advanced search

<< Back To Home

CSU 61/2011: THE RIGHT TO SUTURES: SOCIAL EPIDEMIOLOGY, HUMAN RIGHTS, AND SOCIAL JUSTICE

Monday, 21st of February 2011

Full text is at http://www.hhrjournal.org/index.php/hhr/article/view/365/558http://www.hhrjournal.org/index.php/hhr/article/view/365/558

‘The article examines the convergences and contrasts between social epidemiology, social medicine, and human rights approaches toward advancing global health and health equity. The first section describes the goals and work of the WHO Commission on Social Determinants of Health. The second section discusses the role of human rights in the Commission’s work. The third section evaluates, from the perspective of social epidemiology, two rights-based approaches to advancing health and health equity as compared to a view that focuses more broadly on social justice. The concluding section identifies four areas where social epidemiologists, practitioners of social medicine, and health and human rights advocates can and must work together in order to make progress on health and health equity.’

 

Good reading.

 

BD

 

The right to sutures: social epidemiology, human rights, and social justice

 

Sridhar Venkatapuram, Ruth Bell, and Michael Marmot

abstract

 

The article examines the convergences and contrasts between social epidemiology, social

medicine, and human rights approaches toward advancing global health and health

equity. The first section describes the goals and work of the WHO Commission on

Social Determinants of Health. The second section discusses the role of human rights

in the Commission’s work. The third section evaluates, from the perspective of social

epidemiology, two rights-based approaches to advancing health and health equity as

compared to a view that focuses more broadly on social justice. The concluding section

identifies four areas where social epidemiologists, practitioners of social medicine, and

health and human rights advocates can and must work together in order to make

progress on health and health equity.

Each of three fields — health and human rights, social medicine, and

social epidemiology — has valuable insights, and professionals working

in these fields hold important roles in advancing the health of people in

society. In particular, despite the comparatively recent establishment of

the health and human rights field, it has made an enormous contribution

to the advancement of global health equity. It has done so by providing

an analytical framework to identify and protect the most vulnerable

anywhere in the world from poorly conceived public health policies as

well as from the egregious abuses that make them vulnerable to ill health

and mortality. While health and human rights advocates have from the

start taken a global perspective, social medicine and social epidemiology

have been slower to catch up. Advancing global health and health equity

against a wide variety of threats — including abusive actors, unjustifiable

reasoning, and plain complacency of those who have the power to make

a difference — will require coherent reasoning and coordination across

the fields of social epidemiology, social medicine, and health and human

rights. So it is welcome and commendable that this journal, the original

publication of the health and human rights field, is taking the lead toward

building such coherence and cooperation with a special issue on social

determinants of health.

In this article, we examine the convergences and contrasts between

social epidemiology, social medicine, and human rights approaches

toward advancing global health and health equity. For the purposes of

this article, we understand social medicine to be the practice of clinical

medicine in a manner that demonstrates social awareness, while social

epidemiology is the study of the social distribution of disease and causes

of that distribution across groups and individuals. The first section of

the article describes the goals and work of the WHO Commission on

Social Determinants of Health. The second section discusses the role

of human rights in the Commission’s work. The third section evaluates,

from the perspective of social epidemiology, two rights-based approach-

Sridhar Venkatapuram

MSc, MPhil, PhD, is the

ESRC–DFID Research

Fellow in the Department

of Epidemiology and Public

Health and a member of

the Centre for Philosophy,

Justice and Health, at

University College London,

United Kingdom.

Ruth Bell, PhD, is a Senior

Research Fellow in the

Department of Epidemiology

and Public Health at

University College London.

Michael Marmot, MPH,

PhD, FRCP, FFPHM,

FMedSci, is Head of the

Department of Epidemiology

and Public Health,

University College London,

and served as Chairman

of the WHO Commission

on Social Determinants of

Health and the Strategic

Review of Health

Inequalities in England Post

2010. He is currently Chair

of the European Review on

the social determinants of

health and the health divide.

Please address correspondence

to the authors c/o

Sridhar Venkatapuram,

UCL Department of

Epidemiology and Public

Health, 1–19 Torrington

Place, London WC1E 6BT,

United Kingdom, email:

s.venkatapuram@ucl.ac.uk.

Competing interests: None

declared.

Copyright © 2010

Venkatapuram, Bell, and

Marmot. This is an open

access article distributed

under the terms of

the Creative Commons

Attribution Non-Commercial

License (http://creativecommons.

org/licenses/

by-nc/3.0/), which permits

unrestricted non-commercial

use, distribution, and

reproduction in any medium,

provided the original author

and source are credited.

venkatapuram, bell, and marmot

4 • health and human rights volume 12, no. 2

es to advancing health and health equity in comparison

to a view that focuses more broadly on social

justice. The article concludes by identifying four areas

where social epidemiologists, practitioners of social

medicine, and health and human rights advocates can

and must work together in order to make progress on

health and health equity.

the commission on social determinants

of health

The WHO Commission on Social Determinants of

Health (“the Commission”) was set up in 2005 by the

late J. W. Lee, then Director-General of the World

Health Organization, with the mission to collect and

synthesize global evidence on the social determinants

of health, assess their impact on health inequity, and

make recommendations for action to address that

inequity.1 Members of the Commission and its secretariat

were motivated by three driving forces: a belief

in social justice, respect for evidence, and frustration

that there was far too little action on the social determinants

of ill health and health inequalities. These

powerful motivating forces led to three years of

detailed work compiling and analyzing research, consulting

with experts from around the world as well

as across many disciplines and professions, meeting

with governments and practitioners, and producing

a final report and recommendations.2 Rather than

being an end in itself, the work of the Commission

and the resultant report, Closing the gap in a generation:

Health equity through action on the social determinants of

health (hereafter Final Report) is meant to instigate discussions

within institutions and the public sphere and

help promote social action and policies to advance

health and health equity, both within countries and

transnationally.

