Public Health and Human Rights: Challenges, Synergies, MethodologiesJune 22nd, 2008 Chris Beyrer MD, MPHCenter for Public Health and Human Rights Johns Hopkins Bloomberg School of Public Health

Core ThemesHuman rights abrogation or protection can have profound impacts on the health of individuals, communities, and populations

Rights violations which affect populations need to be investigated and addressed using population-based methods

Responses based on human rights principles may improve disease prevention and control, and better the human rights contexts for those at dual risk

OutlineIntroduction

II.Health rights and human rights

Putting PHHR into practiceLuke Mullany, PhD

IntroductionModern human rights movement a response to Nazi atrocities of WWIIUniversal Declaration of Human Rights passed by United Nations on December 10, 1948Defines the fundamental human rights of persons and violations of those rightsUniversalistAspirationalLacking enforcement mechanisms

UDHRResolutions include:

Article 4: Prohibits slaveryArticle 5: Prohibits tortureArticle 18: Freedom of thoughtArticle 19: Freedom of opinion and of expressionArticle 25: Standard of Living Includes access to medical care as a human right

Human Rights Instruments and Public Health 1948 The Universal Declaration of Human Rights

1976 International Covenant on Civil and Political Rights1976 International Covenant on Economic, Social and Cultural RightsGeneral Comment 14: Health rights Prevention, treatment, control of epidemic diseases Focus on realizing rights of women to health throughout the life span

1981 Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) Health services to be consistent with the human rights of women:

Autonomy, Privacy, Confidentiality, Informed consent, and Choice

State ResponsibilitiesSignatory States must not violate these rights

Commit to measurable progress to:RespectProtectFulfill

What is meant by The Right to HealthThe right to health does not mean the right to be healthy, nor does it mean poor governments must put in place expensive health services for they have no resources. But it does require authorities put in place policies and action plans which lead to available and accessible health care for all in the shortest possible time. To ensure that this happens is the challenge facing both the human rights community and public health professionals.UN High Commissioner for Human Rights, Mary Robinson

The Center for Public Health and Human Rights at HopkinsFocus is the impact of rights of violations on the health of populationsResearch, Teaching, Advocacy

Use of population based methods (epidemiology) to study, document, measure these impactsBring increased awareness of human rights and health interactions to the scientific communityEnhance public health through rights based interventionsAdvocate for public health and human rights

PHHR Center ActivitiesBurma: Cross border health and rights projects with ethnic minority health groups (IDPs, migrants); HIV/AIDS epi; Mobile Obstetric Medics (Gates Inst.); Capacity building for human rights and democracy (DOS)Southern Africa: MSM, HR, and HIV (OSI)Russia: MSM, HR, and HIV (Ford, NIH)China: Treatment access and advocacy for blood donors (OSI, Levi Strauss)Kazakhstan, Kyrgyzstan: HIV prevention, NSEPs, HIV VCT access (NIH/NIMH, NIDA)

JHU Press, 2007

Human rights violations and associations with population-level health indicatorsJune 22nd, 2008 Luke C. Mullany, PhD MHSCenter for Public Health and Human Rights Johns Hopkins Bloomberg School of Public Health

Population 50 millionEthnically diverse90% BuddhistMilitary junta (SPDC)Poor health indicatorsIMR: 76/1000U5MR: 104/1000WFP: 33% of children chronically malnourishedWHO: 190 / 191 ranking for health system

Burma

Human rights violationsForced laborDestruction / seizure of crops / livestockArbitrary arrest and detentionForced military conscriptionTorture, rape, executionFour cuts

Backpack Health Worker TeamNovel approach to data collection within internally displaced populationsProgrammatic contextIDPs actively gathering information among themselvesWorkers also specific targets of the conflict

Data collection activitiesHealth information systems developed over past 10 years with tech. asst. from CPHHR and Global Health Access Program (www.ghap.org)Major goal: estimation of mortalityU5MR / IMR through surveysTracking of human rights violationsOthers:Morbidity estimationCompliance with specific programsKnowledge / practices / attitudes

