Public Health and Human Rights: Challenges, Synergies,

MethodologiesJune 22nd, 2008

Chris Beyrer MD, MPH

Center for Public Health and Human Rights

Johns Hopkins Bloomberg School of Public Health

Core Themes• Human rights abrogation or protection can have

profound impacts on the health of individuals, communities, and populations

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

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

Outline

I. Introduction

II. Health rights and human rights

III. Putting PHHR into practiceLuke Mullany, PhD

Introduction

• Modern human rights movement a response to Nazi atrocities of WWII

• Universal Declaration of Human Rights passed by United Nations on December 10, 1948– Defines the fundamental human rights of

persons and violations of those rights– Universalist– Aspirational– Lacking enforcement mechanisms

UDHR

Resolutions include:

• Article 4: Prohibits slavery• Article 5: Prohibits torture• Article 18: Freedom of thought• Article 19: Freedom of opinion and of

expression• Article 25: Standard of Living

– Includes access to medical care as a human right

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

1976 International Covenant on Civil and Political Rights

1976 International Covenant on Economic, Social and Cultural Rights

General Comment 14: Health rights Prevention, treatment, control of epidemic

diseases Focus on realizing rights of women to health throughout the

life span

1981 Convention on the Elimination of All Forms of Discrimination against Women (CEDAW)

Health services to be consistent with the human rights of women:

Autonomy, Privacy, Confidentiality, Informed consent, and Choice

State Responsibilities

Signatory States must not violate these rights

Commit to measurable progress to:RespectProtectFulfill

What is meant by “The Right to Health”

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

UN High Commissioner for Human Rights, Mary Robinson

The Center for Public Health and Human Rights at Hopkins

• Focus is the impact of rights of violations on the health of populations

• Research, Teaching, Advocacy

• Use of population based methods (epidemiology) to study, document, measure these impacts

• Bring increased awareness of human rights and health interactions to the scientific community

• Enhance public health through rights based interventions

• Advocate for public health and human rights

PHHR Center Activities

• Burma: Cross border health and rights projects with ethnic minority health groups (IDPs, migrants); HIV/AIDS epi; Mobile Obstetric Medics (Gates Inst.); Capacity building for human rights and democracy (DOS)

• Southern Africa: MSM, HR, and HIV (OSI)• Russia: MSM, HR, and HIV (Ford, NIH)• China: Treatment access and advocacy for

blood donors (OSI, Levi Strauss)• Kazakhstan, Kyrgyzstan: HIV prevention,

NSEPs, HIV VCT access (NIH/NIMH, NIDA)

JHU Press, 2007

Human rights violations and associations with population-level

health indicatorsJune 22nd, 2008

Luke C. Mullany, PhD MHS

Center for Public Health and Human Rights

Johns Hopkins Bloomberg School of Public Health

• Population – 50 million• Ethnically diverse• 90% Buddhist• Military junta (SPDC)• Poor health indicators

– IMR: 76/1000– U5MR: 104/1000– WFP: 33% of children

chronically malnourished– WHO: 190 / 191 ranking for

health system

Burma

Human rights violations

• Forced labor• Destruction / seizure of crops / livestock• Arbitrary arrest and detention• Forced military conscription• Torture, rape, execution• “Four cuts”

Backpack Health Worker Team

• Novel approach to data collection within internally displaced populations

– Programmatic context

– IDPs actively gathering information among themselves

• Workers also specific targets of the conflict

Data collection activities

• Health information systems developed over past 10 years with tech. asst. from CPHHR and Global Health Access Program (www.ghap.org)

• Major goal: estimation of mortality

– U5MR / IMR through surveys

– Tracking of human rights violations

• Others:

– Morbidity estimation

– Compliance with specific programs

– Knowledge / practices / attitudes

Methods - Design

• Retrospective household surveys– Reporting of vital events

– 12 month recall period

• Sampling– Two stage cluster design

– 100 clusters

– 20 households / cluster

Methods - Design

• Cluster selection:– Village based

– Selection proportionate to population size

– Census provides complete lists of population by village

• Household selection – various methods used– “spin the pen”, random-proximity method

– Interval sampling with random start

Survey elements

• Context demands simplicity– Constant movement by interviewers

– Travel on foot

– One page limit

• Household census

• All deaths recorded (cause)

• Listing by age / sex

Results – Sample

• Response rate has varied: 70-92%

• Total sample 7,500-9,000– (5-6 persons / household)

• <5 years old ~ 18-20%

• <15 years old ~ 45 – 50%

• Male to female ratios – consistently <0.9

Population pyramid - 2004

900 800 700 600 500 400 300 200 100 0 100 200 300 400 500 600 700 800 900

Age Group

95-100 90-95 85-90 80-85 75-80 70-75 65-70 60-65 55-60 50-55 45-50 40-45 35-40 30-35 25-30 20-25 15-20 10-15 5-10 0-5

Males Females

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

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

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

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

Impact of human rights violations?

• Overall, mortality rates represent a non-specific, indirect relationship only

• Evidence– Violence-related deaths, especially landmine

– Preponderance of malaria deaths

– Male / female ratio• Families of former rebels Angola (80:100)

• Afghan refugees in Pakistan (88:100)

Indirect, or ecological inference regarding impact of conflict

• Compare likelihood of 1 or more deaths of live born children

• Areas under “Four-Cuts” policy vs. “Cease-Fire” areas

– Four Cuts: 39.9%

– Cease Fire:16.6%

– PRR = 2.40 (2.02 – 2.86)

Measure HRV and health directly?

