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CRITICAL CONCEPTS FOR REACHING POPULATIONS AT RISK |
The author is with the Harvard School of Public Health and is a human rights attorney who at the time of writing was working with nongovernmental organizations in Latin America.
Correspondence: Requests for reprints should be sent to Alicia Ely Yamin, Law and Public Health Program, Department of Health Policy and Management, 677 Huntington Ave., 4th floor, Boston, MA 02115 (e-mail: ayamin{at}hsph.harvard.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONTHE RIGHT TO HEALTH...CLARIFYING CONTENT AND...RELEVANCE TO THE UNITED...APPLICATION OF A RIGHT...CONCLUSIONSReferences |
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In recent years, there have been considerable developments in international law with respect to the normative definition of the right to health, which includes both health care and healthy conditions. These norms offer a framework that shifts the analysis of issues such as disparities in treatment from questions of quality of care to matters of social justice.
Building on work in social epidemiology, a rights paradigm explicitly links health with laws, policies, and practices that sustain a functional democracy and focuses on accountability. In the United States, framing a well-documented problem such as health disparities as a "rights violation" attaches shame and blame to governmental neglect. Further, international law offers standards for evaluating governmental conduct as well as mechanisms for establishing some degree of accountability.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONTHE RIGHT TO HEALTH...CLARIFYING CONTENT AND...RELEVANCE TO THE UNITED...APPLICATION OF A RIGHT...CONCLUSIONSReferences |
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THE RIGHT TO HEALTH UNDER INTERNATIONAL LAW |
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TOPABSTRACTINTRODUCTIONTHE RIGHT TO HEALTH...CLARIFYING CONTENT AND...RELEVANCE TO THE UNITED...APPLICATION OF A RIGHT...CONCLUSIONSReferences |
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The first notion of a right to health under international law is found in the 1948 Universal Declaration of Human Rights (hereafter called Declaration), which was unanimously proclaimed by the UN General Assembly as a common standard for all humanity.7 The Declaration sets forth the right to a "standard of living adequate for the health and well-being of himself and his family, including . . . medical care and . . . the right to security in the event of . . . sickness, disability . . . or other lack of livelihood in circumstances beyond his control."7(article 25) The Declaration does not define the components of a right to health; however, they both include and transcend medical care.
The Cold War polarized countries’ positions on human rights. In 1966, instead of the indissoluble whole reflected in the Declaration, twin covenants on civil and political rights and economic, social, and cultural rights were promulgated.8 The right to health was included in the International Covenant on Economic, Social and Cultural Rights (ICESCR). Article 12 of the ICESCR explicitly sets out a right to health and defines steps that states should take to "realize progressively" "to the maximum available resources" the "highest attainable standard of health," including "the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child"; "the improvement of all aspects of environmental and industrial hygiene"; "the prevention, treatment and control of epidemic, endemic, occupational and other diseases"; and "the creation of conditions which would assure to all medical service and medical attention in the event of sickness."9(article 12(2))
The language of progressive realization and maximal available resources, which suggests different standards for different countries, does not easily jibe with the absoluteness with which people in the United States generally think about rights. Yet in practice, due process and other civil rights may vary just as much. Indeed, the egregious disparities among countries, and in particular between the global north and south, suggest not the irrelevance of defining a right to health but rather the need to situate state obligations within a global political economy in which international institutions and third-party states often exercise inordinate influence over developing countries’ economies and policies. The right to health demands, as do all human rights, "international assistance and cooperation."1,9(article2)–11
The reference to a "highest attainable standard" of health, taken from the World Health Organization constitution,12 builds in a reasonableness standard.10–13 That is, the state has a role to play in leveling the social playing field with respect to health; however, there are factors that are beyond the state’s control.1,10,11 Furthermore, the highest attainable standard will necessarily evolve over time, in response to medical inventions, as well as demographic, epidemiological, and economic shifts.
