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Volume 14 No1 Winter 2003
PHR-UK Conference on Discrimination in Health Care hears UN Special Rapporteur’s Vision

PHR-UK marked 2002’s Human Rights Day with a full-day conference in London to examine the contributions human rights and medical education can make to defeating discrimination in health care.

A broad audience from the GMC, Royal Colleges, BMA, MedSIN, the European Parliament, the Lancet, various NGOs and other bodies heard PHR-UK Chair, Dr. Peter Hall explain the meaning of the concept of the Right to Health. He went on to illustrate how the UN’s General Comment on the Right to Health had been used by PHR-UK as the basis for a report to the UN Committee on Economic, Social and Cultural Rights on the UK’s adherence to its treaty obligations in May 2002. Evidence of inequality was cited in such areas as prison medicine, coronary care, learning disability, cervical screening, HIV/AIDS and care of the terminally ill.

Dr. Hall outlined the UN Committee’s response to this and its implications for the future work for those concerned to see the UK fulfil its treaty obligations regarding the right to health.

The Conference then heard from UCL Professor of Primary Medical Care, Azeem Majeed, who discussed the treatment of coronary heart disease. Recent surveys in south-west London revealed some differences of treatment, and possible explanations were reviewed by Professor Majeed. He then went on to consider a number of solutions before concluding that some groups still have poorer access to health care than others, there needs to be greater awareness of this by patients, clinicians and policy makers and that interventions are needed to reduce differences of treatment.

The afternoon was given over to simultaneous workshops on how a human rights approach could help health professionals defeat discrimination in health care, through a consideration of the work of UN human rights mechanisms, the part played by the UK Human Rights Act and the role of medical education. At a concluding plenary, conferees heard of the importance tomorrow’s doctors placed on human rights as part of their training. It was argued that this should be part of core medical courses at both undergraduate and postgraduate levels employing problem-based learning wherever possible. The importance of the UN’s mechanisms as a place where health practitioners could both ascertain and influence contemporary international human rights standards was discussed. The UK’s Human Rights Act was also seen as way in which doctors could challenge pressures to discriminate in health care provision.

The Conference also benefited from a talk by the UN’s newly elected Special Rapporteur on the Right to Health, Professor Paul Hunt of the University of Essex. Professor Hunt explained that he had been given a broad mandate* and that he wanted to outline his current vision of how it might be fulfilled in the hope that this would illicit observations as well as questions from those present. He said that, during a period of consultations with States, NGOs and members of the UN family, including those within and those outside the human rights bodies, he had identified a number of priorities. These included:

  • the promotion of an awareness of the Right to Health as a fundamental right;

  • a deepening of our understanding of the contours and content of the Right to Health and the obligations these impose and

  • the identification and promotion of examples of good practices in the operationalisation of the Right to Health.

    Professor Hunt said that he proposed to concentrate on two themes, poverty and discrimination. These were themes that covered many of the areas specifically mentioned in his mandate, as well as mental health. He also singled out the situation of health professionals, who held a critical role in health care delivery. He expressed an interest in the oppression of health professionals and in their terms and conditions of employment, particularly in areas where they might be subject to the brain drain.

    Turning to poverty, the Special Rapporteur wondered about the impact on the poor of such policies as privatisation or nationalisation and asked what a pro-poor right to health strategy might look like. He also enquired about the role of benchmarks and indicators in ensuring the progressive realisation of the Right to Health. He also speculated on the impact of trade agreements on the Right to Health and of corruption on health care delivery. Professor Hunt concluded by saying that he would need researchers and resources if he was to accomplish all that he wished within the three years of his mandate. He recognised that close co-operation with other UN actors, such as the World Health Organisation and international financial institutions, as well as with NGOs would also be important.

    There followed a lively discussion which covered a wide range of issues, including the role of UN human rights bodies, the World Trade Organisation, the World Health Organisation, the Alma Ata Agreement, corruption, refugees and internally displaced persons.

