1. 2006 Pan American Health Organization INTRODUCTION TO INTERNATIONAL HEALTH, HUMAN RIGHTS AND PUBLIC HEALTH: DEVELOPMENTS IN THE INTER-AMERICAN HUMAN RIGHTS SYSTEM

2. 2006 Pan American Health Organization “The use of international human rights principles, treaties and standards is seen in PAHO and WHO not as an optional tool to promote and protect public health, but as an essential strategy to improve the health of the people around the world” Dr. Mirta Roses Georgetown Law Center, October 2006 Director Pan American Health Organization/Regional Office of the World Health Organization (PAHO/WHO) “The use of international human rights principles, treaties and standards is seen in PAHO and WHO not as an optional tool to promote and protect public health, but as an essential strategy to improve the health of the people around the world” Dr. Mirta Roses Georgetown Law Center, October 2006 Director Pan American Health Organization/Regional Office of the World Health Organization (PAHO/WHO)

3. 2006 Pan American Health Organization LINKS BETWEEN HEALTH AND HUMAN RIGHTS LAW Violations of human rights can affect negatively the physical and mental health of individuals; Health policies, laws, programs and plans can affect positively or negatively the exercise of the basic human rights and freedoms of the most vulnerable groups; and Enjoyment of health and the exercise of human rights are both essential requirements to reach well-being and a healthy life Violations of human rights can affect negatively the physical and mental health of individuals; Health policies, laws, programs and plans can affect positively or negatively the exercise of the basic human rights and freedoms of the most vulnerable groups; and Enjoyment of health and the exercise of human rights are both essential requirements to reach well-being and a healthy life

4. 2006 Pan American Health Organization FUNDAMENTAL FLAWS WITH REGARD TO POLICIES/PLANS/LAWS/PRACTICES Violations of basic human rights related with health of the most vulnerable such as persons living with HIV, with disabilities, with mental disorders, older persons, among others; Limited awareness of the international and regional human rights instruments among governmental officials and PAHO personnel; Violations of basic human rights related with health of the most vulnerable such as persons living with HIV, with disabilities, with mental disorders, older persons, among others; Limited awareness of the international and regional human rights instruments among governmental officials and PAHO personnel;

5. 2006 Pan American Health Organization Policies, programs and laws are not being formulated consistent with international and regional human rights obligations; Limited participation of civil society organizations; Lack of national mechanisms at the level of Ombudspersons’ offices and other national agencies to monitor the right to health and other related human rights Policies, programs and laws are not being formulated consistent with international and regional human rights obligations; Limited participation of civil society organizations; Lack of national mechanisms at the level of Ombudspersons’ offices and other national agencies to monitor the right to health and other related human rights

6. 2006 Pan American Health Organization THE EXERCISE OF BASIC HUMAN RIGHTS AND THE MOST VULNERABLE IN THE CONTEXT OF PUBLIC HEALTH Persons with disabilities; Persons living with HIV; Persons with mental disorders; Older persons; Indigenous peoples; A particular emphasis on the health and related human rights and freedoms of women and children/adolescents in the context of sexual and reproductive health; and Poor persons without access to essential medicines Persons with disabilities; Persons living with HIV; Persons with mental disorders; Older persons; Indigenous peoples; A particular emphasis on the health and related human rights and freedoms of women and children/adolescents in the context of sexual and reproductive health; and Poor persons without access to essential medicines

7. 2006 Pan American Health Organization HUMAN RIGHTS LAW BINDING INSTRUMENTS (UN SYSTEM) Charter of the United Nations; WHO Constitution; Universal Declaration of Human Rights; International Covenant on Civil and Political Rights; International Covenant on Economic, Social and Cultural Rights; Convention on the Rights of the Child; Convention on the Elimination of All F. of Discrimination against Women; and Convention on the rights of persons with disabilities Charter of the United Nations; WHO Constitution; Universal Declaration of Human Rights; International Covenant on Civil and Political Rights; International Covenant on Economic, Social and Cultural Rights; Convention on the Rights of the Child; Convention on the Elimination of All F. of Discrimination against Women; and Convention on the rights of persons with disabilities

