Health and Human Rights 101 Timothy H. Holtz, MD, MPH Institute of Human Rights Emory University

-Preamble to the WHO Constitution “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being..." -Preamble to the WHO Constitution

What is Health? “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” WHO Definition of Health WHO as a UN related international body links health and human rights Declaration of Alma Ata, 1978 “Health…is a fundamental human right and that 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 sectors in addition to the health sector.” Commitment by WHO for “Health for All by the Year 2000”

Public Health lacks: Conceptual framework based on history How many lay people know what public health is or does? Vocabulary that is understandable Clarity of direction that is insightful System of ethics Biomedical ethics  Public health ethics

Human Rights has: Distinct values agreed upon around the world Codified in internationally recognized treaties Adopted by most countries, unlike few other rules of international engagement

An Alternative Definition Health is the condition in which human rights are fulfilled

Combining Health and Human Rights provides: Common language and framework to reference A junction on which to collaborate Opportunity for cross-disciplinary education A system of public health ethics

Right to Health What does it mean? Where does it come from? health  medical care  health care “Right to Health” = right to health protection = medical care + healthy conditions Where does it come from?

Right to Health Components Declaration of the right to health Prescription of standards aimed at meeting the health needs of specific groups Prescription of ways and means for implementing the right to health

Universal Declaration of Human Rights, Article 25.1 Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control. Non-binding declaration

International Covenant on Economic, Social, and Cultural Rights, (ICESCR) Article 12.1* The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. *Adopted 16 Dec 1966, entered into force 3 Jan 1976, but never ratified by the US

Right to Health in other International Documents Constitution of the World Health Organization (WHO) Convention on the Rights of the Child African Charter on Human and People’s Rights Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) Convention on the Elimination of All Forms of Racial Discrimination (CERD)

Right to Health in National Law 20 Constitutions in Western Hemisphere include language invoking a right to health “Right to Health” in 5 Constitutions “Right to Health Protection” in 8 others US Constitution/Bill of Rights does NOT include any mention of a right to health Argentina, Colombia, and Costa Rica do not

ICESCR, Article 12.2 The steps to be taken by the states parties to the present Covenant to achieve the full realization of this right shall include those necessary for: The provision for the reduction of the still-birth rate and of infant mortality and for the healthy development of the child; The improvement of all aspects of environmental and industrial hygiene; The prevention, treatment, and control of epidemic, endemic, occupational and other diseases; The creation of conditions which would assure to all medical service and medical attention in the event of sickness.

Essential aspects of primary health care approach (Alma Ata): Emphasis on preventive health (immunization/family planning) more than curative medicine Promotion of food supply and proper nutrition Basic sanitation and safe water supply Emphasis on maternal and child health Prevention and control of local endemic diseases Treatment of common diseases and injuries Provision of essential drugs Importance of health education High priority given to vulnerable groups Equal access to all at an affordable cost Importance of participation in planning and implementation

Contemporary expansion of Human Rights Initial focus on civil and political rights has expanded to include advocacy for the realization of economic and social rights, as well as concerns about the environment and consequences of global economic development on health. Wider societal involvement and participation in human rights struggles and discourse is broadening the language and uses of human rights concepts, based always on core fundamentals. Contemporary expansion of human rights #1 Focus for years was on political liberty, freedom of press, freedom from torture Now much more attention being paid to global immiseration that continues in developing countries, that 2 billion people on earth have trouble meeting their daily needs Social and economic rights US has always been at the forefront of advocacy for civil and political rights, and clearly lacking in support for social and economic rights (still has not ratified the ICESCR) Formerly known as first generation and second generation rights, but this dichotomy was product of Cold War, and is no longer useful. All rights in UDHR now seen as fundamental, interrelated. #2 Participation and growth in HR issues of groups such as AI, HRW, and plethora of smaller human rights organizations stressing both civil rights and economic rights, has expanded the usefulness of HR language. Each one of you grew up surrounded by HR language, now can’t get away from it. There was a time when this was not the case.

Contemporary expansion of Human Rights Increasing realization that non-state actors, such as societal institutions and transnational corporations, may strongly affect health status and influence the capacity for realization of rights, yet elude state control. Melding of approach-using human rights protection and promotion concurrently. Contemporary expansion of human rights #3 Area of my interest TNCs are now recognized to have long lasting and profound effects on the health of those who work for them, those who live around them, and those who buy their products Cases examples: Gas explosion of Union Carbide plant in Bhopal India, 1984 Royal Dutch-Shell Oil involvement in exploitation of oil rich lands in Niger river delta, and death of Ken Saro Wiwa at the hands of Nigerian military Hiring of death squads by British Petroleum in Columbia, to protect their refineries Destruction of environment in Ecuador by Texaco Sale of armaments to human rights abusing countries by US weapons manufacturers Exploitation of factory workers by US garment manufacturers ALSO – increasing use of rape as a crime of war, not envisioned by original formers or HR documents, matter of state policy (Bosnia) Becoming more evident that state policies impact the health of women in myriad of ways #4 Protection, emphasizes accountability and redress for violations Like medical treatment after disease occurs Promotion, emphasizes preventing human rights violations before they occur Like preventive medicine practitioners

