Specific topics the course will cover include: reproductive and sexual health; rights issues arising in health care settings; abuses in institutional settings; palliative care; access to medicines and approaches to health-care rationing; structuring remedies to facilitate democratic deliberation and broad participation; strategies with respect to implementation of collective and structural judgments; and factors to consider in assessing the equity impacts of judgments, which include — but go beyond — income, gender, and marginalized status. The goal of this course is not only knowledge dissemination and strategic practice, but the creation of networks around the legal enforcement of health rights.

The week-long course will be held from June 18-22, 2012 in Boston, MA. The course will be conducted in English, and is composed of seminars and group exercises. It is highly participatory and uses case studies extensively. The course is designed for PhD students, scholars, practitioners (e.g., law, public health, human rights or development), policy-makers and advanced master’s students. Space is limited!

Application materials and additional information are available on the FXB Center website. Please direct materials and questions to kfalb ~at~ hsph.harvard.edu.

Photo: U.S. Navy photo by Chief Mass Communications Specialist Robert J. Fluegel [Public domain], via Wikimedia Commons

Photo: By DFID – UK Department for International Development (Flickr: Bracing for a short, sharp jab) [CC-BY-2.0 (www.creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

In Science in the Service of Human Rights, Richard Pierre Claude examines the complex, sometimes fraught relationship between scientific progress and political society in order to propose a guiding framework with which to examine the tensions that may arise from this dynamic. Human rights, Claude contends, must be central to the debate over alleged abuses of science developments and new technologies. He examines international standards of human rights, as outlined in the Universal Declaration of Human Rights and the International Covenant on Economic, Social and Cultural Rights, demonstrating their applicability in the analysis of contentious socio-scientific debates. Claude later expands on his prescription that scientists themselves should become rights-literate so that they can actively serve to safeguard the rights of those affected by their work. He explains, “This book concentrates not so much on science as a discipline as on scientists as carriers of human rights and responsibilities, as people capable of bringing science into the service of human rights, and as the custodians and trustees of everyone’s right to enjoy and share the benefits of science and its applications.”

In offering a rights-based framework to analyze scientific controversies, the book completes its dual goal of providing grass roots empowerment through a thorough explanation of the history and international meanings of human rights, and promoting an environment in which scientists understand the link between science and human rights and take responsibility for the social effects of their work.

- By Judith Fitzpatrick

Virtually all countries are trying to achieve universal health coverage, meaning that their populations use appropriate levels of care without experiencing financial hardship. Governments are likely to come under increasing pressure to accelerate progress towards this goal, especially as the UN General Assembly recognizes the urgency of the topic.

As WHO’s World Health Report demonstrates, health financing issues are critical in determining levels of health coverage – in terms of who is covered, for which services, and to what degree of financial protection. Governments in developing countries  face a major question: Which financing mechanisms will be most effective in achieving universal coverage? In particular, should countries rely more on private mechanisms (including fees at the point of service and private insurance) or public mechanisms (tax financing and social health insurance)?

After decades of debate, a clear consensus is emerging across the world: in fact, public financing mechanisms perform better. Direct patient fees have been shown to be inefficient and grossly inequitable and private insurance mechanisms (both commercial insurance and community insurance) have failed to cover large populations in the informal sector. Only compulsory publicly managed mechanisms have the ability to compel the healthy-wealthy to cross-subsidize the sicker poor. Countries should not look to outlaw private financing, as encouraging the better-off  to finance additional services may help relieve pressure on public budgets. However, as many middle-income countries have shown (notably Thailand, Mexico, Brazil, and China), if governments want to accelerate progress toward universal coverage, they would be advised to concentrate on improving the performance of the public financing mechanisms.

Sixteen-year-old Florence was an orphan doing domestic work when the January 2010 earthquake hit Haiti. She moved with the family she worked for to a displacement camp, where her employer raped her. The rapist threatened to harm her even more if she told anyone, so she didn’t see a doctor. Besides, she didn’t have the money, the means, or the information she needed to get care. She discovered she was pregnant.

