Fall 1998 Human Rights Magazine

This article was adapted from an article written by Jonathan M. Mann for The Hastings Center Report, Vol. 27, No. 3, May-June 1997, and is reproduced here with permission.

The relationships among medicine, public health, ethics, and human rights are now evolving rapidly, in response to a series of events, experiences, and struggles. These include the shock of the worldwide epidemic of human immunodeficiency virus and AIDS, continuing work on diverse aspects of women’s health, and the complex humanitarian emergencies of Somalia, Iraq, Bosnia, Rwanda, and the Congo.

In response, human rights thinking and action have become much more closely allied to, and even integrated with, public health work and in addition, the long-standing absence of an ethics of public health has been highlighted.

To explore the emerging connections between human rights and health it is essential to consider the essential features of modern public health. As defined by the World Health Organization (WHO), health is a state of physical, mental, and social well-being. In turn, public health has been defined by the Institute of Medicine (IOM) as "ensuring the conditions in which people can be healthy." Putting these definitions together raises the central question about the nature of the conditions that are fundamental for assuring optimal physical, mental, and social well-being.

In general, people equate medical care with health. Certainly, this conflation was widely manifested during recent discussions about healthcare and its reform in the United States. Coverage of health issues in this country and around the world frequently portrays access to medical care and the quality of that care as the principal health issue facing individuals and populations.

However, the contribution of medicine to health, while undeniably important (and vital in certain situations) is actually quite circumscribed. For example, it is estimated that only about one-sixth of the years of life expectancy gained in this country during this century can be attributed to the beneficial impact of medicine, medical care, and medical research. Similarly, the World Bank has suggested that a lack of essential clinical services may be responsible for between one-tenth and one-fourth of the global burden of disease; in this country, an estimated 10 percent of preventable premature deaths are associated with a lack of medical care. Of course, none of these data, including the notable decline in diseases like tuberculosis well before antituberculosis drugs became available, should be interpreted to suggest that medical care is not relevant; rather, they suggest its limits.

Returning to the definition of public health, the vast majority of research into the health of populations identifies so-called "societal factors" as the major determinants of health status. Most of the work in this area has focused on socioeconomic status as the key variable, for it is clear, throughout history and in all societies, that the rich live generally longer and healthier lives than the poor. Thus, in the United Kingdom in 1911, the age-adjusted standardized mortality rate among members of the lowest social class was 1.6 times more than that of the highest social class. Interestingly, in 1981, following creation of the National Health Services (NHS) to ensure full access to medical care, and despite a dramatic change in major causes of death (from mainly infectious to mainly chronic diseases), this societal gradient not only persisted, but increased, to a 2.5-fold higher standardized mortality rate among the lowest compared with the highest social class.

A second major question arising from the socioeconomic status/health gradient is the stepwise nature of the gradient. For example, among over 10,000 British civil servants followed for many years, health status and longevity improved for each successive category of civil servants, from lowest to highest. This raises two issues: first, while at least intuitively, explanations seem available for poor health among the destitute when compared with the rich (e.g., lack of good food, housing, and poor sanitary conditions), even the lowest class of British civil servants are not poor. Secondly, why should the civil servants in the next-to-highest group— living in quite comfortable circumstances—experience poorer health than the highest group?

Beyond these unanswered issues, many recent studies have pointed to the limited explanatory power of socioeconomic status, itself an amalgam of current income, years of education, and the job classification. Other factors, including the extent of socioeconomic inequality within a community, the nature, level, and temporal pattern of unemployment, societal connectedness and the extent of involvement in social networks, marital status, early childhood experience, and stresses at work have all been suggested as powerful potential components of a "black box" of societal factors whose dominant role in determining levels of preventable disease, disability, and premature death are nevertheless beyond dispute. (See Adler et al., "Socioeconomic Status and Health: The Challenges of the Gradient," 49 American Psychologist 15 (1994)).

Public health, although starting as a social movement, has at least in recent years, responded relatively little to this profound knowledge about the dominant impact of society on health. To illustrate: certain behaviors have an enormous impact on health, such as cigarette smoking, excess alcohol intake, dietary choices, and levels of exercise and physical fitness. How these behaviors are conceptualized by public health determines how they will be addressed. The basic question is whether and to what extent these behaviors can be considered—and therefore responded to—from the perspective of isolated individual choice.

Public health, and the public, know that these important health-related behaviors are substantially influenced by societal factors and context. Indeed, for many people, the societal context weights heavily on behaviors. Yet public health programs designed to address the health problems associated with these same behaviors generally consist of activities that assume that individuals have essentially complete control over their behavior. Accordingly, traditional public health works to provide people with information and education about risks associated with diet or lack of exercise, along with various clinic-based services such as counseling, or distribution of condoms and other contraceptives. However, while public health may cite, or blame, or otherwise identify the societal-level or contextual issues—which it acknowledges to be of dominant importance, both in influencing individual behavior, and for determining health status more broadly—it does not deal directly with these societal factors.

At least three reasons for this paradoxical public health inaction may be proposed. First, public health has lacked a conceptual framework for identifying and analyzing the essential societal factors that represent the conditions "in which people can be healthy." Second, a related problem: public health lacks a vocabulary with which it can speak about and identify commonalities among health problems experienced by very different populations. Third, there is no consensus about the nature or direction of societal change that would be necessary to address the societal conditions involved. Lacking a coherent conceptual framework, a consistent vocabulary, and consensus about societal change, public health assembles, and then tries valiantly to assimilate, a wide variety of disciplinary perspectives, from economics, political science, social and behavioral science, health systems analysis, and a range of medical specialties. Yet, while each of these perspectives provides some useful insight, public health becomes thereby a little bit of everything, and therefore not enough of anything.

