Category Archives: CH188: The Right to Health

CH188: Framework Convention on Global Health and its historical roots

This past Thursday, we had the third session for CH188: The Right to Health: Problems, Perspectives, and Progress and we focused on 1) readings that laid out the foundational texts that undergird the right to health (the Constitution of the WHO, Universal Declaration of Human Rights, Convention on the Rights of the Child, International Covenant on Economic, Social, and Cultural Rights, etc.), 2) we heard from guest lecturer Eric Friedman, JD who discussed the current work to more formally codify the right to health through the Framework Convention for Global Health (more here, too), and 3) we began a discussion about the ethical reasoning that underpins all of global health thinking and work and the notion of the right to health. It was a busy session and probably a bit too much to try to cover in a three hour seminar, but we powered through and I think it will provide, once again, a useful foundation as we begin to dive into some of the problems that delay our progress towards the right to health.

Eric Friedman skyped with CH188 and shared his view of the opportunity for renewed global governance for the right to health.

Eric Friedman skyped with CH188 and shared his view of the opportunity for renewed global governance for the right to health.

Linking to the last session’s discussion of the history of the global health project, we discussed the historically-rooted documents that to some extent define and provide the structure for arguments and action for the right to health. A couple things stand out to me upon re-reading these documents. First, it’s pretty clear from an international governance that a right to the “highest attainable standard of health” is to be protected across the board. The right to health exists. Second, its important to understand the the historical, cultural, and geopolitical context in which these documents were created. Finally, understanding that history, and the ethical roots of the documents could give us insights for ways to move forward collective work to enable their wider adoption and greater effectiveness.

The Right to Health in International Law

Summary of the right to health through the lens of the International Covenant on Economic, Social, and Cultural Rights. 1

What’s lacking is 1) accountability to these goals and mechanisms of holding individual states accountable for violations of protection for the right to health, 2) a commitment to progressive financing mechanisms to help poor countries move forwards progressive realization, and 3) the grassroots movement of people who acknowledge their right to health and who are organized enough to demand that right through their state actors and through broader international action.

I just finished reading Nitsan Chorev’s fantastic analysis of the World Health Organization2  and it’s strategic transformation during two distinct historical periods: the 1970s and 1980s, and the  1990’s and 2000’s. Her analysis, taken with Salmaan Keshavjee’s historical and ethnographic treatment of neoliberalism, construct a useful lens through which to see the changing power of human rights documents and language. Specifically, she looks at how the the WHO adapts strategically to exogenous pressures from states, private actors, and the changing geopolitical / and economic structures.

The 1970s-80s were largely shaped by the political power of the G77 — the block of the poorest countries in the world, many newly independent from their colonizers — and their ability to utilize the one-country, one-vote procedural process within the WHO to exert significant political power towards expansion of primary care and the push (led by Halfdan Mahler) of “health for all by the year 2000.” It was this balance of power within the WHO that allowed the primary care and health for all movements to gain traction and lead to the meeting at Alma Ata. It was during this period that many of the international human rights documents were drafted and when the right to health as an international legal principle gained the most ground.

But, the progressive political block of the G77 during the 1970s and 80s provoked a significant backlash from the wealthiest and most powerful countries in the world, whose action was shaped largely along the lines of the Cold War. As Keshavjee discussed, elite economists in the US and elsewhere were terrified about the potential for a re-emergence of totalitarianism and saw the expansion of Communism and Socialism throughout the G77 as a major threat to liberalism, liberty, and freedom. Hence, the rise of dogmatic neoliberal logic.

The political and financing environment of the 1990s and 00s for the WHO were very different. Understanding that the U.S. and the U.K. could apply other pressure than votes, they began withholding regularly scheduled dues and fees payments to the WHO. They gradually made more and more of the WHO budget focused on discretionary or dedicated budget line items, rather than general expenses. Additionally, the Gates Foundation and other large private philanthropies took a larger role in financing global health including funding the WHO. This precarious and narrow funding meant that the WHO was highly vulnerable to the pressures of states and organizations deeply entrenched in neoliberal logic. The WHO, which had lost stature due to the failure of malaria eradication efforts in the 1960s, had to adapt or grow increasingly marginalized in the global governance of health.

The WHO strategically adapted by transforming neoliberal logic to (to some extent) serve their purposes. Gro Harlem Brundtland, then Secretary-General of the WHO, sought to enlist economists in the effort to demonstrate how targeted, “cost effective” investments made in the health sector could be powerful drivers of economic growth for low and middle income countries. Cost effectiveness became a way of “rationalizing” spending on health services for the poor and created a technical framework by which the WHO could continue to serve as a powerful technical expert to countries around the world, thus staying relevant.

