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Cheryl E. Easley, PhD, RN, Stephen P. Marks, Docteur d'État, Dipl IHEI and Russell E. Morgan, Jr, DrPH

Cheryl E. Easley is with the Crystal M. Lange College of Nursing and Health Sciences, Saginaw Valley State University, University Center, Mich. Stephen P. Marks is with the François Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health, Boston, Mass. Russell E. Morgan is with SPRY Foundation, Washington, DC, and is chair of the International Human Rights Committee, American Public Health Association.

Correspondence: Requests for reprints should be sent to Russell E. Morgan Jr, DrPH, SPRY Foundation, 10 G St, Suite 600, Washington, DC 20002 (e-mail: morganr{at}ncpssm.org).

	INTRODUCTION

TOP INTRODUCTION BASIC ASSUMPTIONS OF HUMAN... THE RIGHT TO HEALTH LIMITATIONS ON RIGHTS THE ROLE OF EDUCATION THE ROLE OF APHA References

 
Human rights workers and practitioners of public health share common concerns for the well-being of people, the alleviation of suffering and want, and the promotion of social justice. The potential for cooperation between these 2 committed groups has advanced considerably over the past decade or so as scholars, practitioners, administrators, and activists grapple with the differences in disciplinary language and with limited opportunities for contact. It is the intention of the American Public Health Association (APHA) to join others in bridging these differences, so that the combined efforts of these groups can be focused on the shared goal of bettering the human condition around the world.

To advance the dialogue among public health and human rights professionals, there is a growing literature, including several books,^1–3 a peer-reviewed academic journal (Health and Human Rights. An International Journal, published by the François Xavier Bagnoud Center for Health and Human Rights), regular features of this Journal and of The Lancet, and occasional articles in other leading medical journals, such as the Journal of the American Medical Association and the New England Journal of Medicine. A chapter on the topic will appear in the fourth edition of The Oxford Textbook on Public Health.⁴ The movement has been further advanced through several major conferences, such as those organized by the François-Xavier Bagnoud Center for Health and Human Rights in Cambridge, Mass, in 1994 and 1996, and more recently by the University of Iowa⁵ and Temple University,⁶ as well as by coalitions and networks such as the Consortium on Health and Human Rights, the International Federation of Health and Human Rights Organizations, and the International Student Association for Health and Human Rights. (For a fairly complete list of organizations and networks involved in the field, see the University of Minnesota Human Rights Library.⁷)

As we confront the issues of public health in the 21st century—including the worldwide spread of HIV/AIDS and other infections, the aging of our populations, and the questions raised by burgeoning health-related technology in the face of gross disparities in access to basic health care—human rights and public health professionals are challenged to forge powerful partnerships to help us attain our mutual aims.

	BASIC ASSUMPTIONS OF HUMAN RIGHTS DOCUMENTS

TOP INTRODUCTION BASIC ASSUMPTIONS OF HUMAN... THE RIGHT TO HEALTH LIMITATIONS ON RIGHTS THE ROLE OF EDUCATION THE ROLE OF APHA References

 
Rights are claims or entitlements to something or against someone that are recognized by legal rules or moral principles. In other words, they are legally protected interests of rights-holders, implying obligations on the part of duty-holders to respect and observe them. Human rights constitute a special category of rights. According to natural law theory, a human right is a higher-order kind of right that is morally based and that is universal, in the sense that it belongs equally to all persons simply because they are human beings. Human rights are also grounded in positive law theory, according to which rights are entitlements of individuals and groups that are affirmed and protected by the laws of an organized society, whether national or international.

In the United States, for example, the Declaration of Independence uses natural law doctrine in affirming "that all men [sic] ... are endowed by their Creator with certain inalienable Rights," whereas the Bill of Rights, amending the Constitution, sets out legal rights in positive law that can be enforced by the courts. The same may be said for practically every country's political and legal development; constitutions with declarations of rights and judicial and other means of enforcement transform the lofty ideals of human rights into practical reality for citizens. In the international system, a similar process occurs. On the one hand, declarations and other texts express the ever evolving consensus on the content of human rights; on the other hand, a web of international treaties and monitoring mechanisms hold the states accountable for meeting their human rights obligations.

