Disasters, such as earthquakes, floods, civil war, and other sudden large-scale calamities often trigger health crises and can result in responses that compromise and even devalue the fulfillment of human rights. We invite submissions that explore the human rights and health aspects of disaster relief preparation, management, and outcomes. Essays are particularly invited that: explore disparities between implementation in the field and academic literature; offer insights into the traditional definitions of vulnerable groups within the context of humanitarian operations; suggest critical analyses of disaster response from a health rights-based participatory or accountability perspective; consider ethics in crisis response; or examine the increasing role of risk reduction as it relates to both public health and human rights practice.  What voices are missing from the field in human rights analyses of disaster? What new models of practice might improve the right to health for all affected by both disaster and response?

Submission details are available here. All submissions considered eligible for potential publication are subject to external peer review.

To answer this question, Lawrence O. Gostin, Faculty Director of the O’Neill Institute at Georgetown University Law Center, proposes an international call to action through the adoption of a Global Plan for Justice (GPJ),  a voluntary compact among states and their partners in business, philanthropy, and civil society to redress health inequalities. Under the GPJ, states would devote resources to a Global Health Fund based on their ability to pay — for example, 0.25% of Gross National Income (GNI) per annum — in addition to maintaining current development assistance devoted to programs and activities of their choice. Global Health Fund resources would be allocated based on the health needs of developing countries measured by poverty, morbidity, and premature mortality.

Click here to read the full article: “Redressing the Unconscionable Health Gap: A Global Plan for Justice,” Harvard Law and Policy Review 4 (2010), pp. 271–294.

For an explanation of how the GPJ fits into other innovative Global Health Governance strategies, see http://www.law.georgetown.edu/oneillinstitute/documents/2010-07_Global_Plan_for_Justice.pdf and http://www.acslaw.org/node/16479 (explaining the progression from a Joint Learning Initiative for National and Global Responsibilities for Health, to a Global Plan for Justice, through to a Framework Convention on Global Health). See also, Lawrence O. Gostin, Meeting Basic Survival Needs of the World’s Least Healthy People: Toward a Framework Convention on Global Health, 96 Geo. L.J. 331 (2008), http://ssrn.com/abstract=1014082, http://scholarship.law.georgetown.edu/ois_papers/1/.

Over the past eight years, the Constitutional Courts of Argentina, Ecuador, Chile, and Peru have issued decisions banning or highly restricting access to emergency contraceptive drugs. These decisions have all followed a similar pattern in their arguments as well as the same order in which such arguments were considered. Prior to these cases, the battleground over the right to life had been limited to the field of abortion law; using birth control laws would have been considered unusual. This post offers a summary of this trend by looking at the structure of the latest of these Constitutional Court rulings, the decision issued by Peru’s Constitutional Court in 2009.

In 2004, a group of Peruvian citizens used a judicial recourse to challenge a resolution through which Peru’s Ministry of Health authorized the free distribution of emergency contraception pills (ECPs). The process reached the Constitutional Court which, on October 16, 2009, interpreted the Constitution as bestowing a “right to life” from the moment of conception. That is, the Court decided to adopt a stand according to which conception happens at the moment when an ovum is fertilized, based on the understanding that from this point on there exists a “unique individual,” genetically speaking.

Technically, the plaintiffs on this case recognized (though not explicitly) that ECPs did not cause abortions, that is, that they were not abortifacients. An abortion is the termination of a pregnancy; in order for an abortion to take place, there must have been a pregnancy. Medical science and every major health organization in the world agree that pregnancy only begins at the moment in which a fertilized egg is implanted in the uterine wall. This is why the World Health Organization, for example, as well as other leading global health policy organizations, have always asserted that ECPs are not abortifacients.

Thus, while the plaintiffs were (contrary to all precedent) claiming that ECPs were abortifacients, they were not claiming that these drugs could terminate a pregnancy. They argued, rather, that ECPs could prevent an already fertilized egg from implantation in the uterine wall. This led the way for the Court — which then had to decide whether or not ECPs are abortifacients — to identify whether or not ECPs could prevent a fertilized egg from being implanted in the endometrium, that is, whether ECPs could prevent a pregnancy. After examining the scientific evidence, the Peruvian Court declared the existence of a reasonable doubt. That is, they declared that a zygote is materially not a person (it is indeed not even an embryo), nor is it legally a person before international law. But despite this admission, the Court in fact assumed otherwise. After adding that they identified a “reasonable doubt” and thus the establishment of the zygote as a person entitled with a “right to life,” the Court ruled in favor of the plaintiffs, resulting in a ruling that severely restricted emergency contraception.

