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Human rights and reproductive health: political realities and pragmatic choices for married adolescent women living in urban slums, Bangladesh
Rashid, Sabina Faiz
BMC International Health and Human Rights
2011;11(Suppl 3):S3.
In Bangladesh, particularly in urban slums, married adolescent women's human rights to life, health, and reproductive and sexual health remain adversely affected because of the structural inequalities and political economic, social and cultural conditions which shape how rights are understood, negotiated and lived.
The focus of the research and methods was anthropological. An initial survey of 153 married adolescent women was carried out and from this group, 50 in-depth interviews were conducted with selected participants and, from the in-depth interviews, a further eight case studies of women and their families were selected for in-depth repeated interviews and case histories.
This paper speaks of the unanticipated complexities when writing on reproductive rights for poor adolescent women living in the slums, where the discourses on 'universal human rights' are often removed from the reality of adolescent women's everyday lives. Married adolescent women and their families remain extremely vulnerable in the unpredictable, crime-prone and insecure urban slum landscape because of their age, gender and poverty. Adolescent women's understanding of their rights such as the decision to marry early, have children, terminate pregnancies and engage in risky sexual behaviour, are different from the widely accepted discourse on rights globally, which assumes a particular kind of individual thinking and discourse on rights and a certain autonomy women have over their bodies and their lives. This does not necessarily exist in urban slum populations.
The lived experiences and decisions made pertaining to sexual and reproductive health and 'rights' exercised by married adolescent women, their families and slum communities, allow us to reflect on the disconnect between the international legal human rights frameworks as applied to sexual and reproductive health rights, and how these are played out on the ground. These notions are far more complex in environments where married adolescent women and their families live in conditions of poverty and socioeconomic deprivation.
Related Articles
Can rights stop the wrongs? Exploring the connections between framings of sex workers' rights and sexual and reproductive health
Overs, Cheryl
Hawkins, Kate
BMC International Health and Human Rights
2011;11(Suppl 3):S6.
There is growing interest in the ways in which legal and human rights issues related to sex work affect sex workers' vulnerability to HIV and abuses including human trafficking and sexual exploitation. International agencies, such as UNAIDS, have called for decriminalisation of sex work because the delivery of sexual and reproductive health services is affected by criminalisation and social exclusion as experienced by sex workers. The paper reflects on the connections in various actors' framings between sex workers sexual and reproductive health and rights (SRHR) and the ways that international law is interpreted in policing and regulatory practices.
The literature review that informs this paper was carried out by the authors in the course of their work within the Paulo Longo Research Initiative. The review covered academic and grey literature such as resources generated by sex worker rights activists, UN policy positions and print and online media. The argument in this paper has been developed reflectively through long term involvement with key actors in the field of sex workers' rights.
International legislation characterises sex work in various ways which do not always accord with moves toward decriminalisation. Law, policy and regulation at national level and law enforcement vary between settings. The demands of sex worker rights activists do relate to sexual and reproductive health but they place greater emphasis on efforts to remove the structural barriers that limit sex workers' ability to participate in society on an equal footing with other citizens.
Discussion and conclusion
There is a tension between those who wish to uphold the rights of sex workers in order to reduce vulnerability to ill-health and those who insist that sex work is itself a violation of rights. This is reflected in contemporary narratives about sex workers' rights and the ways in which different actors interpret human rights law. The creation of regulatory frameworks around sex work that support health, safety and freedom from abuse requires a better understanding of the broad scope of laws, policies and enforcement practices in different cultural contexts and economic settings, alongside reviews of UN policies and human rights conventions.
Related Articles
Indigenous Health and Socioeconomic Status in India
Subramanian, S. V
Smith, George Davey
Subramanyam, Malavika
PLoS Medicine
Systematic evidence on the patterns of health deprivation among indigenous peoples remains scant in developing countries. We investigate the inequalities in mortality and substance use between indigenous and non-indigenous, and within indigenous, groups in India, with an aim to establishing the relative contribution of socioeconomic status in generating health inequalities.
Methods and Findings
Cross-sectional population-based data were obtained from the 1998–1999 Indian National Family Health Survey. Mortality, smoking, chewing tobacco use, and alcohol use were four separate binary outcomes in our analysis. Indigenous status in the context of India was operationalized through the Indian government category of scheduled tribes, or Adivasis, which refers to people living in tribal communities characterized by distinctive social, cultural, historical, and geographical circumstances.
Indigenous groups experience excess mortality compared to non-indigenous groups, even after adjusting for economic standard of living (odds ratio 1.22; 95% confidence interval 1.13–1.30). They are also more likely to smoke and (especially) drink alcohol, but the prevalence of chewing tobacco is not substantially different between indigenous and non-indigenous groups. There are substantial health variations within indigenous groups, such that indigenous peoples in the bottom quintile of the indigenous-peoples-specific standard of living index have an odds ratio for mortality of 1.61 (95% confidence interval 1.33–1.95) compared to indigenous peoples in the top fifth of the wealth distribution. Smoking, drinking alcohol, and chewing tobacco also show graded associations with socioeconomic status within indigenous groups.
Socioeconomic status differentials substantially account for the health inequalities between indigenous and non-indigenous groups in India. However, a strong socioeconomic gradient in health is also evident within indigenous populations, reiterating the overall importance of socioeconomic status for reducing population-level health disparities, regardless of indigeneity.
Indigenous groups in India were found to have excess mortality rates compared with non-indigenous groups. A socioeconomic gradient within indigenous populations was also found.
Editors' Summary
In many parts of the world the majority of the population are the descendants of immigrants who arrived there within the last few hundred years. Living alongside of them, and in a minority, are the so-called indigenous (or aboriginal) people who are the descendants of people who lived there in more ancient times. It is estimated that there are 300 million indigenous people worldwide. They are frequently marginalized from the rest of the population, their human rights are often abused, and there are serious concerns about their health and welfare. The state of health of the indigenous people of developed countries such as the US and Australia has often been studied, and we have a fairly clear idea of the kinds of problems these people face. Most indigenous people, however, live in developing countries, and less is known about their health.
India is the second-most populous country in the world, with an estimated 1.1 billion inhabitants. An estimated 90 million indigenous people live in India, where they are often referred to as "scheduled tribes" or Adivasis. They live in many parts of the country but are much more numerous in some Indian states than in others.
Why Was This Study Done?
It has often been said that indigenous people in India have worse health than other Indians, though no figures have been compiled to confirm these claims. The researchers wanted to establish whether it is simply an issue of indigenous people being poorer than other Indians—poverty being well known as a cause of disease—or whether being indigenous is, in itself, a health risk. The researchers also wanted to establish whether there are health inequalities within indigenous groups, and if these differences also followed a socioeconomic patterning.
What Did the Researchers Do and Find?
They used figures collected in the 1998–1999 Indian National Family Health Survey. When this survey was conducted, it was noted whether people were considered to be members of scheduled tribes. The researchers also knew, from the survey, about the income of the families, their death rates, and whether they drank alcohol or smoked or chewed tobacco. They found that indigenous people had higher death rates than other Indians. They made statistical calculations to account for differences in standard of living, and this substantially reduced the difference in death rate among indigenous groups, but an indigenous person was still 1.2 times more likely to die than a non-indigenous person with the same standard of living. Indigenous people were also more likely to drink alcohol and smoke tobacco, and here again, differences in standard of living accounted for a substantial portion of the differences. Importantly, the researchers' analysis showed a strong socioeconomic patterning of health inequalities within the indigenous population groups: the health differences between the poorest and richest indigenous groups were similar in scale to the differences between the poorest and richest non-indigenous groups.
What Do These Findings Mean?
The authors consider their finding that there is a socioeconomic gradient in mortality and health behaviors among indigenous people to be an important result from the study. The socioeconomic marginalization of indigenous people from the rest of Indian society does seem to increase their health risks, and so does their use of alcohol and tobacco. However, if their standard of living can be improved there would be major benefits for their health and welfare.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030421.
A useful discussion of the term "indigenous people" (with links to documents about international agreements intended to improve their human rights) may be found on Wikipedia. (Wikipedia is an internet encyclopedia that anyone can edit.)
Survival International is a human rights organization that campaigns for the rights of indigenous peoples, helping them preserve their land and culture.
The charity Health Unlimited also works with indigenous people and its Web site includes links to recent studies and conferences.
A news item from the BBC describes a recent investigation into the health of indigenous people worldwide.
The World Health Organization has produced a number of reports on the health of indigenous people
Related Articles
The Human Right to Water: The Importance of Domestic and Productive Water Rights
Hall, Ralph P.
