Rights to Health

Chris Beyrer's heroes watch over him. There, on a shelf of his seventh-floor office, rests a photo of Maha Ghosananda, the late Buddhist spiritual leader known as the "Gandhi of Cambodia." On Beyrer's PC desktop, Burmese human rights advocate Aung San Suu Kyi stands on a balcony overlooking a river of admirers. Beyrer, a veteran AIDS epidemiologist, is melding such inspired advocacy for human rights with his own scientific skills. The result is the Center for Public Health and Human Rights, which he directs. A pragmatist, Beyrer, MD, MPH '90, knows that policy-makers (and skeptical scientific colleagues) are moved only by evidence. That's why the Center's research relies on population-level tools to quantify the health effects of human rights abuses among marginalized populations like Russian sex workers or ethnic peoples of eastern Burma. Beyrer is co-editor of the new book Public Health & Human Rights: Evidence-Based Approaches (The Johns Hopkins University Press, 2007). In a wide-ranging summer afternoon conversation, Beyrer, an Epidemiology professor, shared his thoughts about human rights, science and health with Johns Hopkins Public Health magazine editor Brian W. Simpson.

Why look at human rights in public health?

It's increasingly clear that we have a problem of what to do when social order and structures are unjust and the distribution of resources limits vulnerable groups, minorities and women's access to health interventions. If you don't look at human rights and you don't think about the ways that justice, equity and participation really operate, then your public health delivery is going to be flawed and limited.

Give us an example.

There's a remarkable overlap between neglected tropical diseases and areas of social conflict. For example, the eradication of river blindness. Ivermectin, the standard treatment, is free. We know how to run the control and treatment programs. And the places where river blindness has resurged—Sierra Leone, Democratic Republic of Congo, Sudan—are just the places where human rights abrogation is the norm. 

What does human rights abrogation really mean?

In conflict settings like Sierra Leone, the Democratic Republic of the Congo and Sudan, military forces specifically target civilian ethnic populations in many cases for forced displacement. The military objective becomes attacks on civilians and that is a fundamental abrogation of human rights. In nonconflict settings, it means deliberately excluding a group—say injection drug users—and systematically discriminating against them. Everybody has a right to health care no matter their status. 

How does the Center's work differ from what most people think of as human rights investigations?

Public health has a wide range of tools that can allow us to look at health and status of populations. The sad truth in 2007 is that a great deal of the human rights violations are not violations of rights of individuals but of populations. In Burma, for example, we have a long-standing civil conflict where the military junta is targeting ethnic groups in eastern Burma—the Mon, Karen, Karenni and Shan peoples. There's forced displacement, forced labor, food theft, direct violence against the population including beatings, shootings, landmines... This is a deliberate attempt to target populations so you need population-based methods to evaluate that. It's not enough in Burma to look at the 1,100 or so political prisoners that we know about. We also have to look at the impact of this conflict on ethnic minorities who make up 40 percent of Burma's population. 

The health effects of brutal regimes seem obvious, if underreported. I'm thinking of malnutrition in Mugabe's Zimbabwe. Why is scientific rigor important?

It's important from the perspective of prosecuting perpetrators. The data must be methodologically sound. Second, it's very important to bring well-done research to our colleagues. Ultimately, we want to be able to say the protection and promotion of human rights has measurable benefits to human health. I think this field will stay in its infancy until we can make those connections and convince people this is important. If you think about where bioethics was 25 years ago, it was not so widely appreciated that the highest ethical standards actually led to the best science. I think that's where we really need to go with human rights: The best evaluations and best implementation of rights-based work is going to improve health outcomes.

How do you do this research?

Our principal partners are the health organizations from the populations dealing with these problems. If you have to get approval from the government that is trying to commit these atrocities, you are going to get a very different picture than if you go through community groups working on the ground.

Aren't local people tempted to paint the worst picture possible?

Of course, it's an issue, but outside people cannot do this kind of work. It is not safe for local people to talk with outsiders in most of these settings. So there are a number of ways you try to deal with it. We do comparisons across interviewers, and that helps if somebody's data look very different. The second thing is that there are some areas where the local people and staff will say it's too unstable or there's too much troop movement. They can't go there to collect information, so, if anything, these methods are biased toward the less conflict-affected zones.

Some would say taking a step closer to advocacy makes the science suffer.

I think part of the duty of a scientist is that your work doesn't stop with scientific publication. You really have to push for that evidence.

What do your colleagues think of this?

I think most of the colleagues I know and work with, they genuinely care about human rights and social justice. It's a very big part of public health. But people will say, "Well, you're trying to change the world and that's much bigger than us." There's some truth to that argument, but the simple truth is that public health is implemented in the public sphere and if the public sphere is unjust and civil liberties are denied, it will not function well. If ethnic groups are excluded, for example, then you can't have an immunization program.

What human rights work are you most proud of?

For the epidemiology plenary for the world AIDS conference in Toronto in 2006, we did a synthesis of how rights abrogation is driving the global HIV epidemic and why. That really has begun to have some traction and is beginning to impact the way people think about the pandemic.

This is an emerging discipline. Funding must be a challenge.

The School has been enormously supportive... but I will not pretend this is not a risky and somewhat uncertain enterprise. I mean, what NIH institute funds human rights research exactly?

There's not an NIH institute devoted to it.

No. Not yet. But hopefully there will be.