Even after the Court conferred the zygote with the “right to life” of a human being, the ruling failed to deliver a balanced decision that supports human rights, by its failure to explicitly recognize that the existence of a fertilized egg does not nullify the status of women as subjects of human rights. Instead, the Peruvian Court (and also the Argentine, Ecuadorean, and Chilean Courts) present a clear human rights violation — of women’s rights — as if it is comparable with an entirely hypothetical violation, i.e., the rights violation of a fertilized ovum that might possibly have existed if a fertilized egg had not been prevented from implantation in the uterine wall. By this legislation, an indisputably human person who has human rights that are on the verge of being violated has been sacrificed in the name of conjectural assumptions woven together in a legal argument to create the appearance of a person.

Photo by Laurie Wen

Monday, March 8 marked the celebration of International Women’s Day, a global tribute to the economic, political and social achievements of women past, present and future. In this guest post, Dr. Agnès Binagwaho, Permanent Secretary of Rwanda’s Ministry of Health, reflects on the human rights of women in Rwanda.

Sixteen years ago, during the 1994 Rwandan Genocide, perpetrated by Hutu extremists against Tutsis and the Hutu moderates, where one million people were killed — more than one tenth of the Rwandan population — women’s rights were profoundly denied, as many of our mothers, sisters, and girls endured systematic massive rape that resulted, often intentionally, in the devastating effects of a slow death by HIV/AIDS infection. During that time the country was destroyed, its health system ceasing to function as health professionals were killed or left the country and infrastructure and materials were destroyed. As this week we celebrated International Women’s Day 2010, I salute the fact that rape as a weapon of war has been recognized as a crime against humanity.

Times have changed in Rwanda. Thanks to the new leadership since 1994, most of the population thinks “out of the box,” with a strong belief that there is always a solution if we work hard to find it and if we search for solutions within our culture and within ourselves. In this short essay, I would like to share how the situation during the time of the genocide has been reversed to favor women rights and how it impacts my work.

Click here to continue reading Agnès Binagwaho’s piece, “What do human rights mean for a working woman in the Rwandan health sector? Reflections on International Women’s Day.”

The wealth of global response to Haiti’s January earthquake suggests a tremendous sense of global responsibility for a country whose current death toll is over 200,000. Now that Haiti is on the world’s central radar, how might those involved in rebuilding ensure that Haiti become a lasting center of global responsibility? That is, what’s the relationship between empathy for those affected by disaster and an engagement in transformation?

Certainly Haiti is in desperate need. Yet the discrepancy between the aid provided before 16:23 on Tuesday, January 12, 2010, and the outpouring of funds since then is hardly consistent with the constancy of need that Haiti has expressed for decades. Will Haiti remain a point of awareness for those who feel this recent increase in responsibility, or will it disappear back into the realm of public health experts and anthropology lectures at elite universities as it has so often before?

If a similar event struck even one American city — a hypothetical transformation in 12 hours, in which time all basic health indicators, poverty levels, and living conditions become identical to a portion of the population on the outskirts of Port-au-Prince in 2008 — gross national income per capita would drop US$43,000. Infant mortality would jump 857%. Three percent more people would have AIDS, and TB rates would increase by 1,344 %. Unimaginable? Yet even these changes would fail to convey the years that Haiti has lived as one of the most impoverished nations of the world. A history of discord and poverty has combined to create an unshakable stigma that shrouds any association with the country. With this comes outside prejudice, and from prejudice the extensive debilitating components of social suffering. An earthquake with a magnitude of 7.0 hitting the country’s capital city is only the tip of the iceberg. Haiti needs the world to extend a hand not only in the coming months, but the coming decades.

Psychological factors make it so easy for us to forget, and sometimes hard to empathize with, suffering. Perhaps by acknowledging our psychological default setting we can improve everyday awareness of global suffering and increase long term action.

