International Pandemic Treaty: Is it really necessary?
by Hafidz L. Botua
The worldwide impact of the COVID-19 pandemic is devastating in many aspects. On March 30th 2021, the World Health Organization (WHO) officials and a group of world leaders met to initiate the formation of a treaty to improve the preparation and response towards future pandemics, so-called the “international pandemic treaty”.[1] According to the joint statement made, the agreement aims to strengthen international cooperation and resilience to future pandemics by enhancing the capability in mitigation efforts and providing equitable access to medical countermeasures. Subsequently, it aims for a better implementation of the International Health Regulations (IHR).[2]
The IHR, which has been the major framework for dealing with the pandemic for years, was also addressed in the meeting. This leads to a question, is the IHR itself insufficient to implement? Pursuant to this notion, this article would elaborate and analyse how the existing framework handles the pandemics (I) and whether a new treaty is necessary in light of this conception (II).
I. The Rule and the Pandemics
This section provides a quick overview of the IHR as the main framework against pandemics (A) and how it is applied in the present COVID-19 Pandemic (B).
A. About the IHR
The IHR takes the lead in dealing with diseases that spread across the world. As a legally binding international rule, it strives for international cooperation to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.[3]
Historically, the IHR was formed in 1969 following the revision of the International Sanitary Regulations 1951 as the first framework for global infectious disease prevention. Afterwards, it was amended in 1973 and 1981, in light of increased international travel and trade, as well as the emergence or re-emergence of international disease threats and other public health risks.[4]
Later, in 1995, the 48th World Health Assembly began revising the existing instrument. In 2003, an Intergovernmental Working Group was formed to study and suggest a draft revision of the Regulations which resulted in the adoption of the IHR 2005 by the 58th World Health Assembly on 23 May 2005,[5] later entered into force on 15 June 2007.[6]
In the event that a disease arises to a large scale, which may constitute a public health emergency of international concern (PHEIC), a state shall provide all relevant public health information to the WHO.[7] Since 2007 there have been 6 PHEICs declarations: the 2009 H1N1 Pandemic, the 2014 Polio Outbreak, the 2014 EVD in West Africa, the 2016 Zika Outbreak, another EVD outbreak in 2019 and the current COVID-19 Pandemic.[8] In those circumstances, the WHO would issue a recommendation of health measures that states are implored to implement in handling the pandemic.[9]
Apart from the health measures which are proposed in the recommendation, states could deploy additional health measures which at least achieve the same or greater level of health protection than the WHO recommendations. States shall base their determinations in applying additional health measures upon:[10]
- Scientific principles;
- Available scientific evidence of a risk to human health, or where such evidence is insufficient, the available information including from WHO and other relevant intergovernmental organizations and international bodies; and
- Any available specific guidance or advice from WHO.
The objective of such strict criteria are clear: the IHR does not only aim to facilitate states’ efforts to handle pandemics, but also to avoid unnecessary interference with international travel and traffic which could worsen the social and economic conditions of states that are affected by the disease.[11]
B. The Role of IHR in the COVID-19 Pandemic
The implementation of the IHR could not be separated from the WHO as an international institution with a major and historic responsibility to manage issues regarding the international spread of disease. On 23 January 2020, the Emergency Committee convened by the WHO Director-General held a meeting in response to the reported virus. Even though the conclusion was not yet to declare a PHEIC, the meeting concluded to agree on “the urgency of the situation and suggested that the Committee should be reconvened in a matter of days to examine the situation further”.[12] Later, on 30 January 2020, The Director-General declared that the outbreak of COVID-19 constitutes a PHEIC and accepted the Committee’s advice and issued it as Temporary Recommendations under the Article 15 of the IHR.[13]
However, following the PHEIC declaration, a large number of states applied additional health measures which were contrary to the WHO Recommendations. It was shown by states’ action in imposing mandatory restrictions on international travel and trade, particularly against the People’s Republic of China.[14] Travel restrictions are not supported by science and have been challenged by public health researchers.[15] Moreover, the scientific reasoning behind travel restrictions is questionable since public health researchers stated that it could only hinder disease transmission, rather than prevent the introduction of a novel pathogen.[16]
Despite the fact that this infringement exists, there may not be much that can be done since the IHR only provides limited incentives to ensure State Parties compliance and the WHO has no legal authority to restrain States Parties from disregarding its recommendations. However, to find some clarity, the WHO may request that the State Party concerned reconsider the application of the measures under Article 43.4 of the IHR.
