Health
and Human Rights: An International Journal
Vol.
1, No. 1, Fall 1994
Inaugural Issue
-
Health
and Human Rights
Jonathan
M. Mann, MD, MPH; Lawrence Gostin, JD, LLD (hon.); Sofia
Gruskin, JD, MIA; Troyen Brennan, MD, JD, MPH; Zita Lazzarini,
JD, MPH; Harvey V. Fineberg, MD, PhD
Abstract
Health
and human rights are complementary approaches for defining and
advancing human well-being. This article presents a three-part
provisional framework for exploring potential collaboration
in health and human rights. The first relationship involves
the impact (positive and negative) of health policies, programs
and practices on human rights; the goal is to negotiate an optimal
balance between public health goals and human rights norms.
The second relationship posits that violations of rights have
important health effects, thusfar generally unrecognized, that
must be described and assessed. The third and most fundamental
relationship proposes that promotion and protection of health
are inextricably linked to promotion and protection of human
rights and dignity.The interdependence of health and human rights
has substantial conceptual and practical implications. Research,
teaching, field experience and advocacy are required to explore
this intersection.This work can help revitalize the health field,
contribute to enriching human rights thinking and practice,
and offer new avenues for understanding and advancing human
well-being in the modern world.
Dos
aproximaciones complementares de definir y avanzar el bienestar
de la humanidad son la salud y los derechos humanos. El próposito
de este artículo, cuya armazón está dividida
en tres partes, es de explorar la colaboración potencial
entre los campos de la salud y los derechos humanos. La primera
relacion abarca el impacto (positivo y negativo) de los politícos
de la salud y los programas y las prácticas de los derechos
humanos. El próposito es el encontrar el equilibrio optimo
entre las metas de la salud publica y las normas de los derechos
humanos. La segunda relacíon propone que las violaciones
de los derechos humanos tiene importante consequencionias para
la salud que hasta ahora no hay sido reconsidar y que deben de
ser deseritas y determinadas. La tercera relacíon, que
es la mas fundamental de todas, propone que la promoción
y la protección de la salud esta asociada de modo inextricable
a la promocion y proteccion de la dignidad y de los derechos humanos.
La dependencia recíproca que existe entre la salud y los
derechos humanos tiene importantes implicaciones conceptuales
y prácticas. Hoy en diá la investigación,
la enseñaza, la experiencia practica y la promocion son
requisitos necesario para pader explorar la intersección
entre la salud y los derechos humanos. Este trabajo a su vez intenta
revitalizar el campo de la salud, contribuir al enriquecimiento
de la teoría y la práctica de los derechos humanos,
y ofrecer nuevas vías para comprender y avanzar el bienestar
de la humanidad en al mundo moderno.
Les
droits de l'homme et à la santé sont des approches
complémentaires pour définir et avancer le bien
être de l'homme. Cet article présente un plan provisoire
en trois parties pour examiner la collaboration potentielle entre
le domaine des droits de l'homme et celui de la santé.
Le premier lien a trait à l'impact (positif et negatif)
des politiques, programmes, et pratiques de la santé publique
sur les droits de l'homme; le but est d'arriver à un équilibre
optimal entre les objectifs de la santé publique et les
normes des droits de l'homme. Par le deuxième lien, on
affirme que les violations des droits ont des effets sur la santé
publique, jusqu'à maintenant généralement
non reconnus, qui doivent être décrits et évalués.Par
le troisieme lien, aussi plus fondamental, on propose que la promotion
et la protection de la santé publique sont inextricablement
liées à la promotion et la protection des droits
de l'homme et de la dignité humaine. La dépendence
réciproque de la santé publique et des droits de
l'homme a des implications théoriques et pratiques. Les
recherches, l'enseignement, les experiences de terrains et les
plaidoyers sont necessaires pour explorer cette relation. Ce travail
peut ranimer le domaine de la sante publique, enrichir la pensée
et la pratique des droits de l'homme, et offrir de nouveaux moyens
pour comprendre et améliorer le bien être de l'homme
dans le monde moderne.