There are two primary limitations to comprehending the suffering of others. The first is internal: we are naturally programmed to feel more sympathy towards individuals than groups. Several studies have been done tracking gross donation quantities based on the picture that accompanied a campaign. Those pictures with a single child staring with longing into the camera resulted in considerably more money than the simple addition of one more child to the picture. Human empathy is simply not hardwired to deal with numbers and vast areas of suffering. A death count of 105 seems not much different from 103, yet when a report states that two were dead, we care. Indeed it appears that the fewer the number, the easier it is for onlookers to develop collective empathy. The second limitation is that of language: there are many instances when a limited vocabulary cannot convey the intense emotion that accompanies a tragedy; and increasingly in the medical world, there is an absence of jargon to fully explain the subtleties of suffering. Reading of one’s suffering, in short, can limit our ability to fully comprehend its depths.

Of course, some possess a greater ability to empathize than others, and empathy measures are inevitably generalizations. But taking human nature into account and applying it to a sustainable support strategy could perhaps keep Haiti on the radar. As the world marches on in the coming months and years, it is important that we not only remember Haiti, but also that we actively fight against the natural processes that makes us forget.

For more opinion on this subject see: http://www.nytimes.com/2010/01/14/opinion/14thu1.html

http://www.washingtonpost.com/wp-dyn/content/article/2010/02/01/AR2010020103183.html

http://www.nytimes.com/2009/07/09/opinion/09kristof.html?_r=2

For the empathy study cited see: http://pluto.mscc.huji.ac.il/~msiritov/KogutRitovIdentified.pdf

For up to date info on Haiti see:
http://topics.nytimes.com/top/news/international/countriesandterritories/haiti/index.html?scp=3&sq=haiti%20death%20toll&st=cse

Founded on an unwillingness to accept the grave inequities and double standards that are tolerated every day within the world, Nyaya Health, a small NGO in rural Nepal, operates with a mission of health equity and social justice. Nyaya — which means “justice” in Nepali — founded much of their work upon the model of Partners In Health, taking a rights-based, community-based approach to health care delivery. This post tells the story of Nyaya’s work in Bayalpata, and lessons learned in developing a health system in rural Nepal.

The district of Achham in Nepal suffers from some of the highest rates of poverty and maternal mortality in all of South Asia. Before Nyaya Health opened its first clinic, there was not a single allopathic doctor in the area; perhaps not surprisingly, 1 out of every 125 deliveries results in the mother’s death, with less than 0.5% of deliveries occurring in a health facility. Achham’s remoteness also means that, in a country that boasts one of the world’s most famous trekking and tourism industries, 95% of the households are without electricity and only 45% of people have access to safe drinking water.

In 2008, following a civil war, Nyaya Health opened the first primary health center in the region. Shortly after opening the clinic, the community requested that Nyaya take over administration of Bayalpata Hospital.

Bayalpata Hospital, built in 1976, was designed to be the first hospital in the Achham district of rural western Nepal. In a bureaucratic entanglement of political conflicts, the funding and equipment for the hospital were sent to a more powerful constituency in the district. The people of Achham came together as a community, protesting this injustice; the military opened fire on them as they surrounded the facility, killing several and wounding and imprisoning many more. The hospital remained empty, its walls rotting and decaying with time.

In an effort to bolster the public sector health system, Nyaya partnered with the Nepali Ministry of Health and Population (MOHP) to begin rebuilding.

As Nyaya began to rebuild the dilapidated hospital, broad, system-level infrastructure development was a clear priority. Having sat dormant for over 20 years, Bayalpata Hospital was a shell of a health care facility. With crumbling walls, not a single piece of medical equipment, only a scant few chairs and cabinets, faulty electricity and running water, and staff quarters that were too damaged to be repaired, the hospital required extensive renovation. Complicating this process was the fact that the dirt road leading to the hospital was of incredibly poor quality and often impassable, making transportation of supplies extremely difficult.

In 2009, Nyaya re-opened Bayalpata Hospital. Striving to empower the Nepali public sector, Nyaya prioritized the hiring of an all-Nepali staff. This however, in an area as remote and impoverished as Achham, proved challenging as well: brain drain, both internal (to metropolitan areas such as Kathmandu) and external (to the USA and Europe), pulls the most well-trained from the region, leading to a dearth of qualified personnel. Nevertheless, Nyaya continually works to hire locally, thereby improving the area’s own capacity and development.

