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Few now question that population health is significantly shaped by social ecology. Power, wealth, and social status clearly matter: Their enactment in daily life makes them fundamental social determinants of health. Important as it is that we accept the broad importance of social factors in health, it is not enough. Our current grasp of the importance of social factors in health has to be strengthened by research that more precisely delineates the workings of social health through social processes, and the investment in research must in turn be vindicated by interventions that make a difference. The work presented in this issue of the Journal of Law, Medicine & Ethics is intended to advance the agenda for research and action.
An ecological theory puts health everywhere. Population health is shaped in the hierarchies of the workplace, the neighborhood, and the home.
Greetings from faraway Australia. We used to think that we were separated from the world’s problems—at once victims and beneficiaries of the tyranny of distance. As recent events have shown, we are all liked together—all are vulnerable. Vulnerable to HIV/AIDS. To global warming. To nuclear catastrophe. To terrorism.
In another September, also in dangerous times, the poet WH. Auden wrote in New York a message for our times. His words have been remembered in recent days. This is what he wrote:
On Fifty-second Street Uncertain and afraid As the clever hopes expire Of a low dishonest decade All I have is a voice To undo the folded lie The romantic lie in the brain Of the sensual man-in-the-street And the lie of Authority Whose buildings grope the sky: There is no such thing as the State And no one exists alone; Hunger allows no choice To the citizen or the police; We must love one another or die.
Social epidemiology has made a powerful case that health determined not just by individual-level factors such as our genetic make-up, access to medical services, or lifestyle choices, but also by social conditions, including the economy, law, and culture. Indeed, at the level of populations, evidence suggests that these “structural” factors are the predominant influences on health. Legal scholars in public health, including those in the health and human rights movement, have contended that human rights, laws, and legal practices are powerfully linked to health. Social epidemiology and health-oriented legal scholarship are complementary in their focus and their research needs. Legal scholarship has identified plausible ways in which legal and human rights factors could be influencing health, but empirical evidence has been limited.
It is one of the remarkable and significant consequence of the AIDS epidemic that out of the context of enormous suffering and death there emerged a forceful set of ideas linking the domains of health and human rights. At first, the effort centered on the observation that protecting individuals from discrimination and unwarranted intrusions on liberty were, contrary to previous epidemics, crucial to protecting the public health and interrupting the spread of HIV But in fairly short order, the scope of the health and human rights perspective expanded dramatically to focus on the ways in which the most fundamental social arrangements rendered individuals and communities vulnerable to HIV Racial and ethnic minorities, those who were marginalized, and women were at risk because of their subordinate status. In the face of such an understanding, nothing short of social change could be adequate to the challenge posed by the AIDS epidemic.
In the foundational piece in this issue of the journal, “Integrating Law and Social Epidemiology,” Burris, Kawachi, and Sarat present a model for understanding the relationship between law and health. This article uses the case of a specific health condition, the human immunodeficiency virus (HIV) infection, as an opportunity to flesh out this schema and to test how the model “fits” the world of the HIV pandemic. In applying the model to this communicable disease, we hope to illustrate the multitude of ways that laws affect the course of the pandemic as well as the course of an individual’s vulnerability or resilience to the disease, and how the complexities of an individual’s life dealing with the virus interface with the world of laws and legal institutions.
In public health and the social sciences, there is growing recognition of the role that social context plays in determining health. Frequently, social relations of inequality are among the most important features of social context identified in this work, and emphasis is placed on identifying and addressing these inequalities in order to improve health. Within the field of HIV/AIDS prevention as well, researchers have begun to look beyond individuals for an understanding of the structural causes of HIV-related risk. This research demands that greater attention be paid to the social mechanisms and contextual factors that lead to HIV risk. Among these factors are law and social policy, which form a part of the context in which risk-taking occurs and which can promote both HIV transmission and prevention. On the one hand, laws limiting access to sterile injection equipment have contributed to HIV-related risk behavioxs among injection drug users (IDUS).
In recent years, consumer debt and the bankruptcy filing rate have received substantial public and media attention in the United States. That attention pales in comparison with widespread concerns and media reporting about health. Yet, both sets of discussions may be relevant to individuals and families facing a combination of health problems and financial problems. In a recent study, nearly half of the sample of individual bankruptcy filers reported they also were dealing with illness, injury, or substantial medical debt.
Whether somethmg other than coincidence explains this correlation is worthy of consideration for those who study health. For some debtors, debt problems may be health-care finance issues; income interruption or financial obligations stemming from health ailments may contribute to financial downfall?
The opposite relationship, however, not only is possible, but potentially more pervasive.
Zoning laws determine what types of land uses and densities can occur on each property lot in a municipality, and therefore also govern the range of potential environmental and health impacts resulting from the land use. Zoning regulations are the most ubiquitous of the land use laws in the United States, as well as in many other countries. As such, they have far-reaching effects on the location of noxious uses, and any concomitant environmental or human health impacts.
Zoning has enormous implications, in general, for shaping our environment, and because changes to zoning are made through a political process, it has possibilities for abuse. One zoning expert stated:
I suppose what really disturbs me is that because zoning is the most universal of the legal tools for shaping the character of the municipality, any unwise use of the process has a far greater impact upon our national character than does the abuse of a less widely employed device.
