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,
for all of you for joining. So when talking about global legal epidemiology, this is something that we've been developing, colleagues and I,
at the Global Strategy Lab for quite some time when talking about it,
it's important to note from beginning what we are talking about, but also what we're not talking about.
And I'm particularly pleased to present this today because it's the first time we've really publicly been talking about this.
So I look forward to discussing with you afterwards. So global epidemiology.
So what what is it? So first, I should say we're right up front.
I didn't invent the term epidemiology.
Long standing, disciplined, studying patterns of health and disease, using systematic methods and the causes of health and disease.
I also didn't invent the term global legal entity and also invent the term legal epidemiology.
So a few years ago, Scott Harris and colleagues wrote about the need to bring a systematic study for the deployment of law
as a factor in the cause and distribution and the prevention of disease and injury in a population.
So this idea of applying rigorous scientific methods in order to understand law as a cause or a factor
in the cause of the distribution of health patterns is an idea that's been increasingly out there,
and this is something that's come from various traditions.
Criminologists have long focussed on what kind of criminal law policies have different impacts.
Environmental scholars have focussed on what environmental legal policies would drive, let's say, reductions in carbon emissions.
So it's not a new thing. But I think what's important to say is there's at least three intellectual
moves that come by merging these two ideas together of legal and epidemiology.
The first is that the focus is on law as intervention.
So law not just as as a rule, but as an intervention into a society to change the rules of that society.
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.
And the third is about law as achieving particular impacts.
So having a normative affects of trying to actually do something and seeing whether it has those impacts individually.
These aren't crazy ideas.
They're being brought together and they've been they've been really inspiring a whole series of additional scientific studies,
figuring out how do we use law to solve social challenges.
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,
then it's less about legal epidemiology and its domestic context, but instead global legal epidemiology and a global concept.
So in that in this respect, what we've been doing is we've been trying to conceptualise international law as a global population
intervention that's actually independent of the domestic implementation of international law.
And by that, what I mean is we've been thinking of international law as something that changes the world,
irrespective of whether that that change is incorporated into domestic legal systems.
So the thinking is law.
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.
And so what that allows is a whole different sort of way to study it.
So whereas many political scientists, some of whom might be in the room,
would be really interested to be asking questions like what impact does international law have on state behaviour, right?
So how, how might states change their behaviour if there's an in the presence of an international law or not.
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,
when and how does it that international law produce real world outcomes for people?
So it's really about it's a very pragmatic, it's an applied lens,
one that's building on a tradition of both understanding patterns and causes of health and disease,
but also then using systematic and scientific tools to try to tease that out in order to inform future interventions.
And so the goal, in other words,
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?
And so today, during this lecture, I'm going to do four things.
The first is I'll provide a very brief introduction to international law and specifically international health law,
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.
To advance in order to further develop this emerging field of global legal epidemiology.
And the first to share right up front is that in order to develop this as a field,
we need to actually bring together the various kinds of studies that have already happened that can be part of this field.
So there's many studies out there that have looked at what impacts internationals have on different outcomes.
The key, though, is we need to bring it together in order to better yield the insights that that body of literature can offer.
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
methods we need to evaluate treaties and other types of legal agreements.
And what I'll bring forward an example that we've been doing at our lab around evaluating and
using quasi experimental approaches to study whether laws have effects on the national space.
And the third is ideally, after looking sort of at past research and then a shining example of some current research.
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,
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,
which we believe is in need of global collective action solutions.
And I'll try to highlight at that time what kind of insights we've been learning from this field of global legal epidemiology.
So that can be brought to bear on how we could design a future international legal framework around antimicrobial resistance.
So going first to the brief introduction. So what is global health law in this case?
So it's really it's international law related to global health issues.
Now, international law is a set of rules that mainly govern the conduct of countries.
So usually it's national governments, but they can also govern the conduct of individuals in some particular circumstances.
Now, the key with these international laws is we often break them up into reports and think of normative
instruments as either being hard instruments legally binding or soft instruments not legally binding.
But actually when you look at when you read treaty texts and other legal instruments,
what you see there is that there's some provisions that are legally binding and others that are not.
So some, for example, call upon countries hopefully to maybe do things if they can possibly.
Other other provisions are clear requirements imposed on countries or in some cases, individuals.
And so there it's important that what this means is that global health law is a set of normative rules that are,
in some cases, legally binding requirements.
In other cases, importantly, can also include non legally binding recommendations,
all of which create norms and governance and rules upon which actors expectations can converge.
And often, international law or global health law included, will often feature central institutions such as the World Health Organisation,
a UN specialised agency that would then create those norms, mobilise resources and guide collaboration.
Just to highlight some examples. When we think of prominent global health laws, here are just four that come to mind.
So one is the constitution of the World Health Organisation that created that institution as a legal entity.
The second would be the International Health Regulations. This is the international law that governs how countries respond to pandemic outbreaks.
And the third example, which will come up quite prominently later in this talk,
is the WTO Framework Convention on Tobacco Control, which is a treaty geared towards reducing the global consumption of tobacco.
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,
Social and Cultural Rights, which I think forms an important part of this global health law landscape.
But it's not just for laws, actually, if you sort of bring together a list, here's,
I guess, one of the best lists that I could be that we could bring together.
It goes back to 1892, the International Sanitary Convention, many revisions of that convention,
which ultimately ended up as the international health regulations. But in here, you also have, for example, the Biological Weapons Convention.
We don't usually think of that as a global health, as a global health law, and that's okay.
But certainly there's important global health implications. But it's that one or two chemical weapons and many other agreements.
The most recent one we can think of as the UN Convention on the Rights of Persons with Disabilities,
or even more recent than that, the M.I.T. Convention on Mercury. But when thinking about global health law, international law more broadly,
we shouldn't only think of past laws, of which there's many that we could choose.
I also want to point to the fact that we often. Think of international law as a potential solution to different challenges.
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.
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.
For example, here's a commentary in Nature Journal calling for a framework convention on alcohol control.
Another one, a commentary in the Lancet medical journal calling for a framework convention on obesity control.