“The prominent role of the World Health Assembly, and therefore of member states, in the process of decision making has secured the dominance of geopolitical logic in the global health agenda. Especially in the first few decades of the WHO’s history, the Cold War division between East and West directly shaped international health priorities (Litsios 1997, Manela 2010). Following decolonization, the World Health Organization, along with the rest of the UN system, was greatly affected by the demands of the newly independent countries of the Global South for a New International Economic Order. In the mid-1980s, in turn, the NIEO logic was replaced with a U.S.-led neoliberal agenda, best expressed in what has become known as the “Washington Consensus” (Williamson 1990). For UN specialized agencies, including the WHO, each period was characterized by the emergence of a distinct global ideational regime and by exogenous pressures to follow that regime. An overview of the policies formulated by the WHO staff and leadership and adopted by the executive and the assembly illustrates, however, that these policies did not faithfully echo the call for a New International Order in the 1970s nor the neoliberal principles of the 1990s.”

  • Chorev, Nitsan (2012-05-01). The World Health Organization between North and South (p. 5). Cornell University Press. Kindle Edition.

The Framework Convention on Global Health (FCGH) is a modern attempt to once again move the balance of power towards the right to health. Eric Friedman gave a great presentation outlining the growing movement towards a convention, modeled after the Framework Convention on Tobacco Control.

See his slides here.

In hist view, the FCGH couple help address key gaps in financing, work to curb the power of non-health sectors, address problems with health worker migration and “brain drain”, and address health disparities within countries. It could accomplish this by leveraging the power of law (powerful norms, facilitation of collective action, and binding responsibilities to support local advocacy), taking advantage of a globalized world in which nation-states should not be sole unit of analysis, and learning from past experience (FCGTC).

There is much, much more to say on the topic of a Framework Convention for Global Health, but suffice it to say, there is stark opposition to such an idea. See the piece from the Health and Human Rights Journal on “the dark side of the FCGH.” I’m hoping to do another post soon diving in to the debate and potential future of global governance in global health.


Reading and Class Notes:

Grodin et al Chapter 2:
  • Direct human rights abuses continue: Abu-Ghraib, botched executions, torture, etc.
  • Subtle human rights abuses like lack of health systems, discrimination, etc
  • Brief history:
    • Nuremberg Trials — since then interest in health and human rights have grown.
    • Since HIV in the 1980s, health / human rights have had parallel but distinct tracks.
    • Jonathan Mann and the HIV treatment movement was the first global effort to link health and human rights explicitly.
    • Since the AIDS treatment movement, almost all development agencies and UN programs must acknowledge rights in their health work. Even some governments are building legislation / incorporating into their constitutions.
      • Yet, lots of work yet to do and many gaps to be filled.
    • WTHO constitution: one of the best sources of “the right to health.”
  • The idea of health as a human right as a subject is fairly new.
  • Advocacy and bearing witness:
    • Complacency of governments in their response to HIV: activists demanded and pushed for action. Result was dramatically reduced cost of HIV medications
    • A key dilemma: sustainable action, should it be connected to documentation and denouncements of human rights violations? How would that limit the ability to deliver the services that people need / jeopardize the safety of their workers?
  • Rights in Delivery of Care and Programming:
    • Examining laws and policies under which programs are being run
    • Systematically integrating core human rights principles such as participation
    • Focusing on key elements of the right to health.
  • Concerns for the future:
    • Government roles / responsibilities are increasingly being relegated to non-state actors (NGOs corporations, etc): accountability poorly defined inadequate monitoring.
    • Ways forward:
      • need to educate staff and engage them in conversations about right to health.
Lecture Notes:
–> Send class information on the TPP.
Consequentialist / Nonconsequentialist Logitcs + Ethics
  • Rightness / wrongness based on the consequences / outcomes of actions
    • Consequentialist: Utilitarianism is a function of this: action to take is to produce the greatest good for the greatest number. The end is more important than the means.
    • Nonconsequentialist: rightness / wrongness are due to the content of the actions. The means matter more than the ends. Actions can be right or wrong. Libertarianism, contractarianism: No policy that causes compensated harm is allowed.
  • FCGH: what are the values that are underlying this? What are the values and ethics?
    • What constraints will it place on non-state actors?
    • What effects will it have on the SDGs? 17 SDGs
  • Objective <–> Subjective
  • Radical Change <–> Status Quo
  1. http://www.who.int/hhr/Economic_social_cultural.pdf
  2.  The World Health Organization Between North and South. Ithaca: Cornell University Press. (http://www.amazon.com/World-Health-Organization-between-North/dp/0801450659/ref=sr_1_1?ie=UTF8&qid=1454782336&sr=8-1&keywords=world+health+organization+between+north+and+south)

CH188: Second session – social theory, history, and neoliberalism

Yesterday, we had the second session for CH188: The Right to Health – Problems, Perspectives, and Progress.  We covered a broad overview of the recent history of the the global health project and discussed a toolkit of social theories that we’ll use throughout the course to analyze and try to understand progress and challenges in the social movement for the right to health.

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Dr. Salmaan Keshavjee discusses the history of neoliberalism’s infiltration of global health logic.

