Introduction

Political and economic transformations of our global community in recent years have been accompanied by a profound evolution—some might even call it a revolution—in the meaning of the term “human rights.” Once narrowly defined as a concept that referred primarily to the civil and legal rights of prisoners who were oppressed by authoritarian governments, human rights has taken on new dimensions in the post-Cold War era. Those who support human rights are no longer concerned only with the rights of individuals to fair trials or protection from cruel or unjust punishment. Rather, fundamental threats to life, liberty, and personal well-being throughout the world are often rooted in the political chaos or anarchy that has resulted from the disintegration of authoritarian states. Human rights issues today are therefore acquiring a new dimension that represents a powerful union of human rights law and humanitarian service traditions.

As physicians and health professionals, our traditional role in addressing human rights has focused on the need to protect and support colleagues who experienced unfair political reprisals that violate international human rights standards. The Institute of Medicine (IOM) and the National Academy of Sciences have advocated on behalf of hundreds of individual cases involving both well-known and unfamiliar health professionals who are detained, imprisoned, exiled, subject to death threats or who have disappeared for political reasons. We have sent missions of inquiry to Somalia, Chile, South Africa, and Guatemala to express concern about the physical safety and well-being of colleagues and students of science who may be at risk for politically motivated violence. The Committee on Health and Human Rights of the Institute of Medicine has also been authorized to take action on health-related abuses of



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Child Health and Human Rights Introduction Political and economic transformations of our global community in recent years have been accompanied by a profound evolution—some might even call it a revolution—in the meaning of the term “human rights.” Once narrowly defined as a concept that referred primarily to the civil and legal rights of prisoners who were oppressed by authoritarian governments, human rights has taken on new dimensions in the post-Cold War era. Those who support human rights are no longer concerned only with the rights of individuals to fair trials or protection from cruel or unjust punishment. Rather, fundamental threats to life, liberty, and personal well-being throughout the world are often rooted in the political chaos or anarchy that has resulted from the disintegration of authoritarian states. Human rights issues today are therefore acquiring a new dimension that represents a powerful union of human rights law and humanitarian service traditions. As physicians and health professionals, our traditional role in addressing human rights has focused on the need to protect and support colleagues who experienced unfair political reprisals that violate international human rights standards. The Institute of Medicine (IOM) and the National Academy of Sciences have advocated on behalf of hundreds of individual cases involving both well-known and unfamiliar health professionals who are detained, imprisoned, exiled, subject to death threats or who have disappeared for political reasons. We have sent missions of inquiry to Somalia, Chile, South Africa, and Guatemala to express concern about the physical safety and well-being of colleagues and students of science who may be at risk for politically motivated violence. The Committee on Health and Human Rights of the Institute of Medicine has also been authorized to take action on health-related abuses of

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Child Health and Human Rights human rights in the United States and elsewhere. On the evening of March 10, 1993, the IOM Committee on Health and Human Rights invited James P. Grant, executive director of the United Nations Children's Fund (UNICEF) to address the topic of child health and human rights at the National Academy of Sciences in Washington, D.C. This lecture marked an important transition in the human rights activities of the Institute of Medicine. Although casework on behalf of health professionals still lies at the heart of our human rights work, we realize that we must also address the special health needs of vulnerable populations who are victimized by war and civil disorder. When these victims of oppression are groups of women and children rather than individual well-known physicians, the nature of the human rights violations may be extremely difficult to document and assess, and our responses are often challenged by incomplete or contradictory information and the absence of reliable indicators or sources of expertise. Our response is also complicated by the absence of a conceptual and legal framework that can provide a clear rationale for humanitarian interventions that take precedence over national sovereignty. Through casework experience, however, we have learned that health professionals do have valuable skills and resources that can be applied effectively in addressing human rights violations. Physicians, nurses, and others can document individual cases of torture or the systematic use of violence (e.g., patterns of injury that corroborate deliberate violence directed against an individual or population group). Because of the international nature of our professional and collaborative efforts, health professionals can often elicit information from colleagues who treat such injuries and who cannot speak out locally without fear of recrimination. We have the capacity to collect diverse facts and prepare analytical reports that highlight key trends, data, and indicators of the nature of human rights abuses. In some cases, research fields such as genetics, forensic science, statistics, and other disciplines can make direct contributions by documenting the occurrence and scope of human rights violations. Such evidence can sometimes be valuable in investigative or legal proceedings organized by international human rights tribunals. Health professionals also possess a great deal of expertise and experience in the development of humanitarian relief efforts. Access to public health care and medical services in a wide range of areas—sanitation, potable water, sufficient nutrients, treatment of diarrheal diseases, and the vaccination of children—is essential to prevent public health disasters. The challenge before us is to devise ways that draw on our expertise effectively in situations characterized by conflict, uncertainty, and controversy. To meet this challenge, the IOM Committee on Health and Human Rights initiated a professional educational endeavor, of which this lecture is the first step. This undertaking is designed to stimulate discussion and reflection on the fundamental dimensions of the evolving framework for health and human rights, focusing on the following questions:

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Child Health and Human Rights What international legal standards guide and support the human rights concerns of health professionals? What is the relationship of these international standards to the humanitarian relief concerns of health professionals? What course of action is appropriate for organizations such as the Institute of Medicine in responding to the special health needs of vulnerable populations who suffer deprivation as a result of war or internal conflict? THE EMERGENCE OF CHILD HEALTH AS A HUMAN RIGHTS ISSUE The collapse of communism in the Soviet Union and other parts of the world has fostered democratic changes in many regions, but it has also become a dangerous source of political instability. In some regions, the disintegration of stable governments has given way, to anarchy, civil disorder, and internal conflict, spawning waves of refugees and immigrants replacing the heroic political dissidents who formed the focus of our human rights concerns in the past. A search for effective mechanisms to resolve tensions involving nationalism, ethnic hostilities, and civil chaos has fostered a new legitimacy for military interventions designed to ease human suffering and to restore political stability. The new concept of “humanitarian intervention ” has been bolstered by internationally sanctioned efforts designed to enforce the humane treatment of citizens during periods of political turmoil. In this new framework of humanitarian interventions, the role of private human rights organizations has become more complicated and uncertain. The emerging power of international human rights law has created a multitude of opportunities as well as challenges for organizations that have traditionally been concerned with a narrower scope of human rights activity. Because these groups are unaccustomed to serving large numbers of victims, they may be overwhelmed by the extent of the suffering of civilian populations. In order for private human rights organizations to operate effectively, a broad set of issues must be addressed by the health research community. Examples of such issues include the clarification of operating principles that should govern access to health resources by populations at risk for violence; the appropriate definition of medical neutrality for professionals who provide services to citizens in regions affected by civil disorder and violence; the quality of health care services for prisoners, refugees, and displaced populations; the use of international legal sanctions and military force in ensuring compliance with humanitarian standards; the appropriate means of delivery of effective health services for vulnerable groups, especially women, children, the elderly, and the disabled, in regions characterized by chronic violence and deprivation; the physical and psychosocial effects of

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Child Health and Human Rights violence and deprivation on human development; and the role of medical and forensic sciences in documenting the abuse of power, especially torture, executions, and inhumane treatment of prisoners and civilian populations. In addressing these issues, we have chosen to begin with the topic of child health. This choice has been guided by several principles and resources. First of all, a new International Convention on the Rights of the Child has been developed and ratified by 171 countries as of March 1994 and will soon be considered for ratification by our own Congress. The issue of child health and its relationship to the legal rights of the child, therefore, represents an important opportunity to consider the relationship between an emerging international legal standard and our own professional practice. Second, the deprivation and health needs of refugee children in various countries throughout the world have caught our attention repeatedly as we have witnessed the human suffering resulting from conflicts in Iran, South Africa, Bosnia, El Salvador, Somalia, Haiti, Rwanda, and elsewhere. The health and well-being of children in such situations are often important indicators of the welfare of an entire population, for if basic health services are denied to the most vulnerable group of a society, there is little doubt that adults will suffer as well. And the effect of increases of child mortality in any society are devastating to the families and their community. Finally, the area of child health is one in which the Institute of Medicine has acquired some special expertise as a result of a broad range of studies and workshops conducted in recent years. The IOM maintains an active program of studies related to child health and well being. In 1993, the Commission on Behavioral and Social Sciences and Education (CBASSE) and the IOM joined to establish a new entity, the Board on Children and Families, to provide a permanent and highly visible locus within the National Academy of Sciences for promoting a more effective alliance between those who produce scientific knowledge about children and families and those who use it to shape policies and programs. A number of specific IOM studies address child health issues (see Appendix D). In order to explore an important issue in the national health care reform debate, for instance, the IOM held a workshop in July 1994 on issues relating to women and children under health care reform. An earlier report anticipated the national health care reform debate and identified a number of specific health policy goals for pregnant women and children. A 1993 report explored the adequacy of emergency medical services for children in the United States, and suggested ways to make both services and systems more appropriate for children 's needs. Finally, another IOM committee is currently evaluating the nutrition risk criteria of the Special Supplemental Food Program for Women, Infants, and Children (WIC). In December 1993, the Board on Children and Families also conducted a workshop on overcoming barriers to immunization. This workshop explored and

