EDITORIAL Proven Concepts in New Contexts: Applying Public Health, Mental Health, and Human Rights Strategies to Atrocity Prevention
Volume 23/1, June 2021, pp. 5-9
Jocelyn Getgen Kestenbaum, Arlan Fuller, Caitlin Mahoney, and Amy Meade
For the past two years, the editors of this special section (Public and Mental Health, Human Rights, and Atrocity Prevention) have worked in close collaboration to consider the various ways in which human rights and rights-based approaches can promote public health and mental health policies and practices in the prevention of mass atrocity crimes. In June 2019, we convened academics and practitioners engaged in work at the intersections of these disciplines across various contexts and at various intervention points along the continuum of harms that can be defined as atrocity crimes. Represented among these scholars and practitioners were psychologists, sociologists, social psychologists, epidemiologists, public health practitioners, political scientists, legal scholars, human rights practitioners, anthropologists, historians, peace studies scholars, and philosophers. All participants recognized that multi-disciplinary tools and frames were critical to their work in their respective disciplines to identify effective strategies to disrupt causal pathways of identity-based violence, human rights abuses, and mass atrocity crimes.
One result of this work is this special section, where the authors of the collected papers dive deeply into the public health and mental health rights dilemmas that emerge from prevention efforts related to identity-based violence and mass atrocity crimes—including war crimes, crimes against humanity, and genocide.[1] The authors examine the ways in which we can adapt rights and health frameworks, methods, research, tools, and practice toward a more sophisticated and truly interdisciplinary understanding and application of atrocity prevention. In their totality, the papers demonstrate the state of these current fields and the intersecting themes within human rights, public health, mental health, and mass atrocity prevention and, importantly, future potential directions for next collaborative steps.
The protection and fulfillment of mental health rights is critically important within the larger principle of the right to health, yet it receives disparate attention within the biomedical model. As the editorial for HHRJ’s special section on mental health and human rights in 2020 stated, “there is no health without mental health, but there is no mental health without human rights.”[2] Discrimination, disempowerment, and social exclusion are driving factors in the deprivation of health rights and mass atrocity harms. Moreover, individuals with intellectual, cognitive, and psychosocial disabilities face additional exclusion and neglect within the biomedical approach to delivering health care services.
Similarly, as the human rights discourse encourages a shift in emphasis away from the biomedical approach of “treating” or “hospitalizing” the individual, a greater focus needs to be made on preventive approaches that promote the social determinants of mental health.[3] Both the onset and extent of many mental health disorders are influenced by the psychosocial environment, and the risk for developing certain disorders is directly associated with social inequalities.[4] Through understanding and addressing the interdependence and interrelatedness of rights, policy makers and health practitioners can take action to improve daily life across the life course. Relatedly, addressing the social, economic, and physical environments that can improve mental health and well-being can assist in the prevention of mass atrocity and the reconciliation of disputing parties. Given that all three fields paradigmatically emphasize and understand the dynamics of preventing harms, ample room exists to adapt these frameworks for prevention (for example, practitioners, tools, programs, and institutions) to the emerging and still largely nascent atrocity prevention field.
Global discussions on mental health and health governance will be vital to address the necessary policy framing and delivery of services to meet the crisis of mental health, as identified by Tedros Adhanom Ghebreyesus, director-general of the World Health Organization.[5] Decades of neglect and underinvestment in addressing public health, and specifically mental health, has left significant vulnerabilities to trauma and adversity, which can perpetuate cycles of atrocity. The global COVID-19 pandemic has exposed these vulnerabilities and exacerbated the shortage of adequate mental health treatment that existed long before the pandemic. As inequities in the distribution of vaccines are laid bare, so will the access to adequate mental health services for those left behind in the wake of an uneven, inadequate global pandemic response.
Fulfilling the rights to health and mental health also is compounded by atrocity and violent conflict. In the midst of identity-based violence and mass atrocity, the need for public and mental health care becomes greater, and the ability to implement services is even more complex. Yet efforts to create, disseminate, and implement public and mental health care are further compromised in these conditions. Resources are usually scarce, infrastructure is often decimated, and vulnerable target groups face discrimination and marginalization in accessing care. In complex conflict and atrocity settings, individuals and communities face traumatic harms that need immediate short-term and ongoing long-term care. These conditions make the realization of the right to health—and especially the right to mental health—all the more crucial.
One important aspect that this special section considers is that, when addressing health harms at the population level—including intentional violence and trauma—public health, mental health, and human rights tools and frameworks lend themselves naturally to assist in the prevention of war crimes, crimes against humanity, and genocide. The concurrence of these fields, and the potential for innovation and next practices at their intersections, however, remains understudied and undertheorized. With a few important exceptions, the public health field has focused largely on preventing physical disease, addressing interpersonal violence, and responding to humanitarian disasters or crises once they occur or in their immediate aftermath. Similarly, the field of mental health, which has focused largely on the promotion, protection, and restoration of the cognitive, behavioral, emotional, and social well-being of individuals and communities, offers important frames and tools in both the primary prevention of violence and trauma and the healing of individuals and communities in the wake of mass atrocity to promote coping and resilience, while working toward sustainable peace and the prevention of recurrence of mass violence.
