WORK A Journal of Prevention, Assessment " Rehabilitation
ELSEVIER
Work 7 (1996) 213-219
Global health issue
Human rights and health: a workshop for health professionals Donna McIvor Joss Occupational Therapy Department, Worcester State College, 486 Chandler St., Worcester, MA 01602, USA Keywords: Human Rights; Violations; Rehabilitation; Professional responsibility
1. Introduction
Human rights and health are inter-dependent entities. This is true for an individual and is equally valid for a community or a nation. It applies to physical, psychological, and spiritual health. It .also applies to economic, educational, social, environmental, and political well being. Health care professionals who are knowledgeable about human rights and their relationships to health are in a better position to design and implement programs and processes aimed at promoting and protecting the health and well-being of their patients and clients than are their colleagues without that information. These professionals are also better able to identify and carry out effective methods of physical, psychological, and spiritual healing for individuals, communities, and nations whose human rights have been violated. They are also prepared to make the most of opportunities to transmit information about human rights principles and practices to their
* Corresponding author. Tel.: + 1 5087938119; fax: + 1 508
7938192; email: [email protected]
patients and clients, therefore providing them with the means to recognize violations of their rights, and to protect themselves and others from such violations as well as from the negative impact the violations would have on their health. On a larger scale, a thorough knowledge of and determined respect for human rights can form the central principle upon which to build an institution, a community, or a nation, providing a frame of reference for decisions and priorities regarding health care, education, and social services. The purpose of this paper is to: • • • •
Establish a basic knowledge of current international human rights statements and their history; Discuss the extent to which these statements are relevant to individual populations and cultures; Discuss examples of various types of violations of human rights and their effect on physical, psychological, and spiritual health; Explore examples of strategies for the restoration of health following such violations;
1051-9815/96/$15.00 © 1996 Elsevier Science Ireland Ltd. All rights reserved. PIIS1051-9815(96)00208-2
214
•
D. McIvor Joss / Work 7 (1996) 213-219
Begin a dialogue about whether human rights should become a part of the curricula for health professions.
2. A summary of the contents of international human rights documents The Universal Declaration of Human Rights, adopted in 1948, and the two International Covenants on Human Rights, 1966, are the major documents from over 100 instruments concerned with human rights which have been adopted through the United Nations and regional organizations since 1945 (Marks, 1994). According to Stephen Marks, (1994), the statements contained in these documents can be roughly divided into four categories: civil and political rights; economic, social, and cultural rights; rights of peoples and minorities; and principles of application and interpretation. The statements related to these four categories are summarized below: (Columbia University, 1994). 2.1. Civil and political rights
1. Right to life, liberty and security 2. Prohibition of slavery and servitude, and of slave trade 3. Prohibition of torture and cruel, inhuman or degrading treatment or punishment 4. Right not to be arbitrarily arrested, detained, or exiled 5. Right to humane treatment under detention 6. Non-imprisonment for debt 7. Freedom of movement and residence within the borders of each State 8. Right to leave any country, including one's own 9. Right to return to one's own country 10. Right to seek and enjoy asylum from persecution in other countries 11. Right to be a nationality, and not to be deprived of nationality 12. Right to be considered innocent until proven guilty, 13. Right to a fair trial and legal personality
14. Prohibition of arbitrary interference with privacy, family, home, or correspondence 15. Non-expUlsion of aliens 16. Freedom of thought, conscience, and religion 17. Freedom of opinion and expression 18. Prohibition of war propaganda or advocacy of hatred constituting incitement 19. Freedom of assembly 20. Freedom of association 21. Right to marry 22. Equal rights of men and women during marriage and upon divorce 23. Rights of children 24. Rights of political participation 25. Right to equal protection under the law
22. Economic,
socia~
and cultural rights
1. Right to work 2. Right to just and favorable conditions of work 3. Trade union rights and right to strike 4. Right to security of a livelihood in the event of illness, old age or unemployment 5. Protection of family, mothers, and children 6. Right to an adequate standard of living including food, clothing, and housing 7. Right to medical care and necessary social services 8. Right to physical and mental health 9. Right to education, including free and compulsory primary education 10. Right to participate in cultural life 11. Right to enjoy benefits of scientific progress 12. Right of authors to benefit from their scientific, literary, or artistic production 13. Right to rest and leisure including reasonable work hours and holidays with pay
2.3. Rights of peoples and minorities
1. Right of peoples to self-determination 2. Right of peoples to permanent sovereignty over natural resources
D. Mcivor Joss / Work 7 (1996) 213-219
3.
