Health Care is a Right, not a Privilege

“If you have your health, you have everything,” the classic saying goes. This is obviously not perfectly accurate, as many healthy people certainly do not have everything. However, it does reflect the connection that the right to health has to other human rights, and the interdependency that all human rights have with each other. Poor health can keep us from going to school or to work, caring for our families, or fully participating in our communities. States are responsible for respecting, protecting and fulfilling their human rights obligations, with international, regional, national and local actors supporting states and holding them accountable. The right to health exists, distinct from traditional political and civil rights, and there is an entire global apparatus built around making the right meaningful and real. I will spend this year exploring and evaluating these systems and human rights frameworks, seeking to understand how to best implement the human right to health.

The right to health was first recognized in the 1946 World Health Organization (WHO) constitution, which states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” The right to health was also affirmed in the Universal Declaration of Human Rights in 1948 and in the International Covenant on Economic, Social and Cultural Rights (ICESCR) in 1966. States that ratify the ICESCR are bound by international law to protect the right to health with “progressive realization.” This means that states must do everything they can to the best of their available resources. Subsequent human rights instruments address the right to health, including the Convention on the Rights of the Child in 1989 and the Convention on the Rights of Persons with Disabilities in 2006. Every state in the world is now party to at least one human rights treaty that addresses health-related rights. The treaty bodies that monitor the Conventions have made general comments and recommendations on health-related rights issues, providing an authoritative interpretation of what the right to health means. Although a common criticism of the right to health is that it is difficult to define, it has been increasingly specified by a variety of governance actors. International conferences and declarations, such as the UN Sustainable Development Goals, also delineate what the right to health means. States enact domestic legislation and policies that further their commitment; at least 121 constitutions recognize their governments’ health related duties. 

So what does the right to health mean? States are obligated to fulfill the right through the provision of access to health care and hospitals, safe drinking water and sanitation, and food and housing. It entitles people to a system of disease prevention, treatment and control with access to essential medicines. It extends beyond these entitlements to people’s freedoms, such as the freedom to say no to medical treatment. It relates to a range of health determinants, including gender equality, healthy working conditions, and health-related education. The right to health is not the right to be healthy, which is outside of states’ direct control. This is why it is referred to as the right to the “highest attainable standard” of health. UN bodies, specialized agencies, the private sector, and even health professionals have responsibilities related to the right to health. The nature of businesses’ specific obligations are a bit unclear, and states are ultimately accountable for human rights violations, but there is a growing effort to define human rights standards that are applicable to businesses.

The right to health is idealistic in many ways, but it can be monitored and enforced. Accountability and monitoring take place at national, regional and international levels with involvement from states, NGOs, national human rights institutions, international treaty bodies and UN Special Rapporteurs. At the national level, administrative and political mechanisms contribute to accountability, such as national health policies and budgets. National judicial mechanisms can provide legal remedies to individuals when their rights are violated. Incorporating the right to health into national or subnational laws allows courts to judge violations with direct reference to the ICESCR. For example, Argentinian courts have ruled that the state must guarantee an available supply of antiretroviral drugs to people who are HIV-positive. Additionally, the Treatment Action Campaign in South Africa illustrates the ability of NGOs to use advocacy and social mobilization to fight for the right to health in its work for equal access to HIV treatment. In 2001, the Pretoria High Court ruled in favor of the Treatment Action Campaign and held that government restrictions on the drug nevirapine were unconstitutional, since the drug was proven to be effective but the government decided that it could only be distributed at two research sites. The Constitutional Court upheld the Pretoria ruling, stating that the government’s policy did not meet South Africa’s constitutional obligations to provide access to health care that “takes account of pressing social needs.” The government then removed nevirapine restrictions at public hospitals and clinics and created a comprehensive program to progressively realize the rights of pregnant women to prevent mother-to-child HIV transmission.