Based on the collected evidence, the Commission

made its recommendations across three overarching

areas for action. The first is “to improve the conditions

of daily life — the conditions in which people

are born, grow, live, work and age.”3 The second is

to tackle the “structural drivers of those conditions,”

that is, the inequitable distribution of power, money,

and resources. The third is to “measure the problem,

evaluate action, expand the knowledge base, develop

a workforce that is trained in the social determinants

of health, and raise public awareness about the social

determinants of health.” Within these areas of action

the Commission made further recommendations in

twelve areas: 1) early child development and education,

2) healthy places — the living environment, 3)

fair employment and decent work, 4) social protection

across the life course, 5) universal health care,

6) health equity in all policies, 7) fair financing, 8)

market responsibility, 9) gender equity, 10) political

empowerment, 11) good global governance, and 12)

knowledge, monitoring, and skills. The Commission’s

recommendations are necessarily broad given its

global remit and the very different contexts in which

people live their lives around the world. At the same

time, the broad principles embodied in the recommendations

are relevant to and applicable in all

contexts. Developing national or regional strategies

to improve health equity requires contextual analysis

across the areas identified by the Commission.

Indeed, the resolution agreed at the World Health

Assembly in May 2009 urges all member states to

tackle health inequities through action on the social

determinants of health and to assess the impact of

policies and programs on health inequities.4 A number

of countries and regions around the world are in

the process of taking up the Commission’s recommendations

and translating them to suit their national

and regional circumstances, including England, a

number of European countries, Brazil, Argentina,

Chile, Sri Lanka, Thailand, and the Canadian provinces

of Manitoba and Quebec.

The Commission’s recommendations are rooted in

an analytical causal framework that is based on the

intersection of three sets of social dynamics as they

relate to conditions of daily life. The first is that the

conditions of daily life in which individuals are born,

grow, live, work, and age determine their incidence of

disease, their experience of morbidity, and length of

lifespan. Second, these daily living conditions include

proximal determinants such as exposure to harmful

substances and biological organisms, the availability

of material needs such as food, potable water, and

shelter, and the social environments that affect psychobiological

pathways and health-related behaviors.

Third, these daily conditions also have distal structural

drivers or “causes of causes” — the economic,

social, and political conditions that together with

background social and cultural norms create and distribute

the proximate causes across individuals and

social groups.

In other words, poor health and health inequalities

across individuals and social groups are brought

about by multiple and multi-level factors that interact

in complex ways. These factors include the individual

volume 12, no. 2 health and human rights • 5

health and human rights in practice

material circumstances in which people live their lives

as well as social cohesion and psychosocial, behavioral,

and biological factors, and the functioning of

the health care system. The way people interact with

or experience these factors is determined by their

position in the social hierarchy along dimensions

of wealth and income, occupation, education, gender,

race or ethnicity, and geographical location of

residence. All these causal factors are in turn affected

by a political, economic, social, and cultural context

that determines the unequal distribution of power,

prestige, and resources. Figure 1 is a diagram of the

Commission’s conceptual framework.

The Commission’s analysis reflected the intellectual

and disciplinary traditions of social epidemiology

and social medicine. Social epidemiology begins with

observations and measurements of the distribution

of health across social groups differentiated by factors

such as occupation, income, education, gender,

ethnicity/race, age, and geographical area. This then

allows for the identification of the supra-individual

determinants of health and their distribution, and

for an understanding of the causal chain from

social, economic, and political drivers to differential

health outcomes in individuals and social groups.

The Commission’s recommendations for action to

improve individual health and the distribution of

health are grounded in identifying the causal chain,

based on empirical evidence. At the core of the

Commission’s view is the understanding that individual

health — and the distribution of health achievements

across groups — is significantly influenced by

determinants outside the health care system as well

as by the functioning of the system itself. As a result,

the Commission identified universal primary health

care as one important area for social action, but it is

just one of the Commission’s twelve recommended

areas for action to improve health and health equity.

Social medicine begins from the recognition of the

impact of social and economic conditions on access

to, and experience of, medical care as well as their

direct impact on health achievements. Therefore,

social epidemiology and social medicine share the

recognition of the social determinants or social bases

of health and health inequalities. Indeed, the only

thing that could be said to distinguish social epidemiology

and social medicine is the extent to which

medical care is given importance in the analysis of

the social causation and distribution of health and

longevity. Put in another way, social epidemiologists

Figure 1. Commission on Social Determinants of Health conceptual framework

Source: Commission on Social Determinants of Health, Closing the gap in a generation: Health equity through action on the social

determinants of health. Final Report of the Commission on Social Determinants of Health (Geneva: World Health Organization,

2008), p. 43. Available at http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf. Amended from O.

Solar and A. Irwin, “A conceptual framework for action on the social determinants of health,” in Discussion paper for the

Commission on Social Determinants of Health (Geneva: World Health Organization, 2007). Available at http://www.who.

int/social_determinants/resources/csdh_framework_action_05_07.pdf. Reprinted with permission.

Socioeconomic

and political

context

Governance

Policy

Macroeconomic

Social

Health

Cultural and

societal norms

and values

Education

Occupation

Income

Gender

Ethnicity / Race

Social position

Material circumstances

Social cohesion

Psychosocial factors

Behaviors

Biological factors

Health care system

Distribution of

health and

well-being

Social determinants of health and health inequities

venkatapuram, bell, and marmot

6 • health and human rights volume 12, no. 2

are practitioners or supporters of social medicine,

and practitioners of social medicine are social epidemiologists,

but the scope of social epidemiology

is broader than medical care. The broader the scope

of social medicine’s analysis of the social conditions

affecting health and its distribution, the less social

medicine can be distinguished from social epidemiology.

Given this understanding of the relationship

between social medicine and social epidemiology, it

should be clear that the tradition of social medicine

greatly informed the work of the Commission, not

least by many of the individuals involved who consider

themselves to be practitioners of social medicine.

The gap, the gradient, and social justice

The starting position of the Commission was that

there is no inherent biological or “natural” explanation

for the gross inequalities in health achievements

we see between countries and within countries. There

is no inherent biological reason why life expectancy

for a girl born in Japan is 86 years, while for a girl

born in Sierra Leone it is 43 years. Nor is there a

biological explanation for why the maternal mortality

ratio in Sierra Leone is 2,100 deaths per 100,000

live births while in Ireland the ratio is 1 maternal

death per 100,000 live births.5 In the case of Malawi,

Paul Farmer identifies the lack of sutures, sterile

drapes, and anesthesia among the many reasons

for the unacceptably high maternal mortality ratio.6

The Commission concerns itself with such lack of

necessary medical supplies — as part of the conditions

of daily living — and with the upstream causes

of such conditions of daily living. Like Farmer,

the Commission asks: how can these conditions be

improved through social action?