Rights of ethnic, religious, and linguistic minorities
2.4. Principles of application and interpretation 1. Principle of progressive implementation of economic, social and cultural rights 2. Principle of realization of civil and political rights through legislative and other measures 3. Principle of nondiscrimination in respecting and ensuring rights 4. Right to an effective remedy for violations of civil and political rights 5. Principle of equal rights for men and women 6. Possibility of limitations and derogations 7. Right to the highest existing standard of pro'" 'tection For the full texts (English) of the documents from which these statements were summarized, I recommend 'Twenty-Five Human Rights Documents' (1994), Center for the Study of Human Rights, Columbia University, 420 West 118 St., 1108 International Affairs Building, New York, NY, 10027, USA. 3. Cultural relevance of existing human rights statements Any discussion of human rights as stated in existing documents must include the question of cultural relevance. It should be recognized that while the aim of the authors of these documents was universal applicability, the documents were based on cultural values, philosophies, and even the languages of the Western, developed nations. Asia, Africa, and the Arab World were represented poorly if at aU at the meetings from which these documents emerged. The extent to which the documents are applicable and appropriate to individual cultures and nations, as well as the way they are interpreted and implemented, are decisions which faU within the rights of those cultures and nations. The health of the nation, and the health of cultures, and the health of individuals within that nation, should all have equal priority during the decision-making process.
215
The cultural relevance provision should, under no circumstances, be used to excuse acts, even those that have been carried out for generations or centuries, when there is a clear violation of rights. Also, it does not excuse violations of the rights of one community, ethnic group, or nation by another on the pretense that it is done to protect their own cultural identity. It should also be recognized that, in the words of Stephen
Marks, 'The rights proclaimed in the covenants are fully respected nowhere, and that the full realization of these rights constitutes a platform for social transformation of revolutionary proportions (1994, p.299)'.
Since it was not the intent of the framers of the covenants to disrupt the stability of nations or cultures, their interpretation and implementation should be seen as a dynamic process requiring continuous self-study, dialogue, evaluation and adjustment. The extent to which this process occurs and the level of energy invested in the process will be proportional to the dynamic versus the static qualities of the nation involved. 4. Examples of how human rights violations affect health Human rights violations create an environment in which poverty, disease, and disability proliferate, and a population living in these conditions is highly vulnerable to further violations. Once human rights violations have occurred, the lengthy, complex, and expensive process required to obtain recognition of or compensation for violations is out of reach of the majority of individuals and groups in oppressed populations. Therefore, the effects of the violations help to perpetuate the conditions which allow and encourage further violations. The most blatant and violent human rights violations, such as exile, wrongful imprisonment, physical torture, the destruction of homes, and confiscation of property have immediate results that are relatively apparent. The exiled or imprisoned individual is kept from his family and from supporting it; he or she suffers the psychological
216
D. McIvorJoss /Work 7 (1996) 213-219
and physical consequences of separation and imprisonment. The family is at greater risk of health problems associated with poverty as well as the physical and psychological results of separation. A tortured individual is physically injured, possibly disabled permanently; psychological sequelae of torture can include depression, anxiety disorders, sleep disorders, and loss of self-esteem. The family whose house is destroyed must crowd in with relatives, live in a tent, or in some other temporary structure, resulting in stress and sleep disorders for family members. These are relatively immediate and short-term health consequences which are relatively predictable and often temporary. Unfortunately, these are not the only results of such human rights violations. The secondary, long-term health consequences are often more subtle, insidious, and severe. Consider one example of the potential effects of violations of human rights: according to a Human Rights Watch report (1994), in one 6-year period, as many as 50000 young Palestinian men were subjected to arrest, detention and interrogation that included some type of torture or illtreatment. Some of these arrests were for only a few days or weeks, but some were for several years. What will be the social, psychological, physiological, and developmental consequences of imprisonment for a young Arab male? What sort of role models did the prison experience provide for the detained adolescent? Will his values and morals become different from those of his family? Upon release, how will he relate to his family and peers who have not been exposed to the prison culture? Will his relationships with family and friends have been so disrupted that his social support systems outside prison are ineffective? Upon release, will he be able to resume his education? If not, will he be in a position to marry at an age appropriate to his culture, and be able to support a wife and family? Will the portion of these 50000 men who were in prison for several years develop long-term, chronic health problems as a result of poor nutrition, injuries during torture, lack of exercise, and excessive smoking? What psychological problems