Health
and human rights have rarely been linked in an explicit manner.
With few exceptions, notably involving access to health care,
discussions about health have rarely included human rights considerations.
Similarly, except when obvious damage to health is the primary
manifestation of a human rights abuse, such as with torture, health
perspectives have been generally absent from human rights discourse.
Explanations
for the dearth of communication between the fields of health and
human rights include differing philosophical perspectives, vocabularies,
professional recruitment and training, societal roles, and methods
of work. In addition, modern concepts of both health and human
rights are complex and steadily evolving. On a practical level,
health workers may wonder about the applicability or utility ("added
value"), let alone necessity of incorporating human rights
perspectives into their work, and vice versa. In addition, despite
pioneering work seeking to bridge this gap in bioethics, 1,2
jurisprudence, 3 and public health law, 4,5
a history of conflictual relationships between medicine and law,
or between public health officials and civil liberty advocates,
may contribute to anxiety and doubt about the potential for mutually
beneficial collaboration.
Yet
health and human rights are both powerful, modern approaches to
defining and advancing human well-being. Attention to the intersection
of health and human rights may provide practical benefits to those
engaged in health or human rights work, may help reorient thinking
about major global health challenges, and may contribute to broadening
human rights thinking and practice. However, meaningful dialogue
about interactions between health and human rights requires a
common ground. To this end, following a brief overview of selected
features of modern health and human rights, this article proposes
a provisional, mutually accessible framework for structuring discussions
about research, promoting cross-disciplinary education, and exploring
the potential for health and human rights collaboration.
Modern
Concepts of Health
Modern
concepts of health derive from two related although quite different
disciplines: medicine and public health. While medicine generally
focuses on the health of an individual, public health emphasizes
the health of populations. To oversimplify, individual health
has been the concern of medical and other health care services,
generally in the context of physical (and, to a lesser extent,
mental) illness and disability. In contrast, public health has
been defined as, "...(ensuring) the conditions in which people
can be healthy."6 Thus, public health has a distinct
health-promoting goal and emphasizes prevention of disease, disability
and premature death.
Therefore,
from a public health perspective, while the availability of medical
and other health care constitutes one of the essential conditions
for health, it is not synonymous with "health." Only
a small fraction of the variance of health status among populations
can reasonably be attributed to health care; health care is necessary
but clearly not sufficient for health.7
The
most widely used modern definition of health was developed by
the World Health Organization (WHO): "Health is a state of
complete physical, mental and social well-being and not merely
the absence of disease or infirmity."8 Through
this definition, WHO has helped to move health thinking beyond
a limited, biomedical and pathology-based perspective to the more
positive domain of "well-being." Also, by explicitly
including the mental and social dimensions of well-being, WHO
radically expanded the scope of health, and by extension, the
roles and responsibilities of health professionals and their relationship
to the larger society.
The
WHO definition also highlights the importance of health promotion,
defined as "the process of enabling people to increase control
over, and to improve, their health." To do so, "an individual
or group must be able to identify and realize aspirations, to
satisfy needs, and to change or cope with the environment."9
The societal dimensions of this effort were emphasized in
the Declaration of Alma-Ata (1978), which described health as
a "...social goal whose realization requires the action of
many other social and economic sectors in addition to the health
sector."10
Thus,
the modern concept of health includes yet goes beyond health care
to embrace the broader societal dimensions and context of individual
and population well-being. Perhaps the most far-reaching statement
about the expanded scope of health is contained in the preamble
to the WHO Constitution, which declared that "the enjoyment
of the highest attainable standard of health is one of the fundamental
rights of every human being."11
Modern
Human Rights
The
modern idea of human rights is similarly vibrant, hopeful, ambitious
and complex. While there is a long history to human rights thinking,
agreement was reached that all people are "born free and
equal in dignity and rights"12 when the promotion
of human rights was identified as a principal purpose of the United
Nations in 1945.13 Then, in 1948, the Universal Declaration
of Human Rights was adopted as a universal or common standard
of achievement for all peoples and all nations.