Methods - DesignRetrospective household surveysReporting of vital events12 month recall periodSamplingTwo stage cluster design100 clusters20 households / cluster

Methods - DesignCluster selection:Village basedSelection proportionate to population sizeCensus provides complete lists of population by villageHousehold selection various methods usedspin the pen, random-proximity methodInterval sampling with random start

Survey elementsContext demands simplicityConstant movement by interviewersTravel on footOne page limitHousehold censusAll deaths recorded (cause)Listing by age / sex

Results SampleResponse rate has varied: 70-92%Total sample 7,500-9,000(5-6 persons / household)

Population pyramid - 2004Male to Female Ratio 15-25yrs: 0.86Mullany LC, Richards AK, Lee CI, et al. Application of population-based survey methodology to quantify associations between human rights violations and health outcomes in eastern Burma. J Epidemiol Community Health. 2007;61:908-14

Lee TJ, Mullany LC, Richards AK, et al. Mortality rates in conflict zones in Karen, Karenni, and Mon states in eastern Burma. Trop. Med. Int. Health. 2006;11(7):1119-27.Mullany LC, Richards AK, Lee CI, et al. Application of population-based survey methodology to quantify associations between human rights violations and health outcomes in eastern Burma. J Epidemiol Community Health. 2007;61:908-14.

Lee TJ, Mullany LC, Richards AK, et al. Mortality rates in conflict zones in Karen, Karenni, and Mon states in eastern Burma. Trop. Med. Int. Health. 2006;11(7):1119-27.

Impact of human rights violations?Overall, mortality rates represent a non-specific, indirect relationship onlyEvidenceViolence-related deaths, especially landminePreponderance of malaria deathsMale / female ratioFamilies of former rebels Angola (80:100)Afghan refugees in Pakistan (88:100)

Indirect, or ecological inference regarding impact of conflictCompare likelihood of 1 or more deaths of live born childrenAreas under Four-Cuts policy vs. Cease-Fire areasFour Cuts: 39.9%Cease Fire:16.6% PRR = 2.40 (2.02 2.86)

Measure HRV and health directly?Documentation of human rights violations comes largely from legalistic traditionUse classical epidemiological tools to quantify associationsBPHWT structure and experience provided important opportunity to directly link HRV to health outcomes

Linking Morbidity and Mortality to Human RightsBackpack medics added short set of questions to health surveys6 questionshousehold levelpast 12 months recall periodSecondary data analysis of this existing data to quantify associations between HRV and health outcomes

Sample QuestionsIn the past 12 months, how many people, from your household:were forced to work against their willwere shot at, stabbed, or beaten by a soldierhad a landmine or UXO injuryIn the past 12 months, how many times has your household:Had the food supply (including rice field, paddy, food stores, and livestock) been taken or destroyed?Been forcibly displaced or moved due to security risk?

Prevalence of human rights violations, 2004Mullany LC, Richards AK, Lee CI, et al. Application of population-based survey methodology to quantify associations between human rights violations and health outcomes in eastern Burma. J Epidemiol Community Health. 2007;61:908-14.

Violation / Event% of HouseholdsForced Labor32.6%Forced Displacement8.9%Food Destruction / Theft25.2%Landmine Injuries1.3%Multiple rights violations14.4%

Infant mortality: OR=1.72 (0.52 5.74)Child mortality: OR=2.80 (1.04, 7.54)Landmine injury: OR=3.89 (1.01 15.0)Child malnutrition: OR=3.22 (1.74 5.97)Malaria parasitemia: OR=1.58 (0.97 2.57)Families forced to move have higher odds of poor health outcomes:Mullany LC, Richards AK, Lee CI, et al. Application of population-based survey methodology to quantify associations between human rights violations and health outcomes in eastern Burma. J Epidemiol Community Health. 2007;61:908-14.

Child mortality: OR=1.19 (0.67 2.15)Crude mortality: OR=1.58 (1.09, 2.29)Landmine injury: OR=4.55 (1.23 16.9)Child malnutrition: OR=1.94 (1.20 3.14)Malaria parasitemia: OR=1.82 (1.16 2.89)Families reporting theft/destruction of their food supply have higher odds of poor health outcomes:Mullany LC, Richards AK, Lee CI, et al. Application of population-based survey methodology to quantify associations between human rights violations and health outcomes in eastern Burma. J Epidemiol Community Health. 2007;61:908-14.

