Public Health and Human Rights:
Challenges, Synergies,
Methodologies
June 22nd, 2008
Chris Beyrer MD, MPH
Center for Public Health and Human Rights
Johns Hopkins Bloomberg School of Public Health
Core Themes
• Human rights abrogation or protection can have
profound impacts on the health of individuals,
communities, and populations
• Rights violations which affect populations need
to be investigated and addressed using
population-based methods
• Responses based on human rights principles
may improve disease prevention and control,
and better the human rights contexts for those at
dual risk
Outline
I.
Introduction
II.
Health rights and human rights
III. Putting PHHR into practice
Luke Mullany, PhD
Introduction
• Modern human rights movement a response to
Nazi atrocities of WWII
• Universal Declaration of Human Rights passed
by United Nations on December 10, 1948
– Defines the fundamental human rights of persons and
violations of those rights
– Universalist
– Aspirational
– Lacking enforcement mechanisms
UDHR
Resolutions include:
Article 4: Prohibits slavery
Article 5: Prohibits torture
Article 18: Freedom of thought
Article 19: Freedom of opinion and of
expression
• Article 25: Standard of Living
•
•
•
•
– Includes access to medical care as a human right
Human Rights Instruments and Public Health
1948 The Universal Declaration of Human Rights
1976 International Covenant on Civil and Political Rights
1976 International Covenant on Economic, Social and Cultural
Rights
General Comment 14: Health rights
Prevention, treatment, control of epidemic diseases
Focus on realizing rights of women to health throughout the
life span
1981 Convention on the Elimination of All Forms of Discrimination
against Women (CEDAW)
Health services to be consistent with the human rights
of women:
Autonomy, Privacy, Confidentiality, Informed consent, and Choice
State Responsibilities
Signatory States must not violate these
rights
Commit to measurable progress to:
Respect
Protect
Fulfill
What is meant by “The Right to
Health”
“The right to health does not mean the right to be
healthy, nor does it mean poor governments
must put in place expensive health services for
they have no resources. But it does require
authorities put in place policies and action plans
which lead to available and accessible health
care for all in the shortest possible time. To
ensure that this happens is the challenge facing
both the human rights community and public
health professionals.”
UN High Commissioner for Human Rights, Mary Robinson
The Center for Public Health and
Human Rights at Hopkins
• Focus is the impact of rights of violations on the health of
populations
• Research, Teaching, Advocacy
• Use of population based methods (epidemiology) to
study, document, measure these impacts
• Bring increased awareness of human rights and health
interactions to the scientific community
• Enhance public health through rights based interventions
• Advocate for public health and human rights
PHHR Center Activities
• Burma: Cross border health and rights projects
with ethnic minority health groups (IDPs,
migrants); HIV/AIDS epi; Mobile Obstetric
Medics (Gates Inst.); Capacity building for
human rights and democracy (DOS)
• Southern Africa: MSM, HR, and HIV (OSI)
• Russia: MSM, HR, and HIV (Ford, NIH)
• China: Treatment access and advocacy for
blood donors (OSI, Levi Strauss)
• Kazakhstan, Kyrgyzstan: HIV prevention,
NSEPs, HIV VCT access (NIH/NIMH, NIDA)
JHU Press, 2007
Human rights violations and
associations with population-level
health indicators
June 22nd, 2008
Luke C. Mullany, PhD MHS
Center for Public Health and Human Rights
Johns Hopkins Bloomberg School of Public Health
Burma
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•
•
•
•
Population – 50 million
Ethnically diverse
90% Buddhist
Military junta (SPDC)
Poor health indicators
– IMR: 76/1000
– U5MR: 104/1000
– WFP: 33% of children
chronically malnourished
– WHO: 190 / 191 ranking for
health system
Human rights violations
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•
•
•
•
•
Forced labor
Destruction / seizure of crops / livestock
Arbitrary arrest and detention
Forced military conscription
Torture, rape, execution
“Four cuts”
Backpack Health Worker Team
•
Novel approach to data collection
within internally displaced populations
– Programmatic context
– IDPs actively gathering information
among themselves
• Workers also specific targets of the
conflict
Data collection activities
• Health information systems developed over past 10
years with tech. asst. from CPHHR and Global Health
Access Program (www.ghap.org)
• Major goal: estimation of mortality
– U5MR / IMR through surveys
– Tracking of human rights violations
• Others:
– Morbidity estimation
– Compliance with specific programs
– Knowledge / practices / attitudes
Methods - Design
• Retrospective household surveys
– Reporting of vital events
– 12 month recall period
• Sampling
– Two stage cluster design
– 100 clusters
– 20 households / cluster
Methods - Design
• Cluster selection:
– Village based
– Selection proportionate to population size
– Census provides complete lists of population
by village
• Household selection – various methods
used
– “spin the pen”, random-proximity method
– Interval sampling with random start
Survey elements
• Context demands simplicity
– Constant movement by interviewers
– Travel on foot
– One page limit
• Household census
• All deaths recorded (cause)
• Listing by age / sex
Results – Sample
• Response rate has varied: 70-92%
• Total sample 7,500-9,000
– (5-6 persons / household)
• <5 years old ~ 18-20%
• <15 years old ~ 45 – 50%
• Male to female ratios – consistently <0.9
Population pyramid - 2004
Males
Females
Age Group
95-100
90-95
85-90
80-85
75-80
70-75
65-70
60-65
55-60
50-55
45-50
40-45
35-40
30-35
25-30
20-25
15-20
10-15
5-10
0-5
900 800 700 600 500 400 300 200 100 0 100 200 300 400 500 600 700 800 900
Male to Female Ratio 15-25yrs: 0.86
Mullany LC, Richards AK, Lee CI, et al. Application of population-based survey methodology to quantify associations between
human rights violations and health outcomes in eastern Burma. J Epidemiol Community Health. 2007;61:908-14
Lee TJ, Mullany LC, Richards AK, et al. Mortality rates in conflict zones in Karen, Karenni, and Mon states in eastern Burma. Trop.
