Food for shaping a thought (3)

Human Rights Reader 254

-In public health, we uncritically assume scarcity of resources without asking why scarcity.

-WHO comes with technical advice, the World Bank comes with money….countries usually prefer the money.

6. The Millennium Development Goals (MDGs) and the human right to health

39. Together with others, I believe in a few MDG Iron Laws: MDGs suffer from donor over-influence, technical over-emphasis, inattention to action on national social, political and economic inequities, and a lack of systemic financial commitments. The health-specific goals perpetuate a privileging of communicable diseases and encourage quick-fix investments and technical approaches; they reinforce an emphasis on health as an average outcome across an undifferentiated population; they fail to address adequately the social determinants of health (SDH), raising questions about the sustainability of their achievement.  Therefore, conditions of extreme vulnerability, social exclusion, and health inequalities will remain entrenched even if the MDGs are met. * (R. Labonte)

*: At  the People’s Health Movement (PHM), we fear that, after 2015, we will have achieved nothing more than isolated islands of progress in a sea of remaining grievances and persisting human rights violations. (By sticking to the MDGs paradigm, inequalities are staring us in the face now, but will be shouting at us after 2015).

40. Complete debt cancellation, as is being demanded by many, alone will not allow poor countries to reach the MDGs as such a welcome measure will still require high levels of aid.

41. Moreover, nearly every other article in international human rights covenants and conventions has clear implications for health and human rights violations; these articles are a key common link between all of the MDGs. So protecting, promoting and fulfilling human rights is a sure means through which health and development responses can deliver benefits across-MDG lines. Why? Because the human rights-based approach addresses the structural drivers and consequences of preventable ill-health, preventable malnutrition and preventable premature deaths. (UNDP, Huritalk)

42. It is ultimately only multi-pronged strategies that scale-up health and community systems that will have an impact across health and non-health MDGs. So, inescapably, we need to empower women (to, among other, secure their sexual and reproductive health), as well as address the root causes of vulnerability to maternal morbi-mortality and to HIV through fostering gender equality and thus securing human rights. (UNDP) **

**: Remember: Ultimately, women will win the war; patriarchs will end their reign; wrongs will be made right. (J. Koenig).

43. Among other, interventions that build the capacity of key sectors and actors to become more proactive on human rights (HR) and on the human right to health (RTH) are: legal audits and law reform; the provision of legal services; ‘know your rights’ campaigns; stigma and discrimination reduction activities; training and sensitization of law enforcement agents, lawyers and judges; and training of health care providers on HIV-related human rights issues. Activities must also, importantly, empower those most marginalized and vulnerable to know and claim their rights, and to demand the social and legal set-ups that enable them to achieve and reach the MDGs and go beyond. (UNDP)

44. Bottom line here, there is the need to tackle the structural drivers of inequality as a key strategy for accelerating progress on all the MDGs.

7. Human rights and the social determinants of health (SDH)

45. The SDH are influenced not only by national power arrangements, but are increasingly influenced by actors and actions that derive from global economic structures and geopolitical relationships. Therefore, when our deliberations address an issue of such enormous scope as global health inequalities, we have to tackle both national and global constraints in our RTH strategizing.

46. There are many instances of struggles of civil society which do not necessarily achieve fundamental government policy changes, but have nonetheless been responsible for national and sometimes global health gains by successfully addressing key SDH that secure policy changes in specific areas (e.g., the AIDS struggle in South Africa).

47. Another struggle that is unfolding is one related to civil society realizing that the science-of-human-nutrition has become too narrow; rather a science-of-nutrition-problems-in-society is now being proposed and pursued (e.g., the focus on food security is being replaced by one on food sovereignty which has the people’s right to nutrition at its center; it strives for people being able to produce the food of their choice putting those who produce, distribute and consume local foods at the heart of the food system). (U. Jonsson)

48. Yet another struggle comes from the work of HR activists on Trade Related Aspects of Intellectual Property Rights (TRIPS): We, at PHM,  consider patents not to mean ‘property’. To us, a patent is a right a state grants to a patent holder to promote research and invention for human good; therefore, this right must be flexible and in qualified cases contested.

49. The lesson learned here is that the likelihood of these struggles securing policy advances ultimately depends on the extent to which broad social forces are mobilized around the issues of concern.

50. Bottom line here, any improvement in public health must and will be linked to key social and HR betterments.

8. Negative consequences of the General Agreement on Trade and Services (GATS, 1995) on human rights

-The world is today connected by trade and technology, but not by human rights values.

(Mary Robinson)

51. Health care cannot be an issue both of trade and of human rights (HR). These alternatives are incompatible from many points of view: medically, politically, socially, ethically and economically. (J. P. Unger)

52. Public debates to make this clear to everybody are crucial. An informed and educated public and authorities are needed to bring pressure on duty-bearers (trade negotiators included) to make them not only understand, but also staunchly and resolutely defend, the principle that the right to health care (RTHC) is a non-tradable, fundamental HR.

53. Since the context of Globalization is a bit different in every country, GATS has both general and unique connotations in each.

54. Looking at the general connotations, as regards the four modes in which GATS operates (cross-border, consumption abroad, foreign commercial presence, temporary movement of persons)***, a good part of this is overlooked by us as a problem with direct health and RTHC consequences. We need to incorporate parts of this understanding explicitly in our work on the RTHC.


Service supplier not present within the territory of the Member:
Mode 1: Cross-border supply Service delivered within the territory of the Member, from the territory of another Member
Mode 2: Consumption abroad Service delivered outside the territory of the Member, in the territory of another Member, to service consumers therein (from outside)
Service supplier present within the territory of the Member:
Mode 3: Foreign commercial presence Service delivered within the territory of the Member, through the commercial presence of the supplier
Mode 4: Temporary movement of persons Service delivered within the territory of the Member, with the supplier actually present in the country

55. The HR framework further exposes the flaws and dangers to health of the five main rules of GATS, namely: most favored nations ****, equal treatment of foreign and local companies, no market access restrictions to foreign providers, equal national regulations for foreign and national providers, and compensation to rich countries in case GATS regulations are ignored.