We were also very fortunate to have Dr. Salmaan Keshavjee, professor of global health and social medicine at Harvard Medical School deliver a guest lecture on the history of neoliberalism as a set of economic, political, and moral ideas that have shaped global governance systems writ large and have had very specific (and devastating) effects on health care systems for poor people around the world.

See his slides here. 

Dr. Keshavjee made a compelling and sweeping argument about historically rooted  political and moral battle of ideas about the role of the state and the relationship between citizen, market, state, and rights. In order to understand neoliberalism, we first need to understand the roots of the cannon of Western liberal thought: Locke, Mill, Smith. In particular, he focused on Adam Smith who, while believing in the importance of free markets, also believed that states must intervene in the face of market failures, in education, health care, social services, and other types of publicly-valuable capital investments that private actors would not be willing to make. If Adam Smith saw a vibrant democratic state–countered in power by organized guilds, corporations, and democratically engaged citizens–that created the space for a vibrant free and productive economy, then neoliberal thinkers saw it in exactly opposite terms: a completely unfettered economy is the source of free and open democratic society. In other words, the elimination of government intervention equates to greater liberty.
“The central values of civilization are in danger…. The position of the individual and the voluntary group are progressively undermined by extensions of arbitrary power…The group holds that these developments have been fostered …. by a decline of belief in private property and the competitive market; for without the diffused power and initiative associated with these institutions it is difficult to imagine a society in which freedom may be effectively preserved.”
—Statement of Aims, The Mont Pèlerin Society, April 8, 1947

Dr. Keshavjee then went through a detailed historical account of how a group of neoliberal intellectuals (Hayek, Friedman, Mises) developed a very sophisticated strategy in the war of ideas in the wake of World War II. Playing off of fear of the rise of totalitarianism, the rise of the Soviet Union and the expansion of Communism, and the expansive New Deal politics in the United States, they situated economists in major universities, created new think tanks and policy research divisions, published papers and books, and found ways to ensure that their ideas diffused through nodes of symbolic power producers. This was a very Bourdeusian strategy of amassing symbolic capital via “anointing institutions” in order to alter the shape of the field of practice of the global economy. They weren’t just playing a game of politics; they were creating an entirely new set of rules for the game of the political economy.

This ontological revolution — that democracy and liberty come from unfettered economic systems and economic growth, rather than vice versa — was important in shaping of the transnational bureaucracies in the second half of the 20th century, especially the World Bank, the International Monetary Fund, and the World Health Organization.

Dr. Keshavjee ended his talk with a specific case contained in his book, “Blind Spot: How Neoliberalism Infiltrated Global Health“, an ethnography of the revolving drug fund in Badakhshan, Tajikistan. He described this region, between Afghanistan and China that became deeply impoverished after fall of the Soviet Union. It was also the site of an ideological contest between the East and the West due to its geopolitically strategic location. He witnessed how a great organization, the Aga Kahn Foundation (AKF), came to implement a program focused on the development of a “revolving drug fund” — essentially implementing user fees and charging patients to purchase drugs. The originally proposed title for the book was something like, “Charging starving people for medicine” (because that was literally what was happening), but the editors thought it sounded too harsh. What is interesting in his account is how powerfully the history of neoliberalism came to bear on the lives and the bodies of the people in this far-flung region of the world.

After Dr. Keshajvee’s lecture, we had a great conversation about a toolkit of social theories that we will continue to revisit as we encounter more global health challenges and opportunities in the right to health movement. Specifically, we discussed:
  • Peter Berger and Thomas Luckman: The Social Construction of Reality
  • Robert Merton: Unanticipated consequences of purposive social action
  • Max Weber: Power and authority, bureaucracies
  • Michel Foucault: Biopower and surveillance
  • Arthur Kleinman and Paul Farmer: Social suffering and structural violence
As we go forth over the coming weeks in our work to try to understand some of the biggest challenges facing the realization of the comprehensive right to health, we will constantly revisit this history and these social theories.

Dr. Salmaan Keshavjee Guest Lecture:

Liberalism (17th – 18th century):
  • John Locke:
  • Stewart Mill
  • Adam Smith
  • Importance of liberty and about equality
John Maynard Keynes
  • An assault on free market capitalism; need some intervention and investment from the state
  • There can be market failures; market responds to fear and short term gain
  • Society needs to have a broader and longer vision
  • Also needs to be a provider of social services; also involved in the fiscal cycle
  • Welfare state economics
Neoliberalism:
  • A response to Keynsianism
  • Hayek and Freedman: University of Chicago
  • The iron cage, bureaucracy, the result of the more state: the artibrary dictates of government bureaucrats over rational ideas of the individual. A response to Weber — a solution to Weber’s iron cage of rationality
  • Rise of fascism in Austra; Stalin; rise of the New Deal; the fear of liberalism and progressivism and this is a response to that.
  • Fear of the rise of totalitarianism.

Free political system would yield a free economic system; neoliberalism flipped it: free economics drives free political system.