Old Conceptual Model Well- Health Being Human Rights

New Conceptual Model Framework for Understanding Human Rights Health Human Rights Health New conceptual model Human Rights Health

Framework of Understanding RELATIONSHIP #1 Understand the impact, positive or negative, of health policies, programs, and practices on human rights. Maxim/challenge: All public health interventions and programs are potentially burdensome to human rights. Framework of understanding #1 Goal of linking human rights and health is to contribute to advancing human well-being beyond what can be achieved through an isolated medical approach, or human rights based approach. READ REL. #1 Then maxim

Health  Human Rights Three core functions of public health each can have human rights components: Assess health needs and problems, using both investigation, surveillance, and research Develop policies designed to address priority health issues Implement programs to achieve specific health goals, and monitor one’s progress Health and human rights relationship #1 Assessment includes collection of data: Failure to recognize or acknowledge health problems that preferentially affect a marginalized or stigmatized group could violate the right to non-discrimination, through leading to neglect of necessary services Ie migrant workers, documented or undocumented, results in lack of access to care Use of a telephone survey by definition excludes households without phones, which may lead to a biased assessment of community health needs PERSONAL EXP DORCHESTER To develop policies first implies prioritization: May result in discrimination of certain individuals or groups, such as intravenous drug users, or WOMEN Historical neglect at NIH of health care problems of women, ie breast cancer, including women in research on cardiovascular disease, etc. 3rd core function also related to right to non-discrimination, Such as ignoring needs of marginalized populations, poor, uninsured, migrant workers as well as rights concerning security of person and right to liberty CASE of small pox eradication Public health has long tradition, anchored in history of infectious disease control, of limiting the rights of the few for the good of the many 1st example from 18th century, when Robertson sued state of Mass when state refused to allow citizen of Mass to exempt his child from smallpox vaccine Basic public health measures such as mandatory testing and treatment of communicable disease, vaccination, quarantine, and isolation all have human rights aspects to them Principle that certain rights must be restricted in order to protect the community in general is recognized in Article 29 of the UDHR:

Restriction of rights Article 29, UDHR In the exercise of (his) rights and freedoms, everyone shall be subject only to such limitations as are determined by law solely for the purpose of securing due recognition and respect for the rights and freedoms of others and of meeting the just requirements of morality, public order and the general welfare in a democratic society. Health and human rights relationship #1 – impact of policies on human rights Restriction of rights for benefit of health of public Restriction of certain rights in order to protect the health of the community must have Legitimate goal Determined by law Imposed in the least intrusive way possible Not imposed arbitrarily Therefore, the assumption that public health is an unalloyed public good that does not require consideration of human rights norms, must be challenged. This is evident today, in the implementation of the polio eradication project of WHO. Lessons were learned with smallpox eradication, literature is large COERCED, FORCED VACCINATION OF POOR VILLAGERS IN INDIA, ETC. Also, discussions of reporting of names of HIV + individuals is only now becoming the norm, mainly because human rights concerns were brought up from the beginning. HIV has enormous amount of stigmata and discrimination potential associated with it, and still does. Classic practices of contact tracing, name reporting, quarantine were not done with HIV

Derogation of Rights The public good* can take precedence to: “secure due recognition and respect for the rights and freedoms of others; meet the just requirements of morality, public order and the general welfare, and in times of emergency when there are threats to the vital interests of the nation.” -ICCPR, Article 4 *Public health qualifies as one such public good.

The Siracusa Principles Provided for and carried out in accordance with the law; In the interest of a legitimate objective of general interest; Strictly necessary in a democratic society to achieve the objective; There are no less intrusive and restrictive means available to reach the same goal; and The restriction is not imposed arbitrarily UNECOSOC,1985

Framework of Understanding RELATIONSHIP #2 Understand the impact of human rights violations on human health. Maxim: Violations of all human rights, not just those explicitly describing health, have indirect and direct health impacts. Framework of understanding #2 READ #1 Then maxim

Human Rights  Health Obvious and inherent health impact of severe human rights violations Torture Imprisonment under inhumane conditions Summary execution without trial Disappearances (“dirty wars” of Central and South America in 1980s) Other – Unethical research practices Nazi medicine & US Tuskegee study (CDC) Health and human rights relationship #2 Health professionals concerned about human rights have made their expertise available to aid to document such abuses, and try to alleviate their long lasting effects Exhumation of mass graves Examination of torture survivors Medical care in prisons, assessment of health status in poor prisons Asylum interviews by health personnel and documentation of sequelae of torture Long lasting mental health needs of survivors of torture, refugees, etc. Example of torture/refugee survivor programs around the country SHOW SLIDES?

