Global Health and Human Rights

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Global Health and Human Rights

• Hon. Carolyn Bennett, MD MP

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Outline

• QUIZ
• A Rights Based Approach to Health
• Global Efforts Addressing the Determinants of
  Health
• Canadas International Human Rights Commitments
• Unequal Health Outcomes
• Health Inequality in Canada
• Health Inequality Globally
• Public Health 101 Health vs Health Care
• How You Can Make a Difference

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Textbook of International Health,2nd Edition,
Oxford University Press, USA, 1999Paul F. Basch

• QUIZ
• 1. All people have a right to health care
  provided by their government.

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International Health Quiz

• 2. Peoples indigenous cultural traditions
  should be respected even if known to be harmful
  to their health.

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International Health Quiz

• 3. In wealthy countries most health problems are
  caused by inappropriate personal behaviour.

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International Health Quiz

• 4. The most urgent health need in poor countries
  is for more doctors and hospitals.

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International Health Quiz

• 5. The best medicine is the least medicine.

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International Health Quiz

• 6. Most health problems originate in the
  environment and can be combated only by the whole
  community.

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International Health Quiz

• 7. Population control in the developing
  countries is the worlds most urgent health
  priority.

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International Health Quiz

• 8. Most of the major endemic communicable
  diseases will disappear by themselves following
  economic development.

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International Health Quiz

• 9. The provision of medical care to people in
  poor countries is a good vehicle to promote
  religious or political viewpoints.

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International Health Quiz

• 10. A persons genes basically determine his or
  her health and not much can be done about it.

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International Health Quiz

• 11. If we eradicated smallpox we can do the same
  for any disease if we really want to.

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International Health Quiz

• 12. People in the wealthy countries have a moral
  obligation to help people in poor countries.

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International Health Quiz

• 13. The saving of lives from disease and
  starvation may produce more problems than it
  solves.

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International Health Quiz

• 14. Governments in most poor countries are
  corrupt, so foreign aid is generally a waste of
  money and effort.

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International Health Quiz

• 15. The main health problems in developing
  countries are caused simply by lack of water and
  sanitation.

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International Health Quiz

• 16. To help reduce the burden of illness in the
  world one must first become a physician.

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International Health Quiz

• 17. Most people in developing countries really
  do not want modern biomedical science.

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International Health Quiz

• 18. The world is running out of many important
  resources so we must all learn to get by with
  less.

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International Health Quiz

• 19. The best argument to a government official
  for financing health services is that it is good
  economic investment.

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International Health Quiz

• 20. As soon as we learn to control one disease
  another comes up look at AIDS. The whole effort
  is basically useless.

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A Rights-Based Approach to Health

• The right to health means that governments must
  generate conditions in which everyone can be as
  healthy as possible.
• Such conditions range from ensuring availability
  of health services, healthy and safe working
  conditions, adequate housing and nutritious
  food.
• Source World Health Organization, Fact Sheet
  The Right to Health, www.who.int/entity/hhr/right
  _to_health-factsheet.pdf

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Linkages Between Health and Human Rights
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Linkages Between Health and Human Rights

• Violations or lack of attention to human rights
  can have serious health consequences.
• Health policies and programmes can promote or
  violate human rights in their design or
  implementation.
• Vulnerability to ill-health can be reduced by
  taking steps to respect, protect and fulfil human
  rights.

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Global Efforts

• International Covenant on Economic, Social and
  Cultural Rights (the Covenant)
• Ratified in December 1966
• 157 States have ratified the Covenant
• General Comment 14
• The Eight Millennium Development Goals
• 2005 World Summit
• Bangkok Charter for Health Promotion in a
  Globalized World

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The Covenant

• Article 12 of the Covenant states
• The states parties to the present covenant
  recognize the right of everyone to the enjoyment
  of the highest attainable standard of physical
  and mental health
• The Committee on Economic, Social and Cultural
  Rights (CESR), which monitors the Covenant and
  issues General Comments, has rightly recognised
  that the right to health is closely related to
  and dependent upon the realization of other
  rights, such as the rights to food, housing and
  freedom of movement.