Apart from the strict requirements in imposing international trade and travel restrictions, under Article 43.5 of the IHR, states have an obligation to inform the WHO, within 48 hours of implementation, of such measures and their health rationale unless these are covered by a temporary or standing recommendation. In this regard, at least two-thirds of states violate this obligation.[17]
Although the concerns regarding travel restrictions to China might be justified in the unprecedented situation, the government policy might influence different things on certain societies. This is due to the fact that some government leaders and senior officials in some instances have directly or indirectly encouraged hate crimes, racism, or xenophobia by using anti-Chinese rhetoric following the announcement on travel restrictions.[18] If such an attributable political intent to impose certain measures on a specific nation could be proven, then such practice is obviously in violation of the IHR, which mandates “full respect for the dignity, human rights and fundamental freedoms of persons” on the implementation of additional health measures.[19] In this instance, some states failed to promote civil rights of respect for individual dignity and non-discrimination as an inviolable foundation on their policies.[20]
II. The Necessities of International Pandemic Treaty
This initiated International Pandemic Treaty intends to improve pandemic risk surveillance, alerts, response, and implementation, as well as to restore trust in the international health system. We must affirm that there will never be a perfect set of rules; yet, in the case of the IHR, the aforementioned arrangements have already served. The concern with the international framework against pandemics should not exaggeratedly push the normative substance, since the issues mostly reside in the implementation, particularly in the monitoring and enforcement mechanism (A); additionally, states that do not evaluate the occurring issues tend to repeat the same mistakes (B).
A. Ineffective Mechanism on Monitoring and Enforcement
Normatively, it could be said that the IHR lacks effective mechanisms on monitoring and enforcement, which affects the efficacy of the global war against the outbreak, and hence places a high reliance on good faith. The WHO has already provided the “IHR Core Capacity Monitoring Framework” in 2010 (subsequently updated) to guide State Parties in developing the IHR core capacities.[21] However, it fails due to national self-interest which resulted in unreliable reports as the main source of monitoring mechanism.[22] Subsequently, there is no enforcement mechanism to sanction states that disregard any measures issued by the WHO.
The discussions in this section would address the issues within the unimplemented measures which affect the inadequate healthcare (1) and lack of cooperation among the corresponding parties (2).
1. Inadequate Health Care
One of the main issues with the implementation of the IHR is that states failed to invest in their public health systems. Within the IHR innovative approach to 2005 revision, it aims for the establishment of structural and capacity-building responsibilities. These “core capacity requirements” are stipulated in Article 5 (Surveillance) and Article 13 (Public health response) of the IHR. Annex 1 of the IHR (Core Capacity Requirements for Surveillance and Response) additionally requests such core capacity to be implemented ‘as soon as possible but no later than five years from the entry into force’ (namely 15 June 2007), while allowing states to demand for a two-year extension in cases with “justified needs” and a corresponding two-year postponement based on “exceptional circumstances”.[23]
States have used such options when deadlines approached: in 2012, 118 states requested an extension, while 38 failed to report; in 2014, 81 states requested a further postponement, while 48 failed to communicate at all.[24] The extensions ended in 2016, and the WHO Director-General acknowledged that “progress has been made, but these capacities have not been established in many countries,” without naming and shaming non-compliant countries.[25]
Further, only a third of parties could reach the public health systems core capacities required by the revised IHR after more than a decade of its implementation.[26] When measures comprised of monitoring, health management, and screening at ports were urged by the WHO during the COVID-19 Pandemic,[27] the states who had not reached its minimum required standards would be hampered in implementing those measures.
In this instance, good governance, political stability, and population balance are essential factors in achieving universal health coverage.[28] These factors lead to a diverse ability in handling the pandemic, e.g., following the MERS pandemic in South Korea, the government enacted a total of 48 regulatory amendments that aimed for a better preparation against future pandemics.[29] Isolation and tracking systems are now well upgraded. During the current COVID-19, South Korea conducted more than 10,000 tests a day, and brought the epidemic under control in mid-April of 2021.[30]
Meanwhile, China, where the outbreak was first detected, has the ability to construct a hospital in six days to accommodate for the impact of the outbreak.[31] The city was completely cut off from the rest of the world from late January to June.[32] Further, China had completed a 1,500-room temporary hospital in Beijing after being struck by a new wave of coronavirus cases.[33]
On the other hand, countries with lack of capacities like India grappled with record coronavirus cases and a shortage of medical equipment. The country is also facing a devastating lack of medical oxygen and hospital beds.[34] The disparity exists within those countries which could not meet the aforementioned factors.