8. 2006 Pan American Health Organization WHO Constitution (Preamble) “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition…”

9. 2006 Pan American Health Organization INTERNATIONAL COVENANT ON CIVIL AND POLITICAL RIGHTS Art. 7: “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. In particular, no one shall be subjected without his free consent to medical or scientific experimentation”

10. 2006 Pan American Health Organization INTERNATIONAL COVENANT ON ECONOMIC, SOCIAL AND CULTURAL RIGHTS Art. 12: 1.The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. 2.The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for: a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child; b) The improvement of all aspects of environmental and industrial hygiene; c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases; and d) The creation of conditions which would assure to all medical service and attention Art. 12: 1.The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. 2.The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for: a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child; b) The improvement of all aspects of environmental and industrial hygiene; c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases; and d) The creation of conditions which would assure to all medical service and attention

11. 2006 Pan American Health Organization CONVENTION ON THE RIGHTS OF PERSONS WITH DISABILITIES Art. 25: The right to the enjoyment of the highest attainable standard of health In particular, States Parties shall: a)Provide persons with disabilities with the same range, quality and standard of free or affordable health care and programs as provided to other persons including in the area of sexual and reproductive health…; b)Provide those health services needed…and services designed to minimize and prevent further disabilities; including among children and older persons; c)Provide these health services as close as possible to people’s own communities; Art. 25: The right to the enjoyment of the highest attainable standard of health In particular, States Parties shall: a)Provide persons with disabilities with the same range, quality and standard of free or affordable health care and programs as provided to other persons including in the area of sexual and reproductive health…; b)Provide those health services needed…and services designed to minimize and prevent further disabilities; including among children and older persons; c)Provide these health services as close as possible to people’s own communities;

12. 2006 Pan American Health Organization d) Require health professionals to provide care of the same quality to persons with disabilities as to others, including on the basis of free and informed consent by, inter alia, raising awareness of the human rights, dignity, autonomy and needs of persons with disabilities… e)Prohibit discrimination against persons with disabilities in the provision of health insurance… f)Prevent discriminatory denial of health care or health services or food and fluids on the basis of disability; d) Require health professionals to provide care of the same quality to persons with disabilities as to others, including on the basis of free and informed consent by, inter alia, raising awareness of the human rights, dignity, autonomy and needs of persons with disabilities… e)Prohibit discrimination against persons with disabilities in the provision of health insurance… f)Prevent discriminatory denial of health care or health services or food and fluids on the basis of disability;

13. 2006 Pan American Health Organization PROTOCOL OF SAN SALVADOR Art.10: Right to health 1. Everyone shall have the right to health, understood to mean the enjoyment of the highest level of physical and mental and social well-being. 2.In order to ensure the exercise of the right to health, the States parties agree to recognize health as a public good and, particularly, to adopt the following measures to ensure that right: a. Primary health care, that is essential health care made available to all individuals and families in the community; Art.10: Right to health 1. Everyone shall have the right to health, understood to mean the enjoyment of the highest level of physical and mental and social well-being. 2.In order to ensure the exercise of the right to health, the States parties agree to recognize health as a public good and, particularly, to adopt the following measures to ensure that right: a. Primary health care, that is essential health care made available to all individuals and families in the community;

14. 2006 Pan American Health Organization b.Extension of the benefits of health services to all individuals subject to the State’s jurisdiction; c.Universal immunization against the principal infectious diseases; d.Prevention and treatment of endemic, occupational and other diseases e.Education of the population on the prevention and treatment of health problems; and f.Satisfaction of the health needs of the highest risk groups and of those whose poverty makes them the most vulnerable. b.Extension of the benefits of health services to all individuals subject to the State’s jurisdiction; c.Universal immunization against the principal infectious diseases; d.Prevention and treatment of endemic, occupational and other diseases e.Education of the population on the prevention and treatment of health problems; and f.Satisfaction of the health needs of the highest risk groups and of those whose poverty makes them the most vulnerable.

