Pinochet MbekiCrimes against humanity

Crimes against humanity involve ‘widespead or systematic attack’’ against ‘’a civilian population’’ on ‘’political, ethnic or religious grounds’’

Tortured misinformed millions

40,000 about the cause of

HIV/AIDS

civil and economic social

political rights and cultural rights

All human rights are universal, indivisable, and interdependent and interrelated

Physicians for Human Rights-UK

PHR-UK channels the humanity, influence and special skills of the medical profession into securing worldwide observance of the Universal Declaration of Human Rights.

PHR-UK is the only health and human rights organisation in the UK.

PHR-UK’s mission encompasses the whole field of health and human rights

PHR-UK is the leading teacher of health and human rights in the UK

International Federation of Health and Human Organisations

PHR–UK is a member of the International Federation of Health and Human Rights Organisations, made up of the following national organisations: PHR (USA), PHR–UK, PHR–Denmark, JWF Netherlands, PHR–Israel, PHR–Palestine, CEHAT-India, PHR-Bangladesh, PHR-Nigeria, PHR - Zimbabwe

- and the following observer organisations: Amnesty International, the British Medical Association, the International Committee of the Red Cross, the World Medical Association and the Turkish Medical Association.

You will have some understanding:

Of what human rights are

That health is contingent upon respect for human rights

That the right to the highest attainable standard of health has more potential to save lives/relieve suffering than any other discourse

Of why I think doctors should, on qualifying, make some form of public commitment to supporting health rights

That health rights are relevant in contemporary UK medicine

What relationship do human rights have to ethics?

Human rights are based upon the same underlying principles that recognise the unique importance and inherent dignity of every individual as medical ethics

What are human rights?

Universal legal guarantees protecting individuals against interference with fundamental freedoms and human dignity

Guaranteed by international standards

Legally protected

Focus on the dignity of the human being

Obliges states and state actors

Cannot be waived or taken away

Are interdependent and interrelated

Universal

Are health rights important?

30,000 children die daily of preventable disease

500,000 women die annually as a result of pregnancy and childbirth

The manner of the world’s response to the 68 million who presently face death from AIDS in the next 20 years will be the defining issue of the age

infectious diseases kill 17 million people annually (1996)

Chronic disease kills 24 million (half annual deaths) annually

How useful are health rights to health?

The right to the highest attainable standard

is the most powerful tool available to fight

for global health

The importance of the right to the highest attainable standard of health lies in its:

Its foundation in law

Its universality

Its conceptual practicality

Its aspirational appeal

The immediacy of its requirement on governments to both not discriminate and to take steps to progressive realisation

And above all its ownership by the people

How many countries recognise health rights?

Every country in the world is party to at least one human rights treaty containing key provisions on health rights

3 in every every 4 countries have ratified the international covenant on economic social and cultural rights

83 (out of 193) countries have ratified regional treaties containing health rights

109 countries have health rights within their constitutions

The development of health rights

During the first decades of development health rights were almost exclusively a project for lawyers and scholars

The concept has since moved - uncertainly, and largely unloved, into the public arena

It hovers at the edge of most health professionals’ awareness, is largely unknown to the general pubic, and is studiously ignored by most governments

The meaning of the term ‘Right to Health’

• In 1994 Virginia Leary explained (Health and human rights Vol 1. No 1) that the term ‘Right to Health’ has been adopted through common usage as a ‘’shorthand’’ expression for the health rights contained within a number of international laws

 Thus the term has no unique intrinsic meaning - it was chosen because of its lack of specificity (and perhaps succintness) to cover several laws

The term is a form of jargon, in the sense that an extensive knowledge of international law is required to understand its meaning

Medicine is not a stranger to jargon

Medicine has tens of thousands of jargon words

Usually their etymological derivation is based on pathological processes – such as myocardial infarction

Some are named eponymously eg Crohns disease.

