to protect and promote the range of interests and values at stake, amidst these waves of medical tourism for organs, gametes, ova, and health care services? The intensification of international travel and trade also increasingly globalize traditional challenges to public health, for example those resulting from the threat of pandemic influenza and chronic diseases. Unhealthy food habits from the industrialized world are increasingly exported south, disproportionately affecting the health and well-being of the worlds poorer populations. Can law do anything to stem the spread of chronic disease and the ever expanding (pardon the pun) obesity epidemic? The issue contains two papers that focus on legal governance of chronic diseases. Bryan Thomas and Lawrence Gostin clearly take a very different stance than William Bogart on the ability of law to effectively deal with the challenge of chronic diseases. While Thomas and Gostin defend an approach based on the simultaneous embracing of a wide variety of strategies in both national and international law, Bogart reflects skeptically on the laws ability to effectively combat obesity. Thomas and Gostin support the use of restrictive regulations on labelling, food additives, and advertising, but also acknowledge the need to incentivise industry and individual consumers to change behavior. They emphasize, as Gostin has done in earlier publications, that domestic strategies require the support of global governance mechanisms which, to be effective, require specific compliance mechanisms. They also indicate that effective strategies have built on engagement with industry and civil society. Bogart reflects more critically on existing legal tools to combat obesity. He challenges current public health policies first for failing to be clear about the nature of the public health problem: is the problem purely one of the high incidence of overweight people Bogart
global health and the law spring 2013

provocatively uses the term fat or is it the absence of healthy living and exercise? He also suggests that the dominant public health approach focusing on weight loss and self-control results in stigmatization and discrimination, while failing to provide an effective remedy. Legal interventions may, according to Bogart, only play a limited role in the promotion of public health. A less zealous focus on healthy living, he argues, should guide legal interventions in this area. Among the most topical challenges in the context of global health are those associated with medical tourism, including the global provision of organs and reproductive services. Two contributions focus on transnational reproductive services. Erin Nelson argues, based on an analysis of some contrasting examples of national approaches to commercial surrogacy, that domestic law prohibitions on commercial surrogacy are a driver of international surrogacy practices and generate considerable legal complications. Nelson elaborates on some of these complications, showing us how national citizenship and parentage rules can result in stateless children through international surrogacy arrangements. Although these problems are international in scope, she maintains that domestic law reform can help both to address these legal complications and to reduce the demand for international surrogacy. In sharp contrast Jocelyn Downie and Franoise Baylis argue for the transnational application and need for enforcement of existing laws. They discuss how the Canadian government fails to deal adequately with the transnational trade in human eggs notwithstanding the enactment of the federal Assisted Human Reproduction Act, which included relevant prohibitions and the establishment of a dedicated regulatory agency. The weaknesses, gaps, and uncertainties in the Canadian legal regime with respect to the transnational trade in human eggs, they argue, hold lessons for other jurisdictions. Downie and Baylis recommend that the Canadian government and its regulatory authorities should take immediate action to fill statutory gaps, explain to stakeholders the effects of the relevant law, and enforce that law. They should also counteract the transnational trade by using policy tools to pursue domestic self-sufficiency. Glenn Cohen tackles the issue of transplant tourism. He decorticates various traditional arguments made in the literature about the moral wrongness of the global sale of organs, paying particular attention to the corruption argument. Most traditional objections, he argues, are not substantiated. For Cohen, the strongest ethical argument for the prohibition of transplant tourism draws on evidence that informed consent is often lacking a very substantial number of seller/ donors subsequently regret their donation. Cohen 13