The preamble to the Universal Declaration proposes that human
rights and dignity are self-evident, the "highest aspiration
of the common people," and "the foundation of freedom,
justice and peace." "Social progress and better standards
of life in larger freedom," including the prevention of "barbarous
acts which have outraged the conscience of mankind," and,
broadly speaking, individual and collective well-being, are considered
to depend upon the "promotion of universal respect for and
observance of human rights."
Several fundamental characteristics of modern human rights include:
they are rights of individuals; these rights inhere in individuals
because they are human; they apply to all people around the world;
and they principally involve the relationship between the state
and the individual. The specific rights which form the corpus
of human rights law are listed in several key documents: foremost
is the Universal Declaration of Human Rights (UDHR), which, along
with the United Nations Charter (UN Charter), the International
Covenant on Civil and Political Rights (ICCPR)and its Optional
Protocolsand the International Covenant on Economic, Social and
Cultural Rights (ICESCR), constitute what is often called the
"International Bill of Human Rights." The UDHR was drawn
up to give more specific definition to the rights and freedoms
referred to in the UN Charter. The ICCPR and the ICESCR further
elaborate the content set out in the UDHR, as well as setting
out the conditions in which states can permissibly restrict rights.
Although the UDHR is not a legally binding document, nations (states)
have endowed it with great legitimacy through their actions, including
its legal and political invocation at the national and international
level. For example, portions of the UDHR are cited in numerous
national constitutions, and governments often refer to the UDHR
when accusing other governments of violating human rights. The
Covenants are legally binding, but only on the states which have
become parties to them. Parties to the Covenants accept certain
procedures and responsibilities, including periodic submission
of reports on their compliance with the substantive provisions
of the texts.
Building upon this central core of documents, a large number of
additional declarations and conventions have been adopted at the
international and regional levels, focusing upon either specific
populations (such as the International Convention on the Elimination
of All Forms of Racial Discrimination, entry into force in 1969;
the Convention on the Elimination of All Forms of Discrimination
Against Women, 1981; the Convention on the Rights of the Child,
1989) or issues (such as the Convention Against Torture and Other
Cruel, Inhuman or Degrading Treatment or Punishment, entry into
force in 1987; the Declaration on the Elimination of all Forms
of Intolerance and of Discrimination Based on Religion or Belief,
1981).
Since 1948, the promotion and protection of human rights have
received increased attention from communities and nations around
the world. While there are few legal sanctions to compel states
to meet their human rights obligations, states are increasingly
monitored for their compliance with human rights norms by other
states, nongovernmental organizations, the media and private individuals.
The growing legitimacy of the human rights framework lies in the
increasing application of human rights standards by a steadily
widening range of actors in the world community. The awarding
of the Nobel Peace Prize for human rights work to Amnesty International
and to Ms. Rigoberta Menchu symbolizes this extraordinary level
of contemporary interest and concern with human rights.
Since the late 1940s, human rights advocacy and related challenges
have gradually extended the boundaries of the human rights movement
in four related ways. First, the initial advocacy focus on civil
and political rights and certain economic and social rights is
expanding to include concerns about the environment and global
socioeconomic development. For example, although the right to
a "social and international order in which (human rights)
can be fully realized" (UDHR, Article 28) invokes broad political
issues at the global level, attention to this core concept as
a right has only grown in recent years.
Second, while the grounding of human rights thinking and practice
in law (at national and international levels) remains fundamental,
wider social involvement and participation in human rights struggles
is increasingly broadening the language and uses of human rights
concepts.