Thus, human rights are founded both on moral philosophy, drawing on the meaning and implications of being human, and on legal and political processes by which human societies are governed. Ethics, as a branch of philosophy that deals primarily with defining morally good action, operates in a related but different realm of discourse. As public health professionals, we encounter ethics as descriptions of or prescriptions for moral behavior toward our patients or clients. These ethical mandates are often codified by professional organizations and serve as a guide to decision making in specific practice situations. Human rights also result from moral judgment about good behavior, but in the form of mutually agreed-upon norms articulating the just claims of individuals and groups and the related obligations of the state. The universality of human rights claims derive from the agreement of practically all states to be bound by them, rather than from human nature.

The assertion of international human rights is a historical development that has taken place essentially since the Second World War. Formal codification of human rights, stimulated by abhorrence of the atrocities committed during the war, was launched when the United Nations Charter proclaimed "international co-operation ... in promoting and encouraging respect for human rights"⁸ as one of the purposes of the organization. To advance that purpose, the United Nations General Assembly adopted the Universal Declaration of Human Rights⁹ in 1948, followed in 1966 by the International Covenant on Civil and Political Rights¹⁰ and the International Covenant on Economic, Social and Cultural Rights (ICESCR).¹¹ Collectively, these 3 documents form what is known as the International Bill of Human Rights.

Other major United Nations treaties address racial discrimination, refugees, discrimination against women, torture, and the rights of the child. These texts, and equivalents adopted by the regional organizations in Europe, the American states, and Africa, contain the bedrock human rights obligations of states, including the right to health.

	THE RIGHT TO HEALTH

TOP INTRODUCTION BASIC ASSUMPTIONS OF HUMAN... THE RIGHT TO HEALTH LIMITATIONS ON RIGHTS THE ROLE OF EDUCATION THE ROLE OF APHA References

 
The international recognition of the right to health began with the reference to health in the United Nations Charter¹² and took form in the preamble to the 1946 Constitution of the World Health Organization, which affirms, "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition."¹³ The Declaration of Alma-Ata, which was adopted by the International Conference on Primary Health Care in 1978, further proclaimed this right as a "most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector."¹⁴ The Universal Declaration of Human Rights affirms everyone's "right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control."⁹

The right to health is affirmed in the Convention on the Rights of the Child,¹⁵ the Convention on the Elimination of All Forms of Racial Discrimination,¹⁶ the Convention on the Elimination of All Forms of Discrimination Against Women,¹⁷ and especially in the ICESCR.¹¹ By ratifying the ICESCR, states recognize "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health" and agree to take steps to achieve the full realization of this right. Both the Convention on the Elimination of All Forms of Discrimination Against Women and the Convention on the Rights of the Child elaborate health-related human rights for their target populations. The Committee on Economic Social and Cultural Rights, which monitors application of the ICESCR, adopted an interpretive document in the form of a "general comment" on the right to health in May 2000, setting out in detail what states are expected to do to fulfill their obligations to realize this right.¹⁸

Human rights, including the right to health, are often said to be "interdependent." Clearly, the right to the highest attainable standard of health rests on the right to safe and healthy working conditions, clean water, and freedom from environmental toxins, but it depends in equal measure on the recognition of the dignity of the individual and the rights to education, free speech, and participation in the political process. Conversely, the ability to fully exercise other fundamental human rights depends on the right to health. Violation of any human right, including the right to health, contributes to the infringement of other rights.

	LIMITATIONS ON RIGHTS

TOP INTRODUCTION BASIC ASSUMPTIONS OF HUMAN... THE RIGHT TO HEALTH LIMITATIONS ON RIGHTS THE ROLE OF EDUCATION THE ROLE OF APHA References

 
It is of particular interest to public health practitioners to understand whether human rights are supposed to be absolute or relative to the exigencies of preventing and treating disease and injury and other constraints on government. One scholar noted, regarding the United States, "that public health and individual rights sometimes cannot coexist."¹⁹ International human rights texts acknowledge circumstances under which rights may be suspended in times of national emergency; certain rights, however, are considered nonderogable, such as the right to life; the right to freedom from torture and enslavement; the rights to freedom of thought, conscience, and religion; and the right to recognition as a person before the law.

