Professor Gostin’s Keynote
Georgetown Law Journal Symposium: Law and the Nation’s Health
Opening remarks by Dr. Anthony Fauci and Keynote by Lawrence Gostin
Dr. Anthony Fauci
Thank you very much, it is a real pleasure to be with you this morning. I am here today to tell you a little bit about Larry Gostin. While I know many of you have been friends with Larry Gostin over the years, I have had the opportunity to work closely with him over many years and may be able to provide a bit of a different perspective.
I want to take just a few minutes before his plenary address to highlight some important elements of Larry’s career that some of you may not know. First, with regard to his pedigree, he received his BA in 1971 from the State University of New York at Bradford, his law degree from Duke, and Fulbright Fellowship at Oxford University, University of London in Psychiatry in law. This impressive list of accomplishments is only the beginning.
During the next four decades, I had the privilege being Larry’s colleague and friend, as he would evolve into one of the most influential figures in the world; pointing out and ensuring that ethical consideration prevailed in any discussions or activity involved global health. As a lawyer, he became the world’s expert on global health law, and used the law to ensure the implementation of ethical principles in this arena.
From the earliest days of the AIDS pandemics, when I had the privilege of working side by side with Larry, he fought tirelessly for the rights of people living with HIV/AIDS. Beginning in 1988, he collaborated with Jonathan Mann, the then director of the WHO Global Program for AIDS, to publish a fundamental framework for understanding the link between health and human rights, as well as for promoting the importance of human rights impact assessments for formulating and evaluating public health policies.
By serving on the National Institute of Allergy and Infectious Diseases (NIAID) Office of Research Advisory Committee, Larry provided critical legal and bioethical advice to the Director of the National Institute of Health, the Secretary of Health and Human Services (HHS), and to myself as the Director of the NIAID. He also served on the Center of Disease Control (CDC) National Advisory Committee on HIV and STD prevention, and on the Food and Drug Administration (FDA) Drug Safety and Risk Management Advisory Committee. I think it is fair to say, there has not been an important government agency for which Larry has not been a primary advisor.
That interest on impact also went beyond HIV, as he has been involved in the ethics plans to mitigate public health threats of outbreaks such as Anthrax, Zika and Ebola. Following the anthrax attack after September the 11, 2011, Larry drafted the Model Emergency Powers Act to safeguard the liberty and privacy of individuals, while simultaneously protecting the public’s health. He also provided unique and crucial insight on two global commissions on the lesson we have learned from the 2014 and 2016 West Africa Ebola outbreaks, and again served as an advisor to the UN Secretary General on a post Ebola commission.
Today, his unwavering commitment for national and global health security is demonstrated by key leadership roles, where Larry advises just about everybody who plays a major role in the global health arena – such as NIAID, the National Medicine Research Council, the World Health Organization, the World Bank – on a wide range of public health threats from the opioid crisis, to the global HIV pandemic, to Zika, cancer, the pandemic flu, and the International Health Regulations. Just last week, Larry was interviewed on the Voice of America on the increasingly critical need for community engagement as a vital component of how we respond to the latest Ebola outbreak in Democratic Republic of Congo. His work on the AIDS pandemic, public health law and now global health law, has established new fields of research and advocacy for the right to health.
Global health with justice has been the tie that binds Larry’s career. Ill health, whether it be HIV or a mental disability, and one’s ability to secure rights and justice, is ultimately caused by poverty, being poor, and being born in poor country. He has written several textbooks, given major lectures, and has published countless writings, all of which have inspired an untold number of students in this room to enter the growing fields of public and global health law with the aim of seeking global health with justice. As you know, he founded the O’Neill Institute for National and Global Health Law as the founding O’Neill Chair in global health law at Georgetown University Law Center. He directs the WHO Collaborating Center on National and Global Health Law and serves as co-chair of the Lancet – O’Neill Commission on Global Health and the Law. So, you could imagine that he does not really have any time to sleep! Larry has received numerous prestigious awards that I cannot even begin to mention all of them. In 2017, Larry wrote a pioneer essay about his one hundred- and one-year-old father called, “In the world’s richest country, is it too much to ask that we treat everyone when they are sick, care for them when they are suffering, allow them to die humanely and with dignity when the journey is over?” This one sentence captures all that Larry believes in and fights for every day.
On a personal note, I have had the privilege of knowing Larry, as I previously mentioned, for the past four decades and, beneath that ferocious warrior for human rights and justice is one of the kindest, most gentle, most considerate, and unselfish people whose life is guided by the highest level of integrity. Larry, I feel fortunate to have been your friend and colleague for so many years and today, along with participants of the special symposium on Law and the Nation’s Health, I recognize and honor your tireless dedication and service to national and global health with justice. Congratulations on your remarkable accomplishments my friend, and I wish you continued success in the future.
