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close this bookThe Courier N 150 - March - April 1995 - Dossier: Refugees - Country Reports: The Bahamas, Guyana (EC Courier, 1995, 104 p.)
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Health and human rights

by Jonathan Mann

For the first time in history, it is now possible to bring together- in an explicit and comprehensive manner-two great ideas of our time. health and human rights For it is now clear that these two forms of discourse are languages with a common goal: promoting and protecting human well-being. Each represents a long process of seeking to describe the nature and forms of human suffering. and then of working to challenge the necessity of this suffering and to alleviate it.

Paradoxically, in the past, the activities and practice of health and of human rights were generally considered to be-or at least functioned as if they were - mutually conflictual, or even antagonistic. Within this context, health officials often perceived human rights activists as simply opposing necessary health measures, and creating barriers to their work; while human rights workers often considered health workers as professionals with a corporatist self-interest. Iacking social responsibility. These attitudes blocked awareness of the great overarching commonality of interest between health and human rights which we can now see

In recent years, an understanding of the wider complementary and even synergistic relationship between human rights and health has emerged through experience with the HIV/AIDS pandemic The history of the health/human rights connection in AIDS has three distinct phases The first period, early in the pandemic, was confrontational Facing this new health threat, health officials and politicians often pressed for urgent measures In a rather reflex manner, many simply reached back into the long traditions of communicable disease control, and proposed coercive approaches, including mandatory testing, and even involuntary quarantine or isolation of HIV infected people. Whether these strategies were actually effective in the past as health officials believed, such coercive approaches were hallowed by long use However, largely because the initial recognition of AIDS was among gay men in the USA and other industrialised countries, and given the context of gay liberation and achievements within the women's health movement, the coercive measures, proposed as necessary to protect public health. were opposed as violating human rights and dignity. This confrontation expressed clearly the traditional operational antagonism of the human rights arid health domains.

'Increased HIV vulnerability of marginalised groups reveals a fundamental connection between AIDS and human rights'

Rather quickly, practical experience with HlV-prevention led to a new phase in the relationship. For in cities and countries around the world, it became obvious that threats and coercion were counter-productive to public health For when those at highest risk of HIV infection became afraid of the consequences of being found to have contracted the virus, they avoided participating in the public health programmes designed to help them. It became clear to health officials that the effectiveness of their prevention programmes was being undermined by coercive, traditional public health approaches.

This led to the formulation, by the World Health Organisation, of a so-called 'public health rationale) for preventing discrimination against HlV-infected people. In a radical break with the past, the need to prevent this discrimination was incorporated explicitly and directly into the strategies for preventing the spread of viral illness. Thus, this second phase recognised and responded to the practical and public health consequences of discrimination; at this stage, discrimination was understood as a tragic and counter productive effect of the AIDS pandemic.

Yet, as the pandemic intensified and continued to spread inexorably around the world, and as the limits of the public health programmes to prevent HIV infection became more evident. a critical discovery was made which illuminated a much more fundamental connection between AIDS and human rights Reviewing the evolution of the epidemic in different countries-industrialised and developing -a societal risk factor for HIV infection became evident. It became clear that to the extent that people belonged to marginalised, stigmatised and discriminated-against populations, their vulnerability to becoming HlV-infected was increased For example, in the United States, the HIV epidemic had moved increasingly into the African-American and Latino communities, the inner cities and to women.

We have also seen that neglect and violation of women's rights and dignity create risk environments for women worldwide. Thus, in East Africa, women who are married and monogamous are increasingly becoming infected with HIV. They know about AIDS: condoms are available in the market place. Yet many, even if they know that their husband is HlV-infected, are not in a position to refuse unwanted or unprotected sexual intercourse-for fear of being beaten, without legal recourse, or divorced, which is equivalent to social and economic death. In short, their unequal rights, roles and status make them vulnerable to HIV and, for this reason, women's groups are seeking changes in laws governing divorce, marriage and inheritance - as anti-AIDS measures These steps towards social and legal equality will be much more effective in HIV prevention than just putting out more, or more colourful, posters, or trying to flood the country with condoms. It is in this context, considering not only AIDS, but also other sexually transmitted diseases, reproductive health and sexual violence, that it is clear that male-dominated societies are a threat to public health.