will develop as a result of torture, isolation, or being separated from one's family? Will these physical and psychological problems interfere with the men's potential for success in education, employment, marriage, and the ability to bear and bring up children? What are the effects on the community and the nation when such a large number from one generation have suffered the prison experience and its consequences? Violations of economic, social, and cultural rights can also result in severe health consequences, both immediate and secondary. For example, the negative effect on child and maternal health of limited education, particularly for women, has been well established in both human rights and health literature (Gray, 1993). Loss of the opportunity to work has had a most visible effect in Gaza. The long-term effects of so many years of lost income for so many people, and all the related health implications are staggering to contemplate. For example, unemployment and high levels of stress may account for only part of the extremely high incidence of smoking among Palestinian males, but enough to attribute these factors with the responsibility of some of the tobacco-related diseases to be found in the population. These include the effects on the smoker's cardiovascular system, and the incidence of tobacco induced cancer. They also include the effects of 'second-hand' smoke on other members of the family, effects which are unusually powerful in populations living in refugee camp housing which is densely concentrated. The health consequences of human rights violations will depend on the nature, frequency, severity, scope and duration of the violations, as well as the importance of the particular violation to the individual, family or culture. Individuals and families frequently suffer multiple and repeated violations. It may be that years of repeated humiliation or frustrated aspirations are as detrimental to health as imprisonment or exile. According to Jonathan Mann and Sofia Gruskin (1995): Several lines of evidence suggest that regular and severe violations of individual or collective dignity have severe adverse effects on health. Yet, until or unless these impacts
D. McIvor Joss / Work 7 (1996) 213-219
on well-being are manifested in biomedically-recognized forms (e.g. hypertension, diabetes, heart disease, ulcers, psychosis), their existence as a health problem remains unclear and unvalidated.
Reliable and valid instruments to identify, measure, and predict short- and long-term effects on health of human rights violations are essential to document and track the incidence and prevalence of critical health problems, and to evaluate the effectiveness of various methods used to reduce both the violations and the extent of health consequences. The instruments should be appropriate to the culture, language, age, gender, and socioeconomic status of the individual, family, and community involved. 5. Strategies for the protection and restoration of health of victims of human rights violations Once violations of human rights have occurred, treatment can be divided into two types of intervention: immediate, acute-care treatment of apparent physical and psychological impairment; and prevention or rehabilitation of long-term disability. The following strategies focus primarily on preventing or remedying the long-term problems. This approach is appropriate for a population which has experienced numerous and repeated violations over many years. It also reflects a belief that it is the long-term problems, especially when they are cumulative in nature due to repeated violations, that produce a population which is highly vulnerable and unable to protect itself from further violations. Ultimately, the approach is both rehabilitative and preventive.
5.1. Strategies 1. Encourage, support, publicize and reward creative efforts of individuals and groups who have experienced the effects of violations of human rights. Sponsor festivals that provide a forum and audience for music, art, drama, poetry, photography, and literature. Put paint brushes, cameras, pens or word processors, musical instruments in the hands of people in at-risk groups: children, elders, former
217
prisoners, individuals who have been physically or psychologically traumatized, those who have lived their lives under occupation, in refugee camps, as transients fleeing economic, environmental, or political disasters, or as members of disempowered and persecuted groups. They all have experiences that demand expression. Make available the walls, auditoriums, and media of the community. Print their stories and poetry in newspapers and journals. Encourage them to play their music, act their plays, read their poetry and tell their stories in public gatherings, and on film. The arts provide a positive vehicle for the authentic expression of the effects of traumatic experiences. The creative process is therapeutic for the artist, and provides catharsis for the audiences who have had similar experiences. The entire body of Jewish Holocaust literature and art is an excellent example of the positive effects of the creative act. There are additional benefits of this approach. The creative efforts result in permanent documentation of events from the artist's perspective, which may be very different from the official history as construed by the news reporters, politicians, or historians. In addition, an artist can often reach individuals in a personal way that would not be possible through media such as newspaper articles or T.V. news broadcasts. By encouraging the development and practice of artistic skills, health providers can help their clients transform the negative effects of trauma into creative, productive energy. At the same time, they can help give the victims a means to inform a wider audience of their, and their people's, experiences. 2. Develop a corps of rehabilitation workers who are trained to treat holistically, that is, to treat psychological and physical problems concurrently, taking into consideration the patient's environment, culture, goals, priorities, and potential. Seek funds for members of populations whose rights have been violated to be educated as occupational therapists, psychologists, social workers and other appropriate health care specialists. Invite volunteer health professionals to train re-
218
D. McIvor Joss / Work 7 (1996) 213-219