    In thanking the Special Rapporteur, PHR-UK Chair, Dr. Hall said how very grateful he was that Professor Hunt had chosen PHR-UK’s conference to share publicly his vision of his mandate. Dr. Hall assured Professor Hunt of our deep interest in his work, and expressed a readiness to co-operate with the Special Rapporteur in any way possible.

    The Foreign Secretary’s death penalty panel

    by Harold Hillman

    On the 1st July 2002, I was invited to join the Foreign and Commonwealth Office (FCO) Death Penalty Panel, as a representative of PHR-UK, and to meet the Foreign Secretary Mr. Jack Straw. The small group included Lady Vivienne Stern of NACRO, Prof. Roger Hood of the University of Oxford, Prof. Peter Hodgkinson of the University of Westminster’s Centre on the Death Penalty, Mr. Philip Sapsford QC, Head of Goldsmith’s Chambers, Mr. Saul Lehrfreund, a lawyer involved in several Caribbean cases, and representatives of Amnesty International-UK and A-I’s International Section. Foreign Office officials also attended.

    Mr. Straw took the Chair and responded actively to all the points raised. Among these were: the gradual diminution of the death penalty in the USA, some success in having it commuted in the Caribbean and Belize, the possible influence of the FCO in reducing the use of the death penalty and torture abroad.

    I took the opportunity of pointing out that both the electric chair and hanging were extremely painful and humiliating, contrary to popular opinion in the US and the West Indies. The electric chair as sole method of execution was used only in about four states in the US, where lethal injection was now the most widely used method of execution. One of the reasons execution remained in many countries was because it was viewed as cheaper than prolonged imprisonment. I suggested this could be an area for research by human rights groups. I also reminded the Foreign Secretary that, on its own admission, China executed more people than did the rest of the world put together. The Foreign Secretary said he would raise this with the Government when he visited China shortly.

    After an informal lunch, panel members met several members of the Human Rights Policy Department (HRPD), including its Head, and the Heads of Departments concerned with China and with North America. I also discussed informally the possibility of the UK attempting to add Protocols to the Geneva Convention, extending to civilians and the prohibition of torture, an area on which PHR-UK might well advise.

    (Editor’s note: PHR-UK is delighted that Harold Hillman agreed to accept its nomination to the Foreign Office’s Death Penalty Panel. Dr. Hillman is a pain specialist, who has published on medical aspects of the death penalty. He has provided written testimony for cases involving the death penalty in the United States, and is well known to a number of the Panel’s members. In our view, Dr. Hillman’s medical expertise provides an essential element to the Panel’s thinking, and we are currently seeking funding to enable him to brief the UN Human Rights Committee in Geneva.

    The Foreign Secretary’s Death Penalty Panel, which usually meets twice each year, advises the FCO on practical measures to promote the universal abolition of the death penalty. It was established by the then Foreign Secretary Robin Cook in 1998. Members maintain contact with the HRPD and relevant geographical departments. They are unpaid for their work.)

    Investing for long term growth

    The latter half of 2002 saw few indicators of an economic rally, as companies continued to report lower than expected returns and investments continued to dwindle. In London, rental returns continued to fall, and a number of investors who had pulled out of stocks and shares earlier in the decade to seek a more favourable return on their capital in rental properties, decided to sell up. ISSAs have also reduced their return.

    Human rights organisations report a growing concern amongst the foundations that provide the grants that NGOs rely on to pay their overheads and wage bills. Foundations are advising NGOs that, although they may get their usual grant this year, they should not assume that they will get them next year, since foundations too rely on investment returns for the grants they make, and investment returns are down everywhere.

    PHR-UK is luckier than many human rights groups, who may not be able to renew office leases or staff contracts next year. Because our members fund us, we can probably ride out the economic downturn. In fact, the economic downturn may help PHR-UK. As members see the poor economic yield they get, even from managed investment funds, they are likely to look for a better investment. Human rights are a very sound investment.