Professor Larry Gostin
I didn’t think Tony would actually get me to cry, but I did; it is overwhelming, particularly from Tony. We have known each other for 40 years and he looks a lot better than me. I think there is only one word that captures Tony: he is a national treasure. He has literally been our scientific and moral voice, our conscious in so many areas – from AIDS to Zika to Ebola to Influenza. Just to have Tony here is such an honor. Tony, I cannot even begin to thank you and what your friendship has meant to me.
I also wanted to take this opportunity today to thank the whole Georgetown Law Journal team, who have always done a fantastic job, with a particular acknowledgment of Caitlin Haynes and Grace Paras, who have been amazing law journal editors. It is really humbling and joyful for me, and all of us in the room, that they devoted this journal to Law and the Nation’s Health. I would also like to say thank you to Sam Halabi: the whole symposium was your idea. I never ever thought it would come to fruition but, were it not for you, it would never have even had a germ of inspiration.
The O’Neill Institute community is like a family. Katie Gottschalk, our executive director, is here, along with many others including Matt Kavanagh, Jeff Crowley, Regina LaBelle, Oscar Cabrera, all of whom mean so much to the Institute. And of course, none of this would be possible without the support of Tim and Linda O’Neill. Georgetown – the law school, faculty and the students – has become my second home and my community. Many of my colleagues were from here: Nan, Tim, Craig, David, John Monahan and others, have been spectacular friends and supports to me throughout my many years at this institution. I do not know if students here realize the privilege that you have got, to have the heath law faculty that we have just here. These are our people who really have loved the intellectual search for health and justice in America and globally. Abby, Dana, Jen, Glen, Mary, Emily, and More have really been very inspirational and, for me, they are my heroes. They are the ones who spoken with such clarity and voice about health in America and globally and it is just a true honor to be here with them. Finally, there is one special person in here at Georgetown that I must acknowledge: Eric Friedman. Eric has been my partner in writing for such a long time. He is a young person from Yale Law School that has off the charts intelligence and who could be doing anything in his life. He is modest, compassionate, and thinks every day: I have to hold him back because he sometimes lets his heart get beyond his head in what we can argue, but I really love it. Thank you very much Eric.
When I wrote the Global Health Law book and thought about the last chapter, I had a lot of trouble thinking about how I could encapsulate it. So, what I did was something that I often tell students: “sometimes, over simplification can actually bring a certain clarity to your thinking”. The book has a lot of legal technicality in it and I felt that it was all right to oversimplify. So, I asked three big questions and said, “If you could frame these questions and successfully answer them, you would be coming a long way to achieving global health with justice.” The three questions may seem naive but I am going to try to explain why we do the exact opposite nationally and globally, despite the fact that these questions should be intuitive to us as human beings.
First, “what would an ideal state of health be?” What does that mean and how do we assure the conditions in which people can be healthy? The second is “how do we get to health with justice. That is, how do you equitably distribute the benefit of good health?” The third is “how would you get there? What steps would you take?” This one is the hard talk and I am not going to spend much time talking about that here. However, for the Georgetown Law Journal article that Eric and I are writing, we are spending most of it on the question on “how you get there and what are the designed features”.
If you think about what you hear in global health, you will have things that strike me as opposite conclusions and yet the opposites are both true. I will explain why. If you ask Dr. Tedros – the Director-General of World Health Organization – or Bill Gates, or Michel Bloomberg, they will all say: “don’t give up on global health; we are doing really, really well.” And we are! We are doing phenomenally well in global health. We have got reductions in maternal and child mortality; people are living longer around the world; absolute poverty has gone way down; 20 million people in lower income countries in sub-Saharan Africa are on antiretroviral medication. In all of those areas ,we are doing well. Many of the gains we have made really track with the Millennium Development Goals. We have to see what the UN Sustainable Development Goals will bring us, but we have been doing enormously well.
Then you have another narrative, which is about justice. When I wrote the Global Health Law book, I asked my editors at Harvard, “Who shall I have write the foreword? Who would you like?”, and one of them gave me the best advice I ever got. She said, “Nobody cares what they think, so come up with another idea.” The other idea that I came up with was to work with our civil society partners around the world. We went to young children and asked them to tell us about a day in their lives, and from those conversation, we published their stories. I wanted to read two of these stories for you to give you an understanding about what peoples’ real lives are.
Nmurubu is a young woman living in Ggaba, the suburb of Kampala in Uganda. She says:
“I live in a very rowdy place; no clean water, no good toilets or bathrooms. I have to move long distances every day for clean water to cook. At night, the conditions worsen. There is hardly any electricity; the mosquito noise fills up the place; cockroaches move around me and it makes me sick. Even when I fall sick, I hardly ever go to a hospital. My mother, who would have helped me with medication fees, is living with AIDS. Life is too hard and complicated for me. I have to cook food for my brother; this forces me to cook one meal a day because we do not have the money to get the food we need to get healthy and a lot of violence happens to me and my friends. We are all raped, robbed and our properties are stolen. I am thinking of getting a job, but I know the salary would be too small. I am so sad I need a new life.”
