Rave Review of “Rights-Based Approaches to Public Health,” by our own Dr. Elvira Beracochea

Congratulations, Dr. Beracochea! A glowing review of her new book, Rights-Based Approaches to Public Health, was recently published in PsycCritiques, a collection of reviews from the American Psychological Association. I have posted the review below. This is a wonderful accomplishment for Dr. Beracochea and her fellow editors and authors of this book. The IH section is fortunate to have you!

Public Health and Human Rights: Realigning Approaches to Improve Global Health Problems

Reviewed by
Will Ross

At a time of heart-crushing stories of human deprivation due to regional conflict, forces of nature, or uncaring and at times immoral state policies, the world’s attention turns to the public health community for problem assessment and effective deployment of resources and programs to stabilize critical conditions on the ground. With great timing, the editors of Rights-Based Approaches to Public Health offer a targeted and innovative strategy to
combat global health problems. Balanced, comprehensive, and steeped in the historical traditions of human rights, the book persuasively moves the reader from abstract conceptions of inalienable human rights to evidence-based, pragmatic solutions that highlight the systematic integration of human rights principles in human development work.

For the audience of public health students, seasoned and novice public health
professionals, health care practitioners, and policy experts, the editors provide an overview of a rights-based approach that is elegant in simplicity and highly executable in design, referencing the UN’s (2000) General Comment 14 on the Right to the Highest Attainable Standard of Physical and Mental Health: “Every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life of dignity” (para. 1).

The editors and authors present a framework for a rights-based approach that is
normatively based on international human rights standards and that cannot be easily dismissed as political in nature or hegemonic. Most important, the editors charge some of the world’s most respected public health practitioners and human rights advocates to craft sensible methods of operationalizing the basic human rights principles outlined in the UN’s (2003) Human Rights-Based Approach: Statement of Common Understanding, which posits that human rights are universal, inalienable, interdependent, and interrelated. In essence,
they have created a veritable “how-to” guide that, when implemented, can in sustainable fashion uplift the human condition worldwide.

Universality of Rights-Based Approaches: Uniting Us All?

As detailed by the editors, a cardinal feature of a rights-based approach is its timelessness and universality, increasing its appeal to professionals who labor to keep the plight of marginalized communities on the global radar screen. By using the universal language of rights-based approaches, public health professionals may be better positioned to leverage greater social and political capital and enhanced resource allocation for their cause. Striking examples of rights-based approaches in diverse settings are outlined in the book, from demands for water rights in Haiti to conflict-affected settings such as the Gaza Strip and advocacy of children’s rights in Kosovo.

If the dramatic contemporary examples outlined in the book are not sufficient, the authors could easily extend the discussion further and call attention to the severe drought and attendant famine in Somalia, where the UN’s Food Security and Nutrition Analysis Unit (2011) found that nearly 250,000 people continue to face imminent starvation, or the Democratic Republic of the Congo, where U.S. researchers note that more than 400,000 women are raped each year (Peterman, Palermo, & Bredenkamp, 2011). In all instances a rights-based approach can reverse the erosion of socioeconomic stability that fosters such
injustices while holding the state accountable for protecting and fulfilling the rights of individuals in affected communities.

Inherent in a rights-based approach claim that individuals have the right to the highest attainable standard of health is the realization that health professionals cannot disentangle physical health from the myriad social and economic factors that influence health. If a rights-based approach empowers rights holders in asserting that human rights are universal and inalienable, then it is the incumbent responsibility of the duty bearer—entities sanctioned to protect society—to ensure the fulfillment of those rights. This conceptual framework is in contradistinction to traditional needs-based approaches, whose altruistic intent and actions may be perceived as both patronizing and lacking in accountability, and thus not amenable to legal redress in the event of adverse outcomes.

Marrying Rights-Based Approaches to Health Care Reform

A critical chapter for U.S. readers (Chapter 4) is “A Rights-Based Approach to Health Care Reform.” In the United States, profligate health care spending has not translated into improved health outcomes when compared with those of other developed countries. A fundamental, if not fatal, flaw in the U.S. health care delivery system is the disconnect between the high-quality acute, specialty care available to some who have the ability to pay in a system rooted in free enterprise and the haphazard primary and preventive care that is unevenly distributed across locales. Although unintended, this result is not unexpected in a country that has failed to embrace a full definition of health.

The divide on the proper role of government in health care in the United States was presaged in the response to the World Health Organization’s (1946) definition of health, promulgated in the 1948 UN convention:

a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity. . . . Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures. (p. 2)

This provision was rebuffed on the grounds that it was outwardly socialistic in intent and lacked legal standing, on the basis of the interpretation that health care was not among the enumerated rights in the U.S. Constitution.

The perennial argument surrounding the government’s role in health care has since devolved into rants about market-based reforms as opposed to moral-based claims of health care as a right for every citizen. Such a false dichotomy only promotes greater social division; consensus will be gained when every country affirms the connection between health and human rights. A rights-based approach to health, which has been relatively absent from the contemporary discourse on health reform, could effectively realign staunch political forces around the unassailable conceptual framework of health as a public good rather than a commodity.

The rights-based approach permits a more nuanced view of the roots of health
inequities; consequently, more systematic steps can be taken to ameliorate inequities since a framework exists that addresses the social determinants of health. Rights-Based Approaches to Public Health outlines several international treaties, such as the 1977 International Covenant on Economic, Social, and Cultural Rights, which would reduce stillbirth rates and infant mortality by paving the way for special protection for mothers in the childbirth period. Although the United States signed the treaty, it did not ratify it and so failed to allocate the requisite resources to enforce the treaty.

