Scott Burris

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Human Rights The Link to HIV Interventions

• Scott Burris
• Temple University Beasley School of Law
• The Center for Law and the Publics Health/Johns
  Hopkins Bloomberg School of Public health
• A CDC/WHO/PAHO Collaborating Center

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Titanic
A Story About Human Rights, Health Policy and
Health
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Initial research findings

• Deaths 1517 of 2223 passengers and crew
• Causes of death
• hypothermia
• drowning
• Major individual risk factors
• not using a lifeboat (odds ratio gt 250,000)
• traveling 3rd Class (steerage passengers were 20
  X more likely not to use lifeboat than 1st Class
  female)
• male gender (male death rate 3 X female death
  rate)

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• Interventions
• Educate at-risk passengers about value of using
  lifeboats
• Skills-building on lifeboat entry
• Special focus on male lifeboat issues

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• What happened?
• Interventions did not reduce deaths in similar
  accidents.
• Interventions did not reduce disparities based on
  wealth and gender

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Because how people behaved that night was just
the tip of the iceberg

• The problem was not bad choices, but poor options
• Cause of death was as much gender and class as
  hypothermia and drowning
• Individual risk factors did not explain
  population vulnerability

There were too few lifeboats!
Access to lifeboats depended on wealth!
Women and children first!
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Which means

• The imperative was to create ships on which
  people could be healthy
• Structural interventions (i.e., interventions
  that change the environment)
• Laws requiring sufficient lifeboats
• Policies to reduce inequality and its enforcement
  among passengers

? Human Rights!
There were too few lifeboats!
Access to lifeboats depended on wealth!
Women and children first!
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Titanic The Moral of the Story
Social Epidemiology is providing the evidence
that human rights are crucial to health Human
rights are a crucial tool to maximizing the level
and just distribution of health in this world
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Social determinants of health (e.g., inequality)
Particular pathologies (e.g., HIV)
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Structural interventions Changing the environment
Social determinants of health (e.g., inequality)
Particular pathologies (e.g., HIV)
Individual interventions Helping people cope
with current environment
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Structural interventions Changing the environment
Change the environmental factors that drive
health inequalities
Universal ARV access
Evidence
Change the environmental factors causing a
particular disease
Social determinants of health (e.g., inequality)
Particular pathologies (e.g., HIV)
Help individuals deal with specific diseases
Help individuals cope with social causes of
disease
Right to highest attainable standard of health
Individual ARV treatment
Microbicides
Individual interventions Helping people cope
with current environment
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Structural interventions Changing the environment
Education Income sufficiency Work rights Civil
rights Self-determination Collective efficacy
Universal ARV access
Evidence
Social determinants of health (e.g., inequality)
Particular pathologies (e.g., HIV)
Fundamental Human Rights
Right to highest attainable standard of health
Individual ARV treatment
Microbicides
Individual interventions Helping people cope
with current environment
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Structural interventions Changing the environment
Criminalization of drug use is a major driver of
HIV among IDUs and of health inequalities in
populations with high IDU prevalence
Universal ARV access
Evidence
Social determinants of health (e.g., inequality)
Particular pathologies (e.g., HIV)
SEP
Fundamental Human Rights
Right to highest attainable standard of health
Individual interventions Helping people cope
with current environment
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Structural interventions Changing the environment
Control Money Voice Collective efficacy Own
mistakes
We can follow the evidence by respecting
communities in daily practice
Evidence
Social determinants of health (e.g., inequality)
Particular pathologies (e.g., HIV)
Fundamental Human Rights
Right to highest attainable standard of health
Individual ARV treatment
Teaching women to negotiate with partners
Individual interventions Helping people cope
with current environment
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Structural interventions Changing the environment
Collective efficacy Control Voice Own Mistakes
Evidence
Social determinants of health (e.g., inequality)
Particular pathologies (e.g., HIV)
Sex worker collective
Fundamental Human Rights
Right to highest attainable standard of health
Individual ARV treatment
Individual interventions Helping people cope
with current environment
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The Challenge to Practice
Sex workers who participated in a collective had
no better STD outcomes than sex workers in a
traditional intervention BUT They were better at
seeking medical help and they felt more optimistic
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The Challenge to Practice

• Are we willing to cede power and particularly
  control over resources, goals and methods to
  the communities we work in?
• Are they allowed to decide HIV/AIDS is not
  problem number one?
• Are they allowed to make mistakes and learn over
  time?

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Summary of the Evidence

• Social conditions, including human rights
  conditions, are crucial drivers of health
• Human rights action is an important element of
  structural interventions to address social causes
  of disease
• Empowerment or more accurately ceding power
  is essential in intervention designs, and daily
  practice.
• More
• Burris, Scott C., Kawachi, Ichiro and Sarat,
  Austin, Integrating Law and Social Epidemiology.
  Journal of Law, Medicine and Ethics, Vol. 30, p.
  510, 2002. Available at SSRN http//ssrn.com/abst
  ract1004746
• WHO Commission on Social Determinants of Health,
  http//www.who.int/social_determinants/en/
• Volume 10, Issue !, Health and Human Rights An
  International Journal (an excellent issue devoted
  to where the movement goes from here)
  http//www.hhrjournal.org/index.php/hhr

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