In its Final Report, the Commission presented evidence

that the systematic differences in health

achievements between countries and within countries

across groups stratified by education, income,

occupation, gender, ethnicity, race, and geographical

area of residence are determined by social, political,

and economic policies and practices. This evidence

militates against analyses that focus narrowly on biological

processes at the individual level in a contextual

vacuum. One piece of compelling evidence can be

found, for example, by examining under-five mortality

against household wealth in developing countries

(Figure 2). The difference in mortality levels within

each country illustrates one detail of the scale of

inequality in this indicator, with a substantial gap

between the best and the worst off and, importantly,

a step-wise gradient across the whole society.

The Commission argues that systematic differences

in health achievements that are avoidable or preventable

by reasonable means are unfair; they are health

“inequities.” To return to Paul Farmer’s example,

reducing maternal mortality through the provision

of sutures certainly falls into the category of reasonable

means in that it is both practically possible

to provide sutures and providing sutures is neither

morally offensive nor unreasonable. The same is true

of many interventions that would make significant

improvements in the conditions of daily living (the

circumstances in which people are born, grow, live,

work, and age). Indeed, a major source of the frustration

driving the Commission’s work to collect evidence

was the recognition of how much health and

health equity could be improved through reasonable

means in contrast to the poor reasoning and complacency

of many societies and international institutions.

Based on collected evidence and its analysis of

the causation and distribution of ill health, the

Commission adopted the view that taking action to

reduce health inequities is a matter of social justice.

The Commission states, “Achieving health equity

within a generation is achievable, it is the right thing

to do, and now is the right time to do it.”7 This is

not meant to be hollow rhetoric. Any meaningful

understanding and commitment to the idea of

social justice entails addressing manifest injustices,

and such manifest injustices exist where reasonable

means could be deployed to alleviate disproportionate

ill health or prevent mortality. This social justice

imperative applies to improving the health of those

who suffer most egregiously as well as improving

the health of those represented by the gradient, the

remaining majority of the population. In light of the

unprecedented intellectual and material resources

that exist in the world today, the goal of social action,

in principle, should be to flatten the social gradient

in health by leveling up health outcomes across the

social spectrum so that all are capable of achieving

the health of the healthiest. This is what is meant by

“closing the gap in a generation.”

volume 12, no. 2 health and human rights • 7

health and human rights in practice

Is closing the gap in a generation feasible?

Numerous epidemiological studies have shown that

gaps and gradients in health can vary significantly

between countries and within countries over time, and

there have been natural experiments that also provide

valuable information. We know, therefore, that average

measures of population health and the distribution

of health are susceptible to social and political

action. For example, with the deep political, social,

and economic changes that followed the dissolution

of the former USSR, average population health measures

worsened, and the gradient in adult mortality

by education steepened in Russia since the 1980s.8 In

New Zealand, “indigenous inequalities,” that is, measurable

health inequalities between mortality rates

of the indigenous and non-indigenous populations,

widened between the mid-1980s and the mid-1990s

following a period when structural adjustment policies

were introduced and social and income inequalities

increased. These inequalities then narrowed

following the introduction of pro-equity policies

and health reforms in the late 1990s.9 Prevalence of

certain chronic diseases is lower among low-income

residents in the Canadian province of Quebec, which

instigated an anti-poverty strategy in 2002, than in

equivalent populations in other Canadian provinces

that did not have such a policy.10 Studies comparing

Nordic countries with other developed countries

associate generous and universal social welfare policies

with lower levels of poverty and better outcomes

for disadvantaged people.11 While these findings do

not demonstrate direct causality, there is a plausible

causal chain linking political decisions and social

action to changes in the health of entire populations

and lower socioeconomic groups. We have evidence

that the absolute levels and social gradient of health

achievements can rapidly worsen within a single

generation.12 The Commission asserts that health

and health equity could also improve dramatically in

a single generation if and when appropriate social

action is taken within and across countries.

the commission and human rights

From the start, the Commission based its work on

an awareness of human rights and the relationship

between human rights and health. It also built on

opportunities to discuss with human rights experts

— including Paul Hunt, the former United Nations

Rapporteur on the Right to Health — the possible

role of international human rights law in the

Commission’s analysis and Final Report. While it was

clear that human rights law would be an important

part of implementing the Commission’s recommendations,

members of the Commission were not

convinced that explicit consideration of the legal

Figure 2. Under-5 mortality rate per 1000 live births by level of household wealth.

Source: Commission on Social Determinants of Health, Closing the gap in a generation: health equity through action on the social

determinants of health. Final Report of the Commission on Social Determinants of Health (Geneva: World Health Organization,

2008), p. 30, using DHS data adapted from D. R. Gwatkin, S. Rutstein, K. Johnson, et al., Socio-economic differences in health,

nutrition, and population within developing countries: An overview, Country Reports on HNP and Poverty (Washington: World

Bank, 2007). Reprinted with permission.

0

50

100

150

200

Uganda

2000/2001

India

1998/1999

Turkmenistan

2000

Peru

2000

Morocco

2003/2004

Poorest Less poor Middle Less rich Richest

venkatapuram, bell, and marmot

8 • health and human rights volume 12, no. 2

human right to health changed their final causal

analysis. That is, to what extent can the violation of

human rights — as defined by international statutes

— explain the (social) causation and distribution of

ill health and mortality? On the one hand, all the

social determinants identified thus far in the causal

chain of ill health and mortality could conceivably

be recast as violations of human rights. Such recasting

without providing the underlying epidemiological

information and analysis would not in and of itself

supply convincing evidence of causation. Further,

providing epidemiological evidence with accompanying

human rights legal analysis does not provide

additional explanatory value. After epidemiological

analysis, however, human rights law has immense value

in guiding how societies must act in order to protect,

promote, and fulfill the rights implicated in the

social epidemiological analysis. The Commission said

as much in the Final Report by stating that the right

to health as set out by Paul Hunt’s report presents a

compelling case for action on the social determinants

of health. On the other hand, it is not immediately

clear how a human rights analysis of health can capture

some of the central findings in social epidemiology,

namely, the observations about the health of

social groups and the broad social gradient in health

within and across countries.

When evaluating the role of human rights in the

Commission’s analysis and recommendations, one

also must bear in mind that the Commission was

very aware that within the WHO and in the global

health policy arena, the two dominant approaches to

analyzing poor health and health inequalities focus

on medical interventions/health systems or economic

policy. The focus on disease prevalence and

medical care/health systems aims to address ill health

through the provision of medical interventions such

as vertical programs or better functioning of health

systems broadly conceived. And the perspective of

economics, exemplified by the WHO Commission

on Macroeconomics and Health, focuses on improving

the cost-effectiveness of health systems in order

to improve economic growth while also being mindful

of the health needs of the “ultra” income-poor.

