Global Commission on HIV and the law

The Global Commission on HIV and the Law consisted of fourteen distinguished individuals who advocate on issues of HIV, public health, law and development. Fernando Henrique Cardoso, former president of Brazil, chaired the Commission.

The Commission’s unique convening power allowed it to focus on high-impact issues of HIV and the law, which have important ramifications for global health and development. The Commission advocated for evidence and human rights based legal environments for effective and efficient HIV responses.

HIV is one of the world’s most important public health issues. The Commission writes:

In just three decades, over 30 million people have died of AIDS, and 34 million more have been infected with HIV. The HIV epidemic has become one of the greatest public health challenges of our time. It is also a crisis of law, human rights and social justice. The good news is that we now have all the evidence and tools we need to radically slow new HIV infections and stop HIV related deaths. Paradoxically, this comes at a time when bad laws and other political obstacles are standing in the way of success.

34 million people are living with HIV, 7,400 are newly infected daily and 1.8 million died in 2010 alone. The legal environment—laws, enforcement and justice systems—has immense potential to better the lives of HIV-positive people and to help turn the crisis around. International law and treaties that protect equality of access to health care and prohibit discrimination—including that based on health or legal status—underpin the salutary power of national laws.

But nations have squandered the potential of the legal system. Worse, punitive laws, discriminatory and brutal policing and denial of access to justice for people with and at risk of acquiring HIV are fuelling the epidemic. These legal practices create and punish vulnerability. They promote risky behaviour, hinder people from accessing prevention tools and treatment, and exacerbate the stigma and social inequalities that make people more vulnerable to HIV infection and illness. HIV-positive people—be they parents or spouses, sex workers or health workers, lovers or assailants—interact intimately with others, who in turn interact with others in ever-larger circles, from the community to the globe. From public health to national wealth, social solidarity to equality and justice, HIV affects everyone. The prevention, treatment and care of HIV—and the protection and promotion of the human rights of those who live with it—are everyone’s responsibility.

The Global Commission on HIV and the Law undertook 18 months of extensive research, consultation, analysis and deliberation. Its sources included the testimony of more than 700 people most affected by HIV-related legal environments from 140 countries, in addition to expert submissions and the large body of scholarship on HIV, health and the law.

The Commission’s findings offer cause for both distress and hope for people living with or at risk for HIV. In June 2011, 192 countries committed to reviewing legislation and creating enabling legal and social environments that support effective and efficient HIV responses. The Commission’s recommendations offer guidance to governments and international bodies in shaping laws and legal practices that are science based, pragmatic, humane and just. The findings and recommendations also offer advocacy tools for people living with HIV, civil society, and communities affected by HIV. The recommendations take into account the fact that many laws exist for purposes beyond public health, such as the maintenance of order, public safety and the regulation of trade. But they place the highest priority on creating legal environments that defend and promote internationally recognised human rights and legal norms.

The Commission’s Report (PDF) may be downloaded from here.

Chairman’s end of year message

One of the developments that has been really valuable to Australia21 in the last year has been our increased capacity to engage with subscribers, supporters - and critics - of our work.

Feedback on these weekly email updates and through social media has added richness and diversity to the reach we have been able to achieve. We hope to strengthen these connections in the coming year and I encourage you to make your views known to us. We do take notice.

I look back on 2012 as a year of enormous effort by the Directors and staff of Australia21. This effort has enabled us to survive a financially difficult period and to set a firm foundation for the year ahead. I would like to thank everyone for their hard work.

I would also like to thank our patron, Glyn Davis, Vice-Chancellor of the University of Melbourne, for his ongoing interest and support and to acknowledge the continuing assistance of the University of Melbourne, which has been our main corporate sponsor this year.

We have relied heavily also on the generosity of individual donors to fund our projects and operations. This is very much appreciated and I want to emphasise how important these donations, no matter how small, are to us – both for their critical impact on our ability to continue our work and for the encouragement they symbolise.

Finally thank you to all of you, our subscribers, who read what we have to say and stay in touch. Knowing you are there and paying attention makes a huge difference to our efforts. The Directors and staff of Australia21 wish you all a safe and happy festive season.

Paul Barratt, AO
Chairman, Australia21 

On Bernard Keane, Public Health and the Neglect of Social Determinants

Richard Eckersley, director, Australia 21 Ltd (formerly at the National Centre for Epidemiology and Population Health, ANU).

A colleague once caught me helping myself to some cakes left over from a staff party. Getting your fix of fats and sugars, she quipped. Yep, I replied, I was rebelling against public health fascism. I had in mind the growing number, and sometimes authoritarian tone, of health messages telling us how we should live. Hell, even sitting down (for too long) harms health these days.

So [Crikey Canberra correspondent] Bernard Keane’s attack on the ‘preventive health industry’ is understandable and partly right, but for the wrong reasons. It’s not that the health messages are unwarranted: There are real concerns about trends in both physical and mental health, especially among young people (http://blogs.crikey.com.au/croakey/2011/04/22/challenging-accepted-wisdoms-about-young-peoples-health-and-wellbeing/).

But there is a public or preventive health ‘industry’ in the sense of a professional body that applies a specialised, and restricted, view of how to improve people’s health. You can, as Keane does, talk of ‘social elites anxious to impose control on what they disapprove of’, but it is not particularly helpful.

