Introduction
At the World Health Organization’s (WHO) founding in 1948, about a third of the world’s population were subject to colonial domination and rule. Since then, a central issue has been whether the field of global health can make a substantial break from colonialism, class hierarchies, and structural racism in health. One of WHO’s foundational principles is that “the extension to all peoples of the benefits of medical, psychological, and related knowledge is essential to the fullest attainment of health.”Footnote 1 Notwithstanding this, WHO has not adequately shaped its health policies toward redistributive ends.Footnote 2
By examining prior moments where global health found itself at a crossroads, confronting inequalities in peoples’ lived realities in the 1970s, with a push for universal health, and again in 2015 with a call for sustainable development, we can historically contextualize ongoing reform efforts in a continuum of non-transformation. Grounding global health in reparative and distributive justice frameworks and orienting the regime to these ends, is essential for emancipatory transformation in global health.
This symposium engages with recent lawmaking provoked in part by the COVID-19 pandemic. Contributors’ collective efforts in Parts I and II examine global health law in action and canvas key multilateral reforms, exploring emerging dynamics including the potential for regionalism and decolonization, as well as conceptualizing and contesting global health’s past and futures.
Health for All
In 1961, the Non-Aligned Movement of States brought together countries from Asia, Africa, the Americas, and the Middle East to advance their shared interests. These states proclaimed a legally non-binding Declaration of the Establishment of a New International Economic Order (NIEO) in May 1974.Footnote 3 The “soft law” nature of the NIEO is exemplary of how post a heightened period of decolonization, countries in the Global South still lack(ed) the ability to readily translate their priorities into binding international law. The NIEO articulates a vision rooted in reparative justice. For instance, the Declaration pronounces, “the right of all States, territories and peoples under foreign occupation, colonial domination or apartheid to restitution and full compensation for the exploitation and depletion of, and damages to, the natural resources and all other resources of those States, territories and peoples.”Footnote 4 It sought to reshape the world in more equitable ways. Additionally, the NIEO embeds distributive justice principles, specifying that countries in the Global South should have “access to the achievements of modern science and technology and the creation of indigenous technology for the benefit of the developing countries.”Footnote 5 Comparatively, the constitutive instruments of WHO make no mention of reparative or distributive justice for global health inequalities in its operative provisions.Footnote 6 The WHO’s primary sources do not even provide for significant special measures to address or attempt to mitigate structural discrimination in global health.Footnote 7 This is indicative of the field’s conspicuous silence on repairing and redressing historical and compounding injustices in health.Footnote 8
The advocacy efforts of the Non-Aligned Movement of States helped to shape a defining moment in global health history. In 1978, WHO co-hosted an International Conference on Primary Health Care in Alma-Ata, Soviet Union with the UN’s Children Fund. At the conference, states adopted the legally non-binding Declaration of Alma-Ata. It provides that “health is a fundamental human right, and the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic actors in addition to the health sector.”Footnote 9
While the Declaration reaffirms several principles in WHO’s Constitution,Footnote 10 it goes substantially further in prioritizing distributive justice. For example, the Declaration emphasizes that “the existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.”Footnote 11 Moreover, it asserts, “through a fuller and better use of the world’s resources, a considerable part of which is now spent on armaments and military conflicts” that states should release additional resources that could be “devoted to peaceful aims,” especially, “the acceleration of social and economic development of which primary health care” is an essential part.Footnote 12 The Declaration clarifies that budgets are value statements, and that seemingly never-diminishing military spending is not without consequences. It marks one of the rare occasions in global health history where the maldistribution of resources is acknowledged. Due to resistance from entrenched commercial interests and states in the Global North, the far-ranging transformation envisioned in the Declaration was never implemented.
Instead, WHO continued its focus on specific communicable diseases reminiscent of tropical and colonial medicine,Footnote 13 and did not reorient its work in alignment with the Declaration in the short or long term. Indeed, by 1979, the Rockefeller Foundation organized a conference to identify the most cost-effective health strategies, while donor states narrowed contributions to WHO in favor of “selective” primary health care.
By the 1980s, the World Bank and the International Monetary Fund proliferated neoliberal structural adjustment policies. Under which, many nations in the Global South undertook austerity measures to limit deficit spending and balance their budgets, resulting in limited health spending and investments, undercutting efforts to build health capacities, and generating substantial challenges for redressing global health inequities.Footnote 14 Consequently, by 2025, the debt-servicing to external creditors “costs in low- and middle-income countries reached a record $1.4 trillion.”Footnote 15 This siphoning off of much needed resources is diametrically opposed to the visions articulated in Alma-Ata and the NIEO.