The Commission championed an alternative framework

of analysis that presented evidence of the full

breadth of social determinants of health beyond that

generally considered within the realm of medical

interventions/health systems. The Commission also

argued that all avoidable ill health and health inequalities

must be addressed as a matter of social justice,

not just those factors instrumental to economic

growth.

Furthermore, the Commissioners were well aware

that the social distribution of ill health and health

achievements is a secondary concern in both the

focus on controlling diseases and mortality through

medical interventions and in investing in health for

economic growth. It is quite conceivable that average

indicators of health or economic growth targets

could be reached through focusing on improving

the health achievements of the more advantaged in

societies. This is why equity and social justice are concerns

that run throughout the Commission’s analysis.

Finally, but not least important, the Commission

wanted to show that the health of individuals in both

rich and poor countries could be evaluated within

one framework of analysis, that the preventable

deaths and suffering of the disadvantaged and the

social gradient as it affects health in both rich and

poor countries are the result of the way in which we

organize our societies through economic, social, and

political policies and practices.13 For these reasons

and more, the Commission drew largely on the methods

of social and natural sciences research in order to

analyze the causes and distribution of ill health and

mortality within and across countries.

Nevertheless, the idea of human rights and entitlements

came to the fore throughout the Commission’s

discussions. Dr. Ricardo Lagos, former President of

Chile and a member of the Commission, pointed

out that Chile has introduced a system of social

guarantees, or entitlements to health care, for a

number of health conditions as rights of citizenship.

Mirai Chatterjee, a Commission member from

India, described how the Self Employed Women’s

Association campaigned and won legal rights for

poor women in Ahmedabad to work as street market

traders.14 So the ideas of human rights as well as

rights and entitlements were present throughout the

functioning of the Commission and appear in the

Final Report. At the same time, the Commissioners

and others would assert that human rights do not

encompass the entirety of the idea of social justice.

Advancing health and health equity as a matter of

social justice will entail promoting, protecting, and

fulfilling human rights, including the right to health,

as well as taking additional social action. Moreover,

in thinking about health and social justice, the

volume 12, no. 2 health and human rights • 9

health and human rights in practice

Commission recognized an affinity between Amartya

Sen’s ethical arguments for seeing social justice as

the expansion of freedoms and social epidemiological

research on the effects on health of having

control, autonomy, and ability to participate in social

relationships.15 Indeed, Sen’s thinking was influential

in setting up the Commission and he served as one

of the Commissioners. Expanding on Sen’s line of

reasoning, the Commission positioned the concept

of empowerment for individuals, communities, and

nations across three dimensions — material needs,

psychosocial factors (having control over one’s life),

and political voice and participation in decision-making

processes — as fundamental to making progress

toward health equity.

In responding to the Commission’s Final Report, some

human rights advocates such as Paul Hunt and Mary

Robinson have remarked that it should have granted

a larger and far more central role to human rights.16

Received in the positive and constructive manner

that Hunt and Robinson intended, these comments

have been understood to mean that there is much

more unexplored potential in bringing together

human rights analysis and social epidemiology/

social medicine. For example, the role of legal institutions,

particularly those institutions that protect

constitutional and international human rights, may

have distinct contributions to make in addressing

certain social determinants of health or for establishing

social norms. Indeed, no modern approach

to health and human rights would exist without the

legal institutions that have established human rights

law. Although the Commission has formally concluded

its activities, as part of the follow-on activities,

there have been efforts to think more concertedly on

integrating social epidemiology/social medicine and

human rights. In the next section, we present some

of the initial analysis of the convergences and contrasts

between social epidemiology/social medicine

approaches and human rights-based approaches.

While we identify a divergence at the point of causal

analysis of health, we argue these approaches are

not only convergent — in the sense that they both

have common concern and push toward the same

goal of greater health equity — but that they are also

interdependent and must work together in order to

advance health and health equity within and across

countries. As concrete illustration of our reasoning

about how social epidemiology/social medicine and

human rights approaches can and should be integrated

and jointly deployed to advance health and health

equity, we have taken the liberty of focusing on Paul

Farmer’s rhetorical question in an earlier issue of this

journal, “Should there be a right to sutures?”17

human rights and social justice

In describing a visit to Malawi, Farmer reported the

maternal mortality ratio in Malawi as being a shocking

1,800 per 100,000 live births. He described how

the two obstetricians in a maternity hospital faced

severe shortcomings in supplies, facilities, and personnel

compared with the Harvard teaching hospitals

where Farmer works part of the year. However, as a

result of the efforts of the two Malawian obstetricians,

the maternal mortality ratio within the hospital

was reported to be 300 per 100,000 at the time of his

visit. Given that this within-hospital maternal mortality

ratio is still deplorably high, the fact that it could

be seen as a consolation that it was one-sixth of the

national ratio left Farmer speechless. Tarek Meguid,

one of the obstetricians who showed Farmer around

the hospital, described the lack of material resources

— of supplies, facilities, and personnel — in terms

of human rights abuses. Farmer, in turn, asked readers

“Should there be a right to sutures? To sterile

drapes? To anesthesia?”18

Most readers would likely answer with a resounding

“Yes, of course!” And yet, Farmer’s questions raise

one of the central conceptual problems in the health

and human rights paradigm: how to frame a right to

something that is not explicitly identified in human

rights law? How to reconcile an understanding of

the often dire health situation “on the ground” with

the formal texts of human rights law is a dilemma

for which even those deeply committed to the ideals

of human rights often pursue remarkably different

paths in order to advance global health and health

equity. Even among human rights advocates, (putting

aside the views of the skeptics and critics of human

rights), if a particular right to something does not

appear in the legal documents, then such a human

right does not exist. But what if one believes, for

example, that the provision of sutures is not only a

reasonable and feasible means to prevent deaths but

that it should be seen as a human right? In the following

discussion, we frame this issue as one that may

be addressed by pursuing three possible paths. Each

path is a potential answer when faced with this notso-

uncommon situation, where the identification of

the causal pathways to ill health and mortality on the

ground is sought to be integrated with the idea and

law of human rights.

venkatapuram, bell, and marmot

10 • health and human rights volume 12, no. 2

Path 1 would offer the choice to continue to engage

with international human rights law and with

attempts to interpret the existing law via documentation,

reporting, and various avenues of enforcement

with the goal of addressing the missing cause

or treatment, such as in the example of the provision

of sutures. Path 2, rather than seeking formal

engagement with human rights law, would seek to

derive principles and values from human rights law

and infuse them into health programs and interactions

between individuals on the ground. Finally, Path

3 would in fact back away from the arena of human

rights law and would instead attempt to bridge the

analysis of the causes and distribution of ill health

and mortality on the ground with ethical reasoning

about social justice. Out of such ethical reasoning —

informed by evidence of the causes, inequalities, and

consequences of ill health — could arise arguments

for advancing rights and other types of social action.