Med. Int. Health. 2006;11(7):1119-27.
Mullany LC, Richards AK, Lee CI, et al. Application of population-based survey methodology to quantify associations between
human rights violations and health outcomes in eastern Burma. J Epidemiol Community Health. 2007;61:908-14.
Lee TJ, Mullany LC, Richards AK, et al. Mortality rates in conflict zones in Karen, Karenni, and Mon states in eastern Burma. Trop.
Med. Int. Health. 2006;11(7):1119-27.
Impact of human rights violations?
• Overall, mortality rates represent a nonspecific, indirect relationship only
• Evidence
– Violence-related deaths, especially landmine
– Preponderance of malaria deaths
– Male / female ratio
• Families of former rebels Angola (80:100)
• Afghan refugees in Pakistan (88:100)
Indirect, or ecological inference
regarding impact of conflict
• Compare likelihood of 1 or more deaths
of live born children
• Areas under “Four-Cuts” policy vs.
“Cease-Fire” areas
– Four Cuts: 39.9%
– Cease Fire:16.6%
– PRR = 2.40 (2.02 – 2.86)
Measure HRV and health directly?
• Documentation of human rights violations
comes largely from legalistic tradition
• Use classical epidemiological tools to
quantify associations
• BPHWT structure and experience
provided important opportunity to directly
link HRV to health outcomes
Linking Morbidity and Mortality to
Human Rights
• Backpack medics added short set of questions
to health surveys
– 6 questions
– household level
– past 12 months recall period
• Secondary data analysis of this existing data to
quantify associations between HRV and health
outcomes
Sample Questions
•
In the past 12 months, how many people,
from your household:
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–
–
•
were forced to work against their will
were shot at, stabbed, or beaten by a soldier
had a landmine or UXO injury
In the past 12 months, how many times has
your household:
–
–
Had the food supply (including rice field, paddy,
food stores, and livestock) been taken or
destroyed?
Been forcibly displaced or moved due to security
risk?
Prevalence of human rights violations, 2004
Violation / Event
% of
Households
Forced Labor
32.6%
Forced Displacement
8.9%
Food Destruction / Theft
25.2%
Landmine Injuries
1.3%
Multiple rights violations
14.4%
Mullany LC, Richards AK, Lee CI, et al. Application of population-based survey methodology to quantify associations between
human rights violations and health outcomes in eastern Burma. J Epidemiol Community Health. 2007;61:908-14.
Families forced to move have higher odds of
poor health outcomes:
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Infant mortality: OR=1.72 (0.52 – 5.74)
Child mortality: OR=2.80 (1.04, 7.54)
Landmine injury: OR=3.89 (1.01 – 15.0)
Child malnutrition: OR=3.22 (1.74 – 5.97)
Malaria parasitemia: OR=1.58 (0.97 – 2.57)
Mullany LC, Richards AK, Lee CI, et al. Application of population-based survey methodology to quantify associations between
human rights violations and health outcomes in eastern Burma. J Epidemiol Community Health. 2007;61:908-14.
Families reporting theft/destruction of their
food supply have higher odds of poor health
outcomes:
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•
•
•
•
Child mortality: OR=1.19 (0.67 – 2.15)
Crude mortality: OR=1.58 (1.09, 2.29)
Landmine injury: OR=4.55 (1.23 – 16.9)
Child malnutrition: OR=1.94 (1.20 – 3.14)
Malaria parasitemia: OR=1.82 (1.16 – 2.89)
Mullany LC, Richards AK, Lee CI, et al. Application of population-based survey methodology to quantify associations between
human rights violations and health outcomes in eastern Burma. J Epidemiol Community Health. 2007;61:908-14.