Months into her pregnancy, Florence decided to press charges. But the lack of a post-rape medical exam not only affected her health; it also prevented her from pursuing justice for this horrible crime.

In Haiti, the justice system relies on certificates from care practitioners after a post-rape examination as foundational evidence for prosecuting rape. Without this medical certificate, rape charges will not proceed successfully; and because significant numbers of rape victims cannot or do not seek medical attention following rape, many attackers are never charged or punished.

There are few instances in which the health and human rights of women and girls intersect in such an immediate way as after violence. Ending violence against women and girls, like that endured by Florence, is a public health imperative.

Sexual violence causes physical injury, disability, and even death. It can result in sexually transmitted disease, poor reproductive health, unwanted pregnancies, unsafe abortions, and depression. The public health community, including local and international health providers active in Haiti, needs to be prepared to handle the health and social consequences of violence against women, and to work to prevent this violence. Playing a role in successful prosecutions, including by issuing medical certificates after rape, is only one of many ways health professionals can take an active role in ending violence against women.

In Haiti, where I interviewed more than 120 women and girls about sexual violence and access to health care in 2010 and 2011, the government is doing little to inform the public about access to post-rape care, and few health providers are trained to address gender-based violence. Professional schools for doctors and nurses do not include instruction on treating gender-based violence as part of their core curricula or continuing learning programs. Doctors and nurses may not necessarily know how important medical certificates are for rape prosecutions. So even when girls like Florence are able to overcome obstacles in getting to a health facility, they may still not receive appropriate medical services, or the correctly completed medical certificate they need.

November 25 was the 30^th anniversary of the International Day for the Elimination of Violence Against Women. Over these 30 years, enormous gains have been made in some countries in passing laws against sexual and domestic violence and in developing guidelines for health providers to identify, treat, and refer victims of gender-based violence to appropriate services. In Haiti, these gains are just now starting to be made—slowly—with the criminalization of rape in 2005 and new legislation addressing violence against women being discussed.  But these gains mean little to women like Florence when the reality of seeking health services or justice is a far cry from the laws and guidelines.

Health professionals may not know that the women and girls they treat have experienced sexual violence and about the resulting trauma. Naomi, 25, didn’t tell anyone that a man had raped her, but she had an already-scheduled family planning appointment at a clinic shortly after. “I didn’t tell them I had been raped, because I was ashamed,” she told me.Unlike Florence, she had reached medical care—she was there in front of a health professional—and still Naomi slipped through the system.

Health professionals’ ability to recognize, treat, and work to prevent violence against women can have a significant impact on the human rights of women everywhere, and is especially critical in disaster or displacement situations with high risk of sexual violence, like Haiti.

In Haiti, and indeed in many other countries, public health authorities should take immediate steps to inform the public about where victims can go for post-rape care, as well as steps necessary for legal redress, such as obtaining medical certificates. Public health officials should work with medical and nursing schools to ensure that providers have proper training and the ability to recognize signs of violence if a patient is reluctant to speak.

Public health officials should also work with the many nongovernmental organizations operating in Haiti to make sure health professionals know what services are available for psychosocial support, legal assistance, or relocation to safe housing for women victims of violence. Without this, appropriate health care and legal redress will remain out of reach for women like Florence and Naomi.

_____________________________________________________________________________________________

Amanda Klasing is the Americas researcher for the Women’s Rights Division at Human Rights Watch and author of the organization’s report, “‘Nobody Remembers Us’: Failure to Protect Women’s and Girls’ Right to Health and Security in Post-Earthquake Haiti.”

For more information:

Human Rights Watch: ‘Nobody Remembers Us’: Failure to Protect Women’s and Girls’ Right to Health and Security in Post-Earthquake Haiti

People in South Africa overwhelmingly believe that addressing HIV/AIDS is firstly the responsibility of national government, in contrast with the current governance arrangements that put provincial government as the lead for governing health matters. Although foreign donors and civil society play very large roles in governing infectious disease, less than 20 percent of Eastern Cape residents identified them as appropriate authorities in a nationally representative 2009 omnibus survey of South African adults. This highlights a serious disconnect between citizen expectations and reality in terms of who governs infectious disease, which dampens citizen abilities to hold the appropriate authorities accountable.

