Monday, March 27, 2023
processing....
It has been nearly 10 years since I attended my first American Public Health Association (APHA) Annual Meeting as a student of public health. That conference was being held in Indianapolis, Indiana, and along with a group of my fellow students I piled into a car for the road trip from Atlanta. The energy at the conference was electric, and one of the most anticipated sessions of the week was a presentation on health and human rights by Jonathan Mann. At the presentation the room was tightly packed, even though the session took place after 8:30 pm.
Jonathan Mann's presentation was like music to my ears. He talked about the relationships between health and human rights -- how rights violations affected health and how health programs and policies could affect human rights, as well as about the synergistic relationship between the two.[1] I was hooked.
Tragically, Jonathan Mann was lost to the world the following year, 1998, in the crash of Swissair flight 111.[2] Many in the public health community mourned his death and were inspired by his work. The theme of the 2006 annual APHA meeting, Public Health and Human Rights, is evidence of his lasting impact.
In 1997, Mann wrote, "...we are creating, participating in and witnessing an extraordinary moment in social history -- the emergence of a health and human rights movement -- at the intersection and at the time of two enormous paradigm shifts."[3] He was correct. Tremendous progress has been made in developing the fields of public health and human rights as individual disciplines and, thanks to his pioneering work, as a new subdiscipline in and of itself. The ensuring years have also brought increases in research, teaching, and publications related to health and human rights.[4]
In fact, preliminary results of a recent survey of US schools of medicine and public health showed that 57% of schools of public health and 34% of schools of medicine offer health and human rights training as a part of the curriculum.[5] This is a significant increase from a study conducted in 2000, which found rates of 23% and 2% in schools of public health and medicine, respectively.[6] Whether the results of the most recent study represent reality or wishful thinking on the part of those responding to the survey remains to be seen. But the fact that 35% of those who are not currently offering health and human rights training would like to do so in the future signifies part of the paradigm shift to which Mann alluded.[5]
However, even if all schools of medicine, public health, and nursing offered training in health and human rights, the work that Jonathan Mann inspired is far from complete. We remain at a critical juncture, with the dual challenges of the global public health crisis and the continuing gross violations of human rights.
The world today is facing a global public health crisis. The pandemic of AIDS claims 3 million lives per year; more than 40 million people are now infected with HIV, and approximately 5 million new infections occur each year.[7] Newly emerging threats such as extreme multidrug-resistant tuberculosis (XDR-TB) also continue to require time and resources.[8] Lest it appear to those in the United States that the majority of crisis is happening "out there," it is important to recall that in 2005 more than 46 million Americans were without health insurance.[9] The United States is the only developed nation in the world that does not offer, as a bare minimum, universal health insurance.
The natural disaster of Hurricane Katrina in 2005 tested the US public health emergency management systems, with the failure of these systems exposing the "unnatural" disasters of race and class-based disparities that still exist.[10] Beyond the US borders, natural disasters such as the tsunami in Southeast Asia and the devastating earthquake in Pakistan also contributed to the global health crises.[11] Additionally, the man-made conflict in Iraq has produced over 655,000 deaths among Iraqis and the loss of troops. Excessive mortality and morbidity produced by conflicts taking place in Afghanistan, Lebanon, and elsewhere also have contributed.[12]
At the same moment that the world faces disease, disparities, and disaster, both natural and man-made, there is a lack of the most important factor for addressing these challenges: public health professionals.[13] The World Health Organization (WHO) estimated that globally there are 59 million health workers, but an additional 4 million are needed.[14] Healthcare workers must be distributed equitably within and between countries if the huge health obstacles currently before us are to be addressed successfully.
One model for addressing the worldwide shortage of healthcare professionals comes from an unlikely source: Cuba. As a country with few economic resources, in part due to the US blockade, Cuba has long valued the principles of community-based, preventive, and universal healthcare which provide the basis of its successful public health system.[15] Today, more than 25,000 Cuban physicians provide training and direct service outside of their own country in places such as Venezuela, Honduras, The Gambia, and South Africa.[16] The challenge facing these public health professionals, and all of us, is to provide health as a right. The traditional human rights tactic of "naming and shaming" is being exercised in an unexpected way. Cuba has demonstrated better health outcomes than the United States on several important measures.[17] If they can do it, why can't we?
The United States has long been seen as a beacon in the field of human rights. Former first lady Eleanor Roosevelt played an instrumental role in the drafting of the 1948 Universal Declaration of Human Rights, which served as the foundation for modern human rights and included a multiplicity of rights including civil, cultural, economic, political and social.[18] Unfortunately, the United States has, of late, shown disregard, if not outright contempt, for traditional human rights mechanisms. Regrettably, we have not been alone, as many other nation states also failed to live up to their obligations under international human rights law through either direct violation of rights or failure to protect and fulfill the rights of citizens.
Immediately after the end of World War II, the world community was galvanized to ensure that the atrocities of genocide, conflict, and persecution were never repeated. The Universal Declaration of Human Rights and its legally binding daughters, the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights, were intended to provide guarantees for the protection of human rights and fundamental freedoms for all peoples.[19] Over the past 60 years additional human rights treaties adopted have included those focused on the elimination of discrimination on the basis of race or sex, and the protection of vulnerable populations such as refugees and children.
