The Challenge of Interdisciplinarity in Operationalizing the Right to Health

Gillian MacNaughton and Mariah McGill

Abstract

Interdisciplinary collaboration between the health and human rights communities is essential to operationalize the right to health. In practice, however, such collaboration has been infrequent. As noted by Jonathan Mann et al., the fields of health and human rights have “differing philosophical perspectives, vocabularies, professional recruitment and training, societal roles, and methods of work.” These differences have posed barriers to interdisciplinary collaboration. This article focuses on interdisciplinarity—especially between health and human rights communities—as key to realizing the right to health. Drawing on interviews with experts on health and human rights, the article explores the challenges of interdisciplinarity at the Office of the High Commissioner for Human Rights (OHCHR), the United Nations (UN) agency charged with mainstreaming human rights, including the right to health, across the UN system. To operationalize the right to health, experts perceive the need (1) to move beyond legalistic concepts of the right to health; (2) to enhance appreciation of the right to health across UN agencies; (3) to employ health professionals at the OHCHR; (4) to develop deep expertise on the right to health to advise on operationalization; and (5) to understand the right to health as an expanded right that includes the social determinants of health.

Introduction

Scholars and practitioners working to advance the right to health have long recognized that interdisciplinary collaboration between the health and human rights communities is essential to realize the right to health for all. In practice, however, such collaboration, has been infrequent. As Mann et al. noted in the first issue of the Health and Human Rights Journal in 1994, the fields of health and human rights have “differing philosophical perspectives, vocabularies, professional recruitment and training, societal roles, and methods of work.”[1] Moreover, the concepts of health, human rights, and the right to health are complex and continually evolving.[2] Health workers not familiar with the right to health may view rights as primarily a basis for litigation and therefore shy away from them. Human rights practitioners may have little appreciation for the extent to which health is implicated in the realization or violation of all human rights. Indeed, a history of conflicts between practitioners in medicine and law, as well as between public health officials and civil liberties advocates, may prejudice human rights and health communities against each other.[3] Yet both the health and human rights communities are centrally concerned with improving human well-being.

Further, there is no possibility of realizing the right to health for all without human rights experts who focus on and develop expertise on the right to health, as well as health professionals in both public health and medicine who understand and integrate human rights generally and the right to health specifically into their work. Indeed, only through interdisciplinary collaboration between scholars and practitioners in a wide range of social sciences can we mainstream the right to health into policies, planning, institutions, management practices, programs, projects, and operations. And only through mainstreaming the right to health into all aspects of society can we fully operationalize the right to health. While some progress has been made in the 25 years since Mann and colleagues published their article, the problem remains that few health professionals today understand and use the right to health in their work, and few human rights lawyers and practitioners today understand and appreciate the right to health.

In his 2005 address to the United Nations Commission on Human Rights, Kofi Annan stated:

The cause of human rights has entered a new era. For much of the past 60 years, our focus has been on articulating, codifying and enshrining rights. That effort produced a remarkable framework of laws, standards and mechanisms—the Universal Declaration of Human Rights, the international covenants, and much else. Such works needs to continue in some areas. But the era of declaration is now giving way, as it should, to an era of implementation.[4]

While the “era of declaration” called specifically for philosophers and legal scholars to conceptualize and draft human rights instruments, the “era of implementation”—or operationalization—requires interdisciplinary collaboration with health professionals and experts in many more fields. Only with diverse expertise can we solve the complex puzzles necessary to operationalize the right to health. Only through interdisciplinary collaboration can we mainstream the right to health into all United Nations (UN) entities and all sectors of government.