Mass atrocity prevention may be viewed at different points along a cyclical, dynamic continuum: prevention in pre-conflict and pre-atrocity settings, including by addressing legacies of trauma; prevention in conflict and atrocity settings; and prevention postconflict, post-atrocity contexts addressing the aftermath of atrocity crimes to prevent backsliding into atrocity and to promote healing and long-term peace. Ideally, identifying human rights violations as risk factors and accelerants allows for primary prevention of large-scale violence when opportunities for prevention are higher in number and lower in cost and risk, but efforts to address rights violations mid- and postconflict also may be leveraged to prevent further harm to individuals and targeted populations. The risk factors that set societies on a path toward, and impede recovery from, atrocity crimes include issues related to governance, conflict and atrocity histories, economic conditions, and social fragmentation—factors that straddle layers of social and contextual analysis and are often drawn along identity lines. Thus, by necessity, the field of mass atrocity prevention is interdisciplinary, requiring civil society and government cooperation at local, national, and international levels for immediate and long-term success.
In pre-conflict, pre-atrocity settings, the authors of the articles that follow identify how longstanding deprivations of rights and unaddressed legacies of trauma can lead to community strife and the potential for future identity-based violence, as well as serve as sources of agency with violent armed groups that can address needs for survival. In conflict and atrocity contexts, the authors illustrate ways in which assessments of legal obligations of various actors can create opportunities for access to public health and mental health services by protecting individuals as well as health care systems themselves. In postconflict, post-atrocity settings, the authors demonstrate how the recognition of human rights protections can provide safety, security, and dignity to all members of a community and create opportunities for trust, reconciliation, and long-term, lasting peace in the wake of conflict and atrocity crimes.
Pre-conflict, pre-atrocity settings, including addressing legacies of trauma
In “Disrupting Legacies of Trauma: Interdisciplinary Interventions for Health and Human Rights,” Joan Simalchik applies Ignacio Martín Baró’s theory of psychosocial trauma to elucidate the public and mental health challenges of long-term post-atrocity, transitional states. In particular, the paper explores how organized violence, institutional lies, and social polarization create and maintain “circles of silence” that perpetuate health harms. The author concludes with a call for interdisciplinary and community-led efforts to construct “circles of support” that address the social context and the injury to social relations, and may allow individuals and communities to heal.
In “Safeguarding the Lives of Children Affected by Boko Haram: Application of the SAFE Model of Child Protection to a Rights-Based Situation Analysis,” Rosie O’Connor, Theresa S. Betancourt, and Ngozi V. Enelamah explore child protection as a human right within a human security framework. In particular, they probe the security of Nigerian children within the context of and in relation to four core domains: safety and freedom from harm; access to basic physiological needs and health care (including mental health); family and connection to others; and education and economic security. Their theoretical analysis frames the risk and resilience factors contributing to youth involvement in the Nigerian conflict, identifies the gendered dynamics of those factors, and highlights areas for state and humanitarian actors to appeal to these youth and their needs while reducing subsequent vulnerabilities.
Conflict and atrocity settings
In “The Right to Mental Health in Yemen: A Distressed and Ignored Foundation for Peace,” Waleed Alhariri, Amanda McNally, and Sarah Knuckey explain the lack of adequate mental health care in Yemen and analyze how this is contributing to the recurrence of violence in the country. Their article advocates for the creation of a system of mental health care that is efficacious, sustainable, and accessible because, they argue, future peace in Yemen depends on the provision of such mental health services.
In “Monitoring Attacks on Health Care as a Basis to Facilitate Accountability for Human Rights Violations,” Benjamin Mason Meier, Hannah Rice, and Shashika Bandara examine attacks on health care systems in times of conflict as violations of international human rights and humanitarian law, as well as threats to public health. Examining systematic monitoring mechanisms developed by the World Health Organization to prevent, protect, and provide accountability for health worker harms, the article recommends refining the monitoring mechanism to strengthen accountability and public health protection through global health governance.
In the Viewpoint “Addressing the Boko Haram-Induced Mental Health Burden in Nigeria,” Adewale Olusola Adeboye describes the burdens that the Nigerian conflict has placed on public and mental health facilities and providers, individuals, and communities, as well as the deliberate efforts that have been taken to address victims’ needs in the absence of a coordinated government response. The viewpoint concludes with a call to expedite the passage of a robust national public mental health policy toward the full realization of mental health rights.
