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First. Thank you very much, Julie, and thank you to the Oxford Martin School for hosting this talk and inviting me to be here and of course,

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for all of you for joining. So when talking about global legal epidemiology, this is something that we've been developing, colleagues and I,

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at the Global Strategy Lab for quite some time when talking about it,

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it's important to note from beginning what we are talking about, but also what we're not talking about.

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And I'm particularly pleased to present this today because it's the first time we've really publicly been talking about this.

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So I look forward to discussing with you afterwards. So global epidemiology.

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So what what is it? So first, I should say we're right up front.

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I didn't invent the term epidemiology.

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Long standing, disciplined, studying patterns of health and disease, using systematic methods and the causes of health and disease.

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I also didn't invent the term global legal entity and also invent the term legal epidemiology.

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So a few years ago, Scott Harris and colleagues wrote about the need to bring a systematic study for the deployment of law

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as a factor in the cause and distribution and the prevention of disease and injury in a population.

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So this idea of applying rigorous scientific methods in order to understand law as a cause or a factor

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in the cause of the distribution of health patterns is an idea that's been increasingly out there,

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and this is something that's come from various traditions.

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Criminologists have long focussed on what kind of criminal law policies have different impacts.

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Environmental scholars have focussed on what environmental legal policies would drive, let's say, reductions in carbon emissions.

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So it's not a new thing. But I think what's important to say is there's at least three intellectual

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moves that come by merging these two ideas together of legal and epidemiology.

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The first is that the focus is on law as intervention.

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So law not just as as a rule, but as an intervention into a society to change the rules of that society.

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The second move is around thinking of law as an object of study, not just what the law is, but what impact the law has on society.

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And the third is about law as achieving particular impacts.

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So having a normative affects of trying to actually do something and seeing whether it has those impacts individually.

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These aren't crazy ideas.

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They're being brought together and they've been they've been really inspiring a whole series of additional scientific studies,

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figuring out how do we use law to solve social challenges.

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And so my concept as an international lawyer and someone who's deeply caring about global health as my sort of sandbox in which I work,

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then it's less about legal epidemiology and its domestic context, but instead global legal epidemiology and a global concept.

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So in that in this respect, what we've been doing is we've been trying to conceptualise international law as a global population

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intervention that's actually independent of the domestic implementation of international law.

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And by that, what I mean is we've been thinking of international law as something that changes the world,

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irrespective of whether that that change is incorporated into domestic legal systems.

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So the thinking is law.

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International law actually makes worldwide changes, whether or not a country decides to sign up for the law or not, whether they ratify a law or not.

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And so what that allows is a whole different sort of way to study it.

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So whereas many political scientists, some of whom might be in the room,

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would be really interested to be asking questions like what impact does international law have on state behaviour, right?

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So how, how might states change their behaviour if there's an in the presence of an international law or not.

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That's not the question here. The question here would be when and how does international law, whether or not it's ratified by an individual country,

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when and how does it that international law produce real world outcomes for people?

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So it's really about it's a very pragmatic, it's an applied lens,

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one that's building on a tradition of both understanding patterns and causes of health and disease,

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but also then using systematic and scientific tools to try to tease that out in order to inform future interventions.

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And so the goal, in other words,

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would be how do we bring a scientific approach to bear on how we use global governance and legal mechanisms in order to solve real world challenges?

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And so today, during this lecture, I'm going to do four things.

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The first is I'll provide a very brief introduction to international law and specifically international health law,

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given that's the area in which I work. Very quickly from there, what I'll do is I'll move to three different areas where I think we need.

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To advance in order to further develop this emerging field of global legal epidemiology.

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And the first to share right up front is that in order to develop this as a field,

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we need to actually bring together the various kinds of studies that have already happened that can be part of this field.

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So there's many studies out there that have looked at what impacts internationals have on different outcomes.

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The key, though, is we need to bring it together in order to better yield the insights that that body of literature can offer.

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And so we're starting to do that. The second is I want to talk method and I want to talk about the kinds of rigorous

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methods we need to evaluate treaties and other types of legal agreements.

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And what I'll bring forward an example that we've been doing at our lab around evaluating and

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using quasi experimental approaches to study whether laws have effects on the national space.

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And the third is ideally, after looking sort of at past research and then a shining example of some current research.

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Ideally, I can I'm going to point you towards one example where we've been trying to apply some of these insights in order to design future treaties,

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in order to make them more effective. And for that, I'll bring your example of antimicrobial resistance, which is a global collective action problem,

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which we believe is in need of global collective action solutions.

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And I'll try to highlight at that time what kind of insights we've been learning from this field of global legal epidemiology.

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So that can be brought to bear on how we could design a future international legal framework around antimicrobial resistance.

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So going first to the brief introduction. So what is global health law in this case?

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So it's really it's international law related to global health issues.

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Now, international law is a set of rules that mainly govern the conduct of countries.

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So usually it's national governments, but they can also govern the conduct of individuals in some particular circumstances.

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Now, the key with these international laws is we often break them up into reports and think of normative

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instruments as either being hard instruments legally binding or soft instruments not legally binding.

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But actually when you look at when you read treaty texts and other legal instruments,

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what you see there is that there's some provisions that are legally binding and others that are not.

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So some, for example, call upon countries hopefully to maybe do things if they can possibly.

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Other other provisions are clear requirements imposed on countries or in some cases, individuals.

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And so there it's important that what this means is that global health law is a set of normative rules that are,

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in some cases, legally binding requirements.

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In other cases, importantly, can also include non legally binding recommendations,

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all of which create norms and governance and rules upon which actors expectations can converge.

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And often, international law or global health law included, will often feature central institutions such as the World Health Organisation,

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a UN specialised agency that would then create those norms, mobilise resources and guide collaboration.

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Just to highlight some examples. When we think of prominent global health laws, here are just four that come to mind.

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So one is the constitution of the World Health Organisation that created that institution as a legal entity.

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The second would be the International Health Regulations. This is the international law that governs how countries respond to pandemic outbreaks.

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And the third example, which will come up quite prominently later in this talk,

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is the WTO Framework Convention on Tobacco Control, which is a treaty geared towards reducing the global consumption of tobacco.

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A fourth example not often thought of as a global health law, but specifically there's a right to health in the International Covenant on Economic,

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Social and Cultural Rights, which I think forms an important part of this global health law landscape.

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But it's not just for laws, actually, if you sort of bring together a list, here's,

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I guess, one of the best lists that I could be that we could bring together.

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It goes back to 1892, the International Sanitary Convention, many revisions of that convention,

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which ultimately ended up as the international health regulations. But in here, you also have, for example, the Biological Weapons Convention.

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We don't usually think of that as a global health, as a global health law, and that's okay.

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But certainly there's important global health implications. But it's that one or two chemical weapons and many other agreements.

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The most recent one we can think of as the UN Convention on the Rights of Persons with Disabilities,

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or even more recent than that, the M.I.T. Convention on Mercury. But when thinking about global health law, international law more broadly,

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we shouldn't only think of past laws, of which there's many that we could choose.

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I also want to point to the fact that we often. Think of international law as a potential solution to different challenges.

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So for example, often what we see is that if there's a global problem, we see people calling for international law to solve that problem.

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And what it ends up with is maybe many calls and a difficult decision making process to figure out which to pursue, which not to pursue.

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For example, here's a commentary in Nature Journal calling for a framework convention on alcohol control.

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Another one, a commentary in the Lancet medical journal calling for a framework convention on obesity control.

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A blog asking Should we propose a global nutrition treaty?

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Another comments in nature calling for a global treaty on non-communicable diseases.

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Calling for a treaty on health care. Corruption. Another one on fighting fake drugs.

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Another one on a research and development treaty. A Framework Convention on Global Health broadly.

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Another one on having a framework convention to require countries to have mandatory impact evaluations.

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So we can learn from each other. Also in The Lancet. And the most recent call being a call for a global treaty on the rights of elder individuals.

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All of this is great. Love the ideas. But what it leads to is a pretty chaotic space where we need to then figure out which

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proposals are actually deserving or would be helped by international law and which would not.

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And without having a very clear sense of that, without bringing a scientific approach to that.

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What ends up being is we have a situation where we have this certain golden hammer and we're trying to hit different problems.

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And it leads to quite a confused landscape. Not good.

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Now, one of the early things that I did working with colleagues is we tried to define what would be a priority criteria that we could use to

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sift through some of these proposals and think about which might be particularly deserving of international attention and which ones not.

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Or at least some sort.

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In the absence of a clear scientific information around whether a treaty would achieve the impact that its proposers think it will have.

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Are there criteria that would allow us to think through? This will likely have an impact and maybe likely not.

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And so the best that we could come up with was something that looks like this,

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where it's really what drives it is and it's longer than just two criteria, but it's to summarise it,

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I can point to these two aspects, which is that the best we could do is okay,

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we should maybe consider using international law when there's a significant transnational dimension.

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So what that means is that you have a risk or a cause that involves multiple states and actually transcends their

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national boundaries such that any one individual state is not its the problem is not contained within that state.

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They can't tackle the problem by themselves. But that's not enough in our criteria.

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What we had thought of was that you also need to be able to achieve something impossible with international law that you couldn't do without it.

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And the reason for that is recognising that there's major costs and using international law.

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And so what would be something that we could achieve sometimes with international law that you can't achieve elsewhere?

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Well, it would have to be something you'd have to be a law that addresses a multilateral

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challenge that cannot practically be addressed by any one state alone.

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Or it could be something that's resolving a collective action problem where benefits are only accrued if multiple states coordinate.

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Or alternatively, it could be something that's advancing a super ordinate norm that embodies humanity and near universal values.

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That was our that was the best we could do a few years ago and trying to think through what such a criterion would look like.

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Another approach, though, would be to think of it in terms of costs and benefits.