Upon opening the hospital in June, 2009, Nyaya had restored two clinical buildings, a staff kitchen, and two of the staff quarters. In addition to outpatient and maternal health services, Bayalpata Hospital became home to the first emergency room in the region, as well as the first inpatient ward. While radiological services were initially limited to ultrasound, an X-ray facility is currently being built, and plans to scale-up comprehensive surgical services are being developed. All services are offered completely free of charge, 24 hours a day, 7 days a week.

Nyaya believes fundamentally in health care as a human right, and accordingly, is working toward the development of not only a hospital, but an entire community-based health system. While still nascent in its work, Nyaya aims to expand its community programs over time, recognizing that only wide-ranging infrastructure development will affect population-level health change. By working toward a goal of full accountability and integration with the public sector in particular, Nyaya aims to walk in solidarity with both the people of Achham and with the local and national governments, strengthening Nepali capacity broadly while prioritizing the most marginalized populations and ensuring health equity for all.

For more information on Nyaya Health, please visit http://www.nyayahealth.org and http://blog.nyayahealth.org.

Photo 1: Sanfe Bagar Primary Health Center

Nyaya Health opened the first community free clinic in the district of Achham in 2008. During the 14 months of its operation, Nyaya’s all-Nepali staff of 20 full-time personnel saw over 17,000 patients, providing the first allopathic physician in a region of over 250,000 people. Nyaya closed the clinic and moved all operations to the nearby Bayalpata Hospital in 2009.

Photo 2: Bayalpata Hospital

Today, seven months after opening its doors, Bayalpata Hospital has a continual flow of patients, and is quickly gaining a reputation for being the best available healthcare in the region. As Nyaya continues to expand its services through its partnership with the Nepali Government, it aims to contribute to the broad-based development of a community health system, focusing on health equity for all in a region that has historically been one of the most marginalized in all of Southern Asia.

Photo 3: Dilapidated Bayalpata Hospital buildings

Having sat unused for nearly three decades in a region with little power, water, or transportation infrastructure, the renovation of the hospital has been, and remains, an extremely complicated process. Of the five original staff quarters, only two have been restored, the others far too damaged to ever be functional again.

Photo 4: Bayalpata Outpatient Department

Bayalpata Hospital sees, on average, ­50 to 60 patients per day in its outpatient department. Patients most commonly present with respiratory infections, gastroenteritis and diarrheal illnesses. All services, including Nyaya’s laboratory and pharmacy, are free.

Photo 5: Emergency department

Upon opening, Bayalpata Hospital became home to the first emergency room in the area, providing services around the clock. Patients’ families frequently carry their loved ones in on homemade stretchers, often walking for over 4 to 6 hours to reach the hospital. Beginning in 2010, Bayalpata Hospital will commence emergency transport services to larger referral hospitals in the South of Nepal, with the region’s first ambulance, a recent donation from the Indian Embassy.

Photo 6: Nyaya laboratory tech Drona Awasthi

By offering point-of-care laboratory services, Nyaya is able to provide top-quality healthcare despite the remoteness of Achham. However, in the winter, because of the poor temperature regulation of the concrete buildings of Bayalpata Hospital, our lab technicians frequently have to use portable heaters to raise the temperature of the equipment before turning them on to avoid causing damage to the machinery.

Photo 7: Staff quarters

In order to provide 24-hour emergency services, Nyaya’s on-call staff all live within the hospital premises. As there are not enough quarters for the entire Bayalpata staff, and because Achham is very rural, this means that other staff have to walk up to 2 hours each day, to and from work, to their homes.

Photo 8: Hospital generator system

Because the regional power grid is shut off for several hours each day (“load-shedding”), and often for weeks at a time altogether, Nyaya relies on generators and inverters to power Bayalpata Hospital. But even this remains complicated: because no skilled maintenance technicians exist in the region, when the generator breaks, it must be shipped across the country where trained personnel spend weeks fixing it, at great costs.