The three paths are not mutually exclusive; all three

could be effective to various degrees and could function

in different arenas and at different institutional

levels — international, national, community, and

family.

The Commission followed the third path for some

of the reasons outlined above. Nevertheless, because

it appears that human rights are given a diminished

role in Path 3 in comparison to the first two paths,

it seems worthwhile to examine the intellectual and

strategic motivations for pursuing each of the different

ways of engaging with human rights to advance

health and health equity.

On seeing the lack of medical supplies in Malawi

as part of the causal chain of maternal mortality

among poor women, Farmer was motivated to ask

the questions in terms of “should there be a right?”

because there are in fact, no enunciated human rights

to sutures, to sterile drapes, or anesthesia. If there

were indeed such human rights to sutures and other

relevant medical supplies and services stated in the

law, the concern would, understandably, be about

enforcement and implementation of the legal rights.

Indeed, a significant part — if not most — of the

health and human rights scholarship over the past

decade has concerned interpreting, implementing, or

enforcing the right to health and other human rights

related to health already existing in international law.

But there is no such explicitly articulated legal right

to sutures. Nevertheless, Farmer continues to press

this example in terms of human rights law, calling

attention to a broader definition of human rights that

encompasses economic and social rights. Although

no explicit human right to sutures is stated in either

the Universal Declaration of Human Rights, the

Covenant on Economic, Social and Cultural Rights,

or in Right to Health General Comment No. 14, the

existing language and rights in these legal human

rights documents can be interpreted to provide individuals

with a right to such essential health care supplies

as sutures, sterile drapes, and anesthesia. Should

effectively realizing this interpretation prove difficult,

then it may still be possible to interpret rights to

these supplies in the more recent conventions and

declarations. For those who are disturbed about the

unjustifiable lack of life-saving materials — that is,

of medical neglect — such a search to make use of

human rights law is motivated by both the fact that

economic and social rights are intended to guarantee

the material needs of human beings, and because

human rights law is law; it has potential power —

legal, political, and moral — to make governments

and, increasingly, other actors, behave in particular

ways to provide material goods and social conditions.

Farmer presents an additional line of reasoning for

increased enforcement of economic and social rights

(that is, pursuing Path 1), aside from the fact that they

imply rights to various health care goods and services.

He argues that more vigorous enforcement of economic

and social rights would improve living conditions,

leading to better health outcomes. To carry this

point further, such improved health achievements

would, in turn, also create more active citizens and

democratic institutions. At the risk of being too simplistic,

the reasoning for pursuing Path 1 would be to

argue that where the causes of preventable morbidity

and mortality are due to medical neglect and material

privation, the enforcement of economic and social

rights will provide health care, create conditions for

better health and longevity, and create stronger social

and political institutions. Farmer and many other

individuals following this line of reasoning exhort

practitioners of health and human rights and public

health communities (and anyone else with the power

to effect change) to fight against the entrenched

orthodoxies in so many arenas, and to champion the

enforcement and realization of economic and social

rights. From this perspective, it is understandable,

then, why human rights advocates express disappointment

when analysis of health issues, especially

on a global scale, is not explicitly framed in terms of

existing human rights law, particularly an overarching

right to health. It appears to be a wasted opportunity,

one that fails both to recognize and make use

volume 12, no. 2 health and human rights • 11

health and human rights in practice

of the entitlements identified in human rights law at

the same time it fails to help support the efforts for

greater enforcement and implementation of human

rights law, particularly economic and social rights.

It is on this point — the recognition of the effects of

economic and social conditions on the health of individuals

and populations — that social medicine and

human rights perspectives converge. The practice of

social medicine has a long history and its practitioners

have been centrally focused on the social conditions

affecting the health of the worst off in societies.

There has always been an overlap between those

who are socially excluded from economic, political,

and other resources and those who bear the highest

burden of poor health. The causal relationship

between poor health and social, economic, and political

deprivations would understandably lead any medical

professional working with the socially excluded

to draw on concepts of protections and entitlements

such as those enshrined in international human

rights. Where it is clearly visible that the social structure

— the social, economic, and political conditions

and underlying ideologies — is allowing or, indeed,

directly causing avoidable disease and deaths on a

large scale, the idea and law of human rights appears

to be the only available mechanism to fight back; one

might envision human rights in such a setting acting

as a safety net that empowers those who suffer

most egregiously to claw back up the great chasm of

inequality and deprivation. Moreover, in the present

era of increasing globalization, international human

rights law may be the best available instrument to

address the ill health caused by transnational actors

who are, in many cases, more powerful than some

governments.

Before presenting points seen as critical of such

rights-based approaches to health issues — especially

as these paths reflect the perspectives of individuals

whom we greatly admire — it seems appropriate

and necessary to recall the words of Onora O’Neill,

a notable philosopher who has written extensively on

human rights. When asked by one of the authors of

this article why she seems to be so critical of some

arguments for human rights while also being so

emphatically concerned with acute deprivations in the

world, she replied that it is because we care so much

about the idea of human rights that we must ensure

that arguments to support them are unimpeachable.19

So, it is our hope that our evaluation of the first two

approaches — increased enforcement of economic

and social rights (Path 1) and infusing principles of

human rights legislation into health programs and

interactions between individuals on the ground (Path

2) — should not be misunderstood as being critical

of the idea of human rights in our effort to share our

reasoning for choosing the third path, which appears

to diminish the role of human rights in comparison

to the first two. It is indeed because we care about

the idea of human rights greatly that we are publicly

presenting our reasoning. Sofia Gruskin, Editor of

this journal for over a decade, expressed a similar

concern when she wrote that “[g]reater clarity about

the central paradigms of health and human rights is

essential to make our work more effective, as well as

to enable us to make counter-arguments that will be

persuasive not only to the skeptics but to the public

health community at large.”20

This idea that international human rights law taken as

a whole offers both rights to health care and rights to

the social and material conditions for good health was

argued by Jonathan Mann and colleagues in the very

first issue of this journal in 1994.21 Central to their

“health and human rights framework” hypothesis

was the notion that “the promotion and protection

of human rights and promotion and protection of

health are fundamentally linked.”22 It was evidently

clear in the early 1990s, in light of the way HIV/AIDS

was being dealt with in most countries, that public

health programs can negatively affect human rights

and that human rights violations can have negative

health effects. Mann and colleagues transformed the

conflict between a public health policy perspective

and a human rights perspective into a hypothesis that

a society that realizes the full breadth of human rights

would produce healthier individuals and populations.