Van Koppen, Barbara
Van Houweling, Emily
Science and Engineering Ethics
The United Nations (UN) Universal Declaration of Human Rights engenders important state commitments to respect, fulfill, and protect a broad range of socio-economic rights. In 2010, a milestone was reached when the UN General Assembly recognized the human right to safe and clean drinking water and sanitation. However, water plays an important role in realizing other human rights such as the right to food and livelihoods, and in realizing the Convention on the Elimination of All Forms of Discrimination against Women. These broader water-related rights have been recognized but have not yet been operationalized. This paper unravels these broader water-related rights in a more holistic interpretation of existing international human rights law. By focusing on an emerging approach to water services provision—known as 'domestic-plus' services—the paper argues how this approach operationalizes a comprehensive range of socio-economic rights in rural and peri-urban areas. Domestic-plus services provide water for domestic and productive uses around homesteads, which challenges the widespread practice in the public sector of planning and designing water infrastructure for a single-use. Evidence is presented to show that people in rural communities are already using their water supplies planned for domestic uses to support a wide range of productive activities. Domestic-plus services recognize and plan for these multiple-uses, while respecting the priority for clean and safe drinking water. The paper concludes that domestic-plus services operationalize the obligation to progressively fulfill a comprehensive range of indivisible socio-economic rights in rural and peri-urban areas.
Human right to water; Multiple-use water services; Domestic-plus; Livelihoods; Gender
Related Articles
Exploring synergies between human rights and public health ethics: A whole greater than the sum of its parts
Nixon, Stephanie
Forman, Lisa
BMC International Health and Human Rights
The fields of human rights and public health ethics are each concerned with promoting health and elucidating norms for action. To date, however, little has been written about the contribution that these two justificatory frameworks can make together. This article explores how a combined approach may make a more comprehensive contribution to resolving normative health issues and to advancing a normative framework for global health action than either approach made alone. We explore this synergy by first providing overviews of public health ethics and of international human rights law relevant to health and, second, by articulating complementarities between human rights and public health ethics.
We argue that public health ethics can contribute to human rights by: (a) reinforcing the normative claims of international human rights law, (b) strengthening advocacy for human rights, and (c) bridging the divide between public health practitioners and human rights advocates in certain contemporary health domains. We then discuss how human rights can contribute to public health ethics by contributing to discourses on the determinants of health through: (a) definitions of the right to health and the notion of the indivisibility of rights, (b) emphasis on the duties of states to progressively realize the health of citizens, and (c) recognition of the protection of human rights as itself a determinant of health. We also discuss the role that human rights can play for the emergent field of public health ethics by refocusing attention on the health and illness on marginalized individuals and populations.
Actors within the fields of public health, ethics and human rights can gain analytic tools by embracing the untapped potential for collaboration inherent in such a combined approach.
Related Articles
Globalizing queer? AIDS, homophobia and the politics of sexual identity in India
Kole, Subir K
Globalization and Health
Queerness is now global. Many emerging economies of the global South are experiencing queer mobilization and sexual identity politics raising fundamental questions of citizenship and human rights on the one hand; and discourses of nationalism, cultural identity, imperialism, tradition and family-values on the other. While some researchers argue that with economic globalization in the developing world, a Western, hegemonic notion of lesbian, gay, bisexual and transgender (LGBT) identity has been exported to traditional societies thereby destroying indigenous sexual cultures and diversities, other scholars do not consider globalization as a significant factor in global queer mobilization and sexual identity politics. This paper aims at exploring the debate around globalization and contemporary queer politics in developing world with special reference to India. After briefly tracing the history of sexual identity politics, this paper examines the process of queer mobilization in relation to emergence of HIV/AIDS epidemic and forces of neoliberal globalization. I argue that the twin-process of globalization and AIDS epidemic has significantly influenced the mobilization of queer communities, while simultaneously strengthening right wing "homophobic" discourses of heterosexist nationalism in India.
Related Articles
Adolescent pregnancies and girls' sexual and reproductive rights in the amazon basin of Ecuador: an analysis of providers' and policy makers' discourses
Goicolea, Isabel
Wulff, Marianne
Sebastian, Miguel San
Öhman, Ann
BMC International Health and Human Rights
Adolescent pregnancies are a common phenomenon that can have both positive and negative consequences. The rights framework allows us to explore adolescent pregnancies not just as isolated events, but in relation to girls' sexual and reproductive freedom and their entitlement to a system of health protection that includes both health services and the so called social determinants of health. The aim of this study was to explore policy makers' and service providers' discourses concerning adolescent pregnancies, and discuss the consequences that those discourses have for the exercise of girls' sexual and reproductive rights' in the province of Orellana, located in the amazon basin of Ecuador.
We held six focus-group discussions and eleven in-depth interviews with 41 Orellana's service providers and policy makers. Interviews were transcribed and analyzed using discourse analysis, specifically looking for interpretative repertoires.
Four interpretative repertoires emerged from the interviews. The first repertoire identified was "sex is not for fun" and reflected a moralistic construction of girls' sexual and reproductive health that emphasized abstinence, and sent contradictory messages regarding contraceptive use. The second repertoire -"gendered sexuality and parenthood"-constructed women as sexually uninterested and responsible mothers, while men were constructed as sexually driven and unreliable. The third repertoire was "professionalizing adolescent pregnancies" and lead to patronizing attitudes towards adolescents and disregard of the importance of non-medical expertise. The final repertoire -"idealization of traditional family"-constructed family as the proper space for the raising of adolescents while at the same time acknowledging that sexual abuse and violence within families was common.
Providers' and policy makers' repertoires determined the areas that the array of sexual and reproductive health services should include, leaving out the ones more prone to cause conflict and opposition, such as gender equality, abortion provision and welfare services for pregnant adolescents. Moralistic attitudes and sexism were present - even if divergences were also found-, limiting services' capability to promote girls' sexual and reproductive health and rights.
Related Articles
Operationalising sexual and reproductive health and rights in sub-Saharan Africa: constraints, dilemmas and strategies
Oronje, Rose Ndakala
Crichton, Joanna
Theobald, Sally
Lithur, Nana Oye
Ibisomi, Latifat
BMC International Health and Human Rights
2011;11(Suppl 3):S8.
The continued poor sexual and reproductive health (SRH) outcomes in sub-Saharan Africa highlight the difficulties in reforming policies and laws, and implementing effective programmes. This paper uses one international and two national case studies to reflect on the challenges, dilemmas and strategies used in operationalising sexual and reproductive health and rights (SRHR) in different African contexts.
The international case study focuses on the progress made by African countries in implementing the African Union's Maputo Plan of Action (for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights) and the experiences of state and non-state stakeholders in this process. The case was developed from an evaluation report of the progress made by nine African countries in implementing the Plan of Action, qualitative interviews exploring stakeholders' experiences and perceptions of the operationalisation of the plan (carried out as part of the evaluation) in Botswana and Nigeria, and authors' reflections. The first national case study explores the processes involved in influencing Ghana's Domestic Violence Act passed in 2007; developed from a review of scientific papers and organisational publications on the processes involved in influencing the Act, qualitative interview data and authors' reflections. The second national case study examines the experiences with introducing the 2006 Sexual Offences Act in Kenya, and it is developed from organisational publications on the processes of enacting the Act and a review of media reports on the debates and passing of the Act.
Based on the three cases, we argue that prohibitive laws and governments' reluctance to institute and implement comprehensive rights approaches to SRH, lack of political leadership and commitment to funding SRHR policies and programmes, and dominant negative cultural framing of women's issues present the major obstacles to operationalising SRH rights. Analysis of successes points to the strategies for tackling these challenges, which include forming and working through strategic coalitions, employing strategic framing of SRHR issues to counter opposition and gain support, collaborating with government, and employing strategic opportunism.
The strategies identified show future pathways through which challenges to the realisation of SRHR in Africa can be tackled.
Related Articles
Implementing community participation through legislative reform: a study of the policy framework for community participation in the Western Cape province of South Africa
Meier, Benjamin Mason
Pardue, Caitlin
London, Leslie
BMC International Health and Human Rights
Amidst an evolving post-apartheid policy framework for health, policymakers have sought to institutionalize community participation in Primary Health Care, recognizing participation as integral to realizing South Africa's constitutional commitment to the right to health. With evolving South African legislation supporting community involvement in the health system, early policy developments focused on Community Health Committees (HCs) as the principal institutions of community participation. Formally recognized in the National Health Act of 2003, the National Health Act deferred to provincial governments in establishing the specific roles and functions of HCs. As a result, stakeholders developed a Draft Policy Framework for Community Participation in Health (Draft Policy) to formalize participatory institutions in the Western Cape province.
With the Draft Policy as a frame of analysis, the researchers conducted documentary policy analysis and semi-structured interviews on the evolution of South African community participation policy. Moving beyond the specific and unique circumstances of the Western Cape, this study analyzes generalizable themes for rights-based community participation in the health system.
