The obligation to protect health

The written records of ancient China, Egypt, India, and Peru document humankind's earliest efforts to provide safe water, sewage, and drainage systems so as to protect public health. In the absence of a clear scientific understanding of infectious diseases, these efforts were largely linked to religious beliefs. City states in ancient Greece created sanitation systems for the entire community, and medical care for the poor. By the thirteenth century, Italian cities had laws modeled after ancient Roman standards to prevent epidemic disease through maintaining clean water supplies, controlling refuse disposal, and monitoring migrants to the city that might be carrying infectious disease (Kiple, 1995). The Elizabethan Poor Laws in Britain in the early seventeenth century strengthened the responsibility of local authorities for health and welfare. The Public Health Act of 1848, passed to improve sanitation in England and Wales, was one of the great milestones in public health history (Fee and Brown, 2005). By the twentieth century, the authority of local, state, and national governments was extended from sanitation and indigent medical care to activities such as chlorinating and fluoridating community water supplies, conducting insect vector control, screening and inoculating against infectious diseases, partner notification and tracking of sexually transmitted diseases, and regulating food, drugs, and the blood supply. Each of these actions acknowledged the widening responsibility of government to maintain and promote public health, especially in the area of infectious disease control.

In more recent years there has been an explicit recognition of the obligation of governments to protect health as a matter of human rights. The Universal Declaration of Human Rights (1948) recognizes that:

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

The UDHR further recognizes that all people are entitled to "realization ... of the economic, social and cultural rights indispensable for his dignity and the free development of his personality." Among the social rights recognized in the subsequently ratified International Covenant on Economic, Social and Cultural Rights is the right to "the highest attainable standard of health" (International Covenant on Economic, Social and Cultural Rights, 1966). Under this provision, governments are obligated to respect, protect, and fulfill the "right to health" by taking positive actions that ensure access to high-quality health services, and by refraining from or preventing negative actions that interfere with health, such as denying health care to certain populations or censoring health-related information. The right to the highest attainable standard of health is also intimately linked to the enjoyment of a full range of civil and political rights, such as the right to information, equality, and due process under law. So, for example, a government ban on the reporting of a newly identified infectious disease may violate the right to information under the International Covenant on Civil and Political Rights (1966) and also infringe upon the right to health by preventing individuals from protecting themselves from illness. Violence, discrimination, and arbitrary actions by the state also can have both direct and indirect public health impacts - for example, when police officers arbitrarily detain outreach workers providing life-saving HIV-prevention services, this implicates not only due process rights but also the health of those who benefit from these services (Human Rights Watch, 2006a).

While not always defined in the language of human rights obligations, epidemiologists, national governments, and international agencies have increasingly recognized that since health is shaped by the broadest spectrum of social, cultural, and political factors, the analysis of health status and programs designed to respond to poor health must take all of these factors into account. Areas of public health, such as health promotion, that traditionally emphasized individual lifestyle choices and personal responsibility are now being reframed to recognize broader influences on individual behaviors and broader responsibility of government for promoting healthy social environments. A milestone of this shift was the 1986 World Health Organization's Ottawa Charter, which set out five key areas of action for influencing healthy behaviors: building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services (WHO, 1986; Breslow, 1999). Critics of "black box" epidemiology, who advocated for more contextualized and structural analyses to be incorporated into epidemiological studies, mirrored this movement (Susser and Susser, 1996a, 1996b). The field of social epidemiology, which looks at social factors that shape disease vulnerability, also recognizes the important role of political context and human rights violations in fueling infectious disease spread.

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