2. Lack of Cooperation — The Hampered Vaccine Efforts
Cooperation is another key component in dealing with the pandemic; nevertheless, even in states with strong public health capacities, the international cooperation responses to COVID-19 are regrettably inadequate.[35] Article 44 of the IHR requires states to collaborate over any channel including bilaterally, through regional networks and the WHO regional offices, and through intergovernmental organizations and international bodies. However, this provision is too soft to implement. It cannot be denied that cooperation exists, such as the sharing of medical equipment and experts. Still, the poor cooperation specifically in regards to vaccines has become a long unresolved issue.
Currently, efforts to combat the pandemic are focusing on vaccine development and distribution. There is a concern that wealthy countries are ‘blocking’ vaccine efforts for developing countries based on their vaccine manufacturing capabilities, due to patent-related requirements and manufacturing capabilities.[36] Despite the WHO’s demand for patents to be waived during the pandemic, developed countries have refused requests from developing countries to share vaccine manufacturing technology. The bulk of the 459 million vaccines administered worldwide were only in ten countries.[37] A crisis similar to the one in HIV/AIDS drugs (where millions died because patents and high prices restricted antiretrovirals to the global North–until activists challenged patents and prices plummeted), but on a much larger scale, is emerging.[38] Although in the context of a pandemic, monopolists have perfectly reasonable reasons to limit supply. Focusing on rich country markets and keeping the know-how hidden can be a profitable strategy for controlling the vaccine market in the long run.[39]
The pandemic has demonstrated the potential of various countries to obtain vaccines and medicines. However, since global vaccine production capacity is still limited, it is necessary for developing countries to possess the right on vaccine productions apart from their right on a share of it. Other than funding, the collaborations in creating and exchanging vaccines and medicines will complement other initiatives to foster cooperation and help the world’s most vulnerable populations.
B. What do We Learn from the previous Pandemics?
There will always be a lot of time to evaluate and improve the quality of affordable and sophisticated healthcare, which will not be further discussed in this subsection since it is already elaborated above.[40] Subsequently, this part would elaborate on the flawed implementation of the IHR, which is not the first instance of its occurrence.
The reasoning behind the implementations of additional health measures (Article 43 IHR) have always been a problem. The poor scientific basis on the travel and trade measures during the H1N1 pandemic were challenged due to their unnecessarily infringing nature on foreign trade and human rights.[41] Furthermore, the earlier Ebola epidemic is not less troubling. General bans on international travel and entry screening were not recommended by the WHO. However, the same violations occurred by imposing international traffic on West Africa without being backed by science or public health recommendations.[42] The WHO reported that “very few countries informed WHO that they were implementing additional measures significantly interfering with international traffic and when requested to justify their measures, few did so.”[43]
The implementation of Article 44 of the IHR regarding collaboration and assistance has also become an unresolved issue. Throughout the MERS pandemic, the Saudi Arabian government seemed unable to exchange information and to be open to foreign assistance, which undermined the transparency.[44] Additionally, in the context of vaccines during the H1N1 pandemic, equitable vaccine access became an issue since developed countries secured access to most of the vaccine supply, undermining the access for developing countries.[45]
Eventually, the overall habit against outbreaks reveals that adherence to the IHR has been undermined. Thus, reducing national self-interest would be one of the essential requirements to establish effective global governance.
A Way Forward
To put an end to the aforementioned discussion, the author would like to point out that the International Pandemic Treaty is not required. This rationale is based on four requirements for determining whether global health treaties have a realistic chance of producing net positive benefits.[46] First, the problem being addressed must have a major international dimension. Second, the goals should justify the treaties’ coercive nature. Third, prospective global health treaties must have a credible probability of succeeding. Fourth, of the many competing commitment mechanisms, treaties should be the best option.