Framing institutions for the establishment, appointment, and functioning of community participation, the Draft Policy proposed a formal network of communication – from local HCs to the health system. However, this participation structure has struggled to establish itself and function effectively as a result of limitations in community representation, administrative support, capacity building, and policy commitment. Without legislative support for community participation, the enactment of superseding legislation is likely to bring an end to HC structures in the Western Cape.
Attempts to realize community participation have not adequately addressed the underlying factors crucial to promoting effective participation, with policy reforms necessary: to codify clearly defined roles and functions of community representation; to outline how communities engage with government through effective and accountable channels for participation; and to ensure extensive training and capacity building of community representatives. Given the public health importance of structured and effective policies for community participation, and the normative importance of participation in realizing a rights-based approach to health, this analysis informs researchers on the challenges to institutionalizing participation in health systems policy and provides practitioners with a research base to frame future policy reforms.
Participation; Rights-based policy; Community health committees; South Africa
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Health and human rights in today's fight against HIV/AIDS
Stemple, Lara
AIDS (London, England)
2008;22(Suppl 2):S113-S121.
The development of the health and human rights framework coincided with the beginning of the rapid spread of HIV/AIDS. Since then, the international community has increasingly turned to human rights language and instruments to address the disease. Not only are human rights essential to addressing a disease that impacts marginalized groups most severely, but the spread of HIV/AIDS itself exacerbates inequality and impedes the realization of a range of human rights. Policy developments of the past decade include the United Nations (UN) Committee on Economic, Social and Cultural Rights' General Comment on the 'Right to Health', the UN Declaration of Commitment on HIV/AIDS, and the UN's International Guidelines on HIV/AIDS and Human Rights, among others. Rights-related setbacks include the failure of the Declaration and its 5-year follow-up specifically to address men who have sex with men, sex workers, and intravenous drug users, political restrictions placed on urgently needed US President's Emergency Plan for AIDS Relief (PEPFAR) funds, and the failure of many countries to decriminalize same-sex sex and outlaw discrimination against people living with HIV/AIDS. Male circumcision as an HIV prevention measure is a topic around which important debate, touching on gender, informed consent and children's rights, serves to illustrate the ongoing vitality of the health and human rights dialogue. Mechanisms to increase state accountability for addressing HIV/AIDS should be explored in greater depth. Such measures might include an increase in the use of treaty-based judicial mechanisms, the linking of human rights compliance with preferential trade agreements, and rights requirements tied to HIV/ AIDS funding.
circumcision; human rights; male; social justice; women's rights; United Nations
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Universal health coverage from multiple perspectives: a synthesis of conceptual literature and global debates
Abiiro, Gilbert Abotisem
De Allegri, Manuela
BMC International Health and Human Rights
There is an emerging global consensus on the importance of universal health coverage (UHC), but no unanimity on the conceptual definition and scope of UHC, whether UHC is achievable or not, how to move towards it, common indicators for measuring its progress, and its long-term sustainability. This has resulted in various interpretations of the concept, emanating from different disciplinary perspectives. This paper discusses the various dimensions of UHC emerging from these interpretations and argues for the need to pay attention to the complex interactions across the various components of a health system in the pursuit of UHC as a legal human rights issue.
The literature presents UHC as a multi-dimensional concept, operationalized in terms of universal population coverage, universal financial protection, and universal access to quality health care, anchored on the basis of health care as an international legal obligation grounded in international human rights laws. As a legal concept, UHC implies the existence of a legal framework that mandates national governments to provide health care to all residents while compelling the international community to support poor nations in implementing this right. As a humanitarian social concept, UHC aims at achieving universal population coverage by enrolling all residents into health-related social security systems and securing equitable entitlements to the benefits from the health system for all. As a health economics concept, UHC guarantees financial protection by providing a shield against the catastrophic and impoverishing consequences of out-of-pocket expenditure, through the implementation of pooled prepaid financing systems. As a public health concept, UHC has attracted several controversies regarding which services should be covered: comprehensive services vs. minimum basic package, and priority disease-specific interventions vs. primary health care.
As a multi-dimensional concept, grounded in international human rights laws, the move towards UHC in LMICs requires all states to effectively recognize the right to health in their national constitutions. It also requires a human rights-focused integrated approach to health service delivery that recognizes the health system as a complex phenomenon with interlinked functional units whose effective interaction are essential to reach the equilibrium called UHC.
Universal health coverage; Multi-dimensional concept; Rights-based; Population coverage; Financial protection; Access to health services; Health system; Conceptual literature; Global debates
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Human rights, health and the state in Bangladesh
Rahman, Redwanur M
BMC International Health and Human Rights
This paper broadly discusses the role of the State of Bangladesh in the context of the health system and human rights. The interrelation between human rights, health and development are well documented. The recognition of health as a fundamental right by WHO and subsequent approval of health as an instrument of welfare by the Universal Declaration of Human Rights (UDHR) and the International Covenant on Social, Economic and Cultural Rights (ICSECR) further enhances the idea. Moreover, human rights are also recognized as an expedient of human development. The state is entrusted to realize the rights enunciated in the ICSECR.
In exploring the relationship of the human rights and health situation in Bangladesh, it is argued, in this paper, that the constitution and major policy documents of the Bangladesh government have recognized the health rights and development. Bangladesh has ratified most of the international treaties and covenants including ICCPR, ICESCR; and a signatory of international declarations including Alma-Ata, ICPD, Beijing declarations, and Millennium Development Goals. However the implementation of government policies and plans in the development of health institutions, human resources, accessibility and availability, resource distribution, rural-urban disparity, the male-female gap has put the health system in a dismal state. Neither the right to health nor the right to development has been established in the development of health system or in providing health care.
The development and service pattern of the health system have negative correlation with human rights and contributed to the underdevelopment of Bangladesh. The government should take comprehensive approach in prioritizing the health rights of the citizens and progressive realization of these rights.
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Beyrer, Chris
Crago, Anna-Louise
Bekker, Linda-Gail
Butler, Jenny
Shannon, Kate
Kerrigan, Deanna
Decker, Michele R.
Baral, Stefan D.
Poteat, Tonia
Wirtz, Andrea L.
Weir, Brian W.
Barré-Sinoussi, Françoise
Kazatchkine, Michel
Sidibé, Michel
Boily, Marie-Claude
Strathdee, Steffanie A.
The women, men, and transgender persons who sell sex globally have disproportionate risks and burdens of HIV, in low, middle and high income country settings, and in concentrated and generalized epidemic contexts. The greatest HIV burdens continue to be among African women sex workers. Worldwide, sex workers continue to face reduced access to needed HIV prevention, treatment, and care services. Legal environments, policies and policing practices, lack of funding for research and HIV programming, human rights violations and stigma and discrimination continue to challenge sex workers' abilities to protect themselves, their families, and their sexual partners from HIV. These realities must change for the benefits of recent advances in HIV prevention and treatment to be realized and for global control of the HIV pandemic to be achieved. Effective combination prevention and treatment approaches are feasible, can be tailored for cultural competence, can be cost-saving and can help address the unmet needs of sex workers and their communities in ways that uphold their human rights. To address HIV among sex workers will require sustained community engagement and empowerment, continued research, political will, structural and policy reform and innovative programming. But it can and must be done.
sex work; MSM; Transgender women; HIV prevalence; cost effectiveness; molecular epidemiology; human rights
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Influence of health rights discourses and community organizing on equitable access to health: the case of HIV, tuberculosis and cancer in Peru
Sandoval, Clara
Cáceres, Carlos F
Globalization and Health
The right to health is recognized as a fundamental human right. Social participation is implied in the fulfillment of health rights since Alma Ata posited its relevance for successful health programs, although a wide range of interpretations has been observed for this term. While Peruvian law recognizes community and social participation in health, it was the GFATM requirement of mixed public-civil society participation in Country Coordination Mechanisms (CCM) for proposal submission what effectively led to formal community involvement in the national response to HIV and, to a lesser extent, tuberculosis. This has not been the case, however, for other chronic diseases in Peru. This study aims to describe and compare the role of health rights discourse and community involvement in the national response to HIV, tuberculosis and cancer.
Key health policy documents were identified and analyzed. In-depth interviews were conducted with stakeholders, representatives of civil society organizations (CSO), and leaders of organizations of people affected by HIV, cancer and tuberculosis.
Results and discussion
A health rights discourse, well established in the HIV field, is expanding to general health discussions and to the tuberculosis (TB) field in particular. Both HIV and TB programs have National Multisectoral Strategic Plans and recognize participation of affected communities' organizations. Similar mechanisms are non-existent for cancer or other disease-focused programs, although other affected patients are starting some organization efforts. Interviewees agreed that reaching the achievements of HIV mobilization is difficult for other diseases, since the HIV response was modeled based on a global movement with strong networks and advocacy mechanisms, eventually succeeding in the establishment of financial sources like the GFATM. Nevertheless, organizations linked to cancer and other diseases are building a National Patient Network to defend health rights.
