New York, 5 December 2008
Doctor Klag, Dean of the Johns Hopkins Bloomberg School of Public Health
Ladies and Gentlemen,
I am honored to take part in a discussion organized by the oldest and one of the most renowned public health schools in the world, the Johns Hopkins Bloomberg School of Public Health. I am greatly heartened that the School and the New York Academy of Sciences have decided to commemorate the 60th anniversary of the Universal Declaration of Human Rights with a focus on the fundamental link between health and human rights, and more specifically, on the right to the enjoyment of the highest attainable standard of physical and mental health.
The 60th anniversary of the Universal Declaration of Human Rights presents us with an exceptional opportunity to celebrate six decades of human rights struggle, and to chart our course for the challenges ahead of us. While impressive progress has been achieved during this time, old and new forms of discrimination and exclusion, as well as violations of civil, political, economic, social and cultural rights persist.
The full realization of the Declaration’s spirit requires that we take up the entire set of rights it proclaimed as an indivisible and organic whole, inseparable and interdependent, and of equal importance. Economic, social and cultural rights cannot be fully achieved where civil and political rights are curtailed and civil and political rights cannot be fully exercised where economic, social and cultural rights are neglected.
More specifically, and of direct relevance to this conference, the full enjoyment of many other human rights strictly depends on the realization of the right to health. Regardless of age, ethnic or religious background, socio-economic conditions or gender, nationality, disability, or sexual orientation, adequate access to health goods, services and facilities must be granted to all in the event of illness, emergencies or in the normal life cycle of an individual.
Allow me to briefly discuss with you today crucial aspects of the right to health, or to use the full definition in human rights law: “the right to the enjoyment of the highest attainable standard of physical and mental health. I will then outline the critical role that public health plays in relation to the present and future challenges for the respect, protection and fulfillment of human rights. Finally, I will discuss the pervasive effects of poverty and discrimination on the enjoyment of the right to health and human rights.
The right to health as an international norm was articulated for the first time under the auspices of the World Health Organization (WHO) in 1946, with the active engagement of public health professionals, who were committed to ensuring universal standards of life for every human being. WHO’s Constitution of 1946 defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Its Preamble further proclaimed that: “the enjoyment of the highest standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, and economic or social condition”.
Two years later, Article 25 of the Universal Declaration of Human Rights affirmed that “everyone has the right to a standard of living adequate for the health of himself and of his family, including food, clothing, housing and medical care and necessary social services”. Since then, the right to health has become widely accepted as a fundamental human right, explicitly recognized in various international and regional legal instruments, as well as in national constitutions and domestic laws. This recognition gives rise to obligations on the part of States.
To this effect, the 1966 International Covenant on Economic, Social and Cultural Rights is of crucial importance. The Covenant, which the United States of America has signed but not yet ratified, provides the most comprehensive articulation on the right to health by recognizing “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” Under the Covenant, States are required to take steps to achieve the full realization of maternal, child and reproductive health; the improvement of all aspects of environmental and industrial hygiene and the prevention, treatment and control of diseases. Their duties also involve the creation of conditions to ensure to all medical services.
In order to further clarify this matter, let me say that under international human rights law, the right to health includes both “freedoms” and “entitlements.”
The former concern, for instance, the right to be free from non-consensual and uninformed medical treatment, medical experimentation or forced HIV testing. Similarly, freedom from torture and other cruel, inhuman or degrading treatment is an important component of the realization and protection of the right to health.
The latter include the right to a system of protection on an equal basis for all; a system of prevention, treatment and control of diseases; access to essential medicines, sexual and reproductive health; and access to information and education about health for everyone, particularly to prevent unhealthy or risky behavior.
Ladies and Gentlemen,
In order to support State parties in their compliance with these obligations, the Committee on Economic, Social and Cultural Rights, an expert body, has identified some elements to guide the full realization of the right to health, which include: (a) the availability of functioning public health facilities, goods and services, as well as programmes; (b) their accessibility, including both its physical and financial aspects; (c) their acceptability: that is to say, facilities, goods and services must be gender-sensitive, culturally appropriate and respectful of confidentiality; (d) all facilities, goods and services must be of good quality in scientific and medical terms.
As I mentioned previously, in the past 60 years we have come a long way, achieving essential clarity on the scope and content of many international human rights. Other instruments have been adopted at the regional level reflecting the particular human rights concerns of the region and providing for specific mechanisms of protection.