In addition to the ICESCR, a wide array of international and regional treaties recognizes health as a rights issue, and these reflect a broad consensus on the content of the norms.14–19 A review of the international instruments and interpretive documents makes it clear that the right to health as it is enshrined in international law extends well beyond health care to include basic preconditions for health, such as potable water and adequate sanitation and nutrition.1,10,11,13–19
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CLARIFYING CONTENT AND STATES’ OBLIGATIONS |
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TOPABSTRACTINTRODUCTIONTHE RIGHT TO HEALTH...CLARIFYING CONTENT AND...RELEVANCE TO THE UNITED...APPLICATION OF A RIGHT...CONCLUSIONSReferences |
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Realization of the right to health further implies providing individuals and communities with an authentic voice in decisions defining, determining, and affecting their well-being.1,19 Public health has a long tradition of recognizing that participation is integral to health promotion.21 Further, analyses of the importance of structural determinants of health and political economic context are increasingly common.3–6,22–25 Framing health as a right adds to the growing literature in social epidemiology that links health with social justice; it does this by first making explicit the link between health and the construction of a functional democracy. That is, health-related resource distribution, evidence of discrimination and disparities, and the like are analyzed not just in terms of their impact on health status but also their relation to laws, policies, and practices that limit popular participation in decisionmaking and, in turn, the establishment of a genuinely democratic society.2,6,26
Second, failure to respect, protect, or fulfill responsibilities relating to health are construed not only in terms of ensuing social or economic problems, but also explicitly in terms of the accountability of the state and, to a certain extent, other actors, under national and international law.1,6,10–12,26 Thus, a human rights framework simultaneously acknowledges health as inherently political—intimately bound up with social context, ideologies, and power structures—and removes health policy decisions from being matters of pure political discretion by placing them squarely into the domain of law.
As with all international human rights, implementation and enforcement of the right to health critically depend on legislative and judicial action at the national level. More than 70 national constitutions recognize the right to health, and far more countries legislate various aspects of the right to health.11 Further, recent clarification of normative obligations has permitted greater attention to be devoted to potential violations of the right to health by treaty-monitoring committees in their "concluding observations"—or judgments on states’ compliance—as well as enforcement by quasi-judicial international institutions and national courts in specific cases.27–32
Domestic courts and regional bodies that have addressed the question have generally agreed on what minimal standards governments can be required to meet. First, states have an obligation not to adopt retrogressive measures. For example, if a state administers a program to provide antiretroviral drugs, backsliding because of budgetary difficulties is impermissible.33,34 Second, health policies and programs must not be discriminatory.33–35 Third, states must undertake efforts to regulate the conduct of third parties that are interfering with the right to health, such as environmental polluters.36 Fourth, governments can be required to develop national policies and plans of action to respond to health concerns.37
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RELEVANCE TO THE UNITED STATES |
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TOPABSTRACTINTRODUCTIONTHE RIGHT TO HEALTH...CLARIFYING CONTENT AND...RELEVANCE TO THE UNITED...APPLICATION OF A RIGHT...CONCLUSIONSReferences |
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It was not predestined that the United States should have diverged so greatly from the rest of the developed world in its attitudes about access to health care. Even after various reform proposals had floundered, in 1944, before Eleanor Roosevelt and her colleagues included health and medical care in the Declaration, President Franklin Delano Roosevelt argued that every American was entitled to, inter alia, "the right to adequate medical care and the opportunity to achieve and enjoy good health."41(ix) Cold War sentiments undoubtedly played a role in defeating an important proposal by President Harry Truman for national health insurance, just as they distorted international human rights law.42 A wide variety of factors have been cited for the continuing failure of the United States to embrace a national health program, including a lack of class identification and a weak labor movement, negative attitudes about government, and political-structural explanations relating to the US constitutional system.43–45