Within the context of the International Pandemic Treaty, the first and second conditions are unquestionably met, since the transnational nature of global health challenges necessitates binding collective action. However, the other conditions are unlikely to be met, with the third lacking incentives and possibly insufficient accountability, and the fourth due to the treaty not being the best option given the presence of the IHR itself. As previously stated, its aim to achieve a better implementation of the IHR might be “inappropriate” since it is too vague to imagine what kind of regulations would complement the existence of the IHR given that it has already compiled a comprehensive effort against global pandemic, ranging from surveillance to cooperation.
We are undeniably desperate for binding health measures. As a solution, efforts to better utilize or revise existing international instruments for global health purposes may be more effective than pushing for new treaties in terms of achieving health outcomes. Establishing a new treaty means forming a new regime of governance, most of its problems are often too vague on specific commitments, slow to be implemented, hard to enforce, and difficult to update. They have the potential to limit future decision-making and stifle alternative methods.[47]
Revising the IHR might be a better approach and there are three main essential points which should be regulated in future instruments, which are mandatory reporting and monitoring, priority approach towards developing countries, and mandatory dispute resolution process. First, in any step towards preparedness and response against the pandemic, it necessitates rigorous reporting and monitoring processes, such as reports on the steps taken, progress achieved, and issues experienced during implementation. Periodic monitoring processes help states identify and overcome barriers to achieving commitments without criticizing their output. Lack of transparency to fulfil the IHR commitments hampers the IHR from achieving its goal to avoid the disturbance of international traffic during the outbreak.
Second, future instruments should emphasize the needs of poor nations. Another problem of establishing a new treaty is that it is prone to the risks of coercion and paternalism, since treaties tend to be largely dictated by powerful countries on the basis of minimal expectations that they have already met, and so new domestic standards often affect only poorer countries or countries with less governmental capacity. Most developed states have the domestic capabilities to handle the diseases the IHR covers, which renders the regime insignificant for these states.[48] Moreover, the history of the IHR reflects conflicting and shifting interests of various groups of states where the world’s economically powerful countries pressed for restrictions on health measures to address the harm they caused to their trading interests.[49] Thus, the latter initiative is necessary to support developing countries to satisfy the IHR core capacities.
Third, the previous measures need to be strengthened by the mandatory dispute resolution process. Based on the previous pandemics, noncompliance stems from the lack of binding nature of regulations. It might be “undesirable” to rely on sanctioning and dispute mechanisms within this situation, since “the existence of international law relies within the acceptance by society that its rules are binding, not from its enforceability”, as Hart said. However, if it is critical and essential, the future instrument may include a mandatory dispute resolution process, which would not only help ensure that the treaty’s rulings are carried out, but also urge state parties to take the entire system more seriously.[50]
The present IHR roots from the instrument which has been revised a couple of times to serve our needs. However, if the textual clarity to bind the states to comply is not yet dealt with, it could result in one of many loopholes that could lead to a proper ground for violating most of the flexible measures.
The “proposed agreement” aims to eliminate nationalism by enhancing global cooperation. However, the current progress in fighting against the pandemic has not yet shown the interest of states to comply with the already existing framework. The previous pandemics’ rule and the efforts have shown that countries are inclined to cherry pick the laws to obey and then set the precedence of noncompliance to other countries. It is unlikely to have effective global governance if countries disregard each other on their own consensus, so good faith and compliance must be preserved.
In the longer term, it is not about revising and possessing a better regulation, but revising and implementing those rules to serve our needs. Countries could begin by supporting the WHO and one another in the implementation of the IHR instead of maintaining political lip service. As much as ever, the rule of international law must be upheld.
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[1] There are Fiji; Thailand; Portugal; Italy; Romania; United Kingdom; Rwanda; Albania; Chile; Costa Rica; Croatia; European Council; France; Germany; Greece; Indonesia; Kenya; Netherlands; Norway; Republic of Korea; Senegal; Serbia; South Africa; Spain; Trinidad and Tobago; Tunisia; Ukraine. In COVID-19 shows why united action is needed for more robust international health architecture, https://www.who.int/news-room/commentaries/detail/op-ed---covid-19-shows-why-united-action-is-needed-for-more-robust-international-health-architecture, accessed 5 May 2021.
[2] Ibid.
[3] World Health Organization (WHO), International Health Regulations 2005, Article 2.
