EDITORIALS
value to us of our visit to Cuba is what it has meant to our understanding of our own context and system, made clearer when viewed from the perspective of a different set of realities. Let us take the time to understand these perspectives from Cubans and embrace the opportunity for us to learn from one another, given the recent change in the US---Cuban relationship. Learning and viewing reality from different perspectives are critical steps to improving— for both of our systems. j Paul Campbell Erwin, MD, DrPH Ron Bialek, MPP
About the Authors Paul Campbell Erwin is with the Department of Public Health, University of Tennessee,
Searching for Justice and Health
Knoxville. Ron Bialek is with the Public Health Foundation, Washington, DC. Correspondence should be sent to Paul Campbell Erwin, MD, DrPH, Professor and Department Head, Department of Public Health, University of Tennessee, 1914 Andy Holt Avenue, Knoxville, TN 37996 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted March 20, 2015. doi:10.2105/AJPH.2015.302692
Contributors P. C. Erwin and R. Bialek both conceived the focus of the editorial, both contributed to the initial writing, and both contributed to the revisions after review by colleagues.
References 1. Medical Education Cooperation with Cuba. Available at: http://medicc.org/ns. Accessed March 3, 2015. 2. Elam-Evans LD, Yankey D, Singleton JA, Kolasa M. National, state, and selected local area vaccination coverage among
Justice—fairness in how people are dealt with—is not merely about law but also an aspirational goal, resulting in different points of emphases if the focus is on justice and health or justice in health. Two important human aspirations: justice and health, form the central theme of this editorial, their coalescence resulting in fairness in how people are treated and their ability to achieve the highest attainable standard of physical, mental, and social well-being. Justice is about law but it is also about democracy and the distribution of power, social roles, and capacity.1 The determinants of health are numerous and diverse, inclusive of the extent to which people enjoy freedom, live in dignity, and participate in choices affecting them, and the fairness they enjoy in how goods and services are accessed, distributed, afforded, and delivered. Laws, policies, judicial systems, and law enforcement
August 2015, Vol 105, No. 8 | American Journal of Public Health
children aged 19---35 months—United States, 2013. MMWR Morb Mortal Wkly Rep. 2014;63(34):741---748. 3. Greene D, Vedantam S. The psychology behind why some kids go unvaccinated. Morning Edition. National Public Radio. February 4, 2015. Available at: http://www.npr.org/ 2015/02/04/383724467/thepsychology-behind-why-some-kids-gounvaccinated. Accessed March 3, 2015. 4. Overseas Development Institute. Millennium Development Goals (MDG) Report Card: Measuring Progress Across Countries. 2010. Available at: http:// www.odi.org/publications/5027millennium-development-goals-mdgreport-card-measuring-progress-acrosscountries. Accessed March 3, 2015. 5. Save the Children. State of the World’s Mothers 2014. Available at: http://www.savethechildren.org/site/c. 8rKLIXMGIpI4E/b.9126825/k.3E86/ Download_the_2014_SOWM_Report. htm. Accessed March 3, 2015.
2013. Available at: http://www.unaids. org/sites/default/files/media_asset/ UNAIDS_Global_Report_2013_en_1. pdf. Accessed March 3, 2015. 7. Global Health Workforce Alliance and World Health Organization. A Universal Truth: No Health Without a Workforce. 2013. Available at: http:// www.who.int/workforcealliance/ knowledge/resources/hrhreport2013/ en. Accessed March 3, 2015. 8. World Health Organization. Global Health Observatory (GHO) data. 2015. Available at: http://www.who.int/gho/ en. Accessed March 3, 2015. 9. Central Intelligence Agency. The World Fact Book. 2014. Available at: https://www.cia.gov/library/ publications/the-world-factbook/ rankorder/2091rank.html. Accessed March 3, 2015.
