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Keller (Bellevue/NYU) - Health and Human Rights

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  • 1. Health, Human Rights and Advocacy: A Moral Imperative Allen S. Keller, M.D. Associate Professor of Medicine Director, Center for Health and Human Rights NYU School of Medicine
  • 2. Principles of Medical Ethics
    • Beneficence (and nonmaleficence) -Maximize possible benefits and minimize possible harms.
    • Autonomy -Respect for self-determination
    • Justice -Treat all people equitably and with full respect -Consider the effects of medical decisions on other individuals and on society
  • 3. HEALTH
  • 4.  
  • 5. HEALTH
    • “ A state of complete physical, mental and social well-being,and not merely the absence of disease or infirmity.” 1
    • 1 World Health Organization Constitution
  • 6. Human Rights
    • Human Rights are the rights of individuals
      • Individuals have them by virtue of being human
    • Human Rights are universal
      • They apply to all people around the world
    • Human Rights are claims upon society
      • They principally involve the relationship between the state and the individual
  • 7. Human Rights
    • Civil and Political Rights
      • Eg. Freedom of expression/speech, freedom from arbitrary arrest
    • Economic, Social and Cultural Rights
      • Eg. Right to work, right to health, right to cultural identity
      • --------------------------------------------------
    • Negative Rights (Eg. Right to not be tortured)
    • Positive Rights (Eg. Right to education)
    • HUMAN RIGHTS ARE INTERDEPENDENT
  • 8.  
  • 9. The Nuremberg Code
    • From the judgment rendered in the “Doctors Trial” at the Nuremberg Tribunal.
    •   Addresses the question of the permissability of medical experimentation.
    • Enumerates a 10 point code of human experimentation ethics.
    • “ The voluntary consent of the human subject is absolutely essential.”
  • 10. Universal Declaration of Human Rights (Adopted Dec. 10, 1948 by U.N. General Assembly)  
    • Preamble:
    • “ Whereas recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world...”
  • 11. International Covenants/Conventions
    • International treaties enforceable under international law
      • Convention on the Prevention and Punishment of the Crime of Genocide (1951)
      • Covenant on Civil and Political Rights (1976)
      • Covenant on Economic, Social, Cultural Rights (1976)
      • Convention On the Elimination of All Forms of Discrimination Against Women (1981)
      • Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (1987)
      • Convention on the Rights of the Child (1989)
  • 12. Physician Oaths and Codes
    • Hippocratic Oath
      • (Classical Version, Ancient Greece 5 th -4 th Century B.C.)
    • Hippocratic Oath/Declaration of Geneva
      • (Modern version, 1964, 1983)
    • Prayer of Maimonides
    • International Code of Medical Ethics
      • (World Medical Association)
      • These Oaths/Codes focus primarily on the individual Doctor/patient relationship
  • 13.  
  • 14. Principles of Medical Ethics American Medical Association June 2001
      • “ As a member of this Profession, a physician must recognize responsibility to patients first and foremost, as well as to society…”
      • Art. III. A physician shall respect the law and also recognize a
      • responsibility to seek changes in those requirements which are
      • contrary to the best interest of the patient.
      • Art. VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health
      • Art. IX. A physician shall support access to medical care for all people
  • 15. Physician Citizens-Public Roles and Professional Obligations Gruen R, Pearson S, Brennan T. JAMA January 7 2004 Vol 291. No 1
    • Physicians have an ethical and professional responsibility for the health of the community members they serve.
