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Wednesday, April 14, 2010

Remarks Delivered by Paul Hunt on "The Right to Health in Policy and Practice"

Paul Hunt
Remarks as delivered
“The Right to Health in Policy and Practice”
HealthRight International
April 12, 2010


I am going to make some personal remarks, informal observations somewhat anecdotal and a bit rhetorical too. I would like to signal some of what I see as some of the key challenges which now confront some of us who are engaged in the health and human right movement. And I am going to ask a number of questions and I’d be genuinely interested in your views about these questions.

My first report, as UN Special Rapporteur on the Right to Health, came out in 2003. In it, I was expected to set out the objectives for the UN mandate for the next three or six years. Before writing that report, I consulted very widely. I tried to get a sense of what the key objectives were for the health and human rights movement at that time. I then tried to reflect what I perceived as the priorities, and I tried to reflect those priorities in my selected objectives.

I came out with three objectives. One was to raise the profile of the right to health as a fundamental human right. Secondly, to clarify the legal content of the right to health. And thirdly, perhaps most importantly, to identify ways of operationalizing the right to health, to make it real. And those are the three objectives that I identified.

I also identified two themes that I was going to pursue with those objectives in mind. One theme was poverty and the right to health, and the other was discrimination and the right to health. In other words, two access issues.

I think that those three objectives, and those two themes, served my work quite well for six years. Whether I contributed to their achievement, is a separate issue, and whether I correctly captured the priorities of the health and human rights movement in 2003, others will have to judge. But I think that those three objectives and those two themes provided me with quite a useful compass for six years.

I’d be really interested to know what you think are the key priorities today for the health and human rights movement. Of course we will not all tackle all the priorities, whatever they might be. Every organization has to be selective; every individual has to be selective, depending on a whole wide range of factors. Still, I think it would be helpful if we, if possible, share the same sort of direction of travel; if we had a general sense of common purpose, and some very broadly agreed general objectives in the health and human rights movement. And if that’s right, what are they in April 2010 and what are they for HealthRight International for its second 20 years. Do the three broad objectives that I identified remain relevant today.? Or should we be heading off in a slightly different direction? So that is one question

Another question arises from another report that I wrote in 2004, when the UN published a report of mine on sexual and reproductive health rights. It was one of my first reports, and when that came out, I was told, a very sympathetic diplomat in Geneva privately lamented, “Why on earth does Paul choose such hard issues?”  And there was a lot of criticism from unsympathetic voices in Geneva about the report. Some were very publicly critical of this report on sexual and reproductive health rights. The ambassador of Pakistan called public scorn on it, the ambassador of the United States in Geneva was fiercely critical from the floor of the UN Human Rights Commission. I should just say, that the following day that he had made this very fierce criticism from the floor of the UN Commission on Human Rights, I received a call from one of his colleagues, a US diplomat, to go out to coffee with him. And he joked, that if I thought the ambassador’s speech was tough, I should have seen the draft they had received from Washington.He added that I shouldn’t forget that such a speech so critical of sexual and reproductive health rights was written for a domestic audience.

In any event, in 2004, sexual and reproductive health rights was a hard issue. Cairo, 1994, was under attack, Beijing 1995 was being rolled back. Sexual and reproductive health rights didn’t feature explicitly in the MDGs. And that is actually why I thought it was important to prioritize sexual and reproductive health rights in 2004. My question is, is it the priority today? My feeling is, it certainly is. But the context has changed since 2004. So I think it right to ask the question: Should we be continuing to prioritize sexual and reproductive health rights? I’d be very interested to know your answer.

As Rapporteur, you are meant to do country reports, visit countries, and look at the right to health in particular countries. My first country report wasn’t to a country. It was to the World Trade Organization. There were two reasons for that choice. One was that trade liberalization, privatization, deregulation impact on health related goods and services, plainly. I felt it was really important to give attention to those policies and to those impacts, looking at them through the lens of the right to health. So that is one reason why I looked at the WTO.

But frankly, I also wanted to send another message, which was that human rights, including the right to health, penetrate international organizations and international institutions. And when the state ambassadors in the World Trade Organization sit down to figure out the policies for the WTO, they carry with them the states’ human rights obligations. Those human rights obligations aren’t left outside, as it were, in the cloak room. When I prepared that mission with the WTO, we had endless meetings with WTO staffers and also lots of meetings with ambassadors from states to WTO. And I have to say, for most of them, it was this big surprise that there was this thing called the right to health. I had to sort of give them a sort of human rights 101. But that was one of the points of doing the mission and doing the report, was to sort of break down some of the silos that we are very familiar with, with trade here and human rights here and health here so forth. So I was trying to get the ambassadors and the WTO staffers to think about this human rights context.