A blog asking Should we propose a global nutrition treaty?
Another comments in nature calling for a global treaty on non-communicable diseases.
Calling for a treaty on health care. Corruption. Another one on fighting fake drugs.
Another one on a research and development treaty. A Framework Convention on Global Health broadly.
Another one on having a framework convention to require countries to have mandatory impact evaluations.
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.
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
proposals are actually deserving or would be helped by international law and which would not.
And without having a very clear sense of that, without bringing a scientific approach to that.
What ends up being is we have a situation where we have this certain golden hammer and we're trying to hit different problems.
And it leads to quite a confused landscape. Not good.
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
sift through some of these proposals and think about which might be particularly deserving of international attention and which ones not.
Or at least some sort.
In the absence of a clear scientific information around whether a treaty would achieve the impact that its proposers think it will have.
Are there criteria that would allow us to think through? This will likely have an impact and maybe likely not.
And so the best that we could come up with was something that looks like this,
where it's really what drives it is and it's longer than just two criteria, but it's to summarise it,
I can point to these two aspects, which is that the best we could do is okay,
we should maybe consider using international law when there's a significant transnational dimension.
So what that means is that you have a risk or a cause that involves multiple states and actually transcends their
national boundaries such that any one individual state is not its the problem is not contained within that state.
They can't tackle the problem by themselves. But that's not enough in our criteria.
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.
And the reason for that is recognising that there's major costs and using international law.
And so what would be something that we could achieve sometimes with international law that you can't achieve elsewhere?
Well, it would have to be something you'd have to be a law that addresses a multilateral
challenge that cannot practically be addressed by any one state alone.
Or it could be something that's resolving a collective action problem where benefits are only accrued if multiple states coordinate.
Or alternatively, it could be something that's advancing a super ordinate norm that embodies humanity and near universal values.
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.
Another approach, though, would be to think of it in terms of costs and benefits.
And here's a very simplistic way of thinking about this,
but it's clear that there are some benefits for treaties and other international legal mechanisms, a clear expression of commitments.
It's part of an established legal system,
and it is one of the strongest ways in which countries can make commitments to each other and bind themselves to things.
There's some big costs, though,
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.
So, for example, there's some clear costs that this is a lengthy process.
Right. It's not so fast to negotiate a treaty. It's also there's some diminishing political feasibility by that.
What I mean is these aren't always so politically attractive.
And third, there is a limiting this is there is some limiting effects on states.
So it's not always and it's it's putting some limitations on states that they might not otherwise like.
And. In my mind, what would tip the balance?
What we need to tip the balance from costs to benefits would be whether treaties are actually delivering results.
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.
So while the itself this idea, this this field of global legal epidemiology, or at least that term is quite new.
The good news is we have the shoulders of intellectual giants to stand on.
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,
which is about we need to synthesise what we need to find and then synthesise existing research that
is beginning to tease out when can international laws have effects and when don't they have effects?
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.
And what this attempted to do was bring out those studies that had evaluated various treaties,
whether they're environmental treaties, trade treaties, human rights treaties, financial treaties.
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?
So, for example, if there is a trade treaty that international law on trade, did it actually promote more trade,
which is usually what those who signed trade agreements are trying to achieve, increase the amount of trade.
And what we found was a surprisingly or not surprisingly mixed picture.
So in this slide, what you'll see is this is the number of studies that found whether the treaties that
were being evaluated had the effect that the progenitors of those treaties wanted.
So the green indicates the number of studies of the 90 that found that, for example,
international financial law increased financial flows between countries.
The yellow is the number of studies that showed either no effect or mixed results.
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,
the number of quantitative impact evaluations that we found out of the 90 that showed
that actually these treaties sometimes had the opposite effect as to what was intended.
So, for example, on the human rights side, though,
there's quite a bit of red there in the sense and a lot of the theory behind that is that sometimes international
human rights treaties might be giving cover to those governments that actually don't want to act on human rights.
But by enacting an international human rights treaty,
it gives them the cover and buys them time before doing something before a population demands change.
That's really what some of the read is like, but that's not expected by the people proposing an international human rights treaty.
Now, this is this figure is showing by type of international law.
What if instead we look at by type of outcome.
So there is this question of, okay, maybe different types of treaties are having different kinds of effects,
but what about are there maybe some kinds of outcomes that treaties seem to be able
to produce and other kinds of outcomes the treaties don't seem to be able to produce.
And so when we divided up those 90 studies by different kinds of outcomes,
what we consistently found were that treaties were able to increase trade and increase foreign investments and pro finance policies.
What treaties were less successful doing, or at least what we saw less of in these quantitative impact evaluations,
were treaties affecting social policies, social rights and health.
And in fact, the thing that as someone who's worried about global health,
the thing that worried me the most was that we're out of these 90 quantitative impact evaluations that we found,
not a single one found an association between an international treaty and improved health outcomes.
So obviously what that does is it raises some big questions in one's mind,
or it should raise questions in one's mind as to do we want to use international law to
solve these challenges and do we want to use it to solve social and health challenges?
And if we do, we should be pretty purposeful about that.
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.
Systematic reviews are really it's an attempt to be apply a transparent,
systematic process to gathering a whole field of literature that's responding to a very particular question.
And so we're in the process of doing this for at the very end where we found more than 200 studies.
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.
And we're now in the final process of bringing those together.
And so what we're doing there is to just to clarify, as these would be because we've done a systematic search,
we've searched ten different electronic databases, we've done everything in duplicate.
So. Few people have screened the titles and abstracts to make sure could they be relevant.
And then two people reviewed the full text, and there was a whole process to extract information in a way that could be usable.
We did it focussed narrowly on this question, which is summarised in these four bullet points.
So first we're focussed on looking at the impact of international law on health and its various social determinants,
which we're recognising that everything influences health.
We included basically everything, any real outcome of people.
We looked at their impact on countries and within countries and we were looking for some kind of comparison.
Sometimes the study was looking at before and after. Other times they were looking at an alternative group, a comparative comparison group,
and this is what the what a screening flowchart looks like when you're taking this approach.