      • Society grants medical professions-comprising individuals and their collective associations- special social status, monopoly use of knowledge, practice autonomy, and the right to self-regulate
      • In return, the medical profession is expected to promote society’s health
  • 16. Physician Citizens-Public Roles and Professional Obligations Gruen R, Pearson S, Brennan T. JAMA January 7 2004 Vol 291. No 1
    • Social, economic and environmental factors can have significant impact on health and health outcomes
    • Physicians are ideally placed to observe the health effects of soco-ieconomic and environmental factors
    • Physicians can provide information and professional authority that brings legitimacy to these concerns in the public debate
    • Professional Obligations vs. Aspirations
  • 17. Physicians’ Roles in Promoting Human Rights
  • 18. Physicians Roles in Promoting Human Rights (A. Keller. “Human Rights and Advocacy: An Integral Part of Medical Education and Practice., Virtual Mentor, Ethics Journal of the American Medical Association , Jan 2004)
    • Identification
      • Awareness of prevalence of human rights concerns, identifying human rights concerns in clinical context and in the community
    • Treatment
      • providing medical, mental health and social services
    • Documentation
      • Medical/forensic documentation
      • Research, g. Prevalence/health impact of human rights abuses
    • Advocacy
      • Exposing and condemning human rights violations
      • Education colleagues, the public and policy makers
      • Developing/Changing Policy
      • Individual Role/participation in professional organizations
  • 19. Diabetic Ketoacidosis in Prisoners Without Access to Insulin A Keller, R Link, N Bickell, M Charap, A Kalet, M Schwartz JAMA February 3, 1993 Vol 269 No. 5
    • Method:
      • Retrospective chart review of adult males admitted to Bellevue with diabetic ketoacidosis (DKA), 1/1/89-6/30/91
    • Results
      • 41% of of adult male patients admitted for DKA were prisoners
        • (Among all admissions prisoners only constituted 15%)
    • 38(70%) of 54 admissions for DKA among prisoners occurred because prisoners had not received insulin during period immediately following their arrest
    • Conclusions
      • Inadequate access to medication results in serious sequelae for recently arrested prisoners in NYC with insulin dependent diabetes. Access to care for recently arrested prisoners needs to be improved.
  • 20.  
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  • 22.  
  • 23. The Medical and Social Consequences of Land Mines in Cambodia E. Stover, A Keller, J Cobey S Sopheap JAMA, August 3, 1994 Vol. 272 No. 5
    • Reviewed hospital records of 842 patients hospitalized with mine injuries in provincial hospitals located in heavily mined provinces
      • 7% were adult females, 8% were children 15 years or younger
    • Interviewed 16 mine injury patients hospitalized at time of study
      • 13/16 were civilians
      • Mean time from injury to reaching hospital was 6 hours
      • 5/16 patients knew mines were in area when they were injured
  • 24.  
  • 25. War Crimes in Kosovo Iacopino, Frank, Keller, et al. Physicians for Human Rights. August 1999
    • Background
      • The 1999 Kosovo crisis resulted in the largest population displacement in Europe since WWII
    • Method
      • Random sampling of 1,209 Kosovar refugees in 31 refugee camps in Albania and Macedonia
  • 26.  
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  • 35.  
  • 36. Prevalence of Torture
    • Documented to occur in more than 90 countries, worldwide (Source: Human Rights Watch, Amnesty Intl. U.S. State Dept.)
    • 5-35% of refugees and asylum seekers have experienced torture ( Source: studies published in the medical literature)
    • More than 400,000 torture victims, who fled their native countries, are believed to reside in the USA (Source: Office of Refugee Resettlement)
  • 37.  
  • 38. Striking Hard: Torture in Tibet A. Keller et al. Physicians for Human Rights, 1997
    • Background
      • In 1996, torture remained a significant human rights concern in Tibet
    • Methods:
      • Interviewed a sample of 258 Tibetan Refugees in Dharamsala India
    • Findings
      • 15% of Tibetan refugees interviewed reported a history of torture by Chinese authorities in Tibet
      • 47% of refugees interviewed reported having a family member or close friend who was tortured in Tibet
  • 39. Common Forms of Torture
    • Physical
      • Beatings, suspension in painful positions, electric shocks, asphyxiations, chemical exposures, Exposure to loud noises, bright lights, sexual assault, poor conditions of detention-starvation.