The international human rights system has grown apace with the evolution of society. This is the case of a new approach to the issue of disabilities. A new Convention entered into force in May this year to protect the rights of persons with disabilities, including their right to health on an equal basis with others, and to prohibit discrimination against them. Similarly, in the last twenty years, the HIV/AIDS struggle has shown how intertwined public health and human rights are, and how the effectiveness of the work to combat this epidemic must link both perspectives at all times. Thus, a human rights lens has brought visibility to the situation of individuals and groups of individuals that had been systematically marginalized.
However, there is no room for complacency. Despite all the significant advances in human rights law and practice, inequalities and discrimination continue to be issues of great concern all over the world. These disparities affect, for example, universal access to a health system. While the precise nature of “health facilities, goods and services” as defined by international human rights law may be subject to interpretation, there is no doubt that a functioning interaction between the public and private health sectors is entirely a State’s responsibility. In other words, States have an obligation to regulate both the private and public sector, render the two sectors accountable and guarantee access to everyone without discrimination.
Furthermore, States must also take responsibilities for ensuring the availability, accessibility, affordability and quality of the so-called “underlying determinants of health”, that is, safe drinking water, adequate sanitation facilities, availability of hospitals and clinics, trained medical and professional personnel, and existence of sufficient essential medicines of good quality, as defined by the WHO.
International human rights law does not prescribe whether healthcare should be delivered by public or private health providers, or by a combination of the two. The human rights framework does not dictate a particular form of service delivery or pricing policy. However, it envisages a public health system to guarantee that services and care are available to the poor, the vulnerable and the marginalized. Let us recall that such conditions affect mostly children, elderly people, pregnant women, displaced persons, migrants, indigenous peoples, ethnic and racial minorities, among others. Maternal and child mortality are at the highest among the poor and can both be more acute if linked with racial and ethnic discrimination.
According to relevant research, some health-related indicators show, for example, unequal levels of healthcare amongst different racial groups in the United States. “Bringing Human Rights Home”, edited by Cynthia Soohoo, Catherine Albisa and Martha F. Davies, foreword by Louise Arbour, Praeger Publishers, 2008.
African-American men in the poorest areas of major U.S. cities can expect to live 15-20 years less than white men in the nation's most affluent areas. Michael Marmot. “Inequalities in health” New England Journal of Medicine 345, 2 (July 12, 2001):134-36. African American mothers are twice as likely as white mothers to give birth to a low birth weight baby, and African American children are twice as likely as white infants to die before their first birthday. UNDP. Human Development Report 2005 (New York: UNDP, 2005): 58. In 2005, the rate of AIDS diagnoses for African American women was nearly 24 times the rate for white women. TheBody.com. HIV/AIDS Among African Americans. Statistics HIV/AIDS 2005, Accessed 18 November 2008. Available at < http://www.thebody.com/content/art17002.html>
The United Nations Committee on the Elimination of Racial Discrimination (CERD) has also raised similar issues in its concluding observations to the official reports submitted by the United States of America, which ratified the Convention on the Elimination of All Forms of Racial Discrimination in 1994. Yet, many of these conditions are preventable and require a policy response aiming at inclusive public health programmes, tailored to the needs of communities and groups which have been historically marginalized. Moreover, policy and programs must make use of all available resources to prioritize equality in the outcomes, which incorporate clearly established goals and targets. Mechanisms for accountability and redress must also be put in place.
Around the globe, multiple forms of discrimination are likely to affect women the most. Thus they are often marginalized not only because of their gender, ethnicity and religion, but also because of their age. According to the World Bank, in 2005 more than half the estimated 5 million people who contracted HIV worldwide were young persons between the ages of 15 and 24, the majority of them young women. Similarly, while nearly 60 percent of young women in developing countries are mothers by the time they reach 25, they often do not receive any or adequate information about family planning, sexual and reproductive health or clear public health messages, mostly as a result of social barriers that do not allow them to access such information.
Clearly, the enjoyment of the right to education, freedom of expression -including the freedom to seek, receive and impart information and ideas- and the right to enjoy the benefits of scientific progress contribute tremendously to the quality of life and the health outcomes of girls and women. By the same token, limited access to primary and secondary education of good quality, a lack of targeted public health information on sexual and reproductive services, family planning and contraception for adolescents and young adults, and a failure to make anti-retroviral treatment affordable and accessible to everyone regardless of their age and gender, may hinder the exercise of the right to health.
