Health Justice in the Context of Health and Human Rights

In their analytic essay “Health Justice: A Framework for Mitigating the Impacts of HIV and COVID-19 on Disproportionately Affected Communities” (p. 194), Alang and Blackstock propose a health justice framework for understanding and responding to the inequalities exposed and exacerbated by recent pandemics including HIV and COVID-19. Redressing inequitable distributions of power and resources is seen as a pathway toward liberation and advancement of traditionally oppressed communities, and a range of structural interventions are proposed for advancing this work.

This framework, specific to HIV and COVID-19, resonates with the previous work of Benfer et al. on health justice more broadly as well as their recent COVID-19–specific analyses.^1,2 Indeed, although health justice has been variably defined, the notion of redistribution of power and resources is often central.^3–5 Aligned with previous conceptualizations of health justice, Alang and Blackstock focus on the specificities regarding two recent pandemics and how responses to them might be strengthened.

Alang and Blackstock’s conceptualization also speaks to many of the key principles of work at the intersection of health and human rights. Although there is a longer history of work at the intersection of women’s health and human rights, it was in the context of HIV that the relationships between health and human rights were first systematically explored.

Jonathan Mann was a pioneer of health and human rights. Trained as a medical doctor and epidemiologist, he spearheaded the first global strategy on HIV while leading the World Health Organization’s Global Program on AIDS. He then moved into academia, where he explored how vulnerability to HIV was intertwined with the lack of realization of human rights, which laid the groundwork for developing the health and human rights framework.⁶

Mann and colleagues posited three important relationships between health and human rights: (1) health policies, programs, and practices affect (positively and negatively) human rights; (2) violations of human rights have important health effects; and (3) an inextricable link exists between the promotion and protection of health and the promotion and protection of human rights and dignity.⁷ Although initially designed in relation to HIV, this framework was later expanded to be relevant to health more broadly.

The three relationships between health and human rights identified in Mann and colleagues’ early work can be seen in Alang and Blackstock’s essay on health justice. The authors identified shortfalls in policies, programs, and practices in response to HIV and COVID-19 that have had a negative impact on human rights. Such shortfalls include the initial politically motivated nonresponse by governments that fueled not only disease spread but also discrimination against the marginalized populations initially hit hardest by each pandemic.

Resistance to policies such as Medicare for All can be seen as a violation of the right to health, which encompasses the notion of affordability of health services for everyone. As Alang and Blackstock note, there have been gross inequities in access to pandemic prevention and treatment interventions. These inequities can be seen as violations of the rights to health, to equality and nondiscrimination, and to the enjoyment of the benefits of scientific progress. It cannot be assumed that if a technology exists, it is equally available to all. Historical distrust of the medical system, lack of access to information, cost, and health provider bias all play important roles in determining the true accessibility and acceptability of these interventions.

The inextricable link between the promotion and protection of both health and human rights comes to the fore in the lack of attention to structural determinants in pandemic responses. That racially minoritized groups bear a disproportionate COVID-19 burden stems, as the authors note, from centuries of structural racism that have deliberately marginalized these populations. The lack of attention to these systemic and structural drivers of vulnerability in pandemic responses illustrates a critical shortcoming. If we rely on the indivisibility and interrelatedness of human rights—that no right can be considered alone and that the realization of rights is mutually interdependent—it is clear that the promotion and protection of, in this case, the rights to nondiscrimination and to health must be jointly addressed.

The structural interventions proposed also align with this early conceptualization of health and human rights. Human rights, by design, challenge power imbalances. By requiring that rather than treating everyone the same, additional efforts be made to reach and elevate the most marginalized and discriminated against, human rights incorporate the notion of redistributive justice, expressed by Alang and Blackstock as the need to “ensure access to and redistribution of resources.” Linking to the legal basis of the health and human rights framework, the authors also call for the “introduction of mandates and enforcement of regulations that redistribute power” and for “legislation that guarantees support for people with long-haul COVID-19.” Along with evaluations of “intersecting and multidimensional effects of policies across systems,” this draws attention to accountability, which is considered central to work at the intersection of health and human rights; the difference between laws and policies on paper and “on the streets” has been frequently highlighted.^8,9

We need to know what works and what does not work; we also need to know who is fulfilling their obligations in the context of health and human rights and who is not. Central to all of this, and reflecting the right to participation, is the need to “center the experiences of the most impacted communities in policy development.” Taken together, the structural interventions proposed in Alang and Blackstock’s essay seek to ensure that health policies, programs, and actions support human rights, reduce violations of human rights that affect health, and support the mutual promotion and protection of health and rights.

In recent years, scholars and implementers have adopted “rights-based approaches to health” as a way of operationalizing human rights within health interventions. Initial conceptions of rights-based approaches to health were often disease specific, but over time the need to apply them to health more broadly became clear. They now encompass a widely accepted set of human rights and rights principles: attention to the legal and policy environment; participation; equality and nondiscrimination; the availability, accessibility, acceptability, and quality of services; and accountability.¹⁰ Such rights-based approaches to health require systematic and rigorous attention to many of the same issues as Alang and Blackstock’s health justice framework. It will be interesting to see whether there is further development of this health justice framework beyond its current specificity to pandemics, a trajectory that many initially disease-specific models have taken.

Mann and colleagues’ initial conceptualization of health and human rights remains as relevant today in the context of COVID-19 as it was in the context of HIV. Furthermore, more recent work has built from this foundation to strengthen the evidence of the value of work at the intersection of health and human rights. There is, today, more recognition of historical legacies of marginalization and discrimination that negatively affect health and some initial acceptance that societal divisions are as important to consider in pandemic responses as biomedical vulnerability to disease. Yet, what is still missing is large-scale action to tackle these deep-rooted, complex problems. Pandemic preparedness remains focused on biomedical capacity rather than tackling the structures and systems that permeate inequality and injustice and that will continue to disadvantage specific populations in any future pandemic.

Health justice can usefully be grounded in human rights. Underpinned by international law, human rights provide a framework for systematic consideration of the wide range of structural determinants of health inequities alongside the legal obligations of governments to ensure that these inequities are addressed. The strong history of community organizing and grassroots activism among the human rights community might indeed be leveraged to push for government action and accountability at the local, state, and national levels.