[4] WHO Official Records, №209, 1973, resolution WHA26.55. ; WHA34/1981/REC/1 resolution WHA34.13; WHO Official Records, №217, 1974, resolution WHA27.45, and resolution EB67.R13, Amendment of the International Health Regulations (1969).
[5] WHO Resolution WHA58.3.
[6] WHO Resolution WHA56.28.
[7] WHO, International Health Regulations 2005, Article 7; for the scope of disease see Article 9; for the scope of PHEIC see Article 2.
[8] Mullen, Lucia, Christina Potter, Lawrence O. Gostin, Anita Cicero, and Jennifer B. Nuzzo. “An analysis of international health regulations emergency committees and public health emergency of international concern designations.” BMJ global health 5, no. 6 (2020): e002502.
[9] Part III Recommendations — International Health Regulations
[10] WHO, International Health Regulations 2005, Article 43 — “Additional health measures … or would refer to several condition which are otherwise prohibited under Article 25, Article 26, paragraphs 1 and 2 of Article 28, Article 30, paragraph 1(c) of Article 31 and Article 33 of IHR”
[12] See Statement on the meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus 2019 (n-CoV) on 23 January 2020 (who.int) accessed 5 May 2021
[14] WHO, Novel Coronavirus(2019-nCoV) Situation Report — 18 ; Think Global Health, Travel Restrictions on China due to COVID-19, https://www.thinkglobalhealth.org/article/travel-restrictions-china-due-covid-19 accessed on 20 May 2021
[15] Brownstein, John S., Cecily J. Wolfe, and Kenneth D. Mandl. “Empirical evidence for the effect of airline travel on inter-regional influenza spread in the United States.” PLoS Med 3, no. 10 (2006): e401 ; Mateus, Ana LP, Harmony E. Otete, Charles R. Beck, Gayle P. Dolan, and Jonathan S. Nguyen-Van-Tam. “Effectiveness of travel restrictions in the rapid containment of human influenza: a systematic review.” Bulletin of the World Health Organization 92 (2014): 868–880D ; Poletto, Chiara, M. F. Gomes, A. Pastore y Piontti, Luca Rossi, Livio Bioglio, Dennis L. Chao, I. M. Longini Jr, M. Elizabeth Halloran, Vittoria Colizza, and Alessandro Vespignani. “Assessing the impact of travel restrictions on international spread of the 2014 West African Ebola epidemic.” Eurosurveillance 19, no. 42 (2014): 20936.
[16] WHO, Novel coronavirus (2019-nCoV) situation report — 39; Tejpar, A. L. I., and Steven J. Hoffman. “Canada’s violation of international law during the 2014–16 Ebola outbreak.” Canadian Yearbook of International Law/Annuaire canadien de droit international 54 (2017): 366–383 ; World Health Organization. Updated WHO recommendations for international traffic in relation to COVID-19 outbreak, https://www.who.int/news-room/articles-detail/updated-who-recommendations-for-international-traffic-in-relation-to-covid-19-outbreak accessed 5 May 2021
[17] Novel coronavirus (2019-nCoV) situation report — 39 ; WHO, International Health Regulations 2005, Article 43.
[18] Human Rights Watch, Covid-19 Fueling Anti-Asian Racism and Xenophobia Worldwide, https://www.hrw.org/news/2020/05/12/covid-19-fueling-anti-asian-racism-and-xenophobia-worldwide accesed 20 May 2021 ; Ruiz, Neil G., Juliana Menasce Horowitz, and Christine Tamir. “Many Black and Asian Americans say they have experienced discrimination amid the COVID-19 outbreak.” Pew Research Center 1 (2020).
[19] WHO, International Health Regulations 2005, Article 3.
[20] Zidar, Andraž. “WHO International Health Regulations and human rights: from allusions to inclusion.” The International Journal of Human Rights 19, no. 4 (2015): 505–526.
[21] WHO. IHR Core Capacity Monitoring Framework: Checklist and Indicators for Monitoring Progress in the Development of IHR Core Capacities in States Parties. Geneva, Switzerland: WHO; 2013.
[22] WHO. Implementation of the International Health Regulations (2005): report of the Review Committee on Second Extensions for Establishing National Public Health Capacities and on IHR Implementation: report by the Director General. March 27, 2015: para. 17
[23]Both to be granted by the Director-General taking into account the technical advice of the Review Committee based on Article 50 of International Health Regulations 2005.
