Shades of dignity: Exploring the demands of equality in applying human rights frameworks to health

Health and Human Rights

Volumn 11, Issue 2, 2009, Pages 1-18

  Yamin, Alicia Ely ^a  

^a HARVARD LAW SCHOOL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CONCEPTUAL FRAMEWORK; CRITICAL ANALYSIS; HUMAN RIGHTS; PARTICIPATORY APPROACH; POWER RELATIONS; PUBLIC HEALTH;

ARTICLE; HEALTH DISPARITY; HUMAN; HUMAN RIGHTS; PERSONHOOD; PUBLIC HEALTH SERVICE; SOCIAL JUSTICE; SOCIAL PSYCHOLOGY; SOCIOECONOMICS; SOCIOLOGY; MEDICAL SOCIOLOGY; PREJUDICE;

HEALTH STATUS DISPARITIES; HUMAN RIGHTS; HUMANS; PERSONHOOD; PREJUDICE; PUBLIC HEALTH ADMINISTRATION; SOCIAL JUSTICE; SOCIOECONOMIC FACTORS; SOCIOLOGY, MEDICAL;

EID: 77951670570     PISSN: 10790969     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (104)

1. Universal Declaration of Human Rights (UDHR), G.A. Res. 217A (III) (1948), preamble. Available at http://www.un.org/Overview/rights.html.
2. WHO Commission on Social Determinants of Health, Closing the gap in a generation: Health equity through action on the social determinants of health (Geneva: WHO, 2008)
3. see also, M. Powers and R. Faden, Social justice: The moral foundations of public health and policy (New York: Oxford University Press, 2006)
4. S. Anand, F. Peter, and A. Sen (eds), Public health, ethics, and equity (New York: Oxford University Press, 2004).
5. "An interview with Sir Michael Marmot," Social Medicine 4/2 (2009), pp. 109-112.
6. World Bank, World Development Indicators, cited in Table 8 in R. Mohan "The Growth Record of the Indian Economy, 1950-2008: A Story of Sustained Savings and Investment" (Keynote Address at the Growth and Macroeconomic Issues and Challenges in India conference organized by the Institute of Economic Growth, New Delhi, India, February 14, 2008). Available at http://rbidocs.rbi.org.in/rdocs/ Speeches/PDFs/83118.pdf.
7. For a recent report on malnutrition rates in India by ActionAid, see http://www.actionaidindia.org/index.htm; see also, Mohan (see note 4).
8. "World food day... No food for India," India Info.com (October 16, 2009). Available at http://news.indiainfo.com/article/091016103843_world_ food_day/475016.html.
9. See B. Milanovic, "World income inequality in the second half of the 20th century," World Bank Research Paper (Washington, DC: World Bank, 2001), p. 78, cited in A. de Vita, "Inequality and poverty in global perspective," in T. Pogge (ed), Freedom from poverty as a human right: Who owes what to the very poor (New York: Oxford University Press and UNESCO, 2007), pp. 103-132, at 104.
10. As the Center for Economic and Social Rights recently stated, because of the global economic downturn, 400,000 additional infants are predicted to die each year in the short-term and "the right to education - particularly that of girls - is threatened as families can no longer afford the direct and indirect costs of sending their children to school, requiring them instead to carry out domestic or paid work." And literacy - especially girls' literacy - is closely linked to a set of better health outcomes. See "Global crisis hits most vulnerable," UNESCO (March 3, 2009). Available at http://portal.unesco.org/en/ev.php-URL_ID=44687&URL_DO=DO_TOPIC&URL_SECTION=201.html; International Labour Organization (ILO), A global policy package to address the global crisis (Geneva: International Labour Office, 2008). Available at http://www.ilo.org/public/english/bureau/inst/download/policy.pdf.
11. Cited in I. Saiz, "Rights in a recession? Challenges for economic and social rights enforcement in times of crisis," Journal of Human Rights Practice 1/1 (2009), pp. 277-293.