habilitation workers in affected populations to treat individuals and groups who have been victims of human rights violations. Invite educators in the health professions to design educational curricula for these groups, to be implemented on-site. 3. Develop social and support groups for former prisoners, to provide a guided transition between prison and civilian society. Provide the groups with psychologists, occupational therapists, or social workers when appropriate, but give the members the right to develop their own agenda. 4. Offer family counseling and support groups for families with disabled members, former prisoners, and those who have suffered the death of a family member. 5. Emphasize the rights of women, recognize the vital and essential roles they play so incredibly well under such difficult circumstances. Respecting their independence, self-sufficiency, dignity, and responsibility is an effective method of promoting their human rights. Recognize that it is women who are most often responsible for the health of the family. 6. Emphasize the rights of elders, recognize their abilities and potential as well as their past contributions. Encourage their independence and self-sufficiency; give them a part in decision-making, especially about matters that affect them. 7. Emphasize the rights of disabled individuals; develop or support organizations which give disabled people a voice. Seek their advice about how to make society and the environment accessible and user friendly, responsive to their needs. 8. De-stigmatize physical and psychological disabilities through integration. Employ individuals who have overcome psychological problems, or who have obvious physical disabilities. Give disabled individuals positions which make them highly visible to the lay public whenever appropriate, so that the public will begin to take their presence and competence as a matter of course. Integrate children with disabilities into public schools whenever possible so that able-bodied children will learn to work and play with them. 9. Encourage and support the development of adult education and job training programs. Target
disabled individuals, those recovering from psychological trauma, former prisoners, women, and any adults who have had to interrupt or give up their education for any reason. Make adult education convenient, local, sensitive to adult learning styles and schedules, and meaningful to adult values and priorities. 10. Encourage longitudinal studies which document the consequences of various categories of human rights violations, and how consequences vary with age, gender and other socio-economic variables, and the effectiveness of various treatment approaches. 6. Human rights education for health professionals Professionals in health care and education are in a position to be powerfully effective in reducing the incidence of human rights violations and in limiting their deleterious effects on health when they do occur. Prevention starts with education. Most educational curricula in the health professions address human rights only in the limited sense of patients' rights in clinical and research situations. Most curricula need greater emphasis on the professional's responsibility to respect and protect the human rights of patients and students, and to educate their constituents about human rights. The content of the curricula on human rights should include information on the history and content of the internationally recognized human rights documents, their appropriate implementation, how to recognize and document human rights violations, and sources of advocacy and support for victims of violations. Especially important is the content which addresses methods of treating the physical and psychological effects of violations and approaches to communication which will avoid reinforcing the effects of the trauma. The curricula should also provide health professionals with the skills and motivation to teach others to understand and defend their rights. One curriculum in human rights which was designed for Cambodian health professionals is an excellent example of a program which meets the above criteria and is responsive to the social,
D. McIvor Joss / Work 7 (1996) 213-219
political, religious and cultural character of Cambodia (Keller et al., 1995). The curriculum consists of ten 2-hour sessions which include case studies to provide practical examples of clinical situations where health professionals and human rights violations intersect. The content of the sessions is as follows: 1. What are human rights? Why is it important for health professionals to learn about them? 2. The universal declaration of human rights and its significance for health professionals. 3. The right to health care 4. Professional responsibilities 5. Communication skills for health professionals 6. The medical history and physical examination of human rights abuse 7. Human rights and health care for women and children 8. Land mines, torture, and the responsibilities of health professionals 9. Mental health and human rights 10. The role of health professionals in protecting human rights As with all aspects of human rights, an educational program for health professionals would be designed for the particular discipline, language, and culture of the professionals, and would emphasize the most important aspects of the human rights situations they would be likely to encounter.
219
Acknowledgements An earlier version of this paper was presented at the Second International Conference, 'Palestinians in transition: rehabilitation and community development', sponsored by the Gaza Community Mental Health Programme, September
13-15, 1995.
The examples and observations in this paper, as well as the ideas for the intervention strategies are based on 6 years of work and communication with Palestinians both inside and outside Palestine, including a short but intense period of clinical practice as an occupational therapist in the West Bank during the 5 months prior to the Gulf War. I am indebted to my Palestinian friends, patients, and colleagues. References Columbia University (1994) Twenty-Five Human Rights Documents, Center for the Study of Human Rights, N.Y. Gray, A. (1993) Mortality and morbidity: causes and determinants. In: Gray, A. (Ed.), World Health and Disease, Open University Press, Buckingham, UK, pp. 21-37. Keller, C., Hom, S.K., Sopheap, S. and OUerman, G. (1995) Human Rights Education for Cambodian Health Professionals. Health Hum. Rights 1, 256-27l. Mann, J. and Gruskin, S. (1995) Women's Health and Human Rights: Genesis of the Health and Human Rights Movement. Health Hum. Rights 1, 309-312. Marks, S. (1994) Promoting Human Rights, In: Glare, M. and Thomas, D. (Eds.), World Security, Trends and Challenges At Century's End, St. Martin's Press, NY.
