By FXB Research Assistant Carrie Bronsther

On April 16, the Forum at Harvard School of Public Health, in collaboration with the GlobalPost, presented a panel discussion on The Cost of Inaction: The Consequences of Failing the World’s Children. The panel featured four expert participants: Countess Albina du Boisrouvray, Dean Julio Frenk, Professor Sudhir Anand, and Honorable Dr. Timothy Thahane, and was moderated by Samuel Loewenberg.

The participants discussed the implications of the landmark initiative launched by the FXB Center for Health and Human Rights on the “cost of inaction,” or the  failure to respond appropriately to children’s needs. Directed by Professors Amartya Sen and Sudhir Anand, this project tackled two main questions: what are the costs of inaction, and is the cost of inaction greater than the cost of action? Inaction can lead to negative consequences, including financial, health, education, social, and labor-force functioning effects, for individuals, families, the community, the economy, and society as a whole. For this initiative, economists and public health researchers addressed the complex challenges of enumerating and quantifying the multiple social and economic costs that follow when societies fail to address the pressing needs of their most vulnerable members, in particular children.

The panel provided a dynamic discussion on the implications of the initiative and its potential to influence policy makers to think strategically and holistically when setting priorities. As a failure to act, an “inaction” represents a choice and demonstrates a commitment, or lack thereof.  While the fact stands that decisions must be made given limited resources, the failure to invest in children creates limits on the viability and vitality of a society in the future.

It was argued that the costs of investing “upstream” in children can be much smaller than investing “downstream,” where the effects of the lack of investment can be irreversible or extremely costly to reverse. However, it was also noted that downstream costs, the costs of inaction, have less political clout as the benefits are less tangible and are therefore less likely to be taken into consideration for political reasons.

The “cost of inaction” is an essential initiative because it provides the economic evidence for the benefits of a long-term, comprehensive approach, which includes upstream investments. As Countess Boisrouvray discussed, an infrastructure to support children in all aspects of their lives, including access to health, education, water, sanitation, and support systems, is necessary to create productive citizens and a viable society in general.  As Professor Anand pointed out, health systems must be considered as part of a larger system with interrelated components. Throughout the discussion, the panel highlighted the need to consider the consequences of inaction in one area as they relate to another area, such as applying the relationship between not investing in children’s health to ensuing poor education outcomes

Dean Frenk also highlighted the importance of evidence in creating political action, commenting that the initiative makes “what’s invisible visible” and emphasizing the need to create long-term commitments to improve the lives of children as part of a holistic approach. There was discussion on the nearly 7 million deaths of children under the age of five. In particular, the panelists pointed out that even though the number of deaths of children under the age of five has declined in recent years, most of these deaths could still be prevented or treated with access to simple, affordable interventions, such as ensuring a safer pregnancy. The need for investment in a functional health system in general and safe pregnancy in particular was noted as necessary to improve these outcomes. However, the lack of investments in neglected populations, such as children and women, is a barrier to progress. Social awareness of the cost of inaction is therefore essential to general political will and investments.

In their final remarks, the panel’s experts noted that the book provides a guide to influence policy decisions backed by economic evidence and can serve as tool to enhance dialogue between actors and beneficiaries. The initiative bridges gaps between those who generate knowledge and those who use knowledge to create actions, and can thereby help decision makers take a holistic approach to create viable societies.

Book details

The Cost of Inaction: Case studies from Rwanda and Angola
Sudhir Anand, Chris Desmond, Habtamu Fuje, and Nadejda Marques
Harvard University Press (June 2012)
ISBN 9780674065581
348 pages
$19.95

Background:

The FXB Center for Health and Human Rights at Harvard University is an interdisciplinary center that works to protect and promote the rights and wellbeing of children, adolescents, youth and their families in extreme circumstances worldwide. The Center pursues this goal by conducting and supporting research, teaching, advocacy, and targeted action. The Center’s journal, Health and Human Rights, is a leading forum of global health and human rights concerns, publishing academic articles under the editorship of Dr. Paul Farmer, co-founder of Partners In Health. The online open access journal is published by Harvard University Press.