Photo 9: Hospital water pipe

Because of the lack of a water source near the hospital, Nyaya has established large reservoirs at the hospital that are fed by a small pipe running over four kilometers away to the nearest reliable and clean water source. Given the distance the pipeline travels though, there are often breaks in the water supply, requiring Bayalpata staff to follow the pipeline backwards until they can find the leak and repair it. In the future, Nyaya hopes to develop a more permanent, underground system of piped water.

Photo 10: Bayalpata communications satellite

In order to maintain communication with local and regional authorities, and also with Nyaya’s extensive network of international volunteers, Nyaya has established a satellite internet connection, providing high-speed wireless internet in even the most remote of regions.

Photo 11: Bayalpata road following monsoon storm

Complicating Bayalpata’s operations even further, the transportation network in Achham is extremely poor. The roads are frequently washed out during monsoon season, isolating the hospital from its supply chain of pharmaceuticals, medical equipment, food, and other necessities, and preventing patients from getting to the hospital for care. The Nepali government is currently working to improve the quality of the road leading to the hospital, but the exact timeline remains unclear.

Photo 12: Nyaya Health Staff

In its mission to strengthen the Nepali public sector, Nyaya employs an all-Nepali staff, while partnering with volunteer clinical and public health experts from all over the world. Nyaya’s staff consists of 23 full-time personnel and is rapidly expanding. Nyaya’s Board of Directors, and all expatriate volunteers, are exclusively volunteer – Nyaya does not pay consultancy fees, and channels over 99% of its funds directly to health care services in Nepal.

Photo by Meredith Baker

[Editor's note: This is a guest post written by Meredith Baker. Her bio may be found at the end of the article.]

This past winter break, I had the opportunity as part of my undergraduate program to travel to Nicaragua and participate in community development work. While I have witnessed considerable poverty before, the community of Nuevo Amanecer, Nicaragua, brought me to a new understanding of what abject poverty can mean.

While the people of Nuevo Amanecer have a variety of basic needs, such as access to clean drinking water (they walk three miles a day to get water because local wells are contaminated), malnutrition amongst children is perhaps the most visibly dire. According to a UNICEF report, iron deficiency impairs the mental development of 40%–60% of children in developing countries. It can not only lead to anemia, but is also estimated to lower the GDP of developing nations by 2% due to lower energies and therefore low productivity of the workforce. Vitamin A deficiency leads to destroyed immune systems in children under the age of 5 and approximately 1 million deaths each year.

One hundred families live in Nuevo Amanecer (meaning “New Sunrise” in English), a community founded only a few years ago with the help of the Long Island student group “Students for 60,000.” The community serves as a permanent residence for “squatters,” or people who would have otherwise settled illegally or on public land. It was heartbreaking to see the kids of Nuevo Amanecer running around clothed only in dirty underwear – the only pair some of them owned. Most of the children were very skinny, with twig-like arms and legs, rotting teeth, and swollen bellies as a result of malnutrition and hunger. A few toddlers I encountered had thinning copper-colored hair (hypochromotrichia), a frequent symptom of protein deficiency.

The people of Nuevo Amanecer had a community vegetable garden. However, there were never enough fruits or vegetables to go around. The diet for most consisted predominantly of rice: good for carbohydrates, but lacking many other essential nutrients. This made me wonder if there weren’t an inexpensive, easy way to provide fortified foods to help these kids meet their daily dietary needs. Perhaps if the people of Nuevo Amanacer were educated on the necessary macro and micronutrients their bodies needed, and perhaps if aid organizations were able to provide fortified food or multivitamins in greater supply, the community’s emaciated children could at least begin to look and feel like healthy children their age.

Coincidently, my favorite columnist, Nicholas Kristof of The New York Times, was also in Central America at the time, writing a column about malnutrition in Honduras, with suggestions for simple, cheap ways to supply people in developing countries with necessary nutrients. In his article, Kristof reminds us that lack of vitamins and minerals and nutrients can have dire consequences and that it is cheaper and easier to prevent nutrition related birth defects than to treat them.

According to the UN Food and Agricultural Organization, the cost of fortifying food staples, such as sugar, salt, and flour with supplemental nutrients and vitamins can cost as little as 30 cents per person per year. One vitamin A capsule provides enough vitamin A for up to 6 months and costs around 2 cents. A three-month supply of iron pills is only 20 cents. This is a small price to pay for big returns.