So who should be responsible for governing the threat of infectious diseases such as HIV/AIDS, tuberculosis, and malaria? As the “old” paradigm of strong centralized state public health programs was found to be outmoded, a new set of governance models emerged in its wake, all involving greater devolution of authority and more horizontally organized reporting structures. In particular, a few appealing terms have buzzed about during the past three decades of the global AIDS crisis, including “multisectoral,” “synergistic,” “partnership,” “mutual accountability,” and “coordination.” Who could argue with any of these?

The problem, from a policy implementation standpoint, is that these are actually goals in themselves, not levers that can simply be pulled at will to successfully reduce the transmission of diseases, to treat those who are infected, and/or to provide support to those who need it.

Telling a bunch of disparate and often rival interests to just cooperate or to act in a synergistic manner is like taking a bunch of kids to a candy store and telling them to select the healthiest snacks, especially those without excess sugar. It might happen, but it’s not likely without strong incentives and enforceable sanctions.

Cape Town, Western Cape, South Africa.

Too many contemporary best practice recommendations concerning the structure of governance for better global public health seem to rest on politically naïve assumptions. Those who suggest “cooperation” or “coordination” as a strategy rather than as an objective seem to take for granted that the various health-relevant actors and stakeholders in a society will not only prioritize health-related goals, but will consistently do so in a manner that is concerned with the general welfare, and not with their own interests as politicians seeking re-election or as organizations looking for additional resources. While there are many committed civil servants, NGO leaders, and activists who act selflessly each and every day, such patterns are more exceptional than the norm.

In my recently published research on the governance of infectious disease in South Africa (Social Science & Medicine, September 2011) I detail some of the pathologies of an approach that devolves authority to multiple, overlapping actors in a structure recognizable as polycentric governance. I present a case study from South Africa to examine how governance structure affects accountability and performance. The analysis is based on interviews with municipal councilors, hospital and clinic administrators, non-government service providers, political party leaders, academics and journalists, religious leaders, traditional leaders and healers, large businesses, and public law advocates. In addition, we administered a survey to local councilors, and I commissioned a question about perceived governance responsibilities for HIV/AIDS on the aforementioned 2009 omnibus survey of South African adults.

Comments made during the interviews indicate some of the challenges of polycentric governance. While some health programs are organized and administered at the municipality level, funding often comes from the provincial or national arenas, making it difficult for the municipality to hire long-term employees or maintain programs. Although non-governmental organizations provide valuable funding and new projects, they also add to the complexity of the system owing to their fragile resource needs. NGO representatives complained about time wasted on reports and paperwork to comply with PEPFAR and other donors.

Polycentrism may also lead to the unnecessary provision of duplicate services or competition among actors who are carrying out similar programs. For example, in some areas we found two types of local clinics, some run by the municipality, and others managed by the province through the district health system. This resulted in some duplication of services as well as conflict over funding disparities. Provincial clinics were generally better resourced, while municipalities, with very limited tax bases, depend on the provinces for funding.

Many would argue that with a crisis as acute as the AIDS epidemic in South Africa, more actors working to provide resources and solve problems would lead to better outcomes. However, this does not necessarily appear to be the case. Polycentric governance without a clear hierarchy or system for enforcing commitments can lead to duplicate services or gaps that are left unfilled, not to mention confusion and frustration.

This research raises more questions than provides answers. It does not identify the optimal governance structure for the South African case, let alone a general model that might work elsewhere. But it does suggest the need to take much more seriously the question of how to govern, and to distinguish desirable goals from concrete strategies. More systematic reflection and research is needed concerning how to incentivize political leaders at various levels of government, and the range of non-government organizations and service providers to do a better job of prioritizing and coordinating critical disease-related services.

