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A Global Public Goods Approach to the Health of Migrants

A Global Public Goods Approach to the Health of Migrants Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 PUBLIC HEALTH ETHICS VOLUME 8 NUMBER 2 2015 121–129 121 A Global Public Goods Approach to the Health of Migrants Heather Widdows and Herjeet Marway , University of Birmingham Corresponding author: Herjeet Marway, Centre for the Study of Global Ethics, Department of Philosophy, University of Birmingham, Edgbaston, Birmingham. B15 2TT, UK. E-mail: h.widdows@bham.ac.uk. This paper explores a global public goods approach to the health of migrants. It suggests that this ap- proach establishes that there are a number of health goods which must be provided to migrants not because these are theirs by right (although this may independently be the case), but because these goods are primary goods which fit the threefold criteria of global public goods. There are two key advantages to this approach: first, it is non- confrontational and non-oppositional, and second, it provides self-interested arguments to provide at least some health goods to migrants and thus appeals to those little moved by rights-based arguments. This paper adopts a global public goods approach to the Seeking New Frameworks health of migrants. This approach is unusual, as debates Much of the work on the health of migrants, and on the about migrants and what is owed to them, in general, are rights of and the duties to migrants, uses the human largely rights-based. This paper will briefly outline the cur- rights framework to make justice claims, to delineate rent rights-based nature of such debates and suggests that the rights of migrants and the duties owed to all indi- alternative approaches might be useful. We begin by noting the dominance of rights language in the current debate and viduals. Too often, and to caricature, this debate col- lapses into a conflict between the rights of some suggest that this is confrontational and oppositional, so individuals and the rights of others. This is true of motivating the seeking of alternative approaches. We many of the discourses which surround migration, present a global public goods approach building on and which the debate about the health of migrants previous work and consider what, if anything, such an draws upon. Rights language is dominant in discussions approach would deliver in terms of migrant health around defending the rights of immigrants and immi- (Widdows and Cordell, 2011; Widdows, 2013; Widdows gration policy. For instance, the International and West-Oram, 2013). To this end, we define public Convention on the Protection of the Rights of All goods using three key criteria, show how these apply Migrant Workers and Members of Their Families using the examples of the environment and antibiotic ef- (2003) seeks to protect the basic freedoms of all (docu- ficacy and then apply this model to the health of migrants. mented and undocumented) migrants, a proposal This approach might, at first glance, seem unlikely to de- which is based on realizing the individual rights that liver, as it is not obvious why one needs to protect migrant all persons hold under the Universal Declaration of health to protect the health of all. But, while not delivering Human Rights (1948) (UN, 1990). Similarly, there is all the goods of health and healthcare, one might wish it will discussion on the links and tensions between fundamen- deliver some, and some significant health goods. We argue tal, natural and human rights—all of which focus on that there are two key advantages to our approach: first, it is individual rights—and on the extent to which immigra- non-confrontational and non-oppositional, so may be tion policies might be liberalized (Ghoshray, 2006– useful in surmounting the current impasse which assumes 2007). Theorists have tended to compare the interests that one group can only benefit at the expense of another, of one group of people (migrants) against those of an- and second, as a result, it may convince those who have other group (low-skilled, low-paid citizens) and have little interest in the rights of migrants to support the pro- suggested that more open migration policies will exacer- vision of health goods to them. Admittedly, this is a tenta- bate inequalities for the poorest nationals (Borjas, 2001; tive paper which merely begins to explore a different Cafaro, 2008). In this regard, and in general, the conceptual approach. doi:10.1093/phe/phv013 Advance Access publication on 1 June 2015 ! The Author 2015. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 122 WIDDOWS AND MARWAY immigration debate is often couched in the terms of to goods which cannot be other than public, while nor- right versus right (Teitelbaum, 1980). In these complex mative descriptions make claims that such goods have a and competing narratives, the rights of some individuals status which merits protection. Our contention is that descriptive definitions imply a normative definition in are presented as trumping the rights of others, and it is assumed that granting rights to one group of individuals the case of global public goods; why this is so will become clear as we discuss the nature of these goods. will be at the expense of the rights of another group. Furthermore, such discourses about migrants are Let us begin by describing public goods in general, as opposed to global public goods. Public goods are often highly rhetorical and emotional. For instance, poor migrants who are forced to become such, either enjoyed collectively and, as such, are non-rivalrous (in that their use by one does not prevent their use by an- as refugees fleeing from conflict zones or economic mi- grants seeking to escape grinding poverty, are carica- other) (Kaul et al., 1999a), lack excludability (they are inclusive and available to all) and require collective tured (especially by those who are anti-migration) as ‘flooding countries’ and taking jobs. Other migrants, management and maintenance. Examples of public goods include traffic lights (Kaul et al., 1999a), laws particularly highly qualified migrants—colloquially called the brain drain—are criticized for leaving their (Widdows and Cordell, 2011) and education (Kaul et al., 1999b; Sen, 1999). Domestic public goods are countries of origin. Certainly such movements cause enjoyed collectively within a geographical location or difficulties in developing countries, evidenced clearly as part of a community and are characterized by being in the low numbers of health professionals who beneficial to those who have access to them, as well as remain in the developing world. But, conversely, remit- being collectively protected and sustained. This descrip- tances are an important source of income for such coun- tion—especially at the non-global level—is purely de- tries. Such emotional language makes claims for the scriptive. For instance, to say that to obey laws or rights of migrants controversial, especially if rights lan- contribute to street lighting is a public good, which guage is used, as this language tends to imply both con- can only be communally and publically maintained, is frontation and opposition. to describe the good. This does not necessarily imply a It is the individual and confrontational nature of normative claim that such goods should be protected in rights language which leads us, somewhat tentatively, all circumstances and beyond other goods. Indeed, it is to approach the issue of the health of migrants from a not hard to imagine instances where these goods should different perspective, one which is not rights-based, and not be maintained: there are instances where laws can which focuses on communal goods rather than individ- justifiably be broken and street-lighting dimmed (for ual goods. This is not to suggest that individual instance in blackouts or for celebrations). Such local approaches should be abandoned; on the contrary, we goods might contribute to well-being, but they are consider many of these to be strong and useful, and as open to change and can be less important than other global ethicists, we endorse rights and duties for and to goods. all individuals globally. However, while individually When it comes to global public goods in addition to focused theories are crucial to global justice theorizing the descriptive claims—of collective sustainability, non- and individuals must be regarded