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Child Health and Human Rights clarified the difficulties in immunizing young children, discussed efforts to overcome the problems, and served as a neutral venue to examine many of the current proposals for improving immunization coverage. A series of projects initiated by the 1986 National Childhood Vaccine Injury Act assessed the scientific and medical literature bearing on the causal relation between childhood vaccines and serious, adverse health outcomes. The information in these reports has been used by the Department of Health and Human Services to shape its national vaccine injury compensation program. An IOM report issued in 1991 evaluated the justifications for and appropriateness of screening newborns and pregnant women for HIV infection, taking into account the technological, medical, epidemiological, social, and ethical factors. Another congressionally mandated study is currently addressing the prevalence of Fetal Alcohol Syndrome and related conditions in the United States and the adequacy of federal efforts to reduce the incidence of such conditions. THE U.S. EXPERIENCE AS A TROUBLING EXAMPLE In recent years awareness has been growing of the poor record of the United States in fostering the health and social well-being of its children. It is a national disgrace that in the midst of our economic affluence we have such poor levels of infant immunization and prenatal care, resulting in inadequate child health status and child mortality. We have achieved tremendous progress in protecting our children from polio, whooping cough and other childhood infectious diseases, but without more complete immunizations, the picture will change, as it did for measles. Many American children today are not being immunized against traditional childhood diseases, not because our society lacks the resources for immunization, but because we have not committed ourselves to a public health strategy that stresses the importance of interventions directed toward improving the health status of all children. We must do better in protecting and supporting our sons and daughters. There are signs of progress that we need to examine and build upon. The U.S. government report A Culture of Caring, for example, represents a powerful document that could provide a strategic plan to implement many of the health goals of the International Convention of the Rights of the Child. Other reports, such as the 1993 World Development Report Investing in Health prepared by the World Bank, provide important indicators and statistics that measure the comparative burden of selected diseases on children and other age groups. In 1993, a UNICEF report observed that tremendous progress has been made in the last 50 years in addressing infant and child death rates, increasing life expectancy, and providing access to safe water for rural families. However, there

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Child Health and Human Rights is still much that needs to be done; UNICEF has estimated that an additional $25 billion a year is needed to meet the health, nutrition, education, and water and sanitation goals agreed to at the World Summit for Children plus resources for family planning goals. On average, less than 10 percent of the $40 billion a year in official development assistance (ODA) is devoted to basic social needs, amounting to $4 billion per year, about the same amount that our country alone pays for sports shoes each year. PREVENTION AND TREATMENT: NEXT STEPS As health professionals, we know that disease prevention efforts such as immunization, prenatal care, behavioral interventions, screening, and so forth, are preferable to waiting for disease and infection to start before offering treatment interventions. We also know that we have a responsibility to improve our ability to diagnose accurately and to recommend appropriate treatment for illness when prevention fails. In considering the health and welfare of children today, we need to recognize that other lethal threats have taken the place of disease and infection as killers of the young. The health of children in America today is increasingly threatened by guns and violence as well as disease or infection. In 1989, the National Committee for Injury Prevention and Control stated that child homicide is now among the five leading causes of death in childhood, accounting for one in every 20 deaths of people below the age of 18. In 1991, the National Center for Health Statistics indicated that over 4000 children age 0–19 were murdered in 1991 alone. In addressing the experiences of children whose lives have been affected by violence, we cannot lose sight of the complementary roles of prevention and treatment. The global statistics are staggering—officials from the UN High Commission on Refugees estimate that there are currently 20 million refugees, 10 million of whom are children. We increasingly see child residents in refugee camps, including refugee centers in the United States. How can we prevent such human tragedy? How can we treat such children effectively when prevention mechanisms for conflict resolution and the promotion of peace are so inadequate? One important step is to begin to mobilize awareness of and support for the U.S. ratification of the International Convention of the Rights of the Child. A second step is to address more forcefully the issues of equity and access to health resources that are central to discussions of global health care. A third is to examine with care the development reports of the United States government, the World Bank, and other international institutions and to understand the assumptions and rationale that guide strategic plans for international health investments.

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Child Health and Human Rights The challenge of making disease, injury, and violence prevention a worldwide mission in the interest of protecting children is a daunting task. But in this report we begin with an important asset—the expertise and insight of James P. Grant, who has been a forceful leader for decades on behalf of children throughout the world. It is our pleasure to introduce him as a champion of child health and human rights. We look forward to learning from him and to using his insights as a foundation for our own efforts in responding to the challenges that lie ahead. Elena O. Nightingale, M.D. Chair, IOM Human Rights Lecture Program Robert S. Lawrence, M.D. Chair, IOM Committee on Health and Human Rights

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