Child mortality: IRR=2.18 (1.11 4.29)Crude mortality: IRR=1.75 (1.14, 2.70)Landmine injury: IRR=19.8 (2.59 151.2)Malaria parasitemia: IRR=2.34 (1.27 4.32)

Families reporting three or more violations:Child mortality: IRR = 5.23 (1.93 14.4)Exposure to multiple rights violations:Mullany LC, Richards AK, Lee CI, et al. Application of population-based survey methodology to quantify associations between human rights violations and health outcomes in eastern Burma. J Epidemiol Community Health. 2007;61:908-14.

Mobile Obstetric Medics (MOM)Providing essential maternal health services in the conflict zones in Eastern Burma

Karen, Karenni, Mon, Shan ethnic teams, Mae Tao Clinic (Dr. Cynthia Maung), Hopkins, UCLA

Cross border MCH programFamily planning, ANC and PNC careBringing Emergency Obstetric care to the household level

Supported by Bill & Melinda Gates Institute for Population and Reproductive Health at Johns Hopkins

Mobile teams carrying medical supplies to IDP Communities, Eastern Burma, 2007. The Mobile Obstetric Medic Project

Baseline Survey ResultsAccess to attendant with ability to deliver component low: 5.1%Insecticide Treated Net: 21.6%Malaria Test: 21.9% Iron/Folate: 11.8%Any ANC visit: 39%Content unknown, unlikely effective

Baseline Survey ResultsUnmet need is high; substantial potential for family planning impact25% do something to delay pregnancyOverall 61% with unmet need for limiting/spacingNeonatal, infant, child mortality rates moderately highLower than more unstable direct conflict areasHigher than Burma national estimates

For access to individual ANC interventions, trend toward decreased access for those experiencing human rights violations

Forced relocation:Odds Ratioanemia: 2.90 (1.90, 4.44)unmet need: 1.68 (1.15, 2.46)No ANC: 3.34 (0.97, 11.5)

Preliminary PRF data

ANC InterventionCoverage - Malaria screening during pregnancy68% - Insecticide treated net75% - Fe/FA supplement91% - Deworming83% - Nutrition / ENC89%Labor and Delivery - Attended by person with some BEOC69% - Misoprostol prophylactic dose given78%PNC Intervention - Family planning counseling provided90%

Cross-Border Medical Obstetric Medic in Eastern Burma, 2007

Adapt interventions to settingDeveloped a field protocol for blood screening for emergency transfusionsBased on living blood bank concept-prescreening of family, community for typingHeat stable rapid test algorithm based on disease prevalenceImproves safety of prior transfusion practices in this setting

How do human rights violations increase vulnerability to STI & HIV?Increased ExposureCoercion, sexual violence, rape as tool of war, population mixingIncreased Acquisition and TransmissionTreatment delays or gaps, barriers to access, lack of condoms/contraception

Increased morbidity and mortalityBarriers to access and to information

Burmese Migrants and Barriers to Access in ThailandKnowledge about CondomsCondom UsageThai NationalsBurmese MigrantsSource: Mullany et al, AIDS Care, 2003; Lertpiriyasuwat et al, AIDS, 2003; Leiter et al, Health & Human Rights, 2006

Barriers to information, health care: Language, Legal, Physical, Economic, & Political

PHR/JHU: Thailands failure to provide access to services violates Thai law AND undermines national HIV and STD programs

P

ConclusionsConstraints inherent in IDP context demand creative thinking and adapted solutionsGrass-roots community organizations can take the lead even in refugee and IDP settingsBuilding capacity to monitor PH programs Ensures success of programsPotential to understand direct and indirect impacts of human rights violations on health

Ways ForwardRecognizeHuman rights contexts of our work

PartnerWith the grassroots, with human rights groups in country and internationally, with those we seek to serve facing rights violations

ActResearch, Advocate, and Fund

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