Exposure to multiple rights violations:
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•
•
•
Child mortality: IRR=2.18 (1.11 – 4.29)
Crude mortality: IRR=1.75 (1.14, 2.70)
Landmine injury: IRR=19.8 (2.59 – 151.2)
Malaria parasitemia: IRR=2.34 (1.27 – 4.32)
• Families reporting three or more violations:
– Child mortality: IRR = 5.23 (1.93 – 14.4)
Mullany LC, Richards AK, Lee CI, et al. Application of population-based survey methodology to quantify associations between
human rights violations and health outcomes in eastern Burma. J Epidemiol Community Health. 2007;61:908-14.
Mobile Obstetric Medics (MOM)
Providing essential maternal health services in the
conflict zones in Eastern Burma
Karen, Karenni, Mon, Shan ethnic teams, Mae Tao
Clinic (Dr. Cynthia Maung), Hopkins, UCLA
Cross border MCH program
– Family planning, ANC and PNC care
– Bringing Emergency Obstetric care to the household
level
Supported by Bill & Melinda Gates Institute for Population and Reproductive Health
at Johns Hopkins
Mobile teams carrying medical supplies to IDP Communities,
Eastern Burma, 2007. The Mobile Obstetric Medic Project
Baseline Survey Results
• Access to attendant with ability to deliver
component low: 5.1%
• Insecticide Treated Net: 21.6%
• Malaria Test: 21.9%
• Iron/Folate: 11.8%
• Any ANC visit: 39%
– Content unknown, unlikely effective
Baseline Survey Results
• Unmet need is high; substantial potential for
family planning impact
– 25% do something to delay pregnancy
– Overall 61% with unmet need for limiting/spacing
• Neonatal, infant, child mortality rates
moderately high
– Lower than more unstable direct conflict areas
– Higher than Burma national estimates
HRVs and Health Indicators
• For access to individual ANC interventions,
trend toward decreased access for those
experiencing human rights violations
• Forced relocation:
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–
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anemia:
unmet need:
No ANC:
<2 core ANC ints
Odds Ratio
2.90 (1.90, 4.44)
1.68 (1.15, 2.46)
3.34 (0.97, 11.5)
7.63 (1.85, 31.5)
Mullany LC, Lee CI, Yone L, Paw P, Shwe Oo EK, Maung C, Lee TJ, Beyrer C. Access to essential maternal health interventions and
human rights violations among displaced communities in eastern Burma. FORTHCOMING, 2008
Preliminary PRF data
ANC Intervention
Coverage
- Malaria screening during pregnancy
68%
- Insecticide treated net
75%
- Fe/FA supplement
91%
- Deworming
83%
- Nutrition / ENC
89%
Labor and Delivery
- Attended by person with some BEOC
69%
- Misoprostol prophylactic dose given
78%
PNC Intervention
- Family planning counseling provided
90%
Cross-Border Medical Obstetric Medic in Eastern Burma, 2007
Adapt interventions to setting
• Developed a field protocol for blood
screening for emergency transfusions
• Based on “living blood bank” conceptprescreening of family, community for
typing
• Heat stable rapid test algorithm based
on disease prevalence
• Improves safety of prior transfusion
practices in this setting
How do human rights violations
increase vulnerability to STI & HIV?
• Increased Exposure
– Coercion, sexual violence, rape as tool of war,
population mixing
• Increased Acquisition and Transmission
– Treatment delays or gaps, barriers to access,
lack of condoms/contraception
• Increased morbidity and mortality
– Barriers to access and to information
Burmese Migrants and Barriers to Access in Thailand
1
Knowledge about Condoms
Condom Usage
0.9
Thai Nationals
Burmese Migrants
0.8
0.7
0.6
P<0.05
0.5
0.4
0.3
0.2
0.1
0
Males
Men
Females
Women
Males
Men
Females
Women
Barriers to information, health care: Language, Legal, Physical, Economic, & Political
PHR/JHU: Thailand’s failure to provide access to services violates Thai law AND
undermines national HIV and STD programs
Source: Mullany et al, AIDS Care, 2003; Lertpiriyasuwat et al, AIDS, 2003;
Leiter et al, Health & Human Rights, 2006
Conclusions
• Constraints inherent in IDP context demand
creative thinking and adapted solutions
• Grass-roots community organizations can
take the lead even in refugee and IDP
settings
• Building capacity to monitor PH programs
– Ensures success of programs
– Potential to understand direct and indirect
impacts of human rights violations on health
Ways Forward
• Recognize
– Human rights contexts of our work
• Partner
– With the grassroots, with human rights groups in
country and internationally, with those we seek to
serve facing rights violations
• Act
– Research, Advocate, and Fund