The top right hand box listing out all the databases we searched in, the number of records we identified in those databases.
When we use our search string, we had different stages of reviewing title an abstract to see.
Could this record that we found, could it possibly contain an impact evaluation of international law?
And then finally and towards the end, reviewing the full text.
So we we read 452 full texts in duplicate for people to see whether it could possibly contain an impact
evaluation and the benefits of taking this kind of scientific approach to answering this kind of question,
which we haven't yet answered, is that it? First, it provides a rigorous, systematic methodology to establish a baseline knowledge of the field.
Right.
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.
And you can track a field's progression in that way. Second is, once we use meta analysis, a meta regression analysis,
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.
And using meta regression analysis, we should be able to identify what factors influence whether one study showed it had an
effect versus those other studies that found international law did not have effect.
So it's really trying to use fairly systematic methodological approaches to tease out effects and do what an individual study couldn't do.
And third, we think it's helpful for informing future decisions by identifying what types of international laws are most likely to produce.
What kind of effects? Under what kind of circumstances?
Having talked about the six hour systematic approach to synthesising existing literature from the past,
let me tell you about one study that we're doing that's currently focussed on evaluating it of current international law.
And I say that because right up France, after we did the after we brought together the various studies for a systematic review,
we recognise that there are lots of studies out there that are trying to identify associations between international law and different outcomes.
But there's very few studies.
In fact, we only really found one study that used quasi experimental methods to evaluate whether international law has had any impacts.
Now, before I talk about quasi experimental methods, I think some people might think, well, let's do a randomised controlled trial, right?
Because randomised controlled trials often called the gold standard as a way to tease out whether something has effects or not.
And so I think in this context you'll probably agree that not only is it possible, so in this case,
imagine we live in a world where we could actually here in this lecture room,
we could decide which countries are going to get in international law and which ones are not.
And we randomised that that treatment. And so in a world where we had that power,
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.
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.
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,
we're conceptualising international law as actually having global population impacts.
Right? So we're seeing international law as something that doesn't just affect the countries that have chosen to ratify it,
but it's actually affecting the world. And it's most easy to think of that in the context of equilibrium effects.
So for example, if you have the impacts of a treaty in one place, if you have a treaty in some countries,
the new technologies that it develops or the new norms that follow would necessarily influence or not.
I said it would probably influence other countries, particularly those surrounding it,
or those that have strong historical relationships or trade relationships with that country that is being influenced by that international law.
So it's a type of network effect. So in that respect a randomised controlled trial wouldn't actually be that great.
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.
Whereas quasi experimental methods can do so.
And basically what a quasi experimental method is, is that you're using an alternative approach to create a control group.
So instead of using randomisation and assigning subjects or in this case countries to a particular treatment,
we're trying to construct a counterfactual using a different method.
And there's many different approaches within quasi experimental methods, and there's many of which to choose from,
and which then makes it even more surprising why we haven't been using these kind of really rigorous approaches to evaluate
whether international laws have had effects and instead have really stayed with just looking at sort of basic associations,
which I think is an opportunity for improvement.
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.
And so the one that we've really focussed in on and trying to use is a bit of a pioneering example,
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.
The first is that this framework convention, so it's a treaty that was adopted through the Assembly of the World Health Organisation.
This treaty has a very clear outcome of interest.
It is there's no doubt that the Framework Convention on Tobacco Control is trying to reduce tobacco consumption.
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,
but it's harder to measure exactly what is human rights and in its various important contexts.
So there's actually a lot of work to try to find indicators in that space. But with tobacco, it's quite easy, right?
It's how much tobacco is consumed in the world.
The second reason why it makes so much sense to focus on this one is because it's gotten a lot of attention,
particularly in global health circles, for being an example of a treaty that's had a major impact.
And so one quote that I often point to is this one from a former director general of the World Health Organisation,
Margaret Chan, who said in a speech, quote, without question, the.
A Framework Convention on tobacco control is the most powerful tool we have as an international community to reduce the global disease burden.
It's quite a strong quote. It's quite a strong statement,
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.
So if we're going to study a treaty,
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.
And just to clarify, of course, I think the contents of a treaty like this is extremely important.
And, of course, we need to do everything we can to reduce tobacco consumption, give visits the number of.
It's one of the number one. It's one of the most prominent risk factors that's leading to disease.
But the question is whether the tool,
whether the international law tool was an effective mechanism in order to promote proven tobacco control policies.
So, for example, we know that tobacco taxes reduce consumption.
We know we need the world and countries around the world to increase tobacco taxes,
especially those countries where economies are growing and lifestyle or wages are going up.
We need tobacco taxes to keep pace, if not exceed the pace of the growth of affordability of tobacco products.
That's clear. The question that we're asking is,
did having a framework convention on tobacco control accelerate that the adoption of tobacco taxes or warning labels or smoke free workplaces,
those sorts of policies? That's the question. Which financer?
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.
So quite a lot of countries are part of this treaty.
And yet, up until this point, 13 years later, there's still no quasi experimental study of its effect.
Like basically nearly every international law.
So again, we're not fully finished. But what I can show you is here's what global tobacco consumption looks like.
It's a small figure, but what I would focus on is just the black line, the horizontal black line.
And what you see that that that's the global trend for its cigarette consumption per capita from 1970 to the present.
What you'll see there, though, when you contrast it to the dotted line,
which is the year at which the Framework Convention on Tobacco Control was adopted.
What you'll see there is that if you would imagine that if that treaty had an effect,
even visually, you as audience would be able to see a discontinuity in that trend line.
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.
If it had the opposite effect, you'd see an immediate opposite effect.
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.
So you would see there that that's the black line of this was having a global effect would
ideally trend down so the slope would go downwards or if it had the opposite effect,
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.
And in fact, if anything, you sort of see it maybe curve a little up.
And so we did bring statistical methods to bear on this.
And what you're seeing here is a sneak peek at our results. When we did an event model,
where what we did is we constructed a post 2003 counterfactual by using associations for various variables with tobacco exception before 2003.