ELSEVIER
Work 7 (1996) 213-219
Global health issue
Human rights and health: a workshop for health professionals Donna McIvor Joss Occupational Therapy Department, Worcester State College, 486 Chandler St., Worcester, MA 01602, USA Keywords: Human Rights; Violations; Rehabilitation; Professional responsibility
1. Introduction
Human rights and health are inter-dependent entities. This is true for an individual and is equally valid for a community or a nation. It applies to physical, psychological, and spiritual health. It .also applies to economic, educational, social, environmental, and political well being. Health care professionals who are knowledgeable about human rights and their relationships to health are in a better position to design and implement programs and processes aimed at promoting and protecting the health and well-being of their patients and clients than are their colleagues without that information. These professionals are also better able to identify and carry out effective methods of physical, psychological, and spiritual healing for individuals, communities, and nations whose human rights have been violated. They are also prepared to make the most of opportunities to transmit information about human rights principles and practices to their
* Corresponding author. Tel.: + 1 5087938119; fax: + 1 508
7938192; email: [email protected]
patients and clients, therefore providing them with the means to recognize violations of their rights, and to protect themselves and others from such violations as well as from the negative impact the violations would have on their health. On a larger scale, a thorough knowledge of and determined respect for human rights can form the central principle upon which to build an institution, a community, or a nation, providing a frame of reference for decisions and priorities regarding health care, education, and social services. The purpose of this paper is to: • • • •
Establish a basic knowledge of current international human rights statements and their history; Discuss the extent to which these statements are relevant to individual populations and cultures; Discuss examples of various types of violations of human rights and their effect on physical, psychological, and spiritual health; Explore examples of strategies for the restoration of health following such violations;
1051-9815/96/$15.00 © 1996 Elsevier Science Ireland Ltd. All rights reserved. PIIS1051-9815(96)00208-2
214
•
D. McIvor Joss / Work 7 (1996) 213-219
Begin a dialogue about whether human rights should become a part of the curricula for health professions.
2. A summary of the contents of international human rights documents The Universal Declaration of Human Rights, adopted in 1948, and the two International Covenants on Human Rights, 1966, are the major documents from over 100 instruments concerned with human rights which have been adopted through the United Nations and regional organizations since 1945 (Marks, 1994). According to Stephen Marks, (1994), the statements contained in these documents can be roughly divided into four categories: civil and political rights; economic, social, and cultural rights; rights of peoples and minorities; and principles of application and interpretation. The statements related to these four categories are summarized below: (Columbia University, 1994). 2.1. Civil and political rights
1. Right to life, liberty and security 2. Prohibition of slavery and servitude, and of slave trade 3. Prohibition of torture and cruel, inhuman or degrading treatment or punishment 4. Right not to be arbitrarily arrested, detained, or exiled 5. Right to humane treatment under detention 6. Non-imprisonment for debt 7. Freedom of movement and residence within the borders of each State 8. Right to leave any country, including one's own 9. Right to return to one's own country 10. Right to seek and enjoy asylum from persecution in other countries 11. Right to be a nationality, and not to be deprived of nationality 12. Right to be considered innocent until proven guilty, 13. Right to a fair trial and legal personality
14. Prohibition of arbitrary interference with privacy, family, home, or correspondence 15. Non-expUlsion of aliens 16. Freedom of thought, conscience, and religion 17. Freedom of opinion and expression 18. Prohibition of war propaganda or advocacy of hatred constituting incitement 19. Freedom of assembly 20. Freedom of association 21. Right to marry 22. Equal rights of men and women during marriage and upon divorce 23. Rights of children 24. Rights of political participation 25. Right to equal protection under the law
22. Economic,
socia~
and cultural rights
1. Right to work 2. Right to just and favorable conditions of work 3. Trade union rights and right to strike 4. Right to security of a livelihood in the event of illness, old age or unemployment 5. Protection of family, mothers, and children 6. Right to an adequate standard of living including food, clothing, and housing 7. Right to medical care and necessary social services 8. Right to physical and mental health 9. Right to education, including free and compulsory primary education 10. Right to participate in cultural life 11. Right to enjoy benefits of scientific progress 12. Right of authors to benefit from their scientific, literary, or artistic production 13. Right to rest and leisure including reasonable work hours and holidays with pay
2.3. Rights of peoples and minorities
1. Right of peoples to self-determination 2. Right of peoples to permanent sovereignty over natural resources
D. Mcivor Joss / Work 7 (1996) 213-219
3.