Syphilis is named after a mythological shepherd called Syphilus

GMC – duties of a doctor (15)

A patient must be able to trust doctors with their lives and well-being … a doctor must:

Make the care of your patient your first concern

Treat every patient politely and considerately

Respect patients’ dignity and privacy

Listen to patients and respect their views

Give patients information in a way that they can understand

Respect the rights of patients to be fully involved in decisions about their care etc etc

The term ‘Right to Health’

When interpreted literally, as surely the huge majority of people, being unfamiliar with international law, will do, the term ‘Right to Health’ purports to establish a guarantee of health

It can be argued that health rights masquerade under a misleading title

Some non cognoscenti will recognise there can never be a guarantee and will, at best be puzzled - at worst mistrust health rights

The remainder will misunderstand the term

Equivalent terms to ‘Right to Health’?

Virginia Leary justified using the term ‘Right to Health’ by equating the widespread adoption and understanding of terms such as ‘natural justice’ , ‘due process’, and ‘freedom of association’.

A closer analogy to the ‘Right to Health’ might be to use the term ‘Right to Justice’ for Article 14 of the Covenant of Civil and Political Rights, which guarantees due process. Due process can no more guarantee justice than does medical intervention guarantee health (not to mention immortality)

Contemporary use of the different terms for health rights

The term ‘Right to Health’ is ubiquitous, its use almost invariable when referring to health rights

Article 12 of the International Covenant on Economic Social and Cultural Rights (the most authoritative health right) refers to ‘the enjoyment of the right to the highest attainable standard of physical and mental health’

General Comment 14 refers to the ‘Right to the highest attainable standard of health’

At its most reductionalist, it is a claim (as WHO’s excellent 25 questions and answers on health and human rights puts it) to a set of social arrangements – ‘a right to an enabling environment’

An ‘enabling environment’

My interpretation of the term ‘enabling environment’ is a protective envelope providing:-

the underlying determinants of health

healthcare

respect for all the human rights within the International Bill of Human Rights

the framework for implementation that is GC14

a number of disadvantages:

Most UN people refer to the ‘Right to Health’ rather than ‘Right to the highest attainable standard of Health’

If we wish to shorten the term into an acronym it becomes RHASH

The title for the most beautiful discourse in existence is … General Comment 14 – hardly inspiring or memorable

The 65 paragraph GC14 is pretty indigestible stuff

Doctors and other health professionals’ perspective

Issues of health are central to their professional interest and they justifiably consider themselves an authority on health

As much medical practice involves optimising and palliating (as opposed to curing) compromised organ function, chronic disorders and fatal diseases, the term ‘Right to Health’ taken literally appears oxymoronic (Leary charactarises a literal interpretation as absurd)

Good communications are essential to good quality medical practice and ambiguous terms that risk misleading patients, are not viewed with favour

Any misunderstanding of the term ‘Right to Health’ by patients is likely to have a negative impact upon medical practice

The general public’s perspective

Health is of paramount personal importance to everyone

Huge numbers of people die of treatable or preventable diseases

The capacity to misunderstand nuances of meaning will be greatest amongst those who have a restricted education and restricted access to information - the very ones who have greatest need to understand health rights

 Illness or the threat of illness can engender much emotion and passion that may interfere with the rational processing of terms that are ambiguous

Governments’ perspective

Goverments are responsible for observing their obligations with regard to health rights

Health systems consume large proportions of GNP

Governments are required, to a greater of lesser extent, to respond to their electorate’s, or public, opinion. They are less likely to collaborate over health rights that are ambiquous if they equate poor comprehension by the electorate with unrealistic expectations and unrealistic demands

Two main type of rights

First and second generation rights

1. First generation: negative rights (freedom from slavery, torture, deprivation of life etc) – promoted in the Cold War by the West; also known as civil and political rights.