12. See, for example, WHO Commission on the Social Determinants of Health (see note 2); I. Kawachi and B. Kennedy, The health of nations: Why inequality is harmful to your health (New York: The New Press, 2002).
13. See, for example, R. Wilkinson and K. Pickett, The spirit level: Why more equal societies almost always do better (London: Penguin, 2009).
14. "An interview with Sir Michael Marmot" (see note 3); WHO Commission on the Social Determinants of Health (see note 2).
15. I consider effective enjoyment of rights to be closely related to Amartya Sen's notion of capabilities. See, for example, A. Sen, Inequality reexamined (New York: Oxford University Press, 1992); see also, A. Sen, Commodities and capabilities (New York: Oxford University Press, 1999).
16. See, for example, World Health Organization, Human rights, health and poverty reduction strategies, WHO/ETH/HDP/05.1 Draft (Geneva: WHO, 2005). Available at http://www.who.int/hhr/news/HRHPRS.pdf.
17. See, for example, I. Khan, The unheard truth (New York: Norton, 2009). Available at http://shop.amnesty.org/products/the-unheard-truth-a-book-by-irene-khan; Pogge (see note 7).
18. See Universal Declaration of Human Rights (see note 1).
19. Given the vast literature of social justice and health, it is notable how few scholars have engaged with the framework of human rights. The few articles that have attempted to bridge the gap have related poverty, equity, and human rights, rather than exploring the demands of the complex notion of equality. See, for example, P. Braveman and S. Gruskin, "Poverty, equity, human rights and health," Bulletin of the World Health Organization 81/7 (2003a), pp. 539-545
20. P. Braveman and S. Gruskin, "Defining equity in health," Journal of Epidemiology and Community Health 57 (2003b), pp. 254-258.
21. A. Sen, "Elements of a theory of human rights," Philosophy and Public Affairs 32 (2004), pp. 315-356.
22. "Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane." Martin Luther King Jr. (National Convention of the Medical Committee for Human Rights, Chicago, 1966).
23. International Covenant on Economic, Social and Cultural Rights (ICESCR), G.A. Res. 2200A (XXI) (1966), Art. 2. Available at http://www2.ohchr.org/english/law/cescr.htm.
24. Committee on Economic, Social and Cultural Rights, General Comment No. 20, Non- Discrimination in Economic, Social and Cultural Rights, UN Doc. No. E/C.12/GC/20 (2009), para. 7.
25. Committee on Economic, Social and Cultural Rights, General Comment No. 20, Non- Discrimination in Economic, Social and Cultural Rights, UN Doc. No. E/C.12/GC/20 (2009), para. 10.
26. According to the UNAIDS Protocol for the identification of discrimination against people living with HIV, such discrimination includes "any measure entailing an arbitrary distinction among persons depending upon their confirmed or suspected HIV serostatus or state of health." UNAIDS, Protocol for the identification of discrimination against people living with HIV (Geneva: Joint UN Programme on HIV/ AIDS, 2000). Available at http://data.unaids.org/Publications/IRC-pub01/JC295-Protocol_en.pdf.
27. The UNAIDS/OHCHR International guidelines on HIV/AIDS and human rights call for broad anti-discrimination laws and policies, not just with respect to health care but also to social security, welfare benefits, employment, education, sport, accommodations, clubs, trade unions, qualifying bodies, access to transport, and other services. UNAIDS, 2008 Report on the global AIDS epidemic (Mexico City: Joint UN Programme on HIV/ AIDS, 2008), p. 77. Available at http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp.
28. L. Temkin, Inequality (New York: Oxford University Press, 1993), p. 101.
29. C. MacKinnon, Sex equality (New York: Foundation Press, 2001).
30. P. Braveman, "Measuring health inequalities: The politics of the World Health Report 2000," in R. Hofrichter (ed), Politics, ideology and inequity and the distribution of disease (San Francisco, CA: John Wiley and Sons, 2003), pp. 305-320.