    A £300 trip to Geneva in 1998, persuaded the UN Committee on Economic, Social and Cultural Rights to take a look at the right to health. By 2000, the Committee had produced a definitive explanation of how countries and the international community could improve the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

    By 2002, the UN Commission on Human Rights had appointed Professor Paul Hunt to produce a report within three years on developments in the right to health, including laws, policies and good practices, as well as obstacles. Professor Hunt, who teaches in the world famous Human Rights Centre of Essex University, is mandated to consult widely; and his report should contain recommendations with particular reference to the health needs of children and women.

    It is too soon to guess what the Hunt Report will recommend, but this is the first time that the UN has invested such expertise in the Right to Health. Paul Hunt is the author of Reclaiming Social Rights, published in 1996 by Dartmouth Publications, which examines the Right to Health, and this year he co-authored a paper on poverty reduction strategies, for the Office of the High Commissioner in Geneva. He has also served as Rapporteur to the UN Committee on Economic, Social and Cultural Rights, where he took a leading role in drafting General Comments for the guidance of States parties and in developing the Committee’s dialogue with international financial institutions. He will have an assistant, based in Palais Wilson, in Geneva.

    Whatever the new Special Rapporteur on the Right to Health comes up with, it is likely to contribute to an improvement in the health of many people around the world, perhaps not immediately, but soon. That’s an excellent return on our £300 investment of 1998, and one that will lead to long term growth.

    [If you want to invest in the Right to Health, send your cheque to PHR-UK c/o Dr. Peter Hall, 91, Harlech Rd, Abbots Langley, Herts WD5 0BE. (Ed.)]

    Record Number Attends PHR-UK Annual Health and Human Rights Meeting

    Over sixty enthusiasts braved a damp November day to learn about the human rights approach to HIV/AIDS at PHR-UK’s Annual Meeting. Marianne Haslegrave, of the Commonwealth Medical Association Trust, outlined a number of areas where human rights provided protections for people living with HIV or AIDS, including the right to life, the right to employment, the right to education, the right to be free from discrimination and the right to health. She discussed the size, nature and transmission of HIV as well as examples of good practice, including the provision of anti-retroviral treatment for employees by major companies, such as de Beers and Anglo-American.

    Turning to the role of health practitioners, Marianne indicated the difficulties involved in fulfilling ethical obligations in Malawi, where there is one doctor for every 55,000 people. She also explained the difficulties involved in testing male health in some societies where rigid gender role divisions exist. Shortages of pledges for the required $13 billion per year needed to combat AIDS, TB and Malaria were also discussed.

    Simon Wright, HIV Campaign Manager (UK) for ActionAid, spoke about the success of a rights-based approach to HIV/AIDS. He provided examples from India, where grassroot groups are contesting discriminatory laws surrounding marriage and consensual sex. Simon also discussed progress in Africa, where the successes of South Africa’s treatment access campaign are being shared with civil society organisations in other States, such as Kenya.

    In the afternoon, Dr Peter Hall and Bernie Hamilton led a workshop on campaigning for change, which demonstrated how human rights could be asserted at national, regional and global levels to protect people living with HIV/AIDS.

    The meeting was held at University College London, and was jointly organised by Medical Students International (MedSIN), which has long taken a very lively interest in human rights. A number of students from the UCL courses in health and human rights led by Peter Hall and Bernie Hamilton, helped in the organisation of the meeting, including Bryony Whipp.

    The Annual Health and Human Rights Meeting was also the occasion of PHR-UK’s annual general meeting. The meeting resolved to review its current web sites, with a view to assessing the possibility of amalgamating them in some way. Any reader who is or knows of a techie who could volunteer to do this for PHR-UK should contact the Chair, Dr. Peter Hall.*

    Executive Committee members Dr. Peter Hall and Dr. Harold Hillman were re-elected. Dr. Helen Bygrave was newly elected to the Executive Committee following the resignation of Dr. Andrew Carney. Dr. Hall recalled Andrew’s service to PHR-UK, including his involvement its the historic trip to Rwanda in 1994. Dr. Bygrave, like all Committee members, will help in efforts to raise funds for PHR-UK’s work. She will also take a lead role in organising one of our future conferences.

