Public Health Policy Shapes COVID-19 Impact: UN Expert’s Final Report

Dainius Pūras

In my final report as Special Rapporteur on the right to health, presented to the UN General Assembly this week, I stress that the most effective “vaccine” for global health challenges has been, and will always be, the full realization of all human rights, including the promotion of physical and mental health through the meaningful participation and empowerment of all people.

Throughout my six-year tenure of the right to health mandate I have emphasized the interdependence of all human rights and stressed the indivisibility of the right to health and other human rights: the right to health enables the attainment of other rights and vice versa. In this final report I have applied this understanding of human rights to the biggest global health emergency of the past 100 years–the coronavirus disease (COVID-19) pandemic. I have observed that the impact of the coronavirus is determined to a large extent by public health policy, leadership, socioeconomic inequality, systemic racism, and structural discrimination more than by biological factors.

The actions taken by countries to contain COVID-19 present myriad human rights challenges and opportunities, and as observed in a statement with other UN experts, “the COVID-19 crisis cannot be solved with public health and emergency measures only; all other human rights must be addressed too”. The global spread of COVID-19 and the impact of measures to contain it provide graphic illustration of the interdependence, interrelatedness, and indivisibility of human rights.

There is no possibility of achieving universal health coverage, or containing a pandemic, if discrimination excludes different segments of society from information or services. Robust human rights review procedures at the national and international levels provide opportunities to hold duty bearers to account for their human rights obligations, including in the context of COVID-19.

Throughout my tenure, I have drawn attention to imbalances of power throughout health systems. These can exist in the relationship between health-care workers and patients, between primary health care and specialized medicine, between stakeholders and interest groups within and outside the health sector and between the private sector and the public. These imbalances have resulted in many health systems being underprepared for a pandemic, because in many countries public health has not been prioritized in health systems and has been chronically underfunded. There has also been a historic funding imbalance between physical and mental health-care services, with the latter receiving so little, and now finding itself unable to meet the demand created by the mental stresses related to the pandemic.

It is also of great concern that the health sector in many countries is seriously affected by corruption. This originates from power imbalances, is perpetuated by non-transparent decision-making, and it erodes trust in government. As large funds are being made available for pandemic responses and emergency assistance, it is crucial that transparency and accountability measures are adhered to by all countries, not just those that are historically considered corrupt. For example, reports suggest that COVID-19 economic stimulus responses in some countries have authorized billions of dollars in loans, loan guarantees and other investments to businesses, with minimal oversight requirements and inadequate conflict-of-interest provisions.

Trust is a crucial component in pandemic responses, and in the fulfilment of the right to health at all times. In states that have long upheld human rights principles, and in which there is trust in the leadership, there appears to have been less loss of life and disruption to society. These populations have generally supported and accepted a temporary loss of some freedoms in an effort to save lives and return to normal economic and social function as soon as possible.

Another of the themes I have raised frequently is the dominance of the biomedical paradigm in health. This emphasizes cures and profitability, often at the expense of looking at the role of the underlying determinants of health, including discrimination and vulnerabilities, as the real cause of ill health. In the COVID-19 context, an emphasis on biomedical interventions focuses on vaccine development and medical treatments. However, without broader public health and human rights inputs, these developments will fail to reach everyone, and groups in more vulnerable, remote, disadvantaged or discriminated situations will be less likely to receive them. Viral infections do not have a perfect technical fix: immunity is not guaranteed for everyone, it can be short-lived, or not found at all. If a vaccine is found, it must become part of a larger containment campaign, be made available to all as a “people’s vaccine”, without diverting funding from the responses needed to protect persons in vulnerable situations.

There are three “issues in focus” that I examine in the context of COVID-19 in this report. The first is deprivation of liberty and confinement in penal and medical institutions, and the increased risk of COVID-19 to the people living and working in these facilities. The pandemic might provide an opportunity for states to re-think their confinement policies, to question the effectiveness of incarceration and adopt alternatives, for example by decriminalizing activities deemed immoral, such as drug use and sex work. Community-based alternatives grounded in social justice and human rights would help to fulfil the right to health, not just now, but also beyond the pandemic. I question the wisdom of congregating people in care facilities under any circumstances, especially given the global tragedy of the high COVID-19 fatality rates in care homes for older persons.

The second issue pertains to mental health. I urge states to adopt human rights-based approaches to the support for all people experiencing mental distress and to stop the overuse of biomedical interventions and coercive treatments when addressing any treatment gaps. Rights-based approaches can mitigate the psychological distress of an economic crisis by ensuring that people who lose their income are protected by government support packages, that they do not lose their homes, and that their social rights are protected. I believe it is imperative that the burden of managing and coping with the social, financial, and mental health impacts of COVID-19 does not fall on individuals but that they are well supported by health care and other social services. In this report I repeat messages from my earlier reports that the global community needs to abandon outdated practices resulting in the institutionalization of people with intellectual, cognitive, and psychosocial disabilities in closed  long-term care institutions. This pandemic presents a good opportunity to radically reduce the use of institutionalization in mental health care, with a view to its eventual full elimination.

Digital surveillance is another COVID-19 related rights concern. Technologies deployed in the COVID-19 context have included drones and street cameras with face recognition software identifying people in public without masks, and digital tracing tools that monitor individuals’ movements for the purpose of controlling the spread of the virus through rapid contact tracing. These systems can have a chilling effect across society because their lack of transparency, and the difficulty of achieving redress if errors of identification or supposition are made, leaves everyone vulnerable to their determinations. Furthermore, this surveillance, particularly when linked to systems of social credit scoring, breaks down trust in a society. States have human rights obligations to use these technologies for the shortest time possible. I also draw attention to human rights issues raised by possible introduction of “immunity passports”. I suggest that this is not a solution that effectively addresses the public health crisis, but rather, it could lead to discriminatory impacts on fundamental rights.

Despite the human rights concerns and issues raised by COVID-19, I leave this mandate with some sense of optimism. The pandemic and other global movements have demonstrated the power of participatory democracy and solidarity and the ongoing strength and resilience of our collective humanity during challenging crises. Universal human rights principles have been under attack by populist and authoritarian governments for the past few years: the COVID-19 global crisis provides an excellent opportunity to revitalize these principles and make them the basis of a more sustainable, just, and fairer future for everyone.

Dainius Pūras, MD, Clinic of Psychiatry, Vilnius University, Lithuania, was the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of health 2014-2020.