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And here's a very simplistic way of thinking about this,

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but it's clear that there are some benefits for treaties and other international legal mechanisms, a clear expression of commitments.

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It's part of an established legal system,

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and it is one of the strongest ways in which countries can make commitments to each other and bind themselves to things.

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There's some big costs, though,

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and such that I think it's a very open question as to whether we would want to use this mechanism or not in the absence of more information.

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So, for example, there's some clear costs that this is a lengthy process.

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Right. It's not so fast to negotiate a treaty. It's also there's some diminishing political feasibility by that.

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What I mean is these aren't always so politically attractive.

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And third, there is a limiting this is there is some limiting effects on states.

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So it's not always and it's it's putting some limitations on states that they might not otherwise like.

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And. In my mind, what would tip the balance?

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What we need to tip the balance from costs to benefits would be whether treaties are actually delivering results.

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For me, that's what that's what we do it. Now in that context, I think the good news is we're not actually starting from scratch.

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So while the itself this idea, this this field of global legal epidemiology, or at least that term is quite new.

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The good news is we have the shoulders of intellectual giants to stand on.

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And the way we can do that is, as I said, is for the first of the three things I'm going to do during this lecture,

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which is about we need to synthesise what we need to find and then synthesise existing research that

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is beginning to tease out when can international laws have effects and when don't they have effects?

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And so to do that, our first go at this was a study that brought together 90 existing quantitative impact evaluations of various kinds of treaties.

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And what this attempted to do was bring out those studies that had evaluated various treaties,

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whether they're environmental treaties, trade treaties, human rights treaties, financial treaties.

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We tried to get a sense of did those studies find that the treaties had the effects that the proposers of the treaties had wanted to achieve?

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So, for example, if there is a trade treaty that international law on trade, did it actually promote more trade,

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which is usually what those who signed trade agreements are trying to achieve, increase the amount of trade.

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And what we found was a surprisingly or not surprisingly mixed picture.

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So in this slide, what you'll see is this is the number of studies that found whether the treaties that

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were being evaluated had the effect that the progenitors of those treaties wanted.

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So the green indicates the number of studies of the 90 that found that, for example,

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international financial law increased financial flows between countries.

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The yellow is the number of studies that showed either no effect or mixed results.

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And what was most surprising and what motivated a lot of further inquiry is the red, because the red are all the number of studies,

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the number of quantitative impact evaluations that we found out of the 90 that showed

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that actually these treaties sometimes had the opposite effect as to what was intended.

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So, for example, on the human rights side, though,

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there's quite a bit of red there in the sense and a lot of the theory behind that is that sometimes international

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human rights treaties might be giving cover to those governments that actually don't want to act on human rights.

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But by enacting an international human rights treaty,

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it gives them the cover and buys them time before doing something before a population demands change.

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That's really what some of the read is like, but that's not expected by the people proposing an international human rights treaty.

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Now, this is this figure is showing by type of international law.

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What if instead we look at by type of outcome.

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So there is this question of, okay, maybe different types of treaties are having different kinds of effects,

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but what about are there maybe some kinds of outcomes that treaties seem to be able

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to produce and other kinds of outcomes the treaties don't seem to be able to produce.

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And so when we divided up those 90 studies by different kinds of outcomes,

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what we consistently found were that treaties were able to increase trade and increase foreign investments and pro finance policies.

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What treaties were less successful doing, or at least what we saw less of in these quantitative impact evaluations,

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were treaties affecting social policies, social rights and health.

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And in fact, the thing that as someone who's worried about global health,

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the thing that worried me the most was that we're out of these 90 quantitative impact evaluations that we found,

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not a single one found an association between an international treaty and improved health outcomes.

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So obviously what that does is it raises some big questions in one's mind,

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or it should raise questions in one's mind as to do we want to use international law to

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solve these challenges and do we want to use it to solve social and health challenges?

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And if we do, we should be pretty purposeful about that.

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So as a follow on to this, the next stage is to do a full systematic review for those who aren't from a health or medical medicine background.

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Systematic reviews are really it's an attempt to be apply a transparent,

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systematic process to gathering a whole field of literature that's responding to a very particular question.

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And so we're in the process of doing this for at the very end where we found more than 200 studies.

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So actually the first the first study that I showed you with the figures that was based on 90 quantitative impact evaluations, we found over 200.

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And we're now in the final process of bringing those together.

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And so what we're doing there is to just to clarify, as these would be because we've done a systematic search,

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we've searched ten different electronic databases, we've done everything in duplicate.

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So. Few people have screened the titles and abstracts to make sure could they be relevant.

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And then two people reviewed the full text, and there was a whole process to extract information in a way that could be usable.

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We did it focussed narrowly on this question, which is summarised in these four bullet points.

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So first we're focussed on looking at the impact of international law on health and its various social determinants,

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which we're recognising that everything influences health.

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We included basically everything, any real outcome of people.

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We looked at their impact on countries and within countries and we were looking for some kind of comparison.

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Sometimes the study was looking at before and after. Other times they were looking at an alternative group, a comparative comparison group,

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and this is what the what a screening flowchart looks like when you're taking this approach.

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The top right hand box listing out all the databases we searched in, the number of records we identified in those databases.

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When we use our search string, we had different stages of reviewing title an abstract to see.

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Could this record that we found, could it possibly contain an impact evaluation of international law?

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And then finally and towards the end, reviewing the full text.

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So we we read 452 full texts in duplicate for people to see whether it could possibly contain an impact

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evaluation and the benefits of taking this kind of scientific approach to answering this kind of question,

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which we haven't yet answered, is that it? First, it provides a rigorous, systematic methodology to establish a baseline knowledge of the field.

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Right.

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Imagine we could reproduce this systematic review and do it again in a few years to see how many more studies have been published during that time.

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And you can track a field's progression in that way. Second is, once we use meta analysis, a meta regression analysis,

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we should be able to pool the results of those over 200 studies to hone in on what overall, what is the average effect of an international law.

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And using meta regression analysis, we should be able to identify what factors influence whether one study showed it had an

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effect versus those other studies that found international law did not have effect.

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So it's really trying to use fairly systematic methodological approaches to tease out effects and do what an individual study couldn't do.

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And third, we think it's helpful for informing future decisions by identifying what types of international laws are most likely to produce.

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What kind of effects? Under what kind of circumstances?

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Having talked about the six hour systematic approach to synthesising existing literature from the past,

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let me tell you about one study that we're doing that's currently focussed on evaluating it of current international law.

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And I say that because right up France, after we did the after we brought together the various studies for a systematic review,

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we recognise that there are lots of studies out there that are trying to identify associations between international law and different outcomes.

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But there's very few studies.

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In fact, we only really found one study that used quasi experimental methods to evaluate whether international law has had any impacts.

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Now, before I talk about quasi experimental methods, I think some people might think, well, let's do a randomised controlled trial, right?

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Because randomised controlled trials often called the gold standard as a way to tease out whether something has effects or not.

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And so I think in this context you'll probably agree that not only is it possible, so in this case,

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imagine we live in a world where we could actually here in this lecture room,

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we could decide which countries are going to get in international law and which ones are not.

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And we randomised that that treatment. And so in a world where we had that power,

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what we could do is we could then say okay because it was randomly decided which countries get a treaty and which ones don't.

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We could look at the average effects in the two countries compared and the difference we could attribute to the presence of international law or not.

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Now, that sounds not only kind of crazy, but actually it's not even a good method in this case because as I as I explained at the beginning,

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we're conceptualising international law as actually having global population impacts.

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Right? So we're seeing international law as something that doesn't just affect the countries that have chosen to ratify it,

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but it's actually affecting the world. And it's most easy to think of that in the context of equilibrium effects.

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So for example, if you have the impacts of a treaty in one place, if you have a treaty in some countries,

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the new technologies that it develops or the new norms that follow would necessarily influence or not.

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I said it would probably influence other countries, particularly those surrounding it,

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or those that have strong historical relationships or trade relationships with that country that is being influenced by that international law.

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So it's a type of network effect. So in that respect a randomised controlled trial wouldn't actually be that great.

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Even if we could randomise which countries get an international law, which ones don't because it wouldn't account for the spill-over effects.

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Whereas quasi experimental methods can do so.

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And basically what a quasi experimental method is, is that you're using an alternative approach to create a control group.

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So instead of using randomisation and assigning subjects or in this case countries to a particular treatment,

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we're trying to construct a counterfactual using a different method.

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And there's many different approaches within quasi experimental methods, and there's many of which to choose from,

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and which then makes it even more surprising why we haven't been using these kind of really rigorous approaches to evaluate

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whether international laws have had effects and instead have really stayed with just looking at sort of basic associations,

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which I think is an opportunity for improvement.

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Now the first, when we're talking about trying to sort of up the game of this field, it makes sense to focus in on an example.

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And so the one that we've really focussed in on and trying to use is a bit of a pioneering example,

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is focusing on the framework convention on Tobacco Control. Now there's a few reasons why this is a great place to push forward this whole field.

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The first is that this framework convention, so it's a treaty that was adopted through the Assembly of the World Health Organisation.

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This treaty has a very clear outcome of interest.

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It is there's no doubt that the Framework Convention on Tobacco Control is trying to reduce tobacco consumption.

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So there's a clear independent variable that we can look at. Whereas by contrast, human rights treaties, yes, they're trying to promote human rights,

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but it's harder to measure exactly what is human rights and in its various important contexts.

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So there's actually a lot of work to try to find indicators in that space. But with tobacco, it's quite easy, right?

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It's how much tobacco is consumed in the world.

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The second reason why it makes so much sense to focus on this one is because it's gotten a lot of attention,

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particularly in global health circles, for being an example of a treaty that's had a major impact.

