Scott Burris Temple University Beasley School of Law & The Center for Law and the Public’s Health/Johns Hopkins Bloo

1. Human Rights: The Link to HIV Interventions Scott Burris Temple University Beasley School of Law & The Center for Law and the Public’s Health/Johns Hopkins Bloomberg School of Public health A CDC/WHO/PAHO Collaborating Center

2. Titanic A Story About Human Rights, Health Policy and Health

3. Initial research findings: • Deaths : 1517 of 2223 passengers and crew • Causes of death: • hypothermia • drowning • Major individual risk factors: • not using a lifeboat (odds ratio > 250,000) • traveling 3rd Class (steerage passengers were 20 X more likely not to use lifeboat than 1st Class female) • male gender (male death rate 3 X female death rate)

4. Interventions: • Educate at-risk passengers about value of using lifeboats • Skills-building on lifeboat entry • Special focus on male lifeboat issues

5. What happened? • Interventions did not reduce deaths in similar accidents. • Interventions did not reduce disparities based on wealth and gender

6. Because how people behaved that night was just … the tip of the iceberg • The problem was not bad choices, but poor options • Cause of death was as much gender and class as hypothermia and drowning • Individual risk factors did not explain population vulnerability There were too few lifeboats! Access to lifeboats depended on wealth! “Women and children first”!

7. Which means… • The imperative was to create ships on which people could be healthy • Structural interventions (i.e., interventions that change the environment): • Laws requiring sufficient lifeboats • Policies to reduce inequality and its enforcement among passengers  Human Rights! There were too few lifeboats! Access to lifeboats depended on wealth! “Women and children first”!

8. Titanic The Moral of the Story Social Epidemiology is providing the evidence that human rights are crucial to health Human rights are a crucial tool to maximizing the level and just distribution of health in this world

9. Social determinants of health (e.g., inequality) Particular pathologies (e.g., HIV)

10. Structural interventions: Changing the environment Social determinants of health (e.g., inequality) Particular pathologies (e.g., HIV) Individual interventions: Helping people cope with current environment

11. Structural interventions: Changing the environment Change the environmental factors that drive health inequalities Universal ARV access Evidence Change the environmental factors causing a particular disease Social determinants of health (e.g., inequality) Particular pathologies (e.g., HIV) Help individuals cope with social causes of disease Help individuals deal with specific diseases Right to highest attainable standard of health Individual ARV treatment Microbicides Individual interventions: Helping people cope with current environment

12. Structural interventions: Changing the environment Education Income sufficiency Work rights Civil rights Self-determination Collective efficacy Universal ARV access Evidence Social determinants of health (e.g., inequality) Particular pathologies (e.g., HIV) Fundamental Human Rights Right to highest attainable standard of health Individual ARV treatment Microbicides Individual interventions: Helping people cope with current environment

13. Structural interventions: Changing the environment Criminalization of drug use is a major driver of HIV among IDUs and of health inequalities in populations with high IDU prevalence Universal ARV access Evidence Social determinants of health (e.g., inequality) Particular pathologies (e.g., HIV) SEP Fundamental Human Rights Right to highest attainable standard of health Individual interventions: Helping people cope with current environment

14. Structural interventions: Changing the environment Control Money Voice Collective efficacy Own mistakes We can follow the evidence by respecting communities in daily practice Evidence Social determinants of health (e.g., inequality) Particular pathologies (e.g., HIV) Fundamental Human Rights Right to highest attainable standard of health Individual ARV treatment Teaching women to negotiate with partners Individual interventions: Helping people cope with current environment

15. Structural interventions: Changing the environment Collective efficacy Control Voice Own Mistakes Evidence Social determinants of health (e.g., inequality) Particular pathologies (e.g., HIV) Sex worker collective Fundamental Human Rights Right to highest attainable standard of health Individual ARV treatment Individual interventions: Helping people cope with current environment

16. The Challenge to Practice Sex workers who participated in a collective had no better STD outcomes than sex workers in a traditional intervention BUT They were better at seeking medical help and they felt more optimistic

17. The Challenge to Practice • Are we willing to cede power – and particularly control over resources, goals and methods – to the communities we work in? • Are they allowed to decide HIV/AIDS is not problem number one? • Are they allowed to make mistakes and learn over time?

18. Summary of the Evidence • Social conditions, including human rights conditions, are crucial drivers of health • Human rights action is an important element of structural interventions to address social causes of disease • “Empowerment” – or more accurately ceding power – is essential in intervention designs, and daily practice. • More: • Burris, Scott C., Kawachi, Ichiro and Sarat, Austin, Integrating Law and Social Epidemiology. Journal of Law, Medicine and Ethics, Vol. 30, p. 510, 2002. Available at SSRN: http://ssrn.com/abstract=1004746 • WHO Commission on Social Determinants of Health, http://www.who.int/social_determinants/en/ • Volume 10, Issue !, Health and Human Rights: An International Journal (an excellent issue devoted to where the movement goes from here): http://www.hhrjournal.org/index.php/hhr