31. Committee on Economic, Social and Cultural Rights, General Comment No. 14, The Right to the Highest Attainable Standard of Health, UN Doc. No. E/C.12/2000/4 (2000), para. 20.
32. See, for example, Committee on the Elimination of All Forms of Racial Discrimination, General Recommendation No. 32, The meaning and scope of special measures in the International Convention on the Elimination of All Forms [of] Racial Discrimination, UN Doc. No. CERD/C/ GC/32 (2009). Available at http://www.unhcr.org/ refworld/type,GENERAL,CERD,4adc30382,0. html; see also, International Convention on the Elimination of All Forms of Racial Discrimination, G.A. Res. 2106A (XX) (1965), para. 2(2). Available at http://www2.ohchr.org/english/bodies/ratification/2.htm.
33. The recent Stupak-Pitts amendment to the US House of Representatives Health Care Reform Bill would make it even more difficult for women in families earning up to $88,000 a year to obtain an abortion. Stupak of Michigan Amendment to H.R. 3962, as reported by the House Committee on Rules, November 6, 2009.
34. CESCR General Comment No. 14 (see note 27), para. 12.
35. This "disproportionate burden" concept has been fleshed out somewhat more by different courts. The Colombian Constitutional Court found, for example, that such a burden would be "unbearable" if it affected a person's "subsistence minimum." Constitutional Court of Colombia, Sala Segunda de Revisión, Judgment T-760, Magistrado Ponente: Manuel José Cepeda (2008), para. 4.4.5.3.
36. st Session, America's Health Future Act (2009).
37. CESCR General Comment No. 14 (see note 27), para. 29.
38. A. Sen, "Elements of a theory of human rights," Philosophy and Public Affairs 32 (2004), pp. 315-356.
39. A. Williams, "Inequalities in health and intergenerational equity," Health Economics 6 (1997), pp. 117-132.
40. See G. Persad, A. Wertheimer, and E. Emmanuel, "Principles for allocation of scarce medical interventions," Lancet 373/9661 (2009), pp. 423-431.
41. Broadening from specific interventions to resources, Norman Daniels suggests the "prudential lifespan account," which assumes we all age and that resources should be allocated as if we all go through different life stages. See N. Daniels, Just health: Meeting health needs fairly (New York: Cambridge University Press, 2008), p. 178.
42. CESCR General Comment No. 20 (see note 20), para. 8.
43. Constitutional Court of Colombia, Judgment C-521, Magistrado Ponente: Clara Inés Vargas Hernández (2007).
44. For example, customary and statutory laws around the world that prohibit women from inheriting property have enormous impacts on their well-being, as well as their agency and dignity.
45. Uganda Penal Code Act, revised, para. 145 (1950).
46. Naz Foundation v. Government of NCT of Delhi and Others, Delhi High Court, India (2001), WP(C) No. 7455/2001.
47. Ferraz makes a separate argument about the judicial decisions producing more inequality in Brazil as well.
48. Constitutional Court of Colombia, Judgment T-654, Magistrado Rodrigo Uprimny (2004), concurrence.
49. CESCR General Comment No. 20 (see note 20), para. 8.
50. International Convention on the Elimination of All Forms of Discrimination against Women, G.A. Res. 34/180, Art. 10(2) (1979). Available at http://www2.ohchr.org/english/law/cedaw.htm.
51. CERD General Recommendation 32 (see note 28), para. 8: "To treat in an equal manner persons or groups whose situations are objectively different will constitute discrimination in effect, as will the unequal treatment of persons whose situations are objectively the same."
52. CESCR General Comment No. 20 (see note 20), para. 8.
53. Convention on the Rights of Persons with Disabilities, G.A. Res, 61/106, Art. 2 (2006). Available at http://www2.ohchr.org/english/bodies/ratification/15.htm.