Third, while human rights law primarily focuses on the relationship
between individuals and states, awareness is increasing that other
societal institutions and systems, such as transnational business,
may strongly influence the capacity for realization of rights,
yet they may elude state control. For example, exploitation of
natural resources by business interests may seriously harm rights
of local residents, yet the governmental capacity to protect human
rights may be extremely limited, or at best indirect, through
regulation of business practices and laws which offer the opportunity
for redress. In addition, certain individual acts, such as rape,
have not been a traditional concern of human rights law, except
when resulting from systematic state policy (as alleged in Bosnia).
However, it is increasingly evident that state policies impacting
on the status and role of women may contribute importantly, even
if indirectly, to a societal context which increases women's vulnerability
to rape, even though the actual act may be individual, not state-sponsored.
Finally, the twin challenges of human rights promotion (hopefully
preventing rights violations; analogous to health promotion to
prevent disease) and protection (emphasizing accountability and
redress for violations; analogous to medical care once disease
has occurred) have often been approached separately. Initially,
the United Nations system highlighted promotion of rights, and
the nongovernmental human rights movement tended to stress protection
of rights, often in response to horrific and systematic rights
violations. More recently, both intergovernmental and nongovernmental
agencies have recognized and responded to the fundamental interdependence
of rights promotion and protection.
In summary, despite tremendous controversy, especially regarding
the philosophical and cultural context of human rights as currently
defined, a vocabulary and set of human rights norms is increasingly
becoming part of community, national and global life.
A
Provisional Framework: Linkages Between Health and Human Rights
The goal of linking health and human rights is to contribute to
advancing human well-being beyond what could be achieved through
an isolated health- or human rights-based approach. This article
proposes a three-part framework for considering linkages between
health and human rights; all are inter-connected, and each has
substantial practical consequences. The first two are already
well documented, although requiring further elaboration, while
the third represents a central hypothesis calling for substantial
additional analysis and exploration.
First,
the impact (positive and negative) of health policies, programs
and practices on human rights will be considered. This linkage
will be illustrated by focusing on the use of state power in the
context of public health.
The
second relationship is based on the understanding that human rights
violations have health impacts. It is proposed that all rights
violations, particularly when severe, widespread and sustained,
engender important health effects, which must be recognized and
assessed. This process engages health expertise and methodologies
in helping to understand how well-being is affected by violations
of human rights.
The
third part of this framework is based on an overarching proposition:
that promotion and protection of human rights and promotion and
protection of health are fundamentally linked. Even more than
the first two proposed relationships, this intrinsic linkage has
strategic implications and potentially dramatic practical consequences
for work in each domain.
The
First Relationship: The Impact of Health Policies, Programs and
Practices on Human Rights
Around
the world, health care is provided through many diverse public
and private mechanisms. However, the responsibilities of public
health are carried out in large measure through policies and programs
promulgated, implemented and enforced by, or with support from,
the state. Therefore, this first linkage may be best explored
by considering the impact of public health policies, programs
and practices on human rights.
The
three central functions of public health include: assessing health
needs and problems; developing policies designed to address priority
health issues; and assuring programs to implement strategic health
goals.14 Potential benefits to and burdens on human
rights may occur in the pursuit of each of these major areas of
public health responsibility.
For
example, assessment involves collection of data on important health
problems in a population. However, data are not collected on all
possible health problems, nor does the selection of which issues
to assess occur in a societal vacuum. Thus, a state's failure
to recognize or acknowledge health problems that preferentially
affect a marginalized or stigmatized group may violate the right
to non-discrimination by leading to neglect of necessary services,
and in so doing, may adversely affect the realization of other
rights, including the right to "security in the event of...sickness
(or) disability..." (UDHR, Article 25), or to the "special
care and assistance" to which mothers and children are entitled
(UDHR, Article 25).
Once
decisions about which problems to assess have been made, the methodology
of data collection may create additional human rights burdens.