Transforming Our World
In 2015, the UN issued an urgent call for action which recognized “that ending poverty and other deprivations must go hand-in-hand with strategies that improve health and education, [and] reduce inequality.”Footnote 16 Member states agreed to seventeen legally non-binding Sustainable Development Goals (SDG) by the year 2030. SDG 3 concerns ensuring “healthy lives and promoting well-being for all, at all ages,” underpinned by thirteen targets that cover a wide spectrum of health.Footnote 17 It spans universal health coverage, access to essential health-care services, medicines and vaccines, and universal access to sexual and reproductive healthcare services.Footnote 18 None of the SDGs, including SDG 10 dedicated to “reducing inequality within and among countries,”Footnote 19 specifically integrate elimination of inequalities due to legacies and ongoing effects of colonialism, class exploitation, and structural discrimination into its framework of targets and indicators, including health.Footnote 20
As 2030 approaches, the scale and pace of change toward achieving the SDGs is woefully insufficient. In 2023, UN Secretary-General António Guterres warned: “Unless we act now, the 2030 Agenda will become an epitaph for a world that might have been.”Footnote 21 The 2025 SDG report indicates “only 35 percent of SDG targets are on track or making moderate progress. Nearly half are moving too slowly and, alarmingly, 18 per cent are in reverse.”Footnote 22 In health, the 2025 report found that: “Low-income and fragile settings face the highest risks due to underfunded systems, service gaps and workforce shortages.”Footnote 23 Moreover, the report called for “a substantial intensification of efforts … to address deep-seated inequalities, strengthen primary care, build resilient and inclusive health systems, and ensure universal access to quality care.”Footnote 24 This is reminiscent of Alma-Ata. Indeed, as indicated in 1978, the problem is not one of scarcity, but of inequitable distribution of resources. Our current reality reflects 2.8 billion adults in the bottom 50 percent, while just fifty-six individuals are in the very top percentile of income and wealth.Footnote 25 Appallingly, the 2022 World Inequality Report found that “contemporary global inequalities are close to their early 20th century level, at the peak of Western imperialism.”Footnote 26 Against this background, this symposium provides a platform for remembering, exposing, and re-imagining global health law.
Reforming the Multilateral System
Contributors in Part I grapple with attempts to shift the legal terrain. For example, several authors engage with India and South Africa’s efforts at the World Trade Organization in 2020 to waive key parts of intellectual property protections for the prevention, containment, and treatment of COVID-19.Footnote 27 Lisa Forman of the Dalla Lana School of Public Health and Jackman Faculty of Law at the University of Toronto maintains that even within the waiver’s temporal and functional restraints, the effect has subtly changed the debate over intellectual property rights by shifting the Overton window to support possible limitations of intellectual property rights during a public health crisis.
Another important initiative began in 2021, when the United States led calls for reform to the 2005 International Health Regulations (IHR). By May 2022, the World Health Assembly formally initiated a revision process under the auspices of an Intergovernmental Working Group.Footnote 28 Several commentators engage with this reform effort, including K. M. Gopakumar and Nithin Ramakrishnan, both of the Third World Network. They assert that the 2024 amendments to IHR mark a significant departure from the past because they provide: equitable access to health products, support diversified production, create a mechanism to mobilize financial resources, and evidence a new focus on implementation. Critically, Forman raises concerns about equity’s meaning in global health and its coherence with human rights law.
Moreover, Forman and other contributors devote sustained analysis to the negotiations beginning in 2021 for a treaty on “pandemic preparedness and response to build a more robust global health architecture.”Footnote 29 For instance, Mark Eccleston-Turner of King’s College London, Gian Luca Burci of the Graduate Institute of International and Development Studies, and Clare Wenham of the London School of Economics and Political Science, analyze two deeply contested aspects of treaty negotiations: primary prevention of disease outbreaks through a “One Health” approach, and the creation of a Pathogen Access and Benefit Sharing (PABS) system designed to improve inequity in access to medical countermeasures.
In May 2025, the World Health Assembly tentatively adopted the Pandemic Agreement. However, the treaty can only be signed and come in force, after the adoption of an annex on PABS. Fifa A. Rahman of Matahari Global Solutions and former consultant to the Africa Centres of Disease Control and Prevention (Africa CDC) in pandemic negotiations, conducts a comparative analysis of access and benefit sharing models in other multilateral treaties and examines existing databases that host genetic sequence data, to challenge arguments that a PABS mechanism will inhibit equity and innovation.