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And so one quote that I often point to is this one from a former director general of the World Health Organisation,

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Margaret Chan, who said in a speech, quote, without question, the.

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A Framework Convention on tobacco control is the most powerful tool we have as an international community to reduce the global disease burden.

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It's quite a strong quote. It's quite a strong statement,

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but it's one that I think does reflect the majority view or at least reflects the view of many people in the global health community.

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So if we're going to study a treaty,

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it makes sense to study one that has universal support and for which we can see whether it actually whether the impact has matched the rhetoric.

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And just to clarify, of course, I think the contents of a treaty like this is extremely important.

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And, of course, we need to do everything we can to reduce tobacco consumption, give visits the number of.

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It's one of the number one. It's one of the most prominent risk factors that's leading to disease.

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But the question is whether the tool,

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whether the international law tool was an effective mechanism in order to promote proven tobacco control policies.

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So, for example, we know that tobacco taxes reduce consumption.

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We know we need the world and countries around the world to increase tobacco taxes,

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especially those countries where economies are growing and lifestyle or wages are going up.

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We need tobacco taxes to keep pace, if not exceed the pace of the growth of affordability of tobacco products.

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That's clear. The question that we're asking is,

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did having a framework convention on tobacco control accelerate that the adoption of tobacco taxes or warning labels or smoke free workplaces,

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those sorts of policies? That's the question. Which financer?

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So when looking at the facts, say this is a treaty that's been adopted, it's actually been ratified or acceded to by 181 countries.

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So quite a lot of countries are part of this treaty.

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And yet, up until this point, 13 years later, there's still no quasi experimental study of its effect.

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Like basically nearly every international law.

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So again, we're not fully finished. But what I can show you is here's what global tobacco consumption looks like.

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It's a small figure, but what I would focus on is just the black line, the horizontal black line.

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And what you see that that that's the global trend for its cigarette consumption per capita from 1970 to the present.

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What you'll see there, though, when you contrast it to the dotted line,

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which is the year at which the Framework Convention on Tobacco Control was adopted.

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What you'll see there is that if you would imagine that if that treaty had an effect,

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even visually, you as audience would be able to see a discontinuity in that trend line.

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So, for example, if there is an immediate effect, you would see a jump, ideally a jump down in the consumption levels that are seen globally.

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If it had the opposite effect, you'd see an immediate opposite effect.

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You'd see a jump up. And if you saw a slow, a small impact, but slowly over time, what you'd expect to see is a discontinuity in the trend.

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So you would see there that that's the black line of this was having a global effect would

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ideally trend down so the slope would go downwards or if it had the opposite effect,

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the slope would go upwards. And so what you see here, though, when when thinking it, when looking for discontinuity, is that you don't see one.

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And in fact, if anything, you sort of see it maybe curve a little up.

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And so we did bring statistical methods to bear on this.

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And what you're seeing here is a sneak peek at our results. When we did an event model,

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where what we did is we constructed a post 2003 counterfactual by using associations for various variables with tobacco exception before 2003.

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And then when we modelled it out as a comparison, we actually found that based on all available data we had before 2003,

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we would have predicted that tobacco consumption would be lower today than it is.

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And so what you see there is the grey line of the two that are not dotted.

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So the grey solid line, that's what we would have predicted based on relationships between tobacco consumption and things like GDP,

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education, gender equity in various countries around the world.

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Projecting those variables going forward beyond 23, we would have seen, we would have predicted the grey solid line.

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In reality, we see the black solid line and we've done this as part of the study that hopefully will be out very soon.

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We've done all sorts of robustness checks about looking at maybe there'd be a delayed effect.

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Maybe, and maybe it is one country driving the results, looking at different regions.

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And so it's it's been quite an interesting project,

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but one that because we took the scientific approach and tried to use epidemiologic methods to tease out an effect,

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hopefully what it does is it allows us to drill down to that question of is this treaty having an effect?

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And if so, in what places? In what? Context.

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And ideally, from there, it starts to generate the science of treaties as social tools.

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Now, in terms of the implications of this, it's not just a matter of figuring out whether it works.

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Another key point that we learned in this process was that both data and certainly, unfortunately, existing data was not.

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We couldn't use it in order to conduct a quasi experimental impact evaluation.

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Some of the leading data on tobacco, which is provided by the Institute for Health Metrics and Evaluation based in Seattle, what they do,

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they often they are generating their data using variables and they are smoothing out

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their data often because it's imputed from in context where there's missing data.

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And so that's great data to be able to have come up with an estimate for how many people are consuming tobacco or how much tobacco is being consumed.

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But because it's generated through it's created through a particular process and model process,

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what it means is that you can't take advantage of of trying to find discontinuities in the data.

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So our approach that we showed before,

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it was all about trying to identify when we know there are sudden changes in the data or when is there a change in slope.

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That's what we did in our previous study.

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You can't do that when the data is actually created, assuming there wouldn't be any of those discontinuities.

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So in that respect, it's just we couldn't we couldn't use that data.

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So we had spent an enormous amount of energy trying to bring this data together.

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How great would it be if part of the Framework Convention on Tobacco Control,

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each country was required to report how much tobacco was consumed in that country, whether it would be such great data?

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That's another question. But I think data is and is something we need to have contained in treaties or other mechanisms.

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And then, of course, there's we also learned this is a great need to further study some of these trends and causes.

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It's a challenge. Has this treaty had effects? So in terms of methods,

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I think what this shows in many cases in this case is that more rigorous methods allow us to evaluate whether international laws can have results.

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And if they don't have results, I think it leads to next questions of why not.

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Again, I don't think we should necessarily question whether this treaty was good or bad.

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I think overall it's clear that what it's trying to promote is very good.

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So a reduction in tobacco consumption and the kinds of policies that it's promoting within the treaty.

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Again, no doubt they're very good and they're proven in many contexts to work.

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But what we have to ask is what's the best delivery mechanism for this?

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And the key in my mind is that because we know that international law can have some very important effects in some contexts,

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I think it's it behoves us to then reserve international law mechanisms for those contexts when it can work.

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Because I'm definitely a believer in international law. I am an international lawyer, after all.

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But I think what we need to do is then think through very carefully when we use that that golden hammer, because it's actually not so golden.

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If there's some costs involved and if we always point to it as our tool, it diminishes our argument for using it when it's really needed.

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And so in that, what I'm going to do is I'm going to use this third and last part of this lecture,

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which is all about how do we use this knowledge that we're gaining about international law as a social intervention,

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as a health intervention on the world?

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How do we use that knowledge in order to design a future treaty, a future international legal agreement on a topic of great concern?

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And so I think just right up front,

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some emerging lessons are not so out of line with what has been generated through theoretical traditions with Earth, through theory.

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So specifically, some of what we've identified in some of our earlier work was that when designing an international legal mechanism,

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there are some factors that are more important than probably other factors.

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If your goal is to have effects. So in terms of less important factors, it seems, although we're still working to confirm these sorts of conclusions,

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it seems that what's less important is empowering individuals to bring claims against

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governments are holding them responsible as individuals vis a vis the states.

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Less important, it seems to be about addressing a global challenge that requires urgent action.

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By that, what I mean is simply the nature of the problem. Just because it's an important problem doesn't mean that we're going to see

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that the international laws to address that problem are going to have effects.

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And also just simply being about promoting a certain ideal or a certain norm living in an ethical world is not enough.

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Doing good is not enough for the goal of doing good. So it seems like potentially more important factors are instead of incentives.

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So, for example, providing immediate benefits to states and governing elites so that actions align with their short term interests.

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Second would be creating institutions that create mechanisms that over time are promoting compliance,

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dispute resolution, accountability and third interests.

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So aligning what needs to happen with powerful interest groups who can advocate for the full implementation of these international legal mechanisms.

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This shouldn't be so surprising. So, in fact, many people in the room are probably saying, yeah, that makes sense.

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And in fact, it very much aligns with quite a few different theoretical frameworks around how international law can have effects.

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Here's just ten examples of different ideas that have been put forward in the literature that

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have been very helpful around identifying how could treaties possibly have real world outcomes.

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And from here, so just to go through them very briefly. But international laws can help set agendas.

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They can provide powerful legal language that people can use to claim results or claim judicial or judicial intervention.

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International laws can have provisions that either incentivise certain behaviours, disincentivize certain behaviours.

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They can provide a focal point for social mobilisation. They can legitimate certain groups concerns when previously maybe they weren't legitimated.

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They can serve as a rallying point for networks of expertise.

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They can serve a matter of it's also the power of the process.

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So even if you forget the treaty itself, that results. Think of how potentially powerful that negotiating process is,

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where countries are sharing ideas and bringing attention and temps in this list of ten examples.

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Public awareness. So maybe the public is more aware of a certain issue if it's the subject of international treaty.

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Now, when thinking of these sort of lesson, I wanted to know take some time and apply it to the issue that I've been grappled

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with for the last few years and working with colleagues around the world,

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including colleagues here, which is that problem of superbugs and unfortunately, superbugs are not as cuddly as Bugs Bunny over here.

389
00:40:21,590 --> 00:40:28,999
Rather quite terrifying. And what makes them terrifying in my mind is that really what we're talking about is a natural

390
00:40:29,000 --> 00:40:36,469
evolutionary process whereby microbes are slowly developing resistance to the antimicrobials,

391
00:40:36,470 --> 00:40:40,670
the drugs that we've long depended upon to kill them when we get sick.

392
00:40:41,210 --> 00:40:48,260
So what's happening is over time, as we've we've been using and abusing antimicrobial drugs.

393
00:40:48,650 --> 00:40:57,080
What happens is that it mites. It provides a breeding ground for those microbes that happen to have some resistance to the drugs.

394
00:40:57,470 --> 00:41:05,000
It gets them to multiply. And then those become the most dominant forms of those bacteria viruses, fungi, parasites.