A World Health Organization official give a dose of Polio Vaccine to Somali child in Mogadishu, Somalia, Monday, Sept. 11, 2006. (AP Photo/Mohamed Sheikh Nor)
At the international level, UN Treaty Bodies, along with the UN Special Rapporteur on the right to health, implement human rights treaties. Each treaty is monitored by a committee, which evaluates governments and issues recommendations for further action. Several committees have individual complaints mechanisms, where those who claim to be victims of human rights violations can submit complaints. 

Through this series of blog posts, I will write about the usefulness of the human rights framework to global health endeavors. I strongly believe that, as the UN High Commissioner on Human Rights and WHO have stated, “The right to health is a fundamental part of our human rights and of our understanding of a life in dignity.” Physical and mental health allow adults to work and children to learn. The right to health cannot be realized without the realization of other rights that exist at the root of poverty, such as the rights to food, housing and water. Through exploring victories and pitfalls, I want to improve our understanding of how to best implement the right to health in practice. Achieving health equity worldwide requires innovative and interdisciplinary work, which necessitates a comprehensive understanding of international human rights law and governance.

Evidence for Concern Outweighed by Evidence for Hope

“It is my aspiration that health finally will be seen not as a blessing to be wished for, but as a human right to be fought for,” said UN Secretary-General Kofi Annan. The human rights framework creates a platform to fight for the human right to health, facilitating international mechanisms for monitoring and accountability and mobilizing civil society to claim their own rights. My first blog post outlined some of the mechanisms in place that can be leveraged to protect and advocate for the right to health, including NGOs’ social mobilization, UN treaty bodies and national health policies. Despite its utility, the human rights framework has flaws that must be identified and discussed. There is a lack of international consensus on the nature and scope of health-related rights and state obligations. Although the consensus is growing, many states, including the U.S., disagree with the Office of the United Nations High Commissioner for Human Rights (OHCHR)’s Fact Sheet 31, which seeks to define the right to health. The United States considers the fact sheet to be misleading in its legal conclusions about the obligations of states, including “equal and timely access to basic health services” and “participation of the population in health-related decision-making at the national and community levels.” The U.S. has even stated that the legal conclusions in the Fact Sheet do not foster respect for international law, viewing them as policy objectives that have been morphed into assertions of legal obligation that do not meet international law standards. The U.S. finds it problematic that so much of what the Fact Sheet asserts to be included in the right to health is not actually being implemented in most states, and thinks that much of what the Fact Sheet delineates cannot be implemented at the national level. 

The United States’ criticism elucidates a key issue with progressively realized rights. The idea behind progressive realization is that, although resource constraints limit states’ abilities to protect and fulfill human rights obligations, they should take appropriate measures towards full realization to the maximum of their available resources. Although the provision of health care can be limited by resource constraints and thus falls under progressive realization, states are obligated to eliminate discrimination and to “take steps.” In relation to the right to health, it is difficult to determine if a country is taking sufficient steps for progressive realization. UN treaty bodies and the Special Rapporteur on the right to the highest attainable standard of health conduct this monitoring and oversight work at the international level. It is much more difficult to determine if a country is working hard enough toward certain goals than if it has actually met those goals, and this murky ground in accountability and monitoring that comes with progressive realization is a significant obstacle.

However, UN treaty bodies and the Special Rapporteur are not alone in efforts to monitor the right to health and to hold states accountable. The human rights framework empowers individuals to claim their own rights. To me, the most compelling work of human rights is in impacting civil society and creating stakeholders on the ground who can pressure governments, expose gaps in health care, and advocate for rights to be implemented.

