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Making the case for human rights in global health education, research and policy.

The 2010 CPHA conference brought 533 researchers to Toronto to explore public and global health. Yet only four papers at this conference explicitly addressed human rights (two of which were presented by the author). Certainly there is a small and important cohort of Canadian scholarship on health and human rights. (1) Nonetheless, the low representation of human rights-based papers at the CPHA conference and indeed, within the pages of this journal, suggest that, beyond this cohort, human rights remain relatively marginal within the mainstream of Canadian public and global health research. (2) This marginality suggests a significant misalignment with the growing recognition globally of the inextricable relationship and distinctive contribution of human rights to public and global health. To the extent that this gap reflects unawareness or resistance to human rights, this comment attempts to 'make the case' for why human rights should be viewed as essential components of public and global health research, education and practice.

The relationship between human rights and public and global health

The idea that human rights and health are in an inextricable relationship was first advanced by Jonathan Mann, who argued that if human rights are not protected, health will suffer, and that if health programs, policies and research do not assess their impact on human rights, their health outcomes will suffer. (3) This thesis has undergirded a growing health and human rights scholarship aimed at exploring these interdependent relationships. (4) Human rights are now widely seen as critical to health-practitioner education across a range of disciplines, (5) with curricula adopted globally at schools of public health and medicine, law and policy studies. (6) While the paucity of rights at the CPHA conference may reflect unawareness of or opposition to human rights, (7) it may also reflect a belief that human rights are adequately subsumed within other ethical approaches to public and global health (a hypothesis supported by the strong focus on equity at the CPHA conference). While human rights and public health ethics may operate synergistically when it comes to health inequities, neither approach alone may be sufficient to achieve their goals. (8) It is therefore worthwhile both to recognize that human rights may reinforce claims made through public health ethics, and to specify the distinctive contributions of human rights and particularly the right to health toward achieving health equity (understood as systematic disparities in health judged to be avoidable by reasonable action, and therefore unfair). (8)

The normative and legal contribution of international human rights law on health

International human rights law focuses on protecting the inherent dignity and equal and inalienable rights of all people, with health viewed as integral to this vision. This body of law contributes a normative specificity to public and global health research, education and practice, and an analytical framework grounded in law. This contribution is apparent in General Comment 14, an extensive interpretation of the right to health, issued in 2000 by the UN Committee on Economic, Social and Cultural Rights. (9) The comment clarifies that individual entitlements under this right are not absolute, and can be limited by the availability of resources and progressive realization, implicitly requiring decision-makers to balance individual and collective needs when realizing this right. General Comment 14 identifies the essential elements of this right that all governments must provide irrespective of economic ability, including health care goods, facilities and services like essential drugs, clinics and health workers which must be: available in sufficient quantities; physically and economically accessible without discrimination; medically, ethically and culturally appropriate; and of good quality. These elements (known as the 'AAAQ framework') are increasingly recognized to assist in identifying health disparities and inequities, including by disaggregating (and ergo, identifying) the goods, facilities, services and populations that health policy and programs seeking equity should appropriately focus on. General Comment 14 also specifies state duties corresponding to essential and other elements of the right to health, including minimum core duties that states must comply with irrespective of resources, and duties to respect, protect and fulfil access to adequate, affordable health and health care more generally. These duties have important implications for how alternative political or commercial interests are balanced in health-related decision-making at all levels, particularly given the health and developmental impacts of globalization. (10)

Moreover, the duties imposed by the right to health often hold the force of binding law. Rights to medical care and health are extensively entrenched in international law: from the Universal Declaration on Human Rights, which recognizes medical care as a component of every person's right to a standard of living adequate for their health and well-being, to the International Covenant on Economic, Social and Cultural Rights, where state parties recognize everyone's right to the enjoyment of the highest attainable standard of health and agree to take a number of steps to achieve this. (11) Numerous other international and regional instruments protect rights to health, some of which have been ratified by a majority of states globally. (12)

Certainly ratification alone does not assure positive population health outcomes. (13) Nonetheless ratification produces important downstream legal consequences not reliant on state benevolence, particularly where active social movements can lodge claims with independent judiciaries whose orders are implemented by government. Indeed, the last decade has seen an exponential rise in right to health litigation globally, where social actors have sued governments on the basis of ratified international human rights treaties and domestic laws. (14) Notably, wherever legal action has been successful, countries have both ratified the International Covenant on Social, Economic and Cultural Rights and entrenched the right to health in domestic constitutions. (15) Certainly 'successful' cases that favour individual claims at the expense of collective interests may not be conducive to good public health. Yet, as the South African case on perinatal HIV transmission described in reference 15 attests, individual claims can benefit collective health interests and potentially assist in reducing systematic disparities in health care access. (16)

The practical contribution of rights: Access to AIDS medicines and rights-based approaches to health