INTRO D UCTION

further discusses a variety of potential international and national legal interventions. In addition to hard and soft international legal instruments, domestic law reform can, according to Cohen, decrease transplant tourism. Destination countries can increase enforcement of prohibitions on organ sales. Home countries can give extraterritorial application to their prohibitions on organ sales, disallow health insurance coverage for follow-up medication and treatment, and require doctors to report suspected transplant tourists. Home countries can also use legal tools to increase the domestic organ supply. Y.Y. Brandon Chen and Colleen M. Flood challenge the assumption that it is up to the critics of medical tourism to clearly demonstrate the problems therewith arguing that, given the clear equity problems that arise with differential treatment in receiving countries, the burden of proof should lie with the proponents of medical tourism. They discuss how the limited empirical evidence suggests that modern medical tourism in which patients from developed countries seek treatment in low- and middle-income countries has a net negative impact on health equity and access to health care, especially primary and preventative health care, in destination countries. Chen and Flood suggest that developed countries should focus on ensuring sufficient domestic health care systems and insurance for their populations in order to reduce demand on the part of their citizens for medical tourism. Destination countries should insist upon direct cross-subsidization of the public health care system by the medical tourism industry. Finally, Timothy Caulfield and colleagues discuss the growing transnational travel of patients looking for highly experimental stem cell treatments at very high financial costs stem cell tourism. They raise doubt about the effectiveness of legal prohibitions. Such prohibitions, they suggest, are unlikely to deter this lucrative industry which preys on highly motivated but often ill-informed patients. Rather than focus on complex international regulations, they suggest the path forward requires improved patient education, which should inform decision-making and may deter stem cell tourism.Because prospective patients of these therapies tend to doubt the reasonableness of decisions made in the context of their own health care system and the approval process for new therapies, education should focus on the nature and importance of translational research and regulation and the ultimate goals of assessing both efficacy and safety. Educational material, they argue, needs to be readily available online in order to be effective. So can we conclude that law makes a difference to global health challenges? Our special symposium pro14

vides no definitive answer but instead adds complexity to the question. The contributions oscillate between shades of optimism and pessimism. Optimistic stories of the success of law or at least its potential highlight the interplay between international agreements, international monitoring and governance, domestic health human rights and litigation, and the role of NGOs. However, even the most optimistic commentators admit that success is hard won and frequently decades in the making, such as for example, in the case of tobacco control. This seems likely to be the case (and success certainly cannot be assumed) for new global challenges such as obesity. Several subthemes emerged as contributors explored optimistic scenarios. One theme, raised by Aeyal Gross and bearing further exploration, concerns whether the courts are more likely to be protective of health human rights that exist as part of government policy as opposed to ensuring the realization of these rights when not in place. The success of tobacco control litigation would seem to fall in line with this theme as demonstrative of courts protecting existing government policy but not catalyzing progressive change. Yet another sub-theme, raised by Mariana Prado, is whether litigation, which seems to undermine equality, might have a long-term positive knock-on effect in other areas, including the health care system and the operation of the courts. Social science research is needed to assess what the long-term impact of these changes are, even if these changes may not outweigh the immediate costs to access to care. Those contributors who are more pessimistic about the role of law also raised a number of sub-themes to flesh out the nature of their pessimism. First is the theme that the law alone is simply not mighty enough to combat some of the enormous global health challenges. Huge pressures on domestic health care systems aging populations, rising costs, new technologies, and bans on unethical practices will generate a pipeline of medical tourists. Some call for more assiduous efforts on the part of governments to regulate and yet others are concerned that domestic efforts to protect health-related human rights (for example by limiting commercial surrogacy) merely offload the problem to other jurisdictions such as India. Some commentators contend that global problems like medical tourism can only be truly met through global solutions and call for the establishment of international law and global governance mechanisms. Yet this fall-back position itself draws pessimism, as others express doubt that international law and norms are progressive or even benign, and they point to concerns regarding the potential for international trade agreements to exacerbate rather than ameliorate existjournal of law, medicine & ethics