A protester waves a placard during a rally, Friday, June 23, 2017, in downtown Denver, against the Republican health bill that was recently unveiled in the U.S. Senate. More than 100 protesters crowded the sidewalk outside the building in which U.S. Sen. Cory Gardner, R-Colo., has his office. (AP Photo/David Zalubowski)
The rights-based approach to health care also faces deep political challenges. Atul Gawande, a writer for The New Yorker, discussed the right to health care in the United States in a recent article that chronicles Americans’ varying opinions, looking for common ground. To some Americans, the idea of a right to health care is unsettling because it fails to distinguish between the deserving and the undeserving, those who work for it and those who do not. Other Americans Gawande spoke to, like one man named Arnold, think about it differently. Arnold said, “I think the goal should be security. Not just financial security but mental security—knowing that, no matter how bad things get, this shouldn’t be what you worry about. We don’t worry about the Fire Department, or the police. We don’t worry about the roads we travel on. And it’s not, like, ‘Here’s the traffic lane for the ones who did well and saved money, and you poor people, you have to drive over here. Somebody I know said to me, ‘If we give everybody health care, it’ll be abused.’ I told her that’s a risk we take. The roads are abused. A lot of things are abused. It’s part of the deal.” This deal is where health care breaks down in America. Policy is never perfect, and some people will almost always take out more while others put in more. Necessities like health care can only be provided through “collective effort and shared costs,” but when there is so much variety in what different people put into and get out of the system, the belief in the right breaks down. This creates a political obstacle to a rights-based approach to health. 

Although the feasibility, definition and political support of the right to health are significant obstacles, there is ample evidence that the human rights framework is making our world a healthier, more equitable place. For example, there has been a paradigm shift in recognizing the rights of people with disabilities. They are no longer viewed as objects of medical treatment or charity, but as people who are capable of making their own decisions and exercising their rights, especially related to their health care. Additionally, the Treatment Action Campaign (TAC), an NGO in South Africa, successfully pressured companies to provide antiretroviral drugs to African countries at lower prices by utilizing a rights-based approach and human rights language. Moreover, during August 2017 in Chile, the Constitutional Court ruled in favor of a bill that approved several exceptions to the criminalization of abortion, illustrating improved recognition of women’s rights, although implementation of the law is still a challenge.

Members of The Treatment Action Campaign (TAC) during their protest in Pretoria, South Africa, Tuesday, May 30, 2006. (AP Photo/Themba Hadebe)
It is difficult to make causal connections between human rights work and improvements in health outcomes. Although evaluating the effectiveness of human rights frameworks is a challenge, Kathryn Sikkink, a professor of human rights policy, argues in her book Evidence for Hope that human rights movements have been vastly effective. Sikkink illustrates that activists and scholars use different yardsticks to measure progress, leading to disagreements about the efficacy of human rights, but her investigation into current trends shows that human rights are actually working, even if change comes slowly and as the result of struggle. 

Nothing About Us Without Us

Advocacy groups and social movements have ample power to promote the human right to health. As much as the right to health is delineated by international bodies and addressed by state actors, activists and civil society groups fighting for their own rights are more crucial in the health equity movement than we often think. The rise of global civil society has generated many positive impacts on health. Firstly, activist groups have helped to push health concerns up the policy agenda. For example, Médecins Sans Frontières’s Access Campaign, launched in 1999, helped to increase access to essential medicines and continues to push for the development and affordability of life-saving treatments. Civil society can also mobilize health financing efforts and directly shape health policymaking, as a group of civil society organizations did when they came together as the Framework Convention Alliance and influenced the negotiation process of the World Health Organization (WHO) Framework Convention on Tobacco Control. Advocacy groups address a diverse array of health topics, such as female genital mutilation and corporal punishment. Two specific examples show how advocacy can place issues on the global health agenda in different ways: HIV/AIDS through civil disobedience and skillful use of the media in the United States, and cervical cancer by framing the debate as a human rights and women’s rights issue. 