395
00:41:05,330 --> 00:41:10,610
And as a result, what means over time is slowly. The drugs that we've been depending on are no longer working.

396
00:41:11,000 --> 00:41:14,480
And so we are in a bit of a chess game with microbes here.

397
00:41:14,540 --> 00:41:18,440
That's one analogy you can use. And unfortunately, we're not winning.

398
00:41:19,280 --> 00:41:25,760
I mean, this is a problem that we've known about ever since Fleming found penicillin.

399
00:41:26,240 --> 00:41:29,870
And this is a problem that is not going away.

400
00:41:29,870 --> 00:41:32,419
It's only accelerated. And in the last 30 years,

401
00:41:32,420 --> 00:41:38,900
there really just hasn't been new antibiotics or new classes of antibiotics in order to come to this sort of war that we see.

402
00:41:39,050 --> 00:41:40,520
And so we need new approaches.

403
00:41:42,250 --> 00:41:49,219
And the key why I'm going to be talking about this in the context of global legal epidemiology is that this is a challenge.

404
00:41:49,220 --> 00:41:57,170
This challenge of antimicrobial resistance is one that, yes, the underlying biological mechanism is one that's always going to happen.

405
00:41:57,780 --> 00:42:04,220
But what makes it a human challenge and a human health challenge is the way that we're using these medicines and abusing them.

406
00:42:04,790 --> 00:42:10,580
So on the left finger, you'll see that it's really just showing that the more antibiotics we use, the faster they stop working.

407
00:42:11,150 --> 00:42:15,670
So it's showing by countries on the on the X axis,

408
00:42:15,680 --> 00:42:22,280
it's the daily antibiotic use per 1000 people within countries modelled onto the percentage

409
00:42:22,280 --> 00:42:26,210
of pneumonia causing bacteria within that country that are resistant to antibiotics.

410
00:42:26,570 --> 00:42:30,530
And so it's a clear association in those countries that use more antibiotics.

411
00:42:30,770 --> 00:42:39,470
There's more resistance. The second is that this would be okay if all those antibiotics and other antimicrobials were being used for good purposes.

412
00:42:39,680 --> 00:42:42,620
If they actually were saving lives, I wouldn't be so worried.

413
00:42:43,490 --> 00:42:50,240
The challenge is that a lot of our use of antimicrobials is actually not effective and only then causes harm.

414
00:42:50,750 --> 00:42:57,740
So, for example, there's a study in the U.S. where they looked at the people who went into their doctor's office with a sore throat.

415
00:42:58,460 --> 00:43:04,610
And what they knew is that about one in every ten people so 10% of people who have a sore throat, that sore throat is.

416
00:43:04,810 --> 00:43:09,160
Caused by a bacterial infection. Usually it's a viral infection or not.

417
00:43:09,700 --> 00:43:14,830
And so if you have a bacterial infection, maybe taking an antibiotic could work.

418
00:43:15,340 --> 00:43:19,750
But if you have a virus, you're not going to be helped by taking something that kills bacteria.

419
00:43:20,260 --> 00:43:27,850
And yet what they found is that of the 10% or 10% of people went in probably with a bacterial infection,

420
00:43:27,850 --> 00:43:32,230
but 60% of people walked out with a prescription for an antibiotic.

421
00:43:33,430 --> 00:43:43,180
What that means is that at the very least, 50% of Americans who walked into their doctor's office with a sore throat inappropriately came out

422
00:43:43,180 --> 00:43:47,110
of that same doctor's office with a prescription for something that's not going to help them.

423
00:43:47,440 --> 00:43:53,410
And that's only going to harm society because it contributes to the resistance that develops in microbes.

424
00:43:54,640 --> 00:43:59,560
Unfortunately, this problem is not just in humans, it's also within animals.

425
00:43:59,590 --> 00:44:05,770
And in fact, 80% of antibiotics are estimated to be used on the farm, not in humans,

426
00:44:06,250 --> 00:44:10,480
although from a human health perspective, it's not that 80% of the problem is on the farm.

427
00:44:10,870 --> 00:44:15,820
Most of human, mostly human health aspects are caused by human consumption.

428
00:44:16,150 --> 00:44:20,350
But the problem is a one health problem in need of a one health solution.

429
00:44:20,920 --> 00:44:25,750
And the stakes are quite high. So this is something that some people often don't talk about.

430
00:44:26,200 --> 00:44:33,700
But 700,000 people are dying every year. And a study that was commissioned by the UK government, led by Jim O'Neill,

431
00:44:33,850 --> 00:44:39,940
showed that by 2050 it's estimated that 10 million people per year will die from antimicrobial resistance.

432
00:44:40,150 --> 00:44:45,400
If we don't do anything. And so that would be more than cancer. This is a problem we often don't label.

433
00:44:45,400 --> 00:44:50,740
It's antimicrobial resistance. But this is something that's killing a lot of people and will kill even more.

434
00:44:51,850 --> 00:44:59,680
But how does this all relate to global legal epidemiology? Well, the reason is that if we're trying to find legal tools to solve legal challenges,

435
00:45:00,010 --> 00:45:07,360
it's important to recognise what kind of problems could possibly be beneficial, be benefited by these kind of legal approaches.

436
00:45:07,810 --> 00:45:12,730
And so in this case, it's what's really important is to note that antimicrobial resistance is one of

437
00:45:12,730 --> 00:45:16,840
those challenges for which there hasn't been sufficient level of global action.

438
00:45:17,110 --> 00:45:21,610
And there's some particular reasons for that which maybe international law can help with.

439
00:45:22,090 --> 00:45:29,170
The first is that there's no silver bullet solution. There's no one quick fix that can resolve this and explain that more in a second.

440
00:45:29,710 --> 00:45:37,090
The second is that there's some global market failures. Specifically, we actually under provide some of these medicines for people around the world.

441
00:45:37,450 --> 00:45:40,510
We over provide for others and there's insufficient innovation.

442
00:45:41,020 --> 00:45:45,760
And third, there's some global governance gaps, which is really classic collective action problems.

443
00:45:46,930 --> 00:45:51,740
So to go into that in just slightly more detail, when I mentioned there's no silver bullet solution.

444
00:45:52,120 --> 00:45:57,880
What I the reason for that is because there isn't actually just one problem associated with antimicrobial resistance.

445
00:45:58,270 --> 00:46:05,110
There's actually at least three problems. One is that we need to provide access for the millions of people without antimicrobials.

446
00:46:05,740 --> 00:46:12,760
Think of those who who don't have access to such medicines. Two is we need to conserve the effectiveness of existing drugs.

447
00:46:13,300 --> 00:46:16,480
And third, we need innovation towards creating new antimicrobials.

448
00:46:17,320 --> 00:46:22,180
And it's not even that easy, because actually these are interlocking problems.

449
00:46:22,180 --> 00:46:24,640
So we can't address one without addressing the other.

450
00:46:25,090 --> 00:46:31,690
So more specifically, we can't address access without conservation and innovation because it would actually speed up resistance.

451
00:46:32,140 --> 00:46:38,140
Right. So imagine we we live in a world where we provided access to everybody on every street corner to these medicines.

452
00:46:38,440 --> 00:46:43,900
It would actually speed up resistance because it would increase inappropriate use of conservation.

453
00:46:44,110 --> 00:46:51,190
It constrains access by definition. And then it would undermine innovation because it creates a smaller market for the sale of these products.

454
00:46:51,850 --> 00:46:55,000
And third, innovation without access would be unjust.

455
00:46:55,600 --> 00:46:58,210
And innovation without conservation is wasteful.

456
00:46:58,540 --> 00:47:04,089
So imagine we spent billions of dollars coming up with a new antibiotic, and then within a couple of years,

457
00:47:04,090 --> 00:47:09,640
it's no longer working because we've abused it in terms of the global market failure.

458
00:47:10,480 --> 00:47:14,440
I'm just going to point to a couple of game theoretic problems that are in this space.

459
00:47:14,860 --> 00:47:17,110
So, for example, when it comes to conservation,

460
00:47:17,110 --> 00:47:24,670
we see a classic global commons dilemma whereby we have a common pool of effectiveness of antimicrobials.

461
00:47:25,030 --> 00:47:29,290
And each country might be individually incentivised to draw upon that pool of

462
00:47:29,290 --> 00:47:34,540
effectiveness and insufficiently incentivised to manage that common pool resource.

463
00:47:34,960 --> 00:47:39,910
It's exactly like what we see with climate change also when it comes to innovation.

464
00:47:39,910 --> 00:47:48,160
As a second example, there is a free rider problem. So why would countries invest in developing new antibiotics or new antivirals when

465
00:47:48,160 --> 00:47:51,970
they can just wait for another country to make that investment and reap the rewards?

466
00:47:52,780 --> 00:47:55,210
And so there's insufficient levels of investment as a result.

467
00:47:55,750 --> 00:48:01,329
And third, just quickly on global governance gaps, we see that there's actually are there actually in this case,

468
00:48:01,330 --> 00:48:04,120
are a lot of actors doing a lot of different things?

469
00:48:04,730 --> 00:48:12,200
What we see is insufficient levels of coordination, insufficient levels of compliance, leadership and financing.

470
00:48:13,190 --> 00:48:18,259
And so, again, so how does global legal terminology fit in? Well, it seems, based on what I've described,

471
00:48:18,260 --> 00:48:24,410
that a natural step to address some of these challenges is actually through an international legal mechanism.

472
00:48:24,740 --> 00:48:32,510
And I say that as somebody who actually has been quite critical about using international legal tools to solve global challenges,

473
00:48:32,510 --> 00:48:39,860
particularly global health challenges. Yet when you think of the type of interlocking problem and when you think of the

474
00:48:39,860 --> 00:48:44,060
highly global governance space in which we're following a highly legalised space,

475
00:48:44,570 --> 00:48:50,150
it seems like this actually could be a solution that we should all be pursuing.