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General Comment 14

• The right to health extends not only to timely
  and appropriate health care but also to the
  underlying determinants of health,
• Such as
• Access to safe and potable water
• Adequate sanitation
• An adequate supply of safe food
• Nutrition and housing
• Healthy occupational
• Environmental conditions
• Access to health-related education
• Information, including on sexual and reproductive
  health.

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General Comment 14

• The right to health contains four elements
• Availability
• Accessibility
• Acceptability
• Quality

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The Right to Health
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Eight Millennium Development Goals

• Eradicate extreme poverty and hunger
• Achieve universal primary education
• Promote gender equality and empower women
• Reduce child mortality
• Improve maternal health
• Combat HIV/AIDS, malaria and other diseases
• Ensure environmental sustainability and
• Develop a global partnership for development.

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2005 World Summit

• Reaffirmed the values of the UN and the
  objectives of the Millennium Development Goals.
• They agreed to implementing policies that would
  ensure adequate investment in a sustainable
  manner in
• Health
• Clean water and sanitation
• Housing and education
• The provision of public goods and social safety
  nets to protect vulnerable and disadvantaged
  sectors of society

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The Bangkok Charter for Health Promotion in a
Globalized World

• The Bangkok Charter call on all governments at
  all levels to tackle poor health and inequalities
  as a matter of urgency.
• Local, regional and national governments must
• give priority to investments in health
• within and outside the health sector
• provide sustainable financing for health
  promotion

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CANADAS INTERNATIONAL HUMAN RIGHTS COMMITMENTS

• Since World War II, Canada has played an active
  role in advancing, defending, and expanding the
  reach of human rights at the United Nations, and
  around the world, while also providing assistance
  to others to develop their human rights regimes.

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CANADAS INTERNATIONAL HUMAN RIGHTS COMMITMENTS

• International Covenant on Economic, Social and
  Cultural Rights (CESCR) May 19, 1976
• International Covenant on Civil and Political
  Rights (CCPR) - May 19, 1976
• Optional Protocol to the International Covenant
  on Civil and Political Rights (CCPR-OP1) - May
  19, 1976
• Second Optional Protocol to the International
  Covenant on Civil and Political Rights (CCPR-OP2)
  aimed at abolition of the death penalty Nov.
  25, 2005
• International Convention on the Elimination of
  All Forms of Racial Discrimination (CERD) Oct.
  14, 1970
• Convention on the Elimination of All Forms of
  Discrimination against Women (CEDAW) Dec. 10,
  1981

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CANADAS INTERNATIONAL HUMAN RIGHTS COMMITMENTS
Continued

• Convention against Torture and Other Cruel,
  Inhuman or Degrading Treatment or Punishment
  (CAT) June 24 1987
• Convention on the Rights of the Child (CRC)
  Dec. 13, 1991
• International Convention on the Protection of the
  Rights of All Migrant Workers and Members of
  Their Families (MWC)
• Convention on the Rights of Persons with
  Disabilities Mar. 30 2007
• American Convention on Human Rights
• Additional Protocol to the American Convention on
  Human Rights in the Area of Economic, Social, and
  Cultural Rights

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Health Inequality in Canada

• UN Committee on Economic Social and Cultural
  Rights 2006 Concluding Observations for Canada
  identified a number of subjects of concern which
  are direct determinants of health, notably
• The governments restrictive interpretation of
  its obligations under the Covenant
• The lack of legal redress available to
  individuals when governments fail to implement
  the Covenant
• The absence of a legally enforceable right to
  adequate social assistance benefits for all
  persons in need on a non-discriminatory basis

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Health Inequality in Canada, Continued

• The disparities that still persist between
  Aboriginal peoples and the rest of the Canadian
  population.
• The absence of an official poverty line.
• The insufficiency of minimum wage and social
  assistance transfers to ensure the realization of
  the right to an adequate standard of living for
  all.
• The authorization given to provinces and
  territories to deduct the amount of the child
  benefit under the National Child Benefit from the
  amount of social assistance received by parents
  on welfare.

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Health Inequality in Canada, Continued

• United Nations Special Rapporteur on adequate
  housing during his visit to Canada observed that
• Everywhere that I visited in Canada, I met
  people who are homeless and living in inadequate
  and insecure housing conditions. On this mission
  I heard of hundreds of people who have died, as a
  direct result of Canadas nation-wide housing
  crisis.
• Source United Nations Special Rapporteur on
  adequate housing, Miloon Kothari, Mission to
  Canada Preliminary Observations, Ottawa, 22
  October 2007.