as the primary locus of excludability and so on—we add further descriptive moral concern, overly individualist theories fail to claims upon which we invoke a normative claim. recognize key goods and harms, because theories deter- Global public goods, in contrast to other public goods, mine a priori which goods and harms can be recognized are goods which require all individuals to behave in and which cannot (Widdows and West-Oram, 2013). certain ways if they are to be sustained (descriptive Our alternative approach is not intended to replace claim). More importantly, in this category are only rights-based approaches, but to complement and to be those public goods which if not sustained would dra- used alongside other approaches. matically harm the well-being of all individuals (another descriptive claim). These descriptive claims define goods which are crucial to protect (because the harms Defining Global Public Goods which follow if they are not are so severe) and which In this paper, we focus on global public goods, rather require action by all, and so result in a normative asser- than public goods in general. Definitions of (global) tion that they should be protected. Accordingly, such public goods are contentious; some are descriptive and global public goods should be treated as ‘primary some are normative. Adopting a descriptive definition goods’ and should be protected legally and in policy supposedly avoids value-laden claims and merely points and at all levels regardless of the wishes of individuals Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 HEALTH AND GLOBAL PUBLIC GOODS 123 or states. To break this down, according to this defin- harms include those which follow from increases in sea ition of global public goods, three criteria must be met: level (Barnett and Adger, 2003), coastal and habitat ero- sion (Feagin et al., 2005), species extinction (Thomas First, if the global public good is not protected then et al., 2004), extreme weather events (McMichael all individuals (current and future) will be exposed to et al., 1996), exacerbated health risks (McMichael and significant harm (and often will actually suffer harm, Haines, 1997; Haines et al., 2006), greater movement of harms preventable by the protection of the good), people (Reuveny, 2007) and increased risks of conflict Second, the global public good cannot be protected (Barnett and Adger, 2007). Already people are suffering without collective action (nor can the resulting as a result of climate change; for instance, increased harms be prevented without collective action), flooding is documented in a number of African cities (Douglas et al., 2008) and extreme weather events have If these two descriptive criteria are met then we argue already been experienced (for instance, the 2003 that a—normative—claim is implied, that: European heat waves and the 2004 and 2005 Atlantic hurricane seasons; Van Aalst 2006) Accordingly, cur- Third, a global public good which meets the descrip- rent and future individuals are likely to actually suffer tive criteria is a primary good which should be pro- harm, harms which would have been prevented had the tected to prevent significant harms to all individuals environment been adequately protected. Likewise, the and accordingly states and/or individuals cannot be second criterion is met, as the environment cannot be allowed to choose to neglect this good. protected without collective action (nor can the result- ing harms be prevented without collective action). Some If this reasoning holds, the normative claim follows individuals cannot continue to engage in environment- upon the descriptive claims, in that if the first two cri- harming actions (from air travel to the burning of fossil teria are correct, then one has strong reasons for accept- fuels) if any are to avoid harm. So the first and second ing the third, as only if one accepts the third can the descriptive criteria are met. good (established as primary by criteria one and two) be systematically protected. If the good really is a primary good—failure to protect it results in exposure of all in- Efficacy of Antibiotics dividuals to significant harm and it can only be pro- A parallel argument can be made for the efficacy of anti- tected by collective action—then the third criteria biotics. First, if antibiotic efficacy is not protected, then should apply. In practice, the normative claim may not all individuals (current and future) will be exposed to be recognized or respected—and we will explore this— significant harm (and often will actually suffer harm, even though it reasonably follows from the first two harms preventable by the protection of the good). The criteria. Of course if any of the criteria can be shown harms of antibiotic resistance (the failure to protect not to apply—for instance, that the harm is not signifi- antibiotic efficacy) are significant. It is possible we will cant or that collective action is not required to protect return to a pre-antibiotic era where common infectious the good—then the claim will, of course, be under- diseases again become lethal. Pathogens which are re- mined. But, this would not be to deny the normative sistant to antibiotics include multi- or extremely drug- claim, but rather to deny that the good in question really resistant tuberculosis (Ormerod, 2005), methicillin-re- is a primary good of the type under discussion. To il- sistant Staphylococcus aureus (Cosgrove, 2006) and lustrate, let us consider the environment, the archetypal multidrug-resistant plague (Welch et al., 2007). The global public good and antibiotic efficacy, which we extent of these threats is such that on World Health have previously argued should also be considered in Day 2011, the World Health Organization released a this category. set of policy proposals to address antibiotic resistance (World Health Organization, 2012) and stated that ‘[t]he world is on the brink of losing these miracle The Environment cures’ (Chan, 2011). More recently, the Government The environment is collectively enjoyed by all, it is non- of the United Kingdom hosted an international event rivalrous and non-excludable and requires collective to discuss the problem of drug resistance (UK maintenance. In terms of the first criterion, if the envir- Department of Health, 2013). Accordingly, the harms onment is not protected, then all individuals (current which flow from the failure to protect antibiotic efficacy and future) will be exposed to significant harm. Likely are extreme and immanent. Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 124 WIDDOWS AND MARWAY Second, the good of antibiotic efficacy cannot be pro- Global Public Goods and the tected without collective action (nor can the resulting harms be prevented without collective action). In the Health of Migrants current model, the use of antibiotics is largely regarded Having laid out why a global public good approach as a private issue, or one which is a matter for market might be interesting and useful for considering the forces. Accordingly, the wider consequences of inappro- health of migrants (first, it moves the debate from com- priate, inefficient and over- or underuse have been lar- peting individual rights, and second, it provides self- gely ignored (Cars et al., 2008; Olivier et al., 2010). In interested reasons for those not convinced by migrant the developed world, antibiotics are essentially com- rights arguments) and having described the nature of modities. Antibiotics are used by those who can afford global public goods, we will in this final section consider them, by consumers who are either using them as what a public goods approach might contribute to the patients or for food production or agri-businesses. health of migrants. The last section outlined the defining Patterns of use in the developing world also contribute criteria of global public goods. At first glance it might to the erosion of the good, for complex and understand- seem unlikely that the health of migrants can be convin- able reasons. The poor, typically in developing coun- cingly argued to fit these criteria. Surely the health of tries, are often unable to afford full courses of drugs. migrants can be neglected and they can be refused health This leads to the sharing of medicines and stockpiling goods without all individuals being exposed to signifi- ‘excess doses’. As a result, efficacy decreases and resistant cant harm? However, while some health care (both as diseases increase. Collective action is required, for while prevention and treatment) could be denied to migrants antibiotic resistance is an inevitable consequence of any without exposing others to harm, there are at least some use of antibiotics, the harms could be reduced and the areas where we can argue that protecting migrant health rapid rise of antibiotic resistance slowed significantly does protect all individuals (and that if migrant health is with collective action, so meeting the second criterion. not protected that individuals will actually suffer pre- In both cases, of the environment and antibiotic re- ventable harm). It is these we will focus on. sistance, then the first and second criteria are met and We can begin with the global public good we have just the third, normative criteria, follows from these, in the considered, that of antibiotic efficacy. As a global public sense that if the first two are met, it would be unreason- good then antibiotic use by migrants should be managed able not to introduce policy which requires global public to protect antibiotic efficacy; as it should for all. Thus, goods to be systematically protected. Given this then, we have the first health good which should be given to the identification of a global public good will generate migrants, not because it is their right to have correct obligations on individuals, states and globally and cor- antibiotic treatment, but to protect the global public responding restrictions on individuals’ and states’ use good of antibiotic efficacy and thus to protect all. One and abuse of the good. However, recognizing that obli- reply to this suggestion might be that antibiotic efficacy gations follow if global public goods are to be protected would be better protected simply by refusing antibiotics is not the same as actually fulfilling—and if necessarily to migrants; however, experience in contexts where enforcing—such obligations. The harms of failing to access to antibiotics, especially for serious conditions, protect the environment and antibiotic efficacy are is reduced is that misuse is common. For instance, as known and therefore, effectively, such goods are recog- discussed in the previous section with regard to antibi- nized, at least in discourse, as primary goods. This is otic use in the developing world, in contexts where evidenced by a call for global action to protect these access is scarce and treatment is correspondingly goods; for instance, in the Kyoto protocol and the highly valuable, misuse, in the form of stock-piling Copenhagen accord as well as in subsequent discussions and failure to finish courses of treatment, is high. Such at Cancun, Durban, Doha and Warsaw; in the ongoing behaviour contributes significantly to the increase of work of the Intergovernmental Panel on Climate antibiotic resistance. Of course, if it were possible to Change (most recently its 2014 report); and in global absolutely deny all antibiotics to all migrants, then this initiatives by the WHO and national governments to protect the efficacy of antibiotics. These endeavours might contribute to protecting antibiotic efficacy, but this is unlikely in practical terms, and of course would be are, of course, inadequate and the needs—or rather preferences—of states and individuals continue to exceptionally harmful and require additional, probably coercive measures, to enforce. There are a number of trump these global public goods. But, although too often practice has not changed significantly, the primary other health goods which might well be offered to mi- nature of these goods is recognized. grants on these grounds and we will consider just two Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 HEALTH AND GLOBAL PUBLIC GOODS 125 more of these; first, the management of infectious dis- good model with focuses on threats to all and collective ease and second, herd immunity. action. This brings us to the second criterion; the global First then, managing infectious disease. In an age of public good cannot be protected without collective pandemics, this is a particularly important global health action (nor can the resulting harms be prevented with- good, as we are, at the time of writing, six months into out collective action). Here collective action could be a the worst Ebola epidemic in history. This health good large number of interventions including the enforcing of overlaps with antibiotic efficacy. The risks of infectious quarantine, the use of protective equipment and proto- disease rise as strains of antibiotic diseases rise and cols, measures to prevent movements of people and diseases become ever harder to treat and increasingly global access to health care professionals and to treat- life-threatening, such as multi-resistant TB, already ment. What is required is significant. In a recent com- mentioned above. But, there are other global health ment on the Ebola crisis, Lawrence Gostin offers a list of goods which follow from considering the significant what is needed to manage outbreaks of infectious dis- harms of infectious disease. ease including, ‘community, laboratory, public health, In terms of the first criterion, if the global public good and clinical personnel; infection-control equipment, supplied, and protocols; health worker training; labora- of being ‘as free as reasonably possible from infectious disease’ (or some similarly conceived good) is not pro- tory facilities with high biosafety capabilities; health tected, then all individuals (current and future) will be facilities, including safe isolation units; and communi- exposed to significant harm (and often will actually cation systems that can effectively deliver important suffer harm, harms preventable by the protection of public health information’ (Gostin, 2014: 1). To provide the good). The current Ebola pandemic shows the dif- such very necessary goods for all, a collective model is ficulty of containing such threats locally in areas lacking needed. One possibility, which Gostin discusses, is a health infrastructure and health professionals— Global Health Emergency workforce (which was pro- returning us to the debate at the beginning of the posed by the WHO in 2011 but which was never actua- paper regarding the global flow of health workers from lized) (Gostin, 2014). However, whatever approach is the developing world. Such issues are exacerbated by taken, clearly collective goods are in question and col- fear and misinformation, and as a result, healthcare lective models which can prioritize such goods are likely workers may fail to report for work or be stigmatized to be more effective than those which focus on if they do. But, and importantly for global public good individuals. claims, epidemics threaten not only the local area, but As the first two criteria are met, so the normative they are global threats (although predictably the burden criteria are invoked; that, this is a primary good which falls disproportionally on the poor). This said global should be protected if significant harms to all individuals concern is greatest when the developed world is threa- are to be prevented, and accordingly states and/or indi- tened. This is shown in the response, or lack of it, to viduals cannot be allowed to choose to neglect them. Ebola and was true in the SARS outbreak. This epidemic The immediate threat of infectious disease means that originated in China on 16 November 2002, but the protecting this good and preventing the attendant global response began on 12 March, when the WHO harms is often recognized as globally significant, and issued a global alert. This was after the first reported perhaps, this is an area in which the need to protect case in Canada on 5 March; and a few days post the migrants, as part of protecting all, is easy to recognize. alert, and on the same day that emergency travel This then, is another instance in which a public good advice was issued (15 March), three ill passengers were approach does result in providing some health goods for taken off a plane traveling from New York to Singapore migrants. Moreover, these goods might be extensive if (WHO, 2003a). While the greatest death toll occurred in one considers what requiring goods such as health in- China (5327) and the Hong Kong Special frastructure might entail. Administrative Region (1755), and the highest number Second then, and more briefly, herd immunity. of fatalities in the West reaching a fraction of that (250, Herd immunity is the emergent property of vaccination in Canada) (WHO, 2003b), the response was heightened by which all members of a given community are pro- with the spread of the disease to the West. tected from a specific vaccine-preventable disease by Given that disease is no respecter of borders and in- majority participation in vaccination programmes for fectious health threats are global, the first criterion is that disease (Anderson and May, 1985). When the met, the harms are indeed significant. The fact that the number of vaccinated persons falls below the herd im- developed world has shown willingness to respond when munity threshold, resurgence of the disease becomes threatened might be used to support a global public likely. Herd immunity is interesting as a global Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 126 WIDDOWS AND MARWAY public good because it relies on collective action of most to migrants on global public good grounds. Using this (not quite all), recognizing that some people—the im- approach denies there is conflict between the rights of munocompromised, the very young and very old—are one group of individuals and another group of individ- unable to participate in vaccination programmes for uals or between the global public good and individuals’ safety reasons. Like the environment and antibiotic rights. Only together can these goods be protected and the harms to individuals prevented. Conceptualizing it efficacy, herd immunity (broadly) fits the criteria out- lined above: first, if the public good is not protected, in this way simply removes the claim that the rights (or resources) are in competition on these issues. For any to then all individuals (current and future) will be exposed to significant harm; and second, the global public good be protected, all must be protected. Further, it provides a reason for those who do not support the rights of cannot be protected without collective action (nor can the resulting harms be prevented without collective migrants to grant such health goods to them. As a final comment it is of course the case that these action). From these then follows the normative require- ment, the third criteria, that this good should be prior- health goods are provided to migrants not because they are migrants but because they need to be provided to all itized and protected. Unlike antibiotic efficacy, a small number of non-compliant individuals will not destroy to protect public goods. This of course is the case, but this parallels many migrant rights arguments which use the global public good, but even with this caveat, the general case is the same, states must act to protect herd human rights to claim migrants’ rights; again, argu- ments based on what should be provided to all. This immunity and nearly all individuals must to do the alternative approach should be used separately and same. together with individual approaches to improve the This discussion—of antibiotic efficacy, of managing provision of health goods to migrants. infectious disease and of herd immunity—provides just a small number of examples of the types of health goods which migrants might be entitled to from a global public Acknowledgements good perspective. There are many more goods which could fall into the global public good category, or We would like to acknowlege the on-going support of which could be argued to contribute to the goods we the University of Birmingham. The argument about have outlined. For example, it might be possible to make global public goods is one which we have been develop- an argument that access to clean water, food and ad- ing both in health and more generally. For example, equate shelter as well as to basic health goods is a global exploring whether security can be reconceptualised as public good, as they vastly reduce the likelihood of the a global public is a possibity which we are exploring in spread of infectious disease and so contribute to pro- an ESRC funded project (Nuclear Ethics and Global tecting a global public good. Alternatively, perhaps, ar- Security: Reforming the Nuclear Non-Proliferation guments about access to contraception and abortion Regime) led by Professor Nicholas Wheeler, ICCS, might be made on global public goods grounds regard- University of Birmingham. ing population control. Cashing out the details of exactly what a global public goods account could con- tribute to the health of migrants would take further dis- Funding cussion. But, while it may not grant the full basket of health goods that a rights-based approach can, it will at Funding for gold access provided by the University of least give additional reasons for some health measures to Birmingham. be granted to all migrants and automatically. Notes Conclusion 1. Our recent work on non-individual ethical models is This brief discussion has shown that there are at least in genetics (Widdows, 2013) and in debates about some health goods which should be provided to mi- global ethics and health ethics more generally grants. Providing such goods is justified not on individ- (Widdows, 2007; Widdows and West-Oram, 2013). ual rights grounds but on the grounds of the protection 2. It is important to note that there is no human right of all. This provides a means for all to endorse these to free movement as such because, while all persons goods. At least some basic health goods (in the forms are permitted to leave a territory, sovereign states of both treatment and prevention) should be accorded continue to reserve the power to determine who Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 HEALTH AND GLOBAL PUBLIC GOODS 127 can enter or stay in their territory. However, the 8. This paper builds on previous work done by 2003 International Convention on the Protection Widdows and Peter West-Oram (Widdows and West-Oram, 2013). of the Rights of All Migrant Workers and Members of Their Families seeks to ensure that 9. Since the introduction of antimicrobial medicines in the 30s (Cohen, 1992; Van Epps, 2006), the threat both illegal and legal migrants and their families posed by common, often lethal, and formerly un- are protected in basic and important ways in the treatable, diseases has been dramatically reduced host government’s policies (OHCHR, 2014). (Iseman, 1993; Reichman, 1997). 3. This language occurs in various media, public and 10. Cars et al. (2008), for instance, argue that there is a political discourse about immigrants. See, for ex- trend of antibiotic resistance and that while individ- ample, Ana (1999) and Travis and Malik (2013). ual stakeholders might be aware of the problem, 4. In 2010, The Economist reported that ‘Remittances collective action—from politicians, public health [in the Philippines] are now equivalent to 11% of workers and consumers—has been slow partly be- the economy’ (Banyan, 2010). In 2014, The World cause responsibility for taking relevant measures Bank reported that remittances to developing coun- does not lie with one body in particular. They tries are set to increase ‘7.8 per cent over the 2013 press for collective action from national and inter- volume of $404 billion, rising to $516 billion in national leaders, behavioural change from con- 2016’ (The World Bank, 2014). Moreover, they sumers and providers and bodies that are willing argue that remittances ‘remain a key source of ex- to develop antibacterial agents to respond to current ternal resource flows for developing countries, far public health needs. In this regard, they contend that exceeding official development assistance and more antibiotics must be regarded as a common good. stable than private debt and portfolio equity flows. 11. WHO state that they will continue their support of For many developing countries, remittances are an bodies linking the global environmental and important source of foreign exchange, surpassing health agendas by providing expertise and advice earnings from major exports, and covering a sub- (WHO, 2014). National government responses stantial portion of imports.’ (The World Bank, vary but a good range of measures is listed in envir- 2014). onmental assessments of European countries 5. We are not alone in introducing collective (European Environmental Agency, 2010). approaches into this debate; however, such inter- 12. Elsewhere we explore in more details whether herd ventions are relatively few. 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A Global Public Goods Approach to the Health of Migrants

