day because he ended up tortured to death in a local jail for simply urinating in public. Or the campesino (peasant farmer) who was mercilessly harassed and finally murdered with impunity by drug traffickers when he wouldn’t relinquish the land his family had received from “The Great One”—Lázaro Cárdenas—after the Mexican Revolution.1 Or the young woman who got caught up in helping a drug dealer for money, was subjected to a Kafkaesque trial, and was then sexually assaulted by a guard in prison. Or a dozen other people for whom severe poverty itself was a prison of despair.
Profound poverty makes people hostages to their fates, and entire futures dissolve because of petty bureaucratic decisions or arbitrary abuses of power. In Behind the Beautiful Forevers, Katherine Boo writes of Annawadi, a slum in Mumbai, India, saying that for the very poor, good fortune “derived not just from what people did, or how well they did it, but from the accidents and catastrophes they dodged. A decent life was the train that hadn’t hit you, the slumlord you hadn’t offended, the malaria you hadn’t caught.”2 People who are not just of modest means but who live in extreme poverty are constantly faced with “Sophie’s choices” about which child goes to school, which will get health care, who will get to eat that day.3 When poverty takes away such basic power over one’s life, it makes self-governance and therefore dignity impossible, and it represents violations of a series of human rights, including health and other economic and social rights, under international law.
I was still doing conventional civil and political rights work in Mexico when I participated in a fact-finding delegation to Baborigame, a small village in the southern part of the Sierra Tarahumara in the state of Chihuahua. Baborigame would be a short flight to Tucson, Arizona, where some of the most sophisticated medical care in the world is available. But the Sierra Tarahumara is a mountainous area, and in the early 1990s it had extremely poor infrastructure. The terrain and difficulty of access made the Sierra Tarahumara ideal for cultivating opium poppies, and drug lords forced many of the indigenous campesinos who owned small tracts of land in the area to do just that. As I have described elsewhere, in 1992, the Mexican military burned down much of the village of Baborigame, took away men to torture them, stole and killed livestock, and displaced the entire population.4 Allegedly the military was eradicating opium poppies, but it is entirely possible that the eradication merely reflected a transfer of control between the cartels, on whose payrolls were many of the Mexican officials engaged in the so-called “drug war.”
Along with a small group that included both Mexican and international human rights activists, I went to investigate the events that had occurred in Baborigame.5 One morning, the helicopter going to survey the eradicated crops from the air was full and I stayed behind with the missionary nuns, who did what they could to attend to the impoverished Tepehuac community in this isolated area of northern Mexico. The Tepehuac community, like the vast majority of indigenous groups in Mexico, was disproportionately represented among the most severely impoverished in the country. At the time, the government was providing almost no water, sanitation, or health services to this remote area. The small group of nuns provided basic primary care and did whatever they could for patients who required more complicated attention, such as a man with leprosy who had lost some of his limb function.
I had no idea that I was going to watch a child die that day. By the time his mother, Pilar, brought him in, the infant was so dehydrated and weak that he was incapable of crying. Given the nuns’ meager supplies, there was nothing to do but pray and watch as life faded from his tiny body. Pilar held his body and cried softly. We all cried. The commonly accepted narrative that the destitute or those in certain “other” cultures experience less grief over the loss of a child because it is so common is simply not true. But it may allow the privileged to distance themselves from the implications of having to address the immense suffering of fellow human beings, whether in the slum across the street or across the world.
Apart from the images of the last minutes of the child’s life, what I recall most vividly from that day more than twenty years ago was that his mother did not express the rage, in addition to sadness, which I felt so acutely—rage that her community lived without adequate water, sanitation, and food; rage that there was no accessible health care when her son did fall ill as a result; rage that her son had died an entirely preventable death because of these deprivations and the systematic discrimination against indigenous populations in Mexico. Pilar understood the military’s arbitrary detentions, tortures, theft of livestock, and wanton destruction of property as human rights violations. Indeed, denouncing those abuses to my delegation is what had brought her and her neighbors down the mountain. Nevertheless, her anger did not appear to extend to her living conditions, which were the underlying cause of her son’s death. What was striking on that cold morning in 1992 was the absence of the mother’s sense of the terrible injustice implicit in her son’s suffering and death. To her, as with so many mothers and families I have met before and after her, the death of her son was simply “the will of God.”6
I have no doubt that the impotence Pilar felt—and her actual powerlessness—was just as profound as that which Rosa experienced as she watched her brother being tortured. Indeed, when the World Bank published the groundbreaking Voices of the Poor study in 2000, which attempts to understand people’s experiences of poverty through discussions with tens of thousands of poor people around the globe, what came across was that “again and again, powerlessness seems to be at the core of the bad life.”7 The very poor are at the mercy of fate, as well as the capricious whims of those in power; when poverty is combined with other axes of identity, such as ethnicity in this case, or gender, race, or caste, the disempowering effects can increase exponentially. Moreover, as the World Bank study showed, being extremely poor not only means going without food or shelter or education, it also often means being treated badly by institutions, such as the health and justice systems, and excluded from voice in those institutions as well as in the larger society.
Yet the human decisions and human actions that lay behind the death of Pilar’s son seem more obscure, more invisible, than what happened to Héctor Quijano. Once again, how we understand causation and the boundaries of human responsibility lie at the heart of how we respond to different forms of suffering. That is, if we understand Pilar’s son’s death as misfortune or personal tragedy, it elicits a very different response than if we understand it as injustice, for which the ground was laid by human decisions and actions, not by divine will. Although the first perhaps creates sympathy, the second calls on us to translate compassion into political, social, and legal action.
Philosopher Thomas Pogge writes that extreme poverty—and the suffering and human rights violations that it creates—are intimately connected to our social arrangements at national and global levels: “Severe poverty today, while no less horrific than that experienced by the early American settlers, is fundamentally different in context and causation. Its persistence is not forced on us by natural contingencies of soil, seeds, or climate. Rather, its persistence is driven by the ways that economic interactions are structured: by interlocking national and international institutional arrangements…. We can avoid it … by restructuring national and global legal systems so that everyone has real opportunities to escape and avoid severe poverty.”8 It was through experiences such as the one in Baborigame, that I came to feel at a visceral level that for human rights frameworks to be relevant to the struggles for dignity of the great majority of the world, these frameworks needed to provide useful approaches to restructuring those national and global systems.
In this chapter, I first set out the interconnectedness of all human rights—economic, social, cultural, civil, and political. I go on to explore what it would mean to conceive of issues relating to social and economic conditions—and to health, in particular—as rights, and how doing so is directly related to our understanding of the importance of dignity and has consequences for how we address lack of access to the most basic conditions of public health and health care. I then describe how modern human rights law has evolved, including eroding the differential treatment of categories of rights. But I also note challenges presented by prevailing neoliberal economic paradigms and their relationship to narrow conceptions of rights.