Emerging Dynamics
Contributors in Part I also explore emerging dynamics in global health such as the potential for regionalism and decolonization. For instance, Luciano Bottini Filho of Sheffield Hallam University, Deborah Gleeson of La Trobe University, and Pedro A. Villarreal of the German Institute for International and Security Affairs maintain that after twenty-five-year negotiations, the EU–Mercosur Agreement indicates that regional trade agreements may serve as an important innovation in global health governance.
Roojin Habibi of the University of Ottawa explores a different regional dynamic. Habibi examines the Africa CDC’s new authority to declare a Public Health Emergency of Continental Security. Habibi traces the promises and pitfalls of proliferating emergency powers to argue that reliance on parallel regional and international health emergency declarations risks reinforcing fragmentation, diluting accountability, and entrenching crisis-driven responses in global health governance. Relatedly, Omowamiwa Kolawole, of Dalla Lana School of Public Health at the University of Toronto, and Uchechukwu Ngwaba of Lincoln Alexander School of Law at Toronto Metropolitan University, also examine the Africa CDC. However, they see regionalism as more promising than Habibi; with regional health governance bodies offering a potential alternative pathway to decolonize global health.
Rounding out Part I, Kriti Sharma and Robert Eckford of Global Health Advocacy Incubator, and Margherita Melillo of the World Bank argue that domestic legal reform of civil registration and vital statistics systems are integral to making progress toward the realization of Sustainable Development Goals. They ground their discussion by examining progress toward achieving universal birth registration and at least 80 percent death registration, and state practice in Cambodia and Cameroon. They maintain that strengthening these systems must become a central element of the global health law agenda beyond 2030.
Situating Global Health Law at a Crossroads
Contributors in Part II zoom out to examine how current developments portend a potential shift in global health. For example, Priti Patnaik, founder and publisher of Geneva Health Files, argues that emerging economies shaped contemporary global health diplomacy. Similarly, Loyce Pace of Meharry Medical College and former Assistant Secretary for Global Affairs at the U.S. Department of Health and Human Services and Ngozi Erondu of the O’Neill Institute at Georgetown University Law Center examine how recent shifts in global health security governance are reshaping the allocation of authority under international law. They argue that the retrenchment of the United States and other traditional leaders, alongside the emergence of state-led and regionally anchored initiatives, has accelerated a move toward decentralized and multipolar governance that is legally consequential.
Contributors in Part II differ on how to conceptualize the field. For instance, Benjamin Mason Meier of University of North Carolina at Chapel Hill, Judith Bueno de Mesquita of Essex Law School, and Sharifah Sekalala of University of Warwick, argue that human rights are a central normative framework for global health law and governance, and strengthening it, will help to support health equity. In contrast, Alicia Yamin of the Global Health and Rights Project at Harvard Law School bemoans the frequently aspirational theorizing of global health law as a field that is fundamentally concerned with global health equity, human rights, and justice. Instead, Yamin employs a law and political economy perspective to argue that a human rights framework should be deployed for open dissidence against neoliberalism embedded in the legal architecture of global health governance and global health law. Others like Tsung-Ling Lee of Taipei Medical University and Villarreal, contend that global health law largely operates according to a charity-based approach. Their essay considers whether, recent reform efforts could advance a rights-based, resilience model of international health cooperation.
Commentators like Thana C. de Campos-Rudinsky of the School of Governance and the Institute of Applied Ethics at the Pontifical Catholic University of Chile, and Daniel Wainstock, a Brazilian global health lawyer, similarly advocate for adopting different normative frameworks. For these authors, subsidiarity offers a pragmatic, justice-oriented principle to colonial legacies and systemic inequities in global health by balancing local agency with the duty of non-abandonment, enabling context-sensitive solutions, and equitable global cooperation.
The Path Forward
Which path will global health law take? In many ways, the field remains complicit in the preservation and reification of non-transformation. Recent reform efforts continue this trajectory.Footnote 30 Contemporary initiatives do not sufficiently acknowledge historic or intensifying global health inequalities, nor do they substantially seek to disrupt them.Footnote 31 The continuing subordination that has rendered some states and peoples especially vulnerable to precarity and immiseration is seemingly forcibly forgotten despite the devastating impact and effect on health systems, health infrastructure, health outcomes of peoples, and the quality of life and well-being of individuals around the globe.Footnote 32 Almost eighty years since WHO’s founding, the failure to adequately name, shame, and redress our immensely inequitable material realities,Footnote 33 permeates and structures global health’s past, present, and futures. Global health law in theory, and practice, can either work to disrupt global health inequality, or it can ratify, and exacerbate it.
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