And then when we modelled it out as a comparison, we actually found that based on all available data we had before 2003,
we would have predicted that tobacco consumption would be lower today than it is.
And so what you see there is the grey line of the two that are not dotted.
So the grey solid line, that's what we would have predicted based on relationships between tobacco consumption and things like GDP,
education, gender equity in various countries around the world.
Projecting those variables going forward beyond 23, we would have seen, we would have predicted the grey solid line.
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.
We've done all sorts of robustness checks about looking at maybe there'd be a delayed effect.
Maybe, and maybe it is one country driving the results, looking at different regions.
And so it's it's been quite an interesting project,
but one that because we took the scientific approach and tried to use epidemiologic methods to tease out an effect,
hopefully what it does is it allows us to drill down to that question of is this treaty having an effect?
And if so, in what places? In what? Context.
And ideally, from there, it starts to generate the science of treaties as social tools.
Now, in terms of the implications of this, it's not just a matter of figuring out whether it works.
Another key point that we learned in this process was that both data and certainly, unfortunately, existing data was not.
We couldn't use it in order to conduct a quasi experimental impact evaluation.
Some of the leading data on tobacco, which is provided by the Institute for Health Metrics and Evaluation based in Seattle, what they do,
they often they are generating their data using variables and they are smoothing out
their data often because it's imputed from in context where there's missing data.
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.
But because it's generated through it's created through a particular process and model process,
what it means is that you can't take advantage of of trying to find discontinuities in the data.
So our approach that we showed before,
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.
That's what we did in our previous study.
You can't do that when the data is actually created, assuming there wouldn't be any of those discontinuities.
So in that respect, it's just we couldn't we couldn't use that data.
So we had spent an enormous amount of energy trying to bring this data together.
How great would it be if part of the Framework Convention on Tobacco Control,
each country was required to report how much tobacco was consumed in that country, whether it would be such great data?
That's another question. But I think data is and is something we need to have contained in treaties or other mechanisms.
And then, of course, there's we also learned this is a great need to further study some of these trends and causes.
It's a challenge. Has this treaty had effects? So in terms of methods,
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.
And if they don't have results, I think it leads to next questions of why not.
Again, I don't think we should necessarily question whether this treaty was good or bad.
I think overall it's clear that what it's trying to promote is very good.
So a reduction in tobacco consumption and the kinds of policies that it's promoting within the treaty.
Again, no doubt they're very good and they're proven in many contexts to work.
But what we have to ask is what's the best delivery mechanism for this?
And the key in my mind is that because we know that international law can have some very important effects in some contexts,
I think it's it behoves us to then reserve international law mechanisms for those contexts when it can work.
Because I'm definitely a believer in international law. I am an international lawyer, after all.
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.
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.
And so in that, what I'm going to do is I'm going to use this third and last part of this lecture,
which is all about how do we use this knowledge that we're gaining about international law as a social intervention,
as a health intervention on the world?
How do we use that knowledge in order to design a future treaty, a future international legal agreement on a topic of great concern?
And so I think just right up front,
some emerging lessons are not so out of line with what has been generated through theoretical traditions with Earth, through theory.
So specifically, some of what we've identified in some of our earlier work was that when designing an international legal mechanism,
there are some factors that are more important than probably other factors.
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,
it seems that what's less important is empowering individuals to bring claims against
governments are holding them responsible as individuals vis a vis the states.
Less important, it seems to be about addressing a global challenge that requires urgent action.
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
that the international laws to address that problem are going to have effects.
And also just simply being about promoting a certain ideal or a certain norm living in an ethical world is not enough.
Doing good is not enough for the goal of doing good. So it seems like potentially more important factors are instead of incentives.
So, for example, providing immediate benefits to states and governing elites so that actions align with their short term interests.
Second would be creating institutions that create mechanisms that over time are promoting compliance,
dispute resolution, accountability and third interests.
So aligning what needs to happen with powerful interest groups who can advocate for the full implementation of these international legal mechanisms.
This shouldn't be so surprising. So, in fact, many people in the room are probably saying, yeah, that makes sense.
And in fact, it very much aligns with quite a few different theoretical frameworks around how international law can have effects.
Here's just ten examples of different ideas that have been put forward in the literature that
have been very helpful around identifying how could treaties possibly have real world outcomes.
And from here, so just to go through them very briefly. But international laws can help set agendas.
They can provide powerful legal language that people can use to claim results or claim judicial or judicial intervention.
International laws can have provisions that either incentivise certain behaviours, disincentivize certain behaviours.
They can provide a focal point for social mobilisation. They can legitimate certain groups concerns when previously maybe they weren't legitimated.
They can serve as a rallying point for networks of expertise.
They can serve a matter of it's also the power of the process.
So even if you forget the treaty itself, that results. Think of how potentially powerful that negotiating process is,
where countries are sharing ideas and bringing attention and temps in this list of ten examples.
Public awareness. So maybe the public is more aware of a certain issue if it's the subject of international treaty.
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
with for the last few years and working with colleagues around the world,
including colleagues here, which is that problem of superbugs and unfortunately, superbugs are not as cuddly as Bugs Bunny over here.
Rather quite terrifying. And what makes them terrifying in my mind is that really what we're talking about is a natural
evolutionary process whereby microbes are slowly developing resistance to the antimicrobials,
the drugs that we've long depended upon to kill them when we get sick.
So what's happening is over time, as we've we've been using and abusing antimicrobial drugs.
What happens is that it mites. It provides a breeding ground for those microbes that happen to have some resistance to the drugs.
It gets them to multiply. And then those become the most dominant forms of those bacteria viruses, fungi, parasites.
And as a result, what means over time is slowly. The drugs that we've been depending on are no longer working.
And so we are in a bit of a chess game with microbes here.
That's one analogy you can use. And unfortunately, we're not winning.
I mean, this is a problem that we've known about ever since Fleming found penicillin.
And this is a problem that is not going away.
It's only accelerated. And in the last 30 years,
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.
And so we need new approaches.
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.
This challenge of antimicrobial resistance is one that, yes, the underlying biological mechanism is one that's always going to happen.