Before the late 1980s, HIV/AIDS in the United States was often treated with a cold indifference. There was discriminatory hostility and homophobic sentiment towards HIV/AIDS. For years, President Reagan never said the word AIDS. Ways of thinking about and addressing HIV/AIDS all changed because of activism. Activists with passion and knowledge forged the path to transforming how we think about and act on HIV/AIDS, research and development of antiretroviral drugs (ARVs) and health overall. ACT UP advanced the policy status of AIDS, carrying out advocacy efforts at local, national and international levels to pressure governments and pharmaceutical companies to increase and facilitate drug development and access. HIV/AIDS activists engaged in organized civil disobedience to gain the attention of the American public. They took over the Food & Drug Administration (FDA) for a day by blocking doors, walkways and roads in 1988. In 1989, they infiltrated the New York Stock Exchange and chained themselves to the VIP balcony to protest the price of AZT, the only approved ARV at the time. And in 1990, they stormed the NIH (National Institutes of Health) to draw attention “to the AIDS crisis, community concerns and activist-led clinical-trial critiques.” HIV/AIDS activists became “patient experts” in the relevant political and scientific processes, allowing them to present knowledgeable, specific demands to make experimental drugs available more quickly and more fairly. Government agencies like the FDA and NIH began to listen to the activists, including them in decision-making and asking for their input.

In the 1980s and 1990s, AIDS garnered media attention with the diagnoses or AIDS-related deaths of popular celebrities, such as Keith Haring, Earvin “Magic” Johnson, Rudolf Nureyev and Freddy Mercury. ACT UP’s demonstrations aimed to engage the media as much as possible so that when spokespeople and activists demanded action from politicians, the public paid attention.

Demonstrators from the organization ACT UP, angry with the federal government’s response to the AIDS crisis, protest in front of the headquarters of the Food and Drug Administration in Rockville, Md., Oct. 11, 1988, and effectively shut it down. A police officer steps into the group and by mid-morning some 50 of the protesters were arrested. (AP Photo/J. Scott Applewhite)
Advocacy groups also use issue framing as a way to get their concerns noticed. Keck & Sikkink argue in their book Activists Beyond Borders that the power of civil society networks arises from their information, ideas and strategies to “alter the information and value contexts within which states make policies,” framing the debate around what the people who are most affected by the issue actually care about. Many stakeholders have framed cervical cancer as a women’s rights and human rights issue. Activists like Princess Nikky of Nigeria and other First Ladies of Africa have framed cervical cancer as it relates to women’s rights and women’s health. In Tanzania, First Lady Mama Salma Kikwete raised awareness of cervical cancer and attracted donors through her work for the Medical Women’s Association of Tanzania. The First Ladies of several African countries started a Forum of African First Ladies Against Breast and Cervical Cancer and hosted several conferences as part of their “Stop Cervical Cancer in Africa” movement. The human rights framing broadens the discussion beyond the epidemiological burden of cervical cancer, linking it to gender equality, human rights and health. Additionally, drug companies market human papillomavirus vaccines as a woman’s choice, right and duty, invoking a women’s rights frame.
Cherie Blair, third left, wife of the former U.K. prime minister Tony Blair, joins African first ladies Hadidja Aboubakar Ikililou Dhoinine, of Comoros, Salma Kikwete, of Tanzania, Callista Mutharika, former first lady of Malawi, Chantal Yayi, of Benin, and Hajiya Amina Namadi Sambo, wife of Nigerian vice president, left to right, at the RAND African First Ladies Initiative, Wednesday, Sept. 26, 2012, in New York. Current and former first ladies gathered to explore ways to grow their leadership roles on issues such as maternal health, girls education and women’s economic development. (Diane Bondareff/AP Images for RAND Corporation)
Beyond unintentional consequences, criticism of global civil society also includes concerns about the domination of the Global North, where most global advocacy organizations have headquarters. Disparities of wealth, housing, education, political power and other factors underscore the power and privilege enjoyed by the Global North. It is home to two thirds of non-governmental organizations (NGOs) accredited by the UN Economic & Social Council and most global civil society funding.  The unequal power dynamic can lead to a lack of representation in decision-making if the groups do not actually represent the individuals for which they advocate. The prominence of Global North in funding and headquarters can also create a lack of transparency if it is difficult to tell who makes up the group, how it is funded or how it makes decisions. Sometimes, advocacy organizations are actually fronts for industry, such as the tobacco industry, the food and beverage industry and the petroleum industry with organizations like the Alliance for Better Foods, the Center for Consumer Freedom and the Global Climate Coalition

