I, “Starting Points,” I suggest that a transformative engagement between health and human rights requires rethinking conventional approaches to human rights, as well as to health. I came to public health not from the perspective of healing, as many others do, but from a traditional lawyer’s training in human rights and with a profound concern for social justice. At the time, in the early 1990s, the human rights movement was almost exclusively focused on civil and political rights violations. But as some others did, I grew to feel that if the movement did not address social injustice, it would remain a marginal discourse for social emancipation.
In Chapter 1, beginning with a description of one of the first cases of torture that I ever worked on in Mexico, I set out thoughts about what torture does to us as human beings—the nature of suffering it inflicts and how it strips away the possibility of self-government, agency, and therefore human dignity. The concept of the equal dignity of all human beings, of the need to see other people as ends in and of themselves rather than as instruments for the advancement of our own or others’ aims, is the core of a rights framework. And that simple concept—of according all people equal dignity—has enormous implications for the way our societies and world are organized.
I go on to explore the links among human rights, dignity, and health, beginning with a three-pronged paradigm that Jonathan Mann and colleagues set out in the early 1990s, at the beginning of what has become known as the health and human rights movement. There are serious health consequences to torture, and unfortunately the historical involvement of health professionals in torture and other abuses is all too common. Indeed, some forms of abuse in the health sector rise to the level of torture or cruel, inhuman, and degrading treatment.
However, most violence that affects women’s and children’s health is in the home or in private spaces close to home. Therefore, as human rights law, and domestic law in many countries, has recognized, to address the kinds of violence and suffering that women and children face, regulation of power must extend beyond the public sphere and into the private sphere of the home. Yet the way the public continues to think about human rights often continues to be too limited. If torture shatters the worlds that people construct, these abuses of children, especially girls and sexual minorities, sometimes disabled, often prevent the victims from ever fully developing a sense of themselves as full subjects of rights.
Chapter 2 begins with another example from my early days of human rights advocacy work in Mexico. During the course of investigating an atrocity by the Mexican military in a remote region of Chihuahua state, I found myself watching an infant die. Stunned by the mother’s lack of indignation over her child’s death, I argue that extreme poverty cannot be seen as a “background condition” but should be understood as just as much a violation of human rights as acts directly committed by state agents. The powerlessness wrought by extreme poverty is as devastating as that inflicted through torture, and the effects are the foreseeable result of human decisions about policies and programs at multiple levels. Yet even when there are obvious health consequences, we still too often fail to appreciate the human causality and state responsibility that lie behind these deprivations of dignity.
International law has advanced significantly in terms of eroding unhelpful distinctions between civil and political (CP) rights and economic, social, and cultural (ESC) rights, as has the jurisprudence of various national courts. Indeed, in both international and some national law there is now a concept of minimum essential levels of ESC rights necessary to life with dignity, as well as implications for leveling the playing field. However, just as with reframing state obligations regarding the private sphere, there is still a long way to go to change public understanding of ESC rights so that they are seen as real rights. I argue that to do so requires examining our assumptions about prevailing neoliberal economic paradigms and state responsibilities, as well as about the ways in which power prevents people from exercising freedom in practice and the consequent implications for how we think about justice.
In Chapter 3, I argue that conventional approaches to medicine and public health also require rethinking. Describing an incident that occurred early in my public health career in Haryana, India, I illustrate the limitations to empowering people through conventional public health approaches that treat social determinants—such as caste, gender, and racial hierarchies—as “distal,” or background, factors, as opposed to the proximate behavioral causes on which most interventions as well as research focus.
Applying a human rights framework does not and cannot mean ignoring the need for access to biomedical advances. As Paul Farmer argues, the right to health must include the “right to sutures”—and blood, essential medications, and other supplies.23 At the same time, a meaningful HRBA also calls for contextually grounded strategies to chip away at the power structures that perpetuate patterns of illness and suffering. These are all too often relegated to background conditions that cannot be touched in the short term in public health planning and policies; as a result, they never get addressed. After distinguishing between a right to health and the application of an HRBA or a human rights framework to health, which includes these social determinants that relate to other rights, I explore how such an approach, which builds on work in social medicine and social epidemiology, demands a fundamental shift in the way that health is generally understood in mainstream medical and public health practice.
In Chapter 4, starting with a story from the remote jungle “department” (state) of El Chocó in Colombia, I emphasize the significance of health systems within an HRBA to health. Health is largely a result of social determinants that go beyond the health sector. However, health systems reflect the patterns of discrimination and inequalities found in the overall society; alternatively, they can also help to facilitate greater substantive democracy. Health systems lie at the core of the realization of the right to health, as well as of HRBAs to health. In a rights framework, a health system is understood as a core social institution—“akin to the justice system or a fair political system”—rather than a delivery apparatus for goods and services.24 So, for example, a society in which rich and poor alike feel that the health system is fairly prioritizing their needs is a more just society than one in which rich and poor are treated in different institutions with different standards of care—simply because of access to money.
A fundamental distinction of an HRBA to health systems is a focus on accountability. Arguing that an HRBA requires a “circle of accountability,” Chapter 4 describes how such an approach would differentiate it from a conventional approach at each stage of the policy cycle, from the initial situational analysis through planning and budgeting processes to program implementation and monitoring and review mechanisms to remedies.25 Returning throughout the chapter to the context of Colombia, I outline a systemic judgment by the Colombian Constitutional Court in 2008, which called for restructuring the health system along rights principles. I highlight the importance of that historic judgment, especially to the extent that it arguably destabilized entrenched assumptions and interests in the Colombian health sector and triggered a chain of varied effects. Throughout the book, I emphasize that applying a human rights framework in a transformative way aims to change dynamics of relationships between the public and the state to a relationship of entitlement and obligation and to dis-entrench patterns of power and privilege, which systematically deprive some people of their health and other rights. At the same time, I note challenges for meaningful change that continue to exist in the Colombian context.
In Part II, “Applying Human Rights Frameworks to Health,” I examine specific aspects of HRBAs to health, and human rights frameworks more broadly, and I make more explicit how human rights frameworks can be applied by different actors to produce social transformation, providing examples throughout. As Part
