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Those assessments, which create volumes of solid data, are more successful in persuading governments to act than appeals on behalf of imprisoned or mistreated individuals. Says Beyrer, “Country A may not care two hoots if the opposition leader in Country B is in prison. But if the political context in Country B leads to epidemic diseases in Country A, that has a much broader impact.”
Burma again provides a case in point. The country has long been recognized as a locus of Southeast Asia’s heroin traffic. Because so much transmission of HIV in the region is by contaminated needles, drug trafficking spreads HIV/AIDS. In Burma’s northern Kachin state, according to the Open Society Institute’s Burma Project, tests have revealed that 90 percent of heroin users are HIV-positive and acquire the disease within weeks of first injecting drugs. Export of heroin means export of HIV/AIDS.The Burmese government, implicated in the taking of huge profits from collaboration with the drug trade, has always denied that the country is central to the region’s heroin trafficking and its collateral health effects, Beyrer says. Neighboring countries have their own serious drug and HIV problems. But rather than responding to the public health threat out of Burma, nations like China have denied the dimensions of the trafficking as well, for political reasons, says Beyrer. China, for example, has been reluctant to jeopardize lucrative trade in weaponry with the Burmese junta.
Enter public health professionals, wielding not appeals to conscience on behalf of, say, jailed dissidents, but molecular epidemiology. Beyrer explains: “Molecular epidemiology uses epidemiological tools in concert with genetics to document, for example, the movement of influenza strains. When we were trying to understand the spread of HIV in Southeast Asia, we used it to look at subtypes of HIV among heroin injectors in and around Burma, China, Vietnam, Thailand and India. We found viruses from Burma, spreading along the trafficking routes, in other drug users’ blood in India and China, and thus could show, at the genetic level, how the spread of Burmese heroin was driving the spread of HIV in the region.”
Confronted with the epidemiologists’ data, countries concerned about their own HIV epidemics took notice. China, which had been supplying arms that could be used by the Burmese military to oppress the Karen and cause growing public health crises not only for them but for Thailand, now agreed to a joint U.S.-China intelligence operation on the Burmese border to interdict heroin trafficking. Thailand started working with the U.S. military to interdict traffickers on its border with Burma. Beyrer concedes that neither of these actions is a victory for human rights in Burma. But they represent the power public health data hold in affecting government policy: “You can say to a government that if you keep supporting that dictatorship next door, you’re going to be vulnerable to all these infectious diseases that you thought you’d controlled.
“I can tell you that when you talk to decision makers, they want to see evidence,” Beyrer says. “That’s another thing that epidemiology can do. It gives you something measurable and testable. That’s very important.” He points to the SARS outbreak of 2003. “People saw dramatic evidence that freedom of expression really was a public health issue, because limitations on information let that epidemic get out of control,” he says.
The late Jonathan Mann is credited with first articulating the human rights dimension of public health problems. Mann, who was killed in the crash of a Swissair flight in 1998, was the first director of the World Health Organization’s Global Program on AIDS and founder of the François-Xavier Bagnoud Center for Health and Human Rights at the Harvard School of Public Health. In 1994, he coauthored a seminal paper titled simply “Health and Human Rights.” In that paper’s conclusion, the authors wrote, “...collaboration with health experts can help give voice to the pervasive and serious impact on health associated with lack of respect for rights and dignity...the importance of health as a pre-condition for the capacity to realize and enjoy human rights and dignity must be appreciated.”
Mann argued that human rights issues allowed the AIDS epidemic to spread quickly yet remain ignored for such a long time. In the United States, the infection was first confined mostly to gay men and IV drug users. Had these groups not been marginalized by prejudice and discrimination, Mann argued, the response to the outbreak of AIDS would have been faster and better resourced.
Lawrence Gostin, JD, professor of Health Policy and Management and director of the Center for Law and the Public’s Health at the Bloomberg School and Georgetown University, was a coauthor of “Health and Human Rights” and with Mann taught what he believes to be the first-ever class on the subject. Says Gostin, “We argued that public health improves human rights, that human rights improves health, and that there is a synergistic relationship between the two. That formula is still crucial today.”
Beyrer believes the Bloomberg School’s center is the first in the nation to examine how human rights violations affect infectious disease outcomes. Much of the center’s initial work will concentrate on the human rights–public health dimensions of HIV/AIDS. The Bloomberg School is uniquely positioned for such a focus. Beyrer notes that it has faculty, students and alumni active in population-level health efforts around the world. Among U.S. institutions, it has the largest portfolio of NIH-supported HIV/AIDS research in developing countries. Its international HIV/AIDS training program is three times larger than any other in the country.
Meshing political advocacy and public health science will mean venturing onto potentially hazardous ground. One problematic area is the possibility of introducing to public health research a degree of advocacy-induced subjectivity and observer bias. Says Lawrence, “Getting caught up in advocacy makes it very tempting to interpret data in the most compelling way for strengthening the advocacy position. Careful documentation of human rights abuses followed by a careful advocacy campaign based on those findings usually helps avoid the pitfalls.”
Lawrence and Beyrer have heard the argument that public health professionals should stick to research and leave advocacy to the advocates. So has Gostin: “There is currently a significant backlash against health and human rights among the conservative community. They claim that human rights illegitimately expands the scope of public health. I believe that we in public health need to do more to show the link between human rights and health outcomes. The field of epidemiology is crucial for doing so.”
Beyrer responds that to not apply epidemiological methods to the study of rights abuses just because that research will have a political dimension is in itself a political position. As he wrote in a précis of the center, “Well-intentioned public health efforts that seek to de-politicize threats to health in coercive and repressive settings risk poor outcomes at best, and worse, the possibility that they may lend support to repressive systems that are at the root of problems they seek to address.”
He cautions that the new paradigm doesn’t imply that human rights abuses are behind every public health problem; rather, the tool can be used in “a very limited and precise way” to powerful effect.
“If you scratch the surface of public health people, they all care about human rights,” Beyrer says. “It’s a field full of compassionate and very smart people. But the tradition has been to leave your politics at the door, to go forward with scientific and technical solutions. But if you leave your politics at the door, and politics are playing a central role in the dynamics of an epidemic, you’re doing incomplete science.”