There are new efforts to promote and protect health rights in Peru, probably inspired by the achievements of organizations of people living with HIV (PLHA). The public health sector must consolidate the participation of affected communities' organizations in decision-making processes and implementation of health programs. PLHA organizations have become a key political and social actor in Peruvian public health policy.
HIV; Public policy; Health rights; Community participation; Access to health care
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Experiences with Policing among People Who Inject Drugs in Bangkok, Thailand: A Qualitative Study
Hayashi, Kanna
Small, Will
Csete, Joanne
Hattirat, Sattara
Kerr, Thomas
PLoS Medicine
Using thematic analysis, Kerr and colleagues document the experiences of policing among people who inject drugs in Bangkok and examine how interactions with police can affect drug-using behaviors and health care access.
Please see later in the article for the Editors' Summary
Despite Thailand's commitment to treating people who use drugs as "patients" not "criminals," Thai authorities continue to emphasize criminal law enforcement for drug control. In 2003, Thailand's drug war received international criticism due to extensive human rights violations. However, few studies have since investigated the impact of policing on drug-using populations. Therefore, we sought to examine experiences with policing among people who inject drugs (PWID) in Bangkok, Thailand, between 2008 and 2012.
Methods and Findings
Between July 2011 and June 2012, semi-structured, in-depth interviews were conducted with 42 community-recruited PWID participating in the Mitsampan Community Research Project in Bangkok. Interviews explored PWID's encounters with police during the past three years. Audio-recorded interviews were transcribed verbatim, and a thematic analysis was conducted to document the character of PWID's experiences with police. Respondents indicated that policing activities had noticeably intensified since rapid urine toxicology screening became available to police. Respondents reported various forms of police misconduct, including false accusations, coercion of confessions, excessive use of force, and extortion of money. However, respondents were reluctant to report misconduct to the authorities in the face of social and structural barriers to seeking justice. Respondents' strategies to avoid police impeded access to health care and facilitated transitions towards the misuse of prescribed pharmaceuticals. The study's limitations relate to the transferability of the findings, including the potential biases associated with the small convenience sample.
This study suggests that policing in Bangkok has involved injustices, human rights abuses, and corruption, and policing practices in this setting appeared to have increased PWID's vulnerability to poor health through various pathways. Novel to this study are findings pertaining to the use of urine drug testing by police, which highlight the potential for widespread abuse of this emerging technology. These findings raise concern about ongoing policing practices in this setting.
Please see later in the article for the Editors' Summary
Editors' Summary
In many countries, the dominant strategy used to control illegal drugs such as heroin and methamphetamine is criminal law enforcement, a strategy that sometimes results in human rights abuses such as ill-treatment by police, extrajudicial killings, and arbitrary detention. Moreover, growing evidence suggests that aggressive policing of illicit drug use can have adverse public-health consequences. For example, the fear engendered by intensive policing may cause people who inject drugs (PWID) to avoid services such as needle exchanges, thereby contributing to the HIV/AIDS epidemic. One country with major epidemics of illicit drug use and of HIV/AIDS among PWID is Thailand. Although Thailand reclassified drug users as "patients" instead of "criminals" in 2002, possession and consumption of illicit drugs remain criminal offenses. The 2002 legislation also created a system of compulsory drug detention centers, most of which lack evidence-based addiction treatment services. In 2003, the Thai government launched a campaign to suppress drug trafficking and to enrol 300,000 people who use drugs into treatment. This campaign received international criticism because it involved extensive human rights violations, including more than 2,800 extrajudicial killings of suspected drug users and dealers.
Why Was This Study Done?
Drug-related arrests and compulsory detention of drug users are increasing in Thailand but what is the impact of current policing practices on drug users and on public health? In this qualitative study (a study that aims for an in-depth understanding of human behavior), the researchers use thematic analysis informed by the Rhodes' Risk Environment Framework to document the social and structural factors that led to encounters with the police among PWID in Bangkok between 2008 and 2012, the policing tactics employed during these encounters, and the associated health consequences of these encounters. The Risk Environment Framework posits that a range of social, political, economic, and physical environmental factors interact with each other and shape the production of drug-related harm.
What Did the Researchers Do and Find?
Between July 2011 and June 2012, the researchers conducted in-depth interviews with a convenience sample (a non-random sample from a nearby population) of 42 participants in the Mitsampan Community Research Project, an investigation of drug-using behavior, health care access, and drug-related harms among PWID in Bangkok. Respondents reported that policing activities had intensified since rapid urine toxicology screening became widely available and since the initiation of a crackdown on drug users in 2011. They described various forms of violence and misconduct that they had experienced during confrontations with police, including false accusations, degrading stop and search procedures, and excessive use of force. Urine drug testing was identified as a key tool used by the police, with some respondents describing how police caused unnecessary humiliation by requesting urine samples in public places. It was also reported that the police used positive test results as a means of extortion. Finally, some respondents reported feeling powerless in relation to the police and cited fear of retaliation as an important barrier to obtaining redress for police corruption. Others reported that they had adopted strategies to avoid the police such as staying indoors, a strategy likely to impede access to health care, or changing their drug-using behavior by, for example, injecting midazolam rather than methamphetamine, a practice associated with an increased risk of injection-related complications.
What Do These Findings Mean?
These findings suggest that the policing of PWID in Bangkok between 2008 and 2012 involved injustices, human rights abuses, and corruption and highlight the potential for widespread misuse of urine drug testing. Moreover, they suggest that policing practices in this setting may have increased the vulnerability of PWID to poor health by impeding their access to health care and by increasing the occurrence of risky drug-using behaviors. Because this study involved a small convenience sample of PWID, these findings may not be generalizable to other areas of Bangkok or Thailand and do not indicate whether police misconduct and corruption is highly prevalent across the all police departments in Bangkok. Nevertheless, these findings suggest that multilevel structural changes and interventions are needed to mitigate the harm associated with policing of illicit drug use in Bangkok. These changes will need to ensure full accountability for police misconduct and access to legal services for victims of this misconduct. They will also need to include ethical guidelines for urine drug testing and the reform of policies that promote repressive policing and compulsory detention.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001570.
This study is further discussed in a PLOS Medicine Perspective by Burris and Koester
Human Rights Watch, a global organization dedicated to defending and protecting human rights, has information about drug policy and human rights, which includes information on Thailand
The Global Commission on Drug Policy published a report in June 2012 entitled "The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic" (available in several languages)
The Global Commission on HIV and the Law published a report in July 2012 entitled "HIV and the Law: Risk, Rights and Health" (available in several languages), the Open Society Foundations have prepared a briefing on this report
More information about the Mitsampan Community Research Project is available
Related Articles
'Issues of equity are also issues of rights': Lessons from experiences in Southern Africa
London, Leslie
BMC Public Health
Human rights approaches to health have been criticized as antithetical to equity, principally because they are seen to prioritise rights of individuals at the expense of the interests of groups, a core tenet of public health. The objective of this study was to identify how human rights approaches can promote health equity.
The Network on Equity in Health in Southern Africa undertook an exploration of three regional case studies – antiretroviral access, patient rights charters and civic organization for health. A combination of archival reviews and stakeholder interviews were complemented with a literature review to provide a theoretical framework for the empirical evidence.
Critical success factors for equity are the importance of rights approaches addressing the full spectrum from civil and political, through to socio-economic rights, as well as the need to locate rights in a group context. Human rights approaches succeed in achieving health equity when coupled with community engagement in ways that reinforce community capacity, particularly when strengthening the collective agency of its most vulnerable groups. Additionally, human rights approaches provide opportunities for mobilising resources outside the health sector, and must aim to address the public-private divide at local, national and international levels.
Where it is clear that rights approaches are predicated upon understanding the need to prioritize vulnerable groups and where the way rights are operationalised recognizes the role of agency on the part of those most affected in realising their socio-economic rights, human rights approaches appear to offer powerful tools to support social justice and health equity.
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Adolescent pregnancies in the Amazon Basin of Ecuador: a rights and gender approach to adolescents' sexual and reproductive health
Goicolea, Isabel
Global Health Action
In the Andean region of Latin America over one million adolescent girls get pregnant every year. Adolescent pregnancy (AP) has been associated with adverse health and social outcomes, but it has also been favorably viewed as a pathway to adulthood. AP can also be conceptualized as a marker of inequity, since it disproportionately affects girls from the poorest households and those who have not been able to attend school.