One of the things that I wanted to do in the book was to show that a lot of us here in US think that these are problems somewhere else but in fact, they also exist in the richest country in the world. I was working for quite a long time on tribal reservation in Montana and I should talk about the life expectancy on that reservation compared to the town next door. I met a young man named Johnny who said very things different from Nmurubu.
“I start my day with a cup of joe; I corral ride; break horses. I smoke a bowl of weed about six or seven times a week if I have it. Otherwise, I smoke whatever shows up; It’s a stress reliever. My father uses drugs; he snorts cocaine in front of me; takes my birthday money; even did a line of coke with me, and he used alcohol since before I was born. My dad was verbally abusive and he beat us with a belt. When your family is broken with drugs and alcohol, everyone is hurt. It makes me mad when people in the community do the heavier drugs. What I mean is what little kids get to eat or not to eat and do they get shoes or clothes they need, it depends upon whether the adults do drugs. I know it can’t be stopped but it’s unfair that grown-ups get what they want, and children do without. I want to shout, “when you do meth, hey don’t let your kids be there”. If I could, I would turn our reservation into dry reservation and no gambling. My life is gone, but what about the kids?”
Despite the fact that they are thousands of miles apart, Nmurubu’s and Johnny’s stories have one core that really makes me sad: both of them have lost hope. She says, “I need a new life”, and he says, “my life is gone but what about the kids?” So, they have got this horrible loss of hope. I don’t talk about global health justice as if it was one term. I talk about global health with justice because we actually need both. Global health is an ever-increasing advancement in the health of populations by outcomes, for which we have done reasonably well. While we are on the right trajectory, we can do more and we have to do more. Justice means that you have an equitable distribution of the benefit of good health. You can actually have global health without justice or have justice without global health. You may have low levels of health that is more equitably distributed. However, you need both justice and health and so you have to work on both.
What would an ideal state of health be?
I’ve often posited that there are three things: One was talked about quite a bit today in the first panel with the Affordable Care Act. Although the Affordable Care Act has lots of innovative things about clinical prevention services in public health, and stimulates some work on social determinants, it is primarily about health care. Health care is important and the United Nation General Assembly just adopted a high-level political declaration on universal health coverage, and the O’Neill Institute has been very closely involved with the project on Legal Solutions for Universal Health Coverage. Health care is very important: we all have an understandable yearning for affordable and fully accessible primary, secondary and tertiary, emergency, palliative and other kind of services, along with essential medicines and vaccines. This is the first thing you need to reach an ideal state of health: you need a universal health coverage.
But health care in the doctor’s office or with the nurse is only a very small part of what it takes to make a population healthy. Much more important are public health services, which include things such as infectious disease and other kind of surveillance, vector control, tobacco control, alcohol control, injury prevention, occupational health and safety – all of the things you need to make a population healthy. I’ve spent so much time in my life trying to explain to people everywhere – including people in civil society who want medicines, for example – why population health is actually much more important than the medical care, and that we should focus a lot more on it. I finally got the idea that if I did a Rawlsian experiment, I would be able to convince people, and it has actually worked. I have tried this in Beijing, Delhi, Johannesburg, Seoul, Tokyo, Kampala, Berkeley, and New York, and every single audience had the same response. By John Rawls veil of ignorance, you do not know whether you are rich or poor, male or female, were born in Dhaka or Oslo, but you have to choose between two options. Under the first option, you could choose healthcare: you could get any medicine, any doctor, and any hospital in the world. Under the second option, you could never see a doctor again for the rest of your life but instead, you would wake up to clean water in bathroom; you would go to your kitchen and there would be nutritious, safe food; you would leave your house and you wouldn’t be attacked by malaria and dengue-infected mosquitoes; you would get in your car and you would have a safe vehicle on a safe road; there would be tobacco and alcohol control. The Rawlsian experiment is about which of those two choices you would make if you did not have any information about your personal context. I am not going to make you choose right now, but every place that I have done this experiment around the world intuitively knows. I think all of us in global health have experienced this – I just came back from a very typical urban center in sub-Saharan Africa and I did not feel well. I found out that whenever I go to poor country, I am little asthmatic, have some stomach issue, and I just don’t feel well. But if I am in Oslo, I’m feeling great; I go to Berkeley, I feel nice; I go to Melbourne, I am in heaven; the same in Sydney. Whether it’s in sub-Saharan Africa or Australia, I never see the doctor in any of these places. We are animals, the environment in which we live either helps us thrive or it doesn’t. This brings me to the third element we need for a state of good health, which is actually the most important but also has very little to do with the health sector: it’s the social determinants of health such as housing, employment, gender empowerment, and education.