    Dr. Bygrave is probably best known to members for adding palliative care to the UN General Comment on the Right to Health. She is less well known as a marathon runner, having recently completed the New York marathon in around four hours. Bernie Hamilton, who completed the London Marathon in a similar time twenty years ago, welcomed the election of someone of demonstrable stamina to the Committee. Marathon races provide a wonderful opportunity to raise funds for PHR-UK, which is a registered charity. If you are competing in one, or know anyone who is, please let Dr. Peter Hall know so that he can provide you with a sponsorship form.

    *The official minutes of each AGM become available at the following AGM.

    UN committee calls for improvements in UK’s child health policy

    The UN Committee on the Rights of the Child met on September 19 to consider the UK’s second report on its implementation of the Convention on the Rights off the Child. The Committee expressed concern at persisting inequalities in health and access to health services, linked to socio-economic status, such as the high infant mortality rate among both Irish and Roma travellers. It recommended that the UK take all appropriate measures to reduce these inequalities.

    The Committee was also uneasy about the relatively low rate of breastfeeding, and urged the government to promote breastfeeding and adopt the International Code for Marketing Breast-milk Substitutes. Noting the persistence of female genital mutilation amongst children, despite its illegality, the Committee recommended that the Government enforce the prohibition through education and other measures.

    Turning to adolescent health, the Committee expressed disquiet about the high rates of teenage pregnancies and suicides, the rising incidence of STDs among young persons and the absence of appropriate information, support and protection for homosexual and transsexual young people.

    Responding to the Committee’s concluding observations in October, PHR-UK Chair Dr. Peter Hall said, “We welcome this addition to the recommendations of the UN Committee on Economic, Social and Cultural Rights of last May. Any discrimination in health service delivery is completely unacceptable to the profession, which is increasingly turning to human rights as an appropriate way to combat it.”

    The Children’s Convention is the most popular of the UN’s six core human rights treaties. It was adopted by the UN in 1989 and has been ratified by almost every UN member. Its Committee of independent experts is elected by States parties and Committee members serve terms of four years. They review each State party’s implementation of the treaty approximately every five years. Unlike some human rights treaties, there is no provision for complaints by individual victims. The treaty has optional protocols on the sale of children, child prostitution and child pornography, and on the involvement of children in armed conflict. The UK has not ratified either of these.

    Foreign office brings senior clinicians to Britain for training in evidence against torture

    The UK Foreign Office has announced that it will bring three senior clinicians to Britain each month to improve the quality of forensic evidence in combating torture. The programme will be targeted at countries where the practice of torture is widespread, and will involve visits to both legal and medical organisations. PHR-UK welcomes this initiative, as it is a strong advocate of increasing the knowledge of human rights within the health professions as well as increasing medical input into human rights.

    The UK is taking further measures to combat torture. In partnership with the Human Rights Centre at the University of Essex, it will publish a handbook on judicial safeguards, aimed at the judiciary. It will also provide a staff member for the Special Rapporteur on Prisons of the African Commission on Human Rights. The Foreign Office will continue to supply financial assistance to anti-torture projects through its support for the UN Voluntary Fund for Victims of Torture and for the Organisation for Security and Co-operation in Europe’s anti-torture activities, as well as through human rights projects managed by its embassies.

    The new Optional Protocol to the UN Convention against Torture (CAT) will also benefit from the UK’s support. The Protocol, which is described elsewhere in this Newsletter, fosters the monitoring of places of detention. Britain will assist States to set up their own monitoring systems, which will be complemented by the new CAT procedure. Britain was a key advocate of the new Optional Protocol, and has also lobbied to increase the number of States parties to the Convention against Torture. PHR-UK has been regularly consulting with the Foreign Office regarding anti-torture measures, and there have been regular increases in UK donations to the UN Voluntary Fund for Victims of Torture since we started. Combating torture is one of a number of human rights areas in which medical expertise can play a significant part, and PHR-UK looks forward to further Foreign Office support for ant-torture measures.