The Office of the High Commissioner for Human Rights (OHCHR) is the division of the UN responsible for mainstreaming human rights, including the right to health, across the UN system, and it also takes a lead role in advising governments on implementing the right to health in national contexts. For this reason, this article focuses specifically on the opportunities and challenges of interdisciplinarity faced by the OHCHR in operationalizing the right to health. Paul Hunt, former Special Rapporteur on the right to health, has recently noted that “human rights mainstreaming requires that those working in the field of health and human rights listen to, and learn from, each other with a view to enhancing the rights, dignity, and well-being of individuals, communities, and populations.”[5] He has “the impression that the High Commissioner and OHCHR have approached their mainstreaming mandate with vigor and made notable progress, despite major structural and financial constraints.”[6]

In 2018, the authors of this article published a chapter on the evolution of the right to health at the OHCHR that drew on (1) archival records of the publications and initiatives related to the right to health at the OHCHR; (2) the annual reports of the High Commissioner for Human Rights on the activities of the OHCHR; and (3) semi-structured interviews with 20 experts on the right to health (or economic and social rights more generally), including 10 current and former employees of the OHCHR and 10 external experts who have worked with the OHCHR.[7] In that chapter, we identified four factors that have affected the mainstreaming of the right to health at the OHCHR since 1994. On the positive side, there has been increasing acceptance of economic and social rights as real human rights, and there have been right-to-health champions among OHCHR leadership. On the negative side, the OHCHR has extremely limited capacity and resources for its global human rights mandate, and it faces considerable challenges in moving beyond legal conceptualization to operationalization of the right to health in practice.[8]

In this article, we expand on the last of these factors to discuss in more depth the challenge of interdisciplinarity in the OHCHR’s operationalization of the right to health. We draw on the burgeoning literature on interdisciplinarity and human rights and the data (archival records, annual reports, and interviews) we collected for the 2018 chapter. Additionally, we draw on four follow-up interviews conducted in July 2019 with interviewees (both inside and outside the OHCHR) concerning the entity’s recent work on the right to health, specifically the impact of the 2018 Framework of Cooperation between OHCHR and the World Health Organization (WHO) and the change of High Commissioner for Human Rights in 2018. The article, therefore, both narrows in on the question of interdisciplinarity and updates our previous work on the right to health at the OHCHR.[9]

Following this introduction, the article proceeds in three parts. First, it provides a brief overview of the structure of the OHCHR and where the work on the right to health falls within that structure. Second, it reviews literature on interdisciplinarity and human rights, focusing specifically on the right to health. Third, with the background on the OHCHR and interdisciplinarity, it examines the opportunities and challenges faced by OHCHR employees in carrying out interdisciplinary and inter-organizational work to operationalize the right to health.

Office of the United Nations High Commissioner for Human Rights

The 1993 World Conference on Human Rights adopted the Vienna Declaration and Programme of Action, which recommended that the UN General Assembly consider “the question of the establishment of a High Commissioner for Human Rights for the promotion and protection of all rights.”[10] Later that year, the General Assembly adopted a resolution creating the post and affirmed that the High Commissioner was responsible for protecting and promoting civil and political, and economic, social, and cultural rights alike.[11] Initially, the OHCHR was housed in Geneva and employed six staff.[12] Today, it employs more than 1,300 people, the majority at the head office in Geneva, and others in OHCHR regional or country offices and in UN field presences across the globe.[13]

Broadly, the mandate of the OHCHR is to protect and promote human rights around the world.[14] The OHCHR has four areas of responsibility. First, it supports the UN human rights mechanisms including the Human Rights Council, the 10 human rights treaty bodies, and the 57 Special Procedures (including the Special Rapporteur on the right to health).[15] For example, in 2018, the OHCHR organized a consultation on mental health and human rights at the request of the Human Rights Council.[16]

Second, the OHCHR develops policy guidance, tools, trainings, and methodologies to provide member states and civil society with practical approaches to implementing human rights.[17] Recent examples include Human Rights, Health and Poverty Reduction Strategies, published in 2008, and Reproductive Rights are Human Rights: A Handbook for National Human Rights Institutions, published in 2014.[18]

Third, the OHCHR advises UN agencies on mainstreaming human rights into all their programs. Through UN inter-agency bodies and activities, the OHCHR has advised, for example, on mainstreaming human rights into the Sustainable Development Goals, gender equality and human rights into multilateral environmental agreements, and disability rights across the UN system.[19] Recently, in September 2019, the OHCHR was closely involved in the high-level meeting on universal health coverage held at the UN General Assembly.[20]