Reading Notes:

Reimagining Global Health – Chapter 1: A biosocial approach to global health
  • Biosocial analysis: global health is not yet a discipline, but a collection of problems. It requires an interdisciplinary approach. But, there is an opportunity to transform global health into a coherent discipline.
  • Roots of limited health care in poor and marginalized community but be historically deep and geographically broad: a biosocial approach is necessary.
  • Health disparities and the burden of disease:
    • Relationship between GDP and health — domestic and national aggregate and mask local inequities.
  • Collection of disciplines that make up global health create systematic blind spots that prevent us from seeing roots of certain health disparities and problems. That’s why we need a fully biosocial approach to properly build the field of global health.
  • Global health vs international health — an important, and historically rooted distinction. Pathogens do not recognize borders, and international health has a very specific and important set of historical roots, located in the history of colonialism.
Reimagining Global Health – Chapter 2: Unpacking global health – theory and critique
  • “toolkit” of social theories relevant to global health work.
  • Global health often characterized by action — getting stuff done. Most practitioners have little patience for social theory or critical reflection on the work.
  • Historical roots of schism between theory and practice: Marx, racist anthropologists.
  • Social scientists and theorists seek to “interpret the meaning of social action.”
  • Biosocial analysis and the sociology of knowledge:
    • Peter Berger and Thomas Luckman: The Social Construction of Reality:
      • institutionalization: “reciprocal typifications of habitualized action by types of actors” leads to the objectification of that habitualized action as an institution.
      • Assumptions and accidents become historicized into truths, and knowledge is created.
      • One must understand the social organization that permits the definers to do the defining. Must move from he abstract “what?” to the socially concrete, “says who?”
      • All knowledge in society, in order to be legitimated, is socially constructed through a historical / social process.
      • Diagnostic and Statistical Manual of Mental Illness: DSM, a good example of social construction of knowledge in medicine. DSM in 1970s claimed homosexuality was a mental disease. Medicalization of grieving into clinical depression requiring pharmaceutical intervention is an example of medicalization of illness experience.
      • Important to differentiate between: illness, disease, and sickness. Illness is subjective experience, disease is reinterpretation by medical experts, sickness is a pathology at a population level.
    • Robert Merton: Unanticipated consequences of purposive social action:
      • Purposive action involves motives, and therefor, choices amongst alternatives and must also have a goal and a process.
        • Knowledge assymmetry
        • rigidity of habit
        • imperious immediacy of interest
    • Weber: Power and authority
      • Traditional authority
      • Charismatic authority
      • Rational-legal authority —> derived from bureaucracy
      • Weber predicted that institutions / bureaucracies would become the most important structures governing our society.
      • Sometimes though, create ‘iron cage of rationality’ —> difficult to reform or destroy.
    • Foucault: Biopower
      • explains how biological and medical data are used by institutions of the modern world to define, count, and divide, “discipline” populations
    • Social suffering and structural violence:
      • forms of structural violence that constitute inequity
      • what political, economic, and institutional power do to people.
Reimagining Global Health – Chapter 3: Colonial medicine and its legacies
  • Sometimes it seems like the groundswell of global health is “new” — but global pandemics are not new nor are socialized attempts to control them.
  • The modern field of global health has its roots in colonial medicine and “international health”
  • Global health and global empire:
    • Notions of global health certainly informed the desire to build the aqueducts of Rome.
    • No accident that the redefinition of public health and biomedicine as scientific profession coincided with the moment at which European power started to build empires.
    • History of colonial medicine shows that the sites of imperial occupation often served as laboratories for medical strategies later taken up by colonizers
    • History is ripe with examples of colonial projects that harmed the health of colonized people
    • Colonizers interpreted differences in infectious disease mortality as providential signs that “savage” bodies were inferior and weaker compared to Europeans
    • Colonial medicine was not primarily geared towards beneficial action for the colonized, it was primarily a tool to keep white colonizers alive in service of extractive efforts —> links between “global health” and “global security”
      • Led to the widespread (and still used) term “tropical medicine”
      • Used to reify the idea that black bodies were “hardier” in tropical climates and used to rationalize slavery / exploitation / racism.
    • Concern over poor, sick distant lands and local wealthy ones continues to animate our discussions of biosecurity —> see Ebola / SARS.
    • History of tropical medicine, in part, explains why the term “global health” tends to mean health in other places than the US / Europe. Also a source of reification of difference and double standards.
    • The new paradigm of etiology — shifting locus of disease from the “native” to the organism — should have reformed global health, but it did not.
      • The “healthy carrier” became the locus of control — “Typhoid Mary”
      • Tropical Medicine far from removed radicalized language in global health — it enabled it
  • Missionary Medicine
    • linked to spreading Christianity —> for many in colonized nations, this was their sole source of contact with biomedicine.
    • Colonial medicine focused on populations, medical missions focused on individuals
      • reforming individual souls — personal illness, personal hygiene, personal sin.
  • Global health, global commerce, and the foundations of international health bureaucracies
    • Cholera shows how rise of transnational and continental commerce drives the need for new modes of public and global health intervention
      • OIHP: The Office International d’Hygiene Publique, one of the earliest permeant public health bureaucracies, attempted to contain and prevent the spread of cholera
      • John Snow: first to use epidemiological techniques to understand and demonstrate the etiology of cholera
      • Creation of the Panama Canal: caused the development of Pan-American Health Organization (PAHO), which remains an important player in the global health field today.
        • In many ways a demonstration of Max Weber’s prediction that bureaucracies would come to be the most important forms of organization in society.
  • Health, development, and the legacies of colonialism:
    • Political realities of inequality (post-colonialism) post-war (WW1 and WW2) became reorganized around the concept / language of “development” with practices send deeply rooted in colonial history
    • Limited resources drives “socialization for scarcity”
    • By 1948 the WHO was formed and the first World Health Assembly had been convened: cholera in Egypt demonstrated its power as a convening, coordinating, and technical assistance body
      • This set it up for a much more ambitious project: Malaria eradication
        • Focus on vector control rather than microbial control / treatment: socialization drives “either / or debate”
        • People had a strong belief in the power of technological innovation as a driver of human improvement: DDT as a way of killing mosquitos