Rights of ethnic, religious, and linguistic minorities
2.4. Principles of application and interpretation 1. Principle of progressive implementation of economic, social and cultural rights 2. Principle of realization of civil and political rights through legislative and other measures 3. Principle of nondiscrimination in respecting and ensuring rights 4. Right to an effective remedy for violations of civil and political rights 5. Principle of equal rights for men and women 6. Possibility of limitations and derogations 7. Right to the highest existing standard of pro'" 'tection For the full texts (English) of the documents from which these statements were summarized, I recommend 'Twenty-Five Human Rights Documents' (1994), Center for the Study of Human Rights, Columbia University, 420 West 118 St., 1108 International Affairs Building, New York, NY, 10027, USA. 3. Cultural relevance of existing human rights statements Any discussion of human rights as stated in existing documents must include the question of cultural relevance. It should be recognized that while the aim of the authors of these documents was universal applicability, the documents were based on cultural values, philosophies, and even the languages of the Western, developed nations. Asia, Africa, and the Arab World were represented poorly if at aU at the meetings from which these documents emerged. The extent to which the documents are applicable and appropriate to individual cultures and nations, as well as the way they are interpreted and implemented, are decisions which faU within the rights of those cultures and nations. The health of the nation, and the health of cultures, and the health of individuals within that nation, should all have equal priority during the decision-making process.
215
The cultural relevance provision should, under no circumstances, be used to excuse acts, even those that have been carried out for generations or centuries, when there is a clear violation of rights. Also, it does not excuse violations of the rights of one community, ethnic group, or nation by another on the pretense that it is done to protect their own cultural identity. It should also be recognized that, in the words of Stephen
Marks, 'The rights proclaimed in the covenants are fully respected nowhere, and that the full realization of these rights constitutes a platform for social transformation of revolutionary proportions (1994, p.299)'.
Since it was not the intent of the framers of the covenants to disrupt the stability of nations or cultures, their interpretation and implementation should be seen as a dynamic process requiring continuous self-study, dialogue, evaluation and adjustment. The extent to which this process occurs and the level of energy invested in the process will be proportional to the dynamic versus the static qualities of the nation involved. 4. Examples of how human rights violations affect health Human rights violations create an environment in which poverty, disease, and disability proliferate, and a population living in these conditions is highly vulnerable to further violations. Once human rights violations have occurred, the lengthy, complex, and expensive process required to obtain recognition of or compensation for violations is out of reach of the majority of individuals and groups in oppressed populations. Therefore, the effects of the violations help to perpetuate the conditions which allow and encourage further violations. The most blatant and violent human rights violations, such as exile, wrongful imprisonment, physical torture, the destruction of homes, and confiscation of property have immediate results that are relatively apparent. The exiled or imprisoned individual is kept from his family and from supporting it; he or she suffers the psychological
216
D. McIvorJoss /Work 7 (1996) 213-219
and physical consequences of separation and imprisonment. The family is at greater risk of health problems associated with poverty as well as the physical and psychological results of separation. A tortured individual is physically injured, possibly disabled permanently; psychological sequelae of torture can include depression, anxiety disorders, sleep disorders, and loss of self-esteem. The family whose house is destroyed must crowd in with relatives, live in a tent, or in some other temporary structure, resulting in stress and sleep disorders for family members. These are relatively immediate and short-term health consequences which are relatively predictable and often temporary. Unfortunately, these are not the only results of such human rights violations. The secondary, long-term health consequences are often more subtle, insidious, and severe. Consider one example of the potential effects of violations of human rights: according to a Human Rights Watch report (1994), in one 6-year period, as many as 50000 young Palestinian men were subjected to arrest, detention and interrogation that included some type of torture or illtreatment. Some of these arrests were for only a few days or weeks, but some were for several years. What will be the social, psychological, physiological, and developmental consequences of imprisonment for a young Arab male? What sort of role models did the prison experience provide for the detained adolescent? Will his values and morals become different from those of his family? Upon release, how will he relate to his family and peers who have not been exposed to the prison culture? Will his relationships with family and friends have been so disrupted that his social support systems outside prison are ineffective? Upon release, will he be able to resume his education? If not, will he be in a position to marry at an age appropriate to his culture, and be able to support a wife and family? Will the portion of these 50000 men who were in prison for several years develop long-term, chronic health problems as a result of poor nutrition, injuries during torture, lack of exercise, and excessive smoking? What psychological problems
will develop as a result of torture, isolation, or being separated from one's family? Will these physical and psychological problems interfere with the men's potential for success in education, employment, marriage, and the ability to bear and bring up children? What are the effects on the community and the nation when such a large number from one generation have suffered the prison experience and its consequences? Violations of economic, social, and cultural rights can also result in severe health consequences, both immediate and secondary. For example, the negative effect on child and maternal health of limited education, particularly for women, has been well established in both human rights and health literature (Gray, 1993). Loss of the opportunity to work has had a most visible effect in Gaza. The long-term effects of so many years of lost income for so many people, and all the related health implications are staggering to contemplate. For example, unemployment and high levels of stress may account for only part of the extremely high incidence of smoking among Palestinian males, but enough to attribute these factors with the responsibility of some of the tobacco-related diseases to be found in the population. These include the effects on the smoker's cardiovascular system, and the incidence of tobacco induced cancer. They also include the effects of 'second-hand' smoke on other members of the family, effects which are unusually powerful in populations living in refugee camp housing which is densely concentrated. The health consequences of human rights violations will depend on the nature, frequency, severity, scope and duration of the violations, as well as the importance of the particular violation to the individual, family or culture. Individuals and families frequently suffer multiple and repeated violations. It may be that years of repeated humiliation or frustrated aspirations are as detrimental to health as imprisonment or exile. According to Jonathan Mann and Sofia Gruskin (1995): Several lines of evidence suggest that regular and severe violations of individual or collective dignity have severe adverse effects on health. Yet, until or unless these impacts
D. McIvor Joss / Work 7 (1996) 213-219
on well-being are manifested in biomedically-recognized forms (e.g. hypertension, diabetes, heart disease, ulcers, psychosis), their existence as a health problem remains unclear and unvalidated.