Fourth, as of 2018, the OHCHR operated 17 country offices and 12 regional offices, and supported 77 field presences.[21] In the field, the OHCHR helps UN country teams and governments respond to crises, draft legislation, train government officials, and implement recommendations of the human rights mechanisms.[22] For example, in 2018, through its Colombia office, the OHCHR provided technical support that enabled the governor of Amazonas and indigenous communities to reach agreement to advance the implementation of a comprehensive intercultural health system.[23]

All four areas of OHCHR responsibility involve interdisciplinary work. Thus, an interdisciplinary team to work on the right to health would be ideal. Currently, however, the OHCHR employs one staff member whose sole focus is on the right to health, as well as one staff member to assist the Special Rapporteur on the right to health in carrying out his independent mandate. Nonetheless, because health issues are often interconnected with other rights, staff assigned in other areas—such as children’s rights, women’s and gender rights, environmental rights, and the Sustainable Development Goals—also engage the right to health in their work. OHCHR staff employed in country and regional offices also regularly engage in health-related work.

In recent years, one particular focus of the OHCHR has been on the health rights of women, children, and adolescents. In 2016, the OHCHR established, in collaboration with WHO, the High-Level Working Group for Health and Human Rights of Women, Children and Adolescents.[24] The purpose of the High-Level Working Group was to secure national and international political support for the implementation of the human rights-related measures of the Global Strategy for Women’s, Children’s and Adolescent’s Health (2016–2030).[25] After a year-long consultation with more than 200 individuals and organizations, the High-Level Working Group issued a report in 2017.[26] In its report, the working group notes that health cannot be improved without human rights and asserts the need for sustained, committed leadership at the national and international level to secure human rights to and through health.[27]

The recommendations in the 2017 report are divided into three areas. First, creating an enabling environment includes recommendations to uphold the right to health in national law and address human rights as determinants of health.[28] Second, partnering with people includes recommendations on enabling people to claim their rights and empowering human rights advocates and defenders.[29] Third, strengthening evidence and public accountability focuses on collecting rights-sensitive data and reporting systematically on health and human rights.[30] Additionally, the report called on the OHCHR and WHO to launch a joint program of work to support the implementation of these recommendations at the regional and country level.[31]

In November 2017, the OHCHR and WHO signed a framework of cooperation to implement the recommendations of the working group and deepen collaboration between the two organizations.[32] Specifically, the framework pledges the two organizations to collaborate in the following areas: (1) supporting the advancement of international norms and standards for the realization of the right to health; (2) advancing national-level implementation of human rights standards; (3) enhancing the capacity of member states and other national partners to monitor health and human rights; and (4) cooperating in research and development of guidance to address priority areas related to health and human rights.[33] WHO and the OHCHR have worked together in the past, but the framework of cooperation ushers in a new, deeper relationship between the two organizations and may foster more collaboration between public health and human rights professionals. As the Working Group report points out, such collaboration is important because it can “expand the ways in which problems are identified, deepen analysis, strengthen the setting of priorities and tailor more effective interventions.”[34]

The OHCHR’s efforts to strengthen collaboration with public health and medical professionals may also be supported by the appointment of Michelle Bachelet as the new High Commissioner for Human Rights in September 2018. Bachelet is the former president of Chile and was the first director of UN Women. Notably, Bachelet has a medical degree with a specialization in pediatrics and public health, making her the first High Commissioner with a health background.[35] A High Commissioner with expertise in health has a unique perspective and experience that could help to operationalize the right to health. Although it is too soon to know the impact of Bachelet’s appointment, her strong background in both health and human rights is a promising development.