    Reaction to Jimmy Carter's nobel peace prize

    Human rights advocates the world over share PHR-UK’s pleasure in the award of the Nobel Peace Prize to Jimmy Carter of the USA. President Carter came to office in January 1977, as the nation sought to distance itself from Richard Nixon and those associated with him. Carter didn’t need a human rights platform to get elected, but his commitment to all human rights was unwavering. His Secretary of State Cyrus Vance, in setting out the administration’s foreign policy agenda in April 1974, mentioned the right to food, shelter, health care & education, as well as first generation rights. This commitment to social rights during the Cold War marked the Administration as one of integrity. Less than a year later, President Carter recommended that the Senate ratify a number of core human rights treaties including the International Covenant on Economic Social and Cultural Rights. His administration took a tough line on overseas loans and assistance to military dictators.

    Although Carter lost popularity during the Tehran hostage crisis and failed to get re-elected, he remained true to his commitments, working through the Carter Center in Atlanta, Georgia to promote human rights, peace and democracy, and was often called upon to help resolve tensions in various trouble spots around the world. He also founded an organisation called Habitat for Humanity, which helped poorer people band together to build their homes, often with the help of student volunteers. Long after many folks would have retired, Jimmy Carter and his wife turned up at the Habitat site and did their share of labouring. It was this readiness to do what he could, rather than his rhetorical skills that endeared the President to so many people. In terms of universal rights, Carter could be characterised as the linear descendent of Franklin D. Roosevelt. He rightly deserves the appellation ‘the Human Rights President’.

    We print below Jimmy Carter’s public response to the announcement of his award.

    11 Oct 2002 A Statement From President Jimmy Carter:

    “I am deeply grateful for this honour. I want to thank the Nobel Committee and the many people at The Carter Center who have worked side by side with me and my wife, Rosalynn, to promote peace, health, and human rights.

    People everywhere share the same dream of a caring international community that prevents war and oppression. During the past two decades, as Rosalynn and I travelled around the world for the work of our Center, my concept of human rights has grown to include not only the right to live in peace, but also to adequate health care, shelter, food, and to economic opportunity.

    I hope this award reflects a universal acceptance and even embrace of this broad-based concept of human rights.

    This honour serves as an inspiration not only to us, but also to suffering people around the world, and I accept it on their behalf.”

  • 2002 UN Commission on human rights brings further progress

    The UN Commission on Human Rights, which held its annual meeting in Geneva last Spring, resulted in progress in both economic and social rights as well as civil and political rights. The creation of the post of UN Special Rapporteur on the Right to Health for three years is potentially the most far-reaching development. It follows on naturally from General Comment 14 on the right to health that PHR-UK helped the UN Committee on Economic, Social and Cultural Rights develop between 1998 and 2000. A Human Rights Professor has been appointed to this post, and PHR-UK looks forward to working with him. The Special Rapporteur’s mandate is a broad one, and is set out in Resolution 2002/31. [See INVESTING FOR LONG TERM GROWTH - page 4]

    Another important right to health development is the subject of Resolution 2002/32. This deals with access to medication in the context of pandemics such as HIV/AIDS. It stresses the flexibility of the World Trade Organisation Agreement on Trade-Related Aspects of Intellectual Property (TRIPS Agreement) regarding members’ measures to protect public health, and calls on States to promote accessibility to pharmaceuticals and medical technologies for all, including the most vulnerable and socially disadvantaged groups.

    Progress was slower on the development of the Optional Protocol (OP) to the 1966 Covenant on Economic, Social and Cultural Rights. The protocol is designed to permit the Covenant’s monitoring committee of independent experts to consider communications from anyone concerned about the implementation of the treaty by a party to the OP. The Commission asked an independent expert to submit a report to its next session, on the nature and scope of States Parties obligations; justiciability; the benefits and practicability of a complaints mechanism; and the complementarity between the proposed OP and other complaints mechanisms. The Covenant is one of the six core UN human rights treaties that have monitoring committees of independent experts. It is the only one not to permit consideration of communications from individuals, apart from the 1989 Convention on the Rights of the Child. PHR-UK, together with other NGOs and experts, is following this closely.