[24] WHO, ‘Report of the Review Committee on Second Extensions for Establishing National Public Health Capacities and on IHR Implementation’ (16 January 2015) EB136/22 Add.1, 2.
[25] WHO, ‘Annual Report on the Implementation of the International Health Regulations (2005). Report by the Director-General’ (18 May 2016) A69/20, para 16.
[26] Board, Global Preparedness Monitoring. “A world at risk.” Geneva: World Health Organization and the World Bank (2019).
[27] WHO. Novel coronavirus (2019-nCoV) technical guidance. 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance accessed 5 May 2021
[28] Ranabhat, Chhabi Lal, Mihajlo Jakovljevic, Meghnath Dhimal, and Chun-Bae Kim. “Structural factors responsible for universal health coverage in low-and middle-income countries: results from 118 countries.” Frontiers in public health 7 (2020): 414.
[29] Vox, South Korea’s Covid-19 success story started with failure, accessed from https://www.vox.com/22380161/south-korea-covid-19-coronavirus-pandemic-contact-tracing-testing accessed 5 May 2021
[30] Ibid.
[31] BBC, Coronavirus: How can China build a hospital so quickly?, accessed from https://www.bbc.com/news/world-asia-china-51245156 accessed 5 May 2021
[32] Ibid.
[33] DW, Coronavirus: China builds hospital in 5 days after virus surge, accessed from https://www.dw.com/en/coronavirus-china-builds-hospital-in-5-days-after-virus-surge/a-56247241 accessed 5 May 2021
[34] BBC, India’s Covid crisis deepens amid shortage of jabs, accessed from https://www.bbc.com/news/live/uk-56954831
[35] Aitken T, Chin KL, Liew D, Ofori-Asenso R. Rethinking pandemic preparation: Global Health Security Index (GHSI) is predictive of COVID-19 burden, but in the opposite direction. J Infect 2020; published online May 10.
[36] BBC, Covid: Rich states ‘block’ vaccine plans for developing nations, accessed from https://www.bbc.com/news/world-56465395 accessed 5 May 2021
[37] Ibid.
[38] LPE Project. Amy Kapczynski — How To Vaccinate The World, Part 1, https://lpeproject.org/blog/how-to-vaccinate-the-world-part-1/ accessed 5 May 2021
[39] Ibid.
[40] See II.A.1
[41] Katz, Rebecca, and Julie Fischer. “The revised international Health Regulations: a framework for global pandemic response.” Global health governance 3, no. 2 (2010).
[42] Rhymer, Wendy, and Rick Speare. “Countries’ response to WHO’s travel recommendations during the 2013–2016 Ebola outbreak.” Bulletin of the World Health Organization 95, no. 1 (2017): 10.
[43] World Health Organization Executive Board, IHR and Ebola (Geneva: WHO, January 9, 2015), 3.
[44] Gostin, Lawrence O., and Rebecca Katz. “The International Health Regulations: the governing framework for global health security.” The Milbank Quarterly 94, no. 2 (2016): 264–313.
[45] WHO Director-General Margaret Chan, “Strengthening Multilateral Cooperation on Intellectual Property and Public Health,” speech, World Intellectual Property Organization Conference on Intellectual Property and Public Policy Issues, Geneva, July 14, 2009
[46] Hoffman, Steven J., John-Arne Røttingen, and Julio Frenk. “Assessing proposals for new global health treaties: an analytic framework.” American Journal of Public Health 105, no. 8 (2015): 1523–1530.
[47] Kennedy, David. The international human rights movement: Part of the problem?. Routledge, 2017.
[48] Fidler, David P. “Epic failure of Ebola and global health security.” The Brown Journal of World Affairs 21, no. 2 (2015): 179–197.
[49] Aginam, Obijiofor. Global health governance. University of Toronto Press, 2016.
[50] Asha Behdinan et al., Some Global Policies for Antibiotic Resistance Depend on Legally Binding and Enforceable Commitments, 43 J. L. MED. & ETHICS 68 (2015); S.J. Hoffman, et al., International Law’s Effects on Health and its Social Determinants: Protocol for a Systematic Review, MetaAnalysis, and Meta-Regression Analysis, 5 SYSTEMATIC REVS. 1 (2016).