Interdisciplinarity in human rights research and practice

Since the 1970s, there has been increasing interest in interdisciplinary research, theory, knowledge, and education.[36] Dictionaries define “discipline” as a field of study or a branch of knowledge, instruction, learning, or education.[37] A more specific definition is a “self-contained and isolated domain of human experience which possesses its own community of experts.”[38] In contrast, “‘[i]nterdisciplinarity’ is a synthesis of two or more disciplines, establishing a new level of discourse and integration of knowledge.”[39] For example, interdisciplinary researchers developed new treatments for cancer by combining medicine with nuclear physics.[40] New disciplines, such as biochemistry, may eventually emerge from interdisciplinary work.[41] Unlike interdisciplinarity, “multidisciplinarity” juxtaposes disciplines but does not integrate them—for example, a series of lectures on a topic by people in different disciplines.[42]

Interdisciplinary research and knowledge also presents many opportunities to improve human well-being. In his article “Ten Cheers for Interdisciplinarity,” Moti Nissani argues that combining disciplines provides opportunities for creative breakthroughs, aids in addressing complex or practical problems, emphasizes the unity of knowledge, allows for flexibility in research, and contributes to social change.[43] Similarly, Bernard Choi and Anita Pak maintain that teamwork involving multiple disciplines helps resolve real-world problems, provide different perspectives on a problem, create a comprehensive theory-based hypothesis for research, develop consensus guidelines for complex diseases and conditions, and provide comprehensive health care services and health education.[44]

There are challenges to interdisciplinarity as well. An interdisciplinarian is unlikely to be able to master multiple disciplines as well as a specialist can master one discipline.[45] A jack of all trades will likely be a master of none.[46] Additionally, it is very demanding for the interdisciplinarian—in terms of time and intellectual energy—to keep up in more than one discipline.[47] Further, while a broader interdisciplinary perspective may lead to new perspectives and new knowledge, it may also provide more opportunities for mistakes. Finally, interdisciplinary research teams may call for collaboration of experts in different disciplines who have different ways of thinking and communicate in different languages, which is “a notoriously difficult undertaking.”[48] Despite these challenges, in recent years there has been a surge of interdisciplinary research, practice, and education.

Human rights is an interdisciplinary concept par excellence.[49] While human rights was dominated largely by philosophers and lawyers in the first several decades after the establishment of the United Nations in 1945, scholars and practitioners in many other fields have become involved in human rights, especially since the 1993 World Conference on Human Rights. At that conference, there was a reaffirmation of the indivisibility, interdependency, and interrelatedness of all human rights, which catapulted economic, social, and cultural rights back on to the mainstream human rights agenda.[50] Human rights scholars and practitioners then recognized that, for example, indicators would be necessary to monitor the progressive realization of economic, social, and cultural rights over time. Further, budget analysis would be necessary to assess whether governments were using maximum available resources to realize these rights. These practices called for the expertise of social scientists, statisticians, and others.

The World Conference on Human rights also reaffirmed the right to development.[51] The 1990s, therefore, also saw the new field of legal anthropology emerge to address the role of—and conflicts between—international human rights norms in local processes of social change.[52] At the same time, development economists began to engage with human rights to provide practical guidance for development policies that would comply with international human rights legal obligations.[53] Since 2000, there has been an increasing diversity of disciplinary interest in human rights, including by historians, theologians, literary critics, political scientists, sociologists, economists, and anthropologists, as well as by people in interdisciplinary fields, such as women’s studies, labor studies, public health, and critical theory. Today, human rights is a multidisciplinary and interdisciplinary field—although not yet a discipline—and there is a burgeoning literature on interdisciplinarity in human rights education, research, and practice.[54]

Much of the focus on interdisciplinarity and the right to health has been on encouraging collaboration between the health and human rights communities. This linkage seems obvious; expertise in both health and human rights is necessary to realize the right to health. This limited understanding of interdisciplinarity and the right to health grew out of the disease-specific origins of the health and human rights movement, which focused on HIV/AIDS in the late 1980s and early 1990s. Working together, human rights and health communities called for respecting human rights (to confidentiality, informed consent, and nondiscrimination) to gain the trust of those affected in order to get their help in reducing the spread of the disease. Today, we understand that the potential for interdisciplinary collaboration on health and human rights extends beyond the health and human rights communities to many disciplines and interdisciplinary fields.