Using results from a study carried out in the Amazon Basin of Ecuador, this paper explores APs and adolescents' sexual and reproductive health from a rights and gender approach. The paper points out the main features of a rights and gender approach, and how it can be applied to explore APs. Afterward it describes the methodologies (quantitative and qualitative) and main results of the study, framing the findings within the rights and gender approach. Finally, some implications that could be generalizable to global reserach on APs are highlighted.
The application of the rights and gender framework to explore APs contributes to a more integral view of the issue. The rights and gender framework stresses the importance of the interaction between rights-holders and duty-bearers on the realization of sexual and reproductive rights, and acknowledges the importance of gender–power relations on sexual and reproductive decisions. A rights and gender approach could lead to more integral and constructive interventions, and it could also be useful when exploring other sexual and reproductive health matters.
adolescent pregnancy; reproductive and sexual rights; gender relations; gender structures; agency
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Socio-cultural and service delivery dimensions of maternal mortality in rural central India: a qualitative exploration using a human rights lens
Jat, Tej Ram
Deo, Prakash R.
Goicolea, Isabel
Hurtig, Anna-Karin
San Sebastian, Miguel
Global Health Action
Despite the avoidable nature of maternal mortality, unacceptably high numbers of maternal deaths occur in developing countries. Considering its preventability, maternal mortality is being increasingly recognised as a human rights issue. Integration of a human rights perspective in maternal health programmes could contribute positively in eliminating avertable maternal deaths. This study was conducted to explore socio-cultural and service delivery–related dimensions of maternal deaths in rural central India using a human rights lens.
Social autopsies were conducted for 22 maternal deaths during 2011 in Khargone district in central India. The data were analysed using thematic analysis. The factors associated with maternal deaths were classified by using the 'three delays' framework and were examined by using a human rights lens.
All 22 women tried to access medical assistance, but various factors delayed their access to appropriate care. The underestimation of the severity of complications by family members, gender inequity, and perceptions of low-quality delivery services delayed decisions to seek care. Transportation problems and care seeking at multiple facilities delayed reaching appropriate health facilities. Negligence by health staff and unavailability of blood and emergency obstetric care services delayed receiving adequate care after reaching a health facility.
The study highlighted various socio-cultural and service delivery–related factors which are violating women's human rights and resulting in maternal deaths in rural central India. This study highlights that, despite the health system's conscious effort to improve maternal health, normative elements of a human rights approach to maternal health (i.e. availability, accessibility, acceptability, and quality of maternal health services) were not upheld. The data and analysis suggest that the deceased women and their relatives were unable to claim their entitlements and that the duty bearers were not successful in meeting their obligations. Based on the findings of our study, we conclude that to prevent maternal deaths, further concentrated efforts are required for better community education, women's empowerment, and health systems strengthening to provide appropriate and timely services, including emergency obstetric care, with good quality.
maternal health; maternal death; right to health; rights-based approach; India
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XVII International AIDS Conference: From Evidence to Action - Regional focus
Baijal, Parijat
Kort, Rodney
Journal of the International AIDS Society
2009;12(Suppl 1):S6.
This article summarizes the challenges, opportunities and lessons learned from presentations, discussions and debates addressing major policy and programmatic responses to HIV in six geographical regions: Sub-Saharan Africa, Asia and the Pacific, Eastern Europe and Central Asia, Latin America, Caribbean, and Middle East and North Africa. It draws from AIDS 2008 Leadership and Community Programmes, particularly the six regional sessions, and Global Village activities.
While the epidemiological, cultural and socio-economic contexts in these regions vary considerably, several common, overarching principles and themes emerged. They include: advancing basic human rights, particularly for vulnerable and most at risk populations; ensuring the sustainability of the HIV response through long-term, predictable financing; strengthening health systems; investing in strategic health information; and improving accountability and the involvement of civil society in the response to AIDS.
Equally important is the need to address political barriers to implementing evidence-based interventions such as opioid substitution therapy (OST), needle and syringe programmes (NSPs), comprehensive sexuality education for youth, and sexual and reproductive rights. Finally, these regional discussions emphasized the need for legislative and policy reforms related to structural barriers facing women and girls, MSM, IDUs, sex workers and migrant populations.
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Access To Essential Maternal Health Interventions and Human Rights Violations among Vulnerable Communities in Eastern Burma
Mullany, Luke C
Lee, Catherine I
Yone, Lin
Paw, Palae
Oo, Eh Kalu Shwe
Maung, Cynthia
Lee, Thomas J
Beyrer, Chris
PLoS Medicine
Health indicators are poor and human rights violations are widespread in eastern Burma. Reproductive and maternal health indicators have not been measured in this setting but are necessary as part of an evaluation of a multi-ethnic pilot project exploring strategies to increase access to essential maternal health interventions. The goal of this study is to estimate coverage of maternal health services prior to this project and associations between exposure to human rights violations and access to such services.
Methods and Findings
Selected communities in the Shan, Mon, Karen, and Karenni regions of eastern Burma that were accessible to community-based organizations operating from Thailand were surveyed to estimate coverage of reproductive, maternal, and family planning services, and to assess exposure to household-level human rights violations within the pilot-project target population. Two-stage cluster sampling surveys among ever-married women of reproductive age (15–45 y) documented access to essential antenatal care interventions, skilled attendance at birth, postnatal care, and family planning services. Mid-upper arm circumference, hemoglobin by color scale, and Plasmodium falciparum parasitemia by rapid diagnostic dipstick were measured. Exposure to human rights violations in the prior 12 mo was recorded. Between September 2006 and January 2007, 2,914 surveys were conducted. Eighty-eight percent of women reported a home delivery for their last pregnancy (within previous 5 y). Skilled attendance at birth (5.1%), any (39.3%) or ≥ 4 (16.7%) antenatal visits, use of an insecticide-treated bed net (21.6%), and receipt of iron supplements (11.8%) were low. At the time of the survey, more than 60% of women had hemoglobin level estimates ≤ 11.0 g/dl and 7.2% were Pf positive. Unmet need for contraceptives exceeded 60%. Violations of rights were widely reported: 32.1% of Karenni households reported forced labor and 10% of Karen households had been forced to move. Among Karen households, odds of anemia were 1.51 (95% confidence interval [CI] 0.95–2.40) times higher among women reporting forced displacement, and 7.47 (95% CI 2.21–25.3) higher among those exposed to food security violations. The odds of receiving no antenatal care services were 5.94 (95% CI 2.23–15.8) times higher among those forcibly displaced.
Coverage of basic maternal health interventions is woefully inadequate in these selected populations and substantially lower than even the national estimates for Burma, among the lowest in the region. Considerable political, financial, and human resources are necessary to improve access to maternal health care in these communities.
Luke Mullany and colleagues examine access to essential maternal health interventions and human rights violations within vulnerable communities in eastern Burma.
Editors' Summary
After decades of military rule, Burma has one of the world's worst health-care systems and high levels of ill health. For example, maternal mortality (deaths among women from pregnancy-related causes) is around 360 per 100,000 live births in Burma, whereas in neighboring Thailand it is only 44 per 100,000 live births. Maternal health is even worse in the Shan, Karenni, Karen and Mon states in eastern Burma where ethnic conflicts and enforced village relocations have internally displaced more than half a million people. Here, maternal mortality is thought to be about 1000 per 100, 000 live births. In an effort to improve access to life-saving maternal health interventions in these states, Burmese community-based health organizations, the Johns Hopkins Center for Public Health and Human Rights and the Global Health Access Program in the USA, and the Mae Tao Clinic (a health-worker training center in Thailand) recently set up the Mobile Obstetric Maternal Health Workers (MOM) Project. In this pilot project, local health workers from 12 communities in eastern Burma received training in antenatal care, emergency obstetrics (the care of women during childbirth), blood transfusion, and family planning at the Mae Tao Clinic. Back in Burma, these maternal health workers trained additional local health workers and traditional birth attendants. All these individuals now provide maternal health care to their communities.
Why Was This Study Done?
The effectiveness of the MOM project can only be evaluated if accurate baseline information on women's access to maternal health-care services is available. This information is also needed to ensure the wise use of scarce health-care resources. However, very little is known about reproductive and maternal health in eastern Burma. In this study, the researchers analyze the information on women's access to reproductive and maternal health-care services that was collected during the initial field implementation stage of the MOM project. In addition, they analyze whether exposure to enforced village relocations and other human rights violations affect access to maternal health-care services.
What Did the Researchers Do and Find?