Health programs, they argued, whether public health

or clinical, that were in line with human rights would

lead to better health outcomes, and the respect for all

human rights would create conditions for individuals

to be healthier. In fact it should be noted that the

Commission has expressed a similar view in the Final

Report that correctly designing the social processes in

society to meet the needs or expand freedoms of its

members will improve health and health equity. The

Commission was able, rather than presenting it as a

hypothesis, to make this argument as a conclusion

drawn from empirical research.

One remarkable aspect of Mann’s 1994 hypothesis is

that it leads to conceptualizing human rights law as

one component of a model of causation and distribution

of health. This is illustrated in the discussion

about possible ways to test the hypothesis, where

venkatapuram, bell, and marmot

12 • health and human rights volume 12, no. 2

Mann and his colleagues wrote, “For example, health

professionals could consider using the International

Bill of Human Rights as a coherent guide for assessing

health status of individuals or populations; the extent

to which human rights are realized may represent a

better and more comprehensive index of well-being

than traditional health status indicators.”23 While it

was a groundbreaking contribution to overlay human

rights law onto an analysis of the causes, distribution,

and social responses to health issues, the consequent

substitution of human rights law for the actual causes

of ill health in a model of causation and distribution

of health is problematic. As evident in our sutures

example, for instance, the distinction between the

lack of sutures and the lack of the right to sutures

in explaining maternal mortality is profound in many

respects and should not be minimized.

The observation that the lack of sutures plays a

role in the causes of maternal mortality necessarily

precedes reasoning that there should be a right to

sutures. This epistemological priority or precedence

of recognizing the causal role of the lack of sutures

to the assertion that there should be a right to sutures

is the source of consequent divergence between a

social epidemiology/social medicine and a human

rights approach to advancing health and health equity.

Some human rights advocates would likely want

to assert that it is the violation of the right to sutures

that causes maternal mortality. When it is asserted

that the lack of a right to something is the cause of

ill health and mortality, the distinction between the

causal role and importance of that something and

the right to that something collapses. Moreover, the

collapsing of the two ideas creates confusion as to

what is a human right. Human rights are not natural

facts or objects, but ethical assertions about claims,

privileges, liberties, immunities, and powers in relation

to various human capabilities, including those

capabilities expressed indirectly via material things.24

Unnecessary and avoidable misunderstandings result

from attempting to emphasize the importance of

human rights by casting them as direct causal components

of a model of causation and distribution

of ill health and mortality. Moreover, such attempts

undermine the important scientific analysis of causal

pathways and distribution of ill health and open the

analysis to the risk of being dismissed as conceptually

incoherent. Last, such an analysis potentially

alienates social and natural science researchers who

can be valuable allies in the effort to advance health

equity. The health and human rights framework can

be very powerful indeed, if it supplements rather

than attempts to substitute the analysis of the natural

and social causes, distribution, and consequences of

ill health and mortality. We suggest further below one

possible way that epidemiology and human rights

might be integrated.

But what about the case in which someone is advocating

a right to sutures after recognizing the lack

of sutures as a direct cause of maternal mortality?

For the practitioner of social medicine, the primary

aim is not to enforce economic and social rights, or

any other rights, for their own sake. Rather, the preeminent

goal is to address avoidable ill health and

mortality, the curtailment of well-being. Therefore,

enforcement of economic and social rights is instrumental

in order to address the needs for health care

and other social conditions and material goods. The

problem arises when the law is silent about some

pressing concern, or when the law is insufficient, or,

indeed, incoherent. Aside from being entangled in

legal rubric, stretching the law to cover the causes,

cures, and other necessary social interventions for

some particular health deprivation may begin to look

like “the tail is wagging the dog.” When there is no

right to sutures, and yet the lack of sutures leads to

the deaths of hundreds of thousands of women each

year, it is understandable to seek a right to sutures

somewhere in the law. Yet neither the existing economic

and social rights nor any language in the current

human rights corpus may be capable of doing

all the work we want them to do. At the same time,

it would be unacceptable to conclude that the causes

that are killing people are not human rights concerns

simply because they are not explicitly identified in the

existing law, and also unacceptable to opportunistically

stretch the meaning of rights so much that the

term “human rights” risks becoming an empty concept.

Indeed, it is very helpful if some human rights

exist in the law that have direct bearing on a health

issue at hand, but human rights law should be recognized

as being only one of many instruments of

advancing health and health equity.

The second problem with following Path 1 —

increased enforcement of economic and social rights

— is one of insufficient motivating capacity. The large

number of human rights advocacy organizations in

the world testifies to the fact that the mere existence

of human rights law does not mean that human

rights are universally or even locally realized. Even

at the domestic level, laws identifying certain rights

do not mean that individuals, especially those that

are socially marginalized, have their rights respected

or fulfilled. To exhort that the full spectrum of legal

rights must be respected because it says so in the law

volume 12, no. 2 health and human rights • 13

health and human rights in practice

requires a respect for law, the means to enforce it,

and mechanisms to hold individuals or institutions

accountable for violations. While motivating respect

for rights is difficult and requires constant vigilance

and resources, it is nearly impossible to enforce a

right to something that may not clearly exist in the

law, especially in places where there is no respect for

the law or a lack of institutions to enforce rights. It

should not go unnoticed, however, that individuals

and communities throughout the world recognize

and respect various rights even when such rights are

not specifically stated in the law. And if they are in

the law, respecting such rights may not be primarily

motivated by the fact they are enshrined in the law.