• Documentation of human rights violations comes largely from legalistic tradition

• Use classical epidemiological tools to quantify associations

• BPHWT structure and experience provided important opportunity to directly link HRV to health outcomes

Linking Morbidity and Mortality to Human Rights

• Backpack medics added short set of questions to health surveys– 6 questions– household level– past 12 months recall period

• Secondary data analysis of this existing data to quantify associations between HRV and health outcomes

Sample Questions

• In the past 12 months, how many people, from your household:

– were forced to work against their will– were shot at, stabbed, or beaten by a soldier– had a landmine or UXO injury

• In the past 12 months, how many times has your household:

– Had the food supply (including rice field, paddy, food stores, and livestock) been taken or destroyed?

– Been forcibly displaced or moved due to security risk?

Prevalence of human rights violations, 2004

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

Violation / Event% of Households

Forced Labor 32.6%

Forced Displacement 8.9%

Food Destruction / Theft 25.2%

Landmine Injuries 1.3%

Multiple rights violations 14.4%

• Infant mortality: OR=1.72 (0.52 – 5.74)

• Child mortality: OR=2.80 (1.04, 7.54)

• Landmine injury: OR=3.89 (1.01 – 15.0)

• Child malnutrition: OR=3.22 (1.74 – 5.97)

• Malaria parasitemia: OR=1.58 (0.97 – 2.57)

Families forced to move have higher odds of poor health outcomes:

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

• Child mortality: OR=1.19 (0.67 – 2.15)

• Crude mortality: OR=1.58 (1.09, 2.29)

• Landmine injury: OR=4.55 (1.23 – 16.9)

• Child malnutrition: OR=1.94 (1.20 – 3.14)

• Malaria parasitemia: OR=1.82 (1.16 – 2.89)

Families reporting theft/destruction of their food supply have higher odds of poor health outcomes:

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

• Child mortality: IRR=2.18 (1.11 – 4.29)

• Crude mortality: IRR=1.75 (1.14, 2.70)

• Landmine injury: IRR=19.8 (2.59 – 151.2)

• Malaria parasitemia: IRR=2.34 (1.27 – 4.32)

• Families reporting three or more violations:– Child mortality: IRR = 5.23 (1.93 – 14.4)

Exposure to multiple rights violations:

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

Mobile Obstetric Medics (MOM)

Providing essential maternal health services in the conflict zones in Eastern Burma

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

Cross border MCH program– Family planning, ANC and PNC care– Bringing Emergency Obstetric care to the household

level

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

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

Baseline Survey Results

• Access to attendant with ability to deliver component low: 5.1%

• Insecticide Treated Net: 21.6%

• Malaria Test: 21.9%

• Iron/Folate: 11.8%

• Any ANC visit: 39%– Content unknown, unlikely effective

Baseline Survey Results

• Unmet need is high; substantial potential for family planning impact– 25% do something to delay pregnancy– Overall 61% with unmet need for limiting/spacing

• Neonatal, infant, child mortality rates moderately high– Lower than more unstable direct conflict areas– Higher than Burma national estimates

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

• Forced relocation: Odds Ratio– anemia: 2.90 (1.90, 4.44)– unmet need: 1.68 (1.15, 2.46)– No ANC: 3.34 (0.97, 11.5)– <2 core ANC ints 7.63 (1.85, 31.5)

HRVs and Health Indicators

Mullany LC, Lee CI, Yone L, Paw P, Shwe Oo EK, Maung C, Lee TJ, Beyrer C. Access to essential maternal health interventions and human rights violations among displaced communities in eastern Burma. FORTHCOMING, 2008

Preliminary PRF data

ANC Intervention Coverage

- Malaria screening during pregnancy 68%

- Insecticide treated net 75%

- Fe/FA supplement 91%

- Deworming 83%

- Nutrition / ENC 89%

Labor and Delivery

- Attended by person with some BEOC 69%

- Misoprostol prophylactic dose given 78%

PNC Intervention

- Family planning counseling provided 90%

Cross-Border Medical Obstetric Medic in Eastern Burma, 2007

Adapt interventions to setting

• Developed a field protocol for blood screening for emergency transfusions

• Based on “living blood bank” concept-prescreening of family, community for typing

• Heat stable rapid test algorithm based on disease prevalence

• Improves safety of prior transfusion practices in this setting

How do human rights violations increase vulnerability to STI & HIV?

• Increased Exposure– Coercion, sexual violence, rape as tool of war,

population mixing

• Increased Acquisition and Transmission– Treatment delays or gaps, barriers to access,

lack of condoms/contraception

• Increased morbidity and mortality– Barriers to access and to information

Burmese Migrants and Barriers to Access in Thailand

Knowledge about Condoms Condom Usage

Thai NationalsBurmese Migrants

Source: Mullany et al, AIDS Care, 2003; Lertpiriyasuwat et al, AIDS, 2003; Leiter et al, Health & Human Rights, 2006

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

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

P<0.05

Men Women Men Women

Conclusions• Constraints inherent in IDP context demand

creative thinking and adapted solutions

• Grass-roots community organizations can take the lead even in refugee and IDP settings

• Building capacity to monitor PH programs – Ensures success of programs– Potential to understand direct and indirect

impacts of human rights violations on health

Ways Forward

• Recognize– Human rights contexts of our work

• Partner– With the grassroots, with human rights groups in

country and internationally, with those we seek to serve facing rights violations

• Act– Research, Advocate, and Fund