Health and human rightsBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7036.924 (Published 13 April 1996) Cite this as: BMJ 1996;312:924
- Jonathan M Mann
- Francois-Xavier Bagnoud professor of health and human rights Harvard School of Public Health, Boston, MA 02138, USA
Protecting human rights is essential for promoting health
When the World Health Organisation redefined health as “a state of complete physical, mental and social well-being”1 it not only expanded health far beyond medicine, it openly acknowledged the vast accumulated knowledge about the central role of societal determinants of population health. Despite the public's belief to the contrary, medical care is a relatively minor, albeit important, contributor to health,2 far outweighed by societal factors, of which social class has been the most extensively studied.3 4
In 1988, a seminal report by the United States Institute of Medicine defined the mission of public health as “ensuring the conditions in which people can be healthy.”4 In turn, this required those working in public health to consider the societal nature of these essential conditions in which people could achieve the highest attainable standard of physical, mental, and social wellbeing. Paradoxically, the discipline of public health has generally ignored the societal roots of health in favour of medical interventions, which operate further downstream. For example, public health efforts at preventing and controlling sexually transmitted diseases have focused on diagnosis and treatment, along with educational programmes, rather than confronting societal inequality or other societal issues as “essential conditions” underlying the spread of sexually transmitted diseases. Epidemiological research has contributed to this narrowed focus,5 because it identifies individual risk behaviours in isolation from the critical societal context.
Public health's difficulty in addressing the indisputably predominant societal determinants of health status is exacerbated by the lack of a coherent conceptual framework for analysing societal factors that are relevant to health; the social class approach, while useful, is clearly insufficient.2 3 6 Public health action based on social class is often simply accusatory, and it raises, but cannot answer, the question: “what must be done?” In this sense, “poverty” as a root cause of ill health is both evident and paralysing to further thought and action. Also, without a consistent approach or vocabulary, we cannot identify the societal factors common to different health problems (cancer, heart disease, injuries, infectious diseases) and to different countries. Finally, since the way in which a problem is defined determines what is done about it, the prevailing public health paradigm is unclear about the direction and nature of societal change that is needed to promote public health.
Modern human rights, born in the aftermath of the second world war and crystallised in the Universal Declaration of Human Rights of 1948, reflect a broader, societal approach to the complex problem of human wellbeing. The implicit question behind the modern human rights movement is: “what are the societal (and particularly governmental) roles and responsibilities to help promote individual and collective wellbeing?” This form of the question leads to a specific list of actions that governments should not do (discriminate, torture, imprison under inhumane conditions, interfere with the free flow of information, invade privacy, prevent associative life in society), and a basic minimum that governments should ensure for all (elementary education, housing, food, medical care). While the word health is mentioned only once in the document, to a public health professional the declaration is about the societal preconditions for “physical, mental and social well-being.”
The current health and human rights movement is based on a working hypothesis: that the human rights framework provides a more useful approach for analysing and responding to modern public health challenges than any framework thus far available within the biomedical tradition. The discussion is complicated by the fact that health professionals are generally unaware of the key concepts, meaning, and content of modern human rights. Yet awareness is increasing. Health professionals are learning that promoting and protecting human rights may be essential for promoting and protecting health. This insight was already present in the evolving approach to population and women's health.7 8 It was strongly accelerated in work on HIV and AIDS, in which discrimination (and other human rights issues) were found not only to be tragic results of the pandemic but to be root societal causes of vulnerability to HIV.9 10 Even the World Bank, not generally involved with human rights agendas, reached a similar conclusion when it declared that ensuring girls' rights to education and to non-discrimination within education represented one of the most powerful strategies for improving health in the developing world.11
The world of health and human rights has moved away from earlier simplistic assumptions about a necessary conflict between public health goals and human rights norms.12 Public health professionals increasingly recognise that they must deal directly with the underlying societal issues that determine, to the largest extent, who lives and who dies, when, and of what. For this reason, since 1990, all graduates of the Harvard School of Public Health receive, along with their diploma, a copy of the Universal Declaration of Human Rights. The dean tells them that this will be as important to their future work as a Hippocratic oath would be for a practising clinician. Ultimately this approach, linking human rights work with public health, is both a return to the historical concerns of public health and the beginning of a new chapter in the relationship between health and society.