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| Sunday, 25 December 2005 |
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Features |  |
| News Business Features Editorial
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Health and Human Rights: Need of the hour Continued from last week by Professor Ravindra Fernando (Excerpts from a speech delivered by Professor Ravindra Fernando, Immediate Past President of the Sri Lanka Medical Association (SLMA), who was the Chief Guest at the Foundation Sessions of the Association held recently). The Covenant reminds that the State should accord special protection to mothers during a reasonable period before and after childbirth. During such period working mothers should be accorded paid leave or leave with adequate social security benefits. The Covenant also urged the States that special measures of protection and assistance should be taken on behalf of all children and young persons without any discrimination for reasons of parentage or other conditions. Children and young persons should be protected from economic and social exploitation. Their employment in work harmful to their morals or health or dangerous to life or likely to hamper their normal development should be punishable by law. Goal The WHO/UNICEF Declaration adopted at the International Conference on Primary Health Care in 1978 also uses similar language. It says that health is a fundamental human right and the attainment of the highest possible level of health is the most important social goal whose realisation requires the action of many other social and economic sectors in addition to the health sector. The goal of the Conference in 1978 was to have 'Health for all' by the year 2000. However, many countries including Sri Lanka did not achieve that goal. The Convention on the Rights of the Child in Article 24 says that State Parties recognise the right of the child to the enjoyment of the highest attainable standard of health. Respect for human dignity is an essential element of health and well being of all people. In clinical settings, failure to respect dignity has stigmatized people with conditions such as HIV/AIDS and those with disabilities has resulted in denial of access to appropriate treatment or subject to inappropriate clinical investigations, unwarranted long term institutionalization, for example for mentally ill patients. Denial A few years ago there was uproar for providing surgical treatment for a HIV/AIDS patient in the National Hospital of Sri Lanka by the current President of the SLMA. Some media thought that they should not be treated in state hospitals. Today, health officers as well as the general public are aware of the rights of HIV AIDS patients to some extent. Discrimination against ethnic, religious, racial minorities as well as discrimination on the basis of sex, political opinion, immigration status or sexual orientation potentially threatens the health and well being of people. Discriminative practices threaten physical and mental health and deny people access to health care, deny people appropriate therapies or relegate them to inferior care. Internally displaced persons in Sri Lanka have health problems that need special attention. Poor housing conditions, under nutrition and lack of health facilities affect the internally displaced from the war and as well as from Tsunami. Extreme forms of discrimination exemplified by apartheid, civil strife, ethnic cleansing and genocide and the resulting devaluation of human beings have had devastating long-term consequences to public health. In fact, we also see today that the health indicators in the North and the East are quite different, quite inferior to the health indicators in the South. In many countries women are denied full participation in society and the protection of basic rights. Women work more than two thirds of the world's working hours according to some studies, yet they earn less than 10% of the world's income and own less than 1% of the world's property. Practices that are harmful to their health such as genital mutilation are carried out in some communities to further social policies or cultural traditions. Garment factory workers in Sri Lanka suffer because of poor housing and sanitary facilities and under nutrition. They do not get proper sleep and long working hours affect their health. These are our future mothers. Tea plantation workers' health also is a matter of concern. I did a study of the upcountry tea plucking women in late 80s, which showed a high prevalence of iron deficiency anaemia, goitres, and a high rate of miscarriages, neo-natal mortality and infant mortality. Abortion In Sri Lanka, restrictive laws on abortion affect the health and social well being of women. A pregnancy resulting from even rape or incest cannot be therapeutically terminated and therefore, they have to seek the help of back street abortionists who perform abortions in unsterile, unhygienic conditions leading to pelvic infections and at times infertility for life. Sadly, it is unlikely that these 120-year-old statutes of the Penal Code will be amended for another 120 years due to religious objections. People seeking health care are often denied the independent judgement of health professionals when the State demands that the professionals show great allegiance to the State than to the needs of the patients. Prisoners, detainees, immigrants and others are especially vulnerable to the effects of these conflicts of interests. This we have seen in the North and the East when tortured victims were produced before a District Medical Officer, he had to give a report favourable to the Police or the Army for their personal safety and for their continued work in that area. These reports have been questioned by the Supreme Court and some of the doctors have been reported to the Sri Lanka Medical Council for action. Article 5 of the UDHR guarantees freedom from torture yet torture has been documented in more than 100 countries around the world including Sri Lanka. Torture causes acute trauma and long lasting physical or psychological suffering to survivors, their loved ones and the society. Physicians become complicit in torture when they certify individuals as being able to withstand torture, falsify or fail to report evidence of torture in detention facilities. Physicians, psychologists and forensic pathologists have been at the forefront of efforts to document and expose the use of torture in several countries and their work has led to the emergence of treatment and preventive programmes throughout the world. Since independence, expenditure on health services has been high in Sri Lanka, and as a result, Sri Lanka in terms of key health indicators, such as life expectancy, infant