Other rights may be limited if the restrictions are "prescribed by law and ... necessary in a democratic society"¹⁰ for certain purposes, such as the need to protect public health. Rights subject to restrictions for such purposes, as specified in the International Covenant on Civil and Political Rights, include the right to freedom of movement and residence, the right to freedom of peaceful assembly, the right to freedom of association, the right to manifest one's religion, and the right to freedom of expression. Thus, some temporary restrictions on certain human rights in the interest of public health may be allowed when the situation leaves no alternative, but this action should always be preceded by a careful and deliberate process of decision making, should be monitored, and should be lifted as soon as possible.

	THE ROLE OF EDUCATION

TOP INTRODUCTION BASIC ASSUMPTIONS OF HUMAN... THE RIGHT TO HEALTH LIMITATIONS ON RIGHTS THE ROLE OF EDUCATION THE ROLE OF APHA References

 
As public health practitioners understand these general ideas about human rights and recognize the need to be sensitive to the human rights of all people in the communities in which they practice, they are likely to welcome enhanced education about human rights as a component of basic preparation and continued learning for all disciplines of public health work. Their awareness of the potential impact of public health programs and policies on the human rights of the individuals and groups within their country should extend to the realities of public health around the world and the place human rights can have in improving the health status of people everywhere.

Workers in the fields of public health and human rights share concerns for the dignity and well-being of people, and both fields have historically championed the cause of vulnerable groups such as women and children, the aged, the disabled, and the politically disenfranchised. Most members of both professional disciplines recognize health as a human right and are committed to advocacy, policy-making, and other strategies that ensure the achievement of this and other human rights.

The challenge facing public heath professionals wishing to be more engaged in human rights is to go beyond the emotional attachment to social justice and human rights and acquire the knowledge of the field and the skills necessary to put human rights into health practice. Gruskin and Tarantola proposed 3 levels at which the health and human rights framework can be put into practice.⁴ The first level is acquisition of the tools of a systematic human rights analysis to determine best practice for evidence-based health policy and programs. The second is the level of health systems and practice, where a balance is needed between promoting and protecting human rights and promoting and protecting public health as part of national policy. The third level is health and human rights research.

This agenda, or "pathway to health and human rights,"⁴ requires a considerable investment in education on these topics for local, state, and national health policymakers, administrators, program developers, students, and health care workers, as well as legislators and the general public. It is, therefore, a legitimate aim of APHA to seek to integrate human rights education into all levels of academic and professional training for health practice.

	THE ROLE OF APHA

TOP INTRODUCTION BASIC ASSUMPTIONS OF HUMAN... THE RIGHT TO HEALTH LIMITATIONS ON RIGHTS THE ROLE OF EDUCATION THE ROLE OF APHA References

 
APHA has already demonstrated its commitment to including the human rights framework in public health teaching, research, and practice by sponsoring continuing education institutes and plenary sessions at its annual meetings. APHA's Committee on International Human Rights and the François-Xavier Bagnoud Center for Health and Human Rights are collaborating in the development of a curriculum on health and human rights for students of public health and related fields and for practitioners. The Committee on International Human Rights is also cooperating with an effort to draft an international declaration on health and human rights, spearheaded by Physicians for Human Rights and the François-Xavier Bagnoud Center. Significantly, this Journal devoted its October 1999 issue to human rights and is expanding its coverage of the topic with the current issue. An editorial published in 2000, coauthored by the Executive Director of APHA, concluded, "The time has come to herald human rights as both the foundation of public health practice and the compass of public policy actions."²⁰

Consistent with that commitment, the Committee on International Human Rights distributed a statement of principles on public health and human rights at APHA's annual meeting in 2000 (available at http://www.apha.org/private/PrincPH1.htm). The statement reaffirms the basic commitment of public health workers to human rights and the complementarity of health and human rights action. It is a restatement, for the purposes of engaging the community of public health practitioners, of the underlying premises of the Universal Declaration of Human Rights and the implications for the right to health of the interrelatedness of all human rights.

The APHA text, although brief, acknowledges the importance of the cultural context of public health practice. As set out in the Committee on Economic, Social and Cultural Rights' general comment on the right to health, "All health facilities, goods and services must be respectful of medical ethics and culturally appropriate, i.e. respectful of the culture of individuals, minorities, peoples and communities."¹⁸ (Of course, the reference in the APHA principles to "culturally acceptable health care" means "culturally appropriate" and excludes practices that are harmful to the health or autonomy of individuals, such as harmful and discriminatory traditional practices.)