Hopefully there will be greater U.S. embrace of the UN’s Millennium Development Goals—explicit milestones for the realization of global human development that offer an opportunity to reduce health inequities by spurring economic development. The United States, in its effort to reduce health inequities as outlined in the Centers for Disease Control and Prevention’s (2011) “Health Disparities and Inequalities Report,” will find willing partners in realizing two seminal Millennium Development Goals: reducing child mortality
and improving maternal health.

Limitations of Rights-Based Approaches

The authors and editors of Rights-Based Approaches to Public Health rightfully
acknowledge that the still-nascent field of rights-based public health has limitations that have constrained its widespread adoption. Rights-based approaches rest on the belief that individual empowerment and restored human dignity can be ensured through programmatic efforts that address the social determinants of health. Social determinants of health, as espoused by the World Health Organization’s Commission on Social Determinants of Health (2008, p. 2 of Executive Summary), are “the conditions in which people are born, grow, live, work and age . . . . In their turn, poor and unequal living conditions are the consequence of poor social policies and programmes, unfair economic arrangements, and bad politics.”

Criticism abounds that such an approach is too costly, time intensive, and inherently difficult to measure since it involves restructuring the social fabric of disadvantaged communities and raises the potential for conflicts due to encroachment on national sovereignty. There is correspondingly a lack of solid evidence supporting the effectiveness of rights-based approaches. Finally, a rights-based approach in public health can come across as canonical, even prescriptive in its assertion that individual rights warrant the same protection as societal ones (Berman, 2008).

The book concludes, in powerful tones, that rights-based approaches provide public health professionals the framework and the infrastructure to address the needs of vulnerable populations and society at large. Public health students, academicians, and both medical and public health practitioners should feel empowered to act with this transformative approach that asserts the dignity of humankind.

Berman, G. (2008). Undertaking a human rights-based approach: Lessons for policy, planning, and programming. Bangkok, Thailand: UNESCO Asia and Pacific Regional Bureau for Education.

Centers for Disease Control and Prevention. (2011, January 14). CDC health disparities and inequalities report—United States, 2011. MMWR: Morbidity and Mortality Weekly Report, 60(Suppl).

Peterman, A., Palermo, T., & Bredenkamp, C. (2011). Estimates and determinants of sexual violence against women in the Democratic Republic of Congo. American Journal of Public Health, 101, 1060–1067. doi:10.2105/AJPH.2010.300070

United Nations. (2000). The right to the highest attainable standard of health. Retrieved from http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En

United Nations. (2003). Human rights-based approach: Statement of common
understanding. Retrieved from http://www.unicef.org/sowc04/files/AnnexB.pdf

United Nations Food Security and Nutrition Analysis Unit. (2011, November 18). Famine continues: Observed improvements contingent on continued response. Retrieved from http://www.fsnau.org/in-focus/famine-continues-observed-improvements-contingentcontinued-response

World Health Organization. (1946). Constitution of the World Health Organization. Geneva, Switzerland: Author.

World Health Organization Commission on Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva, Switzerland: World Health Organization.

Dark Star Safari: Is aid in Africa making things worse?

I was encouraged to read Paul Theroux’s Dark Star Safari by a co-worker in back in Texas when I mentioned that I was interested in a career in international health.  “You should definitely read this book.  It tells the truth about the corruption of aid agencies and how they’re actually hurting Africa.”

Map of Africa, with Paul Theroux's route from Dark Star Safari drawn in a dotted line
Theroux’s travel route in Dark Star Safari

She was at least partially right.  Over the course of Theroux’s “safari” across the continent, he lapses into several ranting session about selfishness and self-importance of aid workers (“they were, in general, oafish self-dramatizing prigs, and often complete bastards,” p. 146), the futility of various aid projects, and the corrupting influence that foreign aid has on African governments and people.  He takes it upon himself to diagnose the problem.  “Where are the Africans in all this?  In my view, aid is a failure if in forty years of charity the only people still dishing up the food and doling out the money are foreigners.  No Africans are involved – there is not even a concept of African volunteerism or labor-intensive projects.” (p. 272)  Unfortunately, Theroux never bothers to actually visit an aid agency at all during his trip.  If he had, he might have learned the majority of employees of aid agencies in Africa are Africans.1

Despite this lack of research, there is some truth to Theroux’s perceptions of and rants about the damage that foreign aid does to African countries.  It creates a culture of dependence, stifles sustainable growth, discourages investment, and burdens poor countries with massive debt.  Real per-capita income on the continent is lower now than in the 1970s, and the number of people who live on less than a dollar a day has doubled in the last two decades.2  Corruption siphons off huge amounts of donor funds, and the continuous flow of aid keeps inefficient and abusive governments in power. 

Fortunately, there are organizations that seek to promote education and economic programs that will have lasting effects in the region.  For example, Tostan works with villages in Sénégal and neighboring countries by training local people to lead education modules that focus on hygiene, literacy, and human rights; through their program, they’ve gotten over 4,500 villages to collectively abandon FGM.3  The Acumen Fund provides mid-size loans to early-stage enterprises providing healthcare, water, housing, or agriculture; one of their loans financed the Kenyan Company Advanced Bio-Extracts, the first African company to produce artemisinin for antimalarial drugs.4  These groups bring a fresh approach to the decades-old problem of the stagnation of African communities and economies.

I was not discouraged by Theroux’s tirades; as a field, I feel, or at least I hope, that public health is less prone to “throwing money” at problems and seeks to implement long-lasting behavior changes.  However, despite the author’s vitriol and lack of knowledge on his chosen tirade, his observations are still a powerful reminder that public health professionals can fail people by not giving them the tools to continuously implement the changes we try to effect.