Grassroots activism is an important lever for health equity. Even the success of smallpox eradication through an immunization campaign led by WHO depended on ground-level work. Health workers and field managers were in discussion with community and tribe leaders in West and Central Africa to come to mutual understandings around vaccination and surveillance campaigns. Although top-down institutional policies and goals are necessary to global health endeavors, history shows that social mobilization is an important way to advance human rights. Global health tells this story again and again. Global health requires pressure from the bottom and the top to develop health principles and then translate those principles to articulate how states and organizations can apply them in practice. None of this would succeed without grassroots support. The promotion of the human right to health through advocacy groups and social movements is essential, as it has been with HIV/AIDS and cervical cancer. Empowered society is the key to effective change for global health.

Addressing Non-Communicable Diseases in Africa: The Overlooked Role of Regional Alliances

Diseases no know boundaries. To address changing disease trends in the African region and the rest of the world, regional approaches must be better developed and implemented. Regional collaborations in Africa are promising but have historically been minimal and misguided. People and goods are increasingly moving around the world with ease and speed through globalization. Mobility across and within borders has complex implications for infectious diseases and non-communicable diseases alike. Yearly influenza seasons and outbreaks of diseases such as AIDS, SARS and Ebola do not follow political, geographic or cultural boundaries. Although increasing trade can be beneficial for economies, trade liberalization spreads health risk factors, including tobacco and alcohol. As economies develop, people’s lifestyles become more sedentary, contributing to growing global epidemics of non-communicable diseases (NCDs), including cardiovascular diseases, diabetes, chronic respiratory diseases and cancers. 

Russian Federation Health Minister Veronica Skvorsova, from left, Zimbabwe’s President Robert Mugabe, Paraguay’s President Horacio Cartes, Chile’s President Michelle Bachelet, WHO President Tedros Adhanom, Uruguay’s President Tabare Vazquez, Morocco princess Lalla Salma, Pan American Health Organization regional director Carissa Etienne, World Health Organization for Europe Director Zsuzsanna Jakab and General Secretary of the International Telecomunications Union Houlin Zhao, pose for a group picture during the WHO Global Conference on noncommunicable diseases, in Montevideo, Uruguay, Wednesday, Oct. 18, 2017. (AP Photo/Matilde Campodonico)
To address the impacts of globalization on health, regional politics and the role of regional organizations in global health governance must be better understood and utilized. Politics affect the conceptualization, creation and implementation of health policy, shaping who is entitled to services, which health issues are prioritized, who provides services and how health budgets are spent. 

The African continent has gravitated towards regionalism in an attempt to catalyze development and strengthen African integration and unity. For example, the African Union’s adoption of the African Union Non-Aggression and Common Defense Pact acknowledged the AU’s right of intervention in member states to restore peace and security. Moreover, Africa is expected to have the world’s largest increase in deaths from NCDs, such as cardiovascular diseases, diabetes and cancers, over the next decade. By 2030, NCDs are projected to become the leading cause of death in sub-Saharan Africa. In most countries in Northern Africa, NCDs already account for more than three quarters of all deaths.

Unless urgent action is taken, the growing NCD burden will add tremendous pressure to health systems that are already overstretched. This action must take regional politics into account, as regional actors help to ensure that African voices are heard and reflected in the commitments and resolutions made by their governments to address NCDs. For instance, regional actors have raised maternal, newborn and child health to the highest level of policy decision-making on the African continent and beyond. Regional actors have also driven the expansion of evidence-based interventions to improve maternal and child health and served as platforms for researchers and advocates to pool their expertise. But this is only one example.