Photo by Dorena-wm [CC-BY-2.0 (www.creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

Ernest Drucker’s A Plague of Prisons: The Epidemiology of Mass Incarceration in America analyzes a pressing social issue through an epidemiologic lens.  Applying public health theory to “a different kind of epidemic,” Drucker frames mass incarceration as a chronic and self-sustaining plague that is damaging American families and communities. The author begins his argument by defining mass incarceration and listing its inherent epidemic characteristics:  a rapid growth rate, large magnitude, and persistence. He identifies the 1973 Rockefeller drug laws as the “outbreak” of the plague, noting that the laws, which mandated extended sentences for drug offenses, drove the ballooning rates of incarceration that spanned from the mid-1970s to 1999. With 2.3 million Americans behind bars, 800,000 on parole, and another 4.2 million on probation, Drucker identifies large-scale arrests, sentencing, probation, and parole as drivers of the elevated incidence and overwhelming prevalence of imprisonment. He stresses the magnitude and severity of the “prison plague” by presenting data on years of life lost due to drug incarceration and the poor conditions and suffering status of health care in prisons. Furthering his argument that incarceration is plaguing the health and well being of the United States, he presents imprisonment as a force that destabilizes family life and leads to chronic incapacitation for prisoners even after they have been released.

Drucker closes his book with his prescription for the epidemic, which follows the public health model and offers primary, secondary, and tertiary strategies for prevention.

– By Judith Fitzpatrick

This post is excerpted from a plenary speech given at the International Conference on AIDS in Asia/Pacific (ICAAP), Busan, South Korea, August 27, 2011

Here in Asia, home to more than half the world’s opiate users,  more than 16 million drug users and at least 6.5 million injectors, where HIV prevalence among injectors is among the highest in the world, where the HIV epidemic is largely driven by unsafe injecting practices, where less than 10% of heroin injectors are on methadone, and where injectors can access an average of just two sterile syringes per month, we lack 90% of the resources necessary to provide the essential harm reduction services necessary for realizing the right to health. But while resources are a significant challenge, I would argue that even when we have the resources, it does not ensure access.

Unless and until we address and remove the legal and policy barriers to accessing services for people who use drugs, investing in harm reduction is tantamount to flushing your money down the toilet. No smart investor in harm reduction would ignore the repressive legal and policy environments in which harm reduction services in Asia take place. A good investor would favor interventions that work against the collusion of criminalization, strict law enforcement practices, and the failure to respect, protect, and fulfill human rights for marginalized groups, which undermines and even undoes the benefits of the harm reduction services we are providing.

Thai policeman. Photo by Rico Gustav

Unfortunately, human rights abuses are characteristic of the dominant approaches used by governments to control drugs in this region. The constant threat of police arrest, violence, and incarceration at harm reduction drop-in centers, methadone clinics, and other places where drug users receive services minimizes the impact of these services. Documentation reveals police harassment and interference at health services accessed by drug users; arrest and forced detention at compulsory drug detention centers; a lack of due legal process, unreasonably long pretrial detention, and other breaches of fair trial standards, including false or forced confessions. Forced labor and torture in the name of healthcare is meted out through beatings, chaining, and electric shock; denial of information, prevention tools, antiretroviral therapy, and food are also reported. In Thailand, more than 2,250 people were extra-judicially executed during a 3-month government drug crackdown in 2003; in Cambodia, people who use drugs are forcibly confined in military-run “treatment” centers where staff have no training in addiction or counseling, and appeal is not an option; in Vietnam, drug treatment centers require detainees to work long hours under extremely harsh conditions with little to no compensation, and severe punishment is meted out for those who fail to meet work quotas. In most countries in the region, police interference with needle and syringe programs and opiate substitution therapy programs prevent many users from getting the health services they require.

Failing to provide comprehensive harm reduction services in prisons, which are largely filled with drug offenders, perpetuates unsafe injection, sex practices, and disease transmission among prisoners and their sex and injecting partners. We would never expect someone having sex to reuse a condom, but every day we force injectors to do the equivalent with dirty needles. We would never require a diabetic to visit a clinic daily in order to obtain their insulin, nor deny them insulin for eating a piece of cake; however, we do the equivalent with people who use drugs when we demand directly observed methadone and deny antiretroviral therapy if they do not quit drugs or even methadone. Government laws and policies in this region are allowing this discriminatory treatment.