In this context, the discourse of rights can reconfigure public expectations and commitments. For instance, when access to health care is construed as a matter of right, it is not dependent on good behavior. Even if there is a widespread belief that ill health is often the result of poor personal choices, just as this society provides defense counsel to criminal defendants, who arguably may have exercised poor choices, so too would the state have an obligation to ensure access to health facilities, goods, and services.1 Further, once health is framed as a right, the contours of debates about the role of the state and markets shift. Despite discontent with inefficiencies and poor quality of care in many industrialized countries, the government’s obligations with respect to health care are well entrenched in society as well as law in most of the developed world.39,40
The United States has undertaken international legal obligations relating to the right to health. The United States is a party to the International Convention on the Elimination of all Forms of Racial Discrimination (Race Convention), binding itself to take measures to eliminate racial disparities in public health and health care.14 In other cases, the president has signed treaties signaling the government’s intent to be bound by the provisions in the future, but the Senate has not given its "advice and consent" for ratification. Nevertheless, as a signatory to the ICESCR, the Convention on the Elimination of All Forms of Discrimination Against Women, the Convention on the Rights of the Child, and others, the United States is bound not to contravene object or purpose of those treaties, an obligation that becomes relevant in, inter alia, assessing US trade and aid policies to the extent that these have health impacts.46
Further, despite the notoriously thin legal grounding for any right to health care in domestic law, discrete aspects of health—including health care—are already construed in terms of judicially protected rights in the United States. For example, in addition to entitlements to health coverage for defined population groups at the federal level, the Emergency Medical Treatment and Active Labor Act imposes some obligations for the screening and treatment of persons coming to the emergency department of any hospital participating in the federal Medicare program.47 Federal courts have also been active in ensuring that the conditions and treatment of patients in psychiatric hospitals comply with constitutional standards.48 Also, certain states have been less reluctant than the federal government to impose an affirmative obligation to provide services to under-served populations.49
Moreover, constitutional law can and does change to accommodate changes in public perceptions and political philosophy. As Archibald Cox argued, accepting that government is "not merely about policy but also has affirmative obligations to satisfy basic necessities of citizens [including medical attention] is the next great challenge of North American constitutionalism."50(p118–119) Invoking legal realism, Cass Sunstein goes further, suggesting that "with a modest shift in personnel" on the Supreme Court, economic and social rights, including health, "could well be included in our constitutional understandings, and certainly in the nation’s constitutive commitments, which is where they belong."41(p108)
Even if—especially if—such a "shift in personnel" is not immediately forthcoming, human rights as enshrined in international law offer a powerful alternative discourse to the prevailing market-oriented one through which to understand and mobilize public concern regarding issues such as disparities in treatment and access to care in the United States.10,41 Public consciousness can precede and encourage legal recognition, which in turn reinforces public awareness of concerns in terms of rights.41
For example, the implementation of the right to education is surely deeply flawed in the United States, and experiments with privatizing aspects of education through charter schools and voucher systems may hold appeal to some in the face of gross inefficiencies.51 Nonetheless, in contrast with notions about health care, the notion that everyone has a right to basic education as a prerequisite for sustaining a democratic society is now well ingrained in American culture, as well as in law.52 Yet constitutional recognition of the idea that the federal government has a role to play in adopting proactive measures to ensure some degree of equality in basic education is only 50 years old, which suggests that consciousness of health as a right might be susceptible to a similarly dramatic shift.