Thus far, regional approaches related to health in Africa, outside of maternal, newborn and child health, have been minimal and need to be better developed. Regional organizations can effectively promote regional health diplomacy and governance through engagement with international institutions, civil society, non-governmental organizations and public-private partnerships. Despite growing interest in regionalism throughout Africa, regional approaches to health have not currently met their full potential. For example, the South African Development Community (SADC) is an important member-based organization, headquartered in Botswana, with the main aims of supporting regionalism, development coordination and cooperation. However, SADC has a limited heath presence as a regional organization and diplomatic partner. It has been argued that SADC has the potential to promote regional health diplomacy by increasing its engagement with civil society and non-profit organizations, advancing its trade agenda related to medical purchases and focusing on training and retaining health professionals in the region.

Southern African Development Community (SADC) Council chairperson and South African minister Maite Nkoana-Mashabane attends a meeting in Gaborone in Botswana Thursday, Nov. 16, 2017. The meeting of theSADC Organ on Politics, Defence and Security Co-operation is being held to discuss the political developments in Zimbabwe. (AP Photo)
These recommendations made by academics to improve SADC’s role in health policy relate to a promising tactic in global health governance: regionalizing global health through diplomacy. Regional organizations can act as a broker in global health governance through “regional diplomacy.” Regional diplomacy in global health brings together the disciplines of public health, international affairs, law and economics to affect the transnational negotiations that shape and manage the global policy environment for health. 

A lack of resources, continued conflict in the region and political differences are all obstacles to regional collaboration in Africa, but if governments form partnerships to address these challenges, use donor money effectively and invest in their own health systems, there is immense potential to create beneficial change and minimize the burden of NCDs.

