Collaborative imperatives, elusive dialogues
Alicia Ely Yamin and Alec Irwin
Health and Human Rights 12/2
Published December 2010
The first five issues of Health and Human Rights: An International Journal under Paul Farmer’s editorship addressed different dimensions of rights-based approaches to health. This issue takes up the relationship among human rights-based approaches and two other prominent streams of work linking health and social justice: social medicine and social epidemiology. We are keenly aware that to exaggerate the unified nature of any of these fields obfuscates the important contestations among scholars and practitioners within each of them; far from being monolithic, social medicine, social epidemiology and human rights include a multiplicity of voices that are, in turn, shaped by diverse historical trajectories as well as cultural and political forces. Nevertheless, in imagining this issue, the two of us, coming from two of these different fields, felt that it was worth examining the convergences — and continuing divergences — among these different approaches to promoting health as a matter of social justice. And it now strikes us from the articles in this issue, as well as our experiences in the world, that despite the obvious synergies among these fields, conversations about the links between health and social justice seem to be occurring in parallel, with ensuing missed opportunities for enhancing progress.
In their commonalities and in their dissonances, in their explicit arguments and by what they leave unsaid, the articles gathered here reflect the latest state of a discussion that all recognize as crucial — yet whose progress lags behind shared aspirations. Several contributors acknowledge that these tensions have roots in the intimate and conflicted historical relationship between social medicine and social epidemiology. Social epidemiology has fought to secure scientific legitimacy as the study of how social factors influence population health. In counterpoint, social medicine traditions have often taken an activist stance, prioritizing solidarity with the oppressed and an explicit commitment to transform social and economic conditions that generate health inequities. That these two approaches can complement each other is clear in theory, but often less obvious in practice. Figures from Rudolf Virchow to Salvador Allende to Halfdan Mahler have united the strands. Again, we do not pretend that there are rigid dichotomies; engaged scholarship and reflective activism can be found across the board. Yet, historically, the relationship between social epidemiology and social medicine has remained haunted by Karl Marx’s question of whether our primary goal is to understand the world or to change it.
The connections among social epidemiology, social medicine, and human rights continue to evolve in light of this tension between the need to improve our knowledge and the imperative to act. How much knowledge is enough to guide constructive action on health inequities? Equally important, how can knowledge about the social patterning of health and illness be communicated in a compelling manner to those with the power to set policy? The recent work of the WHO-sponsored Commission on Social Determinants of Health (CSDH) constitutes a milestone in efforts to address these issues by uniting the strengths of multiple constituencies. Sir Michael Marmot, a preeminent social epidemiologist, chaired the CSDH, which also incorporated representatives of social medicine movements, such as the Asociación Latinoamericana de Medicina Social (ALAMES) and the People’s Health Movement. Many contributors to this issue reflect on what the CSDH has achieved and on the questions it leaves open. One striking feature, from our perspective, is the lingering uncertainty expressed by some practitioners of social epidemiology and social medicine about just how human rights can contribute to advancing the agenda for multisectoral health action as it is set out by the CSDH.
Perhaps what human rights most distinctively adds to work in the other fields is an emphasis on assigning responsibility. That is, it is not just that “pathologies of power,” to use Farmer’s phrase, underlie health inequities, but that those pathologies represent abdications or failures of governmental responsibility to ensure a level playing field with respect to social determinants of health and access to care. As Christopher Jochnick has written,
The real potential of human rights lies in its ability to change the way people perceive themselves vis-à-vis the government and other actors. A rights framework provides a mechanism for reanalyzing and renaming ‘problems’ as ‘violations,’ and, as such, something that need not and should not be tolerated.1
Human rights provides not only a set of principles for guiding health policy and programming, often referred to as procedural dimensions, which we have elaborated on in the last four issues: accountability, equality/non-discrimination; and participation; in addition to emphasizing international assistance and cooperation. As a body of international law, human rights also provides a framework of norms, institutions, and procedures. Throughout the last five issues, we have eschewed the outdated notion of a or the “health and human rights framework.” Indeed, we have gone to lengths to illustrate how diverse rights-based approaches can be, and to dispel the notion that there is a simple formula to deploy. In unpacking how human rights approaches might assimilate lessons about social determinants of health, the article in this issue by the human rights scholar, Audrey Chapman, makes that point vividly.
Nevertheless, applying a human rights framework to health ineluctably engages the law. The nature of human rights as law is fundamental — both to its power and to its limitations — in effecting social justice in health. It also may explain some of the continuing reservations that scholars and activists in other fields have regarding human rights. On the one hand, there is a healthy skepticism toward the law; changes in laws and policies do not necessarily translate into changes in programs and practices on the ground. On the other hand, law is unquestionably a social determinant of health in questions that range from criminalization of activities and sexual practices to different forms of discrimination. Moreover, courts are increasingly becoming relevant political actors in shaping health policies in many countries around the world based on rights principles, with often unclear effects on health equity, and this is a trend to which practitioners of social epidemiology and social medicine should certainly be attuned.
Yet, based upon the pieces in this issue and from our experiences, to many in public health, legal argument and interpretation are implicitly or explicitly deemed lesser “technical” matters, while to lawyers, epidemiological, biostatistical and even clinical skills are viewed as “technical” and secondary to the normative grounding of rights. Moreover, there are profound epistemological differences that accompany the different disciplinary perspectives on data, evidence, and establishing truth.
We are not disheartened by these challenges, however. Indeed, the enormously positive feedback we have received on the last five issues of this journal, coupled with our own work in the world, lead us both to reaffirm the belief with which we began this editorial undertaking: there is an urgent need for a forum on health and social justice that can begin to connect these various strands of thought. There is surely a long journey ahead, but we very much hope that the journal can increasingly provide a space that bridges the evident gaps that continue to exist between communities of scholars and activists from social medicine, social epidemiology, and human rights.
Alicia Ely Yamin, JD, MPH, is the Joseph H. Flom Global Health and Human Rights Fellow at Harvard Law School and an Adjunct Lecturer at the Harvard School of Public Health. She is also a Senior Researcher at the Christian Michelsen Institute (Bergen Norway) and a Special Adviser to Amnesty International’s global campaign on poverty, Demand Dignity.
Alec Irwin, PhD, is a researcher at Harvard University.
Please address correspondence to the authors c/o Alicia Ely Yamin at ayamin@law.harvard.edu.
Reference
1. C. Jochnick, “Confronting the impunity of non-state actors: New fields for the promotion of human rights,” Human Rights Quarterly 21 (1999), p. 59.