Let me now turn to the second important question of justice. If you ask any epidemiologist in the world what the single greatest predictor of good or bad health is, the answer would be an individual’s postal code. Where you live determines so much of your health status because it is your environment and your social conditions. This fact is truly unjust and really unconscionable if you think about it. I’ll mention a few data points from our article on equality, both globally and within countries. A lot of people think that the problem is between rich countries and poor countries; however, your social determinant matters a lot within both rich and poor countries.
There are global disparities: life expectancy globally ranges from 54 years in Sierra Leone to 85 years in Japan, Switzerland, and Hong Kong – that’s a 30 years’ difference. There is an 18-year gap between high- and low- income countries, and a 20-year life expectancy gap between sub-Saharan Africa and the European Union. Within the United States, a baby born in a white wealthy suburb of St. Louis can expect to live 35 years longer than a baby born in a mostly black lower-income suburb that is only a few miles away. The same thing is true with Blackfeet right outside the reservation that has astoundingly high rates of life expectancy. In New York City, maternal death of black women is 12 times higher than that of white women. In South Africa, a life expectancy of a black South African is 16 years lower than a white South African. Realities in indigenous communities are particularly egregious: the Aché, an indigenous group in Paraguay, has a TB incidence rate of 75 times than the overall population. In Canada, indigenous Inuit peoples have 300 times greater TB incidence than non-native Canadians. Another clear indicator of disparities would be maternal access to skilled birth attendants. In sub-Saharan Africa, less than 30 percent of women in the poorest wealth quintile have access to skilled birth attendants compared to more than 80 percent in the wealthiest [quintile].
The question, therefore, is about justice. The panel before this keynote speech eloquently talked about the kind of hard choices we make, one of which is about how we attain justice. The problem with this is that even President Obama never used one of the words that we would need for reaching justice. This word is redistribution. Although the current democratic presidential primaries are recognizing the idea of redistribution, it is really hard for political figures to argue openly for redistribution. It did occur to me, however, that the public health approach brings us a fair way toward justice by the fact that it works on the environment: if we get rid all of the mosquitoes that have malaria, Zika or whatever it might be, everybody benefits; if we have safe roads and safer cars, everybody benefits; if we have sanitation, hygiene, cleaner air, and safe food, everybody benefits. So, you do need some form of redistribution and you can actually make peoples’ environments much more conducive to health.
If I had another talk to give, it would be about how being healthy is distinctly a hard choice to make. We make it really hard to make healthy choices. For instance, the food you would buy from a supermarket would be low in fat but high in sodium, or you would buy bread or soy milk that has got sugar and salt in it. This is why we need both justice and good health, and we need to answer the question of how we would get there. I do not have the time to go through the three proposals that we are going to put forward in the Georgetown Law Journal. We have got several of these ideas coming out, in the BMJ and The Lancet. One of these ideas was devised in the Georgetown Law Journal more than a decade ago at the founding of the O’Neill Institute. Some of you were actually there where I posited an idea for a Framework Convention on Global Health, a right to health instrument that embeds clear standards on the right to health, accountability, monitoring, and inclusive participation. This idea has come a long way since then; it has been discussed by many people and we have civil society campaigns and an NGO based in Switzerland fighting for it. The second idea we put forward is our national program for equity: the idea is that we actually have to focus on equity at national level as we have very clear parameters on how we get to it. In the law journal article, we will discuss the seven principles of national equity strategies and how we can get programs of action because we measure aggregate outcomes and not disaggregated outcomes; we want to make what we want to measure, achieve, and be held accountable for it. The final thing that is coming out in The Lancet is what we call “a right to health capacity fund”. Which is not a full health system fund but it would focus on civil society capacities to fight for the right to health. These three proposals would be the three ways we need to get to the ideal state of health: (1) a global treaty, (2) national strategy for equity, and (3) a funding mechanism.
I will close by linking something personal to what I have been talking about. In about three days’ time, my granddaughter Aviva is going to turn three, she shares my birthday, and we are both going to New York to have a birthday party. As a granddad, you have to wonder ‘what is the world that we are leaving for our children?’, and it is not a very pretty one. We are leaving them a really dirty planet that is almost getting to the point of being irreversible. We are leaving them enormous debt as my generation takes so much of the resources in the money and not giving it to the children. We are leaving them with a failed promise that we would leave no one behind. And while we’ve done fairly well with health outcomes around the world, we have left so many people behind. We owe it to Aviva, Nmurubu, Johnny, and all of the children to actually do better and, if we want to have a legacy, it is our legacy for the young people in the world because they are the future. Thank you very much.