Collecting information from individuals, such as whether they
are infected with the human immunodeficiency virus (HIV), have
breast cancer, or are genetically predisposed to heart disease,
can clearly burden rights to security of person (associated with
the concept of informed consent) and of arbitrary interference
with privacy. In addition, the right of non-discrimination may
be threatened even by an apparently simple information-gathering
exercise. For example, a health survey conducted via telephone,
by excluding households without telephones (usually associated
with lower socioeconomic status), may result in a biased assessment,
which may in turn lead to policies or programs that fail to recognize
or meet needs of the entire population. Also, personal health
status or health behavior information (such as sexual orientation,
or history of drug use) has the potential for misuse by the state,
whether directly or if it is made available to others, resulting
in grievous harm to individuals and violations of many rights.
Thus, misuse of information about HIV infection status has led
to: restrictions of the right to work and to education; violations
of the right to marry and found a family; attacks upon honor and
reputation; limitations of freedom of movement; arbitrary detention
or exile; and even cruel, inhuman or degrading treatment.
The
second major task of public health is to develop policies to prevent
and control priority health problems. Important burdens on human
rights may arise in the policy-development process. For example,
if a government refuses to disclose the scientific basis of health
policy or permit debate on its merits, or in other ways refuses
to inform and involve the public in policy development, the rights
to "seek, receive and impart information and ideas...regardless
of frontiers" (UDHR, Article 19) and "to take part in
the government...directly or through freely chosen representatives"
(UDHR, Article 21) may be violated. Then, prioritization of health
issues may result in discrimination against individuals, as when
the major health problems of a population defined on the basis
of sex, race, religion or language are systematically given lower
priority (e.g., sickle cell disease in the United States, which
affects primarily the African-American population; or more globally,
maternal mortality, breast cancer and other health problems of
women).
The
third core function of public health, to assure services capable
of realizing policy goals, is also closely linked with the right
to non-discrimination. When health and social services do not
take logistic, financial, and socio-cultural barriers to their
access and enjoyment into account, intentional or unintentional
discrimination may readily occur. For example, in clinics for
maternal and child health, details such as hours of service, accessibility
via public transportation and availability of daycare may strongly
and adversely influence service utilization.15
It
is essential to recognize that in seeking to fulfill each of its
core functions and responsibilities, public health may burden
human rights. In the past, when restrictions on human rights were
recognized, they were often simply justified as necessary to protect
public health. Indeed, public health has a long tradition, anchored
in the history of infectious disease control, of limiting the
"rights of the few" for the "good of the many."
Thus, coercive measures such as mandatory testing and treatment,
quarantine, and isolation are considered basic measures of traditional
communicable disease control.16
The
principle that certain rights must be restricted in order to protect
the community is explicitly recognized in the International Bill
of Human Rights: limitations are considered permissible to "(secure)
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."(UDHR, Article
29). However, the permissible restriction of rights is bound in
several ways. First, certain rights (e.g., right to life, right
to be free from torture) are considered inviolable under any circumstances.
Restriction of other rights must be: in the interest of a legitimate
objective; determined by law; imposed in the least intrusive means
possible; not imposed arbitrarily; and strictly necessary in a
"democratic society" to achieve its purposes.
Unfortunately,
public health decisions to restrict human rights have frequently
been made in an uncritical, unsystematic and unscientific manner.
Therefore, the prevailing assumption that public health, as articulated
through specific policies and programs, is an unalloyed public
good that does not require consideration of human rights norms
must be challenged. For the present, it may be useful to adopt
the maxim that health policies and programs should be considered
discriminatory and burdensome on human rights until proven otherwise.
Yet
this approach raises three related and vital questions. First,
why should public health officials be concerned about burdening
human rights? Second, to what extent is respect for human rights
and dignity compatible with, or complementary to public health
goals? Finally, how can an optimal balance between public health
goals and human rights norms be negotiated?
Justifying
public health concern for human rights norms could be based on
the primary value of promoting societal respect for human rights
as well as on arguments of public health effectiveness. At least
to the extent that public health goals are not seriously compromised
by respect for human rights norms, public health, as a state function,
is obligated to respect human rights and dignity.