While successful litigation, at its best, provides a fairly concrete indication of how human rights can effectively remediate isolated health inequities, it does not necessarily illustrate whether human rights can improve population health outcomes. I argue that this impact is evident in the AIDS treatment movement, where social movements used rights-based approaches to challenge refusals by the pharmaceutical industry, their host governments and international institutions, to advance access to affordable antiretroviral treatment in Sub-Saharan Africa (the vast epicentre of the global HIV/AIDS pandemic). These efforts not only achieved a dramatic global reduction in the price of AIDS drugs, but saw corporations, governments and international organizations shift towards advocating universal access to antiretroviral treatment. As a result, access to these drugs in Sub-Saharan Africa has increased from under 1 percent to over 40 percent in just six years. Moreover, declining mortality from AIDS is evident in Sub-Saharan Africa for the first time. The AIDS medicines experience therefore illustrates how rights-based methods can effectively challenge economic and political interests that may sustain gross health inequities, and in so doing, positively impact upon population health. The question remains whether this success can be replicated in other areas, including gross global disparities in maternal and infant mortality. Certainly the AIDS experience illustrates how social movements could use rights-based litigation, advocacy and social action to advance health equity. However, I argue that rights can work more systematically to advance health equity than the intermittent incidence and narrow ambit of litigation or even issue-based advocacy may permit.

Rights-based approaches which seek to operationalize the concepts and standards of human rights offer guidance to policy and programs seeking health equity. Rights-based approaches mandate the incorporation of core human rights principles like nondiscrimination, participation and accountability, demand a focus on the poor and marginalized and require explicit reference to international human rights instruments. Backman et al. suggest that just as the right to a fair trial has advanced a well-functioning court system, the right to health "can help to establish health systems that are reasonably equitable." (16) Accordingly, Backman and colleagues have identified the right to health features of health systems, proposing 72 indicators to guide researchers and policy-makers in achieving health equity, strengthening health systems and realizing the right to health. These indicators exemplify how human rights can pragmatically assist efforts to achieve health equity globally.

CONCLUSION

I do not suggest that human rights can single-handedly resolve widening health disparities, simply that there is increasingly strong recognition of their contribution as complementary powerful principles to drive the public and global health project. For the majority of Canadian public and global health researchers to ignore these contributions needlessly silos these disciplines and restricts potentially powerful tools available to them. This 'rights gap' places Canadian health research outside the growing vanguard exploring the contribution of human rights to public and global health-related work. Canadian academic and research institutions should take up their rightful place within health and human rights research, education and practice globally, including by, as a first step, ramping up human rights-oriented education for health professionals within Canadian universities as a core complement to other ethical approaches to public and global health.

Received: August 5, 2010

Accepted: December 20, 2010

REFERENCES

(1.) See for example, Schrecker S, Chapman AR, Labonte R, De Vogli R. Advancing health equity in the global marketplace: How human rights can help. Soc Sci Med 2010;71(8):1520; Orbinski J, Beyrer C, Singh S. Violations of human rights: Health practitioners as witnesses. Lancet2007;370(9588):698; Gruskin S, Mills EJ, Tarantola D. History, principles, and practice of health and human rights. Lancet 2007;370(4):449; and Denburg AE. Global child health ethics: Testing the limits of moral communities. Public Health Ethics 2010;3(3):239.

(2.) CJPH has published only two commentaries explicitly dealing with human rights: VanderPlaat M, Teles N. Mainstreaming social justice: Human rights and public health. Can J Public Health 2005;96(1):34; and Edwards NC, MacLean Davison C. Social justice and core competencies for public health: Improving the fit. Can J Public Health 2008;99(2):130.

(3.) Mann J, Gruskin S, Grodin MA, Annas GJ (Eds.), Health and Human Rights: A Reader. New York, NY: Routledge, 1999.

(4.) See for example, Gruskin S, Mills EJ, Tarantola D. History, principles, and practice of health and human rights. The Lancet 2007;370(4):449; Hunt P. The human right to the highest attainable standard of health: New opportunities and challenges. Transactions of the Royal Society of Tropical Medicine and Hygiene 2006;100(7):603; Farmer P. Challenging orthodoxies: The road ahead for health and human rights. Health and Human Rights 2008;10(1):1; and Beyrer C, Pizer HF (Eds.), Public Health and Human Rights: Evidence-Based Approaches. Baltimore, MD: Johns Hopkins University Press, 2007.

(5.) See for example, World Conference on Human Rights. The Vienna Declaration and Programme of Action. 1993, para. 82; World Medical Association. Resolution on the Inclusion of Medical Ethics and Human Rights in the Curriculum of Medical Schools Worldwide. 1999; International Council of Nurses. Position Statement on Nurses and Human Rights, 1998. Available at: http://www.icn.ch/pshum rights.html (Accessed July 15, 2010); Rodriguez-Garcia R, Akhter MN. Human rights: The foundation of public health practice. Am J Public Health 2000;90(5):693 (reflecting the position of the American Public Health Association); Consortium for Health and Human Rights. A Call to Action on the 50th Anniversary of the Universal Declaration of Human Rights. JAMA 1998;280(5):462.