        • Donor preferences for narrow, top-down strategies for stopping disease.
        • WHO abandoned the program in 1969 — it had failed
        • Ignored the biosocial fact that malaria biology is deeply embedded within the social fabric of farming and other practices.
      • Smallpox Eradication
        • WHO started the program in 1967 as the malaria program was starting to wind down.
        • Was successful because of better management, also because of an easier biology / life cycle in which to intervene
Reimagining Global Health – Chapter 4: Health for all? Competing theories and geopolitics
  • The notion that all people deserve access to health care was gained support in the 1978 international conference in Alma-Ata, Kazakhstan; but it was soon to be eclipsed by neoliberalism: a different kind of idealism that placed its hopes in the market to efficiently deliver services to the poor.
  • This history offers insight into the evolution and action of key global health bureaucracies:
    • WHO
    • United Nations Childrens Fund (UNICEF)
    • International Monetary Fund (IMF)
    • World Bank (WB)
  • Alma-Ata and the primary care movement —> ascendance of structural adjustment —> UNICEF’s selective primary care —> emergence of the WB as key player
  • 1978: Alma-Ata and “health for all by the year 2000″
    • Divergent economic and political ideologies of the Cold War shaped the public health discourse of the 1970s
    • Vertical programs a major focus: attempt at Malaria eradication and smallpox eradication campaigns by WHO: seeking out “magic bullets”
    • Chinese “barefoot doctor” model — example of “horizontal” primary care focus.
    • Halfdan Mahler: forceful leader in global health and one of the cheerleaders of the primary care movement
    • Alma-Ata Declaration:
      • Introduces the idea of “appropriate technology”
      • Critique of “medical elitism”: lambasts top-down delivery
      • Frames health as a mechanism for social and economic development
    • Bold goals failed for several reasons:
      • It did not specify who would pay for these scale-ups and service delivery.
      • Early 1980s brought the sovereign debt crisis that left many poor countries unable to pay and dried up foreign aid.
      • Emergence of an alternative health agenda: selective primary care.
  • Selective Primary Care: an interim agenda
    • Months after Alma-Ata, group of policy makers met in Bellagio, Italy to discuss future.
    • Selective Primary Care became the idea that emerged as an interim strategy
      • High return on each dollar spent
      • Focused on a narrow set of “cost-effective” interventions termed “GOBI”
        • Growth Monitoring
        • Oral rehydration therapy
        • Breastfeeding
        • Immunizations
      • UNICEF + Jim Grant (the director) became one of the biggest champions of SPHC
    • Shifting ideologies in Washington, the WB, began focusing increasingly on market-oriented solutions to health care provision.
  • Rise of neoliberalism:
    • Reagan + Thatcher: deep belief and faith in “free markets”: neoliberalism: Friedrich von Hayek and Milton Freedman
    • Appointed free market purists to head IMF / WB: became known as the “Washington Consensus”
      • “Stabilize, liberalize, privatize”
      • Structural adjustment policies tied to World Bank + IMF loans to low income countries
      • Forced cuts to public spending on social services (health care + education) in order to meet payment schedules and stipulations imposed by WB loans
  • Commodification of Health
    • Diminished role for the public sector in provision of health services led to increase in private sector and “market” oriented solutions.
    • This was a major erosion in the notion of a “state protected right to health”
  • Bamako Initiative: 1987
    • African Ministers of Health embraced WB’s policies for financing and instituted “user fees” to meet funding gaps
    • Poor people had no money to spend on health care services so no reduction in “overconsumption”
    • Did not raise the 15 – 20% of budget revenue they had anticipated.
    • Example of unintended consequences of purposive social action
    • Berger + Luckman: social construction of reality — technical knowledge of finance supplanted other forms of knowledge (social, political, medical, etc)
  • Rise of UNICEF
    • “Child Survival Revolution: Jim Grant as forceful advocate of GOBI-FFF
    • “national immunization days”
    • Critiqued as a narrow cheap interventions services that prevented the growth of stronger delivery systems
    • Arguments of cost effectiveness and efficiency were not challenges again by values of rights, equity, and justice until the rise of HIV and the HIV treatment movement led by ACT UP
  • 1993 WB World Development Report: Investing in Health
    • Codification of “cost effectiveness”
    • Invention and recommendation of the DALY as the means of measuring and deciding what to do in health
  • Redefining the possible: HIV and a social movement for treatment
L. London: What is a human-rights based approach to health and does it matter? (Health and Human Rights Journal)
  • Three aspects:
    • Indivisibility of civil + political rights and socioeconomic rights
    • active agency by those vulnerable to rights violations
    • powerful normative role of rights in establishing accountability and protections
  • Despite incredible technological progress, less than 40% of live births are attended by a skilled practitioner in poor countries.
  • In HIV care and treatment, rights-based approaches challenged public health to think about exclusion and enable integration of rights-based approaches to health.
  • Examples where we have fallen short of the rhetoric:
    • mandatory testing vs. scale up of treatment; continued discrimination of people living with HIV
    • MDR / XDR TB treatment and therapy: the artificial dichotomy of prevention and treatment
    • “This leads logically to the second consideration: without an active civil society, paper commitments to rights mean very little.”
  • Case of informal settlement outside of Cape Town, SA:
    • The case (known as the Grootboom case) made legal precedent in establishing the justiciability of socio-economic rights in the courts and was hailed beyond just the borders of South Africa as advancing popular claims to basic needs that are socio-economic entitlements in human rights law.
      • Despite the case, there has been no major shift in the housing or access to services guaranteed by law, largely because of a large social movement demanding the right to housing.
    • Contrary case: the treatment access movement:
      • The Treatment Access Campaign (TAC) is the most obvious illustration of success.
      • mutual reinforcement of the courts and grassroots political action in advancing and actualizing rights.
      • Amartya Sen:
        • “The implementation of human rights can go well beyond legislation, and a theory of human rights cannot besensibly confined within the juridical model within which it is frequently incarcerated. For example, public recognition and agitation can be part of the obligations … generated by the acknowledgement of human rights.”
  • Opportunity with rights: Defining who is a rights holder, who is a duty bearer, and what the nature of the obligation is, allows a much clearer opportunity to establish accountability (typically of government) for the realization of rights and creates a range of mechanisms to hold governments accountable.
  • Often, rather than acknowledging health as a right, policy-makers frame health policy decisions as service delivery issues, requiring technical inputs to reach the best “evidence-based” decisions, a public health phenomenon gaining increasing popularity worldwide.
    • In doing so, the state is relieved of its burden of progressive realization.
  • Making human rights a shared objective:
    • invoking a human rights framework does not, of itself, inevitably mean a conflictual relationship between civil society and the state.