Trained survey workers asked nearly 3000 ever-married women of reproductive age in the selected communities about their access to antenatal and postnatal care, skilled birth attendants, and family planning. They measured each woman's mid-upper arm circumference (an indicator of nutritional status) and tested them for anemia (iron deficiency) and infection with malaria parasites (a common cause of anemia in tropical countries). Finally, they asked the women about any recent violations of their human rights such as forced labour or relocation. Nearly 90% of the women reported a home delivery for their last baby. A skilled attendant was present at only one in 20 births and only one in three women had any antenatal care. One third of the women received postnatal care and only a third said they had access to effective contraceptives. Few women had received iron supplements or had used insecticide-treated bednets to avoid malaria-carrying mosquitos. Consequently, more than half the women were anemic and 7.2% were infected with malaria parasites. Many women also showed signs of poor nutrition. Finally, human rights violations were widely reported by the women. In Karen, the region containing most of the study communities, forced relocation tripled the risk of women developing anemia and greatly decreased their chances of receiving any antenatal care.
What Do These Findings Mean?
These findings show that access to maternal health-care interventions is extremely limited and that poor nutrition, anemia, and malaria, all of which increase the risk of pregnancy complications, are widespread in the communities in the MOM project. Because these communities had some basic health services and access to training in Thailand before the project started, these results probably underestimate the lack of access to maternal health-care services in eastern Burma. Nevertheless, it is clear that considerable political, financial, and human resources will be needed to improve maternal health in this region. Finally, the findings also reveal a link between human rights violations and reduced access to maternal health-care services. Thus, the scale of human rights violations will need to be considered when evaluating programs designed to improve maternal health in Burma and in other places where there is ongoing conflict.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050242.
This research article is further discussed in a PLoS Medicine Perspective by Macaya Douoguih
The World Health Organization provides information on all aspects of health in Burma (in several languages)
The Mae Tao Clinic also provides general information about Burma and its health services
More information about the MOM project is available in a previous publication by the researchers
The Burma Campaign UK and Human Rights Watch both provide detailed information about human rights violations in Burma
The United Nations Population Fund provides information about safe motherhood and ongoing efforts to save mothers' lives around the world
Related Articles
Global constitutionalism, responsibility to protect, and extra-territorial obligations to realize the right to health: time to overcome the double standard (once again)
Ooms, Gorik
Hammonds, Rachel
International Journal for Equity in Health
If human rights are "inalienable rights of all members of the human family", as is enshrined in the Universal Declaration of Human Rights, then no government should be allowed to deny people of them. When some governments fail to realize them for the people under their jurisdiction, the international community has a responsibility to step in.
This extra-territorial effect of human rights was not included in the original conception of human rights. It is of recent date, and, in practice, limited to interventions to end severe violations of civil and political human rights. For economic, social and cultural human rights, extra-territorial obligations are still contested.
In this paper, we elaborate three contentions: first, that the realization of social human rights requires the acceptance of and compliance with extra-territorial obligations; second, that compliance with extra-territorial obligations would help transform the international assistance paradigm from charity into legal obligation; and third, that for global constitutionalism to succeed in improving the fairness of the international legal order requires acceptance of the indivisibility of human rights.
Human rights; Right to health; Global constitutionalism; Responsibility to protect; Extra-territorial obligations
Related Articles
Religious communities and HIV prevention: an intervention-study using a human rights-based approach
Paiva, V.
Garcia, J.
Rios, L.F.
Santos, A.O.
Terto, V.
Munõz-Laboy, M.
Global public health
Religious communities have been a challenge to HIV prevention globally. Focusing on the acceptability component of the right to health, this intervention study examined how local Catholic, Evangelical and Afro-Brazilian religious communities can collaborate to foster young people's sexual health and ensure their access to comprehensive HIV prevention in their communities in Brazil. This article describes the process of a three-stage sexual health promotion and HIV prevention initiative that used a multicultural human rights approach to intervention. Methods included 27 in-depth interviews with religious authorities on sexuality, AIDS prevention and human rights, and training 18 young people as research-agents, who surveyed 177 youth on the same issues using self-administered questionnaires. The results, analysed using a rights-based perspective on health and the vulnerability framework, were discussed in daylong interfaith workshops. Emblematic of the collaborative process, workshops are the focus of the analysis. Our findings suggest that this human rights framework is effective in increasing inter-religious tolerance and in providing a collective understanding of the sexuality and prevention needs of youth from different religious communities, and also serves as a platform for the expansion of state AIDS programmes based on laical principles.
sexuality; human rights; youth; HIV prevention; religion
Related Articles
Reinterpreting Ethnic Patterns among White and African American Men Who Inject Heroin: A Social Science of Medicine Approach
Bourgois, Philippe
Martinez, Alexis
Kral, Alex
Edlin, Brian R
Schonberg, Jeff
Ciccarone, Dan
PLoS Medicine
Street-based heroin injectors represent an especially vulnerable population group subject to negative health outcomes and social stigma. Effective clinical treatment and public health intervention for this population requires an understanding of their cultural environment and experiences. Social science theory and methods offer tools to understand the reasons for economic and ethnic disparities that cause individual suffering and stress at the institutional level.
Methods and Findings
We used a cross-methodological approach that incorporated quantitative, clinical, and ethnographic data collected by two contemporaneous long-term San Francisco studies, one epidemiological and one ethnographic, to explore the impact of ethnicity on street-based heroin-injecting men 45 years of age or older who were self-identified as either African American or white. We triangulated our ethnographic findings by statistically examining 14 relevant epidemiological variables stratified by median age and ethnicity. We observed significant differences in social practices between self-identified African Americans and whites in our ethnographic social network sample with respect to patterns of (1) drug consumption; (2) income generation; (3) social and institutional relationships; and (4) personal health and hygiene. African Americans and whites tended to experience different structural relationships to their shared condition of addiction and poverty. Specifically, this generation of San Francisco injectors grew up as the children of poor rural to urban immigrants in an era (the late 1960s through 1970s) when industrial jobs disappeared and heroin became fashionable. This was also when violent segregated inner city youth gangs proliferated and the federal government initiated its "War on Drugs." African Americans had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families. Most of the whites were expelled from their families when they began engaging in drug-related crime. These historical-structural conditions generated distinct presentations of self. Whites styled themselves as outcasts, defeated by addiction. They professed to be injecting heroin to stave off "dopesickness" rather than to seek pleasure. African Americans, in contrast, cast their physical addiction as an oppositional pursuit of autonomy and pleasure. They considered themselves to be professional outlaws and rejected any appearance of abjection. Many, but not all, of these ethnographic findings were corroborated by our epidemiological data, highlighting the variability of behaviors within ethnic categories.
Bringing quantitative and qualitative methodologies and perspectives into a collaborative dialog among cross-disciplinary researchers highlights the fact that clinical practice must go beyond simple racial or cultural categories. A clinical social science approach provides insights into how sociocultural processes are mediated by historically rooted and institutionally enforced power relations. Recognizing the logical underpinnings of ethnically specific behavioral patterns of street-based injectors is the foundation for cultural competence and for successful clinical relationships. It reduces the risk of suboptimal medical care for an exceptionally vulnerable and challenging patient population. Social science approaches can also help explain larger-scale patterns of health disparities; inform new approaches to structural and institutional-level public health initiatives; and enable clinicians to take more leadership in changing public policies that have negative health consequences.
Bourgois and colleagues found that the African American and white men in their study had a different pattern of drug use and risk behaviors, adopted different strategies for survival, and had different personal histories.
Editors' Summary
There are stark differences in the health of different ethnic groups in America. For example, the life expectancy for white men is 75.4 years, but it is only 69.2 years for African-American men. The reasons behind these disparities are unclear, though there are several possible explanations. Perhaps, for example, different ethnic groups are treated differently by health professionals (with some groups receiving poorer quality health care). Or maybe the health disparities are due to differences across ethnic groups in income level (we know that richer people are healthier). These disparities are likely to persist unless we gain a better understanding of how they arise.
Why Was This Study Done?
The researchers wanted to study the health of a very vulnerable community of people: heroin users living on the streets in the San Francisco Bay Area. The health status of this community is extremely poor, and its members are highly stigmatized—including by health professionals themselves. The researchers wanted to know whether African American men and white men who live on the streets have a different pattern of drug use, whether they adopt varying strategies for survival, and whether they have different personal histories. Knowledge of such differences would help the health community to provide more tailored and culturally appropriate interventions. Physicians, nurses, and social workers often treat street-based drug users, especially in emergency rooms and free clinics. These health professionals regularly report that their interactions with street-based drug users are frustrating and confrontational. The researchers hoped that their study would help these professionals to have a better understanding of the cultural backgrounds and motivations of their drug-using patients.
What Did the Researchers Do and Find?