476
00:48:50,450 --> 00:48:57,079
And more specifically, I think it's whether here are just some key reasons why international law would be, I think,

477
00:48:57,080 --> 00:49:00,830
relevant is because there is such interdependence among countries,

478
00:49:01,250 --> 00:49:06,770
which means that we need all countries or most countries to act in order for any country to be safe.

479
00:49:07,490 --> 00:49:10,610
It's not just that we need action. We need interlocking action.

480
00:49:10,910 --> 00:49:18,140
And how do we do that? How do we get those interlocking actions unless it's through a coordinated mechanism?

481
00:49:18,680 --> 00:49:24,530
These actions are costly, which means we need we need to make sure that each party for them to invest.

482
00:49:24,800 --> 00:49:28,250
They need to know that other countries are going to invest, too, at the same time.

483
00:49:29,030 --> 00:49:34,520
And fourth, we need to be able to lock in commitments and disincentivize deviation.

484
00:49:34,850 --> 00:49:38,870
Because unfortunately, on this problem, most of the costs are short term.

485
00:49:39,200 --> 00:49:41,270
Most of the benefits are long term.

486
00:49:42,170 --> 00:49:49,790
And so from that perspective, it's clear that we, in my mind that we need a institutionalise grand bargain in order to make progress in this space.

487
00:49:50,450 --> 00:49:53,509
But the key then, is not just to have a grand bargain.

488
00:49:53,510 --> 00:49:56,930
We need then to make sure that such a grand bargain would actually work.

489
00:49:57,800 --> 00:50:04,100
That's where this whole thing comes into mind. And so on this issue, what we've been trying to do is learn from the past.

490
00:50:04,370 --> 00:50:10,280
We've been trying to learn from those existing studies that have looked at different international laws and trying to figure out, okay,

491
00:50:10,670 --> 00:50:16,640
how do we how do we make sure that if we are going to go into this space and use this precious tool of international law,

492
00:50:17,090 --> 00:50:20,630
how are we going to design it in a way to make sure it actually yields impact?

493
00:50:21,350 --> 00:50:26,900
And so the good news, again, is that there's lots of people talking in this space around what to do.

494
00:50:27,080 --> 00:50:29,389
So there's a lot of people who have published, for example,

495
00:50:29,390 --> 00:50:35,480
this paper that I was part of in The Lancet that focussed on what do countries have to do in order to conserve,

496
00:50:35,750 --> 00:50:42,200
promote access and innovation for antimicrobials? The challenge has been more around the implementation mechanisms.

497
00:50:42,530 --> 00:50:47,690
So what would a what would an international treaty on antimicrobial resistance actually look like?

498
00:50:47,960 --> 00:50:52,430
So if countries decided to come together and have an agreement, what kind of provisions would they put in?

499
00:50:52,760 --> 00:50:53,809
That's the question.

500
00:50:53,810 --> 00:51:02,360
That's where global legal epidemiology can can help, because it's drawing on that, taking that scientific approach to figuring out how to do it.

501
00:51:02,810 --> 00:51:09,530
And in fact, we've started it. So there's a one first goal that I do working with colleagues around the world

502
00:51:09,830 --> 00:51:12,980
was we brought together a special issue of the Journal of Medicine and Ethics,

503
00:51:13,220 --> 00:51:17,370
where we started to raise some of these issues. So what is the advance?

504
00:51:17,390 --> 00:51:21,890
What are some of the advantages of international law? What's an appropriate convening forum?

505
00:51:22,220 --> 00:51:28,640
Those sort of questions. But what hasn't been discussed and what desperately needs to be discussed is if we are going

506
00:51:28,640 --> 00:51:33,620
down this route and if the world does decide that international legal approach makes sense,

507
00:51:34,010 --> 00:51:37,430
we need to figure out exactly what what it would look like, what would be in it.

508
00:51:38,120 --> 00:51:44,030
And so I'm just throwing up here. Another list of ten, another top ten list on top ten list.

509
00:51:44,360 --> 00:51:49,700
But these are just ten examples of the kinds of things that we sometimes see in international

510
00:51:49,700 --> 00:51:55,760
legal agreements that would encourage them to maybe have effects versus not having effect.

511
00:51:56,240 --> 00:52:01,410
So these are implementation mechanisms. So one example would be a monitoring milestone.

512
00:52:01,430 --> 00:52:06,320
So imagine there's a very clear milestone that countries are supposed to achieve

513
00:52:06,620 --> 00:52:10,670
and there's monitoring of country progress towards achieving that milestone.

514
00:52:11,300 --> 00:52:20,000
Alternatively, there's mechanisms in a code of practice. You can create new institutions that coordinate activities like a UN inter-agency task force.

515
00:52:20,570 --> 00:52:27,440
You can have an Intergovernmental Panel on antimicrobial resistance that engages scientists like the IPCC from climate change.

516
00:52:27,890 --> 00:52:30,620
You can have funding agreements to give a global pooled fund.

517
00:52:31,150 --> 00:52:37,200
Controversially, I'm not promoting this, but you could condition benefits or supports an action.

518
00:52:37,250 --> 00:52:38,210
So for example,

519
00:52:38,750 --> 00:52:46,220
one thing you could imagine is that if if a country was going to invest in promoting access for advanced antibiotic in a particular country,

520
00:52:46,640 --> 00:52:55,940
maybe that country should simultaneously have a stewardship program to make sure that the negative externalities of that access program are minimised.

521
00:52:57,170 --> 00:53:04,490
You could create special representatives. You can have a high level panel, multi-stakeholder partnership, lots of different approaches.

522
00:53:04,720 --> 00:53:12,760
S oriented design features that could be included and which previous studies have pointed to have been important for them having impact.

523
00:53:15,100 --> 00:53:23,230
So just to summarise as a final slide, what I tried to do today is introduce this idea of global and legal epidemiology,

524
00:53:23,650 --> 00:53:29,830
bringing a scientific approach to bear on how we use these kind of mechanisms to effect real world change.

525
00:53:30,310 --> 00:53:35,140
And so what is part of this is building this field. We need to do at least three things.

526
00:53:35,470 --> 00:53:40,900
First, we need to be synthesising existing knowledge on what makes it international law effective.

527
00:53:41,410 --> 00:53:49,070
Second, we need to then up our game and use really rigorous approaches to evaluating those international laws.

528
00:53:49,090 --> 00:53:52,450
And so I talked about quasi experimental impact evaluation methods.

529
00:53:53,050 --> 00:53:59,709
And third, we need to then start using this growing body of knowledge in order to inform the design of

530
00:53:59,710 --> 00:54:04,330
future international instruments that can maximise our social outcomes that are desired.

531
00:54:04,900 --> 00:54:08,320
So with that, I look forward to a discussion with you. Thank you very much again.

532
00:54:15,720 --> 00:54:23,160
So we have a roving mike or questions I might ask you one then first of all, people for questions.

533
00:54:23,400 --> 00:54:30,990
So you mentioned this other great global collective action problem, carbon emissions, controlling carbon emissions.

534
00:54:31,000 --> 00:54:39,120
So, I mean, from what you said, it seemed to me that at least, at least for developed countries, antimicrobial resistance,

535
00:54:39,120 --> 00:54:46,050
a vastly greater threat to people's lives than climate change, at least for those people who are alive today.

536
00:54:46,800 --> 00:54:53,220
Yet billions, if not more, have been spent on carbon emissions and controlling them,

537
00:54:53,230 --> 00:54:57,600
and only a tiny, minuscule fraction of that has been spent on anti-microbial resistance.

538
00:54:57,680 --> 00:55:08,610
Why do you think that is, and what do you think you can learn from attempts to use various instruments to control carbon emissions?

539
00:55:09,600 --> 00:55:16,440
Yeah, so it's a it's a great question. I think it's interesting when you look at environmental challenges,

540
00:55:16,950 --> 00:55:22,980
there seems to be it seems to be quite common that the world has used international legal approaches to address them.

541
00:55:23,370 --> 00:55:28,160
So whenever there's whether it's air pollution, whether it's the oceans, whether it's mercury,

542
00:55:28,170 --> 00:55:35,490
mercury and the environment, we often see I that community, that regime going towards international legal mechanisms.

543
00:55:35,880 --> 00:55:41,550
You haven't seen the same thing in global health. And so in that respect, I mean, in that respect,

544
00:55:41,550 --> 00:55:48,630
it makes sense then that in climate change you would see a series of sequential series of treaties focussed on that issue and related issues,

545
00:55:48,900 --> 00:55:54,270
whereas in health we haven't seen that approach as much. We have lots to learn in terms of funding.

546
00:55:54,690 --> 00:56:00,630
It's a good question except that actually when you talk to an environmental a global environmental governance scholar,

547
00:56:00,900 --> 00:56:07,470
they actually often get jealous of the health field where because the health field has lots of global funds and different alliances,

548
00:56:07,740 --> 00:56:10,590
where there has been actually a lot of funding on global health,

549
00:56:10,920 --> 00:56:15,630
there's been I guess there's the perception that there's actually been less on global environmental governance.

550
00:56:15,720 --> 00:56:22,110
But your points are good when I don't have a good answer around why we've seen so much attention on one and not the other.

551
00:56:22,140 --> 00:56:29,250
I think the good news, though. But I'll flag about antimicrobial resistance is that it should be a slightly easier

552
00:56:29,910 --> 00:56:34,500
it should be a should definitely be an easier problem to address than climate change.

553
00:56:35,040 --> 00:56:39,450
Even a couple of reasons, not just because of the technical nature of that issue,

554
00:56:40,140 --> 00:56:47,400
but also because antimicrobial resistance affects everyone rich, poor, powerful, weak.