CH188: Introduction to the right to health

Yesterday we kicked off an exciting new course at Tufts University: Community Health 188 – The Right to Heath: Problems, Perspectives, and Progress. We had the first session of our weekly, three hour, 15 person seminar focusing on an ‘introduction to the right to health’ that I co-led with Prof. Fernando Ona, who is an amazing epidemiologist, social worker, and thinker on social / political movements in health.

I have to say that I was really nervous going in to this course. I’ve never served as a listed instructor for a university course and since this is a new course, it was a bit of an uncharted territory for both Fernando and me.  But, the first class went surprisingly well. The students were excited to be there, had good ideas about global health and the right to health, and they already seemed actively engaged in participating.

In addition to going over the syllabus, getting to know one another with a fun icebreaker, and sharing a bit about our vision for the course, we engaged in two substantial activities: the drawbridge exercise 1 and the core elements of the human rights approach 2.

The drawbridge exercise in particular was a fascinating experience. The scenario essentially provides a skeleton sketch of a society in which all powerful, jealous Baron orders the death of his Baroness wife who he discovers is having an affair. Participants are asked to rank the cast of characters based on who is most culpable for the death of the Baroness. The discussion provided a great template to begin our conversation of human rights: where does power reside? What values templates and cultural values dominate? Who decides?

This led into a great conversation about the core elements of human rights discourse and practice. We discussed what it meant for human rights to be:

  • Universal and inalienable
  • Interdependent and indivisible
  • Equal and nondiscriminatory
  • Both rights and obligations

All of this sets us up well for week 2: “roots of global health and the right to health project”, which will critically unpack the history of the construction of human rights and how this history has particularly affected the emergence of the field of global health delivery. We are really fortunate to have Dr. Salmaan Keshavjee coming to speak for the first half of the seminar to discuss the the roots of neoliberalism as a collection of ideas, the politics of implementing neoliberal policies in resource flows, and the implications of that history on the current global health regime. 3

I’m really looking forward to next week!