In the immediate term, well-established standards relating to nondiscrimination and equal protection are extremely relevant to creating accountability for aspects of the right to health in the United States.53 For example, once a state has taken steps to implement health rights, such as through Medicaid, courts are obligated to ensure that it is done in a nondiscriminatory manner, which affords judicial protection.54
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APPLICATION OF A RIGHT TO HEALTH IN THE UNITED STATES |
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A human rights analysis of this situation determines first the normative obligation and then the violation. As a party to the Race Convention, the US government has undertaken not just a moral but a legal obligation "to prohibit and to eliminate racial discrimination in all its forms and to guarantee the right of everyone, without distinction as to race, colour, or national or ethnic origin, to equality before the law, notably in the enjoyment of . . . the rights to public health [and] medical care."14(article5(e)(iv)) Under the Race Convention, the government undertakes not just to sanction incidents of discrimination but to affirmatively eradicate racial discrimination in all its forms.14 Further, even under devolution or decentralization schemes, the ultimate accountability for state and local law and policy resides with the federal government under international law. Thus, when state or local governments fail to eliminate health disparities, the federal government cannot divest itself of final responsibility.59
On the domestic level, Title VI of the Civil Rights Act of 1964 prohibits discrimination in all health care activities receiving federal funding, which virtually all do in one form or another.53 Title VI, together with its regulations, arguably prohibits both intentional and disproportionate adverse impact discrimination.17,60,61,62(p953),63 Under international law it is clear that discrimination under international law need not be intentional; it need only have the effect of impairing or nullifying the enjoyment of rights to constitute a violation.1,14,64
In its review of the United States’ country report in 2001, the UN committee that monitors compliance with the Race Convention (CERD) specifically noted its concern with respect to "persistent disparities in the enjoyment of, in particular, . . . access to public and private health care" and recommended that the United States "take all appropriate measures, including [affirmative] measures . . . to ensure [these rights]."65(¶398) The CERD’s concluding observations make it clear that a right-to-health framework goes beyond both medical and ethical and quality-of-care issues to focus on state accountability. As illustrated by a 2003 Physicians for Human Rights report, a rights approach to racial disparities in treatment includes such issues as provider education and service delivery but emphasizes governmental accountability for redress, as well as for improved collection, analysis, and dissemination of appropriately disaggregated data that permits the detection of disparities and potential discrimination; it also includes the creation of effective enforcement mechanisms, such as a Health Section within the Civil Rights Division of the Department of Justice.56
Data collection and analysis as well as policymaking concerned with creating a society in which diverse individuals of all racial groups are on an equal footing requires recognizing that discrimination travels along various axes of identity.56 As CERD has recognized, discrimination can have both racial and gendered dimensions, doubly disempowering women of color and affecting their health in ways different from those affecting men.66 Similarly, as Krieger writes, "Since the global expansion of European power and economies in the mid-15th century and contingent territorial conquest and intercontinental slave trade, people have lived in a world of racialized class relations and class-contingent race relations. It logically follows that racial/ethnic inequalities are shaped and fostered by class inequalities and vice versa."25(p197)
Discrimination affects multiple social determinants of health in the United States, as well as treatment, and minorities are far more likely to lack access to care than Whites; this demonstrates that discrimination within the health care system must be understood and addressed within the broader society, not just as a health issue but as a democracy issue.67 For example, in his report on his site visit to the United States in 1994, the UN Special Rapporteur on Contemporary Forms of Racism, Racial Discrimination, Xenophobia and Related Intolerance (Special Rapporteur) noted not only the manifold consequences of racism and racial discrimination in the field of health but also referred to the responsibility of the US government for "sociological inertia, structural obstacles and individual resistance hindering the emergence of a truly integrated society based on the equal dignity of the members of the American nation."68(¶112)
Explicitly applying the discourse of rights to a well-known social problem such as disparities in treatment signals that certain people and social groups have been aggrieved by the government’s inaction and failure to regulate others’ actions. In the recommendations in his 1994 report, the Special Rapporteur forcefully stated that it was incumbent on the government to ensure that both public and private actors recognize that "when persons from ethnic minorities aspire to equal treatment, they are not asking for favours, but seeking to enjoy the rights guaranteed by the United States Constitution in their daily lives."68(¶112[2]) Further, CERD has specifically called for protections of the rights, including health, of migrant workers and other noncitizens as well.69,70
Although statements by the Special Rapporteur and the CERD do not have the same practical effect as domestic statutes and court decisions in the United States, no amount of cynical dismissals can change the fact that they reflect on the US government’s compliance with legal obligations under international law.10,59 Additionally, these statements are relevant to efforts to create moral and political accountability. That is, they can be instrumental in mobilizing awareness among the general public of health as fundamental to creating a genuinely inclusive society in the United States. Thus, the rights framework helps to change the bounds of discussions about what needs to be done from how to improve service delivery to what laws, policies, and political actions are necessary to promote and protect the peoples’ dignity in all spheres of life on a nondiscriminatory basis.
