¹Department of Public Health Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada

Correspondence: Anne-Emanuelle Birn, Department of Public Health Sciences, Faculty of Medicine, University of Toronto, 155 College St., Room 662, Toronto, ON, Canada M5T 3M7. E-mail: ae.birn@utoronto.ca

For those who consider collective health the platform upon which humanity can flourish, the relationship between human rights and health is crucial. The year 2008 marks the 60th anniversary of the Universal Declaration of Human Rights (UDHR), a landmark in – although not the foundation of – the struggle for human life, dignity, and social protection. This is an important moment to reflect on the promise and precariousness of health and human rights efforts.

International health agencies, policymakers, advocates, and activists increasingly invoke the health implications of human rights, but little attention has been paid to when, how, and by whom these connections have been forged. The two articles in this special section of the Journal of Public Health Policy address this issue from the perspective of international and, particularly, North American actors. The authors first presented their work at the Spirit of 1848 Caucus's Social History of Public Health session titled "Health & Human Rights: Critical historical perspectives from the Cold War to the New World Order," held during the American Public Health Association's 134th Annual Meeting, held in Boston in November 2006.

This introduction traces four themes illuminated by historical analyses of health and human rights efforts:

• shared idealism;
• bearing witness;
• legislation, enforcement, and accountability;
• addressing underlying determinants.

As a caveat, it is historically misleading to cite the UDHR as the start of worldwide (health and) human rights efforts. Struggles for emancipation from slavery, feudalism, and workplace exploitation date back thousands of years (1, 2, 3). The political movements that coalesced in the 1848 uprisings against class-based, imperialist, racial, gender, and other forms of oppression articulated the profound connections between social justice and public health (4). In that spirit, we can conceptualize contemporary efforts for health and human rights as having very deep roots indeed.

Nonetheless, the UDHR's adoption, by proclamation, at the United Nations (UN) General Assembly in 1948 established a marker of shared idealism based on health as a universal right (5). Widely cited Article 25 declares: "Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in....sickness......disability....old age..." (6). Promulgated virtually simultaneously, the Constitution of the World Health Organization (WHO) asserts that the "enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being (7)."

The UDHR's universalist rhetoric emerged hand in hand with the short-lived optimism characterizing the creation of the UN in the wake of World War II. It then quickly dissipated, as Daniel Tarantola points out, amidst Cold War competition between Eastern (Soviet-led) and Western (US-led) blocs. Indeed, when pressure mounted to operationalize the UDHR through binding international covenants in the 1960s, "shared idealism" became "ideals split asunder," with a liberal camp touting political and civil rights, and a radically redistributive camp favoring economic, social, and cultural rights. (See in this issue Tarantola, A Perspective on the History of Health and Human Rights: From the Cold War to the Gold War.)

In the context of African American freedom struggles in the United States, this translated into the ideological and racialized reduction of human rights into civil rights (8). Internationally, the very notion of shared idealism was illusory in a world bifurcated ideologically, ever menaced by hot, cold, and nuclear warfare. Former US President Jimmy Carter, to cite just one example, staked a reputation on his belief in human rights, yet he repeatedly overlooked rights violations both within the United States and by Cold War allies (9).

Notwithstanding disillusionment stemming from the limited ability of human rights efforts to yield concrete gains, its instruments helped engender an important movement to document from a health perspective the sordid reality of human rights abuses. Médecins sans Frontières, the French-international non-governmental organization, used a "bearing witness" approach in the 1970s, continuing this role to the present (10). In North America, as long-time progressive health activist H. Jack Geiger recounts, he and five other doctors plus a lawyer founded Physicians for Human Rights (PHR) in 1986 (11). Launched the year after International Physicians for the Prevention of Nuclear War won the Nobel Peace prize, PHR initially employed "traditional" human rights-based approaches (name and shame), deploying the special expertise of physicians to document the health impact of predominantly civil and political rights abuses against individuals, including torture, physical abuse, and imprisonment. PHR's early work focused on harms to health caused by the Chilean dictatorship, Israel's occupation of the West Bank and Gaza, and the first Gulf War in 1991, employing epidemiologic methods, forensic pathology, and developing DNA technologies (e.g., to identify persons buried in mass graves).