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Health Inequality in Canada, Continued

• In recent review by United Nations authorities,
  including most recently the May 2006 period
  review of Canadas compliance with the
  International Covenant on Economic, Social and
  Cultural Rights, Canadas continuing failure to
  incorporate these international legal standards
  into Canadian domestic law has been noted with
  growing concern.

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Health Inequality in Canada, Continued

• Canadians are among the healthiest people in the
  world, but some Canadians are not as healthy as
  others.
• The following are significant factors associated
  with health disparities that can cause early
  deaths, disease, disability, and distress
• Socio-economic status
• Aboriginal identity
• Gender
• Geographic location

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Health Inequality in Canada, Continued
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Health Status People with Disabilities

• Numerous studies have reported that the health
  status of people with disabilities is
  significantly worse than the general Canadian
  population.
• Disabled Canadians encounter more difficulties
  with their health and generally score a lower
  rating on their self-reported well-being
  indicators.
• Individuals with a disability are more likely to
  report difficulties in accessing health care
  services compared to the non-disabled.

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Health Status People with Disabilities contd

• An increased chronic disease prevalence and lower
  life expectancy has been reported among Canadian
  disabled compared to the general population.
• People with disabilities have been reported to
  utilize more health care services, take more
  prescriptions and spend more days in hospital
  compared to the non-disabled Canadian population.
  

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Aboriginal Health Status

• Aboriginal health inequalities in Canada are
  among the starkest.
• First Nations overall mortality is 45 higher
  than for Canada (based on the 2000 aged
  standardized rates).
• Rate of First Nations youth suicide (10 to 19
  years) was 4.3 times greater than that for Canada
  in 2000.
• Inuit suicide rate (all ages) is 11 times higher
  than the Canadian rate. 83 of suicides are
  male, and 83 are under 30 years of age.

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Infant Mortality Rates
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Health Inequality Globally

• The WHO Fact File highlights the reality of
  global health inequalities
• Poverty, social exclusion, poor housing and poor
  health systems are among the main social causes
  of ill health.
• Differences in the quality of life within and
  between countries affect how long people live. A
  child born in Japan has a chance of living 43
  years longer than a child born in Sierra Leone.
• The probability of a man dying between the ages
  of 15 and 60 is 8.2 in Sweden, 48.5 in the
  Russian Federation, and 84.5 in Lesotho.
• In Australia, there is a 20-year gap in life
  expectancy between Australian Aboriginal and
  Torres Strait Islander peoples, and the
  Australian average.

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Health Inequality Globally, Continued

• Low- and middle-income countries account for 85
  of the worlds road deaths.
• In 2002, nearly 11 million children died before
  reaching their fifth birthday 98 of these
  deaths were in developing countries.
• Inequality in income is increasing in countries
  that account for more than 80 of the worlds
  population.
• Few governments have explicit policies for
  tackling socially determined health inequalities.

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Health Inequality Globally, Continued
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Dr. Harry Jeene African Medical and Relief
FoundationNGO presentation WHA 2007

• Life is a right
• What we are left with is terminal disease

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Developing countries Jeene

• Investing in a number of interventions have
  proven to be enormously cost effective,
• eg H20 and immunization
• In developing countries there is still a huge
  under-expenditure in these interventions, with a
  resulting massive suffering and loss of life, and
  loss of development opportunities.

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Ministries of Diseases Jeene

• Mirroring the way Northern countries are
  structured, developing countries also fund health
  as a set of diseases.
• Communicable diseases still form the main burden
  of disease in the developing world, but
  non-communicable and chronic diseases are growing
  fast in importance
• In the richer countries AIDS, though communicable
  is becoming a chronic disease. Curing or
  mitigation disease
• The vast majority of health expenditure goes
  toward hospital treatment of chronic disease This
  is certainly the case in the OECD
• Almost all expenditure is on mitigation. Very
  little money is invested in prevention

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Developing countries Jeene

• Budgets are still overwhelmed by the enormous
  burden of communicable diseases
• Communicable diseases have a high priority in
  population perception, and thus on the ability of
  policy makers to set priorities for healthy
  public policies