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONTHE RIGHT TO HEALTH...CLARIFYING CONTENT AND...RELEVANCE TO THE UNITED...APPLICATION OF A RIGHT...CONCLUSIONSReferences |
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In the United States, framing an otherwise acknowledged problem such as disparities in treatment as a "rights violation" suggests that the situation could be different and that the government bears responsibility. The language of rights attaches shame and blame to governmental neglect. Further, the international norms relating to a right to health offer standards for evaluating governmental conduct and mechanisms for establishing some degree of accountability.
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Footnotes |
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Accepted for publication January 30, 2005.
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References |
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2. Yamin AE. Transformative combinations: women’s health and human rights. J Am Womens Assoc. 1997;52:169–173.
3. Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No: 80–94.
4. Marmot M, Wilkinson RG, eds. Social Determinants of Health. London, England: Oxford University Press; 1999.
5. Berkman L, Kawachi I. A historical framework for social epidemiology. In: Berkman L, Kawachi I, eds. Social Epidemiology. New York, NY: Oxford University Press; 2000:3–12.
6. Marks S. The new partnership of health and human rights. Hum Rights Dialogue. 2001;2:21–22. Available at: http://www.cceia.org/viewMedia.php/prmTemplateID/8/prmID/650. Accessed March 13, 2005.
7. Universal Declaration of Human Rights. United Nations General Assembly Resolution 217 A (III). New York, NY: United Nations; 1948.
8. Craven M. The International Covenant on Economic, Social and Cultural Rights: A Perspective on Its Development. Oxford, England: Clarendon Press; 1995.
9. International Covenant on Economic, Social and Cultural Rights. New York, NY: United Nations; 1966. UN document A/6316. Available at: http://www.unhchr.ch/html/menu3/b/a_cescr.htm. Accessed April 26, 2005.
10. Kinney E. The international right to health: what does this mean for our nation and our world? Indiana Law Rev. 2001;34:1457–1475.[Medline]
11. Toebes B. The Right to Health as a Right in International Law. Oxford, England: Intersentia/Hart; 1999.
12. World Health Organization. Constitution. Geneva, Switzerland: World Health Organization; 1946.
13. Chapman A. Core obligations related to the right to health. In: Chapman A, Russell S, eds. Core Obligations: Building a Framework for Economic, Social and Cultural Rights. New York, NY: Intersentia; 2002:85–216.
14. International Convention on the Elimination of All Forms of Racial Discrimination. New York, NY: United Nations; 1966. UN document A/6014. Available at: http://www.unhchr.ch/html/menu3/b/d_icerd.htm. Accessed April 26, 2005.
15. Convention on the Rights of the Child. New York, NY: United Nations; 1989. UN document A/44/736. Available at: http://www.unhchr.ch/html/menu3/b/k2crc.htm. Accessed April 26, 2005.
16. Convention on the Elimination of All Forms of Discrimination Against Women. New York, NY: United Nations; 1979. UN document A/34/36.
17. Additional Protocol to the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights (Protocol of San Salvador). Washington, DC: Organization of American States; 1988.
18. African [Banjul] Charter on Human and Peoples’ Rights. Banjul, Gambia: Organization of African Unity (African Union); 1982. OAU document CAB/LEG/67/3 rev 5.
19. Convention Concerning Indigenous and Tribal Peoples in Independent Countries (Convention 169). Geneva, Switzerland: International Labour Organization; 1989.
20. Vienna Declaration and Programme of Action, Report of the World Conference on Human Rights. Vienna, Austria: United Nations; 1993. UN document A/CONF.157/23.
21. Report of the International Conference on Primary Health Care [Declaration of Alma-Ata]. Geneva, Switzerland: World Health Organization; 1978.
22. Krieger N. Theories for social epidemiology in the 21st century: an ecosocial perspective. Int J Epidemiol. 2001;30:668–677.
23. Navarro V, Shi L. The political context of social inequalities in health. Int J Health Serv. 2001;31:1–21.[ISI][Medline]
24. Geronimous A. Addressing structural influences on the health of populations. Am J Public Health. 2000;90:867–872.
25. Krieger N. Does racism harm health? Did child abuse exist before 1962? On explicit questions, critical science, and current controversies: an eco-social perspective. Am J Public Health. 2003;93:194–199.