The Moral Argument for Mental Health

My blog posts throughout the year have focused on how to implement a rights-based approach in global health efforts. For my final post, I will focus on the global health issue I am most passionate about and explore an underused argument for its prioritization: the moral case for mental health. Mental health disorders account for approximately 12% of the global burden of disease, and they are a leading cause of disability worldwide. Researchers and policymakers often make economic arguments for scaling up mental health services; common mental disorders cost the global economy $1 trillion lost in productivity annually. In addition to economic and epidemiological arguments, the moral argument should be made to prioritize mental health in global health efforts. Growing recognition of the burden and costs associated with mental health has led to significant developments in mental health research, treatment and funding. However, mental health care reform should also include a focus on the human rights of those with mental illnesses, as they experience some of the worst possible human rights violations. A moral argument focused on human rights can be used to continue elevating mental health on the global policy agenda. In the words of Arthur Kleinman, “The fundamental truth of global mental health is moral: individuals with mental illness exist under the worst of moral conditions.”The World Health Organization estimates that 450 million people in the world have a mental health disorder, and approximately 80% of people who need mental health treatment do not receive it. This is largely due to a lack of mental health care providers; almost half of the world’s population lives in countries where there is one psychiatrist to serve 200,000 or more people. Evidence of the disease burden and the proven effectiveness of task sharing interventions in improving mental health have helped to elevate the status of global mental health, but action still remains insufficient.
Male patients spend time in the main courtyard at the Psychiatric Hospital in Managua, Feb. 5, 2009. The World Health Organization warned that the financial global crisis will probably worsen the situation of mental health care in poor countries, as the majority of people who suffer from a mental disorder in developing countries do not receive treatment and many are stigmatized and are subject to rejection and abuse. (AP Photo/Esteban Felix)
Moral arguments should be used to sustain mental health’s rise up the policy agenda. For HIV/AIDS, moral arguments were effectively used by academic researchers, community organizers, people living with AIDS, and celebrities. Responses to the AIDS epidemic grew partially out of scientific evidence and progress for treatment, but vast transformations came from focusing on the lived experiences of those with AIDS. Countries all over the world changed their policies on antiretroviral drugs to reduce the cost of medicines, including India, United States and South Africa. As articulated by Patel, Saraceno and Kleinman (2006), moral arguments were made that “those living with HIV/AIDS in developing countries had the right to access antiretroviral drugs, that the state had to provide them for free, that drug companies had to reduce their prices, that apparently complex treatment regimens could be provided by primary health care providers with appropriate training and support, that discrimination against people with HIV/AIDS had to be combated vigorously, and that knowledge about HIV/AIDS was the most powerful tool to combat stigma.” These arguments facilitated a moral transformation in how the entire epidemic was viewed and addressed. “Effective change in global mental health will have to prioritize moral transformation as the foundation, much as it was for the reform that spurred HIV/AIDS treatment in Africa and Asia,” wrote Kleinman in 2009, almost ten years ago. Consideration of the human rights of those with mental disorders is still mostly absent from mental health policy and dialogue. Transformations to focus on the lived daily experiences of those with mental illnesses, including anxiety and depression disorders and those with psychosis, dementia and other severe illnesses, should be incorporated into mental health programs, policies and advocacy efforts. As shown by activism and action centered on the lived experiences of those living with AIDS, prioritizing the moral conditions of those with chronic mental illness is possible.In making the moral case for mental health, Patel, Saraceno and Kleinman focus on the connections between mental health and physical health, the need to make psychiatric drugs affordable, the effects of urbanization and globalization on lifestyle changes and suicide, the lack of mental health specialists in low-resource settings, how it is unethical to deny effective and affordable treatment to those with from treatable disorders, and lastly, human rights violations. Their final point, the tragic history of human rights violations, speaks to the dire need to promote morality and human rights in global mental health initiatives.In poor societies and wealthy societies, those with mental illnesses experience discrimination, abuse, and rejection. Today, America’s prisons and jails are the country’s de facto mental health system. More than 383,000 people with mental disorders are behind bars in the United States, which is nearly ten times the number of patients in all of the country’s psychiatric hospitals. Moreover, 25% of homeless people in the United States have a severe mental illness at any given point in time, and 45% of homeless people in the United States have had any mental illness. 

In this Oct. 12, 2017 photo, Dominic, who battles mental illness, sits on a sidewalk under the Smith Ave. Bridge in Everett, Wash., which is a constant gathering place for homeless people battling addiction and mental illness. Dominic has been identified as one of the top chronic and costliest users of emergency and other services in Everett, but despite the efforts of a specialized team of experts, he remains on the streets. (AP Photo/Ted S. Warren) 
Some of the most disturbing examples of human rights violations are in low-resource settings. In Ghana, those with severe mental illnesses have been caged and chained to tree stumps, not out of malice but because of a severe lack of resources for mental health and a dearth of policy implementation. In India in 2001, over 20 people with mental illness were burned to death when a fire took place in a healing temple where they were chained to their beds, known as the Erwadi tragedy. A Time article from 2003 describes how those with severe mental illnesses throughout Southeast Asia are often kept in crowded wards where they rarely see health care providers, are given electroconvulsive therapy without anesthesia, and frequently lose contact with their families. Stigma contributes to those with mental disorders being unable to find jobs, attend school, live alone, purchase insurance, attain friendships, or participate in everyday social activities. Understanding and articulating the systemic and structural ways in which the human rights of the mentally ill are denied could help empower those with mental illnesses, their family members, and other supports to advocate for their rights.A human rights framing should be incorporated into mental health policies, programs and awareness campaigns to prioritize the individual dignity of those with mental health issues, ultimately helping to reduce stigma and mobilize resources. Focusing on the “on-the-ground ordinary moral experience of people in the worlds they inhabit locally” could not only allow mental health to gain political clout, but could make mental health interventions more feasible, acceptable and effective. The evidence exists to implement change in mental health, but research alone does not seem sufficient to bring mental health treatment to all who need it. The moral argument matters now.