Those contributors who are more pessimistic about the role of law also raised a number of sub-themes to flesh out the nature of their pessimism. First is the theme that the law alone is simply not mighty enough to combat some of the enormous global health challenges. Huge pressures on domestic health care systems — aging populations, rising costs, new technologies, and bans on unethical practices — will generate a pipeline of medical tourists. Some call for more assiduous efforts on the part of governments to regulate and yet others are concerned that domestic efforts to protect health-related human rights (for example by limiting commercial surrogacy) merely offload the problem to other jurisdictions such as India. Some commentators contend that global problems — like medical tourism — can only be truly met through global solutions and call for the establishment of international law and global governance mechanisms. Yet this fall-back position itself draws pessimism, as others express doubt that international law and norms are progressive or even benign, and they point to concerns regarding the potential for international trade agreements to exacerbate rather than ameliorate existing vulnerabilities and inequities in access to health care unless greater policy cohesion between trade and health objectives can be achieved. Pessimists also point out that the usual tool of lawyers — litigation — may result in distortion of limited resources from the most vulnerable to those with wealth — a problem that is exacerbated by access to justice problems. Litigation may be counterproductive when it under- mines specific health policy decisions that have been developed in response to complex health systems challenges (e.g., funding decisions; or decisions reflecting a careful balancing of public and private funding mechanisms)