26. Krieger N, Gruskin S. Frameworks matter: ecosocial and health and human rights perspectives on disparities among women’s health—the case of tuberculosis. J Am Womens Assoc. 2001;56:137–142.
27. UN Committee on the Elimination of Discrimination Against Women. General Recommendation No. 24: Women and Health. Geneva, Switzerland; 1999. UN document CEDAW/C/1999/I/WG.II/WP.2/Rev.1. Available at: http://www.unhchr.ch/tbs/doc.nsf/(symbol)/CEDAW+General+recom.+24.En?OpenDocument. Accessed April 26, 2005.
28. UN Committee on the Rights of the Child. General Comment No. 3: HIV/AIDS and the Rights of the Child. Geneva, Switzerland; 2003. UN document CRC/GC/2003/1.
29. UN Committee on the Rights of the Child. General Comment No. 4: Adolescent Health and Development in the Context of the Rights of the Child. Geneva, Switzerland; 2003. UN document CRC/GC/2003/4. Available at: http://www.unhchr.ch/tbs/doc.nsf/(symbol)/CRC.GC.2003.4.En?OpenDocument. Accessed April 26, 2005.
30. Report of the International Conference on Population and Development. Cairo, Egypt: United Nations; 1994. UN document A/Conf.171/13. Available at: http://www.un.org/popin/icpd/conference/offeng/poa.html. Accessed April 26, 2005.
31. Interim Report of Paul Hunt, Special Rapporteur of the Commission on Human Rights. New York, NY: United Nations; 2003. Available at: http://ods-dds-ny.un.org/doc/UNDOC/GEN/G03/109/79/PDF/G0310979.pdf. Accessed March 13, 2005.
32. Concluding Observations of the Committee on Economic, Social and Cultural Rights: Ecuador. Geneva, Switzerland: United Nations; 2004. Available at: http://www.unhchr.ch/tbs/doc.nsf/(Symbol)/E.C.12.1.Add.100.En. Accessed March 6, 2005.
33. Cortez v Instituto Venezolano de Seguros Sociales (Supreme Court of Venezuela, Constitutional Chamber 2001). Available at: http://www.tsj.gov.ve/decisiones/scon/Mayo/881-080502-00-0995.htm. Accessed March 6, 2005.
34. Jofre Mendoza v Ministerio de Salud. Constitutional Tribunal of Ecuador, Third Court, Decision No, 0749-2003-RA (2004).
35. Alejandro Moreno Alvarez v Estado Colombiano. SU.819/99 (Constitutional Court of Colombia, 1999). Available at: http://bib.minjusticia.gov.co/jurisprudencia/CorteConstitucional/1999/Tutela/su819-99.htm. Accessed March 18, 2005.
36. Social and Economic Rights Action Center v Nigeria. Communication 155/96 (African Commission on Human & Peoples’ Rights, Oct. 2001) ¶ 67. Available at: http://www.achpr.org/DECISIONS_30th_Session-_Oct.2001_eng.pdf. Accessed March 13, 2005.
37. Minister of Health v Treatment Action Campaign. CCT 8/02 (Constitutional Court of South Africa, 2002). Available at: http://www.tac.org.za (PDF file). Accessed April 28, 2005.
38. Henkin L. Foreign Affairs and the United States Constitution. 2nd ed. New York, NY: Oxford University Press; 1996:170–230.
39. Light DW. Universal health care: lessons from the British experience. Am J Public Health. 2003;93:25–30.
40. Brown L. Comparing health systems in four countries: lessons for the United States. Am J Public Health. 2003:93:52–56.
41. Sunstein C. The Second Bill of Rights: FDR’s Unfinished Revolution and Why We Need It More Than Ever. New York, NY: Basic Books; 2004.
42. Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books; 1982:281–283.
43. Vladeck B. Universal health insurance in the United States: reflections on the past, the present, and the future [editorial]. Am J Public Health. 2003;93: 16–19.
