Public Health and Human Rights:

Challenges, Synergies,
Methodologies
June 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 practice

Luke 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:
Respect
Protect
Fulfill

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 indicators
June 22nd, 2008

Luke C. Mullany, PhD MHS

Center for Public Health and Human Rights
Johns Hopkins Bloomberg School of Public Health

Burma

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

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

Age Group

Males

Females

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

Male to Female Ratio 15-25yrs: 0.86

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.
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 nonspecific, 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

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%

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.

Families forced to move have higher odds of

poor health outcomes:

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)

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.

Families reporting theft/destruction of their

food supply have higher odds of poor health
outcomes:

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)

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.

Exposure to multiple rights violations:

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)
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

HRVs and Health Indicators

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

anemia:
unmet need:
No ANC:
<2 core ANC ints

Odds Ratio
2.90 (1.90, 4.44)
1.68 (1.15, 2.46)
3.34 (0.97, 11.5)
7.63 (1.85, 31.5)

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 conceptprescreening 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 Nationals
Burmese Migrants

P<0.05

Men

Women

Men

Women

Barriers to information, health care: Language, Legal, Physical, Economic, & Political
PHR/JHU: Thailands failure to provide access to services violates Thai law AND
undermines national HIV and STD programs

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

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