(6.) See for example, Harvard School of Public Health. Health and Human Rights Database. Available at: http://www.hsph.harvard.edu/pihhr/resources_hhrdatabase.html (Accessed July 12, 2010).

(7.) Some opposition to human rights within public health circles may stem from the view that human rights as individualistic claims conflict with collective public health imperatives. While such conflicts can occur, international human rights law does permit certain rights (including health) to be limited in service of collective interests, and therefore for the most part conflict can be avoided or reduced (the case of routine testing for HIV as a case in point). See United Nations Economic and Social Council: Siracusa principles on the limitation and derogation provisions in the International Covenant on Civil and Political Rights Rep. No. U.N. Doc. E/CN.4/1985/4, Annex; 1985.

(8.) See Nixon S, Forman L. Exploring the synergies between human rights and public health ethics: A whole greater than the sum of its parts? BMC International Health and Human Rights 2008;8(2) doi:10.1186/1472-698X-8-2; World Health Organization Commission on the Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health: Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization, 2008. Available at: http://www.who.int/social_determinants/ final_report/en/ (Accessed July 15, 2010); and Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health 2003;57(4):254.

(9.) United Nations Committee on Economic, Social, and Cultural Rights. General comment no. 14: The right to the highest attainable standard of health. UN Doc E/C.12/2000/4, August 11, 2000.

(10.) See for example, Meier BM. Advancing health rights in a globalized world: Responding to globalization through a collective human right to public health. J Law Med Ethics 2007;35(4):545; Forman L. Trade rules, intellectual property and the right to health. Ethics Int Affairs 2007;21(3):337; and UN Special Rapporteur on the Right to Health. Human rights guidelines for pharmaceutical companies in relation to access to medicines, 2006. Available at: http://www.utoronto.ca/cphs/ resources.hunt%20index.htm (Accessed July 15, 2010).

(11.) Universal Declaration of Human Rights, GA Res. 217 (III), UN GAOR, 3d Sess. Supp. No. 13, UN Doc A/810 (1948) 71, and United Nations, International Covenant on Economic, Social, and Cultural Rights, 16 December 1966, 993 U.N.T.S. 3.

(12.) These include: United Nations, International Convention on the Rights of the Child, 20 November 1989, U.K.T.S. 1992 No. 44, 28 I.L.M. 1448 1989, article 24.1, United Nations, International Convention on the Elimination of Racial Discrimination, 21 December 1965, 660 U.N.T.S. 195, 5 I.L.M. 352 1966, article 5.e.iv, United Nations, Convention on the Elimination of All Forms of Discrimination Against Women, 18 December 1979, U.K.T.S. 1989 No. 2, 19 I.L.M. 33 1980, articles 11.1.f and 12; United Nations General Assembly, Convention on the Rights of Persons with Disabilities, 24 January 2007, A/RES/61/106.

(13.) See for example, Palmer A, Tomkinson J, Phung C, Ford N, Joffres M, Fernandes KA, et al. Does ratification of human-rights treaties have effects on population health? Lancet 2009;373(9679):1987. In contrast see Hsieh A, Amon JJ. Ratification of human rights treaties: The beginning not the end. Lancet 2009;374(9688):447.

(14.) See for example, Gloppen S. Litigation as a strategy to hold governments accountable for implementing the right to health. Health and Human Rights 2008;10(2):21; and Hogerzeil HV, Samson M, Casanovas JV, Rahmani-Ocora L. Is access to essential medicines as part of the fulfillment of the right to health enforceable through the courts? Lancet 2006;368(9532):305.

(15.) See for example, Minister of Health and another v.Treatment Action Campaign and others (2002) 5 S.Afr.L.R. 721 (S.Afr.Const.Ct), where a social group successfully claimed access to drugs to prevent perinatal transmission of HIV/AIDS on the basis of international and domestic human rights protections, with the court order ultimately assuring the establishment of a national perinatal program.

(16.) Backman G, Hunt P, Khosla R, Jaramilla-Strouss C, Mekuria Fikre B, Rumble C, et al. Health systems and the right to health: An assessment of 194 countries. Lancet 2008;372(9655):2047.

Lisa Forman, LLB, MA, SJD

Assistant Professor, Dalla Lana School of Public Health; Director, Comparative Program on Health and Society, Munk School of Global Affairs, University of Toronto, Toronto, ON

Correspondence: Dr. Lisa Forman, Assistant Professor, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON M5T 3M7, E-mail: lisa.forman@utoronto.ca.

Conflict of Interest: None to declare.
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Title Annotation:COMMENTARY
Author:Forman, Lisa
Publication:Canadian Journal of Public Health
Article Type:Report
Geographic Code:1CANA
Date:May 1, 2011
Words:2720
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