Description:

The Health and Human Rights Journal intern will assist the managing director with production and editorial tasks. The intern will report directly to the managing director and will also take direction from the FXB program director and the Health and Human Rights executive editor. The intern will have substantive writing opportunities, and will provide timely assistance with the publication of the journal, blog, and associated social media. The intern will gain holistic experience in academic journal production. Please note that this is an unpaid internship.

Requirements:

• Proofreading experience
• Interest in digital and open access publishing
• Experience with blogging and other social media

Preferences:

• Working knowledge of Dreamweaver, Adobe InDesign, Photoshop or other photo editing software
• Interest in health as a human right

Specific Responsibilities:

• Proofread journal articles
• Manage book reviews, seeking new titles for review and liaising with publishers for review copies
• Read titles and draft short book reviews for the blog and journal
• Post articles and metadata on the HHR Journal site through Open Journal Systems (OJS)
• Write short blog pieces for the HHR blog
• Promote HHR on listservs and social media
• Edit contributors’ blog posts and draft/publish them on WordPress
• Locate and prepare photos to accompany blog posts
• Solicit new contributors to the HHR blog
• Attend occasional seminars/panels to gather information for blog posts
• Manage coding and upload of new HHR issues to PubMed
• Seek new ways for HHR to increase visibility and readership
• Perform other duties and research tasks as required

Please send resumes to hhrjournal@hsph.harvard.edu.

By Ashish Premkumar, Allison Barker, Amanda DeLoureiro, MPH, Leela Sarathy, Daniel A. Dworkis

As medical students, we operate in a world of graduated clinical responsibility, traversing the divide from taking vitals to complex differential diagnoses and unsupervised minor procedures. We are taught that as our skills and sophistication grow, we will be caring for increasingly complex patients. When patients suffering from violations of their human rights are mentioned, often in the context “global health,” they are almost inevitably placed at the end of this graduated spectrum. We are told if you learn to take care of the “normal” patients, then eventually you will figure out how to care for the patient whose very existence has been shattered. For now, you do not have to worry about it; just learn how to hold the scissors properly when repairing this laceration.

There is a sound logic in this, as holding scissors correctly is indeed difficult in the beginning, but as medical students working in the largest safety-net hospital in New England, the reality is that we are regularly exposed from the beginning of our training to patients suffering from significant violations of their human rights. These patients, our patients, whose rights have been violated by acts of interpersonal and systemic violence, are impossible to ignore, impossible to put off until we are more sophisticated. They need us now; they need us to learn how to care for them.

We are not unique in recognizing this need. Article 44, General Comment 14 of the International Covenant on Economic, Social, and Cultural Rights requires that states must “provide appropriate training for health personnel, including education on health and human rights.”¹ Panosian and Coates note in their 2006 editorial “The New Medical ‘Missionaries’” that medical students are “[…] [h]ungry to discuss diseases of poverty as well as international policy and aid programs. In the curricula at most medical schools and postgraduate institutions in the United States, these topics receive little time and attention.”^2,3 Furthermore, when medical schools do explicitly address issues of health and human rights, it is usually in the context of global health electives, or relegated to become part of the so-called “hidden curriculum,” the body of knowledge passed informally from doctor-to-student or student-to-student. Physician interest and student self-selection are major forces promoting this training; education that is provided is subject to both faculty interest in the subject matter and perseverance of interested students in seeking out elective coursework.⁴ As a result, the fund of knowledge relating to health and human rights is often fragmented and is rarely an integral feature of medical education in many schools.

However, in a rapidly globalizing society, where refugees from Somalia end up in Section Eight housing in Boston or illegal migrant workers in the Gulf suffer from asthma due to substandard living conditions, issues that once were designated “international” quickly become local. Today, human rights abuses and their sequelae find themselves in our primary care panels, our operating rooms, and our emergency departments with a frightening regularity. Teaching about human rights abuses as issues beyond America’s borders leaves our physicians and medical students unprepared to meet the needs of increasingly complex individuals living in this country who have faced similar challenges.

