Meeting Basic Survival Needs of the World's Least Healthy People: Toward a Framework Convention on Global Health

Lawrence O. Gostin, Georgetown University Law Center

This O'Neill Institute Paper has been moved to the Georgetown Law Faculty Lectures and Appearances series. It is currently available at


This article searches for solutions to the most perplexing problems in global health—problems so important that they affect the fate of millions of people, with economic, political, and security ramifications for the world’s population. There are a variety of solutions scholars propose to improve global health and close the yawning health gap between rich and poor: global health is in the national interests of the major State powers; States owe an ethical duty to act; or international legal norms require effective action. However, arguments based on national interest, ethics, or international law have logical weaknesses. The coincidence of national and global interests is much narrower than scholars claim. Ethical arguments unravel when searching questions are asked about who exactly has the duty to act and at what level of commitment. And international law has serious structural problems of application, definition, and enforcement.

What is truly needed, and which richer countries instinctively do for their own citizens, is to meet what I call “basic survival needs.” By focusing on the major determinants of health, the international community could dramatically improve prospects for good health. Basic survival needs include sanitation and sewage, pest control, clean air and water, tobacco reduction, diet and nutrition, essential medicines and vaccines, and functioning health systems. Meeting everyday survival needs may lack the glamour of high-technology medicine or dramatic rescue, but what they lack in excitement they gain in their potential impact on health, precisely because they deal with the major causes of common disease and disabilities across the globe.

If meeting basic survival needs can truly make a difference for the world’s population then how can international law play a constructive role? What is required is an innovative way of structuring international obligations. A vehicle such as a Framework Convention on Global Health (FCGH) could powerfully improve global health governance. Such a Framework Convention would commit States to a set of targets, both economic and logistic, and dismantle barriers to constructive engagement by the private and charitable sectors. It would stimulate creative public/private partnerships and actively engage civil society stakeholders. A FCGH could set achievable goals for global health spending as a proportion of GNP; define areas of cost effective investment to meet basic survival needs; build sustainable health systems; and create incentives for scientific innovation for affordable vaccines and essential medicines.

This article first examines the compelling issue of global health equity, and inquires whether it is fair that people in poor countries suffer such a disproportionate burden of disease and premature death. Second, the article explains a basic problem in global health: why health hazards seem to change form and migrate everywhere on the earth. Third, the article inquires why governments should care about serious health threats outside their borders, and explores the alternative rationales: direct health benefits, economic benefits, and improved national security. Fourth, the article describes how the international community focuses on a few high profile, heart-rending, issues while largely ignoring deeper, systemic problems in global health. By focusing on basic survival needs, the international community could dramatically improve prospects for the world’s population. Finally, the article explores the value of international law itself, and proposes an innovative mechanism for global health reform—a Framework Convention on Global Health.