Human Rights  Health Direct and indirect health consequences of many other human rights violations UDHR Article 23-Violation of the right to work under just and favorable work conditions, and right to join trade unions. UDHR Article 26-Violation of right to education. UDHR Article 1-Violation of right to collective dignity. UDHR Article 25.2-Violation of women’s rights. Health and human rights relationship #2 cont’d Direct and indirect health consequences of many other human rights violations Right to work under favorable work conditions: there are more than 120 million work related injuries each year worldwide, and 220,000 deaths on the job 160 million cases of occupational disease from physical, chemical, and biologic hazards also, only 10% of workers in developing countries have access to occupational health services Right to join trade unions? we take that for granted in 1997 there were 4210 reported cases of harassment of workers for attempting to organize including 299 murders of trade unionists for attempting to realize their rights in Colombia alone, there were 160 murders Education: Role of literacy and health Improving the literacy of mother’s has dramatic effect on health of whole family, namely the children Also, we know that poor nutritional status of children can lead to poor educational performance, thus the poor realization of the right to education Dignity: Case that Virginia Leary illustrates for us in her reading – the ruling of the Inter-American Commission on Human Rights in 1985, against the Brazilian government on behalf of the Yanomami Indians, that Brazil had violated the American Declaration of the Rights and Duties of Man – for the government failing to preserve the health of this vulnerable group. Though dignity not in the ruling, it was used in implicit in the foundation of the argument against the government to illustrate that Brazil had not respected the collective dignity of this population at risk.

Human Rights  Health Discrimination Health policies Compromise of medical independence Lack of access to medical care Violent conflict affecting civilian populations Indiscriminate harm from weapons Unethical research practices Dangerous environmental exposures Health and human rights relationship #2 cont’d Direct and indirect health consequences of many other human rights violations Right to work under favorable work conditions: there are more than 120 million work related injuries each year worldwide, and 220,000 deaths on the job 160 million cases of occupational disease from physical, chemical, and biologic hazards also, only 10% of workers in developing countries have access to occupational health services Right to join trade unions? we take that for granted in 1997 there were 4210 reported cases of harassment of workers for attempting to organize including 299 murders of trade unionists for attempting to realize their rights in Colombia alone, there were 160 murders Education: Role of literacy and health Improving the literacy of mother’s has dramatic effect on health of whole family, namely the children Also, we know that poor nutritional status of children can lead to poor educational performance, thus the poor realization of the right to education Dignity: Case that Virginia Leary illustrates for us in her reading – the ruling of the Inter-American Commission on Human Rights in 1985, against the Brazilian government on behalf of the Yanomami Indians, that Brazil had violated the American Declaration of the Rights and Duties of Man – for the government failing to preserve the health of this vulnerable group. Though dignity not in the ruling, it was used in implicit in the foundation of the argument against the government to illustrate that Brazil had not respected the collective dignity of this population at risk.

Framework of Understanding RELATIONSHIP #3 Understand that the promotion and protection of human rights and the promotion and protection of health are fundamentally linked. Maxim: This inextricable connection is at the core of human health. It has strategic implications and practical consequences. Framework of understanding #3 READ RELATIONSHIP Then maxim

Health  Human Rights What are the underlying conditions needed for health? Complementary approach and interdependence of all rights in advancing human well-being Dignity and health Health and human rights relationship #3 One can ask yourself, what are the underlying conditions for well-being? Is it just the fact of whether you smoke, or don’t exercise, or have a family history of heart disease? How much of a role does socioeconomic status play? Interdependence of all rights for health, not just the mention of a right to health in the UDHR, ICESCR Dignity: example of global pandemic of HIV Clear now, almost 20 years into the pandemic, that vulnerability to HIV is now recognized to be integrally connected to the loss of dignity, and more specifically, each act of discrimination, marginalization, and stigmatization can increase the risk of becoming exposed to the virus, and once ill, determine the trajectory and outcome of one’s treatment. Very true to the experience of HIV+ individuals in the US But it is no more true than the experience of HIV in places like Haiti and sub saharan Africa, where the pandemic marches apace, affecting black more than white, women more than men, poor more than rich

Health   Human Rights Individual and population vulnerability to disease, disability, and the ultimate outcome once ill (death) is inextricably linked, and in fact dependent upon, respect for human rights and dignity. Health and human rights relationship #3 conclusion

One final concept… Rights (provided by States) are often accompanied by duties (of individuals)

So, now that you know what your rights are… You have a duty to participate as a civil actor to guarantee that your (and others) rights are respected, protected and fulfilled.

What you can do? Join ISAHHR and Human Rights Week Join HRI-L listserv Contact Tarun Gulrajani at tgulraj@sph.emory.edu Join HRI-L listserv Send a message to listserv@listserv.emory.edu Subscribe hri-l firstname lastname Take “IH 508;Health and Human Rights” Volunteer for conference April 14-16 2005

Where can you learn more? UDHR and other HR documents http://www.un.org/rights Twenty-five Human Rights Documents Center for the Study of Human Rights 25 Questions and Answers on Health and Human Rights http://www.who.int/hhr/information/25_questions_hhr.pdf Health and Human Rights; A Reader Edited by Jonathan Mann, Sofia Gruskin, Michael Grodin, George Annas

-Louise Arbour, United Nations High Commissioner for Human Rights “Human rights are our common heritage and their realization depends on the contributions that each and every one of us is willing to make, individually and collectively, now and in the future." -Louise Arbour, United Nations High Commissioner for Human Rights