The
major argument for linking human rights and health promotion is
described below. However, it is also important to recognize that
contemporary thinking about optimal strategies for disease control
has evolved; efforts to confront the most serious global health
threats, including cancer, cardiovascular disease and other chronic
diseases, injuries, reproductive health, infectious diseases,
and individual and collective violence, increasingly emphasize
the role of personal behavior within a broad social context. Thus,
the traditional public health paradigm and strategies developed
for diseases such as smallpox, often involving coercive approaches
and activities which may have burdened human rights, are now understood
to be less relevant today. For example, WHO's strategy for preventing
spread of the human immunodeficiency virus (HIV) excludes classic
practices such as isolation and quarantine (except under truly
remarkable circumstances) and explicitly calls for supporting
and preventing discrimination against HIV-infected people.
The
idea that human rights and public health must inevitably conflict
is increasingly tempered with awareness of their complementarity.
Health policy-makers' and practitioners' lack of familiarity with
modern human rights concepts and core documents complicates efforts
to negotiate, in specific situations and different cultural contexts,
the optimal balance between public health objectives and human
rights norms. Similarly, human rights workers may choose not to
confront health policies or programs, either to avoid seeming
to under-value community health or due to uncertainty about how
and on what grounds to challenge public health officials. Recently,
in the context of HIV/AIDS, new approaches have been developed,
seeking to maximize realization of public health goals while simultaneously
protecting and promoting human rights.17 Yet HIV/AIDS
is not unique; efforts to harmonize health and human rights goals
are clearly possible in other areas. At present, an effort to
identify human rights burdens created by public health policies,
programs and practices, followed by negotiation towards an optimal
balance whenever public health and human rights goals appear to
conflict, is a necessary minimum. An approach to realizing health
objectives that simultaneously promotesor at least respects rights
and dignity is clearly desirable.
The
Second Relationship: Health Impacts Resulting from Violations
of Human Rights
Health
impacts are obvious and inherent in the popular understanding
of certain severe human rights violations, such as torture, imprisonment
under inhumane conditions, summary execution, and "disappearances."
For this reason, health experts concerned about human rights have
increasingly made their expertise available to help document such
abuses.18 Examples of this type of medical-human rights
collaboration include: exhumation of mass graves to examine allegations
of executions;18 examination of torture victims;20
and entry of health personnel into prisons to assess health status.21
However,
health impacts of rights violations go beyond these issues in
at least two ways. First, the duration and extent of health impacts
resulting from severe abuses of rights and dignity remain generally
under-appreciated. Torture, imprisonment under inhumane conditions,
or trauma associated with witnessing summary executions, torture,
rape or mistreatment of others have been shown to lead to severe,
probably life-long effects on physical, mental and social well-being.22
In addition, a more complete understanding of the negative health
effects of torture must also include its broad influence on mental
and social well-being; torture is often used as a political tool
to discourage people from meaningful participation in or resistance
to government.23
Second,
and beyond these serious problems, it is increasingly evident
that violations of many more, if not all, human rights have negative
effects on health. For example, the right to information may be
violated when cigarettes are marketed without governmental assurance
that information regarding the harmful health effects of tobacco
smoking will also be available. The health cost of this violation
can be quantified through measures of tobacco-related preventable
illness, disability and premature death, including excess cancers,
cardiovascular and respiratory disease. Other violations of the
right to information, with substantial health impacts, include
governmental withholding of valid scientific health information
about contraception or measures (e.g., condoms) to prevent infection
with a fatal virus (HIV).
As
another example, the enormous worldwide problem of occupation-related
disease, disability and death reflects violations of the right
to work under "just and favorable conditions" (UDHR,
Article 23). In this context, the World Bank's identification
of increased educational attainment for women as a critical intervention
for improving health status in developing countries powerfully
expresses the pervasive impact of rights realization (in this
case to education, and to non-discrimination on the basis of sex)
on population health status.24
A
related, yet even more complex problem involves the potential
health impact associated with violating individual and collective
dignity. The Universal Declaration of Human Rights considers dignity,
along with rights, to be inherent, inalienable and universal.