2. Second generation: positive rights (to education, food, housing, health etc) – promoted by Communist Countries: also known as economic social and political rights

Multiple choice questions (1)

Which, if any, of the following answers is correct:

  The medical profession remains largely ignorant of what the Right to

Health is because ... a) doctors have selective sensory deficits b) education about the Right to Health is inadequate c) the Right to Health has no relevance to medicine d) medical students are not interested in human rights e) qualified doctors are not interested in human rights

Multiple choice questions (2)

3. Which, if any, of the following answers may be correct:  Doctors are reluctant to learn about the Right to Health because ... a) they think it means more work b) they fear increased litigation c) they know nothing of them d) they relate violations of human rights to torture and murder e) they consider they already provide a comprehensive high quality health

service, and that any suggestion they should be taught about the Right to Health implies they are wrong

f) they are concerned that an obligation to observe patients' Right to Health might be a source of contention between doctors and patients

g) they assume the Right to Health to be a woolly wish list rather than the precisely defined criteria they are

Multiple choice questions (3)

4. Which, if any, of the following answers is correct:

  Medical ethics render health rights superfluous because ... a) doctors know best b) medical ethics prevent health scandals c) doctor are the only people who can define standards for doctors d) medical ethics are universal e) medical ethics are comprehensive and flexible

Multiple choice questions (3)

6. Which, if any, of the following answers is correct:

 

The UK Governments can afford to ignore the Right to Health because ...

a) the UK’s ratification of international treaties has only symbolic importance b) international laws on economic, social and cultural rights (such as the

Right to Health) are not binding c) economic, social and cultural rights are not as important as civil and

political rights such as those found in the Human Rights Act d) patients are unaware that their Right to Health requires they are

consulted on health care policy e) doctors are unaware of the Right to Health

Hippocratic Oath (1)

Hippocratic oath

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but to no one else.

Para 36 of GC14

States have to ensure the appropriate training of doctors and other medical personnel, [...] States have to promote medical research and health education ...

Hippocratic Oath (2)

Hippocratic Oath  I will apply dietetic measures for the benefit of the sick according to my

ability and judgment;

General Comment 14

Non-discrimination - health facilities, goods and services must be accessible to all, especially the most vulnerable or marginalised sections of the population, in law and fact, without discrimination on any of the prohibited grounds. 

Par 35. Obligations to protect include, inter alia, to ensure that medical practitioners and other health professionals meet appropriate standards of education, skill, and ethical codes of conduct.

Hippocratic Oath (3)

Hippocratic Oath Similarly I will not give to a woman an abortive remedy 

Equivalent Human Rights Law

Interpreted, given historically recent developments in mainstream thinking on abortion, as meaning that no abortion will be carried out in the absence of approved and legal indications, and women should have access to reproductive medicine and contraception .General Comment 14.  

Para 14 The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child" (Art. 12 (2) a) may be understood as requiring measures to improve child and maternal health, sexual and reproductive health services, including access to family planning, pre- and post-natal care, emergency obstetric services and access to information, as well as to resources necessary to act on that information.

International Bill of Rights

Universal Declaration of Human Rights 1948

The International Covenant on Civil and Political Rights 1966

The International Covenant on Economic Social and Political Rights 1966

Article 12 of the Covenant on Economic Social and Cultural Rights

1. The states parties … recognise the right of everyone to the highest attainable standard of physical and mental health

2. The steps to be taken … to achieve the full realisation of this right shall include:

A) a reduction in the still birth and infant mortality rates

B) improvement in all aspects of environmental and industrial hygiene

C) prevention, treatment and control of epidemics, endemic, occupational and other diseases

D) creation of conditions which would assure to all medical service and medical attention in the event of sickness

PHR-UK’s part in GC14 development

‘… We write to ask if the Committee might wish to told a hearing regarding Article 12, the right to physical and mental health’ …

Summary record of the public discussion [ref E/C.12/1998/SR.51/Add.1]

The chairperson […] had received a letter from the NGO Physicians for Human Rights urging the committee to return to the question of the right to health.

The decision to go ahead with the day of discussion was taken in May 1999

and General Comment 14 was published in July 2000

Health discrimination

Diabetics form 2-3% of the population and will absorb 5% of the health budget

Diabetics enjoy specialist medical and other health professional care

An analagous population of similar size, with much higher prevalence rates of chronic disorder throughout their lives than the rest of the population, have to scrabble for adequate health resources. eg

Epilepsy 33% (v 0.75% in general population) Mental disorder 50% (v 25% in general population) ] - of whom 10% having a psychosis Sensory impairment (vision or hearing) 48% - both in 18%