Importantly, the right to health is now understood to be a broad right that includes the social determinants of health—the conditions in which we live and work—such as education, housing, environment, work conditions, and health care, as well as discrimination, economic power imbalances, and violence. Given that the right to health is a complex right affected by a wide range of legal, political, economic, cultural, and social determinants, its operationalization for all requires the collaboration of a wide range of disciplinary and interdisciplinary experts. Anthropologists, economists, sociologists, political scientists, geographers, and historians are needed to research, for example, people’s attitudes toward the right to health in different communities and over time, the impact of human rights-based approaches to health, what methods best measure progress in the realization of the right to health, and whether right-to-health litigation helps the wealthy or the poor. Only fully interdisciplinary collaboration across multiple disciplines will enable the full operationalization of the right to health for all across all sectors of our complex societies.

Findings on OHCHR and interdisciplinarity

According to the experts we interviewed, fully operationalizing the right to health will require (1) moving beyond legalistic concepts of the right to health; (2) enhancing appreciation of the right to health across UN agencies; (3) employing health professionals at the OHCHR; (4) developing deep expertise on the right to health to advise on operationalization; and (5) understanding the right to health as an expanded right that includes the social determinants of health.

Moving beyond legalistic concepts of the right to health

Many of the interviewees in our study recognized that interdisciplinary work is essential to realizing the right to health. First, as one of our interviewees explained, “Health is not one topic.”[55] Health involves health policy, health care services, health care insurance, health education, health research, and the social determinants of health, which include all the conditions in which we live and work. Thus, even within public health, there are many disciplines. Second, few people are educated in both health and human rights. One interviewee remarked, “Even though there is a growing convergence of people who are looking at public health and human rights, I think having a technical capacity that’s both legal and public health is still quite a rare skill set.”[56]

In this context, several interviewees discussed the challenges of communicating across disciplines as an impediment to operationalizing the right to health. One interviewee explained:

You still have people who are either human rights people, or who are public health people, but you don’t have a huge number who really can comfortably cover both. And that’s a challenge. … Being able to speak each other’s language is a constant learning process, even for us within our team. That’s a challenge to mainstreaming because you’re trying to educate people on a discipline that is completely foreign to them.[57]

Some interviewees reported the sense that legal and public health professionals often did not speak the same language. Nonlawyers described human rights language of the OHCHR as “too legalistic.” In their view, the OHCHR’s overreliance on a technical-legal approach to human rights does not leave room for health practitioners to engage with them. One interviewee explained that this legalistic approach to the right to health resulted in creating distance between OHCHR staff and those working on the ground.[58] Another interviewee explained:

[S]ometimes the right to health in the discussions in OHCHR becomes very conceptual, legalistic, but I would like to see OHCHR moving forward into putting into practice the right to health … [and] doing something at the country level.[59]

While several interviewees observed that health professionals often viewed human rights as dry legal concepts that were irrelevant to their work, one interviewee felt that the differences due to discipline are overstated and often used as an excuse to minimize the mainstreaming of the right to health into UN initiatives:

I don’t think we speak different languages. … It’s, in some sense, a false barrier that people use to justify not cooperating on different issues or not integrating a human rights approach, for example. The human right to health and human rights generally are to be mainstreamed throughout the UN system. … The World Health Organization, for example, is very clear that the human right to health is part and parcel of their work. I guess when I hear that, it sort of raises some alarm bells in my mind about what’s really going on. … Yeah, sure, you could probably improve communications, but the tools are there to do that already if people are open-minded.[60]

Another interviewee explained that the potential of interdisciplinary collaboration depends on the individual experts involved, the issues they are working on, and the emphasis that their agencies put on mainstreaming. The interviewee explained:

[S]ome are more fairly open and they’re sold on the issue and may even have a little bit of expertise of their own. Some are maybe obliged by a mandate to include human rights input but the extent to which that actually has a real place depends very much on how far that agency feels that they can go in featuring rights. … For some, there isn’t very much space at all afforded to rights simply because there’s no understanding of the relevance of rights.[61]

Overall, the interviewees perceive that the OHCHR could be less legalistic in its interdisciplinary and inter-agency efforts to mainstream the right to health, which would facilitate collaboration with people outside the field of law.