In June, world leaders, including former Secretary-General of the United Nations, Kofi Annan; Dr. Michel Kazatchkine, the head of the GFATM; and five former presidents and prime ministers, formed the Global Commission on Drug Policy and released a report after reviewing the global body of evidence. They describe their findings succinctly in the report’s very first sentence: “The Global War on Drugs has failed, with devastating consequences for individuals and societies around the world.”

The Commission concludes that we must stop the war on drugs and replace drug policies and strategies driven by ideology and political convenience with policies and strategies grounded in science, health, and human rights; and we must adopt appropriate criteria for their evaluation. It suggests that governments hold open debates on alternatives to these failed policies and experiment with humane approaches that do not undermine human rights but rather recognize that drug use is a complex health condition with underlying social, psychological, physical, and other causes for which treatment, and not punishment, is required.

Not only are massive human rights violations taking place under the aegis of public security and drug control, but these methods are also failing to achieve their own goals of reducing and deterring drug use. There are more people using different drugs than ever; however we have less capacity to effectively address their harms.

The findings of the Global Commission on Drug Policy are not new. For decades, people from around the world who use drugs have been shouting this message as they watched their friends die untreated of HIV, overdose, and hepatitis; as they were arrested and beaten and had money extorted and drugs planted on them by police; as they were detained and imprisoned without respect for their basic rights, as they were denied information and prevention tools, antiretroviral therapy, and humane drug treatment. People who use drugs bravely and publicly implored their government leaders to heed their call for an end to the drug war and human rights abuses, but their message fell on deaf ears. It is a tragedy that we have already lost so many beautiful people who were ignored and despised and misunderstood by their governments and communities. Who is accountable? Antonio Maria Costa himself, the former executive director of the United Nations Office on Drugs and Crime (UNODC), says that governments have a legal obligation to put human rights at the center of their drug policies, noting, “Too often, law enforcement and criminal justice systems themselves perpetrate human rights abuses and exclude and marginalize from society those who most need treatment and rehabilitation.” This may sound ironic, given the fact that the UNODC is part of a global drug control system that promotes confusion and misunderstanding about the drug conventions, and actively fights against humane approaches to drug control, bullying countries and creating barriers to change.

Thai AIDS Treatment Action Group protestors. Photo by Rico Gustav

Drug law reform activists are often encouraged to take the long view on policy change. In meeting rooms, we are asked to be patient, to forget about legal reform, or to just wait. Society isn’t “ready,” we are told. The government isn’t “ready.” But as my hero, Reverend Martin Luther King, Jr., wrote in a letter from an Alabama jail, this word, “Wait,” which he too heard for years, has almost always meant “Never.” “Justice too long delayed is justice denied,” he wrote. “Freedom is never voluntarily given by the oppressor; it must be demanded by the oppressed.”

King also said that we have a moral responsibility to disobey unjust laws. I propose that if, in our country, the provision of life-saving prevention tools such as clean needles or opiate substitution therapy is found illegal, it is our moral obligation not to comply.

Thankfully, we have strong examples of ways that countries are moving away from punitive, abstinence-based approaches to drugs and experimenting with legal and policy reform. Countries in Latin America, North America, and Europe have promoted:

• decriminalization of drug possession for personal use,
• proportionality in sentencing,
• alternatives to incarceration for drug possession,
• the removal of paraphernalia laws,
• the establishment of safer injecting facilities and heroin assistance programs as part of a range of low-threshold services for people who use drugs,
• adequate financing for harm reduction, and
• the abolition of the death penalty.

These progressive countries are finding that their reforms do not result in increased drug use, as their opponents feared, but rather lead to increased uptakes in drug treatment, reduced harms from drug use, and also reduced drug use. Countries such as Australia and Switzerland, where criminalizing laws have been reformed or removed, boast low HIV prevalence, while countries such as Thailand, China, and Vietnam, where governments have failed to remove these outdated and ineffectual laws, have extraordinarily high prevalence rates.

As Dr. King reminds us, there is no time to wait. Let us fearlessly advocate for drug law reform so that we may to achieve universal access in Asia. The time is now.