Now, again, is that an appropriate priority in 2010? I’d be interested to know what you think.

I continued with that theme in my work in 2008, when I did a mission, effectively, to the World Bank and the IMF. This time, it was looking at what Sweden was doing in the World Bank and the IMF in relation to the right to health. Why Sweden? Because Sweden has some really good policies, international policies, on how human rights should shape Sweden’s international policies. And it says that poverty reduction shall be one of their overarching considerations at the international level. So, I asked Sweden, if I could see what they were doing outside Sweden in relation to the right to health. So I did one mission, first of all, about the right to health in Sweden, and then a second mission looking at what Swedes were doing in relation to the right to health, outside Sweden. Hence looking at the WTO and the IMF.

Now I don’t know whether you think that that should remain, looking at how the right to health extends into international organizations. Should this be a priority for our future work, or should it not? Should we be looking at the right to health and other human rights obligations of states within the World Bank, IMF and the WTO and so forth and so on? I don’t know whether you think that is one of the priorities that you think we should be focusing on.

Can I just mention very quickly one other thing. I’ll just put it on the table, and some of it’s a bit dull, but I think it is necessary to mention it. We’re still struggling, those of us who are working in the health and human rights movement, it seems to me we are still struggling with identifying appropriate methodologies. As the right to health still remains, as you indicated, somewhat new. It’s rather young, and we haven’t yet constructed the necessary methodologies to deal with a whole range of things that Sukiko and others have been struggling with. Issues surrounding indicators, benchmarks and measurements, impact assessments, and budgetary analysis and so forth and so on. So I think those methodologies – a tad dull – are nonetheless extremely important. And I devoted no less than three, three UN reports to try to figure out a way of approaching indicators and benchmarks, and how to measure the progressive realization of the right to health.

When I look at the website of HealthRight, it sort of confirmed for me, that when we are trying to deepen, to further the promotion the right to health, we have to move from the general to the specific, as HealthRight has done in Nepal and in Kenya, and so forth. There is this cliché that we have heard of that the devil is in the detail. And actually, in a perverse way, I think that is the opposite of the truth in the relation to the right to health. I find it really difficult to take this debate much further forward about how to better promote and protect the right to health if we remain at generalities. I think it is important to get beyond the generalities and look at specifics - specific communities, specific rights, specific bits of the right to health.

We have in the Committee on Economic, Social and Cultural Rights, General Comment 14, that some of you know, which is a general introduction to the right to health. But it is general. I think the challenge now is to look at the right to health in relation to mental health, and the right to health in relation to maternal mortality, and the right to health in relation to neglected diseases, and so forth, and so on. I think that is the way to go actually, and the devil I think isn’t in the detail, but I think it is actually in the general. And I think if you look at the work of CRR, HealthRight, Physicians for Human Rights, I think that that’s one of the messages that comes across, and I think that is the right approach.

I just want to close with four groups of remarks and then I’ll shut up. For me, a crucial challenge is for the health and human rights movement to bring more health workers on board. With the right to health, and it is so trite, but the right to health cannot be operationalized without health workers grasping that the human rights can help them deliver their professional objectives. I think that we need to do a better job conveying that the right to health brings an interesting analytical framework; it brings a compelling program of action that can help health policy makers and practitioners. I think we’ve got to better convey that the right to health is not just about the sort of naming and shaming, and the test cases, and the slogans, and so forth. We’ve got to do a better job at conveying that we now understand that the health and human rights movement has matured, and it is struggling with important issues like indicators, and benchmarks, and budgetary analysis and impact assessment and so forth. We have to be absolutely crystal clear that the health and human rights movement depends upon health workers. And that in a sense a health worker is a human rights worker.

I think also we have to better at assembling simple practical examples of where and how human rights have in enhanced health policies, health programs and practices, and health outcomes. We already have many good practice examples, but we need more, and I think they need to be written up and more widely distributed.

