Waking governments up to their obligations

BMJ 2004; 328 doi: (Published 25 March 2004) Cite this as: BMJ 2004;328:730
  1. Geoff Watts
  1. London

    What do human rights have to do with health? WHO adviser Helena Nygren-Krug tells Geoff Watts that if people are aware they have rights they can bring about improvements in health care

    Was ever there a speedier conversion? When I set off to meet Helena Nygren-Krug, now in her fourth year as the World Health Organization's adviser on health and human rights, I was sceptical about the value of linking the two issues of health and human rights. It was more a fashionable connection than a helpful one, I suspected. Half an hour later I'd more or less changed my mind.

    Swedish by birth and Anglo-American by education, Nygren-Krug trained as a lawyer at the London School of Economics, did a master's degree in human rights, and then moved to Harvard to continue studying human rights law. Now aged 35, she has worked in the United Nation's Office of the Commissioner for Human Rights, and she also spent three years at the Carter Center in Atlanta, the human rights and healthcare charity founded by President Carter. “At the centre there was a move towards bringing the two [health and human rights] together,” she says. “It was in that context that my interest arose.”

    Being married to a public health doctor helped. (Her husband, Etienne Krug, is the director of the department of injuries and violence prevention at WHO.) So did a couple of stints in the field: at the UN's mission in Haiti and as a volunteer for the Red Cross in Tanzania, where she helped to set up a refugee camp on the border with Rwanda after the genocide in that country. “I found that health workers are very often the witnesses of human rights violations,” she says. “I felt very strongly that there ought to be more of a connection.”

    The definition of human rights has undergone inflation in recent decades. Having been invented to protect against loss of liberty, torture, and other such gross abuses, the concept is now as likely to feature in debates on prisoners' access to television or the prohibition on council tenants' ownership of pets. Its currency, you might say, has been devalued. And what does it mean anyway to speak of a “right” to health? The “right” never to develop cancer or catch tuberculosis? Clearly not. As Nygren-Krug emphasises, “The right to health is not the same as the right to be healthy.”

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    Helena Nygren-Krug: “The right to health is not the same as the right to be healthy”


    To explain its stance, WHO identifies three links between health and human rights. The first is clear: that violations of rights can have consequences for health. Such violations might be physical maltreatment, such as torture, or the mental cruelty of unjust imprisonment and solitary confinement.

    The second link is that between the design and implementation of health policies and their effect on human rights. Nygren-Krug offers the example of policies on HIV amd AIDS. “Do we think about people's privacy, do we respect their dignity, do we ensure they can continue in education or employment, do we ensure they're not discriminated against?” If public health is not cognisant of human rights, she says, it may make decisions—often inadvertently—that violate them.

    And so to the third link: taking human rights seriously can reduce people's likelihood of becoming ill. Reducing poverty, improving access to clean water, and giving women the opportunity to be educated are all development issues that affect health.

    So far, so good. At Nygren-Krug's suggestion we met at the London School of Hygiene and Tropical Medicine—virtually a spiritual home to the forging of links between health and everything else. Even in the school's new steel and glass extension, where we were sitting, I began to feel oddly guilty about questioning the link between health and human rights. But I pressed on.

    Why “rights”? Wouldn't the older concept of social justice serve just as well? “Human rights adds something more,” argues Nygen-Krug. “It definitely is about social justice, but it adds an element of accountability and a legal framework that can be used to make governments wake up to their obligations to make things happen.

    “You need to empower individual human beings, especially the most vulnerable, the most voiceless. And the way to do that is to recognise their rights and get them to participate in change. If people are aware they have rights it can make a real difference.”

    I can see how the empowerment argument would apply to a poor developing nation in which basic health resources were unfairly distributed. But how about a rich country such as the United Kingdom trying to deal with, say, uncommon diseases for which there are very expensive drugs that are only marginally beneficial? A claim to such drugs based on the notion of human rights may help the people concerned but would play havoc with attempts to make a rational use of a health budget.

    Nygren-Krug counters by arguing that one of the first things a government has to do is create a national public health policy that should include arrangements for making such decisions. “In South Africa, for instance, where there is a constitutional right to health, a man went to court claiming he had a right to kidney dialysis. The judges looked at issues of equity and scare resources and ruled that he did not have this right.” Health policy makers, she argues, should master the discourse of rights and make sure that such decisions are not left to the ad hoc rulings of a judge.

    I am persuaded.

    In WHO she feels that she is now working with the grain of the organisation rather than against it. When Kofi Annan took over the leadership he made it clear to all its agencies that he didn't want human rights to be left in a box somewhere. He wanted human rights to be part of all the UN's work.

    Although she admits to no personal plans for the future, Nygren-Krug does report an ambition. “I have a commitment to try to institutionalise human rights at WHO before I move on. One day, hopefully, we won't need a separate human rights adviser.” She laughs. “But that's probably a few generations away.”

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