6. UNAIDS. Global Report: UNAIDS Report on the Global AIDS Epidemic
10. National Center for Health Statistics, Centers for Disease Control and Prevention. Deaths: Final Data for 2013. Available at: http://www.cdc. gov/nchs/data/nvsr/nvsr64/ nvsr64_02.pdf. Accessed March 3, 2015.
perform a normative and regulatory function that can impact health in every way from promoting healthy lifestyles to preventing exposure to sources of ill health in the working and living environment; preventing, responding, and mitigating the impact of epidemic diseases; and creating awareness, response, and redress mechanisms. In all, the promotion and protection of justice and health ought to progress hand in hand toward a better world. But this is regrettably not the case. First, our means of measurement and comparison are inadequate. For example, in daily work, it is more challenging to define and draw a pathway toward justice and health than to diagnose and report their opposites: injustice and ill health. Defining the determinants of injustice and ill health may, nonetheless, be a more persuasive call to action than upholding universal values of ostensibly
unattainable goals. As is well known, injustice and ill-health coalesce when fear, denial of freedoms, violence, and deprivation of basic means of livelihood add their destructive toll on individuals and communities. Where injustice prevails as a cause or a consequence of inequity and inequality, its negative impacts on health can and should be described, recognized, measured, and redressed. The increasing body of work done on the social determinants of health has provided important evidence of the negative, positive, but seldom neutral impacts of structural, social, environmental, and other factors on health.2 Second, on the international level, oversight structures and mechanisms—even those established with an eye toward greater coalescence between justice and health—are weak, and on occasion are perverted by attraction toward greater profits. Oversight mechanisms targeted, for
Editorials | 1511
EDITORIALS
example, at risk-generating products such as unhealthy foods or drinks may be more tolerant toward the injustice caused by their promotion in risk-prone communities than in others. Such factors may appear to satisfy the demand from consumers as an expression of their free choice, just as sustaining productivity and employment in the agro-business may be tolerated, despite the negative implications for consumers’ health. International agreements on intellectual property and trade may be used to justify price policies that constitute effective barriers for the poorest to have access to important medication,3 or to curb health promotion initiatives such as laws regulating tobacco sales.4 The adverse consequences of economic globalization for poorer countries and the health of their populations, and the intrinsic difficulties of having global financing without global accountability, have been amply demonstrated.5 In looking for global mechanisms that uphold justice and health as universal values, one finds a constellation of agencies, formal and informal bodies with restricted oversight and narrow mandates. An international system of justice has been in existence since the end of the 19th century, originally to arbitrate disputes between countries. Over the past decades, this system has expanded to include a growing array of courts competent to treat extreme cases directly impacting populations, such as mass war crimes and organized crime. Yet, the jurisdiction of these courts is not universally recognized, may be only
1512 | Editorials
regionally relevant, and remains inadequate to respond to the majority of state failures with direct impacts on justice and health. Injustice, denial of human rights, and their negative impacts on health and survival are highly prevalent in our world. Extreme poverty, exploitation of disempowered communities, humanitarian crises, collective violence, and mass crimes—regardless of their causes, context, or motivations— are but few examples of current challenges confronting us. Thousands of migrants driven out of the African continent by civil strife and poverty are losing their life in the Mediterranean Sea. Nepalese survivors of the recent earthquake in which they lost their relatives, friends, homes, and often meager sources of livelihood, are struggling to rebuild a future with a tiny, unfair share of global resources. Protracted conflicts have pushed millions of refugees across borders in the Middle East while much of the world continues to look away, unable to foster negotiations or put to work available judicial mechanisms or interventions. Evidently, international mechanisms created to respond efficiently and promptly to any such challenges are overwhelmed by their rising spread, the complexity of their nature, and the magnitude of their short- and long-term impacts. Yet, they are also prey to political motives that may overstep the humanitarian goals for which they were initially designed. This is not a call for creating new global governance mechanism(s) to oversee the realization of the rights to health and to