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Chronic Diseases Jeene

• Policy makers are the lucky ones to have survived
  the communicable diseases
• The temptation for these mature people to spend
  money on mitigating chronic diseases is therefore
  irresistible
• As most decision makers are male, female health
  issues are particularly hard to get on the agenda
  
• (Some female health ministers, not enough female
  finance ministers)

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Changing disease patterns Jeene

• World-wide over-nutrition has taken over
  under-nutrition
• Urbanization and a more sedentary lifestyle have
  been major contributors
• Copying a western lifestyle with intense pressure
  from the commercial promotion of instant
  satisfaction foodstuffs is another major factor.

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Deene

• Obesity is a major cause of non-communicable
  diseases
• CVS, including cerebral
• diabetes, including blindness
• arthritis
• -sub-fertility
• depression, stigmatization
• The complexity of "free-choice" is increasing in
  a globalizing world.

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A changing world Deene

• In a world where disease conditions are changing,
  we need a changing approach to health
• It is enormously expensive to treat established
  hypertension, angina or diabetes
• We need to pay more attention to health
  promotion, going beyond prevention rather than
  seeing health as curative and hospitals as key to
  care.

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Health Promotion in partnership Deene

• There is not much profit to be made in Health
  Promotion, certainly not for the pharma, fast
  food and entertainment industries,
• neither for the donors who require quick wins,
  direct attributions and an increasing preference
  for commodities.
• There is even little in it for the formal health
  care providers, including those in primary health
  care
• Major shifts in thinking are required, and these
  can only be driven by communities working as full
  and equal partners with the formal health system,
  especially at the Primary Care level.

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Dr. Deene

• Alma Ata
• We have missed our 2000 target
• We are missing our 2015 MDG targets (and where
  are health promotion, chronic conditions, mental
  health and trauma in these MDG's'anyway ?)
• Civil Society will have to exercise much more
  pressure to get health promotion on the agenda,
  North and South.

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We, the people Deene

• We applaud the move towards one UN system.
• Do not forget that we, the people, elect you as
  government and thus this UN
• We will hold you to account for producing and
  implementing legal frameworks that promote the
  health of us, the people.

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Em PHA sis on the wrong syl LAB le

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Attitude

• Fleeing the medical model.
• Embracing the medicine wheel

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Blame Hippocrates?
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Medical Model

• Tyranny of the acute
• Repair shop
• Top-down cult of efficiency
• Central command and control

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Affirm Hygeia
HYGEIA Goddess of Health
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Public Health 101
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Right ?
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Right ?
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1.Do you think we should have a

• A) strong fence at the top of the cliff
• B) state of the art fleet of ambulances and
  paramedics waiting at the bottom ?

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2. Would you prefer

• A) Clean air
• B) Enough puffers and respirators
• for all

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3. Would you prefer that wait-times were reduced
by

• A) a falls program to reduce preventable hip
  fractures
• B) private orthopaedic hospitals and more
  surgeons

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4.Should we invest in

• A) early learning, child care, literacy, the
  early identification of learning disabilities and
  bullying programmes
• B) increase the budget for young offenders
  incarceration

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5.Should we

• A) assume that the 'grey tsunami' will bankrupt
  our health care system
• B) include our aging population in the planning
  of strategies to keep them well

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6. Is the best approach to food security

• A) food banks and vouchers
• B) Income security, affordable housing, community
  gardens and community kitchens and a national
  food policy

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7. Pick the one that is NOT correct

• Pandemic Preparedness should focus on
• Tamiflu for all
• Working with the vets to keep avian flu a disease
  of birds
• Making sure people wash their hands especially
  the doctors and nurses
• Research on vaccines
• Community care plans for our most vulnerable

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8.Governments should boast about

• how much they spent on the sickness care system
• the health of their citizens, leaving no-one
  behind

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teachable moments

• 2003
• Canada 44 died of SARS
• France14,000 died in the heat wave
• 2005..Katrina, Kasheshewan

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Beyond borders. SARS as a teachable moment

• Beyond silos
• Departments
• Disciplines
• Beyond jurisdictional squabbling
• Naylor report 4 Cs
• Collaboration
• cooperation,
• communication
• clarity of who does what and when
• Germs dont respect borders
• Neither do the social contagions
• Nor the humanitarian imperatives

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Social Determinants of Health vsChoose
Health(modifiable risks)
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(No Transcript)
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The Causes of the Causes

• Versus
• The Causes

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www.who.int/social_determinants/en/
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Commission on the Social Determinants of Health
(CSDH)

• The CSDH Interim Report illustrates
• the disparities in population health among
  different regions of the world.
• These differences in health occur along a number
  of axes of social stratification including
  socioeconomic, political, and cultural.
• Exacerbating the situation is the migration of
  health professionals from developing countries to
  industrialized ones.