Today's short-attention-span world seems to have forgotten the important task that Mrs. Roosevelt and her colleagues charged us with: the promotion of peace and the protection of human rights. Between 1990 and 2001, 57 conflicts took place in 45 locations across the globe.[20] All but 3 of these conflicts were civil wars demonstrating the ongoing need for a democratic, representative government that respects rights of its citizens.
Likewise, the world has watched idly as the conflict in Darfur has taken the dubious honor of being the first genocide of the 21st century. Not to be outdone, the conflict in the Democratic Republic of the Congo has claimed more than 3.9 million civilians since 1998.[21] In Uganda, upwards of 30,000 children commute nightly in order to avoid abduction into the ongoing conflict there.[22] Combatants and civilians involved in the recent conflicts in Iraq and Afghanistan face the possibility of torture, in spite of the existence of the Geneva Conventions and the Convention Against Torture and Other Forms of Cruel, Inhuman or Degrading Treatment or Punishment.[23]
Acute and chronic conflicts such as these result in fear and displacement; it is estimated that there are at least 12 million refugees and 20-25 million internally displaced persons worldwide.[20] Individually, genocide, torture, and displacement represent violations of human rights. Equally important, however, are the violations of the right to health as a result of conflict, which include death and disability at one extreme and the destruction of public health infrastructure and services at the other.
Taken in totality, this disregard for international human rights norms and standards epitomizes the very catastrophe from which our predecessors tried to shield us. In the past decade, we have lost many leaders in health and human rights, including Jonathan Mann, and more recently, the first Special Rapporteur on the Right to Education, Katarina Tomasevski. Many of these were at the forefront in viewing economic, social and cultural rights as equal to civil and political rights.[24] It is a continuing responsibility to ensure that their work was not in vain.
Bleak as the outlook is, given the global public health and human rights situation, it is imperative to continue to seek solutions. Just as the global public health crisis and the gross violations of human rights are intertwined, so are the potential solutions to these disasters. I believe that 3 things are necessary to enable the field of health and human rights to continue to move forward while simultaneously confronting existing challenges: leadership, creativity, and optimism.
The 2 most important international organizations dealing with health and human rights are both at the beginning of a new era in terms of leadership. After the untimely death of Dr. Lee Jong-wook earlier this year, Dr. Margaret Chan of China assumed the position of Director General at the world's most important health body, the WHO.[25,26] Similarly, after concluding his second term as Secretary General of the United Nations at the end of this year, Kofi Annan steps down from his post, clearing the way for the new Secretary, General Ban Ki-moon. Together, Director General Chan and Secretary General Ki-moon will provide guidance to those interested in addressing health and human rights issues. Additionally, the United Nations has appointed a Special Rapporteur on the Right to Health, Paul Hunt. In turn, he adopted 3 broad objectives in undertaking this work.
In addition to leadership at the highest levels, we must also look for leadership within our own ranks. In the 1997 article by Jonathan Mann,[3] he asked, "If not now, when?" Nine years later, the related question is, "If not us, who?"
Fortunately, there is no longer a need to argue that health and human rights are connected. The challenge now is to translate health and human rights theory into practice. The third objective specified by the Special Rapporteur on Health is also a mandate for those working in public health to identify clearly the ways in which rights-based approaches are incorporated directly and indirectly into public health work. This is necessary for clarifying the value added by such rights-based approaches to health. Additionally, how is it that human rights-based approaches aid in the improvement of health policies, programs, and outcomes?
CARE USA has demonstrated some promising programmatic examples toward achieving this kind of clarification. CARE utilizes a 3-pronged approach in its efforts to address poverty: embracing rights-based approaches, forging partnerships, and empowering women.[28] The organization has gradually moved from ameliorative approaches to poverty alleviation to rights-based approaches which examine the structural causes of poverty with the ultimate end goal of poverty elimination.[29] Already these new approaches have had demonstrable effects, including a 10-fold increase in condom use among sex workers in Bangladesh and a 50% reduction in maternal mortality in parts of Peru.[28]
CARE has embraced rights-based approaches not only because it is a morally justified position to take and the belief there is a legal right to health, but also because thus far it has shown efficacy within CARE's poverty elimination programming. Those working in the field of public health may likewise choose to creatively apply the rights framework and rights-based approaches to further an understanding of how and what these approaches add to public health programming.
Finally, a requisite characteristic needed by those working in both public health and human rights is optimism. Optimism is necessary in large part due to the abysmal situations previously described. However, Pollyanna naiveté must not cloud such optimism. When addressing the challenges posed by the global public health and human rights crises, optimism must be joined with a critical view of the structural causes of the challenges. We must stand against inequities that exist as a result of unjust power structures.
Through the use of leadership skills, creativity, and optimism, coupled with an eye towards correcting unjust power structures and eliminating inequities through rights-based approaches, a clear pathway can be paved through the intersection of health and human rights in order to move further towards the realization of the right to health and other human rights envisioned by Jonathan Mann. We do so because, as expressed by Martin Luther King Jr, "the arc of justice is long, but it bends towards justice."[30]