54. Eldridge v. British Colombia (Attorney General) (1997), 3 SCR 624.
55. See A. Gross, "The right to health in an era of privatization and globalization: National and international perspectives," in D. Barak-Erez and A. Gross (eds), Implementing social rights (Oxford: Hart Publishing, 2007), pp. 289-339, at 310.
56. The case was decided on the basis of the right to life and security, not a right to health per se. Chaoulli v. Quebec (Attorney General) (2005) 1 SCR 791.
57. Gross (see note 51), p. 312; see also, dissent in Chaoulli (see note 52), para. 164.
58. Persad et al. (see note 36).
59. See judgments SU-225 de 1998 (M. P. Eduardo Cifuentes Muñoz) and SU-819 de 1999 (M. P. Alvaro Tafúr Galvis) por H. Torres Corredor, "La Corte Constitucional entre la economía y el derecho," in Pensamiento Jurídico, No. 15 (Bogotá: Universidad Nacional de Colombia, 2002).
60. See J. P. Ruger, "Health and social justice," Lancet 364/9439 (2004), pp. 1075-1080.
61. Paula Braveman and Sofia Gruskin (2003a, see note 16) have stated, for example, that "routine assessment of potential health implications for different social groups should become standard practice in the design, implementation and evaluation of all development policies." Available at http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862003000700013.
62. WHO (see note 13).
63. WHO (see note 13).
64. The goals are as follows: eradicate extreme poverty and hunger; achieve universal primary education; promote gender equality and empower women; reduce child mortality; improve maternal health; combat HIV/AIDS, malaria, and other diseases; ensure environmental sustainability; and develop a global partnership for development. UNDP, "About the MDGs: Basics." Available at http://www.undp. org/mdg/basics.shtml.
65. Goals 4, 5, and 6 address child mortality; maternal health; and HIV/AIDS, malaria, and other diseases, respectively.
66. See D. Gwatkin, Who would gain most from efforts to reach the Millennium Development Goals for health: An inquiry into the possibility of progress that fails to reach the poor (Washington, DC: The World Bank, December 2002).
67. L. P. Freedman, W. J. Graham, E. Brazier, et al., "Practical lessons from global safe motherhood initiatives: Time for a new focus on implementation," Lancet 370/9595 (2007), pp. 1383-1391.
68. See the argument for this approach by the director of Human Rights Watch, Kenneth Roth, in his article "Defending economic, social and cultural rights: Practical issues faced by an international human rights organization," Human Rights Quarterly 26/1 (2004), pp. 63-73.
69. See the argument for this approach by the director of Human Rights Watch, Kenneth Roth, in his article "Defending economic, social and cultural rights: Practical issues faced by an international human rights organization," Human Rights Quarterly 26/1 (2004), pp. 63-73.
70. CESCR General Comment No. 14 (see note 27), para. 43.
71. G. Dahlgren and M. Whitehead, Policies and strategies to promote social equity in health. Background document to WHO - strategy paper for Europe (Stockholm: Institute of Future Studies, 1991). Available at http://www.framtidsstudier.se/filebank/files/20080109$110739$fil$mZ8UVQv2wQFShMRF6cuT.pdf.
72. The concept of equity is supplemented by the concept of a minimum level under human rights law. That is, there should be at least a minimum level of obstetric services. UN process indicators provide content to this idea. See A. E. Yamin and D. P. Maine, "Maternal mortality as a human rights issue under international law," Human Rights Quarterly 21/3 (1999), pp. 563-607.
73. World Bank, World Development Report 2006 (Washington, DC: World Bank, 2006). Available at http://siteresources.worldbank.org/INTWDR2006/ Resources/477383-1127230817535/082136412X.pdf.
74. For definitions, see R. M. Sundrum, Income distribution in less developed countries (New York: Routledge, 1990)
75. see also, A. Sen and E. Foster, On economic inequality (Oxford: Oxford University Press, 1997).