15. 2006 Pan American Health Organization HUMAN RIGHTS LAW BINDING INSTRUMENTS (OAS SYSTEM) OAS Charter; American Declaration of the Rights and Duties of Man; American Convention on Human Rights; Additional Protocol to the American Convention on Human Rights “Protocol of San Salvador” Inter-American Convention on the Prevention, Punishment and Eradication of Violence against Women; and Inter-American Convention on the Elimination of All Forms of Discrimination Against Persons with Disabilities OAS Charter; American Declaration of the Rights and Duties of Man; American Convention on Human Rights; Additional Protocol to the American Convention on Human Rights “Protocol of San Salvador” Inter-American Convention on the Prevention, Punishment and Eradication of Violence against Women; and Inter-American Convention on the Elimination of All Forms of Discrimination Against Persons with Disabilities

16. 2006 Pan American Health Organization EXAMPLES OF HUMAN RIGHTS LAW STANDARDS RELATED WITH HEALTH International Guidelines on HIV/AIDS and Human Rights; Principles of the United Nations for older persons; Principles of the United Nations for the protection of persons with mental illness; and General Comment 14 of the CESCR (UN) on the right of everyone to the enjoyment of the highest attainable standard of health International Guidelines on HIV/AIDS and Human Rights; Principles of the United Nations for older persons; Principles of the United Nations for the protection of persons with mental illness; and General Comment 14 of the CESCR (UN) on the right of everyone to the enjoyment of the highest attainable standard of health

17. 2006 Pan American Health Organization EXAMPLES OF WHO AND PAHO TECHNICAL GUIDELINES ON THE RIGHT TO HEALTH AND OTHER RELATED HUMAN RIGHTS WHO resource book on human rights, mental health and legislation; PAHO’s Directing Council Resolution and Technical Document CD47R1 “Disability: Prevention and Rehabilitation in the context of the Right to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health and Other related Rights” WHO resource book on human rights, mental health and legislation; PAHO’s Directing Council Resolution and Technical Document CD47R1 “Disability: Prevention and Rehabilitation in the context of the Right to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health and Other related Rights”

18. 2006 Pan American Health Organization MOST RELEVANT HUMAN RIGHTS AND FUNDAMENTAL FREEDOMS IN THE CONTEXT OF HEALTH PROTECTION (AMERICAN CONVENTION/PROTOCOL) Right to equal protection of the law; Right to personal liberty and security of person; Right to privacy; Right to life; Right to personal integrity; Freedom of movement and residency; Freedom of thought and expression; Right to the highest attainable standard of health (“the right to health”) Right to equal protection of the law; Right to personal liberty and security of person; Right to privacy; Right to life; Right to personal integrity; Freedom of movement and residency; Freedom of thought and expression; Right to the highest attainable standard of health (“the right to health”)

19. 2006 Pan American Health Organization Right to work; Right to education; and Right to enjoy the benefits of scientific progress and its applications (among others) Right to work; Right to education; and Right to enjoy the benefits of scientific progress and its applications (among others)

20. 2006 Pan American Health Organization SCOPE OF THE RIGHT TO HEALTH (GENERAL COMMENT 14) Elements of the right to health (health care facilities, services and goods): Availability; Accessibility; Acceptability; Affordability; Good quality Elements of the right to health (health care facilities, services and goods): Availability; Accessibility; Acceptability; Affordability; Good quality

21. 2006 Pan American Health Organization CORE OBLIGATIONS OF STATES (GENERAL COMMENT 14) States must met these obligations regardless of limited national resources: Health facilities; Minimum essential food; Basic shelter; Sanitation; Potable water; Essential drugs; and Public health strategy States must met these obligations regardless of limited national resources: Health facilities; Minimum essential food; Basic shelter; Sanitation; Potable water; Essential drugs; and Public health strategy