mortality rate, maternal mortality rate, etc. stands well above comparable developing countries and is on par with some developed countries. However, these achievements are now being threatened by emerging and re-emerging communicable and non-communicable diseases, demographic transition, high malnutrition among children, accidents, poisoning, suicide, drug abuse, lack of a clear health policy of all successive governments, financial constraints and weaknesses in the institutional set up and human resource management. In recent years, governments have not been providing adequate resources due to budgetary constraints, especially due to the war in the North and the East. Constraints Financial constraints have been central to most of these issues in the health sector. These constraints have resulted in staff shortages in the health sector, lack of essential but expensive drugs and poor investigation facilities. Private Nursing Homes and Channel Consultation Services continue to help the rich but the poor cannot afford them. Therefore, there is obvious inequality in health care. The latest Central Bank Annual Report reveals that there are 60328 beds in 598 state hospitals and some 8650 beds in 174 private hospitals. The bed ratio in State to private hospitals is approximately 20:3. Currently, over 50% of curative health care services are provided by the private sector. Public expenditure on health care remained low in recent years due to budgetary constraints mainly due to the civil war. This has certainly led to a quantitative and qualitative deterioration of health services. The Supreme Court of Sri Lanka has also recognized this factor. At about 12.45 p.m. on 3rd June 2002, Mr. Gerard Mervin Perera who got off a bus was dragged into a police jeep by police officers saying, "You are the man we are looking for," but gave no reason for his arrest. On the way they dropped the wife and son who were already kept in the jeep. Emergency Mr. Perera was brutally assaulted at the Wattala Police Station with clubs. His right hand was burnt with a matchstick and he was hanged from upper limbs for some time. Next morning, the Police told him that he was arrested, as a suspect for a triple murder, by mistake and released! Mr. Perera was in great pain, with his body swollen, and unable to move his arms. In view of Mr. Perera's condition, his wife and brother took him to the Gampaha Wickramarachchi Ayurevedic Hospital Roman'" where a physician advised immediate emergency treatment at a leading hospital. Accordingly, they admitted him to a private hospital in Colombo. He developed acute renal failure due to muscle damage, which necessitated haemodialysis, and acute respiratory distress syndrome, which required assisted ventilation in an intensive care unit. He had complete loss of power of the muscles around both shoulder joints, and inability to move both arms at the shoulder joints. A fundamental rights case was filed on behalf of Mr. Perera against the state and the police officers in the Supreme Court. The three judges of the Court granting a declaration that Mr. Perera's fundamental rights under Article 11, 13(1) and 13(2) have been infringed by the Police Officers and awarded him a sum of Rs 800,000 as compensation and costs. Mr. Perera also claimed reimbursement of medical expenses incurred at the private hospital amounting to some 1.2 million rupees. Learned Counsel for the Police Officers contended that the charges of the private hospital were exorbitant and that Mr. Perera could have sought treatment at a State hospital. Justice Mark Fernando in his judgement said, "However good the standard of treatment in State hospital may be, there is no doubt that many Sri Lankan do opt for treatment in private hospitals, sometimes in the belief that treatment and care is better, and sometimes because of fears in regard to delays, over-crowding, strikes, shortages of equipment and drugs, etc. Citizens have the right to choose between State and private medical care, and in the circumstances Mr. Perera's wife's choice of the latter was not unreasonable and was probably motivated by nothing other than the desire to save his life." Tragic Justice Fernando also mentioned that the Article 12 of the International Covenant on Economic Social and Cultural rights recognizes the right of everyone "to the enjoyment of the highest attainable standard of physical and mental health." Justice Fernando therefore directed the State to pay Mr. Perera the sum already paid to the hospital, as well as any further sum remaining. We have to file a test case to see whether the Supreme Court will authorize the state to pay the fees of a private hospital if state hospitals delay life saving operations like coronary artery bypass grafts or renal transplants. Sadly, the tragic story of Mr. Perera did not end there. The Attorney-General filed a case against the Police Officers under the Convention against Torture Act of 1994 and Mr. Perera was to give evidence on 2nd December 2004. But he was shot while travelling in a bus, allegedly by a contract killer two weeks before that and he died the following day. The alleged contract killer and a police officer who assaulted Mr. Perera are now in custody awaiting trial for his murder. Resources Just as violation of Human Rights can have serious consequences on the individuals or groups, so do health policies of a Government that can violate Human Rights. Similarly, action taken to protect or promote Human Rights can reduce vulnerability and the impact of ill health in a population. Recognising health as a Human Right promotes not just good health but the recognition of all rights intrinsic to the integrity and dignity of all humans. Locating health in a Human Rights context allows us to identify key health issues within the international and domestic human rights instruments. They are freedom from torture, freedom from violence, protection from harmful traditional practices, right to participation, right to information, right to privacy, right to benefits from scientific progress, right to education, right to food and nutrition, right to adequate standard of living and right to health and social security. The right to health does not mean the right to be healthy. It does not mean that poor governments must put in place expensive health services for which they have no resources. But it necessitates governments and public authorities to put in place policies and action plans which lead to available and accessible health care for all in the shortest possible time. To ensure that this happens is a challenge facing the Human Rights Community, Public Health Professionals and professional bodies like the SLMA.
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