Before the relatively recent establishment of international

human rights law, advocates for the respect

of human rights and for social change drew on arguments

for why such things are good and “the right

thing to do.” Public statements to provide such reasoning

were often accompanied by large-scale social

mobilization; indeed, this ethico-moral approach was

often much more comprehensive than the method

currently employed by rights activists, of pointing to

what is explicitly stated in the law and playing language

games. Realizing rights, whether economic and

social or civil and political, by means of assertions

that they must be respected simply because it says so

in international law, is neither necessary nor sufficient

for advancing health and health equity — unless and

until international law has the power to command full

adherence and there are institutional capacities and

resources in all countries to (progressively) realize all

human rights.

In an attempt partially to overcome many of the

structural and conceptual problems in engaging with

human rights law, Lynn Freedman has proposed an

alternative approach to expand the reach and relevance

of human rights “on the ground.”25 Her strategy

is innovative in that it seeks to supplement the

dominant approach to human rights work that takes

place within international institutions as academic

and legal discussions, and instead focuses on holding

governments accountable for upholding human

rights. We suggest Freedman’s approach as our Path

2. Freedman advocates a strategy that extracts various

values and principles from existing human rights

law and applies them to local contexts — the onthe-

ground analysis of the causal chain of ill health

and mortality. While Freedman focuses on addressing

maternal mortality, and her approach fits nicely

with our example of the right to sutures, this strategy

could be applied to addressing any health issue.

Motivated by the understanding that human dignity

is the core value of human rights law and is meant

to inspire profound and fundamental change in

everyday interactions, Freedman proposes communities

identify a set of values and principles in human

rights law and then articulate how they can help guide

community-level programs to address maternal mortality.

Using the case of the right to sutures, following

Freedman’s path would mean that we do not look for

a right to sutures in the law but that the values and

principles of human rights law can help communities

identify, analyze, and address maternal mortality. In

fact, Freedman interprets the legal discourse on the

human right to health as encompassing the right not

to die an avoidable death in pregnancy and childbirth.

This right then translates into a societal obligation to

provide emergency obstetric care, which would entail

the provision of sutures when needed. But even

when dealing with nongovernmental actors and a

concern not just about sutures but maternal mortality

more broadly, Freedman argues that the two values

of human dignity and non-discrimination (among

others), which are central to human rights law, can

and should guide the manner in which emergency

obstetric care is provided to patients and families as

well as how it impacts hospital staff. This strategy

may be seen as expanding human rights work, perhaps

even liberating human rights from the existing

legal language and mechanisms of international law.

Importantly, rather than making rights into causal

components of health and well-being, Freedman suggests

that human rights values and principles, when

combined with other health-related disciplines such

as epidemiology, medicine, and operations research,

can provide a plan of action for communities and

states — in other words, human rights discourse can

become a community health planning tool.

Although it is an important and worthwhile strategy

to apply human rights law to the reality of how individuals

are living their daily lives, this path also suffers

from insufficient power as a tool for motivation.

It is unclear as to why the values and principles that

Freedman uses to guide maternal mortality programs

should be convincing to others simply on the basis

of their presence in human rights legislation. Indeed,

is it not ethical reasoning that first produced the

values that then became enshrined as various rights

in human rights law? That is, why would individuals

and communities change their views and behaviors

from the status quo to be in line with these values

because these values are derived from human rights

venkatapuram, bell, and marmot

14 • health and human rights volume 12, no. 2

law? Granted, there is an international consensus

embodied in such laws, but how convincing is it that

individuals need to work and interact or programs

are designed and operated in accordance with certain

values and principles because they were derived from

human rights law? Perhaps more persuasive would be

an ethical or moral argument. Why not present these

values and principles as being important in the analysis

of health issues and require allegiance because it is

the right thing to do, or is what is demanded by social

justice? Dignity, non-discrimination, equality, and

participation are all values than can be highlighted

within the ethical reasoning concerning what to do

about maternal mortality in communities throughout

the world. Synthesizing scientific and empirical

insights from fields such as epidemiology, medicine,

operations research, and public health with ethical

reasoning about social justice by communities should

be just as motivating — if not more so — for taking

action than arguing that certain value-motivated

actions are required simply because the values can be

found in human rights law.

Path 2, as argued by Freedman, is indeed the middle

ground between Path 1 and Path 3 (the path taken

by the Commission). The first path, in its best form,

seeks to link the causal and distributional analysis of

health issues with international human rights law. The

second path seeks to craft and guide a social response

by integrating various values with necessary and helpful

insights from different fields while remaining

grounded in human rights law. The third path can be

seen as being a step farther away from either of the

first two, as it seeks to derive values from ethical reasoning

that takes place at community-level, national,

regional, and global spheres. The initial conclusion

of that ethical reasoning, which took place within

the Commission and is now ongoing and open to all,

was to classify ill health and health inequalities that

are avoidable through reasonable means as inequities.

Furthermore, the Commission determined that such

manifest inequities must be addressed as a matter

of social justice. In addition to this ethical argument

— that if one can reasonably prevent ill health and

death, one should do so — is the argument that one

must act to address social determinants of ill health

and health inequalities on the basis of the duties to

protect, promote, and fulfill relevant human rights.

There is broad convergence between research and

action on rights-based approaches and social determinants

of health when existing international agreements

about human rights encompass actions to

address the relevant social determinants. Indeed,

perhaps it can be argued that enunciated rights and

values implicit in human rights law cover the entire

gamut of the social determinants of ill health and

mortality. However, social epidemiology has more

explanatory potential than human rights approaches

because the objects of research are not themselves

ethical assertions, nor is the scope of social epidemiology

limited by what is written in the law. Yet human

rights law has the power to bridge social epidemiology

with social action. The power of human rights

lies in its prescriptive power to guide prospective

social action through identifying legal obligations as

well as underlying moral obligations of societies to

act in particular ways. However, local and global discussions

that link social epidemiological analysis with

ethical reasoning about social justice would involve

more actors and allow for a broader scope of social

action, more expansive rights and responsibilities,

and easier social acceptance. It is necessary to find a

way to integrate these two approaches.

Perhaps one method that avoids the conflation of

causal factors and human rights is to incorporate

rights as distal factors in the chain of causation. A

social environment that does not protect, promote,

or fulfill the rights to food, clothing, shelter, or civil

and political liberties can be understood to have a

role in the chain of causation and distribution of ill

health without being a direct causal factor. It would

also make understandable the assertion that if individuals

have a right to health, then they should also

have a right to the determinants of health. In this

way, integrating epidemiology and human rights —

or constitutional rights for that matter — would illuminate

the role of the lack of rights in the causal

chain of ill health and mortality, while also avoiding

having to show that every violation of a human

right is bad for health. Such an integrated framework

could move forward the agenda to improve health

and health equity by harnessing the power of both

human rights and epidemiology.

joint projects for the future

Given that social epidemiology, social medicine, and

human rights-based approaches are all important

and productive methodologies to advance health and

health equity, it behooves all involved to attempt to

build greater inter-theoretic coherence and collaboration.