22. 2006 Pan American Health Organization LIMITATIONS OF THE RIGHT TO HEALTH According to the Siracusa Principles, the limitations of rights proceed when the restriction: Is provided for in accordance with the law; Is in the interest of a legitimate objective of general interest; Is strictly necessary to achieve an objective; Is necessary to respond to a public health need; Is proportional to the social aim; and Is not imposed arbitrarily According to the Siracusa Principles, the limitations of rights proceed when the restriction: Is provided for in accordance with the law; Is in the interest of a legitimate objective of general interest; Is strictly necessary to achieve an objective; Is necessary to respond to a public health need; Is proportional to the social aim; and Is not imposed arbitrarily

23. 2006 Pan American Health Organization RELEVANT CASE LAW (INTER-AMERICAN SYSTEM) Report 63/99 Case 11.427 “Victor Rosario Congo, Ecuador”: Right to humane treatment, life, and judicial protection; “…The Commission deems it pertinent to apply special standards to the determination of whether the provisions of the Convention have been complied with in cases involving persons suffering mental illnesses…” “…The Commission is of the view that isolation can in itself constitute inhumane treatment. Moreover, when the person kept in isolation in a penitentiary institution has a mental disability this could involve an even more serious violation of the State’s obligation to protect the physical, mental and moral integrity of persons held under its custody…” Report 63/99 Case 11.427 “Victor Rosario Congo, Ecuador”: Right to humane treatment, life, and judicial protection; “…The Commission deems it pertinent to apply special standards to the determination of whether the provisions of the Convention have been complied with in cases involving persons suffering mental illnesses…” “…The Commission is of the view that isolation can in itself constitute inhumane treatment. Moreover, when the person kept in isolation in a penitentiary institution has a mental disability this could involve an even more serious violation of the State’s obligation to protect the physical, mental and moral integrity of persons held under its custody…”

24. 2006 Pan American Health Organization “…The Commission considers that a violation of the right to physical integrity is even more serious in the case of a person held in preventive detention, suffering a mental disease, and therefore in custody of the State in a particularly vulnerable position…” “…The measures needed for his survival consisted in medical care to heal his physical injuries and such vital administrations as cleansing, food, and psycological attention to treat his depression and the psychosis…” “…The Commission considers that a violation of the right to physical integrity is even more serious in the case of a person held in preventive detention, suffering a mental disease, and therefore in custody of the State in a particularly vulnerable position…” “…The measures needed for his survival consisted in medical care to heal his physical injuries and such vital administrations as cleansing, food, and psycological attention to treat his depression and the psychosis…”

25. 2006 Pan American Health Organization Yakye Axa Indigenous Community v. Paraguay and Sawhoyamaxa Indigenous community v. Paraguay (Judgments Inter-American Court, 2005 and 2006) “…Essentially this right [the right to life] includes not only the right of every human being not to be arbitrarily deprived of his life, but also the right that conditions that impede or obstruct access to a dignified existence should not be generated…” (Y) “…States must adopt any measures that may be necessary to create an adequate statutory framework to discourage any threat to the right to life; to establish and effective system of administration of justice able to investigate, punish and repair any depravation of lives by state agents or by individuals…” (S) “…Essentially this right [the right to life] includes not only the right of every human being not to be arbitrarily deprived of his life, but also the right that conditions that impede or obstruct access to a dignified existence should not be generated…” (Y) “…States must adopt any measures that may be necessary to create an adequate statutory framework to discourage any threat to the right to life; to establish and effective system of administration of justice able to investigate, punish and repair any depravation of lives by state agents or by individuals…” (S)

26. 2006 Pan American Health Organization “[T]he Court orders that…the State must supply, immediately and on a regular basis, sufficient drinking water for consumption and personal hygiene of the members of the community; it must provide regular medical care and appropriate medicine to protect the health of all persons, specially children, the elderly and pregnant women, including medicine and adequate treatment for worming of all members of the community; it must supply food in quantities, variety and quality that are sufficient for the memmers of the community to have the minimum conditions for a dignified life; and it must supply sufficient bilingual material for appropriate education of the students at school…” (Y) “[T]he measures adopted by the State in compliance with the order cannot be considered sufficient and adequate. Indeed, for six years after the effective date of the order, the State only delivered food to the alleged victims on ten opportunities, and medicine and educational material in two opportunities…” “[T]he Court orders that…the State must supply, immediately and on a regular basis, sufficient drinking water for consumption and personal hygiene of the members of the community; it must provide regular medical care and appropriate medicine to protect the health of all persons, specially children, the elderly and pregnant women, including medicine and adequate treatment for worming of all members of the community; it must supply food in quantities, variety and quality that are sufficient for the memmers of the community to have the minimum conditions for a dignified life; and it must supply sufficient bilingual material for appropriate education of the students at school…” (Y) “[T]he measures adopted by the State in compliance with the order cannot be considered sufficient and adequate. Indeed, for six years after the effective date of the order, the State only delivered food to the alleged victims on ten opportunities, and medicine and educational material in two opportunities…”

