Grand Challenges for Global Health Law: from Ebola, to Cancer and Diabetes

By Brigit Toebes, University of Groningen, b.c.a.toebes(at)

For the Dutch version, please refer to this link.

In 2014, the largest and by far most serious outbreak of Ebola occurred since the virus was first detected in 1976. With an overall death toll of 11.300, there were more cases and deaths in this outbreak than in all others combined. The disease quickly spread between countries, starting in Guinea and then spreading to Sierra Leone and Liberia.

The International Health Regulations, adopted by the World Health Organization (WHO) in 2005 to monitor such outbreaks, provide for a chain of responses requiring the country where the outbreak occurs to report to WHO and the WHO to respond and to interfere. However, while the affected States were slow to report to WHO, the WHO waited five months before it declared the epidemic a ‘public health emergency of international concern’. Consequently, the UN Security Council interfered with the adoption of UNMEER, the first UN emergency health mission. The Ebola outbreak reveals that the WHO as the primary organization to manage global health, is ill-equipped to deal with a global health security crisis. The International Health Regulations lack an enforcement mechanism and  do not provide for the possibility to sanction States in case of non-compliance. WHO itself lacks the financial means and the capacity to be the key player when a health emergency that potentially poses a threat to global health occurs.

The Ebola crisis also reveals a human rights crisis in the affected countries.  As they have very weak health systems and very poor health infrastructures, these countries lacked the facilities and staff to address the crisis. What is more, given that hospitals were closed after the outbreak, many patients with other compelling needs, including childbirth, were completely left to their own devices. In addition, the countries invoked multiple and often over-restrictive forms of quarantine and restrictions on freedom of movement, including school closures and bans on public gatherings. The communication about the risks of traditional burial rites was poor. As such, human rights including the rights to health, information, privacy, freedom of movement and the right to an adequate standard of living were severely compromised.

While the Ebola crisis challenges global health law in several ways, we should not become possessed with the need to address infectious diseases. Over the coming decennia the world will face a dramatic increase in chronic diseases (non-communicable diseases or NCDs), in particular cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. The WHO estimates that by 2030, NCDs will be the leading cause of death in every region in the world. This pandemic will also come with considerable cost: according to the World Economic Forum, NCDs will cost more than $ 30 trillion over the next 20 years, representing 48% of global GDP. We may conclude that compared to the NCD pandemic, Ebola is peanuts.

NCDs disproportionately affect low- and middle-income countries (LICs and MICs) where –according to the WHO – nearly three quarters of NCD deaths occur. To give one concrete example: research indicates among slum dwellers in Nigeria’s megacity of Lagos, the overall prevalence of hypertension was 38.2% in 2013. In countries like Nigeria, the cost of NCD medication pushes large segments of the population into poverty. Yet high-income countries also face the rising costs of NCD treatment, medicines in particular. In the Netherlands we are currently witnessing a fierce debate about the high prices of essential medicines to treat cancer and other infectious diseases, some of which are becoming unaffordable to individual patients and to the health system at large.

In this context, it will be important to research the possibilities of regulating unhealthy behavior. Chronic diseases are also called lifestyle diseases as they are generally linked to four shared  risk factors that enhance the incidence of these diseases: tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. Here it should be taken into account that regulating lifestyle choices is still controversial: due to an emphasis on autonomy and ‘personal responsibility’, especially in a high- income country like the Netherlands, there is resistance to interfering with such choices.

So far, tobacco remains the only risk factor that is successfully regulated through a treaty. The Framework Convention Tobacco Control, which was adopted in 2003, has led to a tightening of many domestic tobacco laws and to several domestic court cases addressing the harmful effects of tobacco. Should and could international law also regulate the other risk factors, in particular unhealthy food and diets? How can international law tackle the responsibilities of the industry that produces these products? These are some matters that are discussed in the context of international or global health law, an exciting and important new field of public international law that is currently receiving much attention internationally.


Global Health Law Groningen Research Centre

Gian Luca Burci and Brigit Toebes (eds.), Research Handbook on Global Health Law, forthcoming with Edward Elgar Publishers in 2017.

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