Reliable and valid instruments to identify, measure, and predict short- and long-term effects on health of human rights violations are essential to document and track the incidence and prevalence of critical health problems, and to evaluate the effectiveness of various methods used to reduce both the violations and the extent of health consequences. The instruments should be appropriate to the culture, language, age, gender, and socioeconomic status of the individual, family, and community involved. 5. Strategies for the protection and restoration of health of victims of human rights violations Once violations of human rights have occurred, treatment can be divided into two types of intervention: immediate, acute-care treatment of apparent physical and psychological impairment; and prevention or rehabilitation of long-term disability. The following strategies focus primarily on preventing or remedying the long-term problems. This approach is appropriate for a population which has experienced numerous and repeated violations over many years. It also reflects a belief that it is the long-term problems, especially when they are cumulative in nature due to repeated violations, that produce a population which is highly vulnerable and unable to protect itself from further violations. Ultimately, the approach is both rehabilitative and preventive.
5.1. Strategies 1. Encourage, support, publicize and reward creative efforts of individuals and groups who have experienced the effects of violations of human rights. Sponsor festivals that provide a forum and audience for music, art, drama, poetry, photography, and literature. Put paint brushes, cameras, pens or word processors, musical instruments in the hands of people in at-risk groups: children, elders, former
217
prisoners, individuals who have been physically or psychologically traumatized, those who have lived their lives under occupation, in refugee camps, as transients fleeing economic, environmental, or political disasters, or as members of disempowered and persecuted groups. They all have experiences that demand expression. Make available the walls, auditoriums, and media of the community. Print their stories and poetry in newspapers and journals. Encourage them to play their music, act their plays, read their poetry and tell their stories in public gatherings, and on film. The arts provide a positive vehicle for the authentic expression of the effects of traumatic experiences. The creative process is therapeutic for the artist, and provides catharsis for the audiences who have had similar experiences. The entire body of Jewish Holocaust literature and art is an excellent example of the positive effects of the creative act. There are additional benefits of this approach. The creative efforts result in permanent documentation of events from the artist's perspective, which may be very different from the official history as construed by the news reporters, politicians, or historians. In addition, an artist can often reach individuals in a personal way that would not be possible through media such as newspaper articles or T.V. news broadcasts. By encouraging the development and practice of artistic skills, health providers can help their clients transform the negative effects of trauma into creative, productive energy. At the same time, they can help give the victims a means to inform a wider audience of their, and their people's, experiences. 2. Develop a corps of rehabilitation workers who are trained to treat holistically, that is, to treat psychological and physical problems concurrently, taking into consideration the patient's environment, culture, goals, priorities, and potential. Seek funds for members of populations whose rights have been violated to be educated as occupational therapists, psychologists, social workers and other appropriate health care specialists. Invite volunteer health professionals to train re-
218
D. McIvor Joss / Work 7 (1996) 213-219
habilitation workers in affected populations to treat individuals and groups who have been victims of human rights violations. Invite educators in the health professions to design educational curricula for these groups, to be implemented on-site. 3. Develop social and support groups for former prisoners, to provide a guided transition between prison and civilian society. Provide the groups with psychologists, occupational therapists, or social workers when appropriate, but give the members the right to develop their own agenda. 4. Offer family counseling and support groups for families with disabled members, former prisoners, and those who have suffered the death of a family member. 5. Emphasize the rights of women, recognize the vital and essential roles they play so incredibly well under such difficult circumstances. Respecting their independence, self-sufficiency, dignity, and responsibility is an effective method of promoting their human rights. Recognize that it is women who are most often responsible for the health of the family. 6. Emphasize the rights of elders, recognize their abilities and potential as well as their past contributions. Encourage their independence and self-sufficiency; give them a part in decision-making, especially about matters that affect them. 7. Emphasize the rights of disabled individuals; develop or support organizations which give disabled people a voice. Seek their advice about how to make society and the environment accessible and user friendly, responsive to their needs. 8. De-stigmatize physical and psychological disabilities through integration. Employ individuals who have overcome psychological problems, or who have obvious physical disabilities. Give disabled individuals positions which make them highly visible to the lay public whenever appropriate, so that the public will begin to take their presence and competence as a matter of course. Integrate children with disabilities into public schools whenever possible so that able-bodied children will learn to work and play with them. 9. Encourage and support the development of adult education and job training programs. Target