555
00:56:47,820 --> 00:56:49,440
Whereas with climate change,

556
00:56:49,680 --> 00:56:58,409
those who are wealthier and more powerful could be under the perception that they could mitigate the effects of climate change on them by,

557
00:56:58,410 --> 00:57:01,170
for example, moving to higher ground or changing where they live.

558
00:57:01,620 --> 00:57:08,310
Whereas with anti-microbial resistance, it's not something that wealth or power could protect oneself against.

559
00:57:08,760 --> 00:57:28,460
So I'm optimistic as a result. Steve, can I prove you a little bit more on why you think the Framework Convention on Tobacco Control didn't work?

560
00:57:28,760 --> 00:57:38,629
I like the draft that you presented. The framework was a collection of instruments, as I think you said, including what most of them,

561
00:57:38,630 --> 00:57:44,150
but some of them in particular, like taxation, are extremely powerful at national level.

562
00:57:44,660 --> 00:57:50,240
That's been demonstrated and they are implemented by law at national level.

563
00:57:51,200 --> 00:57:59,239
So your your in your synthesis of the framework convention, are you saying that international law,

564
00:57:59,240 --> 00:58:05,600
the treaty in that instance had no added value to the value that we already know about at national level?

565
00:58:06,170 --> 00:58:11,750
Or is there some other explanation in your data why you think it's not is not so effective?

566
00:58:11,780 --> 00:58:15,490
It's important to understand, I think, why it doesn't work internationally,

567
00:58:15,500 --> 00:58:20,990
whereas nationally all of the constituent instruments of the framework are very effective.

568
00:58:22,560 --> 00:58:28,310
Yes. Thanks for the great question. And that's actually what we need to figure out, in a sense.

569
00:58:28,310 --> 00:58:31,760
So. So just to confirm. Yes, that is our conclusion.

570
00:58:31,790 --> 00:58:39,890
I mean, let me be very clear. The tobacco control policies that are promoted by this treaty are effective.

571
00:58:40,100 --> 00:58:46,969
There's been so many studies, so many more that needed showing that tobacco taxes reduce tobacco consumption,

572
00:58:46,970 --> 00:58:50,870
which is great, and that warnings work and that the smoke free environments are great.

573
00:58:51,110 --> 00:58:54,620
So it's it's not the policies that are in the framework conventions about control.

574
00:58:54,620 --> 00:58:58,760
That's that I'm debating. The only the question I'm raising is, I guess,

575
00:58:59,390 --> 00:59:06,020
did the creation of the Framework Convention on Tobacco Control accelerate the adoption of those policies,

576
00:59:06,380 --> 00:59:11,690
or would countries have adopted the many ways? And I, I think there's many hypotheses.

577
00:59:12,020 --> 00:59:17,210
And with this data, we can't tease out exactly which one, but one could be around.

578
00:59:17,480 --> 00:59:21,380
There hasn't been sufficient implementation of the Framework Convention on Tobacco Control.

579
00:59:21,770 --> 00:59:29,540
In fact, today or a fact yesterday, I guess, was when the Conference of Parties for the CTC were meeting in Geneva Focus.

580
00:59:29,540 --> 00:59:33,380
And the big focus for them was on we need to accelerate implementation.

581
00:59:34,100 --> 00:59:41,600
So I think there's already recognition among 136 countries there that that treaty has not been fully implemented as much as it's wanted.

582
00:59:41,600 --> 00:59:42,680
So that's one mechanism.

583
00:59:43,010 --> 00:59:51,020
So but then my question is, did that treaty cause more countries to have those policies than otherwise without the treaty or not?

584
00:59:51,350 --> 00:59:57,170
And I think it's an open question in the sense that, yes, of course, all the attention on tobacco control has probably been helpful.

585
00:59:57,500 --> 01:00:00,050
The resources that have followed also helpful.

586
01:00:00,680 --> 01:00:05,479
But could we have gotten that attention or would we have gotten the attention without the treaty mechanism,

587
01:00:05,480 --> 01:00:13,400
for example, having created a global pooled fund to support countries to adopt tobacco control policies?

588
01:00:13,730 --> 01:00:17,390
Would it have had more effect than a treaty? I don't know.

589
01:00:17,450 --> 01:00:20,240
We don't have a global fund, but I am asking that question.

590
01:00:20,300 --> 01:00:26,480
And this study, I think, shows that we should be asking that kind of question because I think Emory,

591
01:00:26,480 --> 01:00:29,930
the director, Sir Charles Godfrey, was next in line.

592
01:00:31,460 --> 01:00:36,890
Sorry about that. I just to follow up on Chris's question, I'm afraid this is a rather nerdy question,

593
01:00:36,890 --> 01:00:46,550
but I'm trying to grasp how the quasi experimental technique worked and looking at the the quite broad confidence intervals on the graph.

594
01:00:47,120 --> 01:00:53,270
And are you able to do in this technique a sort of power analysis?

595
01:00:53,570 --> 01:00:57,920
What could it be working? But you just don't have the power to tell.

596
01:00:58,220 --> 01:01:04,760
And how big an effect would it have to have before it would it would show up in your analysis?

597
01:01:05,360 --> 01:01:16,250
Yes. So so you're right. So based on this event model, we can't conclude because of the the confidence interval that it's not the other way around.

598
01:01:16,310 --> 01:01:21,140
So you're right, based on this, we, though also debuts also an interrupted time series analysis.

599
01:01:21,560 --> 01:01:27,470
And in that method, had I shown that figure, it would show it's beyond the confidence interval.

600
01:01:27,980 --> 01:01:38,810
So in that respect, we've used two methods trying to basically we did the best attempt we could to try to find impact.

601
01:01:39,650 --> 01:01:42,770
And the reason we try so is like multiple testing.

602
01:01:42,770 --> 01:01:48,110
We try to do all sorts of all sorts of different assumptions, trying to find impact.

603
01:01:48,560 --> 01:01:53,330
And what we kept on getting were things like this, where this would be.

604
01:01:53,330 --> 01:01:56,600
So the conclusion here would be we can't conclude a statistical difference,

605
01:01:56,960 --> 01:02:02,480
but our best guess would be that actual consumption is higher than what was predicted.

606
01:02:02,780 --> 01:02:07,429
Now that being said, I'm not actually we're not concluding out of the study that the effects caused harm.

607
01:02:07,430 --> 01:02:11,000
I don't think it did at all, but at least it didn't.

608
01:02:11,180 --> 01:02:18,410
It doesn't seem like it caused enough of an acceleration that we pick it up using these methods.

609
01:02:19,300 --> 01:02:25,750
Maybe it did cause some, but the impact, at least according to these methods, don't seem to.

610
01:02:25,840 --> 01:02:31,750
It wasn't large enough for us to find it. That's maybe the best. And that's that's the way we're going to frame the conclusion.

611
01:02:31,960 --> 01:02:35,020
Yeah. So thanks.

612
01:02:35,020 --> 01:02:39,249
And really like the focus of what was the second part of the presentation.

613
01:02:39,250 --> 01:02:43,840
So the evaluation of this new tool probably.

614
01:02:44,200 --> 01:02:49,689
And I was wondering whether in addition to this study on like the tobacco consumption convention,

615
01:02:49,690 --> 01:02:56,829
whether there is and other like examples from international, probably even public international already, maybe even.

616
01:02:56,830 --> 01:03:02,799
Yeah. Domains that are more remote to the health domain that could tell you like moderating

617
01:03:02,800 --> 01:03:08,230
about moderating factors such as whether recommendations are less effective than

618
01:03:08,230 --> 01:03:12,129
requirements with this distinction that you introduced in the beginning and similar

619
01:03:12,130 --> 01:03:18,040
things so that you you can have a more informed choice and even evaluation then of yeah.

620
01:03:19,480 --> 01:03:23,200
Rules that might work or not legal. Right? Definitely.

621
01:03:23,200 --> 01:03:30,819
So I think you're pointing to a really important part of this, which is that, of course, we can't just focus on legal mechanisms.

622
01:03:30,820 --> 01:03:33,969
We have to focus also on internal alternatives to them. Right.

623
01:03:33,970 --> 01:03:36,790
So you mentioned recommendations. There's also guidelines.

624
01:03:36,790 --> 01:03:43,090
There's a whole suite of global governance instruments that could be used and that are being evaluated.

625
01:03:43,300 --> 01:03:47,770
So, for example, there is a quasi experimental impact evaluation of the Millennium Development

626
01:03:47,770 --> 01:03:52,630
Goals and the impact of articulating those goals and particular outcomes.

627
01:03:53,110 --> 01:03:59,930
That's an interesting it's a really interesting study, but it's it points to the fact that to achieve progress, we don't always need law.

628
01:03:59,980 --> 01:04:05,500
In fact, as I said beginning, I my starting point was one of being critical for this type of mechanism.

629
01:04:06,520 --> 01:04:12,640
And so what we also need is as part of developing the science of global governance or global governance instruments,

630
01:04:12,880 --> 01:04:14,650
we need to also be focusing on others.

631
01:04:14,980 --> 01:04:22,600
I myself have been more focussed on the legal instruments because I'm an international lawyer, but there's a lot of people in political science,

632
01:04:22,600 --> 01:04:29,649
international sociology and other places that have been focussed on others because in many respects a lot of people,

633
01:04:29,650 --> 01:04:35,500
a lot of the theories for why international law could be effective are around things like norms, changing norms.

634
01:04:36,130 --> 01:04:40,150
And that makes sense to me. It's a change, you know, and then you don't need a law.

635
01:04:40,330 --> 01:04:46,690
You don't necessarily need an international law to change the norm. So as a result, it points to the potential effectiveness of others.

