EDITORIAL 25 Years: Exploring the Health and Human Rights Journey

Carmel Williams, Joseph J. Amon, Mary T. Bassett, Ana V. Diez Roux, and Paul E. Farmer

Dedication: to founding editor Jonathan Mann and to Albina du Boisrouvray, who, as Mann wrote in his first editorial, “immediately understood, provided the means, and continues to share ideas and inspiration with us.

A true history of any movement makes for a rich, complex, and often contradictory story. Partial stories are easier to tell, and teach. Such a partial story of health and human rights might begin with crediting Jonathan Mann for starting the modern human rights and health movement 25 years ago, building upon the Constitution of the WHO, which in 1946 identified the enjoyment of the highest attainable standard of health as one of the fundamental rights of every human being. This partial story would observe definitive events including the adoption by the Committee on Economic, Social and Cultural Rights of General Comment 14 in 2000, defining the obligations that States parties have regarding the right to health at national and international levels. The story could go on to highlight certain influential conferences and groundbreaking legal cases for the right to health. It might note the ever-increasing deployment of human rights-based approaches to health and growing global recognition of the right to health. All of which would be true, but far from a whole truth.

This partial history would almost certainly draw on Mann’s co-authored paper in the first issue of the Health and Human Rights Journal (HHRJ) in 1994, in which ‘health’ and ‘human rights’ were described as ‘complementary approaches for defining and advancing human well-being’.[1] The two fields, health and human rights, the paper argued, had profound impacts upon each other, but each harbored suspicion of the other. Although the paper recognised synergies between the two fields that could advance public health, it did not quite acknowledge a ‘right to health’. Our partial history would highlight how, in its formative years, ‘health and human rights’ discussions were predominantly disease focused, especially on HIV/AIDS, and tended to be grounded upon the impact of discrimination, especially arising from violence and other abuses of civil and political human rights. At the start of the new millennium, our simple narrative might draw on evidence to show that the use of the term ‘right to health’ increased in the literature and in constitutions around the globe. With Kofi Annan’s declaration in 2005 of an era of human rights implementation, so began the operationalization of the right to health. This included the judicialization of the right to health, mainstreaming human rights in global health organizations, grassroots advocacy, and rights-based approaches to health programming.

All of which is true, but far from a whole (or only) truth.

This simplistic telling omits the details of the movement’s struggles and victories and provides little guidance on how to tackle today’s very real attacks on social rights, and how the tensions and synergies between distinct and overlapping fields—health and human rights—continue to be contested and evolve. A somewhat different, but complementary, history can be found in the papers published by HHRJ which has been dedicated exclusively to the health and human rights field since its first issue. Looking through our archives, we see the prescience of Mann’s comment that the journal would “inform and expand the space within which ideas about the intersection between health and human rights can venture forth into the world, to be cited and criticized, debated and discussed, torn down and built up”.[2]

Over the past 25 years, HHRJ has published more than 650 articles, with indeed much citing, criticizing, and debating. From the start, different understandings of the meaning of health and human rights emerged. In the first issue where Mann et al spoke of health and human rights as an intersection between two disciplines, Virginia Leary addressed ‘the right to health’, as one right. In her paper, Leary referred to a formative multi-disciplinary workshop on the right to health organized by the Hague Academy of International Law and the United Nations University in 1978. “It established the phrase ‘right to health’ within the context of international human rights and drew attention to sources of the right” (long predating our simple historical narrative).[3] Both the Mann and the Leary papers stressed the need for interdisciplinarity, with Leary calling on “collaboration among human rights scholars and practitioners, WHO, UNICEF, and public health and development experts.”[4]

At the same time that Leary was calling for collaboration, the Mann paper anticipated conflict between a human rights framework (which Mann et al described as more capable at describing determinants of health) and traditional biomedical and public health approaches. In a 1995 paper, Mann writes of the “resistance” to incorporating a human rights framework which will come from within public health and that health workers would wonder about the applicability or utility, let alone necessity, of incorporating human rights perspectives into their work. As seen in the December 2019 issue, in a special section guest edited by Lawrence Gostin (one of Mann’s co-authors of the 1994 paper) and Benjamin Mason Meier, papers continue to discuss the adoption of human rights within UN agencies, showing progress but acknowledging that there is no comprehensive mainstreaming of human rights. The acceptance of, and resistance to, human rights among health workers was also the focus of the special rapporteur on the right to health in his latest report to the UN General Assembly. He observes that without rights-based health education, medical hierarchies and biomedical paradigms of health are not challenged, and social determinants are downplayed. These critiques and ongoing debate around the integration of human rights frameworks in medicine and public health—resistance and acceptance—reflect the continued vibrancy and vitality (and potency) of health and human rights scholarship 25 years since the first publication of Health and Human Rights Journal.