It is of vital importance to society that public health professionals and scientist become ever more conscientious and active in countering discrimination. This can be done, for example, by providing easy to understand, accurate information to every patient or user of services at all times; by making use of technology to reduce the information and knowledge gap, and by prioritizing research and development in areas where the poorest are often left unprotected, such as in the case of neglected tropical diseases. Moreover, professionals and scientist must protect privacy and confidentiality in all health-related information, to place human dignity at the centre of their research, and to ensure that prior informed consent is granted for any intervention
Ladies and Gentlemen,
While the vast majority of professionals and researchers in the health sector around the world adhere to the highest ethical standards and contribute to the promotion and protection of human rights, deviations and infringement of deontology have also been noted. In 2005, the former Special Rapporteur on the right to health—a human rights expert—pointed out that some health professionals “wittingly or unwittingly have been complicit in human rights violations.” Political, legal, economic, social and cultural pressures that may conflict with human rights mean that they sometimes have to make decisions in their daily work. Personal views of health professionals may also influence attitudes and practices in ways that may be inconsistent with the rights of the persons they are treating. For example, in some countries, health professionals, under institutional or societal pressures or out of their own views, deny treatment to marginalized groups, such as immigrants; disclose confidential medical records, or deny sexual and reproductive health information and services to women and adolescents. Health professionals have also, at times, been subject to pressures to participate in human rights violations including torture, forced sterilizations and female genital mutilation. In sum, decisions made by health professionals can mean the difference between the protection and the violation of human rights.” A/60/348, Paragraphs 8 and 9.
Human rights specialists have also underscored the need to give proper relevance and attention to diseases that have been long neglected, such as chagas disease, dengue or lymphatic filariasis, leprosy, among other neglected tropical diseases which can be endemic, chronic, disabling, or deadly conditions. Typically, these neglected diseases affect the poor, and typically research on them is under-funded.
An additional dimension that we should not ignore is the need for more consistent efforts on the promotion and protection of the rights of health professionals and scientists, who often find themselves under threat.
This may occur when they are forced to commit violations by societal or State pressure. Due to a lack of knowledge of or access to the human rights system that would protect them, many professionals solely rely on their own professional ethics to fend off coercion and abuse. Some have suffered and continue to suffer ostracism, persecution, false allegations or detention as a result of defending their patients’ rights, or the common good in the face of other more veiled or less altruistic interests. This explains why in several countries the list of human rights defenders under threat includes health professionals, particularly those working with issues of sexual and reproductive health, sexual orientation, HIV/AIDS and sex workers. We need to ensure that appropriate mechanisms of accountability, access to independent judicial systems and redress avenues, and adequate human rights training are in place for health professionals.
Promoting and securing the right to enjoyment of the highest attainable standard of health is not only the right thing to do. It is also a legal obligation, and a foundation for prosperity, stability and poverty reduction. Progress in health is also at the core of meeting most of the UN Millennium Development Goals (MDGs). A world that is greatly out of balance in matters of health is neither stable nor secure.
For these reasons, the United Nations Secretary-General Ban Ki-Moon has made global health a priority, and identified the strengthening of health systems, women’s and girls’ health and the prevention and eradication of neglected diseases that affect mainly the world’s poor as key priorities for immediate action.
The enjoyment of the right to health is not about charity, it is about entitlements, freedoms, obligations and accountability. National health legislation and policies need to be developed or strengthened to reflect this internationally recognized legal obligation. The human rights principles of equality and freedom from discrimination are central to any efforts to ensure the right to health for all. The most vulnerable need to be engaged as active participants and engines of change in decision-making processes affecting their health, including at community levels. This not only renders health policies and programmes inclusive, but it also and crucially empowers people.
The core value of the human rights based approach to health is that international law holds Governments accountable for implementing the legal commitments undertaken to respect, protect and fulfil the right to the highest attainable standard of health for all. An accountability system requires national legal and regulatory frameworks that translate the right to health into tangible and measurable national standards.
Our concerted efforts are needed to ensure that human rights remain at the core of the global health agenda. I would like to reiterate the support of the Office of the High Commissioner for Human Rights and the United Nations as we strive towards achieving the full enjoyment of the right to the highest adequate standard of health for everyone without discrimination.
I thank you for your attention.