Over the course of six years, the researchers directly observed about 70 men living on the streets who injected heroin as they went about their usual lives (this type of research is called "participant observation"). The researchers specifically looked to see whether there were differences between the white and African American men. All the men gave their consent to be studied in this way and to be photographed. The researchers also studied a database of interviews with almost 7,000 injection drug users conducted over five years, drawing out the data on differences between white and African men. The researchers found that the white men were more likely to supplement their heroin use with inexpensive fortified wine, while African American men were more likely to supplement heroin with crack. Most of the white men were expelled from their families when they began engaging in drug-related crime, and these men tended to consider themselves as destitute outcasts. African American men had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families, and these men tended to consider themselves as professional outlaws. The white men persevered less in attempting to find a vein in which to inject heroin, and so were more likely to inject the drug directly under the skin—this meant that they were more likely to suffer from skin abscesses. The white men generated most of their income from panhandling (begging for money), while the African American men generated most of their income through petty crime and/or through offering services such as washing car windows at gas stations.
What Do These Findings Mean?
Among street-based heroin users, there are important differences between white men and African American men in the type of drugs used, the method of drug use, their social backgrounds, the way in which they identify themselves, and the health risks that they take. By understanding these differences, health professionals should be better placed to provide tailored and appropriate care when these men present to clinics and emergency rooms. As the researchers say, "understanding of different ethnic populations of drug injectors may reduce difficult clinical interactions and resultant physician frustration while improving patient access and adherence to care." One limitation of this study is that the researchers studied one specific community in one particular area of the US—so we should not assume that their findings would apply to street-based heroin users elsewhere.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030452.
The US Centers for Disease Control (CDC) has a web page on HIV prevention among injection drug users
The World Health Organization has collected documents on reducing the risk of HIV in injection drug users and on harm reduction approaches
The International Harm Reduction Association has information relevant to a global audience on reducing drug-related harm among individuals and communities
US-focused information on harm reduction is available via the websites of the Harm Reduction Coalition and the Chicago Recovery Alliance
Canada-focused information can be found at the Street Works Web site
The Harm Reduction Journal publishes open-access articles
The CDC has a web page on eliminating racial and ethnic health disparities
The Drug Policy Alliance has a web page on drug policy in the United States
Related Articles
Community empowerment and involvement of female sex workers in targeted sexual and reproductive health interventions in Africa: a systematic review
Moore, Lizzie
Chersich, Matthew F
Steen, Richard
Reza-Paul, Sushena
Dhana, Ashar
Vuylsteke, Bea
Lafort, Yves
Scorgie, Fiona
Globalization and Health
Female sex workers (FSWs) experience high levels of sexual and reproductive health (SRH) morbidity, violence and discrimination. Successful SRH interventions for FSWs in India and elsewhere have long prioritised community mobilisation and structural interventions, yet little is known about similar approaches in African settings. We systematically reviewed community empowerment processes within FSW SRH projects in Africa, and assessed them using a framework developed by Ashodaya, an Indian sex worker organisation.
In November 2012 we searched Medline and Web of Science for studies of FSW health services in Africa, and consulted experts and websites of international organisations. Titles and abstracts were screened to identify studies describing relevant services, using a broad definition of empowerment. Data were extracted on service-delivery models and degree of FSW involvement, and analysed with reference to a four-stage framework developed by Ashodaya. This conceptualises community empowerment as progressing from (1) initial engagement with the sex worker community, to (2) community involvement in targeted activities, to (3) ownership, and finally, (4) sustainability of action beyond the community.
Of 5413 articles screened, 129 were included, describing 42 projects. Targeted services in FSW 'hotspots' were generally isolated and limited in coverage and scope, mostly offering only free condoms and STI treatment. Many services were provided as part of research activities and offered via a clinic with associated community outreach. Empowerment processes were usually limited to peer-education (stage 2 of framework). Community mobilisation as an activity in its own right was rarely documented and while most projects successfully engaged communities, few progressed to involvement, community ownership or sustainability. Only a few interventions had evolved to facilitate collective action through formal democratic structures (stage 3). These reported improved sexual negotiating power and community solidarity, and positive behavioural and clinical outcomes. Sustainability of many projects was weakened by disunity within transient communities, variable commitment of programmers, low human resource capacity and general resource limitations.
Most FSW SRH projects in Africa implemented participatory processes consistent with only the earliest stages of community empowerment, although isolated projects demonstrate proof of concept for successful empowerment interventions in African settings.
Female sex workers; Community mobilisation; Structural interventions; Africa
Related Articles
Community attitude towards the reproductive rights and sexual life of people living with HIV/AIDS in Olorunda Local Government Area, Osogbo, Nigeria
Asekun-Olarinmoye, EO
Asekun-Olarinmoye, IO
Adebimpe, WO
Olugbenga-Bello, AI
HIV/AIDS (Auckland, N.Z.)
Globally, the Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic remains a major public health problem. In most countries in sub-Saharan Africa, HIV/AIDS has already reversed the post-independence developmental gains.
This study assessed community attitudes regarding the reproductive rights and sexual life of people living with HIV/AIDS (PLWHA) in Olorunda Local Government Area of Osun State, Southwestern Nigeria.
Design and methods
In a community-based descriptive cross-sectional study, the sample size calculation was based on the assumption that 67% of the target population has a negative attitude regarding the reproductive rights of PLWHA; a confidence interval (CI) of 95% was used. A minimum sample size of 340 was obtained using the formula n = Z2pq/d2. An anticipated 10% nonresponse rate was added to obtain a sample size of 374; a multistage sampling technique was utilized to select a total of 450 respondents. Data collected through a semistructured standardized and pretested questionnaire were analyzed using Statistical Package for Social Sciences software, version 15.
The study revealed that 283 (66.6%) and 142 (33.4%) of respondents were urban and rural dwellers, respectively. Mean age of respondents was 28.7 years ± 2.2 years. Four hundred and two (94.6%) respondents were aware of HIV/AIDS, and 88.7% had knowledge of at least six different modes of HIV/AIDS transmission. About 30.7% of respondents had discriminatory and stigmatizing attitudes towards PLWHA, and 50.9% and 44.8% had negative attitudes towards their sexual and reproductive rights, respectively. There were significant associations between gender, marital status, educational status, occupation, and residential area of respondents and their attitude towards the reproductive and sexual right of PLWHA (P < 0.05).
Conclusion and recommendation
Discriminatory and stigmatizing attitudes to PLWHA found among respondents translated into a negative attitude regarding the reproductive and sexual rights of PLWHA. There is an urgent need to institute programs for raising community awareness about the rights of PLWHA, especially in rural areas, and to strengthen legislative provisions for protecting and preserving the reproductive rights of PLWHA.
community attitudes; PLWHA; reproductive and sexual rights
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About blueste34k23 : Ya I'm cool so what
blueste34k23's FML badges
How depressing, no badges acquired at all. :/
blueste34k23's favorite FMLs
Today, I was visiting my daughter, whose husband was still asleep at noon. I made a point of stomping around on the hardwood floor and speaking loudly to wake his lazy ass up. Turns out he's now working a 14-hour graveyard shift, and it has no negative effect on his shoe-throwing skills. FML
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2008 GMC Yukon Top Comparisons
Users ranked 2008 GMC Yukon against other cars which they drove/owned. Each ranking was based on 9 categories. Here is the summary of top rankings.
User Reviews
Displaying all 7 2008 GMC Yukon reviews.
CarGurus https://www.cargurus.com
2008 GMC Yukon Hybrid Review
Comfortable And Fuel Efficient — I like that it has more space than needed in the back seats but do to this it takes up the possibility of some cargo space and I dislike that you can't fold all rear seats flat. Overall I like the fact of having a 6.0 lt engine and fuel efficient engine.
Primary Use: Family transportation
Pros: Comfortable and has a great suspension.
Cons: No cargo space nor can you fold all rear seats flat.
Looking for a Used Yukon in your area?
CarGurus has 9,912 nationwide Yukon listings starting at $2,500.
CarGurus https://www.cargurus.com
2008 GMC Yukon Hybrid Review
Smooth Ride — Has Hybrid technology, which is a battery and gas powered engine. It switches between both when needed. Leather interior, electric seats, Navigation, SiriusXM, moon roof, third row seating, DVD player. Recently purchased, hoping to add more positives in the near future.
Primary Use: Family transportation
Pros: saves on gas, luxurious interior
Cons: not as high as tahoe
CarGurus https://www.cargurus.com
2008 GMC Yukon Hybrid 4WD Review
2008 Gmc Yukon Hybrid — I absolutely love this car. It is great for long road trips because of the gas mileage, cargo size, and the interior is fantastic. The only problem I have is because the vehicle is so large, people have a tendency to park too close.
Primary Use: Family transportation
Pros: Great gas mileage for a huge SUV. Plenty of cargo unless someone is sitting in the 3rd row seats.
Cons: The third row seats are removable but they are heavy.
CarGurus https://www.cargurus.com
2008 GMC Yukon SLT2 4WD Review
Perfection — smooth ride, many features, great get up and go, the v4 gas savings helps quite a bit. I can get up to 24 mpg on the highway at 75 mph. I love the ability of the yukon to go anywhere and everywhere
Primary Use: Sport/fun (spirited driving, track racing, off-roading, etc.)