But what makes it a human challenge and a human health challenge is the way that we're using these medicines and abusing them.
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.
So it's showing by countries on the on the X axis,
it's the daily antibiotic use per 1000 people within countries modelled onto the percentage
of pneumonia causing bacteria within that country that are resistant to antibiotics.
And so it's a clear association in those countries that use more antibiotics.
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.
If they actually were saving lives, I wouldn't be so worried.
The challenge is that a lot of our use of antimicrobials is actually not effective and only then causes harm.
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.
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.
Caused by a bacterial infection. Usually it's a viral infection or not.
And so if you have a bacterial infection, maybe taking an antibiotic could work.
But if you have a virus, you're not going to be helped by taking something that kills bacteria.
And yet what they found is that of the 10% or 10% of people went in probably with a bacterial infection,
but 60% of people walked out with a prescription for an antibiotic.
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
of that same doctor's office with a prescription for something that's not going to help them.
And that's only going to harm society because it contributes to the resistance that develops in microbes.
Unfortunately, this problem is not just in humans, it's also within animals.
And in fact, 80% of antibiotics are estimated to be used on the farm, not in humans,
although from a human health perspective, it's not that 80% of the problem is on the farm.
Most of human, mostly human health aspects are caused by human consumption.
But the problem is a one health problem in need of a one health solution.
And the stakes are quite high. So this is something that some people often don't talk about.
But 700,000 people are dying every year. And a study that was commissioned by the UK government, led by Jim O'Neill,
showed that by 2050 it's estimated that 10 million people per year will die from antimicrobial resistance.
If we don't do anything. And so that would be more than cancer. This is a problem we often don't label.
It's antimicrobial resistance. But this is something that's killing a lot of people and will kill even more.
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,
it's important to recognise what kind of problems could possibly be beneficial, be benefited by these kind of legal approaches.
And so in this case, it's what's really important is to note that antimicrobial resistance is one of
those challenges for which there hasn't been sufficient level of global action.
And there's some particular reasons for that which maybe international law can help with.
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.
The second is that there's some global market failures. Specifically, we actually under provide some of these medicines for people around the world.
We over provide for others and there's insufficient innovation.
And third, there's some global governance gaps, which is really classic collective action problems.
So to go into that in just slightly more detail, when I mentioned there's no silver bullet solution.
What I the reason for that is because there isn't actually just one problem associated with antimicrobial resistance.
There's actually at least three problems. One is that we need to provide access for the millions of people without antimicrobials.
Think of those who who don't have access to such medicines. Two is we need to conserve the effectiveness of existing drugs.
And third, we need innovation towards creating new antimicrobials.
And it's not even that easy, because actually these are interlocking problems.
So we can't address one without addressing the other.
So more specifically, we can't address access without conservation and innovation because it would actually speed up resistance.
Right. So imagine we we live in a world where we provided access to everybody on every street corner to these medicines.
It would actually speed up resistance because it would increase inappropriate use of conservation.
It constrains access by definition. And then it would undermine innovation because it creates a smaller market for the sale of these products.
And third, innovation without access would be unjust.
And innovation without conservation is wasteful.
So imagine we spent billions of dollars coming up with a new antibiotic, and then within a couple of years,
it's no longer working because we've abused it in terms of the global market failure.
I'm just going to point to a couple of game theoretic problems that are in this space.
So, for example, when it comes to conservation,
we see a classic global commons dilemma whereby we have a common pool of effectiveness of antimicrobials.
And each country might be individually incentivised to draw upon that pool of
effectiveness and insufficiently incentivised to manage that common pool resource.
It's exactly like what we see with climate change also when it comes to innovation.
As a second example, there is a free rider problem. So why would countries invest in developing new antibiotics or new antivirals when
they can just wait for another country to make that investment and reap the rewards?
And so there's insufficient levels of investment as a result.
And third, just quickly on global governance gaps, we see that there's actually are there actually in this case,
are a lot of actors doing a lot of different things?
What we see is insufficient levels of coordination, insufficient levels of compliance, leadership and financing.
And so, again, so how does global legal terminology fit in? Well, it seems, based on what I've described,
that a natural step to address some of these challenges is actually through an international legal mechanism.
And I say that as somebody who actually has been quite critical about using international legal tools to solve global challenges,
particularly global health challenges. Yet when you think of the type of interlocking problem and when you think of the
highly global governance space in which we're following a highly legalised space,
it seems like this actually could be a solution that we should all be pursuing.
And more specifically, I think it's whether here are just some key reasons why international law would be, I think,
relevant is because there is such interdependence among countries,
which means that we need all countries or most countries to act in order for any country to be safe.
It's not just that we need action. We need interlocking action.
And how do we do that? How do we get those interlocking actions unless it's through a coordinated mechanism?
These actions are costly, which means we need we need to make sure that each party for them to invest.
They need to know that other countries are going to invest, too, at the same time.
And fourth, we need to be able to lock in commitments and disincentivize deviation.
Because unfortunately, on this problem, most of the costs are short term.
Most of the benefits are long term.
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.
But the key then, is not just to have a grand bargain.
We need then to make sure that such a grand bargain would actually work.
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.
We've been trying to learn from those existing studies that have looked at different international laws and trying to figure out, okay,
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,
how are we going to design it in a way to make sure it actually yields impact?
And so the good news, again, is that there's lots of people talking in this space around what to do.
So there's a lot of people who have published, for example,
this paper that I was part of in The Lancet that focussed on what do countries have to do in order to conserve,
promote access and innovation for antimicrobials? The challenge has been more around the implementation mechanisms.
So what would a what would an international treaty on antimicrobial resistance actually look like?
So if countries decided to come together and have an agreement, what kind of provisions would they put in?
That's the question.
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.
And in fact, we've started it. So there's a one first goal that I do working with colleagues around the world
was we brought together a special issue of the Journal of Medicine and Ethics,
where we started to raise some of these issues. So what is the advance?
What are some of the advantages of international law? What's an appropriate convening forum?