Enhancing appreciation of the right to health across UN agencies

Many of the challenges that interviewees discussed arose in the context of the OHCHR’s efforts to help other UN entities mainstream human rights into their work. While some of the challenges of inter-agency collaboration may be due to disciplinary differences, some of them may be due to agency culture and structure. One interviewee explained:

Across any of our work, we find inter-agency collaboration can be very challenging in spite of all the best intentions because organizations have different demands, different pressures from different donors and different mandates and governing bodies to respond to.[62]

OHCHR staff have counterparts—human rights officers—in other UN entities, with whom they often work to advise on mainstreaming human rights into the agency. In inter-agency efforts, OHCHR staff view their role as a collaborator. In discussing work with WHO, the United Nations Population Fund, UNAIDS, and UN Women, one interviewee explained:

I see it more as a collaboration than us bringing something to them. In all of these agencies, we have human rights advisors with whom we work, and we try to talk together about how we can be most constructive in whatever process that we’re in, so trying to bring practical recommendations about how to present human rights in any given context.[63]

Interviewees viewed this collaborative approach across UN entities positively. Further, as the human rights officers across agencies have a “human rights disciplinary alignment,” even if their home agencies have different priorities and cultures, this facilitates communication between the organizations. As one interviewee explained:

I think fundamentally, it benefits both and probably is mutually supportive, because, on the one hand, it’s not that easy being OHCHR and trying to carve out a permanent place or an embedded place within the larger workings of WHO, but by the same token, I can imagine it’s not easy being the one rights voice sitting inside WHO trying to be heard. So it’s probably helpful to have that kind of combined organizational approach.[64]

Interviewees also noted that the OHCHR has grown considerably over the years, and its mainstreaming work has consequently grown in terms of the number of staff and the scope of work that they do. Further, interviewees noted that the OHCHR is working more on economic and social rights—including the right to health—today than it has in the past. In particular, OHCHR collaboration with WHO has been stronger in recent years, and the OHCHR is also working on health, to some extent, at the country level. Some interviewees view the closer relationship of the OHCHR with WHO as possible due to greater understanding in the health community more generally that human rights are necessary to improving health outcomes. One interviewee explained:

My impression is … that there’s been a gradually more receptive acknowledgment and recognition within the wider health community, including the World Health Organization, that actually, if you want to improve health outcomes you can’t ignore human rights. And that actually … considering human rights integrity when you’re designing and delivering health strategies or health service is completely at one with delivering improved health outcomes. And I think probably, the World Health Organization, under the large global health players, had not really fully appreciated that.[65]

While inter-agency and interdisciplinary challenges remain, most interviewees indicated that collaboration in both respects has been improving in recent years. One remaining issue for some interviewees is the tendency to self-censor when they are afraid that they may get pushback on rights issues. One interviewee reflected:

I wonder to what extent we allow that to calibrate the strength of our messaging. … It’s a matter of trying to correctly take the temperature, to read the room a little bit so it’s not always the same. With certain interlocutors you can go further, with others you’re there, but you’re there on sufferance. With others, your sort of input is really actively sought.[66]

In sum, interviewees described both a lack of political will and an underappreciation of the value of a human rights approach to health as obstacles to interdisciplinary collaboration and mainstreaming the right to health across UN agencies. On the other hand, they felt successful in supporting other human rights officers across UN agencies and perceive that human rights are gradually being accepted across agencies as necessary to improving health.