Week 1 Class / Reading Notes:

My hopes for the class:
  • That we create a safe space of learning, encounter, and action, that opens our imaginations to new social realities and grounds those imagined ideas in rigorous scholarship and research.
  • That we  make a decent case that the right to health is a useful construction and that we can implement programs that can progressively realize this utopian idea.
  • That we can build facility with the history that has come to construct the modern notion of the right to health and the political forces which have limited progress.
  • That we can come to have a basic understanding of the sociology of social movements, community organizing, and methods of attempting to purposively drive social change.
  • That we can grow our understanding of policy making, advocacy, and action — and start to take action ourselves.
  • That I can learn from this experience — pedagogically, intellectually, spiritually, emotionally.
Follow my reflections here: http://acriticalengagement.com/
Structure of the class:
Part 1: A right to health? Building a common understanding
  • Introduction to the right to health
  • Roots of global health and the right to health project
  • Laws, institutions, and governance in the right to health
Part 2: The Right to Health: Scoping and mapping the problems
  • Key problems in the right to health 1 (structure of the “field” of global health, financing, neoliberalism)
  • Key problems in the right to health 2 (innovations, mental health, NCDs, etc)
  • Key problems in the right to health 3 (gender discrimination)
Part 3: Driving progress: Developing a right to health toolkit
  • Health systems strengthening and the science of global health delivery
  • Policy analysis and policy making 1 (applied policy analysis)
  • Policy analysis and policy making 2 (presentations on policy analysis or policy proposal)
  • Community organizing and social movements 1 (social theory and social movements)
  • Community organizing and social movements 2 (discussion of PIH Engage and ways that we could work together after the course)
  • SDGs, UHC, and the future of the right to health movement
Reading Notes:
 