The human rights paradigm—specifically legal, advocacy, and public health approaches⁵ — gives us a framework in which to understand and rectify our patients’ circumstances and should become a larger component of undergraduate medical education. This view has been advanced previously by multiple organizations including the American Medical Association, Association of American Medical Colleges, American College of Physicians, and World Medical Association, who collectively have called for physicians to be competent in and to advocate for human rights issues, including those of socioeconomic inequality, social justice, and violence.^{6, 7, 8, 9, 10} Additionally, Cotter et al. noted that 62% of deans of medical schools and schools of public health want these issues taught to their students.⁴ Major barriers noted were lack of funding, lack of trained personnel, and most notably, lack of time in the curriculum. And while medical students need to be trained to identify and understand the theoretical aspects of human rights violations, we also must begin to form a critical praxis towards addressing these issues in our patients. Human rights training and advocacy, to quote Gruen et al., “[…] bridge the gap between rhetoric and reality—the rhetoric of social responsibility espoused in aspirational statements of professionalism and the realities of medical practice and the mechanisms by which social factors affect the health and care of patients.”¹¹

What we want to emphasize is that this call for further education is not merely coming from the top-down—from teacher to student—but also from the bottom-up. We not only see a need for further education in the connection between human rights and health, but we also urge our colleagues both at home and abroad to realize that these issues are not in just in the confines of certain geopolitical spheres or relegated to historical aberrances. These problems currently exist, and moreover, they exist in our hospitals. While the barriers to including this training mentioned above are not insignificant, we believe this formal training is crucial to our aspirations to become socially conscious physicians. Without it, we may understand how to hold our scissors correctly while repairing a laceration, without ever understanding why our patient was cut or what we can do about it.

The authors are students in the Advocacy Training Program at Boston University School of Medicine, 700 Albany Street, Boston, MA.

For correspondence, e-mail ashprem1@bu.edu.

References

¹ International Covenant on Economic, Social, and Cultural Rights. G.A. Res. 2200 (XX) (1966). Available at: http://www.un-documents.net/icescr.htm.

² International Covenant on Economic, Social, and Cultural Rights. G.A. Res. 2200 (XX) (1966). Available at: http://www.un-documents.net/icescr.htme. 354/17 (2006), pp. 1771-1773.

³ L.E. Cotter et al. “Health and Human Rights Education in U.S. Schools of Medicine and Public Health: Current Status and Future Challenges.” PLoS ONE 4/3 (2009), pp. e4916.

⁴ University of Southern California Global Health Institute. “Global Health and Human Rights Syllabi Database.” Available at http://globalhealth.usc.edu/Home/Resources/Pages/Syllabi%20Database%20Overview.

⁵ S. Gruskin,  “Rights-based approaches to health: Something for everyone,” Health and Human Rights 9/2 (2006), pp. 5-9.

⁶ World Medical Association, Resolution on the inclusion of medical ethics and human rights in the curriculum of medical schools world-wide (1999). Available at http://www.wma.net/e/policy/e8.htm.

⁷ American Medical Association, Declaration of professional responsibility: Medicine’s social contract with humanity (2001). Available: http://www.ama-assn. org/ama/upload/mm/369/declaration.pdf.

⁸ L. Snyder and C. Leffler, “Ethics manual: fifth edition,” Annals of Internal Medicine 142/7 (2005), pp. 560-82.

⁹ L. Rubenstein, “The human rights imperative in medical education” Association of American Medical Colleges (2004). Available at http://www.aamc.org/newsroom/reporter/ jan08/viewpoint.htm.

¹⁰ American Association of Medical Colleges, Behavioral and social science foundations for future physicians (2012). Available at https://www.aamc.org/download/271020/data/behavioralandsocialsciencefoundationsforfuturephysicians.pdf.

¹¹ R. L. Gruen, S. D. Pearson, and T. A. Brennan,  “Physician-citizens: Public roles and professional obligations,” Journal of the American Medical Association 291/1 (2004), pp. 94-98.

Photos by:
- Mass Communication Specialist 2nd Class Eddie Harrison [Public domain], via Wikimedia Commons
- Staff Sgt. Alesia Goosic [Public domain], via Wikimedia Commons

MSF teams near the eastern border of Morocco have seen a dramatic influx of migrants with severe physical wounds such as broken limbs, dislocated jaws, and concussions. As reported on AlertNet, the migrants claim they are being attacked by Moroccan and Spanish security forces. The sub-Saharan African migrants have been traveling through Morocco in an attempt to either reach Europe or return to their homes. They have been subject to abuse, degrading treatment, and terrible living conditions, and are vulnerable targets for criminal gangs, traffickers, and bandits.