44. Klein R. Lessons for (and from) America. Am J Public Health. 2003;93: 61–63.
45. Navarro V. Policy without politics: the limits of social engineering. Am J Public Health. 2003;93:64–66.
46. Vienna Convention on the Law of Treaties. Article 18. 1155 UNTS 331, 340; 8 ILM. 679, 692 (1969).
47. Emergency Medical Treatment and Labor Act, 42 USCA 
1395dd(e)(2) (1994); Interim Final Rule with Comment period, 59 Federal Register 32086 (1994) (codified at 59 CFR 32086).
48. Wyatt v Stickney, 344 F Supp 373 (MD Ala 1972).
49. State Health Facilities Association v Axelrod, 568 NYS2d 1, 569 NE2d 860 (NY 1991).
50. Cox A. The Role of the Supreme Court in American Government. New York, NY: Oxford University Press; 1977:118–119.
51. Report of the Special Rapporteur on the Right to Education, Katarina Tomasevski, Mission to the United States of America. New York, NY: United Nations; 2001.
52. Brown v Board of Education I, 347 US 483 (1954).
53. Title VI, Civil Rights Act of 1964. As amended, 42 USC 2000d (1994).
54. Linton v Tennessee Commissioner of Health and Environment, 779 F Supp 925 (MD Tenn 1990); affirmed 65 F3d 508 (6th Cir, 1995).
55. Smedley BD, Stith A, Nelson AR, eds, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2002.
56. Panel on Racial and Ethnic Disparities Convened by Physicians for Human Rights. The Right to Equal Treatment. Boston, Mass: Physicians for Human Rights; 2003.
57. Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J. Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA. 1998;279:1703–1708.
58. Agency for Healthcare Research and Quality. The National Healthcare Disparities Report. Washington, DC: US Department of Health and Human Services; 2003. Available at: http://www.ahrq.gov/qual/nhdr03/nhdrsum03.htmFindings. Accessed March 6, 2005.
59. McDougall G. Toward a meaningful international regime: the domestic relevance of international efforts to eliminate all forms of racial discrimination. Howard Law J. 1997;40:571.
60. Alexander v Choate, 469 US 287, 293 (1985).
61. Alexander v Sandoval. 532 US 275, 281–282 (2001).
62. Watson SD. Reinvigorating Title VI: defending health care discrimination—it shouldn’t be so easy. Fordham Law Rev. 1990;58:939–978.
63. Furrow BR, Greaney TL, Johnson SH, Stoltzfus Jost T, Schwartz RL. Health Law. 2nd ed. Saint Paul, Minn: Westlaw; 2000.
64. Committee on Economic, Social and Cultural Rights. General Comment No. 3: the Nature of States Parties’ Obligations. Geneva, Switzerland: United Nations; 1990. UN document E/1991/23, annex III.
65. Concluding Observations of the Committee on the Elimination of Racial Discrimination: United States of America. Geneva, Switzerland: United Nations: 2001. UN document A/56/18.
66. UN Committee on the Elimination of All Forms of Racial Discrimination. General Recommendation XXV: Gender-Related Dimensions of Racial Discrimination. Geneva, Switzerland: United Nations. 2000. UN document CERD/A/55/18, annex V.
67. Institute of Medicine. Coverage Matters: Insurance and Health Care. Washington, DC: National Academies Press; 2001.
68. Implementation of the Programme of Action for the Second Decade to Combat Racism and Racial Discrimination, Report of Mr. Maurice Glele-Ahanhanzo, Special Rapporteur on Contemporary Forms of Racism, Racial Discrimination, Xenophobia and Related Intolerance on His Mission to the United States of America from 9 to 22 October 1994. Geneva, Switzerland: United Nations; 2005. UN document E/CN.4/1995/78/Add.1.
69. UN Committee on the Elimination of All Forms of Racial Discrimination. Thematic Discussion on Non-Citizens and Racial Discrimination. Geneva, Switzerland: United Nations; 2004. UN document CERD/C/SR.1624.
70. UN Committee on the Elimination of All Forms of Racial Discrimination. General Recommendation XXX: Discrimination Against Non-Citizens. Geneva, Switzerland: United Nations; 2004. UN document CERD/C/64/Misc.11/rev.3.
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