76. S. Anand, F. Diderichsen, T. Evans, et al., "Measuring disparities in health: Methods and indicators," in T. Evans, M. Whitehead, F. Diderichsen, et al. (eds), Challenging inequities in health: From ethics to action (London: Oxford University Press, 2001).
77. Amartya Sen, who is critical of the GINI coefficient, proposes an "intersection approach" that discerns whether and when a number of different measures agree versus when they produce different outcomes. Sen and Foster (see note 70), p. 33.
78. N. Kondo, G. Sembajwe, I. Kawachi, et al., "Income inequality, mortality, and self rated health: Meta-analysis of multilevel studies," British Medical Journal 339/102 (2009), pp. 1-9 [online edition]. Available at http://www.bmj.com/cgi/reprint/339/ nov10_2/b4471.
79. N. Kondo, G. Sembajwe, I. Kawachi, et al., "Income inequality, mortality, and self rated health: Meta-analysis of multilevel studies," British Medical Journal 339/102 (2009), pp. 1-9 [online edition]. Available at http://www.bmj.com/cgi/reprint/339/ nov10_2/b4471.
80. Wilkinson and Pickett (see note 10). 76. Temkin (see note 24), p. 297.
81. Ultimately, Temkin argues that it gets first worse and then better.
82. Temkin (see note 24), p. 30.
83. J. Rawls, A theory of justice (Cambridge: Harvard University Press, 1971).
84. Temkin (see note 24), p. 34.
85. Temkin (see note 24), p. 41.
86. Temkin (see note 24), pp. 104-105.
87. Sen and Foster (see note 70), p. 36.
88. A. B. Atkinson, "On the measurement of inequality," Journal of Economic Theory 2 (1970), p. 251, cited in Temkin (see note 24), p. 183.
89. World Bank (see note 69).
90. See, for example, K. Arrow, "Extended sympathy and the possibility of social choice," Equality and Justice in a Democratic Society 7/2 (1978), pp. 223-237.
91. A. Sen, The idea of justice (Cambridge: Harvard University Press/Belknap Press, 2009), p. 233.
92. A. Sen, The idea of justice (Cambridge: Harvard University Press/Belknap Press, 2009), p. 258.
93. A. Sen, The idea of justice (Cambridge: Harvard University Press/Belknap Press, 2009), p. 259.
94. See National Institute for Health and Clinical Excellence (NICE), "Measuring effectiveness and cost-effectiveness." Available at http://www.nice.org.uk/newsroom/features/measuringeffectivenessandcosteffectivenesstheqaly.jsp.
95. In ethics these are known as the aggregation and severity problems.
96. Ruger (see note 56), p. 1079.
97. Ruger (see note 56), p. 1079.
98. Ruger (see note 56), p. 1079. See also, Daniels (see note 37). 95. Sen (see note 87), p. 242.
99. See A. E. Yamin, "Suffering and powerlessness: The significance of promoting participation in rights-based approaches to health," Health and Human Rights: An International Journal 11/1 (2009), pp. 5-22. Available at http://www.hhrjournal.org/ index.php/hhr/article/view/127/200.
100. N. Fraser, "Rethinking the public sphere: A contribution to the critique of actually existing democracy," Social Text 25/26 (1990), pp. 56-80, at 76.
101. N. Fraser, "Rethinking the public sphere: A contribution to the critique of actually existing democracy," Social Text 25/26 (1990), pp. 56-80, at 76.
102. N. Fraser, "Rethinking the public sphere: A contribution to the critique of actually existing democracy," Social Text 25/26 (1990), p. 73.
103. See P. Hunt and G. Bachman, "Health systems and the right to the highest attainable standard of health," Health and Human Rights: An International Journal 10/1 (2008), pp. 81-92. Available at http://www.hhrjournal.org/index.php/hhr/article/view/22/69.
104. Pogge (see note 7), p. 4.