    Civil and political rights saw a breakthrough with the creation of an Optional Protocol to the 1984 Convention against Torture. The OP will permit a Sub-Committee of ten independent experts to visit any place of detention of a State Party. The experts may interview anyone there in private, and discuss their findings and recommendations, in confidence with the State party. They may offer training and technical assistance, and a Special Fund is to be established to facilitate the implementation of the recommendations.

    The OP will benefit from the experiences of the Council of Europe’s Committee for the Prevention of Torture (CPT), which has been exercising these powers for over ten years. PHR-UK members may know that Dr. Olav Rasmussen is a member of both the CPT and the UN Committee against Torture. It is widely held that short notice inspections of places of detention can play a major role in preventing torture and ill-treatment of detainees. The CPT’s reports are normally posted on www.cpt.coe.int and an account of the CPT’s early years, by its first Chairperson, can be seen in Inhuman States by Antonio Cassese, 1996 Cambridge; Polity Press. PHR-UK will be pressing the UN to appoint health professionals to the new Sub-Committee when election time comes round.

  • PHR-UK advocates health and human rights education for all doctors - urgently

    The Lancet of December 7th 2002 featured a Health and Human Rights section timed to mark Human Rights Day three days later. The section comprised three articles - the first written by the new Special Rapporteur on the Right to Health, who explained how Right to Health issues are moving from the margins of practice towards mainstream medicine. The second dealt with the relevance of the Right to Health to public health practice and the third, written by the PHR-UK chair, advocated human education rights for all doctors as a matter of urgency.

    The imperative to educate doctors about human rights concerns most compellingly their obligation to practise ethically. Evidence was quoted of discrimination by doctors against marginalised groups of patients throughout the world, resulting their being inadequately treated and having higher morbidity and mortality rates. The article contends that doctors should commit to supporting those sections of the Universal Declaration of Human Rights that are relevant to medical practice and General Comment 14, which defines patients' health rights.

    Since then more evidence of ethical malpractice has been published - a report from Transparency International demonstrates the health service to be the most corrupt service sector in India, as gauged by people's experiences. For instance the dominant form of corruption after achieving hospital admission, which itself often requires irregular payment, was perceived as being "improper care including medicine, food, and treatment from doctors and nurses". The key actors facilitating corruption in this sector were identified as physicians (77%) followed closely followed by hospital staff (67%).

    The BMJ of 11th January 2003 reports grossly unethical practice within the UK National Health Service. A questionnaire demonstrates what appears to be a widespread practice of requiring medical students to perform intimate examinations on unconscious patients in the absence of consent. The article suggests a confounding factor to be that ethical values change, so that what was once acceptable may later become unacceptable. The authors characterise the need for students to learn skills through practising on patients as an ethical dilemma because patients may be vulnerable and obtaining informed consent can be difficult.

    A major advantage of the medical profession committing to human rights is that their fundamental values are immutable and can be relied on to constantly guide ethical medical care in a world of changing social values. No medical practitioner who has assimilated the principles laid down in the 54 year old Universal Declaration of Human Rights could countenance students performing intimate examination without consent. As Professor Jennifer Leaning said in her BMJ editorial of 29 November 1997 - "[...] what the Universal Declaration of Human Rights provides, is a recognition of the separate, inviolate nature of the individual person who will face that young doctor in the casualty area, the examination room, the office, the conference room. From the opening statement in article 1, that every human being is 'born free and equal in dignity and rights,' the document enumerates the critical freedoms that fill the space surrounding every man, woman, and child on earth."

    In a world where service requirements disproportionately pressurise doctors in such a way as threatens the integrity of patients, there is no better alternative to adopting patients' human rights to the highest standard of health as the guiding principles by which to define ethical patient care.



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