27. 2006 Pan American Health Organization Ximenes Lopes v. Brazil (judgment, Inter-American Court, 2006) “…Pursuant to Article 2 of the Convention, the State must create an appropriate legal framework to establish the standards of treatment and hospitalization to be complied with by health care institutions. The States must establish and adopt in their respective legal systems all such measures as may be necessary so that the provisions of the Convention may be met and enforced…” “…In view of the foregoing, the Court considers that the States are responsible for regulating and supervising at all times the rendering of services and the implementation of the national programs regarding the performance of public quality health care services so that they may deter any threat to the right to life and the physical integrity of the individuals undergoing treatment. They must create the proper mechanisms to carry out inspection at psychiatric institutions, submit, investigate, and solve complaints and take the appropriate disciplinary or judicial actions regarding cases of professional misconduct or the violation of the patients’ rights…” “…Pursuant to Article 2 of the Convention, the State must create an appropriate legal framework to establish the standards of treatment and hospitalization to be complied with by health care institutions. The States must establish and adopt in their respective legal systems all such measures as may be necessary so that the provisions of the Convention may be met and enforced…” “…In view of the foregoing, the Court considers that the States are responsible for regulating and supervising at all times the rendering of services and the implementation of the national programs regarding the performance of public quality health care services so that they may deter any threat to the right to life and the physical integrity of the individuals undergoing treatment. They must create the proper mechanisms to carry out inspection at psychiatric institutions, submit, investigate, and solve complaints and take the appropriate disciplinary or judicial actions regarding cases of professional misconduct or the violation of the patients’ rights…”

28. 2006 Pan American Health Organization PAHO’s TECHNICAL COLLABORATION ON HUMAN RIGHTS LAW National training workshops; Training workshops tailored for PAHO personnel; Coordination of national technical committees to formulate/review national policies, laws and programs consistent with international human rights law; Strengthening national mechanisms for monitoring the right to health and other related human rights and freedoms; and Collaboration of PAHO with Regional and International human rights bodies National training workshops; Training workshops tailored for PAHO personnel; Coordination of national technical committees to formulate/review national policies, laws and programs consistent with international human rights law; Strengthening national mechanisms for monitoring the right to health and other related human rights and freedoms; and Collaboration of PAHO with Regional and International human rights bodies

29. 2006 Pan American Health Organization NEW TRENDS Violations of human rights as actions that can affect physical and mental health and that imply State responsibility and accountability; Inclusion of health as a right in the agendas of international and regional human rights bodies and specialized agencies; Collaboration of PAHO with Congress and the Judiciary with regard to the interpretation of human rights law in the context of health Violations of human rights as actions that can affect physical and mental health and that imply State responsibility and accountability; Inclusion of health as a right in the agendas of international and regional human rights bodies and specialized agencies; Collaboration of PAHO with Congress and the Judiciary with regard to the interpretation of human rights law in the context of health

30. 2006 Pan American Health Organization Support of health policies, plans, laws and programs with human rights provisions that are enshrined in international human rights treaties and standards; and Involvement of PAHO and WHO in the area of human rights promotion and protection Support of health policies, plans, laws and programs with human rights provisions that are enshrined in international human rights treaties and standards; and Involvement of PAHO and WHO in the area of human rights promotion and protection

31. 2006 Pan American Health Organization THE RIGHT TO THE ENJOYMENT THE HIGHEST ATTAINABLE STANDARD OF HEALTH