JAMA: Retreat From Human Rights and Adverse Consequences for Health

Featured Journal Content
March 6, 2018, Vol 319, No. 9, Pages 843-943

Retreat From Human Rights and Adverse Consequences for Health
Diederik Lohman, MA
JAMA. 2018;319(9):861-862. doi:10.1001/jama.2018.0271
The international environment for human rights has rapidly deteriorated in recent years. Populist leaders have come to power in an increasing number of countries, often on political platforms that are explicitly hostile to human rights. These leaders tend to portray respect for human rights as an inconvenient obstacle to their agendas rather than as an essential limit on their power. Meanwhile, many governments that have traditionally been proponents of human rights, although often with records that do not entirely reflect human rights, have encountered internal challenges from authoritarian populists or far-right political parties that have turned their focus inward and weakened their willingness to stand up for human rights internationally.

This development has serious consequences. As the Human Rights Watch 2018 World Report, released on January 18, notes, this trend has left an “open field for murderous leaders and their enablers.”1 The report details mass atrocities carried out with near impunity in Yemen, Syria, Burma, South Sudan, and elsewhere. It also provides ample examples of rapidly decreasing political space in many countries as governments seize the opportunity to eliminate free speech, the political opposition, and nongovernmental groups as a fragmented international community stands by paralyzed.

Populist and authoritarian leaders have had civil and political rights, first and foremost, as their focus, rather than economic and social rights, including the right to health. In some cases, populists have exploited public frustration about health care and other social policies to gain electoral support for their anti-rights agendas. However, the retreat from human rights is also a threat to health because it inevitably undermines key building blocks for good public health policy such as the ability to have robust public discussion on complex health issues and to critique government policies that affect public health.

Effects on Health During Conflict
Perhaps the most glaring example of the effect of this retreat from human rights on health globally is the failure of countries and multilateral organizations to effectively counteract the rapid increase in recent years in attacks on health care facilities during conflict. Although international humanitarian law explicitly grants health care facilities protected status, reports of attacks on these facilities and on health care workers during conflict have become so common that many incidents do not even attract media attention.

Last year, a report from the Safeguarding Health in Conflict Coalition documented attacks on health care facilities and workers in 23 countries across 3 continents.2 The report indicated that hospitals and clinics had been bombed or shelled in 10 countries, health care workers had been killed or abducted in 15, and military or police forces had occupied health care facilities in 7. The report documented 108 attacks on health care facilities in Syria, identified the Syrian and Russian governments as the worst offenders, and noted that the level of violence inflicted on health care facilities and health care workers was “remarkably high” as well in Afghanistan, Iraq, South Sudan, and Yemen.2

Due to a lack of data, it is impossible to quantify the full effects of these attacks on the health of the population of these countries. However, those effects are sure to be substantial. Many attacks described in the coalition report led to the suspension of essential health programs, destruction of health care infrastructure, flight of health care workers, and disruptions in deliveries of essential medicines and supplies. In Pakistan, one of the last remaining countries where polio is endemic, attacks by militants on individuals who provide vaccinations for polio led to a temporary suspension of the vaccination program in 2016, although enhanced security measures allowed the program to resume in 2017 without further incident.2

A Human Rights Watch review of 25 attacks on hospitals and health care workers in 10 countries between 2013 and 2016 documented that the attacks resulted in the deaths of more than 230 people, injuries to 180 more, and the closure or destruction of 6 hospitals.3 Yet the review found that no individuals faced criminal charges for their role in the attacks and most of the attacks were not investigated, even though at least 16 of the attacks may have constituted war crimes.3 The attacks involved military forces or armed groups from Afghanistan, Central African Republic, Iraq, Israel, Libya, Russia, Saudi Arabia, South Sudan, Sudan, Syria, Ukraine, and the United States.3 Even though the adverse effects of these attacks on a population can be enormous, most governments showed no greater willingness to investigate alleged attacks on health care facilities than they have with other potentially unlawful attacks in which their forces were involved, and instead apparently ignored, denied, or even justified them.3