Thus, the failure to realise human rights and respect human dignity has now been recognised as a major cause - actually as the root cause of vulnerability to a global epidemic. This understanding resulted from concrete and practical experience, not from simply theoretical considerations, it was discovered in communities, not in governmental bureaucracies or universities. In this manner, field experience of global efforts against AIDS has led to a critical insight of importance beyond AIDS, for a careful analysis of the other major health problems of the world, including cancer, heart disease, injuries, individual and collective violence, and other infectious diseases, shows that they are all closely linked with the status of respect for human rights and dignity. Thus the struggle against a new global epidemic has led us to the threshold of a new understanding of health and society.

'Health is a state of physical, mental and social well-being'

The modern concept of health is expressed in the WHO's excellent definition: 'Health is a state of physical, mental and social well-being' In the past, health tended to be considered just in terms of illness. disability and death, and generally only the physical dimension was taken into account. Thus, the WHO definition was revolutionary.

Next, public health was defined es 'ensuring the conditions in which people can be healthy', or, to take both definitions together, public health seeks to ensure the conditions in which people can achieve physical, mental and social well-being Yet what are these essential conditions for health? While various classifications have been proposed, at least four dimensions must be considered: genetics, the physical environment, health care and the enormous range of issues generally covered by the convenient term 'social factors'. In contrast to the prevailing myth. medical care accounts for only a small part of health. Medical care is not, and should never be considered, synonymous with 'health'; while its importance is unchallenged, by far the most important determinants of health status are the socalled 'social factors'.

The next obvious question involves the specific nature of these societal determinants of health. Socio-economic status has been the best-studied potential explanatory factor and indeed, through out the world and over time, the rich and well-educated live longer and have less illness and disability than the poor. Yet the socio-economic status analysis has three major limitations. First. there is an increasing number of discordant observations. Why do married Canadian men and women live longer than their single fellow-citizens? Why does the health status of Mexican immigrants to Los Angeles decline as their socio-economic status rises? Why is the health of those Germans living in the former East Germany declining precipitously while their socio-economic status is improving 7 Why are obese women in the United States more likely to live in poverty and to have less education than non-obese women?

The second problem with the socio-economic explanation is related to the variables taken into account in the analysis. In most studies, socio-economic status is determined by considering a few simple issues; income, highest educational attainment. and job category. Yet the size of the gap between the rich and poor, the magnitude of societal inequality, is also relevant, and psychological characteristics such as hostility and depression are clearly important, as are other social features such as 'connect-edness' end integration into the social fabric.

The third problem with the traditional socio-economic status argument is that it leads to paralysis and inaction. For once the health professionals have identified poverty and low socio-economic status as the critical determinants of health status, what concrete and practical steps can they take? The overwhelming nature of the problem leads to professional disempowerment, and to the common situation in which health workers readily identify so-called 'social factors' as the most important determinants of health, yet their work does not directly address these root causes of ill-health, disability and premature death. Countless talks about health problems acknowledge the 'vital social, economic and other factors', yet these factors are rarely discussed!

The combination of this modern perspective of health as well being, the modern appreciation for the overwhelming importance of the societal determinants of health status, and the insights generated by experience with HIV/AIDS prevention and care, have catalysed a new and broader approach to the connection between health and modern human rights thought and action.

For does not the human rights movement seek to describe, in its language, the underlying and essential preconditions for human well being? Is not the vision of modern human rights based on the practical and concrete idea that well-being can be promoted and protected through specific measures addressing these underlying causes? Or, to put it negatively, in the absence of certain essential conditions such as education, non-discrimination, personal security, freedom of thought and an adequate standard of living or respect for inherent dignity of the person - human well-being is constrained, restricted and violated.

'Three relationships'

This fundamental correspondence and complementarity of purpose- using different languages, strategies and methods, Ieads us to consider three relationships between health and human rights. Each relationship has specific and concrete implications for action and for research, arid. at least as seen from the perspective of a public health professional, each raises important issues of professional roles arid responsibility Each is also the subject of current work at the Francois-Xavier Bagnoud Center for Health and Human Rights at the Harvard School of Public Health.