While we draw a simplified history of health and human rights, we can also draw a simplified history of public health. This history, over the same time period, would almost certainly emphasize the increasing attention to social (and political) determinants of health and the critical role of inequality and racism in driving population health. Using evidence and advocacy, public health is increasingly drawing attention to the ways health is fundamentally shaped by the economy and social structures. The seeds of this focus might be found in the adoption of the Declaration of Alma Ata in 1978 by UN member states. The declaration framed the right to health as a foundational social and economic right, interrelated and dependent on other rights beyond health.

But the Alma Ata declaration could also be seen as a point of divergence between those who drew upon its call for a right to health, and advanced it with language around State obligations and accountability, and those who focused less on a ‘legalistic’ approach and more upon its call for a New International Economic Order. Mann could not have known how rapidly income inequality would grow or foreseen the dismantlement of the welfare states of the global north, to which so many of the newly independent nations of Africa and Asia had then aspired. Rigorous attention to income inequality has been relatively scant in the pages of the Journal, although increasing quantitative analysis of human rights and measures of income inequality (for example by the Center for Economic and Social Rights) show some attention to this field.

Looking forward, developing stronger links between a health and human rights framework and work on the social determinants or health and health equity, seems likely. In the next 25 years, we hope to work towards building and making more obvious these connections. This is aligned with Mann’s vision who, writing in 1995, saw health and human rights in this broader way, offering traditional public health something it lacked—a sense of coherence and common purpose—and something heroic—a role of public health practitioners as change agents and advocates.[5]

Papers published by the Journal broadly cover legal and health research, policy, advocacy, and grassroots activism, always from a human rights perspective. Papers by health workers often reflect on the issues beyond the specific health condition being addressed, examining for example, how rights to non-discrimination, due process, privacy, freedom of expression and the right to information, impact on the attainment of health generally. While Mann was strongly associated with the fight against HIV, and the field of health and human rights has strong ties to the HIV activists who have defined a right to HIV prevention and treatment, the Journal from the beginning has published articles that seek to define or explore the relevance of human rights to multiple health related domains and issues including gender, reproductive health, disability, prisons, and clean water and the environment.

Accompanying the current issue, the journal is launching an online series of ‘Viewpoints’ to collate the many histories of health and human rights, to present challenges we face now, and prepare for those not yet apparent. Many of the initial commentaries have been written by contributors to the journal over the past 25 years, and we hope to see submissions from new voices, and especially health and human rights activists working in the field. While the journal has been steadfast in its focus on publishing papers that theorize and demonstrate the impact of human rights, and the right to health, we acknowledge there is much work left to be done to promote the uptake of human rights-based approaches to health, and to demonstrate the effectiveness of such approaches. It is for this reason that the Journal welcomes Jonathan Mann’s other academic legacy—the Dornsife School of Public Health at Drexel University, where Mann was the founding Dean—as a publishing partner. Dornsife’s focus since its inception, has been on the right to health, health equity, and research in the service of true community and policy impact. Drexel brings practical knowledge and experience and a commitment to a health and human rights approach to public health that will further enrich the Journal as it embarks on its next 25 years.

Mann and his prescient identification of the need for a strong human rights framework within public health will continue to be evident, and explored, in these pages. As always, we thank our readers, authors, reviewers, as well as human rights activists working on the frontlines, for their contribution to our common goal of seeing the right to the highest attainable standard of health realized for all.

Carmel Williams, PhD, is Executive Editor of Health and Human Rights

Joseph J Amon, PhD, MSPH, is Senior Editor, Health and Human Rights, and Director, Office of Global Health, Drexel University Dornsife School of Public Health, Philadelphia, USA

Mary T Bassett, MD, MPH, is Contributing Editor of Health and Human Rights, and Director, FXB Center for Health and Human Rights, Harvard University, Boston, USA

Ana V. Diez Roux, MD, PhD, MPH, is Dean, Drexel University Dornsife School of Public Health, Philadelphia, USA

Paul E Farmer, MD, PhD, is Editor-in-Chief of Health and Human Rights, and Kolokotrones University Professor, Harvard University, Boston, USA.

References

[1] J. M. Mann, L. Gostin, S. Gruskin, T. Brennan, Z. Lazzarini, and H. V. Fineberg, “Health and Human Rights,” Health and Human Rights Journal 1/1 (1994), p.19.

[2] Ibid, p. 1.

[3] V. A. Leary, “The Right to Health in International Human Rights Law”, Health and Human Rights Journal 1/1 (1994), p.29

[4] Ibid, p.27

[5] J. Mann, “Human Rights and the New Public Health”, Health and Human Rights Journal 1/3 (1996), p.228