Since the migrants are classified as “illegal” in Morocco, they are forced to live in “makeshift shelters in forests, caves, and abandoned buildings with no sanitation and limited food and water” while others have taken to the streets to beg for resources. MSF teams report that almost half of their migrant medical consultations in the area have been illnesses and injuries due to the poor living conditions. MSF reports their injuries have not only been physical; there is evidence of a substantial psychological toll that these migrants must endure. MSF psychologists describe the migrants as consumed by a “profound sense of failure and [an inability] to imagine any other kind of future for themselves.”

AlertNet cited a MSF report entitled “Violence, Vulnerability, and Migration: Trapped at the Gates of Europe” which has tried to place more state-level responsibility over the care and protection of migrants in European-bordered countries. However, they have found that the EU has actually tightened its border restrictions and shifted accountability of policing illegal immigration to neighboring countries. This political confusion and shirking of responsibility has been identified as a major contributing factor to the rise of migrant community raids in Morocco and the subsequent violent arrests of refugees and asylum seekers.

Read the full AlertNet article here.
Read the full MSF report here.

Photo by: DFID – UK Department for International Development [CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

Earlier this month, the UN Special Rapporteur on torture and other cruel, inhuman, or degrading treatment or punishment released a report focusing “on certain forms of abuses in health-care settings that may cross a threshold of mistreatment.” According to this report, certain health care policies such as drug treatment can cover up abusive practices and torture that often go unnoticed. This report comes on the heels of a joint statement of 12 United Nations agencies which called for the close of compulsory drug detention and rehabilitation centers. Such centers were revealed to be sites of increased vulnerability to HIV and tuberculosis, lack of access to health care, and other such widespread human rights abuses.

In response, Human Rights Watch (HRW) urged donors to seriously reconsider their funding policies, especially to compulsory drug detention centers. In their own private research into government-run detention centers in South and East Asian countries, HRW workers reached similar conclusions. They found that people placed in these detention centers are often held without due process and face serious abuse, physical and sexual violence, and forced labor in these centers. Often, these conditions are covered up under the label of “rehabilitation.”

International donors are major players who have continued to provide funding and support to many drug detention centers, even knowing the human rights consequences. Funding from the US, Australia, UN agencies, and the EU has contributed to the expansion of drug detention programs—a phenomenon that the UN and HRW are now seeking to end.

The Special Rapporteur’s report highlights many viable alternatives, such as establishing a mechanism to monitor drug dependence treatment practices. He and HRW caution against simply opening new centers, for the centers’ intrinsic structures and policies lends to human rights abuses and poor health conditions. HRW health and human rights advocacy director Rebecca Schleifer strongly advocates international donors to seek to, “make it a priority to end these abuses and redirect their support to voluntary, community-based treatment and other programs that truly respect drug users’ human rights.”

Read the full UN special rapporteur report here
Read the full UN joint statement here
Read the full HRW article here

Photo: By B.navez (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0-2.5-2.0-1.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

The François-Xavier Bagnoud Center for Health and Human Rights is hosting a set of expert panel discussions to mark International Roma Day on April 8, 2013 from 1:30 p.m. to 5:45 p.m. at the Minda de Gunzburg Center for European Studies (27 Kirkland Street, Cambridge, MA).

The “Realizing Roma Rights: Addressing Violence, Discrimination and Segregation in Europe” conference will bring together policymakers, academics, and activists from across Europe and the United States to address the inter-related themes of extremism, structural discrimination and youth disempowerment.

The conference is jointly organized by the FXB Center, the Mahindra Humanities Center at Harvard University, the Minda de Gunzburg Center for European Studies at Harvard University, and the Organization for Security and Cooperation in Europe/Office for Democratic Institutions and Human Rights (OSCE/ODIHR). The program will conclude with a cocktail reception and performance by world-renowned musician Lulo Reinhardt. To view the conference draft agenda, please click here.

To secure your participation, please email Bonnie Shnayerson (bshnayer@hsph.harvard.edu) by March 25.