Pros: smooth ride
Cons: gas savings
CarGurus https://www.cargurus.com
2008 GMC Yukon SLE1 4WD Review
2008 Gmc Yukon With 22" Gmc Wheels — good on gas, lots of power, very reliable and good appearance and handling, it has 22 " gmc rims and a abs black honeycomb grille with no emblem, magna flow exhaust and air intake. very good family vehicle never any break downs
Primary Use: Family transportation
Pros: good handling and goo appearance
Cons: magna flow exhaust drones
CarGurus https://www.cargurus.com
2008 GMC Yukon Hybrid 4WD Review
CarGurus https://www.cargurus.com
2008 GMC Yukon SLT1 4WD Review
My Baby — The GMC Yukon is perhaps my favorite SUV. It has a lot of room and the performance is excellent. It takes the turns of the road with ease. My Yukon cost me about 60,000 but that was the upgraded version. The regular edition of the Yukon runs for about 42,000.
Pros: Exterior and Interior are divine, rides sweetly
Cons: Gas guzzler
Displaying all 7 2008 GMC Yukon reviews.
Reviews From Other Years
2015 GMC Yukon Reviews
Great Vehicle
The room in this vehicle is amazing! The hidden compartment and valet mode for locking out the radio is neat. I would recommend this vehicle to anyone that is looking for reliable family vehicle. The ... Read More
2009 GMC Yukon Reviews
Best Automobile I've Owned To Date!
at first i was hesitant to get an SUV, considering it is just me, but after owning a Yukon, I don't think I will ever go back to a car! this vehicle is built to last - I am sure whoever buys it will h... Read More
Quiet Smooth And Comfortable
Love the room and towing capabilities. Smooth ride and great for long trips. I would recommend this for a family that loves to travel and/or pull a boat or camper to the lake. Or just to drive it as a... Read More
2007 GMC Yukon Reviews
Great Overall Family Car
The great thing about this car is that it is very spacious and very comfortable when it comes to road trips, everyone would be comfortable and it's also great for everyday use such as commuting to wor... Read More
I Have Loved This Truck Especially The Color And The Power It Has And Options
I just want to buy a newer truck so I can't say enough good things about my truck I bought it off the show room floor it was beautiful !! Its reliable and easy to take care of and well maintained Read More
2006 GMC Yukon Reviews
Excellent Comfortable Vehicle
I like the 2006 Yukon, but have not been in a 2007. It has enough room for my family and travels nicely and comofortably. Read More
2005 GMC Yukon Reviews
Looks Can Be Deceiving
I use this truck for work mainly and travel all over the country as a contractor. I like the overall looks of the truck, plenty of room for tools and luggage. I've owned 2 others this one seems to be ... Read More
Great Overall
a great passenger vehicle with 4 wheel drive,gets good gas mileage for its size.it has seating for up to eight people.great power for towing or hauling.has a sunroof which i like.and a rear dvd player... Read More
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text:
In this Internet era, public approval of the FBI is headed down hard.
Trump's corporate tax cut is supply-side stimulus I could agree with if done right, even though it primarily helps the rich. Trump's cut of the top rate from 35% to 15% is the largest of its kind in the history the United States.
2016 has been according to one buysider, "the most difficult, treacherous year" for the hedge fund community in recent history as a result of unprecedented shifts in market sentiment, choppy trading, low conviction, investor redemptions, illiquidity and volatility month after month, which has left the hedge fund community exhausted and reeling even as the S&P hits all time highs.
The summer doldrums continue with another listless overnight session, not helpd by Japan markets which are closed for holiday, as Asian stocks fell fractionally, while European stocks rebounded as oil trimmed losses after the the IEA said pent-up demand would absorb record crude output (something they have said every single month). S&P futures have wiped out almost all of yesterday's losses and were up over 0.2% in early trading.
Disappointing fiscal stimulus, loss of faith in The BoJ, and increasingly headless-chicken policymakers has sparked a sudden and severe rush for the exits from Japan's government bond markets. 10Y JGB yields exploded from -30bps to almost 0bps in the last 4 days - the biggest crash in prices in over 3 years. This bloodbath is roiling the rest of the global developed bond market with Bund yield spiking (+12bps in last 2 days, almost back to 0), Swiss, UK, and Danish bonds are all blowing out, and Treasury yields up 14bps since Friday alone.
The new risk scenario for CNY is 8.0 (20% increase in USD-CNY). The caveat is that the pain threshold for the market appears to be much higher than before and the implications for the global financial markets will primarily depend on the speed of depreciation. We believe that it would take significantly more pressure on capital flows than what we have seen over the past few years, or an economic hard landing, for our risk scenario to unfold.
Whereas spot prices have stabilized, there appears to be little conviction among traders and other financial market participants about the course of exchange rates and asset prices going forward. Market sentiment remains tentative; small catalysts can be very disruptive. A common trading floor comment is: "No one knows how to price the Brexit scenario going forward."
When one looks at the actual dynamics within the bookies, an odd divergence emerges: "Although Ladbrokes has received a higher volume of bets to leave the EU, those making a punt on remain were placing higher financially larger" - the average stake on a bet to remain was £450, compared to £75 on a bet to leave."
Despite the surge in risk assets and bookies' odds, opinion polls show the Leave and Remain campaigns still neck and neck ahead of Thursday's U.K. referendum on EU membership. Here are some key events that could drive market sentiment in the days and weeks ahead.
A new global financial crisis looms. Best to hope for the best, but be prepared financially for less benign scenarios ...
With financial conditions having significantly recovered, it is reasonable to expect that the Yellen call will soon be back in the money following the June FOMC meeting. We believe June is largely off the table given the weakness of Friday's employment report and the UK referendum on its EU membership in June. But we think the July meeting is live, without our US Economics team seeing a 40% probability of a second hike. With equity markets posting new highs this week, we think the 'Yellen call' is on track to move back into the money in 2016H2.
Betweeen Doha hopes (and nopes), Nigerian supply 'disruptions' which apparently cannot be stopped (conveniently for many oil producers, equity bulls, and central bank inflation watchers), and non-transitory Chinese 'demand', WTI crude has topped $51 this morning - almost doubling off the February lows. While still down YoY, oil prices have recovered to 11-month highs, soothing credit-driven anxiety in markets (even though bankruptcies continue) and enabling hedgers to pile in (crushing the crude curve). With rig counts rising once more (and global GDP being slashed), one questions how sustainable this frothy bounce will be...
BofA: "last week, BofAML clients were net sellers of US stocks for the 18th consecutive week, continuing the longest uninterrupted selling streak in our data history (since '08)."
From April 2015 through May 2016, every single one of the 173 stocks that Emperor analysts covered had a buy recommendation. The analysts were so wrong that shorting every one would have yielded 13 percent through last week. As we reported last year, Chinese retail investors opened enough brokerage accounts for every man, woman, and child in LA. As it turns out, that's precisely how Emperor was making its money, by securities turnover and margin loans due to an influx of new retail customers. The firm threw day trade buy recommendations out on every single stock and watched new inexperienced "investors" trade on that data. That effort takes Wall Street's lazy clustering to an entirely new level.
On March 10, 2016 when the ECB announced the biggest expansion to quantitative easing in European history, when it shocked the market by announcing not only a reduction in its negative rate and expansion in the TLTRO program, but also the launch of a corporate bond monetization program.Well maybe not "shocked" the market, because as Bloomberg writes, ECB board members met with representatives of banks and investment managers including Goldman Sachs, BlackRock, Credit Suisse and Moore Europe Capital Management in February, just days before the ECB's March 10 announcement.
In what may be one of the least relevant payroll reports in a long time as the Fed already knows the labor market is doing better quantiatively (qualitatively it has been all about low-paying jobs gaining at the expense of higher paying manufacturing and info-tech positions) and as has further demonstrated it is no longer jobs data dependent, here is what Wall Street consensus expects: total payrolls +200,000, down from 215K in March; a 4.9% unemployment rate; average hourly earnings rising 0.3% (last 0.3%) M/M and 2.4% Y/Y (last 2.3%); on labor force participation of 63%.
While there was no unexpected overnight central bank announcement unlike yesterday's surprise by the RBA which unleashed volatility havoc in the FX market, which promptly spilled over into all asset classes, overnight stocks around the world saw another leg lower without a tangible catalyst, while EM currencies fell to a one-month low after two Fed presidents raised concern investors had become too complacent in their belief that U.S. interest rate raises will stay on hold. Or perhaps all that is happening is that after ignoring Trump, the market is starting to finally price in the possible reality of the Donald in the White House (although as Jeff Gundlach pointed out, Trump would be a far better president for the economy and the market than Hillary or Bernie).
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