justice. These do exist, and their efficiency would gain tremendously from more generous resources in support of their work. Rather, this is a call for favoring bottom-up processes rekindling people’s commitment to justice and health—no matter who they are and where they live—over the top-down approach to global health governance promoted by some. Notably, this is where growing attention in the public health discourse to the interface between health and human rights may be of use, particularly from application of their normative, internationally adopted norms, principles, tools, and accountability mechanisms. While we, as citizens of every country, have a role in advocating for more efficient global prevention and mitigation of current crises, we also have a role to play within our professional environments. We need to jointly engage more actively in bringing out the evidence of the causal relationship between a justice protective of all human rights (civil, political, economic, social, and cultural) and progress in health. We also have a duty to document and expose the international negative impacts of failures affecting both justice and health. This evidence should inform national and international health policies and political agendas and provide directions for building and reinforcing capacity to advance justice and health at all levels. By doing so, we will not just name issues of concern and blame the perpetrators but construct and reframe our professional and personal agendas toward the realization of
justice and health and other human rights. j Daniel Tarantola, MD Kenneth Camargo, MD, PhD Sofia Gruskin, JD, MIA
About the Authors Daniel Tarantola is a Professor of Health and Human Rights and an International and Global Health Consultant, Femey-Voltaire, France. Kenneth Camargo is a Senior Associate Professor, Instituto de Medicina Social/Universidade do Estado do Rio de Janeiro and Honorary Vice-President for Latin America and the Caribbean, Rio de Janeiro, Brazil. Sofia Gruskin is with the Keck School of Medicine, the Gould School of Law and the Program on Global Health and Human Rights, Institute for Global Health, University of Southern California, Los Angeles. All three co-authors are Associate Editors of the American Journal of Public Health. Correspondence should be sent to Daniel Tarantola MD, 15, Chemin de Valavran, 01210 Ferney-Voltaire, France (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted May 2, 2015. doi:10.2105/AJPH.2015.302760
Contributors All authors contributed equally to this editorial.
References 1. Farmer P. Pathologies of power: rethinking health and human rights. Am J Public Health. 1999;89(10):1486---1496. 2. WHO Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008. 3. Vawda YA, Baker BK. Achieving social justice in the human rights/intellectual property debate: realising the goal of access to medicines. Afr Human Rights Law J. 2013;13(1):1---27. 4. Mackay JM, Bettcher DW, Minhas R, Schotte K. Successes and new emerging challenges in tobacco control: addressing the vector. Tob Control. 2012;21(2):77---79. 5. Navarro V. Neoliberalism and its consequences: the world health situation since Alma Ata. Glob Soc Policy. 2008;8:152.
American Journal of Public Health | August 2015, Vol 105, No. 8
value to us of our visit to Cuba is what it has meant to our understanding of our own context and system, made clearer when viewed from the perspective of a different set of realities. Let us take the time to understand these perspectives from Cubans and embrace the opportunity for us to learn from one another, given the recent change in the US---Cuban relationship. Learning and viewing reality from different perspectives are critical steps to improving— for both of our systems. j Paul Campbell Erwin, MD, DrPH Ron Bialek, MPP
About the Authors Paul Campbell Erwin is with the Department of Public Health, University of Tennessee,
Searching for Justice and Health
Knoxville. Ron Bialek is with the Public Health Foundation, Washington, DC. Correspondence should be sent to Paul Campbell Erwin, MD, DrPH, Professor and Department Head, Department of Public Health, University of Tennessee, 1914 Andy Holt Avenue, Knoxville, TN 37996 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted March 20, 2015. doi:10.2105/AJPH.2015.302692
Contributors P. C. Erwin and R. Bialek both conceived the focus of the editorial, both contributed to the initial writing, and both contributed to the revisions after review by colleagues.
References 1. Medical Education Cooperation with Cuba. Available at: http://medicc.org/ns. Accessed March 3, 2015. 2. Elam-Evans LD, Yankey D, Singleton JA, Kolasa M. National, state, and selected local area vaccination coverage among
Justice—fairness in how people are dealt with—is not merely about law but also an aspirational goal, resulting in different points of emphases if the focus is on justice and health or justice in health. Two important human aspirations: justice and health, form the central theme of this editorial, their coalescence resulting in fairness in how people are treated and their ability to achieve the highest attainable standard of physical, mental, and social well-being. Justice is about law but it is also about democracy and the distribution of power, social roles, and capacity.1 The determinants of health are numerous and diverse, inclusive of the extent to which people enjoy freedom, live in dignity, and participate in choices affecting them, and the fairness they enjoy in how goods and services are accessed, distributed, afforded, and delivered. Laws, policies, judicial systems, and law enforcement
August 2015, Vol 105, No. 8 | American Journal of Public Health
children aged 19---35 months—United States, 2013. MMWR Morb Mortal Wkly Rep. 2014;63(34):741---748. 3. Greene D, Vedantam S. The psychology behind why some kids go unvaccinated. Morning Edition. National Public Radio. February 4, 2015. Available at: http://www.npr.org/ 2015/02/04/383724467/thepsychology-behind-why-some-kids-gounvaccinated. Accessed March 3, 2015. 4. Overseas Development Institute. Millennium Development Goals (MDG) Report Card: Measuring Progress Across Countries. 2010. Available at: http:// www.odi.org/publications/5027millennium-development-goals-mdgreport-card-measuring-progress-acrosscountries. Accessed March 3, 2015. 5. Save the Children. State of the World’s Mothers 2014. Available at: http://www.savethechildren.org/site/c. 8rKLIXMGIpI4E/b.9126825/k.3E86/ Download_the_2014_SOWM_Report. htm. Accessed March 3, 2015.