Those sort of questions. But what hasn't been discussed and what desperately needs to be discussed is if we are going
down this route and if the world does decide that international legal approach makes sense,
we need to figure out exactly what what it would look like, what would be in it.
And so I'm just throwing up here. Another list of ten, another top ten list on top ten list.
But these are just ten examples of the kinds of things that we sometimes see in international
legal agreements that would encourage them to maybe have effects versus not having effect.
So these are implementation mechanisms. So one example would be a monitoring milestone.
So imagine there's a very clear milestone that countries are supposed to achieve
and there's monitoring of country progress towards achieving that milestone.
Alternatively, there's mechanisms in a code of practice. You can create new institutions that coordinate activities like a UN inter-agency task force.
You can have an Intergovernmental Panel on antimicrobial resistance that engages scientists like the IPCC from climate change.
You can have funding agreements to give a global pooled fund.
Controversially, I'm not promoting this, but you could condition benefits or supports an action.
So for example,
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,
maybe that country should simultaneously have a stewardship program to make sure that the negative externalities of that access program are minimised.
You could create special representatives. You can have a high level panel, multi-stakeholder partnership, lots of different approaches.
S oriented design features that could be included and which previous studies have pointed to have been important for them having impact.
So just to summarise as a final slide, what I tried to do today is introduce this idea of global and legal epidemiology,
bringing a scientific approach to bear on how we use these kind of mechanisms to effect real world change.
And so what is part of this is building this field. We need to do at least three things.
First, we need to be synthesising existing knowledge on what makes it international law effective.
Second, we need to then up our game and use really rigorous approaches to evaluating those international laws.
And so I talked about quasi experimental impact evaluation methods.
And third, we need to then start using this growing body of knowledge in order to inform the design of
future international instruments that can maximise our social outcomes that are desired.
So with that, I look forward to a discussion with you. Thank you very much again.
So we have a roving mike or questions I might ask you one then first of all, people for questions.
So you mentioned this other great global collective action problem, carbon emissions, controlling carbon emissions.
So, I mean, from what you said, it seemed to me that at least, at least for developed countries, antimicrobial resistance,
a vastly greater threat to people's lives than climate change, at least for those people who are alive today.
Yet billions, if not more, have been spent on carbon emissions and controlling them,
and only a tiny, minuscule fraction of that has been spent on anti-microbial resistance.
Why do you think that is, and what do you think you can learn from attempts to use various instruments to control carbon emissions?
Yeah, so it's a it's a great question. I think it's interesting when you look at environmental challenges,
there seems to be it seems to be quite common that the world has used international legal approaches to address them.
So whenever there's whether it's air pollution, whether it's the oceans, whether it's mercury,
mercury and the environment, we often see I that community, that regime going towards international legal mechanisms.
You haven't seen the same thing in global health. And so in that respect, I mean, in that respect,
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,
whereas in health we haven't seen that approach as much. We have lots to learn in terms of funding.
It's a good question except that actually when you talk to an environmental a global environmental governance scholar,
they actually often get jealous of the health field where because the health field has lots of global funds and different alliances,
where there has been actually a lot of funding on global health,
there's been I guess there's the perception that there's actually been less on global environmental governance.
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.
I think the good news, though. But I'll flag about antimicrobial resistance is that it should be a slightly easier
it should be a should definitely be an easier problem to address than climate change.
Even a couple of reasons, not just because of the technical nature of that issue,
but also because antimicrobial resistance affects everyone rich, poor, powerful, weak.
Whereas with climate change,
those who are wealthier and more powerful could be under the perception that they could mitigate the effects of climate change on them by,
for example, moving to higher ground or changing where they live.
Whereas with anti-microbial resistance, it's not something that wealth or power could protect oneself against.
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?
I like the draft that you presented. The framework was a collection of instruments, as I think you said, including what most of them,
but some of them in particular, like taxation, are extremely powerful at national level.
That's been demonstrated and they are implemented by law at national level.
So your your in your synthesis of the framework convention, are you saying that international law,
the treaty in that instance had no added value to the value that we already know about at national level?
Or is there some other explanation in your data why you think it's not is not so effective?
It's important to understand, I think, why it doesn't work internationally,
whereas nationally all of the constituent instruments of the framework are very effective.
Yes. Thanks for the great question. And that's actually what we need to figure out, in a sense.
So. So just to confirm. Yes, that is our conclusion.
I mean, let me be very clear. The tobacco control policies that are promoted by this treaty are effective.
There's been so many studies, so many more that needed showing that tobacco taxes reduce tobacco consumption,
which is great, and that warnings work and that the smoke free environments are great.
So it's it's not the policies that are in the framework conventions about control.
That's that I'm debating. The only the question I'm raising is, I guess,
did the creation of the Framework Convention on Tobacco Control accelerate the adoption of those policies,
or would countries have adopted the many ways? And I, I think there's many hypotheses.
And with this data, we can't tease out exactly which one, but one could be around.
There hasn't been sufficient implementation of the Framework Convention on Tobacco Control.
In fact, today or a fact yesterday, I guess, was when the Conference of Parties for the CTC were meeting in Geneva Focus.
And the big focus for them was on we need to accelerate implementation.
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.
So that's one mechanism.
So but then my question is, did that treaty cause more countries to have those policies than otherwise without the treaty or not?
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.
The resources that have followed also helpful.
But could we have gotten that attention or would we have gotten the attention without the treaty mechanism,
for example, having created a global pooled fund to support countries to adopt tobacco control policies?
Would it have had more effect than a treaty? I don't know.
We don't have a global fund, but I am asking that question.
And this study, I think, shows that we should be asking that kind of question because I think Emory,
the director, Sir Charles Godfrey, was next in line.
Sorry about that. I just to follow up on Chris's question, I'm afraid this is a rather nerdy question,
but I'm trying to grasp how the quasi experimental technique worked and looking at the the quite broad confidence intervals on the graph.
And are you able to do in this technique a sort of power analysis?
What could it be working? But you just don't have the power to tell.
And how big an effect would it have to have before it would it would show up in your analysis?