Employing health professionals at the OHCHR

Within the OHCHR, interviewees noted that public health professionals were very underrepresented on the staff. This is also a difficulty in the health and human rights field generally. Of the 20 experts we interviewed for this study, 15 have an education in law and only 3 in health or medicine. Experts in both law and health/medicine all agreed, however, that greater involvement of health professionals is necessary to operationalize the right to health. One interviewee maintained that having health professionals more involved in OHCHR policy and program decisions would make human rights more relevant to health professionals. Another interviewee explained, “Health professionals have got to grasp the right to health, and it can’t just be seen as a dry, dusty legal concept. It’s got to be given meaning, operational meaning. It’s easier to convey that if a health professional is saying it.”[67]

Interviewees expressed the view that while lawyers may have played an important role in conceptualizing the right to health, it cannot be operationalized without the full participation of health professionals. As one interviewee explained:

In my view we’ve reached a point where it’s critical that health professionals are more closely involved in advocating and endeavoring to operationalize the right to health. Lawyers cannot operationalize the right to health. As I often say, if we’re dependent on lawyers for operationalization of the right to health, we will all die prematurely. They can’t do it.[68]

Indeed, interviewees indicated that the absence of health professionals in efforts to mainstream the right to health on the ground prevented it from being operationalized. For some, the disciplinary barrier between lawyers and health professionals continues to make the right to health merely an aspiration or an abstraction to those in the health community. One interviewee stated:

There’s still a long way to go before people in the health care community understand what this human rights approach actually is. … For most of the health community, human rights is for lawyers and for idealists and maybe some politicians. This is of course wrong, and a misconception, and I think much more work has to be done on that level.[69]

Overall, interviewees perceive that greater participation of health professionals is necessary to operationalize the right to health on the ground.

Developing deep expertise on the right to health

Interviewees remarked that considerable expertise is needed to do interdisciplinary work on the right to health. A basic understanding of the right to health is simply not adequate to have the flexibility to be able to explain the uses of the right to health in complex contexts to those not familiar with human rights. Many OHCHR staff in the field do not have that kind of expertise in the right to health. One interviewee explained:

There’s a difference between coming to health discussions with very generic human rights messages and coming to health discussions with human rights messages which are very concrete and saying, “Well, here’s the type of thing a health worker could do to help uphold human rights within the facility in which they work, and here’s the type of thing that will help [that the] policy makers could do.”[70]

Similarly, another interviewee stated, “I think part of engaging in health, like any topic, is you need colleagues who build specific expertise in that area so that they can make contributions which resonate with that community.”[71] As a third interviewee indicated, however, it is difficult for an employee at the OHCHR to develop substantial expertise on the right to health because most people trained in human rights do not receive much training on the right to health, and once they develop it at the OHCHR, they are then moved to another position. The interviewee explained:

[T]he substantive support has been weaker than ideal. That’s not to say that the people who work on the [right to health] mandate aren’t very competent and able individuals. They are. But it’s just that when they start off in the post, they have a lot to learn because health is a big and complicated human right. And the fact that recruitment is normally through internal sort of reshuffling … and that health is sometimes quite marginal generally within the human rights family, what we tend to find is that people who don’t necessarily have a background [in health] come in and they have to learn it all again from scratch.[72]

This lack of expertise on the right to health makes it especially difficult at the country level, where substantial knowledge and experience is needed to advise in mainstreaming the right to health into policies and practices. As one interviewee noted, the backgrounds or skill sets of different country offices vary and probably reflect their previous roles at the OHCHR, which do not likely involve substantial work on the right to health.[73] Another interviewee noted that few people at the country level have any expertise in the right to health because most education programs still provide more in-depth training on civil and political rights than on economic, social, and cultural rights. A third indicated that the OHCHR is increasingly doing work on economic and social rights, and staff are therefore learning about using these rights, but “it’s a learning curve.”[74]

Understanding the right to health as an expanded right

Several interviewees explained that the right to health is now more often understood, at the OHCHR and beyond, to include not just health care but also the social determinants of health. One interviewee explained:

This idea of social and environmental determinants of health and a holistic approach on things like poverty and on discrimination, etc., being part of the determinative factors impacting health is, I think, really gaining widespread acceptance and shaping the way that health is being addressed and public health is being addressed, which in my view is a very positive thing.[75]