I he first relationship involves the potential impacts of health policies, programmes and practices on human rights and dignity. For while human rights recognises that public health protection may be an acceptable reason for restricting some rights, under some circumstances, it is also clear that health officials do not generally take human rights burdens explicitly into consideration as they develop their policies and programmes. In part. this failure is inadvertent-and due to simple ignorance of human rights concepts, norms or practices within the health professions; and in part it is related to the legacy of conflict between health and human rights. In contrast. we at the Center believe that modern public health professionals have, and can be expected to be held to. a dual standard: to protect public health and to protect human rights. To promote this process. we have developed an instrument-called the public health human rights impact assessment to help negotiate an optimal balance between public health goals and respect for human rights and dignity.

A second general relationship between human rights and health involves the health impacts of violations of human rights and dignity. This is an arena in which a great deal of work has already been done -by organisations such as Physicians for Human Rights, Amnesty International. Doctors of the World (Medecins du Monde) and Doctors without Borders (Medecins sans frontieres) - as health workers have applied medical and, to a lesser extent, public health skills to help document the existence and scope of human rights abuses. Most of this excellent work has focused on rights abuses in which the physical health dimension is immediately evident as in cases of torture, or imprisonment under inhumane conditions Yet the analysis must be developed further; we propose that violations of all human rights, as well as violations of dignity. have identifiable arid measurable impacts on health. For example, when governments promote marketing of tobacco products or alcohol without information about their health dangers, is not the right to information violated? Or what about the health consequences of violating the right to association found to be of such importance in discovering solutions to concrete health problems at the community level? Or the health impact of violating the right to rest and leisure, or to safe and favourable conditions of work. or to information about reproductive health services?

The third relationship is the most profound Based on reasons and experience already mentioned, we propose that the promotion and protection of health is inextricably linked with the promotion and protection of human rights. In other words, health promotion and protection require, and depend upon, the extent to which human rights are realised and dignity is respected. From this viewpoint, the human rights framework may provide a better one for analysis of health and for action to promote and protect health than the existing biomedical and pathology-based approaches which have been developed by the health professions. For the human rights framework addresses the requirements for physical, mental and social well-being, or, to put this in health language, it identifies and addresses the 'conditions in which people can be healthy' This analysis does not minimise the value of biomedically-derived and traditional public health approaches, but it directly addresses the distinction between the societal root causes and the surface manifestations of ill-health, disability and premature death. Thus, when the World Bank states that increasing the educational attainment of women in developing countries would be a powerful and effective intervention for improving health status, they are not abandoning the need for medical services. or safe water, or prevention of epidemic disease. Rather, the analysis recognises that medical clinics. water pumps and immunisation programmes will ultimately be most successful in promoting and protecting health when women have the education - itself a human right-which is also such a critical precondition for realising other human rights.

'Linkage with human rights offers promise of revitalisation'

From the viewpoint of public health, the linkage with human rights offers the promise of revitalisation. For public health has, in some ways, lost its bearings. While expanding enormously its scientific capacity to measure, public health has lost its clarity about why it is measuring, and to what purpose. By joining the expertise and knowledge of health to modern human rights thinking, we can learn how to attack simultaneously the root causes and the pathological expressions of these underlying societal conditions in terms of ill-health, disability and premature death. This could provide a strategic coherence to public health work which is currently lacking, and help discover ways to link, at a higher level of common interest, diverse health issues such as breast cancer, child abuse, violence, heart disease, sexually transmitted diseases, drug use and automobile injuries

To human rights, the linkage with health expertise and methodology can be enriching and useful in practice Health-based understandings of wellbeing may help broaden human rights thinking and practice. Documentation of the health impacts of rights abuses may expand the capacity for societal dialogue about these abuses and about their wider implications for society. This can be accomplished without seeking to justify human rights and dignity on health grounds, or indeed for any pragmatic purpose. In addition, the right to health can only be developed and made meaningful through dialogue between health and human rights disciplines.

Therefore, the challenge before us is to have the courage to transcend the disciplinary and historical walls which separate the domains of health and human rights Ignorance hurts us all; human rights workers must become literate about health. We must also be bold, because we are engaged in, and urging forward, the great work and hope of our time for advancing human well being in a sustainable world. Work in health and in human rights engages us in a profound challenge of personal and societal transformation - and one cannot proceed without the other.