disabled individuals, those recovering from psychological trauma, former prisoners, women, and any adults who have had to interrupt or give up their education for any reason. Make adult education convenient, local, sensitive to adult learning styles and schedules, and meaningful to adult values and priorities. 10. Encourage longitudinal studies which document the consequences of various categories of human rights violations, and how consequences vary with age, gender and other socio-economic variables, and the effectiveness of various treatment approaches. 6. Human rights education for health professionals Professionals in health care and education are in a position to be powerfully effective in reducing the incidence of human rights violations and in limiting their deleterious effects on health when they do occur. Prevention starts with education. Most educational curricula in the health professions address human rights only in the limited sense of patients' rights in clinical and research situations. Most curricula need greater emphasis on the professional's responsibility to respect and protect the human rights of patients and students, and to educate their constituents about human rights. The content of the curricula on human rights should include information on the history and content of the internationally recognized human rights documents, their appropriate implementation, how to recognize and document human rights violations, and sources of advocacy and support for victims of violations. Especially important is the content which addresses methods of treating the physical and psychological effects of violations and approaches to communication which will avoid reinforcing the effects of the trauma. The curricula should also provide health professionals with the skills and motivation to teach others to understand and defend their rights. One curriculum in human rights which was designed for Cambodian health professionals is an excellent example of a program which meets the above criteria and is responsive to the social,
D. McIvor Joss / Work 7 (1996) 213-219
political, religious and cultural character of Cambodia (Keller et al., 1995). The curriculum consists of ten 2-hour sessions which include case studies to provide practical examples of clinical situations where health professionals and human rights violations intersect. The content of the sessions is as follows: 1. What are human rights? Why is it important for health professionals to learn about them? 2. The universal declaration of human rights and its significance for health professionals. 3. The right to health care 4. Professional responsibilities 5. Communication skills for health professionals 6. The medical history and physical examination of human rights abuse 7. Human rights and health care for women and children 8. Land mines, torture, and the responsibilities of health professionals 9. Mental health and human rights 10. The role of health professionals in protecting human rights As with all aspects of human rights, an educational program for health professionals would be designed for the particular discipline, language, and culture of the professionals, and would emphasize the most important aspects of the human rights situations they would be likely to encounter.
219
Acknowledgements An earlier version of this paper was presented at the Second International Conference, 'Palestinians in transition: rehabilitation and community development', sponsored by the Gaza Community Mental Health Programme, September
13-15, 1995.
The examples and observations in this paper, as well as the ideas for the intervention strategies are based on 6 years of work and communication with Palestinians both inside and outside Palestine, including a short but intense period of clinical practice as an occupational therapist in the West Bank during the 5 months prior to the Gulf War. I am indebted to my Palestinian friends, patients, and colleagues. References Columbia University (1994) Twenty-Five Human Rights Documents, Center for the Study of Human Rights, N.Y. Gray, A. (1993) Mortality and morbidity: causes and determinants. In: Gray, A. (Ed.), World Health and Disease, Open University Press, Buckingham, UK, pp. 21-37. Keller, C., Hom, S.K., Sopheap, S. and OUerman, G. (1995) Human Rights Education for Cambodian Health Professionals. Health Hum. Rights 1, 256-27l. Mann, J. and Gruskin, S. (1995) Women's Health and Human Rights: Genesis of the Health and Human Rights Movement. Health Hum. Rights 1, 309-312. Marks, S. (1994) Promoting Human Rights, In: Glare, M. and Thomas, D. (Eds.), World Security, Trends and Challenges At Century's End, St. Martin's Press, NY.