Over time, PHR's focus on the health consequences of torture and denial of civil and political rights – reflecting dominant US human rights conceptions – was increasingly influenced by colleagues in Latin America, the Middle East, Asia, and elsewhere. More recently, PHR – like Amnesty International and other human rights groups – has learned to view health and human rights more broadly, in terms of how violations of social, economic, and cultural rights harm the health of both individuals and populations. PHR's work expanded to tackle, among other issues, the effects of apartheid and the impact of racial discrimination on health care.

PHR's transformation mirrored that of other key health and human rights thinkers and actors. Elizabeth Fee and Manon Parry discuss US physician-epidemiologist Jonathan Mann's role at the helm of WHO's HIV/AIDS office, where he brought human rights concerns to the fore of his responsibilities. (See in this issue, Fee and Parry, Jonathan Mann, HIV/AIDS and Human Rights.) In contrast to most of his international health counterparts, Mann contextualized HIV/AIDS as an issue of human rights, not solely of biological or behavioral origins. (For a critique of the behavioralist approach to AIDS, see Alison Katz's work.) (12). Early on, as PHR had, Mann focused rather narrowly on violations of the civil and political rights of people with HIV, perhaps reflecting how powerfully the paradigm of civil rights had pervaded the US public health community. Subsequently, particularly as the HIV/AIDS epidemic unfolded in Africa, Mann called attention to the need to address broader structural issues – including poverty, discrimination, and accessible health care systems – to curb the spread of the disease (13, 14).

In the 1990s, Mann also participated with various other activists and scholars – including Sofia Gruskin and Daniel Tarantola, who have continued this work following Mann's death – in transforming the bearing witness, violation-by-violation approach to health and human rights into a proactive framework for enforcement and accountability. These health and legal advocate-experts are harnessing existing human rights instruments into rights-based approaches to health, employing the following logic. Health is codified as a human right according to the International Bill of Human Rights that includes three documents – the UDHR, the International Covenant on Economic, Social, and Cultural Rights (ICESCR), and the International Covenant on Civil and Political Rights. All but a handful of countries have signed it; over two-thirds of all countries, furthermore, have health or health care-related rights enshrined in their constitutions (15). Signatory governments are thus obligated to respect, protect, and fulfill the rights set forth in these documents (16). The WHO, too, now recognizes that the promotion of health and the respect, protection, and fulfillment of human rights are inextricably linked (17, 18).

Because the human right to health "gives rise to entitlements and obligations, it demands effective mechanisms of accountability (19)." The shift from civil and political rights to enforceable economic, social, and cultural rights, including the rights to food, shelter, and freedom from discrimination in health services (20), creates many new possibilities for using human rights treaties as a legal tool to improve health conditions, country by country and internationally. Many health determinants have been brought under the tent of human rights (21, 22). These include:

• education,
• economic and social protection,
• environmental sustainability,
• fair employment and labor rights,
• equitable marriage, divorce, and custody laws,
• political freedom and choice,
• adequate food, physical integrity, water and sanitation,
• secure housing and living conditions,
• freedom of religious observance,
• and social justice writ large.

Notwithstanding these developments, scholars and activists criticize health and human rights approaches on several grounds. In principle, legal frameworks are more likely to succeed in societies able to translate theoretical rights into concrete measures. First, however, they must agree to these frameworks. The United States, with one of the most extensive judiciaries in the world, is among the few non-ratifiers of key human rights treaties including the Convention on the Rights of the Child (CRC) and the ICESCR. But ratification is not enough: the majority of signatories – even those with well-developed judiciaries – have not realized their obligations (e.g., Canada has been intransigent in addressing child poverty despite having signed the CRC). To date, failure to comply with human rights treaty obligations has not been subject to effective enforcement mechanisms.

Still, the right to health may be successfully deployed when enforceable legal instruments (domestic constitutions or ratified international human rights treaties), combined with effective and willing judiciaries, are bolstered by social justice movements, political parties representative of worker and peasant interests, and political systems that do not privilege elites over majority interests (23). Increasingly, moreover, enforceable rights exist in countries at differing levels of economic development (24, 25). Social rights jurisprudence emerging in South Africa and many Latin American countries demonstrates that the right-to-health is more than a good set of standards to guide policy. Of course, political mobilization supporting developments in the law is essential, given the potential redistributive implications of the legally enforceable and justiciable right to health (and the pervasive (neo)liberal ideology in many societies that directly and indirectly impedes right to health jurisprudence and its implementation).