    • Psychological
      • Verbal abuse, threats of death, further torture, harm to self or family/friends, mock execution. Forced behaviors (ex. forced sexual intercourse or forced to engage in practices against ones religion). Sleep deprivation
  • 40.  
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  • 49.  
  • 50. Physicians’ Roles in Preventing Torture and its health consequences
    • Identification
      • Awareness of prevalence of torture, identifying torture victims in immigrant/refugee populations
    • Treatment
      • Ensuring access to medical, mental health and social services
    • Documentation
      • Asylum/ Forensic Evaluations. Istanbul Protocol
    • Advocacy
      • Exposing and condemning torture
      • Humane treatment of asylum seekers
      • Ensure adequate funding/support for torture treatment centers (UN. Voluntary fund for Victims of Torture, Torture Victims Relief Act)
  • 51.  
  • 52. Torture Treatment Centers
    • International Rehabilitation Council for Torture Victims:
      • (IRCT) Promotes and supports rehabilitation of victims and prevention of torture through nearly 200 rehabilitation centres worldwide.
    • National Consortium of Torture Treatment Programs (USA)
      • Includes more than 25 programs throughout the United States providing services to torture victims.
  • 53. Bellevue/NYU Program for Survivors of Torture
    • Treatment:
      • comprehensive medical, mental health and social services, regardless of ability to pay.
      • Since 1995, more than 1,000 men, women and children from over 70 countries have received care. (More than 600 clients seen in past year)
    • Education:
      • Clinical training for current/ future health professionals.
      • Presentations/trainings in a variety of forums
    • Research
      • Prevalence and health consequences of torture.
      • Effective Treatments.
  • 54.  
  • 55.  
  • 56. Mental Health of Detained Asylum Seekers A Keller et al. Lancet Nov 2003
      • Background: Worldwide there is a growing trend toward detaining asylum seekers, including torture victims, for months or years pending adjudication of their asylum claims
      • Method: Consecutive sample of 70 asylum seekers detained in the New York area interviewed about their experiences in detention and their psychological symptoms
      • Results:
      • -High levels of anxiety, depression, PTSD (significantly higher than found in other studies of refugees/asylum seekers living in the community, which worsened the longer individuals were in detention.
      • -On follow up interviews 2 months or later, those released had improvement, though not entire resolution in symptoms, compared with worsening of symptoms among those still detained.
      • Conclusion: Detention of asylum seekers appears to significantly exacerbate psychological symptoms in this population
  • 57.  
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  • 64.  
  • 65. Physician Participation in Torture
    • Represent violation of codes of medical Ethics (Declaration of Tokyo, World Medical Association)
      • Direct participation in torture sessions
      • Falsifying medical records of prisoners or failing to report torture to higher authorities
  • 66.  
  • 67. Examining Asylum Seekers
    • Medical documentation can be crucial in the asylum process
    • Organizations coordinating medical/forensic evaluations for asylum seekers:
      • Physicians for Human Rights ( www.phrusa.org )
      • Doctors of the World ( www.doctorsoftheworld.org )
    • Istanbul Protocol
      • Provides international guidelines for documenting torture
        • (see PHR manual “Examining Asylum Seekers”: (Iacopino, Allden, Keller, editors available at www.phrusa.org )
  • 68.  
  • 69. Advocacy and Medicine
    • Individual patient
      • Assist with obtaining appropriate care
      • Documenting injuries in victims of violence
    • Community
      • Care for vulnerable, underserved populations
        • Homeless Clinic, Hepatitis B Project, Torture Survivors Program
        • Ensuring access to services
        • (eg. Keeping Bellevue/Gouverneur Pharmacies open)
  • 70. Advocacy and Medicine
    • National
      • Participation in Professional Societies
        • AMA, AMSA, Specialty organizations
        • Physicians for Human Rights, Physicians for Social Responsibility, Physicians for a National Health Plan
    • International
        • International Campaign to Ban Land Mines
        • Global AIDS Campaign