Given that the major determinants of health status are societal in nature, it seems evident that only a framework that expresses fundamental values in societal terms, and a vocabulary of values that links directly with societal structure and function, can be useful to the work of public health. For this reason, modern human rights, arising entirely outside the health domain, and seeking to articulate the societal level preconditions for human well-being, seems a more useful framework, vocabulary, and template for public health efforts to analyze and respond directly to the societal determinants of health than any framework inherited from the past biomedical or public health tradition.

This is the central hypothesis that catalyzes the emerging health and human rights movement: that promoting and protecting human rights is inextricably linked with promoting and protecting health. In this context, and before proceeding, it is important to emphasize that the health and human rights movement respects human rights not only for their instrumental value in contributing to public health goals, but as societal goods of preeminent importance.

Reproductive health and HIV/AIDS provide two clear illustrations of the health and human rights connection. In 1994, the Cairo UN Conference on Population and Development shifted the focus on population policy to the need to help ensure that women are able to make and effectuate free and informed decisions about their reproduction. Traditional public health would respond to this challenge by providing information and education about contraceptive methods along with clinic-based health services to ensure access to a range of contraceptive methods. However, this approach is manifestly inadequate, for by itself it cannot ensure the making and effectuating of free and informed decisions by women. The missing key element is societal, and in Cairo, this was defined in terms of women’s human rights. A cluster of rights, including the rights to health, bodily integrity, privacy, information, education, and equal rights in marriage and divorce, have been called "reproductive rights," because the extent of their realization plays a major role in determining the ability of women to make and effectuate these free and informed choices. Therefore, the Cairo Conference Declaration calls for improving respect for women’s human rights as an integral part of strategies for a successful population policy.

Similarly in HIV/AIDS, it has become clear that the traditional public health approach, combining information and education with specific health services (counseling, HIV testing, needle exchange, condom distribution) is necessary and helpful, yet clearly insufficient for HIV prevention. Vulnerability to the epidemic has now been associated with the extent of realization of human rights. For as the HIV epidemic matures and evolves within each community and country, it focuses inexorably on those groups who—before HIV/AIDS arrived—were already discriminated against, marginalized, and stigmatized within each society. Now that a lack of respect for human rights has been identified as a societal level risk factor for HIV/AIDS vulnerability, HIV prevention efforts are starting to go beyond traditional educational and service-based efforts—to address the rights issues which will be a precondition for greater progress against the epidemic.

In addition to a robust framework for analysis and response to the societal conditions for health, public health also needs an ethics—applicable to the individual public health practitioner. In contrast to the important declarations of medical ethics such as the International Code of Medical Ethics of the World Medical Association and the Nuremberg Principles, the world of public health does not have a reasonably explicit set of ethical guidelines.

In part, this deficiency may stem from the broad diversity of professional identities within public health. Yet, curiously, many of the occupational groups central to public health (epidemiologists, policy analysts, social scientists, biostatisticians, nutritionists, and health system managers) have not yet developed, or are only now developing, widely accepted ethical guidelines or statements of principle for their work in the public health context. Thus, while a public health physician may draw upon medical ethics for guidance, the ethics of a public health physician have yet to be clearly articulated.

The central problem is one of coherence and identity. Public health cannot develop an ethics until it has clarified its own identity; technical expertise and methodology are not substitutes for conceptual coherence. Two related steps seem essential for public health to reach toward this analytic and definitional clarity.

First, public health must divest itself of its biomedical conceptual foundation. The language of disease, disability, and death is not the language of well-being; the vocabulary of diseases may detract from analysis and response to underlying societal conditions, of which traditional morbidity and mortality are expressions. In addition, the taxonomy of biomedicine is so strongly imbued with a focus on the individual that the impact of larger forces is easily missed.

Second, a human rights framework for analysis and response to the societal determinants of health is a precondition for developing an ethics of public health. The human rights framework can provide the coherence and clarity required for public health to identify and work with conscious attention to its roles and responsibilities. At that point, an ethics of public health, rather than the ethics of individual constituent disciplines within public health, can emerge. Issues of respect for autonomy, beneficence, nonmaleficence, and justice can then be articulated from within the profession, with understanding of goals and responsibilities implicit in the mission of improving public health.

For example, the challenges for public health officials in balancing the two goals of a modern public health—to promote and protect public health, and also to ensure that human rights and dignity are not violated—call urgently for ethical analysis. The official nature of much public health activity places public health practitioners in a complex environment, in which work to promote rights inevitably challenges the state system within which the official is employed. Ethical considerations are highly relevant to collecting, disseminating, and acting on information about the health impacts of the entire range of human rights violations. And, as public health seeks to "ensure the conditions in which people can be healthy," and as those conditions are societal, to be engaged in public health necessarily involves a commitment to societal transformation. The difficulties in assessing human rights status and in developing useful and appropriate ways to promote human rights and dignity, necessarily engage ethical issues for the public health professional.

In conclusion, there is much more to health than new scientific discoveries, development of new technologies, emerging or reemerging diseases, and changes in patterns of morbidity, and mortality around the world. For we are living at a time of a paradigm shift in thinking about health. Health as well-being, although already defined in this manner by the WHO, lacks more than rudimentary definition, especially regarding its mental and societal dimensions. The universe of human suffering and its alleviation is being more fully explored. Awareness of the limits of medicine and medical care, growing recognition of the health impacts of societal structure and function, globalization and consequent interdependence, and the sometimes active, sometimes ineffectual actions of nation-states, lead toward new challenges and a new vision of global health. The health and human rights perspective offers a useful and intriguing approach for public health analysis and action in a new era in the relationship between society and health.

As published in Human Rights, Fall 1998, Vol. 25, No. 4, p.2-5.