Flood and Lemmens

ing vulnerabilities and inequities in access to health care unless greater policy cohesion between trade and health objectives can be achieved. Pessimists also point out that the usual tool of lawyers litigation may result in distortion of limited resources from the most vulnerable to those with wealth a problem that is exacerbated by access to justice problems. Litigation may be counterproductive when it undermines specific health policy decisions that have been developed in response to complex health systems challenges (e.g., funding decisions; or decisions reflecting a careful balancing of public and private funding mechanisms). Border-crossing practices not only evoke various technical transnational legal questions. Several contributions indirectly touched on the fact that globalization of health care has implications for national health care systems and for patients who receive health care strictly within national boundaries. When patients obtain information about the approval or funding of promising new treatments in other countries, health care systems are easily put under pressure to do the same, or to financially support patients in accessing treatment outside their jurisdiction. Similarly, health research and drug development processes that take place around the world influence national medical practices and health care policies. The serious pressures thus created on governments and health care providers should be an impetus for some of the worlds influential countries to take seriously the need for global coordination and enforcement. Several contributions developed the argument that health rights are not only about individually enforceable claims, but more about the recognition of positive and more systemic obligations to implement equitable health protection and promotion. References in human rights documents and in the literature to the concept of progressive realization of the right to health reflects a recognition of the limits of traditional rightsbased approaches not only in the context of complex health care decision making, but also in other areas of social life. Clearly, laws contribution to domestic or global health cannot only be about the creation of individually enforceable claims against the state or against others. All forms of rights conceptually entail both negative and positive duties, and acknowledgment of such heralds a more sophisticated understanding of how law operates (or should operate) in a larger societal context. No one obtains good health care in splendid isolation. Many of the challenges in the distribution of health and health care presented by recent globalization trends are different in nature from some of the

historical challenges, due to the speed with which people, goods, services, culture, and ideas travel the globe. But the profound technological, cultural and social changes associated with globalization also provide unique opportunities, for example with respect to improved knowledge sharing and, based on that, better-informed and more thoughtful policymaking. In the face of these overwhelming global health challenges, as legal advocates and scholars we must do more than simply proclaim the importance of healthrelated human rights. We need to rigorously research the short- and long-term impacts of different legal tools, honing our institutional responses to address global health challenges. We need to critically assess successes and failures of global legal interventions, harvesting the new communication and technological means to share our findings. We hope that this special issue contributes in a modest way to make health care rights work for those who need them the most. To end we would like to thank the people who helped make our conference and this special edition possible. We would like to thank Bryan Thomas who researched and advised us on potential contributors and did much of the background work we needed to host this event. Close to the conference itself we were aided by the stellar work of Arthur Wilson, Melissa Casco, and Bernadette Mount, the latter of whom stepped into the breach at the last minute and attended to the enormous number of tasks needed to make an event like ours a success. We would not have been able to convene our scholars without the help of generous sponsors (see http://nhlc2012.ca/sponsors/). With respect to this special journal edition, we thank Andrew Martin and Marcelo Rodriguez Ferrere for their organizational support and editing and review comments on many of the contributions; our anonymous peer-reviewers for their detailed feedback; ASLME President Mary-Anne Bobinski for her sage counsel; and Ted Hutchinson and his JLME team for their terrific editorial work. Final and heartfelt thanks to our contributors for their vibrant presentations and thought-provoking articles. References
1.  L. Gostin, The Unconscionable Health Gap: A Global Plan for Justice, The Lancet 375, no. 9725 (2010): 1504-1505. 2.  WHO Fact Sheet no. 178, Children: Reducing Mortality (September 2012), available at <http://www.who.int/mediacentre/factsheets/fs178/en/index.html> (last visited March 4, 2012). 3.  We define law broadly to include international law and agreements, constitutional law, ordinary legislation, regulation, administrative law, and soft law measures, but limited to those soft law measures with some normative strength and tools for enforcement (administrative decision-making and guidelines), etc. 4.  CEDAW/C/49/D/17/ 2008, 10 August 2011.

global health and the law spring 2013

15