2013. Available at: http://www.unaids. org/sites/default/files/media_asset/ UNAIDS_Global_Report_2013_en_1. pdf. Accessed March 3, 2015. 7. Global Health Workforce Alliance and World Health Organization. A Universal Truth: No Health Without a Workforce. 2013. Available at: http:// www.who.int/workforcealliance/ knowledge/resources/hrhreport2013/ en. Accessed March 3, 2015. 8. World Health Organization. Global Health Observatory (GHO) data. 2015. Available at: http://www.who.int/gho/ en. Accessed March 3, 2015. 9. Central Intelligence Agency. The World Fact Book. 2014. Available at: https://www.cia.gov/library/ publications/the-world-factbook/ rankorder/2091rank.html. Accessed March 3, 2015.
6. UNAIDS. Global Report: UNAIDS Report on the Global AIDS Epidemic
10. National Center for Health Statistics, Centers for Disease Control and Prevention. Deaths: Final Data for 2013. Available at: http://www.cdc. gov/nchs/data/nvsr/nvsr64/ nvsr64_02.pdf. Accessed March 3, 2015.
perform a normative and regulatory function that can impact health in every way from promoting healthy lifestyles to preventing exposure to sources of ill health in the working and living environment; preventing, responding, and mitigating the impact of epidemic diseases; and creating awareness, response, and redress mechanisms. In all, the promotion and protection of justice and health ought to progress hand in hand toward a better world. But this is regrettably not the case. First, our means of measurement and comparison are inadequate. For example, in daily work, it is more challenging to define and draw a pathway toward justice and health than to diagnose and report their opposites: injustice and ill health. Defining the determinants of injustice and ill health may, nonetheless, be a more persuasive call to action than upholding universal values of ostensibly
unattainable goals. As is well known, injustice and ill-health coalesce when fear, denial of freedoms, violence, and deprivation of basic means of livelihood add their destructive toll on individuals and communities. Where injustice prevails as a cause or a consequence of inequity and inequality, its negative impacts on health can and should be described, recognized, measured, and redressed. The increasing body of work done on the social determinants of health has provided important evidence of the negative, positive, but seldom neutral impacts of structural, social, environmental, and other factors on health.2 Second, on the international level, oversight structures and mechanisms—even those established with an eye toward greater coalescence between justice and health—are weak, and on occasion are perverted by attraction toward greater profits. Oversight mechanisms targeted, for
Editorials | 1511
EDITORIALS
example, at risk-generating products such as unhealthy foods or drinks may be more tolerant toward the injustice caused by their promotion in risk-prone communities than in others. Such factors may appear to satisfy the demand from consumers as an expression of their free choice, just as sustaining productivity and employment in the agro-business may be tolerated, despite the negative implications for consumers’ health. International agreements on intellectual property and trade may be used to justify price policies that constitute effective barriers for the poorest to have access to important medication,3 or to curb health promotion initiatives such as laws regulating tobacco sales.4 The adverse consequences of economic globalization for poorer countries and the health of their populations, and the intrinsic difficulties of having global financing without global accountability, have been amply demonstrated.5 In looking for global mechanisms that uphold justice and health as universal values, one finds a constellation of agencies, formal and informal bodies with restricted oversight and narrow mandates. An international system of justice has been in existence since the end of the 19th century, originally to arbitrate disputes between countries. Over the past decades, this system has expanded to include a growing array of courts competent to treat extreme cases directly impacting populations, such as mass war crimes and organized crime. Yet, the jurisdiction of these courts is not universally recognized, may be only
1512 | Editorials