Widdows, Heather; Marway, Herjeet
Public Health Ethics , Volume 8 (2) – Jul 1, 2015
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Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 PUBLIC HEALTH ETHICS VOLUME 8 NUMBER 2 2015 121–129 121 A Global Public Goods Approach to the Health of Migrants Heather Widdows and Herjeet Marway , University of Birmingham Corresponding author: Herjeet Marway, Centre for the Study of Global Ethics, Department of Philosophy, University of Birmingham, Edgbaston, Birmingham. B15 2TT, UK. E-mail: h.widdows@bham.ac.uk. This paper explores a global public goods approach to the health of migrants. It suggests that this ap- proach establishes that there are a number of health goods which must be provided to migrants not because these are theirs by right (although this may independently be the case), but because these goods are primary goods which fit the threefold criteria of global public goods. There are two key advantages to this approach: first, it is non- confrontational and non-oppositional, and second, it provides self-interested arguments to provide at least some health goods to migrants and thus appeals to those little moved by rights-based arguments. This paper adopts a global public goods approach to the Seeking New Frameworks health of migrants. This approach is unusual, as debates Much of the work on the health of migrants, and on the about migrants and what is owed to them, in general, are rights of and the duties to migrants, uses the human largely rights-based. This paper will briefly outline the cur- rights framework to make justice claims, to delineate rent rights-based nature of such debates and suggests that the rights of migrants and the duties owed to all indi- alternative approaches might be useful. We begin by noting the dominance of rights language in the current debate and viduals. Too often, and to caricature, this debate col- lapses into a conflict between the rights of some suggest that this is confrontational and oppositional, so individuals and the rights of others. This is true of motivating the seeking of alternative approaches. We many of the discourses which surround migration, present a global public goods approach building on and which the debate about the health of migrants previous work and consider what, if anything, such an draws upon. Rights language is dominant in discussions approach would deliver in terms of migrant health around defending the rights of immigrants and immi- (Widdows and Cordell, 2011; Widdows, 2013; Widdows gration policy. For instance, the International and West-Oram, 2013). To this end, we define public Convention on the Protection of the Rights of All goods using three key criteria, show how these apply Migrant Workers and Members of Their Families using the examples of the environment and antibiotic ef- (2003) seeks to protect the basic freedoms of all (docu- ficacy and then apply this model to the health of migrants. mented and undocumented) migrants, a proposal This approach might, at first glance, seem unlikely to de- which is based on realizing the individual rights that liver, as it is not obvious why one needs to protect migrant all persons hold under the Universal Declaration of health to protect the health of all. But, while not delivering Human Rights (1948) (UN, 1990). Similarly, there is all the goods of health and healthcare, one might wish it will discussion on the links and tensions between fundamen- deliver some, and some significant health goods. We argue tal, natural and human rights—all of which focus on that there are two key advantages to our approach: first, it is individual rights—and on the extent to which immigra- non-confrontational and non-oppositional, so may be tion policies might be liberalized (Ghoshray, 2006– useful in surmounting the current impasse which assumes 2007). Theorists have tended to compare the interests that one group can only benefit at the expense of another, of one group of people (migrants) against those of an- and second, as a result, it may convince those who have other group (low-skilled, low-paid citizens) and have little interest in the rights of migrants to support the pro- suggested that more open migration policies will exacer- vision of health goods to them. Admittedly, this is a tenta- bate inequalities for the poorest nationals (Borjas, 2001; tive paper which merely begins to explore a different Cafaro, 2008). In this regard, and in general, the conceptual approach. doi:10.1093/phe/phv013 Advance Access publication on 1 June 2015 ! The Author 2015. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 122 WIDDOWS AND MARWAY immigration debate is often couched in the terms of to goods which cannot be other than public, while nor- right versus right (Teitelbaum, 1980). In these complex mative descriptions make claims that such goods have a and competing narratives, the rights of some individuals status which merits protection. Our contention is that descriptive definitions imply a normative definition in are presented as trumping the rights of others, and it is assumed that granting rights to one group of individuals the case of global public goods; why this is so will become clear as we discuss the nature of these goods. will be at the expense of the rights of another group. Furthermore, such discourses about migrants are Let us begin by describing public goods in general, as opposed to global public goods. Public goods are often highly rhetorical and emotional. For instance, poor migrants who are forced to become such, either enjoyed collectively and, as such, are non-rivalrous (in that their use by one does not prevent their use by an- as refugees fleeing from conflict zones or economic mi- grants seeking to escape grinding poverty, are carica- other) (Kaul et al., 1999a), lack excludability (they are inclusive and available to all) and require collective tured (especially by those who are anti-migration) as ‘flooding countries’ and taking jobs. Other migrants, management and maintenance. Examples of public goods include traffic lights (Kaul et al., 1999a), laws particularly highly qualified migrants—colloquially called the brain drain—are criticized for leaving their (Widdows and Cordell, 2011) and education (Kaul et al., 1999b; Sen, 1999). Domestic public goods are countries of origin. Certainly such movements cause enjoyed collectively within a geographical location or difficulties in developing countries, evidenced clearly as part of a community and are characterized by being in the low numbers of health professionals who beneficial to those who have access to them, as well as remain in the developing world. But, conversely, remit- being collectively protected and sustained. This descrip- tances are an important source of income for such coun- tion—especially at the non-global level—is purely de- tries. Such emotional language makes claims for the scriptive. For instance, to say that to obey laws or rights of migrants controversial, especially if rights lan- contribute to street lighting is a public good, which guage is used, as this language tends to imply both con- can only be communally and publically maintained, is frontation and opposition. to describe the good. This does not necessarily imply a It is the individual and confrontational nature of normative claim that such goods should be protected in rights language which leads us, somewhat tentatively, all circumstances and beyond other goods. Indeed, it is to approach the issue of the health of migrants from a not hard to imagine instances where these goods should different perspective, one which is not rights-based, and not be maintained: there are instances where laws can which focuses on communal goods rather than individ- justifiably be broken and street-lighting dimmed (for ual goods. This is not to suggest that individual instance in blackouts or for celebrations). Such local approaches should be abandoned; on the contrary, we goods might contribute to well-being, but they are consider many of these to be strong and useful, and as open to change and can be less important than other global ethicists, we endorse rights and duties for and to goods. all individuals globally. However, while individually When it comes to global public goods in addition to focused theories are crucial to global justice theorizing the descriptive claims—of collective sustainability, non- and individuals must be regarded as the