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Sir Michael Marmot

• The worst thing for a physician is to patch
  people up and send them straight back into the
  situation that made them sick in the first place.
• Evidence is not enough. There has to be the
  desire, the political will for change. Given that
  will - a big given but I am an optimist - the
  evidence of what works will be a great help.

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F.R.E.D.

• Important principles underlying all human rights,
  including the right to health.
• Fairness
• Respect
• Equality
• Dignity

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Ilona Kickbusch

• Health diplomacy
• Analyzing the systems that work. Leadership,
  champion
• Role of universities in health literacy

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Zimmerman Glouberman

• Romanow discussion paper 8
• Complex adaptive system
• Example Brazil v.s. Africa

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The mobilization of shameIrwin Cotler

Management 101 If its measured it gets
noticed, if its noticed it gets done
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Florence Nightengale

• To understand Gods thoughts we must study
  statistics, for these are the measure of His
  purpose.

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GIS

• If a picture is worth a thousand words,
• a map is worth a thousand pictures.

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http//www.worldmapper.org/
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The Public Health Map Generator is a secure,
web-based mapping application, accessible only to
clients registered with the GIS Infrastructure at
the Public Health Agency of Canada.
GIS User

All of the Infrastructures services, including
the Public Health Map Generator, are available at
no cost to all public health professionals in
Canada.
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With the Public Health Map Generator, you can
produce high quality, detailed maps of your own
health data, in combination with extensive
geography from our spatial data warehouse
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How Can You Make a Difference!

• What needs to be done
• Fairness, Respect, Equality and Dignity (FRED)
• take immediate steps to comply with concluding
  observations from UN Committee on Economic Social
  and Cultural Rights
• reproductive health and maternal mortality is one
  potential area for focused attention.
• Another area of special attention internationally
  is the fight against malaria.

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Places Where You Can Get Involved to Make a
Difference

• Canadian HIV/AIDS Legal Network
  http//www.aidslaw.ca/EN/index.htm
• Action Canada for Population and Development
  http//www.acpd.ca/
• Pivot Legal Society http//www.pivotlegal.org/
• Interights http//www.interights.org/
• Childrens Rights Information Network
  http//www.crin.org
• Population Action International
  http//www.populationaction.org

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Leaders Working on the Right to Health

• Timothy Caulfield
• Research Director of the Health Law Institute at
  the University of Alberta
• Rebecca Cook
• Professor and Faculty Chair in International
  Human Rights, and Co-Director of the
  International Programme on Reproductive and
  Sexual Health Law in the Faculty of Law at the
  University of Toronto. 
• Jocelyn Downie
• Professor at the Faculties of Law and Medicine at
  Dalhousie University
• Colleen Flood
• Associate Professor of Law at the University of
  Toronto
• Barbara von Tigerstrom
• Assistant Professor at the University of
  Saskatchewan, Faculty of Law.

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100 years ago

• Every nation that permits people to remain under
  the fetters of preventable disease and permits
  social conditions to exist that make it
  impossible for them to be properly fed, clothed
  and housed so as to maintain a high degree of
  resistance and physical fitness and, who
  endorses a wage that does not afford sufficient
  revenue for the home, a revenue that will make
  possible the development of a sound mind and
  body, is trampling on a primary principle of
  democracy.
• Dr. Charles Hastings, Medical officer of health
  for Toronto, 1907

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We are not tinkers, who patch and mend what is
broken. We must be watchmen, guardians of the
life and health of our generation, so that
stronger and more able generations may come
after. Dr. Elizabeth Blackwell first woman
physician North AmericaWanless Report UK
2003commissisoned by Gordon Brown