This expanded understanding of the right to health makes the right to health relevant to more OHCHR staff and requires collaboration with people working in many sectors and, therefore, in many disciplines beyond health care professionals. One interviewee explained:

I recall that from my previous experience, we would see health as health and that’s it. But my impression now when I see how many different possibilities for collaboration we have with different mechanisms and with different rapporteurs or experts, we do not have that very limited vision.[76]

Still, one interviewee perceived that there is a need for greater appreciation of the right to health as an expanded right and its interconnections with other human rights, which would aid in operationalizing the right to health. The interviewee explained:

I think also it just perhaps may be an under appreciation of the role of health … I keep mentioning this, but health is an enabler of other rights. … I think, once we get to a point where there’s a little bit more understanding of that, then it will enable ultimately a better sort of mainstreaming effort throughout.[77]

In sum, while there is greater understanding today than in the past that the right to health is a broad right that involves many sectors and disciplines, there continues to be a need to mainstream these ideas throughout the UN system.

Conclusion

Our key informants perceive that to fully operationalize the right to health for all, there is a need to move beyond legal norms, to involve more health professionals in mainstreaming efforts, to promote the understanding of the right to health as a broad right that includes the social determinants of health, to enable and support the development of deep expertise on the right to health, and to enhance appreciation for the right to health across all UN agencies. Many of these efforts are underway at the OHCHR.

Our key informants indicated that the new Framework of Cooperation between the OHCHR and WHO provides opportunities to deepen collaboration between the two organizations and to forge closer ties between public health and human rights professionals more broadly. Increased communication and collaboration between these two communities is likely to aid in developing the expertise necessary to foster efforts to operationalize the right to health widely on the ground. Additionally, our key informants indicated that the appointment of the new High Commissioner for Human Rights—a physician with expertise in pediatrics and public health—is likely to lead to greater understanding of the indivisibility, interdependency, and interrelatedness of the right to health with all other human rights—and their relation to health outcomes. This understanding is already building within the OHCHR. Moving beyond the OHCHR and WHO, next steps will involve more constructive engagement among a wide range of professionals, disciplines, interest groups, social movements, and epistemic communities—as well as UN agencies—to make this “era of implementation” of human rights a reality.[78] Nothing less is needed to succeed in this interdisciplinary project to operationalize the right to health for all.

Acknowledgments

We wish to thank the key informants we interviewed for this study for providing invaluable insights into the efforts of the OHCHR to grapple with interdisciplinary and inter-agency challenges to operationalizing the right to health. We also thank the two anonymous reviewers for their excellent suggestions to improve the article. This study received Institutional Review Board approval number 2017062 from the University of Massachusetts Boston on March 14, 2017.

Gillian MacNaughton, JD, MPA, DPhil, is Associate Professor in the School for Global Inclusion and Social Development at the University of Massachusetts Boston, USA.

Mariah McGill, BA, JD, is a Legal Fellow at the Program on Human Rights and the Global Economy at Northeastern University School of Law, USA.

Please address correspondence to Gillian MacNaughton. Email: gillian.macnaughton@umb.edu.

Competing interests: None declared.

Copyright © 2019 MacNaughton and McGill. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non- commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

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[51].           Ibid., paras. 10–11.

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[55].           Interviewee #4.

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[57].           Ibid.

[58].           Interviewee #14.

[59].           Interviewee #2.

[60].           Interviewee #10.

[61].           Interviewee #1.

[62].           Interviewee #18.

[63].           Interviewee #3.

[64].           Interviewee #19.

[65].           Ibid.

[66].           Interviewee #1.

[67].           Interviewee #12.

[68].           Ibid.

[69].           Interviewee #14.

[70].           Interviewee #3.

[71].           Ibid.

[72].           Interviewee #11.

[73].           Interviewee #19.

[74].           Interviewee #3.

[75].           Interviewee #10.

[76].           Interviewee # 9.

[77].           Interviewee #1.

[78].           Hunt (see note 5), p. 491.