636
01:04:46,690 --> 01:04:53,590
And we the key then, in my mind is we have to tease out under what circumstances do which instruments work,

637
01:04:54,220 --> 01:04:57,490
and so that we can be forward looking and say,

638
01:04:57,490 --> 01:05:05,139
okay, we have this type of problem, we should apply this type of solution for that problem and that what and what currently,

639
01:05:05,140 --> 01:05:08,830
unfortunately, what we see is when these things are being negotiated at diplomatic fora,

640
01:05:09,250 --> 01:05:14,649
the ideas that come forward are often based on just what the person happened to have seen or known about.

641
01:05:14,650 --> 01:05:19,490
So if that person was, let's say, married to an environmental scholar, we'd be drawing from the environment.

642
01:05:19,490 --> 01:05:26,889
So if that person before their posting was in Geneva, they were posted in somewhere where there's a having a big mining industry and they look at the

643
01:05:26,890 --> 01:05:31,090
Kimberley process or there would be a lot of it is based on what people individually know,

644
01:05:31,390 --> 01:05:34,360
which is fine because that's way, that's one way we learn.

645
01:05:34,660 --> 01:05:38,410
How much better would it be if we could take a bit of a scientific approach to bear instead?

646
01:05:38,800 --> 01:05:40,980
That's the question. Thank you.

647
01:05:41,410 --> 01:05:56,950
Actually, I was wondering so if the if the putative benefit of the framework was acceleration of uptake of of the tobacco policies in these countries,

648
01:05:57,700 --> 01:05:59,770
could that not have been measured as the outcome?

649
01:06:00,220 --> 01:06:05,470
Or is that information more difficult to come by or because it really would be an interest to see that as a comparison.

650
01:06:06,340 --> 01:06:15,160
Yes. To the policies themselves. Yeah. So there there are another Canadian colleague of mine has been looking at exactly that question.

651
01:06:15,430 --> 01:06:21,160
So yeah, that would be an alternative way of looking at this. So instead of we we're looking at it this.

652
01:06:21,980 --> 01:06:26,000
This Framework Convention, did it have impacts on tobacco consumption?

653
01:06:26,420 --> 01:06:33,350
Instead, we could have said, did this framework have an impact on how fast tobacco control policies were being implemented?

654
01:06:34,010 --> 01:06:40,219
And the weird thing which we've had to grapple with in this study is that those are the ones, the one leading study that is asked.

655
01:06:40,220 --> 01:06:48,650
That second question, the question that you proposed found that it did accelerate national adoption of tobacco control policies.

656
01:06:49,280 --> 01:06:56,450
So last week, when I asked the person who wrote that study this question, how do you reconcile the two results?

657
01:06:56,960 --> 01:07:06,170
The thinking was it might have this this framework convention might have accelerated the formal adoption of a law within a country,

658
01:07:06,170 --> 01:07:09,800
but not necessarily its actual implementation in that country.

659
01:07:10,250 --> 01:07:16,400
So it might have accelerated laws on the books, but not actually the actions within countries.

660
01:07:16,790 --> 01:07:27,710
That's a it's a hypothesis not tested, but it's one that at least explains the two different results that come into play here.

661
01:07:28,250 --> 01:07:34,730
So it's a great, great question. Thank you. I've got another question for you.

662
01:07:35,120 --> 01:07:42,259
So I just want if you can give us an example of of how an international treaty might impact this,

663
01:07:42,260 --> 01:07:51,169
because it seems that it's it's going to be impossible to implement without actually doing something much more significant.

664
01:07:51,170 --> 01:07:56,120
And that is creating a comprehensive, effective health care system all around the world.

665
01:07:56,150 --> 01:08:03,530
So just to take the sort of trivial example that you mentioned, prescription of antibiotics for future tract infections.

666
01:08:06,000 --> 01:08:11,809
The problem that you face is that, you know, as you said, 10% of infections can be bacterial.

667
01:08:11,810 --> 01:08:14,810
If they're missed and not treated, they can be catastrophic.

668
01:08:15,320 --> 01:08:25,640
So you could deal with that by having a very effective health care system, that very effective diagnosis, monitoring doctors got patients back.

669
01:08:26,090 --> 01:08:27,559
It would be enormously intensive,

670
01:08:27,560 --> 01:08:36,139
even in the US to convince people that they weren't taking on an additional risk to themselves for the sake of this future.

671
01:08:36,140 --> 01:08:40,100
Good of protecting antimicrobial factors. That's just in the US.

672
01:08:40,460 --> 01:08:46,880
Then you've got to deal with Africa and India where you don't have health care systems and throwing antibiotics

673
01:08:46,880 --> 01:08:53,500
at a problem might might actually be effective compared to generating a more comprehensive health care system.

674
01:08:53,510 --> 01:09:00,110
So can you give us an example of sort of revolutionising the kind of health care system for the world,

675
01:09:00,470 --> 01:09:03,860
how a treaty is actually going to make progress?

676
01:09:04,470 --> 01:09:11,210
You know, so I think the assumption with the question is that is that we can't do it all.

677
01:09:11,240 --> 01:09:14,930
We can't just fully solve this challenge, which is may be the case.

678
01:09:15,230 --> 01:09:20,150
So I guess in that respect, I guess I'm not trying to solve all the world's problems with the treaty.

679
01:09:20,330 --> 01:09:23,510
I guess, although I do think that there are lots of things that can be done.

680
01:09:23,810 --> 01:09:32,450
So, for example, when it comes to innovation right now, we have insufficient levels of investments in innovation because as countries

681
01:09:32,450 --> 01:09:35,900
are hoping to free ride on each other instead if there is a legal system.

682
01:09:36,180 --> 01:09:40,160
There's a legal agreement where all countries agreed to or those countries that could.

683
01:09:40,580 --> 01:09:42,320
We're participating in funding,

684
01:09:43,250 --> 01:09:49,190
research and development related to antimicrobials and the diagnostics and other vaccines and other things that would support it.

685
01:09:49,670 --> 01:09:52,910
Then we'd have a much we have much greater levels of investments.

686
01:09:53,150 --> 01:10:01,940
That's one tangible example. But I think that the question that points to another very important point, which is that, of course,

687
01:10:02,360 --> 01:10:07,850
what actually happens within countries to address antimicrobial resistance has to be different depending on the country.

688
01:10:08,330 --> 01:10:14,569
That's not the way we usually think about international law. So most people in this room who are thinking of international law,

689
01:10:14,570 --> 01:10:20,910
you're probably thinking of, okay, standard, consistent standards that every country upholds.

690
01:10:20,930 --> 01:10:26,209
So, for example, human rights, all people have the right to the highest attainable standard of health,

691
01:10:26,210 --> 01:10:32,750
and it's just consistently applied in every country. In my mind, that probably won't work to be able to say, okay,

692
01:10:32,750 --> 01:10:39,920
every country should require a doctor's prescription before they can access an antibiotic that doesn't work in a

693
01:10:39,920 --> 01:10:45,860
country where there might not be enough doctors for people to have appropriate access to these lifesaving medicines.

694
01:10:46,190 --> 01:10:53,420
So there'll be different approaches needed. So my mental model looks much more like what the Paris Climate Change Agreement looks like,

695
01:10:53,810 --> 01:11:00,320
which instead of it being a bargain around what content each country or what policies each country will pursue.

696
01:11:00,650 --> 01:11:03,800
Instead, it's a bargain around the process that all countries would follow.

697
01:11:04,130 --> 01:11:09,650
So in that case, each country self declares what they're going to do against it,

698
01:11:09,680 --> 01:11:16,670
towards achieving a certain goal that's identified, and then that self-declaration becomes legally binding on that country.

699
01:11:17,000 --> 01:11:23,810
So what it does is if countries pledge they're committed and then it's the intention is to over time, ratchet up level of impact.

700
01:11:24,170 --> 01:11:32,030
And that's I think that's important to flag because it highlights that some of these feasibility concerns might not

701
01:11:32,030 --> 01:11:38,690
actually be there if the if different countries in the world are helping solve this challenge in its own unique way.

702
01:11:41,870 --> 01:11:49,280
We got Johnny and then Chris. Thanks very much. And I wonder if could go back to the start of the graph of the impact of the tobacco regulation.

703
01:11:49,430 --> 01:11:52,850
The first one. Have you got the one prior to that? Yeah.

704
01:11:52,850 --> 01:12:01,350
So one other line is interesting. There is the high middle income because that seems to be a line which does kind of buck the trend a bit.

705
01:12:01,370 --> 01:12:07,639
So my first question was whether you had a hypothesis for that, whether it was just a bit of an aberration and a bit of a follow up.

706
01:12:07,640 --> 01:12:14,300
If you did start to see some kind of income groups or country groups kind of trending away from the global line in the middle.

707
01:12:14,630 --> 01:12:20,780
Has there been any ethical discussion of whether we should be prioritising some groups rather than others or just focusing on that global average?

708
01:12:22,190 --> 01:12:28,490
So both great questions. So yes, there are some regional, regional differences that we found.

709
01:12:29,150 --> 01:12:34,580
And that's that's not new. Any sort of estimate of tobacco consumption or prevalence.

710
01:12:34,820 --> 01:12:40,910
So there's this variation. So we did we did look at all these and bring it together in a cohesive study.

711
01:12:41,630 --> 01:12:43,910
In terms of the the ethical issue of the priority,

712
01:12:44,270 --> 01:12:51,620
I think it's clear that the priorities probably needs to be on the countries that have the least capacity to address this.

713
01:12:51,950 --> 01:13:00,409
I mean, one really interesting aspect of tobacco is that the industry that's promoting the sale of tobacco is very multinational,

714
01:13:00,410 --> 01:13:09,620
very global, very powerful, very well-funded. And when put up against some countries, it's not really a it's not a good situation.