The United Nations, which has been weakened by divisions and a retreat from rights norms (moral principles), has responded to these attacks with rhetoric but almost no action. In 2016, the UN Security Council adopted a strong resolution condemning attacks on health care facilities, and former UN Secretary-General Ban Ki-moon made 13 recommendations for preventing attacks on medical personnel, as requested by the Security Council.4 The World Health Organization will begin systematic data collection on these incidents (albeit without identification of those responsible). The UN Security Council held a follow-up meeting in May 2017 devoted to protecting civilians, with a special focus on attacks on health care facilities. However, attacks on health care facilities in conflict have continued.

Health Rights Under Authoritarian Regimes
The anti-rights zeal of populist and authoritarian leaders may not specifically target the right to health—and some such leaders have been credited with significant advances in the health of their countries—but good health policy withers without space for robust discussion on policy issues and government accountability. While populist and authoritarian leaders usually first seek to restrict the voice of political opponents or the media, it rarely stops there. Government restrictions intended to hamper the work of civil rights groups also tend to adversely affect groups working on health and other social and economic issues. While international resolve to protect rights has at times been a restraint on the behavior of authoritarian leaders, the global retreat from human rights has given them a freer hand.

A 2017 analysis by Human Rights Watch involving several countries has demonstrated how a lack of public domestic and international accountability can have major negative consequences for health. For example, in the early years of the rule of Hugo Chavez in Venezuela, primarily between 2003 and 2006, the country made significant progress in improving health. However, it also gradually restricted political freedoms, becoming increasingly intolerant of criticism. Since 2015, Venezuela’s health care system has slid into crisis as a result of government mismanagement and dwindling oil revenues, and intolerance of criticism now extends to physicians who publicly discuss the state of the health care system.4 For instance, several Venezuelan physicians reported that government officials had threatened reprisals, including dismissal, after they raised concerns about the scarcity of medicines and medical supplies.4

According to official statistics from Venezuela, in 2016 infant mortality increased 30% (from 8812 to 11 446 infant deaths) and maternal mortality increased 65% (from 457 to 756 deaths).5,6 Human Rights Watch analyses suggest that these increases were related to the severe shortages of basic medicines and medical supplies.4 Yet the government insists that Venezuela is not facing a humanitarian crisis.7

In Equatorial Guinea, with the world’s longest surviving president (since 1979), a lack of political freedoms and accountability has allowed the ruling elite to realize billions of dollars in oil revenues while largely ignoring the dire state of public health. Equatorial Guinea was one of the poorest countries in Africa when large oil reserves were discovered in the early 1990s, but its per capita income increased from US $330 in 1991 to a peak of US $24 304 in 2012.

Yet in 2017, an analysis by Human Rights Watch found that 20 years of oil wealth had done little to improve the country’s health indicators.8 Life expectancy has increased and was 57.5 years in 2015, the latest year for which data are available, but merely kept pace with that of other, much poorer, sub-Saharan African countries. Access to safe drinking water remains the same as in 1995 while it has improved in many other countries in the region. Vaccination rates for children have actually declined since the late 1990s and are among the worst in the world, with only 35% estimated to have received the first dose of the diphtheria, tetanus, and pertussis vaccine in 2016, the second lowest vaccination rate in the world for that year.9 Meanwhile, research by Human Rights Watch shows that the president and his inner circle have accumulated incredible wealth while the government frequently harasses members of civil society and political opposition groups.8

Today’s often hostile climate for human rights threatens to undermine health gains the world has achieved in recent decades. Governments and civil society groups concerned with global health should push back against the populist tide and advocate for a firm commitment to human rights and accountability as an integral part of their agendas.
Corresponding Author: Diederik Lohman, MA, Human Rights Watch, Health and Human Rights, 350 Fifth Ave, 34th Floor, New York, NY 10118 (lohmand@hrw.org).
Published Online: January 18, 2018. doi:10.1001/jama.2018.0271