By Brigit Toebes, Lecturer in international law, University of Groningen, Netherlands

The environment in which humanitarian assistance is provided has changed dramatically over the past decades. While most conflicts taking place in the world today are of a non-international character, there has also been a significant increase in the number of people in need in the aftermath of other emergencies and man-made and natural disasters. In such settings, the security of humanitarian staff has become a major issue, as well as the restrictions imposed on humanitarian assistance. In this post, I will discuss how the right to health offers an important framework for protecting humanitarian aid workers, their equipment and buildings, and the local population receiving the aid.

The primary body of law regulating humanitarian assistance is international humanitarian law (‘Geneva Law’). However, this set of rules only applies fully during international armed conflicts. As such, human rights law forms an important additional framework, in particular during non-international armed conflicts, emergencies, and disasters. Strongly linked to the provision of humanitarian assistance are economic, social, and cultural rights, as these rights are about securing individuals’ rights to basic socio-economic services (food, clothing, water, housing, and health care). A key right in such settings is the right to health, as it protects the delivery of medical services as well as other health-related services, including safe drinking water, adequate sanitation, and food.

When it comes to the applicability of these rights during all types of emergencies, economic, social, and cultural rights rights may not necessarily apply unconditionally. However, there are strong reasons to assume that States are under a legal obligation to guarantee a number of minimum entitlements under all circumstances, including emergencies. General Comment 14 on the right to health defines a set of core obligations or minimum entitlements that are to be guaranteed irrespective of a State’s available resources. These minimum entitlements include access to basic shelter, housing, and sanitation, and an adequate supply of safe and potable water, essential drugs, training for health personnel, as well as equitable distribution of all health facilities, goods, and services, and taking into account the principle of non-discrimination.

It is now broadly accepted that States and potentially other actors have duties to respect, protect, and fulfill human rights. Based on this, we can conclude that States on whose territory the disaster is taking place are under a duty to respect, protect, and support the delivery of health-related services by humanitarian aid workers. Duties to respect imply a duty to accept humanitarian assistance and not to obstruct humanitarian aid workers in the exercise of their tasks, either wilfully or through negligence. Duties to protect mean offering protection to humanitarian aid workers, so as to ensure that they can carry out their tasks safely and adequately. Finally, duties to fulfill imply ensuring the supply of medical aid, adequate food, and shelter to the maximum of a State’s available resources, in support of the humanitarian aid. Likewise, (developed) States that are in a position to assist have duties to provide international assistance and cooperation, as is pointed out in Article 2(1) ICESCR and General Comment 14.

Furthermore, as conflicts and emergencies may involve several non-state actors, varying from armed opposition groups to civil society organizations, the question arises whether the right to health can also bind such non-state entities. The Universal Declaration of Human Rights, by referring to the human rights responsibilities of all actors in society, provides a basis for underlining the human rights responsibilities of non-state actors. Along similar lines, General Comment 14 on the right to health, stresses that all members of society have responsibilities regarding the realization of the right to health. Armed opposition groups are an important and powerful force during an armed conflict and their activities can have a devastating impact on the lives and health of persons engaged in and affected by the conflict. An important factor for them to be bound by human rights law will be, whether they exercise an element of governmental functions and whether they have de facto authority over a population. Hence, when they do, they may have similar duties as the State duties mentioned above.

We may also want to look at the responsibility of humanitarian aid workers and their organizations. Independent aid organizations can be characterized as ‘non-state actors’ which according to General Comment 14 have duties to provide international assistance and cooperation, along with (developed) states. As independent organizations, their employees cannot be characterized as state agents; hence they do not carry direct responsibilities under human rights law. Nonetheless, they have to respect the  ethical codes to which they have committed themselves throughout their training. Doctors among them are morally bound by the relevant medical-ethical codes; for example, the principle of ‘medical neutrality’ implies that medical aid is to be provided to everyone, irrespective of, for example, ethnicity or nationality.

Literature

Barber, Rebecca, Facilitating humanitarian assistance in international humanitarian and human rights law, International Review of the Red Cross, Volume 91, Number 874; June 2009, pp. 371-397.

Bellal A., Giacca G, Stuart C.M. , ‘International law and armed non-state actors in Afghanistan’, 93 International Review of the Red Cross 881, March 2001, pp. 1-33

Committee on Economic, Social and Cultural Rights, The right to the highest attainable standard of health, UN General Comment No. 14 (2000), UN Doc. E/C12/200/4, 11 August 2000.