There is undoubtedly much to be gained intellectually

and practically from interdisciplinary efforts.

volume 12, no. 2 health and human rights • 15

health and human rights in practice

We suggest four possible areas for action with an

open invitation for further proposals.

First, there is the obvious need to undertake a more

thorough mapping of the Commission’s existing

analysis using human rights law. This is not to explain

ill health and inequalities in terms of human rights

violations, but rather to identify what is required in

the form of social action as a matter of law. It may

also be worthwhile to investigate how to motivate

social action at the community level to address the

social determinants of ill health and health inequalities

through enriching local deliberations with human

rights principles. Second, much could be gained from

bringing together social epidemiology and human

rights analyses to develop policy indicators for the

implementation of the Commission’s recommendations

as well as progressive realization of the right

to health. Third, the Commission has (hopefully)

achieved one of its main goals, to bring equity to the

center of discussions on health. Human rights advocates

could help considerably by providing support

in the form of human rights-based arguments for

addressing social gradients in health. Last, not least

important, a rights-based approach to health causes,

distribution, and consequences must be created,

one that is informed by, and builds inter-theoretic

coherence with, social epidemiology as well as other

relevant fields, not least of which are public health,

economics, and operations research.

acknowledgments

The authors would like to thank the editors and

reviewers for their valuable assistance. Research for

the article was made supported by the Joint ESRC–

DFID Scheme for research on international poverty

reduction (RES–167–25–0369) and the Department

of Health in England.

references

1. Information about the Commission is available

at http://www.who.int/social_determinants/thecommission/

en/index.html. For the complete final

report, see Commission on Social Determinants

of Health, Closing the gap in a generation: Health equity

through action on the social determinants of health. Final

Report of the Commission on Social Determinants of

Health (Geneva: World Health Organization, 2008).

Available at http://whqlibdoc.who.int/publications/

2008/9789241563703_eng.pdf.

2. Ibid.

3. The three principles of action are listed in

Commission on Social Determinants of Health (see

note 1), p. 2.

4. World Health Organization, “WHA 62.14:

Reducing health inequities through action on the

social determinants of health,” in World Health

Organization, Sixty-second World Health Assembly,

Geneva, 18–22 May 2008, resolutions and decisions,

annexes (Geneva: World Health Organization, 2009),

pp. 21–24. Available at http://apps.who.int/gb/

ebwha/pdf_files/WHA62-REC1/WHA62_REC1-

en.pdf.

5. World Health Organization, World Health

Statistics 2009 (Geneva: World Health Organization,

2009).

6. P. Farmer, “Challenging orthodoxies: The

road ahead for health and human rights,” Health

and Human Rights: An International Journal 10/1

(2008), pp. 5–19; the discussion on sutures, sterile

drapes, and anesthesia is at p. 9. Available at http://

www.hhrjournal.org/index.php/hhr/article/

view/33/102.

7. Commission on Social Determinants of Health

(see note 1), p. 3.

8. M. Murphy, M. Bobak, A. Nicholson, et al.,

“The widening gap in mortality by educational level

in the Russian Federation, 1980–2001,” American

Journal of Public Health 96/7 (2006), pp. 1293–1299.

9. M. Tobias, T. Blakely, D. Matheson, et al.,

“Changing trends in indigenous inequalities in

mortality: Lessons from New Zealand,” International

Journal of Epidemiology 38/6 (2009), pp. 1711–1722.

10. R. Fang, A. Kmetic, J. Millar, and L. Drasic,

“Disparities in chronic disease among Canada’s lowincome

populations,” Preventing Chronic Disease 6/4

(2009), pp. 1–9. Available at http://www.cdc.gov/

pcd/issues/2009/oct/08_0254.htm.

11. O. Lundberg, M. Å. Yngwe, M. K. Stjärne, et

al., The Nordic experience: Welfare states and public health

(NEWS), Health Equity Studies 12 (Stockholm:

Centre for Health Equity Studies [CHESS],

Stockholm University/Karolinska Institutet, 2008).

Available at http://www.chess.su.se/content/1/

c6/02/90/15/NEWS_Rapport_080819.pdf.

12. On this point, see discussion in Commission

on Social Determinants of Health (see note 1), pp.

venkatapuram, bell, and marmot

16 • health and human rights volume 12, no. 2

32–33.

13. M. Marmot, “Health in an unequal world,”

Lancet 368/9552 (2006), pp 2081–2094.

14. Commission on Social Determinants of Health,

(see note 1), p. 63.

15. A. Sen, Development as freedom (New York: Knopf,

1999); M. Marmot, Status syndrome: How your social

standing directly affects your health and life expectancy

(London: Bloomsbury, 2004).

16. P. Hunt, “Missed opportunities: Human rights

and the Commission on Social Determinants of

Health,” Global Health Promotion 1757-9759 (2009),

Supp 1, pp. 36–41, doi: 10.1177/1757975909103747.

Available at http://physiciansforhumanrights.org/

students/right-to-health-ghac/missed-opportunities.

pdf.

17. Farmer (see note 6), p. 9.

18. Ibid.

19. Personal communication.

20. S. Gruskin, “Rights-based approaches to health:

Something for everyone” [Editorial], Health and

Human Rights: An International Journal 9/2 (2006), p.

6. Available at http://www.hhrjournal.org/archivespdf/

4065399.pdf.bannered.pdf.

21. J. Mann, L. Goskin, S. Gruskin, et al., “Health

and human rights,” Health and Human Rights: An

International Journal 1/1 (1994), pp. 6–23. Available at

http://www.hhrjournal.org/archives-pdf/4065260.

pdf.bannered.pdf.

22. Ibid., p. 21.

23. Ibid.

24. A. Sen, The idea of justice (London: Allen Lane,

2009); J. J. Thomson, The realm of rights (Cambridge,

MA: Harvard University Press, 1990).

25. L. P. Freedman, “Using human rights in maternal

mortality programs: From analysis to strategy,”

International Journal of Gynecology and Obstetrics 75

(2001), pp. 51–60.

--