A. Sen: why and how is health a human right?
  • Legal question: there is no legislation
    • Does a right have to be legally defined?
  • Feasibility question: no way of ensuring good health
    • Common confusion about what is/is not a right: cannot stop murder at all moments everywhere
    • It is a demand to take action to positively promote that goal
  • Policy question: why not the right the health care since policy makers can control that
    • Requires multifaceted approach, not just the provision of health care of a set of policies and programs to promote good health
C. Shuftan: A guided tour through key principles and issues of the human rights based framework as applies to health
  • Human rights paradigm contrasts with the basic human needs approach in important ways
  • Big difference between having basic needs met and the protection of fundamental rights
  • “In the basic needs approach, the individual is seen as an object with needs (and needs do not necessarily imply correlative duties or obligations, but promises). In the rights-based framework, the individual is seen as a subject with legitimate entitlements and claims (and rights always imply and are associated with correlative duties and obligations). Therein lies the big difference.”
  • “Most often, a rights-based framework to health is not even on governments’ ‘radar screens’. The United States, for example, has regarded the socio-economic rights of the Universal Declaration of Human Rights as a wishful “letter to Santa Claus” (Jean Kirkpatrick, former US ambassador to the UN). The US has little sympathy for Social, Economic and Cultural Rights, in contrast to its vociferous and selective support of Civil and Political Rights.”
  • “the process moves the debate from (the flawed approach of) charity/compassion (where there is already fatigue) to the language of rights and duties (accountable to the international community with compliance that can be monitored). [Keep in mind that, as opposed to rights, charity is given mostly when convenient]. (U. Jonsson, 1997)”
  • Adoption of a right to health framework is the beginning of a political movement to develop and implement a non-ethnocentric global, egalitarian, human rights based praxis and ethics.
  • “Is fostering a viable and militant civil society a key to pressure governments into doing what they are supposed to do in the first place after having solemnly signed all those international human rights covenants?”
  • ” The caveat here is that organizations can use (and get away with using) human rights language as non-committal rhetoric just to feel good and ‘move with the tide’.”
—> Interesting form and radical view of the right to health.
—> Nice set of principles and iron-clad rules that can give structure to our thinking and arguments for the right to health.
—> Doesn’t articulate a more specific view of what type of political projects and organizations really would be necessary for this move forward.
S. Gruskin, E. Mills, D. Tarantola: History, principles, and practice of health and human rights
  • Discuss the changing views on human rights in the context of the HIV/AIDS epidemic and propose further development with increased practice, evidence, and action.
  • Considered health and human rights a relatively new approach to thinking about public health — 2007
  • The right to the highest attainable standard of health—often referred to as the right to health —is most prominently connected to the ICESCR.43 It stipulates that:
    • The states parties to the present covenant recognise the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. The steps to be taken by the states parties to the present covenant to achieve the full realisation of this right shall include those necessary for:
    • (a) the provision for the reduction of the stillbirth rate and of infant mortality and for the healthy development of the child;
    • (b) the improvement of all aspects of environmental and industrial hygiene;
    • (c) the prevention, treatment, and control of epidemic, endemic, occupational, and other diseases;
    • (d) the creation of conditions which would assure to all medical service and medical attention in the event of sickness.
  • The idea of health and human rights as a subject of study is fairly new, and we need to recognise the diff erent ways in which advances in health and human rights can be achieved. Human rights feature in many diff erent ways in the health work of international non-governmental organisations, governments, civil society groups, and individuals. These ways can be broadly categorised as advocacy, application of legal standards, and programming (including service delivery).45 Some stakeholders use one approach; others use a combination in their work.
  • A recurring dilemma confronting these organisations is whether sustainable health action should be associated with documentation and denouncements of witnessed human rights violations, as these activities could both limit their ability to provide health services to the populations they serve, and jeopardise the safety of their workers.
  • Treatment Action Campaign in South Africa used the courts to ensure that the government was ordered to provide programmes in public clinics for reduction of mother-to-child transmission of HIV.59 Although these eff orts have resulted in positive changes in the law, advocacy is still needed to move these obligations into practice; thus emphasising how advocacy, and application of the law are interrelated.
25 Questions and Answers on Health and Human Rights — WHO
  • Human rights discourse first popularized and adopted post-WWII
  • Cold War drove a cleavage between civil and political rights and social and economic rights
  • The West argued that civil and political rights had priority and that economic and social rights were mere aspirations. The Eastern bloc argued to the contrary that rights to food, health and education were paramount and civil and political rights secondary. Hence two separate treaties were created in 1966 – the International Covenant on Economic, Social and Cultural Rights (ICESCR) and the International Covenant on Civil and Political Rights (ICCPR).
  • The right to health: The right to the highest attainable standard of health (referred to as “the right to health”) was first reflected in the WHO Constitution (1946)(20)and reiterated in the 1978 Declaration of Alma Ata and in the World Health Declaration adopted by the World Health Assembly in 1998.(21) It has been firmly endorsed in a wide range of international and regional human rights instruments.(22)
  • The principle of progressive realization  of human rights(41)  imposes an obligation to move as expeditiously and effectively as possible towards that goal. It is therefore relevant to both poorer and wealthier countries, as it acknowledges the constraints due to the limits of available resources but requires all countries to show constant progress in moving towards full realization of rights. Any deliberately retrogressive measures require the most careful consideration and need to be fully justified by reference to the totality of the rights provided for in the human rights treaty concerned and in the context of the full use of the maximum available resources.
  •  Equity means that people’s needs, rather than their social privileges, guide the distribution of opportunities for well-being.(63)  This means eliminating disparities in health and in health’s major determinants that are systematically associated with underlying social disadvantage within a society. Within the human rights discourse, the principle of equity is increasingly serving as an important nonlegal generic policy term aimed at ensuring fairness.
A. Yamin: Beyond Compassion: The Central Role of Accountability in Applying a Human Rights Framework to Health
  • Accountability enables passive beneficiaries into claims holders and identifies states and other actors as duty bearers.
  • Compassion is notoriously unstable — we as humans seeking a society with justice, should seek for more stable justice-oriented structures. Rights give such a structure.
  •  In many countries, networks and broad popular movements for social accountability relating to health issues emerged as a reaction to autocratic governments that had enacted neoliberal sector reforms and privatizations of basic services (for example, water) with virtually no consultation and often largely by executive and ministerial decrees.14  These efforts at social accountability highlight the importance of decision-making processes as well as outcomes, of increasing the voices of marginalized or excluded communities with respect not only to the diagnosis of institutional failures that most directly affect them, but also to the negotiation of social policies and health budgets. However, successful models of social accountability also point to the importance of creating coalitions and networks across class, and between grass-roots movements and NGOs.
  •  The subversive potential   and central value   of human rights lies in placing limits on both public lassitude and private greed through a framework and mechanisms for accountability.
    • We need better tools and models for robust accountability for duty-bearers in protecting the right to health.
WHO / UN – The Right to Health – Fact Sheet
  • RTH comes from the 1946 WHO constitution: “The right to the enjoyment of the highest attainable standard of physical and mental health…”
  • 1948 Universal Declaration of Human Rights
  • This is a great primer on what we mean technically by “the right to health”
  • “The right to health” is not the same as “the right to be healthy.”
  • There are immediate obligations on states, but the right to health must be progressively realized.
    • Obligation to respect
    • Obligation to protect
    • Obligation to fulfill
  • In this sense, “the right to health” contains both “positive” and “negative” components.
J.A. Singh, M. Govender, E Mills: Do human rights matter to health?
  • India and South African examples of how “the right to health” can have substantial value
  1. Judith H. Katz. 1978. White Awareness: Handbook for Anti-Racism Training. pp. 70 – 72
  2. UN High Commissioner for Human Rights/World Health Organization. The Right to Health, Fact Sheet No. 31., pages 1-39.
  3. Blind Spot: How Neoliberalism Infiltrated Global Health. http://www.ucpress.edu/book.php?isbn=9780520282834