While important dignity-related health impacts may include such
problems as the poor health status of many indigenous peoples,
a coherent vocabulary and framework to characterize dignity and
different forms of dignity violations are lacking. A taxonomy
and an epidemiology of violations of dignity may uncover an enormous
field of previously suspected, yet thusfar unnamed and therefore
undocumented damage to physical, mental and social well-being.
Assessment
of rights violations' health impacts is in its infancy. Progress
will require: a more sophisticated capacity to document and assess
rights violations; the application of medical, social science
and public health methodologies to identify and assess effects
on physical, mental and social well-being; and research to establish
valid associations between rights violations and health impacts.
Identification
of health impacts associated with violations of rights and dignity
will benefit both health and human rights fields. Using rights
violations as an entry point for recognition of health problems
may help uncover previously unrecognized burdens on physical,
mental or social well-being. From a human rights perspective,
documentation of health impacts of rights violations may contribute
to increased societal awareness of the importance of human rights
promotion and protection.
The
Third Relationship: Health and Human RightsExploring an Inextricable
Linkage
The
proposal that promoting and protecting human rights is inextricably
linked to the challenge of promoting and protecting health derives
in part from recognition that health and human rights are complementary
approaches to the central problem of defining and advancing human
well-being. This fundamental connection leads beyond the single,
albeit broad mention of health in the UDHR (Article 25) and the
specific health-related responsibilities of states listed in Article
12 of the ICESCR, including: reducing stillbirth and infant mortality
and promoting healthy child development; improving environmental
and industrial hygiene; preventing, treating and controlling epidemic,
endemic, occupational and other diseases; and assurance of medical
care.
Modern
concepts of health recognize that underlying "conditions"
establish the foundation for realizing physical, mental and social
well-being. Given the importance of these conditions, it is remarkable
how little priority has been given within health research to their
precise identification and understanding of their modes of action,
relative importance, and possible interactions.
The
most widely accepted analysis focuses on socioeconomic status;
the positive relationship between higher socioeconomic status
and better health status is well documented.25 Yet
this analysis has at least three important limitations. First,
it cannot adequately account for a growing number of discordant
observations, such as: the increased longevity of married Canadian
men and women compared with their single (widowed, divorced, never
married) counterparts;26 health status differences
between minority and majority populations which persist even when
traditional measures of socioeconomic status are considered;27
or reports of differential marital, economic and educational outcomes
among obese, compared with non-obese women.28
A
second problem lies in the definition of poverty and its relationship
to health status. Clearly, poverty may have different health meanings;
for example, distinctions between the health-related meaning of
absolute poverty and relative poverty have been proposed. 29
A
third, practical difficulty is that the socioeconomic paradigm
creates an overwhelming challenge for which health workers are
neither trained nor equipped to deal. Therefore, the identification
of socioeconomic status as the "essential condition"
for good health paradoxically may encourage complacency, apathy
and even policy and programmatic paralysis.
However, alternative or supplementary approaches are emerging
about the nature of the "essential conditions" for health.
