systematic dehumanization that makes dignity impossible. Confronted endlessly with this visual barrage of deformities and desperation, the people in the cars or rushing by on the streets invariably stop seeing the extremely poor as fully human but rather as objects that inspire compassion at times and undoubtedly contempt and loathing at others.
And one step removed from the street—on the web, on our TV screens, and in our newspapers—the masses of people displaced by war or earthquakes, starving to death, or stricken with terrible diseases, which should have been preventable, are paraded before us; CNN, Al Jazeera, and the BBC are constantly feeding us some new atrocity or humanitarian crisis, as our ability to empathize and see the people on the screen as equal human beings grows ever more tenuous.
In human rights we used to believe that simply drawing attention to a horror would be enough to make people take action. Yet, the spectacles of misery all too often fail to focus our attention on the ways in which our social and economic arrangements systematically create the situations in which some people are treated as means rather than ends—with grave effects on their health, as well as on their dignity. As Susan Sontag writes, “The imaginary proximity to the suffering inflicted on others that is granted by [these] images suggests a link between the far away sufferers and the privileged viewer that is simply untrue, that is yet one more mystification of our real relations to power.”39
But in this inexorably interconnected world, we are not innocent spectators of suffering in our own countries or across the globe. For example, what if wages in a country are too low for laborers to exercise choice about their life plans while the wealthy live in palaces? And what if people in the United States or Europe are relying on the cheap labor provided in Guatemala to harvest sugar or in Bangladesh to make clothing—under conditions that make it impossible for them to live with dignity? Do we not owe those strangers the treatment that we would wish for ourselves, and shouldn’t we insist that our governments apply appropriate trade and labor regulations in the countries from which we import products? What level of concern for “the other” is feasible, or required by respect for human dignity, in our globalized world?40 My intention in these pages is to encourage readers not just to have a knee-jerk reaction of sympathy, which as Sontag notes, “proclaims our innocence as well as our impotence,”41 but to explore how a rights framework might make us rethink what we owe each other as full human beings, through the laws and institutional arrangements we devise at national and global levels.
Dignity, Health, and Human Rights
Dignity, health, and human rights are intimately connected. In a classic 1994 article, Jonathan Mann and colleagues described three dimensions of connections between health and human rights. The first dimension relates to the health impacts that result from human rights violations—especially, in their discussion, civil rights violations such as torture. The second dimension involves the impact of health policies, programs, and practices on human rights—again in their original conception, with a focus in particular on civil rights. The final dimension, and one that I discuss at length throughout this book, involves the recognition that health and human rights are integral dimensions of, and can be complementary approaches to advancing human dignity and well-being.42
Let’s start with the recognition that human rights abuses, such as torture, are not only violations of human dignity but also quite evidently bad for people’s health, as is clear from the Quijano case. As director of research and investigations for Physicians for Human Rights (PHR) in the 2000s, I supervised PHR’s investigation into the health effects of the so-called “enhanced interrogation techniques” that the George W. Bush administration was using on detainees in the “war on terror.” In 2006, the Bush administration was claiming that these techniques did not constitute torture because they did not meet the threshold of pain and suffering required under the UN Convention against Torture, which the United States had ratified and implemented through domestic legislation.
In day-to-day conversation, we often use the word “torture” quite loosely. In international law, Article 1 of the UN Convention against Torture sets out four essential elements of the definition of torture: (1) intentional infliction; (2) of severe pain and suffering (physical or mental); (3) for a specific purpose (that is, to obtain information, intimidate, punish, or discriminate); and (4) with the involvement, instigation, consent, or acquiescence of a state official or person acting in an official capacity.43 The severity of pain and suffering must pass a certain threshold level. However, judging whether a specific action meets that threshold depends on all circumstances of case, including duration; intensity; physical and mental effects of the action; and gender, age, and state of health of the victim. The PHR investigation, based in part on in-depth interviews with former detainees, clearly demonstrated that the techniques used did constitute torture.44
The investigation into these so-called enhanced interrogation techniques reinforced that, given the right circumstances, normal individuals have a seemingly infinite capacity for the basest of cruelties, often believing that such behavior is directed at achieving some higher objective—in this case, information about the “war on terror.” Moreover, medical professionals, despite having professional duties of loyalty to patients, are not immune from succumbing to instrumentalizing people to achieve some “higher” goal set out by the state.45 Additional investigations by PHR demonstrated the extent to which health professionals—psychologists, in particular—had been involved in the development and application of the enhanced interrogation techniques.46
The second dimension of Mann and colleagues’ paradigm involves the effects of health policies, programs, and practices on human rights. Quarantine, “shelter in place,” and isolation policies can certainly violate civil liberties and create discrimination and stigmatization, if not carefully tailored, which became all too apparent at different points in the Ebola outbreak that began to spread quickly in 2014 in West Africa. International law recognizes exceptions for public health and public order, and the Siracusa Principles and other international documents have been developed to provide criteria to reduce inadvertent discrimination and disproportionate restrictions on civil rights during public health emergencies.47
For now, I want to focus on the centrality of not reducing people to means in a human rights framework, as we are concerned with people’s dignity. Syphilis experiments, for example, were systematically carried out for forty years on African Americans in the United States.48 The Tuskegee Syphilis Study, conducted from 1932 to 1972, was a research study on the outcome of untreated syphilis on hundreds of African American men in Georgia. The study participants were essentially on a decades-long deathwatch, as the study officers did not treat their advancing and deadly syphilis. A fundamental distinction between a human rights approach to health and a conventional utilitarian approach is that whatever the objective may be—a cure for syphilis or the promise of some other medical breakthrough—it can never justify treating fellow human beings as mere means to that end.
Again and again, in health as well as more broadly, we see that the most egregious abuses are committed in the name of some higher purpose. Mann felt that inadvertent discrimination was so common in public health that it should be assumed, and need to be disproven.49 Moreover, it is not coincidental that, as in the case of the syphilis study, research abuses commonly affect populations that are discriminated against, marginalized, or vulnerable.
It is important to note that the Tuskegee study represented an appalling breach of a number of ethical standards in public health, in addition to the human rights violations it entailed. And in the aftermath of the scandal it caused when the public realized what had been going on for decades, the United States adopted practices and institutions to manage the use of human subjects in research.50 Almost all countries in the world now have some institutions that conduct ethics review of medical, public health, and social science research involving other human beings.
Torture and Cruel, Inhuman, and Degrading Treatment (and Other Abuses)