I want to make an observation as my penultimate point, I am really not sure if it is right, and I genuinely would welcome your thoughts on it. But let me just mention it. When I survey economic, social and cultural rights movement generally, those people working on economic, social and cultural rights, I think there is a small handful of NGOs that stand out. So for instance, in relation to the right to food, FIAN [FoodFirst Information and Action Network] stands out. There are others, but FIAN stands out, based in Europe. In the right to shelter, COHRE [Centre on Housing Rights and Evictions] stands out, the NGO COHRE stands out. And don’t misunderstand me, there are other fantastic NGOs working on the right to food, and the right to shelter, but it seems to me that FIAN and COHRE stand out in relation to food and shelter.

And when I look at the right to health, for me, I think a slightly different picture emerges.  There are terrific NGOs, doing terrific work on the right to health, not least HealthRight, also CRR and Physicians for Human Rights and others. I think it is right to say, but I am really not completely sure, that none of those organizations, doing fantastic work though they are, I don’t think they’ve yet acquired the same sort of level of global recognition as FIAN and COHRE. Now, maybe that is a good thing. Maybe the health and human rights movement is stronger in sort of diversity and as it were specialized NGOs. Or maybe, just maybe, the time is now ripe for one or two stand-out NGOs to focus on the right to health and to acquire the size and stature and level of global recognition enjoyed by FIAN and COHRE. My sense is that the pieces are now in place, the momentum is gathering for that to happen, if we wish. And I’d be interested to know whether or not you agree with the analysis, and if so, if you think it would be a positive development in the evolution of the health and human rights movement.

And my last remarks are actually a bit historical, most of my remarks have been about some signaling what might the future hold for the health and human rights movement, and asking questions, and I’d really welcome your comments on them, now or later. But my last remarks are providing some sort of historical context for our deliberations and our struggles.

So just briefly, indulge me. Sometimes I get the feeling that those of us who are committed to health and human rights are regarded in some quarters as sort of human rights weirdos. We’re seen as just about beyond the pale, on the borders of respectability, sort of marginally subversive. Well, I’m sorry to disappoint some of you who might enjoy that sense of radical chic. But you’re actually headed for the mainstream. Because actually, I think the health and human rights movement has a really venerable pedigree. It has illustrious forbearers that we need to keep in mind and there is nothing very weird about the health and human rights movement at all.

I know I should be looking for it, but I can’t resist remarking that, we’re familiar with the work of Thomas Payne, who helped to shape your republic and your revolution. And most of us think of Thomas Payne as a great pioneering civil and political rights advocate, which he certainly was. As we all know, he wrote the Rights of Man. And part one of the Rights of Man is all about civil and political rights. Unfortunately, in our excitement, we rarely make it beyond part one of the Rights of Man and reach part two, which is a great pity, because if you go to part two of the Rights of Man by Thomas Paine, it is more about economic, social and cultural rights. The health and human rights movement is part of economic, social and cultural rights. So it seems to me that the antecedents of the health and human rights movement can be traced all the way back to that crucible of the American and French Revolutions.

In more recent history, as you know, economic, social and cultural rights were sort of signaled by FDR in 1941 in the state of the union address when he talked about the four freedoms, which you know about – freedom of religion, freedom of expression, freedom from fear, and freedom from want.

That idea of FDR’s in 1941 found its way into Article 1 of UN Charter where it sets out the objectives, which include, the objectives of the United Nations include human rights and development. Then three years later, in 1948, thanks in part to Eleanor Roosevelt, there we have the Universal Declaration of Human Rights which includes economic, social and cultural rights on the same equal basis of civil and political rights. Then we know that Jimmy Carter signed the International Covenant on Economic, Social and Cultural Rights – not ratified, but signed – Congress wouldn’t ratify it, but it was signed. The founder of HealthRight International, Jonathan Mann, was animated by a preoccupation with economic, social and cultural rights. You’ll have to tell me whether or not you think your present president is part of that tradition.

So, I think that I accept that economic, social and cultural rights, including the right to health remain contested. So is the prohibition of torture and degrading treatment contested as shown by recent developments. So economic, social and cultural rights are contested, but they are not beyond the pale. They have respected, illustrious advocates. I think that it is really important that we somehow resist the characterization of economic, social and cultural rights and the right to health as being somehow politically strange or extreme or weird. As I see it, the health and human rights movement has very firm foundations in the respected past as well as a very exciting future.

So thank you very much.