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.
So you're right, based on this, we, though also debuts also an interrupted time series analysis.
And in that method, had I shown that figure, it would show it's beyond the confidence interval.
So in that respect, we've used two methods trying to basically we did the best attempt we could to try to find impact.
And the reason we try so is like multiple testing.
We try to do all sorts of all sorts of different assumptions, trying to find impact.
And what we kept on getting were things like this, where this would be.
So the conclusion here would be we can't conclude a statistical difference,
but our best guess would be that actual consumption is higher than what was predicted.
Now that being said, I'm not actually we're not concluding out of the study that the effects caused harm.
I don't think it did at all, but at least it didn't.
It doesn't seem like it caused enough of an acceleration that we pick it up using these methods.
Maybe it did cause some, but the impact, at least according to these methods, don't seem to.
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.
Yeah. So thanks.
And really like the focus of what was the second part of the presentation.
So the evaluation of this new tool probably.
And I was wondering whether in addition to this study on like the tobacco consumption convention,
whether there is and other like examples from international, probably even public international already, maybe even.
Yeah. Domains that are more remote to the health domain that could tell you like moderating
about moderating factors such as whether recommendations are less effective than
requirements with this distinction that you introduced in the beginning and similar
things so that you you can have a more informed choice and even evaluation then of yeah.
Rules that might work or not legal. Right? Definitely.
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.
We have to focus also on internal alternatives to them. Right.
So you mentioned recommendations. There's also guidelines.
There's a whole suite of global governance instruments that could be used and that are being evaluated.
So, for example, there is a quasi experimental impact evaluation of the Millennium Development
Goals and the impact of articulating those goals and particular outcomes.
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.
In fact, as I said beginning, I my starting point was one of being critical for this type of mechanism.
And so what we also need is as part of developing the science of global governance or global governance instruments,
we need to also be focusing on others.
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,
international sociology and other places that have been focussed on others because in many respects a lot of people,
a lot of the theories for why international law could be effective are around things like norms, changing norms.
And that makes sense to me. It's a change, you know, and then you don't need a law.
You don't necessarily need an international law to change the norm. So as a result, it points to the potential effectiveness of others.
And we the key then, in my mind is we have to tease out under what circumstances do which instruments work,
and so that we can be forward looking and say,
okay, we have this type of problem, we should apply this type of solution for that problem and that what and what currently,
unfortunately, what we see is when these things are being negotiated at diplomatic fora,
the ideas that come forward are often based on just what the person happened to have seen or known about.
So if that person was, let's say, married to an environmental scholar, we'd be drawing from the environment.
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
Kimberley process or there would be a lot of it is based on what people individually know,
which is fine because that's way, that's one way we learn.
How much better would it be if we could take a bit of a scientific approach to bear instead?
That's the question. Thank you.
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,
could that not have been measured as the outcome?
Or is that information more difficult to come by or because it really would be an interest to see that as a comparison.
Yes. To the policies themselves. Yeah. So there there are another Canadian colleague of mine has been looking at exactly that question.
So yeah, that would be an alternative way of looking at this. So instead of we we're looking at it this.
This Framework Convention, did it have impacts on tobacco consumption?
Instead, we could have said, did this framework have an impact on how fast tobacco control policies were being implemented?
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.
That second question, the question that you proposed found that it did accelerate national adoption of tobacco control policies.
So last week, when I asked the person who wrote that study this question, how do you reconcile the two results?
The thinking was it might have this this framework convention might have accelerated the formal adoption of a law within a country,
but not necessarily its actual implementation in that country.
So it might have accelerated laws on the books, but not actually the actions within countries.
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.
So it's a great, great question. Thank you. I've got another question for you.
So I just want if you can give us an example of of how an international treaty might impact this,
because it seems that it's it's going to be impossible to implement without actually doing something much more significant.
And that is creating a comprehensive, effective health care system all around the world.
So just to take the sort of trivial example that you mentioned, prescription of antibiotics for future tract infections.
The problem that you face is that, you know, as you said, 10% of infections can be bacterial.
If they're missed and not treated, they can be catastrophic.
So you could deal with that by having a very effective health care system, that very effective diagnosis, monitoring doctors got patients back.
It would be enormously intensive,
even in the US to convince people that they weren't taking on an additional risk to themselves for the sake of this future.
Good of protecting antimicrobial factors. That's just in the US.
Then you've got to deal with Africa and India where you don't have health care systems and throwing antibiotics
at a problem might might actually be effective compared to generating a more comprehensive health care system.
So can you give us an example of sort of revolutionising the kind of health care system for the world,
how a treaty is actually going to make progress?
You know, so I think the assumption with the question is that is that we can't do it all.
We can't just fully solve this challenge, which is may be the case.
So I guess in that respect, I guess I'm not trying to solve all the world's problems with the treaty.
I guess, although I do think that there are lots of things that can be done.
So, for example, when it comes to innovation right now, we have insufficient levels of investments in innovation because as countries
are hoping to free ride on each other instead if there is a legal system.
There's a legal agreement where all countries agreed to or those countries that could.
We're participating in funding,
research and development related to antimicrobials and the diagnostics and other vaccines and other things that would support it.
Then we'd have a much we have much greater levels of investments.
That's one tangible example. But I think that the question that points to another very important point, which is that, of course,
what actually happens within countries to address antimicrobial resistance has to be different depending on the country.
That's not the way we usually think about international law. So most people in this room who are thinking of international law,
you're probably thinking of, okay, standard, consistent standards that every country upholds.
So, for example, human rights, all people have the right to the highest attainable standard of health,
and it's just consistently applied in every country. In my mind, that probably won't work to be able to say, okay,
every country should require a doctor's prescription before they can access an antibiotic that doesn't work in a
country where there might not be enough doctors for people to have appropriate access to these lifesaving medicines.
So there'll be different approaches needed. So my mental model looks much more like what the Paris Climate Change Agreement looks like,
which instead of it being a bargain around what content each country or what policies each country will pursue.
Instead, it's a bargain around the process that all countries would follow.