primary locus of excludability and so on—we add further descriptive moral concern, overly individualist theories fail to claims upon which we invoke a normative claim. recognize key goods and harms, because theories deter- Global public goods, in contrast to other public goods, mine a priori which goods and harms can be recognized are goods which require all individuals to behave in and which cannot (Widdows and West-Oram, 2013). certain ways if they are to be sustained (descriptive Our alternative approach is not intended to replace claim). More importantly, in this category are only rights-based approaches, but to complement and to be those public goods which if not sustained would dra- used alongside other approaches. matically harm the well-being of all individuals (another descriptive claim). These descriptive claims define goods which are crucial to protect (because the harms Defining Global Public Goods which follow if they are not are so severe) and which In this paper, we focus on global public goods, rather require action by all, and so result in a normative asser- than public goods in general. Definitions of (global) tion that they should be protected. Accordingly, such public goods are contentious; some are descriptive and global public goods should be treated as ‘primary some are normative. Adopting a descriptive definition goods’ and should be protected legally and in policy supposedly avoids value-laden claims and merely points and at all levels regardless of the wishes of individuals Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 HEALTH AND GLOBAL PUBLIC GOODS 123 or states. To break this down, according to this defin- harms include those which follow from increases in sea ition of global public goods, three criteria must be met: level (Barnett and Adger, 2003), coastal and habitat ero- sion (Feagin et al., 2005), species extinction (Thomas First, if the global public good is not protected then et al., 2004), extreme weather events (McMichael all individuals (current and future) will be exposed to et al., 1996), exacerbated health risks (McMichael and significant harm (and often will actually suffer harm, Haines, 1997; Haines et al., 2006), greater movement of harms preventable by the protection of the good), people (Reuveny, 2007) and increased risks of conflict Second, the global public good cannot be protected (Barnett and Adger, 2007). Already people are suffering without collective action (nor can the resulting as a result of climate change; for instance, increased harms be prevented without collective action), flooding is documented in a number of African cities (Douglas et al., 2008) and extreme weather events have If these two descriptive criteria are met then we argue already been experienced (for instance, the 2003 that a—normative—claim is implied, that: European heat waves and the 2004 and 2005 Atlantic hurricane seasons; Van Aalst 2006) Accordingly, cur- Third, a global public good which meets the descrip- rent and future individuals are likely to actually suffer tive criteria is a primary good which should be pro- harm, harms which would have been prevented had the tected to prevent significant harms to all individuals environment been adequately protected. Likewise, the and accordingly states and/or individuals cannot be second criterion is met, as the environment cannot be allowed to choose to neglect this good. protected without collective action (nor can the result- ing harms be prevented without collective action). Some If this reasoning holds, the normative claim follows individuals cannot continue to engage in environment- upon the descriptive claims, in that if the first two cri- harming actions (from air travel to the burning of fossil teria are correct, then one has strong reasons for accept- fuels) if any are to avoid harm. So the first and second ing the third, as only if one accepts the third can the descriptive criteria are met. good (established as primary by criteria one and two) be systematically protected. If the good really is a primary good—failure to protect it results in exposure of all in- Efficacy of Antibiotics dividuals to significant harm and it can only be pro- A parallel argument can be made for the efficacy of anti- tected by collective action—then the third criteria biotics. First, if antibiotic efficacy is not protected, then should apply. In practice, the normative claim may not all individuals (current and future) will be exposed to be recognized or respected—and we will explore this— significant harm (and often will actually suffer harm, even though it reasonably follows from the first two harms preventable by the protection of the good). The criteria. Of course if any of the criteria can be shown harms of antibiotic resistance (the failure to protect not to apply—for instance, that the harm is not signifi- antibiotic efficacy) are significant. It is possible we will cant or that collective action is not required to protect return to a pre-antibiotic era where common infectious the good—then the claim will, of course, be under- diseases again become lethal. Pathogens which are re- mined. But, this would not be to deny the normative sistant to antibiotics include multi- or extremely drug- claim, but rather to deny that the good in question really resistant tuberculosis (Ormerod, 2005), methicillin-re- is a primary good of the type under discussion. To il- sistant Staphylococcus aureus (Cosgrove, 2006) and lustrate, let us consider the environment, the archetypal multidrug-resistant plague (Welch et al., 2007). The global public good and antibiotic efficacy, which we extent of these threats is such that on World Health have previously argued should also be considered in Day 2011, the World Health Organization released a this category. set of policy proposals to address antibiotic resistance (World Health Organization, 2012) and stated that ‘[t]he world is on the brink of losing these miracle The Environment cures’ (Chan, 2011). More recently, the Government The environment is collectively enjoyed by all, it is non- of the United Kingdom hosted an international event rivalrous and non-excludable and requires collective to discuss the problem of drug resistance (UK maintenance. In terms of the first criterion, if the envir- Department of Health, 2013). Accordingly, the harms onment is not protected, then all individuals (current which flow from the failure to protect antibiotic efficacy and future) will be exposed to significant harm. Likely are extreme and immanent. Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 124 WIDDOWS AND MARWAY Second, the good of antibiotic efficacy cannot be pro- Global Public Goods and the tected without collective action (nor can the resulting harms be prevented without collective action). In the Health of Migrants current model, the use of antibiotics is largely regarded Having laid out why a global public good approach as a private issue, or one which is a matter for market might be interesting and useful for considering the forces. Accordingly, the wider consequences of inappro- health of migrants (first, it moves the debate from com- priate, inefficient and over- or underuse have been lar- peting individual rights, and second, it provides self- gely ignored (Cars et al., 2008; Olivier et al., 2010). In interested reasons for those not convinced by migrant the developed world, antibiotics are essentially com- rights arguments) and having described the nature of modities. Antibiotics are used by those who can afford global public goods, we will in this final section consider them, by consumers who are either using them as what a public goods approach might contribute to the patients or for food production or agri-businesses. health of migrants. The last section outlined the defining Patterns of use in the developing world also contribute criteria of global public goods. At first glance it might to the erosion of the good, for complex and understand- seem unlikely that the health of migrants can be convin- able reasons. The poor, typically in developing coun- cingly argued to fit these criteria. Surely the health of tries, are often unable to afford full courses of drugs. migrants can be neglected and they can be refused health This leads to the sharing of medicines and stockpiling goods without all individuals being exposed to signifi- ‘excess doses’. As a result, efficacy decreases and resistant cant harm? However, while some health care (both as