regionally relevant, and remains inadequate to respond to the majority of state failures with direct impacts on justice and health. Injustice, denial of human rights, and their negative impacts on health and survival are highly prevalent in our world. Extreme poverty, exploitation of disempowered communities, humanitarian crises, collective violence, and mass crimes—regardless of their causes, context, or motivations— are but few examples of current challenges confronting us. Thousands of migrants driven out of the African continent by civil strife and poverty are losing their life in the Mediterranean Sea. Nepalese survivors of the recent earthquake in which they lost their relatives, friends, homes, and often meager sources of livelihood, are struggling to rebuild a future with a tiny, unfair share of global resources. Protracted conflicts have pushed millions of refugees across borders in the Middle East while much of the world continues to look away, unable to foster negotiations or put to work available judicial mechanisms or interventions. Evidently, international mechanisms created to respond efficiently and promptly to any such challenges are overwhelmed by their rising spread, the complexity of their nature, and the magnitude of their short- and long-term impacts. Yet, they are also prey to political motives that may overstep the humanitarian goals for which they were initially designed. This is not a call for creating new global governance mechanism(s) to oversee the realization of the rights to health and to
justice. These do exist, and their efficiency would gain tremendously from more generous resources in support of their work. Rather, this is a call for favoring bottom-up processes rekindling people’s commitment to justice and health—no matter who they are and where they live—over the top-down approach to global health governance promoted by some. Notably, this is where growing attention in the public health discourse to the interface between health and human rights may be of use, particularly from application of their normative, internationally adopted norms, principles, tools, and accountability mechanisms. While we, as citizens of every country, have a role in advocating for more efficient global prevention and mitigation of current crises, we also have a role to play within our professional environments. We need to jointly engage more actively in bringing out the evidence of the causal relationship between a justice protective of all human rights (civil, political, economic, social, and cultural) and progress in health. We also have a duty to document and expose the international negative impacts of failures affecting both justice and health. This evidence should inform national and international health policies and political agendas and provide directions for building and reinforcing capacity to advance justice and health at all levels. By doing so, we will not just name issues of concern and blame the perpetrators but construct and reframe our professional and personal agendas toward the realization of
justice and health and other human rights. j Daniel Tarantola, MD Kenneth Camargo, MD, PhD Sofia Gruskin, JD, MIA
About the Authors Daniel Tarantola is a Professor of Health and Human Rights and an International and Global Health Consultant, Femey-Voltaire, France. Kenneth Camargo is a Senior Associate Professor, Instituto de Medicina Social/Universidade do Estado do Rio de Janeiro and Honorary Vice-President for Latin America and the Caribbean, Rio de Janeiro, Brazil. Sofia Gruskin is with the Keck School of Medicine, the Gould School of Law and the Program on Global Health and Human Rights, Institute for Global Health, University of Southern California, Los Angeles. All three co-authors are Associate Editors of the American Journal of Public Health. Correspondence should be sent to Daniel Tarantola MD, 15, Chemin de Valavran, 01210 Ferney-Voltaire, France (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted May 2, 2015. doi:10.2105/AJPH.2015.302760
Contributors All authors contributed equally to this editorial.
References 1. Farmer P. Pathologies of power: rethinking health and human rights. Am J Public Health. 1999;89(10):1486---1496. 2. WHO Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Geneva, Switzerland: World Health Organization; 2008. 3. Vawda YA, Baker BK. Achieving social justice in the human rights/intellectual property debate: realising the goal of access to medicines. Afr Human Rights Law J. 2013;13(1):1---27. 4. Mackay JM, Bettcher DW, Minhas R, Schotte K. Successes and new emerging challenges in tobacco control: addressing the vector. Tob Control. 2012;21(2):77---79. 5. Navarro V. Neoliberalism and its consequences: the world health situation since Alma Ata. Glob Soc Policy. 2008;8:152.
American Journal of Public Health | August 2015, Vol 105, No. 8
