1. While health and human rights advocates have, from the start, taken a global perspective on the causes of ill-health, social medicine and particularly social epidemiology have been slower to catch up. This is not an assertion to be taken lightly. This, simply because advancing global health and health equity against the odds of a wide variety of threats –including abusive non-caring actors, unjustifiable reasoning and procrastination, and plain complacency of those who have the power to make a difference– requires the adoption of a perspective that puts human rights (HR) and the human right to health at the center.
2. “Achieving health equity within a generation* is possible, it is the right thing to do, and now is the right time to do it.” This statement in the Report of WHO’s Commission on the Social Determinants of Health is not meant to be hollow rhetoric. Why? Because the human right to health presents a compelling case for action on health and on the social determinants of health. It implies that if individuals have a right to health, then they also have a right to the determinants of health being overcome.
*: What is meant by closing the gap in a generation is that the goal of social action is to flatten the social gradient in health by leveling up health outcomes across the social spectrum in the next 30 years.
3. There is a more than sufficiently plausible causal chain that links political decisions and social action geared at meaningful changes in the health of entire populations and especially on the health of the lower socioeconomic groups. Despite this plausibility, social epidemiology has chosen to primarily look at biomedical causality chains instead.
4. A social environment that does not respect, protect and fulfill the social, economic and cultural rights (to health, nutrition, education, shelter…) and to civil and political liberties can indeed be accused of having a role in the chain of causation and distribution of preventable ill-health, malnutrition and mortality.
5. So far, the problem with the social determinants (more formally so than in practice) has been on how to frame the rights associated with them if and when they are not explicitly identified in human rights law. In other words, how to reconcile an understanding of the dire health situation on the ground with the formal texts of human rights law has been a dilemma for hardnosed analysts. But, although it is true that HR law does not guarantee the right to be free of, for example, TB, a strong case can be made for it when interpreting the texts pertaining to the human right to health.
6. To carry things to an extreme: What if one believes, for example, that the provision of sutures is not only a reasonable and feasible means to prevent deaths, but that it should be seen as a human right? Although no explicit human right to sutures is stated in either the Universal Declaration of Human Rights, the Covenant on Economic, Social and Cultural Rights, or in the Right to Health’s General Comment No. 14, the existing language and rights in these legal human rights documents can be interpreted to provide individuals with a right to such essential health care supplies as sutures, sterile drapes, and anesthesia.
7. To insist that the full spectrum of international HR rights law must be respected, of course, requires not only its respect, but also the means to enforce it, and mechanisms to hold individuals and institutions accountable for its violation.
8. What I am aiming at here is at proactively deriving health-related standards from human rights law** to infuse them into health programs and to direct them to govern actions of individuals delivering health care services on the ground.
**: Note that this rises arguments for advancing human rights not only in health, but also in social action in other areas.
9. Although we may be working in health, we need to apply the broader definition of human rights that encompasses all economic, social and cultural rights. A more vigorous enforcement of these human rights will improve people’s living conditions, i.e., tackle the social determinants, leading to better health outcomes.
10. When and where it is clearly visible that the social structure –i.e., the social, economic, and underlying political conditions– is condoning or, indeed, directly causing avoidable disease and preventable deaths on a large scale, the human rights framework emerges as the only currently available and viable mechanism to fight back; in such a setting, HR act as an empowering tool for those who suffer unacceptable violations of their right to health –a tool to help them bridge the gap of inequality and deprivation.
11. Moreover, in the present era of increasing globalization, international human rights law is the best available instrument to address the ill-health caused by transnational actors who, in many cases, are more powerful than many a government.
12. As Dr Jonathan Mann once said: “A society that realizes the full breadth of human rights will produce healthier individuals and populations”.
13. It is only when it is accepted that the absence of the right to health is the cause of preventable ill-health and mortality, that the causal role and the importance of the right to health will stand firm and unopposed.***
***: We are reminded here that human rights are not natural facts or objects, but ethical and political assertions about claims, privileges, liberties, immunities, and powers in relation to various human capabilities. (Amartya Sen)
14. Unnecessary and avoidable misunderstandings result from attempting to deemphasize the importance of HR as direct causal components of the pattern and distribution of preventable ill-health, malnutrition and mortality. Actually, the health and human rights framework as a necessity supplements the analysis of the social causes, the distribution, and the consequences of preventable ill-health and mortality as done by social epidemiology.
Are institutions and health care professionals agents for a sustainable social transformation?
15. We have got to get health practitioners to embrace the fight against entrenched orthodoxies in many health areas, as well as get them to champion the enforcement and the realization of people’s economic, social and cultural rights.
16. For the practitioner of social medicine, the primary aim thus is both to address avoidable ill-health, malnutrition and mortality through his/her healing art, as well as to contribute to the enforcement of economic, social and cultural rights, or any other right –for their own sake.
17. What is said here is that it is futile to try to reduce inequalities in health by acting on aspects of health care delivery only (i.e., acting on the supply side only).
18. In practice, what fellow practitioners need is to identify what is required in the form of social action to influence policies, regulations and laws, as well as actions on the ground. This invariably means addressing the social determinants of ill-health and health inequalities by influencing local and national deliberations so that decisions respect the human rights principles (i.e., universality and inalienability, individuality, interdependence and interrelatedness, participation and inclusiveness, equality and non-discrimination, and accountability and rule of law).
19. When HR standards and principles are incorporated into health-related disciplines such as epidemiology, medicine and operations research, they do provide a plan of action not only for practitioners, but also for communities and for states –in other words, the human rights discourse also ought to become a community health planning tool. (L. Freedman)
20. It is thus unacceptable today to continue maintaining that the causes that are directly and indirectly (and unnecessarily) killing people are not a human rights concerns.
Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org