As Jonathan Mann observed, the problem of AIDS-related stigma is inextricably bound to issues of health, human rights, and the law. Such stigma translates into feelings of fear and hostility directed at people with HIV. It finds expression in avoidance and ostracism of people with HIV, discrimination and violence against them, and public support for punitive policies and laws that restrict civil liberties while hindering AIDS prevention efforts. Being the target of stigma inflicts pain, isolation, and hardship on many people with HIV, while the desire to avoid it deters some from being tested for HIV, seeking treatment, or practicing risk-reduction.
The relationship between law and a population’s health is complex and poorly understood. To the extent that scholarship exists on the subject, it has usually focused on epidemics that are concentrated in relatively vulnerable, marginalized communities. Often, individual behaviors are assumed to play a major role in the epidemiology of these diseases. Perhaps, as a result, these illnesses become stigmatized and the object of coercive laws, which in turn become the subject of litigation, legal debate, and ultimately scholarly analysis. Thus, to the extent that U.S. legal scholars have thought about public health in the last 30 years (and they seldom have), they have generally done so in the context of tuberculosis (TB), intravenous drug abuse, and a handful of similar conditions. Likewise, Jonathan Mann’s own appreciation of the importance of human rights to public health emerged in the wake of his work with HIV, which is perhaps the prototypical stigmatized disease.
Respect for and promotion of the human rights of people with HIV/AIDS is now an entrenched component of the global response to HIV. However, as the global HIV epidemic has turned into a global AIDS epidemic, and as the death toll mounts, one area of human rights—the right to health care—has become fiercely contested. In particular, the degree to which patents on medicines impede what the United Nations High Commissioner for Human Rights has described as the “human right” of access to essential medicines is receiving close scrutiny. The controversy generated by a recent article that argues, “in Africa patents and patent law are not a major barrier to treatment access in and of themselves,” is indicative of the intensity of the debate.
The provision of police services and the suppression of crime is one of the first functions of civil government. Article 3 of the Universal Declaration of Human Rights speaks of a right to “security of person.” “The term ‘police’ traditionally connoted social organization, civil authority, or formation of a political community—the control and regulation of affairs affecting the general order and welfare of society,” including the protection of public health. Civil dispute resolution is also an important part of a system that moves people away from self-help and toward reliance on collectively constituted, peaceful channels for working out problems.
A safe and secure environment is tied to health. Research in social epidemiology suggests that a shared sense of security from physical violence and interference with property can contribute to better community health.
The development in 1996 of a new generation of antiretroviral drugs was a major pharmaceutical advancement in the struggle against the epidemics of HIV and AIDS. However, due to high costs, access to these new drugs was almost impossible for most people living with HIV or AIDS. This situatiowhas been even more dramatic for those living with HIV/AIDS in poorer countries. Many of the organizations that are fighting for the rights of those with HIV have since developed human rights advocacy and legal strategies to try to achieve universal access to treatment. These organizations are also fighting for states’ compliance with human rights obligations under health-related treatises and conventions. This paper draws upon the experience gained in Latin America, focusing on the legal strategies that have been explored in Venezuela and the legal consequences for domestic law.
Medicine and its allied health sciences have for too long been peripherally involved in work on human rights. Fifty years ago, the door to greater involvement was opened by Article 25 of the Universal Declaration of Human Rights, which underlined social and economic rights: “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”
Mounting evidence suggests that socioeconomic status is a determinant of health. As nations around the globe increasingly rely on market-based economies, the corporate sector has come to have a powerful influence on the socioeconomic gradient in most nations and hence upon the health status of their populations. At the same time, it has become more difficult for any one nation to influence corporate activities, given the increasing ease with which corporations relocate their operations from country to country, As a result of all of these factors, nations wishing to assure the health of their populations will need to both involve the corporate sector and cooperate with other nations.
In this article, we review the business ethics literature and consider what justification it might provide for requiring multinational corporations to attend to concerns about population health.
Despite growing advances in medical technologies, health status inequalities continue to increase across the globe. Developing countries have been faced with declining expenditures in health and social services, increasing burdens posed by both communicable and non-communicable diseases, and economic systems poorly geared to fostering sustainable development for the poorest and most marginalized. Under such circumstances, the challenges facing health practitioners in countries in transition are complex and diverse, and require the balancing of many conflicting imperatives. This is particularly so in relation to the development of public health policy, where equity, redress of past inequalities, and the god of social justice may seemingly be pitted against macroeconomic adjustments required for national economic development in an increasingly globalized economic order.
For example, pressures to deregulate as part of a market-oriented development philosophy will increase the risks from occupational hazards in populations desperate for paid employment.
In our experience, public health practitioners (rather than scholars) seeking to address a health problem often have just two very basic questions about the law: (1) how can I use the law to create new interventions, or improve existing ones, to protect the public’s health; and (2) will the law prevent me from successfully implementing certain interventions? In this way, the law is seen as either an opportunity for intervention to affect a public health problem, or an obstacle to enacting or implementing a desired intervention.
In addition, because some public health practitioners may not fully understand the intricacies of a given legal area, some possible obstacles to intervention may be either real or perceived. A real legal obstacle is not necessarily an insurmountable one, but it does have genuine legal force. A perceived obstacle has little, if any, true legal application to a given kind of intervention.