The APHA principles also acknowledge the need, in limited circumstances defined in international human rights law, to restrict individual freedom to respond to the need to control disease and treat injury. Finally, they seek to encourage APHA and its members to find new and more effective ways to transform the idea of health and human rights into practice benefiting people everywhere.

The pioneering work on the synergy between health and human rights was done in the final decade of the last century. The first decades of this century offer the opportunity for health practitioners to contribute, each in his or her way, to reaching the full potential of this synergy.

Accepted for publication August 29, 2001.

	References

TOP INTRODUCTION BASIC ASSUMPTIONS OF HUMAN... THE RIGHT TO HEALTH LIMITATIONS ON RIGHTS THE ROLE OF EDUCATION THE ROLE OF APHA References

 
1. Mann JM, Gruskin S, Grodin MA, Annas JG, eds. Health and Human Rights: A Reader. New York, NY: Routledge; 1999.

2. British Medical Association. The Medical Profession and Human Rights. Handbook for a Changing Agenda. London, England: Zed Books; 2001.

3. Health aspects of human rights: a select bibliography (partially annotated). Available at: http://www.edifolini.com/human_rights/human_rigths.html. Accessed October 17, 2001.

4. Gruskin S, Tarantola D. Health and human rights. In: Detels R, McEwen J, Beaglehole R, Tanaka H, eds. The Oxford Textbook of Public Health. 4th ed. Oxford, England: Oxford University Press. In press. Text of this chapter available online (in PDF format) at: http://www.hsph.harvard.edu/fxbcenter/FXBC_WP10-Gruskin_and_Tarantola.pdf. Accessed October 17, 2001.

5. Iowa City appeal on advancing the human right to health. Available at: http://www.hsph.harvard.edu/fxbcenter/Iowa_City_appeal.pdf. Accessed October 17, 2001.

6. Health, Law and Human Rights: Exploring the Connections [conference program]. Available at: http://aslme.org/humanrights2001/. Accessed October 17, 2001.

7. University of Minnesota Human Rights Library. Health and human rights links. Available at: http://www1.umn.edu/humanrts/links/health.html. Accessed October 17, 2001.

8. Charter of the United Nations, article 1(3). Available at: http://www.un.org/aboutun/charter/index.html. Accessed October 5, 2001.

9. Universal Declaration of Human Rights. Available at http://www.un.org/Overview/rights.html. Accessed October 5, 2001.

10. International Covenant on Civil and Political Rights. Available at http://www.unhchr.ch/html/menu3/b/a_ccpr.htm. Accessed October 5, 2001.

11. International Covenant on Economic, Social and Cultural Rights. Available at: http://www.unhchr.ch/html/menu3/b/a_cescr.htm. Accessed October 5, 2001.

12. Toebes BCA. The Right to Health as a Human Right in International Law. Antwerp, Belgium: Intersentia; 1999:15.

13. Constitution of the World Health Organization. July 22, 1946. Available at: http://www.yale.edu/lawweb/avalon/decade/decad051.htm. Accessed October 5, 2001.

14. Declaration of Alma-Ata. Available at: http://www.who.int/hpr/archive/docs/almaata.html. Accessed October 5, 2001.

15. Convention on the Rights of the Child. Article 24. Available at: http://www.unhchr.ch/html/menu3/b/k2crc.htm. Accessed October 8, 2001.

16. Convention on the Elimination of All Forms of Racial Discrimination. UN GA Res 2106A(XX). Article 5. Available at: http://www.unhchr.ch/html/menu3/b/d_icerd.htm. Accessed October 5, 2001.

17. Convention on the Elimination of All Forms of Discrimination Against Women. Articles 11 and 12. Available at: http://www.unhchr.ch/html/menu3/b/e1cedaw.htm. Accessed October 8, 2001.

18. The right to the highest attainable standard of health: 11/08/2000. E/C.12/2000/4, CESCR General comment 14. Available at: http://www.unhchr.ch/tbs/doc.nsf. Accessed October 17, 2001.

19. Gostin L. Public Health Law. Power, Duty, Restraint. Berkeley: University of California Press; 2000:109, 113–305.

20. Rodriguez-Garcia R, Akhter MN. Human rights: the foundation of public health practice. Am J Public Health. 2000;90:693–694.[Free Full Text]

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