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:

• 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.

• 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

• 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)

• 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

• 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

• 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’.”

• 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.

• 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.

• 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.

• 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.

• India and South African examples of how “the right to health” can have substantial value