So in that case, each country self declares what they're going to do against it,
towards achieving a certain goal that's identified, and then that self-declaration becomes legally binding on that country.
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.
And that's I think that's important to flag because it highlights that some of these feasibility concerns might not
actually be there if the if different countries in the world are helping solve this challenge in its own unique way.
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.
The first one. Have you got the one prior to that? Yeah.
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.
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.
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.
Has there been any ethical discussion of whether we should be prioritising some groups rather than others or just focusing on that global average?
So both great questions. So yes, there are some regional, regional differences that we found.
And that's that's not new. Any sort of estimate of tobacco consumption or prevalence.
So there's this variation. So we did we did look at all these and bring it together in a cohesive study.
In terms of the the ethical issue of the priority,
I think it's clear that the priorities probably needs to be on the countries that have the least capacity to address this.
I mean, one really interesting aspect of tobacco is that the industry that's promoting the sale of tobacco is very multinational,
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.
So from an ethical perspective and even just from from an effectiveness perspective,
which is also ethical, it makes sense to focus on those countries that have the least capacity.
And the good news is that's exactly what the World Health Organisation does.
I mean it's been it's been leading the effort for quite some time and I think
most impactful it's been supporting countries that want to go on this path,
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
effectiveness of these national policies that if a country is serious about tobacco control,
it's actually pretty easy for that country to do it. But it's not so easy, right?
Because there's all the political interests, the economic interests at play, lobbying.
And even if a state was able to defy the lobbying and the political interests, economic interests,
there's still just the capacity of how do you enforce things and how do you monitor
and make sure that everyone's complying with laws that might be on the books, but maybe not in practice.
So it's a we tried to tease out some of that, but we can't with most of this data.
Just one last quick one. Stephen, I think you may have just alluded to what I was going to say,
which is that you've examined the question of whether a treaty or not is important,
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.
And some of some of them are clearly quite complex. And complex interventions would limit the effectiveness of a treaty.
But in other instances, for example, polio eradication, that's not an international treaty, but it's a global initiative.
And it's extremely it has been extremely successful because, of course, it's based on a very simple, easy to use vaccine.
And there's essentially no opposition. There is some opposition, but essentially no opposition, let's say, to its use.
And that's why it's been tremendously successful.
So I think in my mind, one lesson from that is that when you're thinking about antimicrobial resistance,
one opportunity is to present a simplified message around the key instruments that work.
I think the debate around antimicrobial resistance is far too confusing at the moment and unnecessarily so.
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.
Yeah. Yeah. So I think. Chris, thank you very much for that.
I agree 100%. I. Yeah, I.
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
was to focus some attention on very particular policies that were shown to be effective.
So that's why it was often called the world's first evidence based treaty.
And so it did that. And did it need to be?
It is the I guess my my question, though, is, did did we need the treaty mechanism in order to highlight those policies?
Maybe we did. Maybe. Maybe 13 years isn't enough time.
I mean, certainly at the Conference of Parties, there was discussion that this treaty remains as relevant today as it was 13 years ago.
And so we just need to accelerate implementation. I think that's a good message.
That's one I certainly believe in. But I and I think you're you're right.
We should try to probably we should learn from this experience. And one success was that simplification.
We need to do that for anti-microbial resistance. Definitely. Again, conscious, we're standing between people in their alcohol.
So we might take one last question. I've got two questions not answered, both of them.
The first is, I think you've touched upon a little bit already,
but you've demonstrated that international law seems to be quite successful in the areas of finances, trade.
Know for that. What is it about global health? Why has it not succeeded in global health?
I guess my second question is also you've mentioned tobacco consumption and antimicrobial resistance, both really important issues.
What other what other is there another issue within global health that you think is is also pressing?
Great. Thanks for those questions. For the first one, I think, first of all,
we should let's take that as a tentative conclusion in the sense that it was drawn from
90 quantitative impact evaluations that we were able to find in a non systematic way.
So based on those 9090s, a lot of studies better than 90 of have easily found quantitative effects.
Valuations showed that the trade ones and they seemed to be from an outcomes perspective they could.
We did find lots of studies that had these outcomes. So trade, yes, but we didn't find many on the social side.
Why? My hypothesis that well, that we mentioned in this study when it was published was that I think these treaties look different.
Right. So when you have a trade treaty, there's a dispute resolution mechanism, there's a compliance mechanism, there's accountability,
there's monitoring, there's implementation mechanisms built into them that over time, rich countries do actually compact.
There's consequences if countries break them. Whereas when you look at human rights treaties, there would be less of that.
So there is a periodic review, there's a peer review mechanism.
There's a time when countries have to go to Geneva and explain themselves.
That's that's not the same as having a World Trade Organisation, a dispute resolution board.
And then when it comes to, for example, the Framework Convention on Tobacco Control,
there's not much of any implementation mechanism or enforcement mechanism.
And I'm not I'm not saying that that's that's what it meant.
It raises questions as to if we have treaties with our teeth, should we have pursued the treaty strategy?
I think when that treaty was initially being negotiated,
it probably was hoped that it would have some enforcement mechanisms, but in the end it didn't have very many.
And so it sort of questions the whole enterprise. But I think that's the key.
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.
We need to learn from these sort of studies and ideally even better studies than just the 90 quantitative impact variations.
Thanks for your question. Okay. Well, so, you know, I think this is one of the most important talks I've heard.
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,
interventions make great physiological sense, but when properly evaluated, scientifically do more harm than good.
And that movement has changed the way medicine has been researched and implemented.
But that scientific methodology hasn't carried over to other areas of life.
Every year, someone introduces a new educational policy or some new social policy without rigorously affecting whether it does more harm than good.
And I think this is a fantastic initiative to subject legal instruments to the same kind of evaluation that occurs in science.
They're meant to improve the world.
And no matter how well-meaning or ideologically driven or plausible they are, they can always do more harm than good.
So I think this is the beginning of a revolution.
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.
So I thank you, Stephen, for bringing us to the beginning of a revolution, and I can't wait to see how it unfolds.
Thank you. And there's drinks next door in the capital.