Postconflict, post-atrocity settings
In “Quantifying the Ripple Effects of Civil War: How Armed Conflict is Associated with More Severe Violence in the Home,” Jocelyn Kelly, Elizabeth Colantuoni, Courtland Robinson, and Michele R. Decker demonstrate the linkages between armed conflict and gender-based violence using quantitative methods to make visible the hidden architectures of violence and atrocity crimes continuing long past mass violence and conflict. The purpose of their research is to recognize these fundamental human rights violations in order to prevent future harms, and especially to disrupt the pathways between political and interpersonal violence in postconflict and post-atrocity contexts.
In “Teaching Truth in Transitional Justice: A Collaborative Approach to Supporting Colombian Educators,” Gabriel Velez focuses on the value of critical and thoughtful teaching to promote acknowledgment and accountability after human rights abuses, in an effort to foster the psychosocial healing of subsequent generations. The author details a research collaboration with Colombia’s truth commission to aid its pedagogical efforts to develop effective resources and support Colombian educators’ instruction about the truth of past atrocities.
Finally, in “Societal Healing in Rwanda: Toward a Multisystemic Framework for Mental Health, Social Cohesion, and Sustainable Livelihoods among Survivors and Perpetrators of the Genocide against the Tutsi,” Alexandros Lordos, Myria Ioannou, Eugène Rutembesa, Stefani Christoforou, Eleni Anastasiou, and Thröstur Björgvinsson discuss the strengths and limitations of the current mental health system and other initiatives—including sociotherapy, transdiagnostic mental health care, and collaborative livelihood projects—in a post-atrocity society recovering from human rights abuses, where mental health outcomes have been, and continue to be, significantly impacted by these acts of genocide. Building on existing innovations, and in partnership with affected communities, they propose a scalable approach for recovery and resilience that would target mental health, social cohesion, and sustainable livelihoods within an integrated multilevel framework to reduce the risk of post-genocidal conflict, future human rights abuses, and atrocity crimes. The paper offers a multisystemic focus on health, human rights, and healing, with a focus on the social determinants of mental health, as a response to adversities that cut across layers of social analysis and place the onus for healing on societal-level factors to aid individual and community coping.
It is our hope that this collection will make significant and lasting contributions to the emerging field of atrocity prevention in both scholarship and practice while bringing additional perspectives to public health, mental health, and human rights scholarship and practice. We recognize the value in the multidisciplinary nature of this project and see it as an opportunity for more cross-pollination among the fields of public and mental health, human rights, and atrocity prevention. The existing literature has not explored the intersections of public health and mental health frameworks and assessment tools in atrocity prevention in any comprehensive way, including in the contexts of early warning and response and of rights-based frameworks. Such discussions will serve to influence and innovate research, policy, and practices in these fields toward developing, adapting, and testing frames and tools for human rights and atrocity prevention. This critical work must be supported, and networks strengthened, toward our ultimate shared goals of preventing identity-based violence and promoting human rights, dignity, and equality for all.
Jocelyn Getgen Kestenbaum is an Associate Professor of Clinical Law at the Benjamin N. Cardozo School of Law and Director of the Benjamin B. Ferencz Human Rights and Atrocity Prevention Clinic and the Cardozo Law Institute in Holocaust and Human Rights, New York, USA.
Arlan F. Fuller is the Chief Operating Officer of Conflict Dynamics International and former Executive Director of the FXB Center for Health and Human Rights at the Harvard T.H. Chan School of Public Health, Boston, USA.
Caitlin O. Mahoney is an Associate Professor of Psychology at Metropolitan State University, St. Paul, USA.
Amy E. Meade is a Lecturer in the Department of Psychiatry at Harvard Medical School, Boston, USA, and an Assistant Psychologist at McLean Hospital, Belmont, USA.
References
[1] An additional product of this deliberative process is our development of an edited volume, Public Health, Mental Health, and Mass Atrocity Prevention, which focuses on understanding and examining the inextricable linkages among public health, mental health, and mass atrocity prevention theory and practice while encouraging collaboration and innovation within and across the multiple disciplines working in these fields. Specifically, the multidisciplinary volume (1) connects concepts of public health, mental health, and mass atrocity prevention by framing and reframing strategies, as well as synthesizing the concepts at the macro level that intersect the fields of public health, mental health, mass violence, and mass atrocity prevention; and (2) addresses various models and interventions, as well as documentation and data collection, to prevent identity-based harms and improve responses to health care workers and others, including police officers, who are on the frontlines of atrocity prevention practice.
[2] A. Chapman, C. Williams, J. Hannah, and D. Pūras, “Reimagining the mental health paradigm for our collective well-being,” Health and Human Rights Journal 22/1 (2020) pp. 1–6.
[3] Human Rights Council, Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health: Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health, UN Doc. A/HRC/41/34 (2019).
[4] Ibid.
[5] World Health Organization, Substantial investment needed to avert mental health crisis (May 14, 2020). Available at https://www.who.int/news/item/14-05-2020-substantial-investment-needed-to-avert-mental-health-crisis.