715
01:13:09,980 --> 01:13:15,050
So from an ethical perspective and even just from from an effectiveness perspective,

716
01:13:16,100 --> 01:13:21,650
which is also ethical, it makes sense to focus on those countries that have the least capacity.

717
01:13:21,890 --> 01:13:25,400
And the good news is that's exactly what the World Health Organisation does.

718
01:13:26,090 --> 01:13:31,370
I mean it's been it's been leading the effort for quite some time and I think

719
01:13:31,370 --> 01:13:35,180
most impactful it's been supporting countries that want to go on this path,

720
01:13:36,140 --> 01:13:42,590
helping them do it. And I think and again, the other good news with tobacco is that there's been so many studies showing the

721
01:13:42,590 --> 01:13:47,390
effectiveness of these national policies that if a country is serious about tobacco control,

722
01:13:47,660 --> 01:13:51,260
it's actually pretty easy for that country to do it. But it's not so easy, right?

723
01:13:51,260 --> 01:13:54,890
Because there's all the political interests, the economic interests at play, lobbying.

724
01:13:55,670 --> 01:14:01,310
And even if a state was able to defy the lobbying and the political interests, economic interests,

725
01:14:01,730 --> 01:14:07,250
there's still just the capacity of how do you enforce things and how do you monitor

726
01:14:07,250 --> 01:14:11,480
and make sure that everyone's complying with laws that might be on the books, but maybe not in practice.

727
01:14:11,960 --> 01:14:16,760
So it's a we tried to tease out some of that, but we can't with most of this data.

728
01:14:19,790 --> 01:14:24,709
Just one last quick one. Stephen, I think you may have just alluded to what I was going to say,

729
01:14:24,710 --> 01:14:29,060
which is that you've examined the question of whether a treaty or not is important,

730
01:14:29,060 --> 01:14:38,030
but clearly whether a treaty will work or not depends on the instrument that it's wrapped around, what kind of intervention you're talking about.

731
01:14:38,630 --> 01:14:44,840
And some of some of them are clearly quite complex. And complex interventions would limit the effectiveness of a treaty.

732
01:14:44,840 --> 01:14:54,440
But in other instances, for example, polio eradication, that's not an international treaty, but it's a global initiative.

733
01:14:54,860 --> 01:15:01,610
And it's extremely it has been extremely successful because, of course, it's based on a very simple, easy to use vaccine.

734
01:15:02,060 --> 01:15:07,549
And there's essentially no opposition. There is some opposition, but essentially no opposition, let's say, to its use.

735
01:15:07,550 --> 01:15:10,129
And that's why it's been tremendously successful.

736
01:15:10,130 --> 01:15:17,240
So I think in my mind, one lesson from that is that when you're thinking about antimicrobial resistance,

737
01:15:17,630 --> 01:15:23,660
one opportunity is to present a simplified message around the key instruments that work.

738
01:15:24,230 --> 01:15:30,770
I think the debate around antimicrobial resistance is far too confusing at the moment and unnecessarily so.

739
01:15:31,400 --> 01:15:40,550
I think there are some simple messages and one virtue a treaty perhaps, or a discussion around that would be to simplify the things that really work.

740
01:15:41,110 --> 01:15:45,079
Yeah. Yeah. So I think. Chris, thank you very much for that.

741
01:15:45,080 --> 01:15:48,420
I agree 100%. I. Yeah, I.

742
01:15:48,540 --> 01:15:57,800
It's way too confusing right now. And one thing that I think we're one shining example of what the FCC has succeeded in doing

743
01:15:58,190 --> 01:16:05,030
was to focus some attention on very particular policies that were shown to be effective.

744
01:16:05,030 --> 01:16:08,360
So that's why it was often called the world's first evidence based treaty.

745
01:16:08,810 --> 01:16:11,440
And so it did that. And did it need to be?

746
01:16:11,450 --> 01:16:20,420
It is the I guess my my question, though, is, did did we need the treaty mechanism in order to highlight those policies?

747
01:16:20,750 --> 01:16:24,590
Maybe we did. Maybe. Maybe 13 years isn't enough time.

748
01:16:24,890 --> 01:16:31,400
I mean, certainly at the Conference of Parties, there was discussion that this treaty remains as relevant today as it was 13 years ago.

749
01:16:31,820 --> 01:16:35,389
And so we just need to accelerate implementation. I think that's a good message.

750
01:16:35,390 --> 01:16:40,340
That's one I certainly believe in. But I and I think you're you're right.

751
01:16:40,520 --> 01:16:46,250
We should try to probably we should learn from this experience. And one success was that simplification.

752
01:16:46,820 --> 01:16:53,000
We need to do that for anti-microbial resistance. Definitely. Again, conscious, we're standing between people in their alcohol.

753
01:16:54,290 --> 01:16:59,410
So we might take one last question. I've got two questions not answered, both of them.

754
01:16:59,660 --> 01:17:03,320
The first is, I think you've touched upon a little bit already,

755
01:17:04,580 --> 01:17:10,480
but you've demonstrated that international law seems to be quite successful in the areas of finances, trade.

756
01:17:10,800 --> 01:17:15,590
Know for that. What is it about global health? Why has it not succeeded in global health?

757
01:17:15,590 --> 01:17:22,220
I guess my second question is also you've mentioned tobacco consumption and antimicrobial resistance, both really important issues.

758
01:17:23,690 --> 01:17:28,610
What other what other is there another issue within global health that you think is is also pressing?

759
01:17:30,260 --> 01:17:34,700
Great. Thanks for those questions. For the first one, I think, first of all,

760
01:17:34,700 --> 01:17:39,649
we should let's take that as a tentative conclusion in the sense that it was drawn from

761
01:17:39,650 --> 01:17:45,800
90 quantitative impact evaluations that we were able to find in a non systematic way.

762
01:17:46,610 --> 01:17:53,179
So based on those 9090s, a lot of studies better than 90 of have easily found quantitative effects.

763
01:17:53,180 --> 01:17:58,100
Valuations showed that the trade ones and they seemed to be from an outcomes perspective they could.

764
01:17:58,550 --> 01:18:03,710
We did find lots of studies that had these outcomes. So trade, yes, but we didn't find many on the social side.

765
01:18:04,130 --> 01:18:14,210
Why? My hypothesis that well, that we mentioned in this study when it was published was that I think these treaties look different.

766
01:18:14,690 --> 01:18:20,749
Right. So when you have a trade treaty, there's a dispute resolution mechanism, there's a compliance mechanism, there's accountability,

767
01:18:20,750 --> 01:18:29,370
there's monitoring, there's implementation mechanisms built into them that over time, rich countries do actually compact.

768
01:18:29,370 --> 01:18:36,820
There's consequences if countries break them. Whereas when you look at human rights treaties, there would be less of that.

769
01:18:36,830 --> 01:18:40,819
So there is a periodic review, there's a peer review mechanism.

770
01:18:40,820 --> 01:18:44,360
There's a time when countries have to go to Geneva and explain themselves.

771
01:18:44,360 --> 01:18:52,100
That's that's not the same as having a World Trade Organisation, a dispute resolution board.

772
01:18:52,700 --> 01:18:55,940
And then when it comes to, for example, the Framework Convention on Tobacco Control,

773
01:18:57,230 --> 01:19:01,370
there's not much of any implementation mechanism or enforcement mechanism.

774
01:19:01,910 --> 01:19:06,200
And I'm not I'm not saying that that's that's what it meant.

775
01:19:06,350 --> 01:19:11,600
It raises questions as to if we have treaties with our teeth, should we have pursued the treaty strategy?

776
01:19:11,870 --> 01:19:14,779
I think when that treaty was initially being negotiated,

777
01:19:14,780 --> 01:19:22,429
it probably was hoped that it would have some enforcement mechanisms, but in the end it didn't have very many.

778
01:19:22,430 --> 01:19:26,000
And so it sort of questions the whole enterprise. But I think that's the key.

779
01:19:26,360 --> 01:19:35,450
The key is then to have instruments that have these sort of things that are institutionally designed for compliance and impact, how to do it.

780
01:19:35,450 --> 01:19:41,630
We need to learn from these sort of studies and ideally even better studies than just the 90 quantitative impact variations.

781
01:19:42,850 --> 01:19:50,240
Thanks for your question. Okay. Well, so, you know, I think this is one of the most important talks I've heard.

782
01:19:51,260 --> 01:19:59,510
You know, the message of the evidence based medicine movement that started in the nineties when I was a postdoc here was that in many cases,

783
01:19:59,510 --> 01:20:09,410
interventions make great physiological sense, but when properly evaluated, scientifically do more harm than good.

784
01:20:10,430 --> 01:20:16,010
And that movement has changed the way medicine has been researched and implemented.

785
01:20:16,370 --> 01:20:20,480
But that scientific methodology hasn't carried over to other areas of life.

786
01:20:20,510 --> 01:20:28,400
Every year, someone introduces a new educational policy or some new social policy without rigorously affecting whether it does more harm than good.

787
01:20:28,940 --> 01:20:38,490
And I think this is a fantastic initiative to subject legal instruments to the same kind of evaluation that occurs in science.

788
01:20:38,510 --> 01:20:40,580
They're meant to improve the world.

789
01:20:40,850 --> 01:20:51,290
And no matter how well-meaning or ideologically driven or plausible they are, they can always do more harm than good.

790
01:20:51,320 --> 01:20:53,780
So I think this is the beginning of a revolution.

791
01:20:53,780 --> 01:21:01,790
And I'm sure in 20 years time people will look back at the sort of dark ages when people just introduced laws and didn't evaluate them.

792
01:21:02,510 --> 01:21:08,350
So I thank you, Stephen, for bringing us to the beginning of a revolution, and I can't wait to see how it unfolds.

793
01:21:08,360 --> 01:21:11,000
Thank you. And there's drinks next door in the capital.