diseases increase. Collective action is required, for while prevention and treatment) could be denied to migrants antibiotic resistance is an inevitable consequence of any without exposing others to harm, there are at least some use of antibiotics, the harms could be reduced and the areas where we can argue that protecting migrant health rapid rise of antibiotic resistance slowed significantly does protect all individuals (and that if migrant health is with collective action, so meeting the second criterion. not protected that individuals will actually suffer pre- In both cases, of the environment and antibiotic re- ventable harm). It is these we will focus on. sistance, then the first and second criteria are met and We can begin with the global public good we have just the third, normative criteria, follows from these, in the considered, that of antibiotic efficacy. As a global public sense that if the first two are met, it would be unreason- good then antibiotic use by migrants should be managed able not to introduce policy which requires global public to protect antibiotic efficacy; as it should for all. Thus, goods to be systematically protected. Given this then, we have the first health good which should be given to the identification of a global public good will generate migrants, not because it is their right to have correct obligations on individuals, states and globally and cor- antibiotic treatment, but to protect the global public responding restrictions on individuals’ and states’ use good of antibiotic efficacy and thus to protect all. One and abuse of the good. However, recognizing that obli- reply to this suggestion might be that antibiotic efficacy gations follow if global public goods are to be protected would be better protected simply by refusing antibiotics is not the same as actually fulfilling—and if necessarily to migrants; however, experience in contexts where enforcing—such obligations. The harms of failing to access to antibiotics, especially for serious conditions, protect the environment and antibiotic efficacy are is reduced is that misuse is common. For instance, as known and therefore, effectively, such goods are recog- discussed in the previous section with regard to antibi- nized, at least in discourse, as primary goods. This is otic use in the developing world, in contexts where evidenced by a call for global action to protect these access is scarce and treatment is correspondingly goods; for instance, in the Kyoto protocol and the highly valuable, misuse, in the form of stock-piling Copenhagen accord as well as in subsequent discussions and failure to finish courses of treatment, is high. Such at Cancun, Durban, Doha and Warsaw; in the ongoing behaviour contributes significantly to the increase of work of the Intergovernmental Panel on Climate antibiotic resistance. Of course, if it were possible to Change (most recently its 2014 report); and in global absolutely deny all antibiotics to all migrants, then this initiatives by the WHO and national governments to protect the efficacy of antibiotics. These endeavours might contribute to protecting antibiotic efficacy, but this is unlikely in practical terms, and of course would be are, of course, inadequate and the needs—or rather preferences—of states and individuals continue to exceptionally harmful and require additional, probably coercive measures, to enforce. There are a number of trump these global public goods. But, although too often practice has not changed significantly, the primary other health goods which might well be offered to mi- nature of these goods is recognized. grants on these grounds and we will consider just two Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 HEALTH AND GLOBAL PUBLIC GOODS 125 more of these; first, the management of infectious dis- good model with focuses on threats to all and collective ease and second, herd immunity. action. This brings us to the second criterion; the global First then, managing infectious disease. In an age of public good cannot be protected without collective pandemics, this is a particularly important global health action (nor can the resulting harms be prevented with- good, as we are, at the time of writing, six months into out collective action). Here collective action could be a the worst Ebola epidemic in history. This health good large number of interventions including the enforcing of overlaps with antibiotic efficacy. The risks of infectious quarantine, the use of protective equipment and proto- disease rise as strains of antibiotic diseases rise and cols, measures to prevent movements of people and diseases become ever harder to treat and increasingly global access to health care professionals and to treat- life-threatening, such as multi-resistant TB, already ment. What is required is significant. In a recent com- mentioned above. But, there are other global health ment on the Ebola crisis, Lawrence Gostin offers a list of goods which follow from considering the significant what is needed to manage outbreaks of infectious dis- harms of infectious disease. ease including, ‘community, laboratory, public health, In terms of the first criterion, if the global public good and clinical personnel; infection-control equipment, supplied, and protocols; health worker training; labora- of being ‘as free as reasonably possible from infectious disease’ (or some similarly conceived good) is not pro- tory facilities with high biosafety capabilities; health tected, then all individuals (current and future) will be facilities, including safe isolation units; and communi- exposed to significant harm (and often will actually cation systems that can effectively deliver important suffer harm, harms preventable by the protection of public health information’ (Gostin, 2014: 1). To provide the good). The current Ebola pandemic shows the dif- such very necessary goods for all, a collective model is ficulty of containing such threats locally in areas lacking needed. One possibility, which Gostin discusses, is a health infrastructure and health professionals— Global Health Emergency workforce (which was pro- returning us to the debate at the beginning of the posed by the WHO in 2011 but which was never actua- paper regarding the global flow of health workers from lized) (Gostin, 2014). However, whatever approach is the developing world. Such issues are exacerbated by taken, clearly collective goods are in question and col- fear and misinformation, and as a result, healthcare lective models which can prioritize such goods are likely workers may fail to report for work or be stigmatized to be more effective than those which focus on if they do. But, and importantly for global public good individuals. claims, epidemics threaten not only the local area, but As the first two criteria are met, so the normative they are global threats (although predictably the burden criteria are invoked; that, this is a primary good which falls disproportionally on the poor). This said global should be protected if significant harms to all individuals concern is greatest when the developed world is threa- are to be prevented, and accordingly states and/or indi- tened. This is shown in the response, or lack of it, to viduals cannot be allowed to choose to neglect them. Ebola and was true in the SARS outbreak. This epidemic The immediate threat of infectious disease means that originated in China on 16 November 2002, but the protecting this good and preventing the attendant global response began on 12 March, when the WHO harms is often recognized as globally significant, and issued a global alert. This was after the first reported perhaps, this is an area in which the need to protect case in Canada on 5 March; and a few days post the migrants, as part of protecting all, is easy to recognize. alert, and on the same day that emergency travel This then, is another instance in which a public good advice was issued (15 March), three ill passengers were approach does result in providing some health goods for taken off a plane traveling from New York to Singapore migrants. Moreover, these goods might be extensive if (WHO, 2003a). While the greatest death toll occurred in one considers what requiring goods such as health in- China (5327) and the Hong Kong Special frastructure might entail. Administrative Region (1755), and the highest number Second then, and more briefly, herd immunity. of fatalities in the West reaching a fraction of that (250, Herd