For example, the Ottawa Charter for Health Promotion (1986) went
beyond poverty to propose that, "the fundamental conditions
and resources for health are peace, shelter, education, food,
income, a stable eco-system, sustainable resources, social justice
and equity."9
Experience
with the global epidemic of HIV/AIDS suggests a further analytic
approach, using a rights analysis.30 For example, married,
monogamous women in East Africa have been documented to be infected
with HIV.31 Although these women know about HIV, and
condoms are accessible in the marketplace, their risk factor is
their inability to control their husbands' sexual behavior, or
to refuse unprotected or unwanted sexual intercourse. Refusal
may result in physical harm, or in divorce, the equivalent of
social and economic death for the woman. Therefore, women's vulnerability
to HIV is now recognized to be integrally connected with discrimination
and unequal rights, involving property, marriage, divorce and
inheritance. The success of condom promotion for HIV prevention
in this population is inherently limited in the absence of legal
and societal changes which, by promoting and protecting women's
rights, would strengthen their ability to negotiate sexual practice
and protect themselves from HIV infection.32
More
broadly, the evolving HIV/AIDS pandemic has shown a consistent
pattern through which discrimination, marginalization, stigmatization
and, more generally, a lack of respect for the human rights and
dignity of individuals and groups heightens their vulnerability
to becoming exposed to HIV. 33,34 In this regard, HIV/AIDS
may be illustrative of a more general phenomenon in which individual
and population vulnerability to disease, disability and premature
death is linked to the status of respect for human rights and
dignity.
Further
exploration of the conceptual and practical dimensions of this
relationship is required. For example, epidemiologically-identified
clusters of preventable disease, excess disability and premature
death could be analyzed to discover the specific limitations or
violations of human rights and dignity which are involved. Similarly,
a broad analysis of the human rights dimensions of major health
problems such as cancer, cardiovascular disease and injuries should
be developed. The hypothesis that promotion and protection of
rights and health are inextricably linked requires much creative
exploration and rigorous evaluation.
The
concept of an inextricable relationship between health and human
rights also has enormous potential practical consequences. For
example, health professionals could consider using the International
Bill of Human Rights as a coherent guide for assessing health
status of individuals or populations; the extent to which human
rights are realized may represent a better and more comprehensive
index of well-being than traditional health status indicators.
Health professionals would also have to consider their responsibility
not only to respect human rights in developing policies, programs
and practices, but to contribute actively from their position
as health workers to improving societal realization of rights.
Health workers have long acknowledged the societal roots of health
status; the human rights linkage may help health professionals
engage in specific and concrete ways with the full range of those
working to promote and protect human rights and dignity in each
society.
From
the perspective of human rights, health experts and expertise
may contribute usefully to societal recognition of the benefits
and costs associated with realizing, or failing to respect human
rights and dignity. This can be accomplished without seeking to
justify human rights and dignity on health grounds (or for any
pragmatic purposes). Rather, collaboration with health experts
can help give voice to the pervasive and serious impact on health
associated with lack of respect for rights and dignity. In addition,
the right to health can only be developed and made meaningful
through dialogue between health and human rights disciplines.
Finally, the importance of health as a pre-condition for the capacity
to realize and enjoy human rights and dignity must be appreciated.
For example, poor nutritional status of children can contribute
subtly yet importantly to limiting realization of the right to
education; in general, people who are healthy may be best equipped
to participate fully and benefit optimally from the protections
and opportunities inherent in the International Bill of Human
Rights.
Conclusion
Thus
far, different philosophical and historical roots, disciplinary
differences in language and approach, and practical barriers to
collaboration impede recognition of important linkages between
health and human rights. The mutually enriching combination of
research, education and field experience will advance understanding
and catalyze further action around human rights and health. Exploration
of the intersection of health and human rights may help revitalize
the health field as well as contribute to broadening human rights
thinking and practice. The health and human rights perspective
offers new avenues for understanding and advancing human well-being
in the modern world.
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About
the Authors
Jonathan
Mann is François-Xavier Bagnoud Professor of Health and
Human Rights and Professor of Epidemiology and International Health
at the Harvard School of Public Health.
Lawrence
Gostin is Professor of Law, Georgetown University Law Center and
Professor of Health Policy, Johns Hopkins School of Hygiene and
Public Health.
Sofia
Gruskin is Research Associate at the François-Xavier Bagnoud
Center for Health and Human Rights.
Troyen
Brennan is Professor of Law and Public Health at the Harvard School
of Public Health.
Zita
Lazzarini is a visiting lecturer in the Department of Health Policy
and Management at the Harvard School of Public Health. Harvey
Fineberg is Dean of the Harvard School of Public Health.