****: Each Member has to accord unconditionally, to services and service suppliers of another Member country, treatment no less favorable than that it accords to like services and service suppliers of any other country.

56. From a RTHC perspective, the immediate key question is: How should civil society in poor countries respond to GATS? A first definite worthy step is: Join the People’s Health Movement’s Global RTHC Campaign! Why? Because, if it is all about creating a critical mass of people and cadres knowledgeable about GATS (as well as about other social determinants of health and about the assorted causes of violations of the RTHC); PHM’s Global RTHC Campaign is a vehicle precisely for this.*****

*****: In a way, the campaign is, a mini-study on the impact of the liberalization of trade in services on health and HR. It zeroes-in on issues that now lack data, where decisions are currently made based on assumptions or outright ignorance. The campaign starts with a diagnosis of equity in health, of access to quality of care, and of affordability of health services –as much as it denounces these as HR violations for which signatory countries have obligations under international law. It is based on the principle that we are not begging, we are demanding. The campaign does look at the HR implications of liberalization of trade so that the latter does not negatively impact the RTHC. It departs from the principle that more informed decisions can be made when people are properly informed. Through the exploitation of the data generated by the campaign’s assessment tool, the campaign aims at giving key information to decision-makers and negotiators engaging them in public debates about the consequences of privatization and other GATS provisions. Its focus is more on warning countries about bilateral negotiations or free trade agreements (FTAs) –which are the ones in which poor countries are most vulnerable. [PHM thinks that the acronym FTA should more appropriately mean Forced Trade Agreements]. The campaign thus helps bureaucrats, negotiators and the general public understand the full impact of the liberalization of trade on health and on HR. Working with groups of claim-holders organized in civil society, the campaign –which is participatory from the outset– identifies and lobbies decision-makers and negotiators so as to establish dialectical claim-holders – duty-bearers working links at different levels. The campaign also engages the press, labor unions, indigenous NGOs, members of parliament, and political parties; it nurtures an ongoing relationship with them. In phases II and III, the campaign will involve/push WHO to act more forcefully on the RTHC, as well as to get more actively involved in WTO (its council for trade services included). In summary, the campaign thus is one of the critical analytical tools we ask you to consider for taking remedial measures. The prospects are good; the problems are many, but well known; the  opportunities are open and promising; As always, PHM welcomes the challenge…and welcomes all of you.  []

9. The need for political action

57. As a corollary to the title of this three-part Reader, let it be noted that aggregate population health is different from the sum of the health of individual members. Populations as a whole quite often act as malfunctioning systems; so we can say that whole populations are sick. It is then political action in the realm of HR that is needed to cure them. (J.P. Mackenbach)

58. Because it is inequalities in power, in money and in the allocation of resources that are key drivers of health inequalities in populations, challenging current power imbalances is fundamental to ameliorating inequities in the SDH. (D. Sanders)  The fact that the holders of such power may relinquish it with reluctance must not deter us from pursuing what is just. That is at the base of the HR-based framework.

59. Furthermore, because there is an enormous inequality of suffering in society, what is needed now is swift political analysis and action (D. Kahneman). The latter not only seems like, but is the important next step –and the human right to health framework applied to health thus starts by tackling the underlying SDH.

60. In this important next step, we need to make local, direct service providers our allies since they are also genuinely claim holders in HR work. But we also have to build broad coalitions with non-health, especially HR, organizations to jointly take up right to health issues. Testimonies of violations of the RTHC by affected individuals, and public events to denounce these violations are further potentially powerful actions. (A. Shukla)

61. Bottom line, to enable the adoption of equity and HR-based measures, governments need the backing (or pushing!) of social justice movements, of labor unions, of political parties… of us. (A-E. Birn)  Even being humble about what we can deliver, there is a role for all of us to play: Today.

Claudio Schuftan, Ho Chi Minh City


Partly taken from L. Conti. Estructura Social y Medicina, in ‘Medicina y Sociedad’. Ed. Fontanella, Barcelona 1972. p. 296-7; D+C, Vol 35, No.9, September 2008; Globalization and Health: Pathways, Evidence and policy, R. Labonte, T. Schrecker, C. Packer and V. Runnels Eds, Routledge Books, 2009; D. Tarantola et al, Human Rights, Health and Development, Technical Series Paper #08.1, UNWS; Development in Practice, 19:8, 2009; and A. Sen, presentation, York, UK,  23 de July 2001.

Post script: Giving a megaphone to the front lines of health has been my core aim in the last three Readers and I count on your voice in 2012 to achieve that aim. (Gva. Hlth. Forum)

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  1. 1Iftikhar Soomro

    Since many days I was trying to complete this article, today i when i finished it by reading bit and bit. I found this not a just article but a very good refrence material. the argument as given in are as food for thoughts for so many health activists.

  2. 2Shelia Mann

    New York – Secretary Of State Hillary Clinton should send a clear message to Tunisias foreign minister Kamel Morjane when they meet on April 28 2010 in Washington DC that his government should respect human rights Human Rights Watch said today..Morjane is in Washington this week for a series of high-level meetings with US officials also including James L. Secretary Clinton should publicly press the foreign minister for an end to the persecution of independent journalists and human rights activists and an easing of internet censorship..Tunisia shows intolerance for nearly all forms of peaceful dissent despite repeated declarations by President Zine el-Abidine Ben Ali that human rights are a central concern of his government.

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