immunity is the emergent property of vaccination in Canada) (WHO, 2003b), the response was heightened by which all members of a given community are pro- with the spread of the disease to the West. tected from a specific vaccine-preventable disease by Given that disease is no respecter of borders and in- majority participation in vaccination programmes for fectious health threats are global, the first criterion is that disease (Anderson and May, 1985). When the met, the harms are indeed significant. The fact that the number of vaccinated persons falls below the herd im- developed world has shown willingness to respond when munity threshold, resurgence of the disease becomes threatened might be used to support a global public likely. Herd immunity is interesting as a global Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 126 WIDDOWS AND MARWAY public good because it relies on collective action of most to migrants on global public good grounds. Using this (not quite all), recognizing that some people—the im- approach denies there is conflict between the rights of munocompromised, the very young and very old—are one group of individuals and another group of individ- unable to participate in vaccination programmes for uals or between the global public good and individuals’ safety reasons. Like the environment and antibiotic rights. Only together can these goods be protected and the harms to individuals prevented. Conceptualizing it efficacy, herd immunity (broadly) fits the criteria out- lined above: first, if the public good is not protected, in this way simply removes the claim that the rights (or resources) are in competition on these issues. For any to then all individuals (current and future) will be exposed to significant harm; and second, the global public good be protected, all must be protected. Further, it provides a reason for those who do not support the rights of cannot be protected without collective action (nor can the resulting harms be prevented without collective migrants to grant such health goods to them. As a final comment it is of course the case that these action). From these then follows the normative require- ment, the third criteria, that this good should be prior- health goods are provided to migrants not because they are migrants but because they need to be provided to all itized and protected. Unlike antibiotic efficacy, a small number of non-compliant individuals will not destroy to protect public goods. This of course is the case, but this parallels many migrant rights arguments which use the global public good, but even with this caveat, the general case is the same, states must act to protect herd human rights to claim migrants’ rights; again, argu- ments based on what should be provided to all. This immunity and nearly all individuals must to do the alternative approach should be used separately and same. together with individual approaches to improve the This discussion—of antibiotic efficacy, of managing provision of health goods to migrants. infectious disease and of herd immunity—provides just a small number of examples of the types of health goods which migrants might be entitled to from a global public Acknowledgements good perspective. There are many more goods which could fall into the global public good category, or We would like to acknowlege the on-going support of which could be argued to contribute to the goods we the University of Birmingham. The argument about have outlined. For example, it might be possible to make global public goods is one which we have been develop- an argument that access to clean water, food and ad- ing both in health and more generally. For example, equate shelter as well as to basic health goods is a global exploring whether security can be reconceptualised as public good, as they vastly reduce the likelihood of the a global public is a possibity which we are exploring in spread of infectious disease and so contribute to pro- an ESRC funded project (Nuclear Ethics and Global tecting a global public good. Alternatively, perhaps, ar- Security: Reforming the Nuclear Non-Proliferation guments about access to contraception and abortion Regime) led by Professor Nicholas Wheeler, ICCS, might be made on global public goods grounds regard- University of Birmingham. ing population control. Cashing out the details of exactly what a global public goods account could con- tribute to the health of migrants would take further dis- Funding cussion. But, while it may not grant the full basket of health goods that a rights-based approach can, it will at Funding for gold access provided by the University of least give additional reasons for some health measures to Birmingham. be granted to all migrants and automatically. Notes Conclusion 1. Our recent work on non-individual ethical models is This brief discussion has shown that there are at least in genetics (Widdows, 2013) and in debates about some health goods which should be provided to mi- global ethics and health ethics more generally grants. Providing such goods is justified not on individ- (Widdows, 2007; Widdows and West-Oram, 2013). ual rights grounds but on the grounds of the protection 2. It is important to note that there is no human right of all. This provides a means for all to endorse these to free movement as such because, while all persons goods. At least some basic health goods (in the forms are permitted to leave a territory, sovereign states of both treatment and prevention) should be accorded continue to reserve the power to determine who Downloaded from https://academic.oup.com/phe/article/8/2/121/2362767 by DeepDyve user on 15 July 2022 HEALTH AND GLOBAL PUBLIC GOODS 127 can enter or stay in their territory. However, the 8. This paper builds on previous work done by 2003 International Convention on the Protection Widdows and Peter West-Oram (Widdows and West-Oram, 2013). of the Rights of All Migrant Workers and Members of Their Families seeks to ensure that 9. Since the introduction of antimicrobial medicines in the 30s (Cohen, 1992; Van Epps, 2006), the threat both illegal and legal migrants and their families posed by common, often lethal, and formerly un- are protected in basic and important ways in the treatable, diseases has been dramatically reduced host government’s policies (OHCHR, 2014). (Iseman, 1993; Reichman, 1997). 3. This language occurs in various media, public and 10. Cars et al. (2008), for instance, argue that there is a political discourse about immigrants. See, for ex- trend of antibiotic resistance and that while individ- ample, Ana (1999) and Travis and Malik (2013). ual stakeholders might be aware of the problem, 4. In 2010, The Economist reported that ‘Remittances collective action—from politicians, public health [in the Philippines] are now equivalent to 11% of workers and consumers—has been slow partly be- the economy’ (Banyan, 2010). In 2014, The World cause responsibility for taking relevant measures Bank reported that remittances to developing coun- does not lie with one body in particular. They tries are set to increase ‘7.8 per cent over the 2013 press for collective action from national and inter- volume of $404 billion, rising to $516 billion in national leaders, behavioural change from con- 2016’ (The World Bank, 2014). Moreover, they sumers and providers and bodies that are willing argue that remittances ‘remain a key source of ex- to develop antibacterial agents to respond to current ternal resource flows for developing countries, far public health needs. In this regard, they contend that exceeding official development assistance and more antibiotics must be regarded as a common good. stable than private debt and portfolio equity flows. 11. WHO state that they will continue their support of For many developing countries, remittances are an bodies linking the global environmental and important source of foreign exchange, surpassing health agendas by providing expertise and advice earnings from major exports, and covering a sub- (WHO, 2014). National government responses stantial portion of imports.’ (The World Bank, vary but a good range of measures is listed in envir- 2014). onmental assessments of European countries 5. We are not alone in introducing collective (European Environmental Agency, 2010). approaches into this debate; however, such inter- 12. Elsewhere we explore in more details whether herd ventions are relatively few. 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