Assessing governance

The diverse chapters in this volume illustrate that factors such as human behavior and socio-economic conditions can have as great or a greater impact on the risk of infectious disease as does the microbiology of disease pathogens. If this is true, it is equally important to examine the factors that structure these socio-ecological factors in the first place. We have argued that government conduct plays an important role in shaping the social context in which individuals live, behave, and make decisions about their health. Not only do governments help to shape the risk environment for infectious disease, but they also determine the manner in which diseases are contained and controlled.

Quantitative analysis of the link between governance and public health provides an interesting starting point for this discussion; however, it has not yet been able to capture the complexity of how governments balance human rights and public health in the context of specific disease threats, and the consequences of the choices and trade-offs made. There are several ways in which the relationship between governance, human rights, and infectious disease may be understood. The degree to which governments are respectful of human rights, and are responsive and accountable to their citizens, will influence the effectiveness with which they respond to disease threats and openly communicate about epidemics. This applies to both epidemic diseases, which governments may conceal in an attempt to maintain social order, as well as to endemic diseases among the poor, which governments may ignore out of political expediency. Individual violations of civil and political rights by governments or non-state actors can constrain the ability of individuals - especially socially marginalized groups - to make informed decisions about their health, thus increasing their vulnerability to infectious disease. These human rights violations may have less to do with health policy per se, and more to do with government actions (and inactions) lying outside the health sphere. A government's commitment to human rights will determine the level of coerciveness with which it responds to infectious disease threats and, in turn, how effectively a disease is contained and controlled. Even governments that choose proactively to address infectious diseases may do so in a manner that sacrifices individual rights to a perceived social benefit. A rational and proportionate balancing of individual rights against larger policy objectives may be more likely to reap benefits for public health than ignoring or downplaying human rights.

What is certain is that governance matters to health - that the way in which people are governed, whether their human rights are respected, and the institutions of democracy and civil society can have tangible health consequences at both the individual and population level. Despite the range of work in this area, there have been few attempts to describe the actual mechanisms by which rights and democracy can impact health, and attempts to measure these relationships in quantitative terms have been limited and largely unsuccessful. Even more rare have been efforts to design programmatic interventions that would enact political reforms in countries hard-hit by infectious disease, and evaluate the health impact of these reforms. Operational work in the area of health and human rights has largely been confined to documentation and advocacy work by non-governmental organizations, and has gained little acceptance by the global health community.

If governments are to effectively address the political factors that shape infectious disease epidemics, greater collaboration between health experts, human rights advocates, and legal professionals is likely to be necessary. Human rights law suggests a full range of concrete and justifiable remedies for abuses that fuel infectious disease and impede civil society's response to it (Mann, 1996). Mechanisms of human rights accountability, such as courts, national human rights institutions, United Nations, and other multilateral procedures, and traditional "naming and shaming" techniques by non-governmental organizations have the ability to further human rights goals and thus have an impact on public health. Greater academic research into the precise links between democracy, human rights, and health can further assist policy-makers in implementing rights-based approaches with rigor and integrity. Tools such as the International Guidelines on HIV/AIDS and Human Rights, the Human Rights Impact Assessment (co-authored by Mann and Gostin), and extensive human rights documentation and advocacy by non-governmental organizations can further operationalize this approach by providing recommendations and policy guidance to governments (Gostin and Mann, 1994; Human Rights Watch, 2006a; Office of the High Commissioner for Human Rights and Joint United Nations Programme on HIV/AIDS, 2006).

Public support for grassroots health activists and community-based organizations, legal protection against political violence, detention, and other human rights abuses, and promotion of a robust and independent civil society should all be recognized as underpinnings for preventing and controlling future infectious epidemic diseases and improving overall health (Navarro, 1978; Committee on Economic, Social and Cultural Rights, 2000; Roth, 2004).

Ultimately, different infectious disease risks present different challenges in balancing human rights and public health goals in the response to epidemics. This balance should be determined by the epidemiologic characteristics of the disease and the methods available and practical for its control, and not by the level of social opprobrium against populations affected, societal discomfort with transmission through illicit or intimate behavior, or fear and ignorance.

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