Another challenge has to do with the complexity of factors that influence human health – the political economy of health writ large – making it more difficult to specify in legal terms what constitutes the right to health, compared to the right to a fair trial or to education. Nonetheless, the ICESCR defines the right to health to include the underlying determinants of health (e.g., sanitation and shelter), and various UN social rights committees have also made advances in this regard (26).

Yet in recent years, the right to health has been distilled – or misinterpreted – as a right to health care by various international and national health actors who argue that improvements in the broad domain of determinants of health may be less easily realized than the right to health care. Not only has "health as a human right" come to signify "health care services as a human right" for some, but this also has been further narrowed to mean access to a particular package of biomedical technologies, such as drugs or surgical sutures (27).

Undoubtedly, such technologies are useful, but they constitute just one component of the larger right to health. Medical reductionism and determinism partially describes the fate of the primary health care and health for all movements, which began in the late 1970s as a rallying cry for integrated social and health care services but were rapidly and selectively narrowed to mean childhood vaccines and vector control (28). Although valuable, campaigns for vaccination and vector control fall far short of ensuring the right to health unless accompanied by adequate nutrition, sanitation, social security, safe employment, decent living conditions, and other elements of social well-being.

The struggle for national health insurance in the United States, for instance, with universal, publicly provided health care services, appropriately exhorts the right to health as its rallying cry (29). For over a century, realization of this right has been repeatedly thwarted by corporate interests, unabashedly led by the self-interested insurance sector. But when (or, less hopefully, if) a national health service is implemented in the United States, the right to health – as opposed to the right to health care – will still be far from achieved. The struggle for anti-retroviral medicines against HIV/AIDS in the face of "big pharma's" power poses an analogous challenge (30). Concreteness of the access to treatment goal – and identification of a clear adversary – should not impede or overshadow the accompanying struggle: without addressing the underlying causes of HIV/AIDS, access to medicines has limited salience indeed.

As these recent historical examples suggest, a right to health approach that stops at providing health care may trap the health and human rights movement into a false sense of success. The inclusion of health and human rights rhetoric in mainstream international health programs poses another kind of trap. While welcome ways to raise consciousness, health and human rights and rights-based approaches, particularly when incompletely incorporated, may be a double-edged sword, akin to community participation, sustainability, decentralization, and other ideas interpreted and applied in distinct or contradistinctive manners to their original conception. Dominant global actors in the health sector, such as the World Bank, have, for example, introduced health and human rights concerns into their portfolios (31). Health and human rights in such mainstream international development venues are, however, typically portrayed as problems of access to medical services (solely) in developing countries. Or they may be narrowly interpreted as questions of informed consent or protection of human subjects within clinical trials. Abiding by ethical norms – important to be sure – is but one element of a commitment to health as a human right. Mainstreaming also tends to emphasize issues of patient confidentiality and intellectual property rights, and portrays health and human rights-based approaches as purely theoretical with no enforcement mechanisms (32).

This is not to say that a health and human rights approach is futile, only that in order to operate effectively, it must be accompanied by large-scale social justice movements aimed at political change and potentially able to use litigation in broader social mobilization. The Brazilian landless people's movement Movimento sem Terra, the international peasants' organization Via Campesina, and the national and international activities of the Bangladesh-founded People's Health Movement all employ integrated health and human rights approaches in fighting for local control over agricultural, environmental, and other social and economic policies as human rights and as determinants of livelihood and health.

Ultimately, health and human rights efforts must per force operate on multiple levels, simultaneously setting norms, standards, and aspirations at the global level, and bearing witness, assuring accountability and enforcement, and fighting for the underlying rights that determine health at international, national, and local levels.

In sum, from a historical perspective, the struggle for health and human rights is an ongoing process – facing ever new challenges and in need of dynamic renewal in response to changing circumstances. Distinguishing health rights from health wrongs is neither a rhetorical exercise nor a particular program to be implemented, but, rather, bona fide partner to political movements.