The ‘industry’ emphasises modifying individual risk factors and lifestyles, particularly tobacco use, poor diet and lack of physical activity, and harmful alcohol use (http://blogs.crikey.com.au/croakey/2011/04/06/challenging-mainstream-thinking-about-health-and-medicine/). It largely overlooks the broader perspective of the social determinants of health (broadly defined to include social, cultural, economic and environmental factors). In doing this, it downplays the political or ideological significance of sickness and ill-health.

As we learn more about health, the bar of healthy living keeps getting raised - at the same time as the weight of unhealthy cultural expectations, or pressures, keeps increasing. Something has to give, and one result is the frustration and resentment expressed in Keane’s articles.

In promoting individual behavioural change, the orthodox public health approach misses the crucial point that social conditions act on population health in ways that cannot be reduced to individual choices. As British epidemiologist Geoffrey Rose observed, there is a relation between the mean of a characteristic in a population (for example, blood pressure or depressive symptoms) and the prevalence of the related disorder. ‘(T)he deviants are simply the tail of the population’s own distribution; they belong to each other…’ Or, as he also said, ‘The visible part of the iceberg (prevalence) is a function of its total mass (the population average)’.

This relationship shows that disease and disorder are the result of social conditions, not just individual lifestyles. Rose also argued that causes of cases can differ from causes of incidence: that is, explanations of why an individual becomes ill can differ from the explanations of why rates of illness in a population rise or fall. Efforts to improve health must match, or be appropriate to, the scale or level at which we seek improvement.

The two approaches – individual and social - are not completely separate and distinct; they represent the ends of a spectrum of interventions. Public health programs, while they are directed at individual behaviour, aim to produce changes in the population as a whole. They range from public education to substantial legislative and regulatory changes to promote healthier living. And it can be argued that social conditions are addressed elsewhere in government: through taxation, welfare, consumer safety and environmental protection, for example.

However, individual and population perspectives are conceptually different in important respects, and the effects of social conditions on population health need to be better understood and acknowledged as a basis for improving public policy and national goals and priorities.

It is very difficult for us to make healthy choices when the social conditions encourage unhealthy preferences. It puts us under considerable stress. As Keane demonstrates, we can respond angrily to attempts by governments and others to interfere in our private lives and to tell us how to live (which is ironic given a vast media-marketing complex spends billions of dollars doing just that, with little opposition).

Industry research on the recommendations of Australia’s National Preventative Health Taskforce (which include tax increases and advertising bans) found more than half of Australians reacted negatively, including agreeing that its report was a political document ‘intent on overturning much of the way we choose to live’.

Richard Wilkinson, co-author of the influential 2009 book, The Spirit Level: Why Equality is Better for Everyone, once told me that people can't keep to good intentions about healthy eating, giving up smoking and taking exercise unless they feel on top of life. ‘When we feel unappreciated, stressed and (with) no way out, we are more likely to eat for comfort and resort to alcohol, drugs, tobacco, and to become more sedentary.’

Wilkinson and others focus on the harm to health of inequality. I’ve emphasised the role of culture, arguing that modern Western culture, with its growing psychological stresses and pressures and its focus on consumption, pleasure and other external trappings of ‘the good life’, is a health hazard.

   

I’ve sometimes illustrated the importance of the social determinants of health by telling ‘the parable of the drowned’, modelled loosely on Hurricane Katrina’s devastation of New Orleans in 2005. Let’s assume most of those who perished drowned. On this basis, the response (reflecting the individual focus of public health campaigns) might be to issue life jackets, or to teach everyone to swim.

Going further, we find that most of the losses occurred in low-lying parts of the city, so the response might be not to build there. We then learn people lived there because they were poor and could not afford to live anywhere else, so poverty needs to be addressed. Then there were problems with the construction of the city’s storm and flood levees and the filling in of coastal wetlands that used to buffer storm surges, raising more questions about governance and city development.

But none of these explanations acknowledges the fundamental cause of the deaths as the hurricane’s severity, and the role of climate change in increasing the probability of such extreme weather events. This implicates industrial civilization. The parable makes clear that understanding and addressing health problems at the level of individual causes of death and disease are very different from understanding and addressing the social causes of a population’s health. As with climate change, so it is with social change.

This wider social perspective tends falls between stools. Public health pays too much attention to the individual; political commentators and analysts have too much regard for political theatre and policy detail. Both perspectives are too restricted. Both need to consider in greater depth the ways in which our world view - the whole framework of our way of life - works against better health and higher wellbeing.

Citation/original source

Eckersley, R. 2012. On Bernard Keane, Public Health and the Neglect of Social Determinants, Croakey, 16 December.

http://blogs.crikey.com.au/croakey/2012/12/16/richard-eckersley-responds-to-bernard-keanes-attack-on-preventative-health-wowsers/

Further reading (available at www.richardeckersley.com.au ):

Eckersley R. 2012. Whatever Happened to Western Civilization? The Cultural Crisis, 20 Years Later. The Futurist, Nov-Dec, pp. 16-22.

Eckersley, R. 2012. The science and politics of population health: giving health a greater role in public policy. Canberra: Australia 21 Ltd.

Engaging young people

At Australia21 we recognise that collaboration between seasoned experience and the fresh vision of youth is critical to Australia’s future.

As a first step in a broader youth engagement strategy we appointed two young people as honorary advisers to the Board in 2012 for a three year term. Here are their reflections on working with Australia21.

Tom Merrett

I have held the position of honorary adviser since March 2012 after having a relationship with Australia21 since 2010 when I participated in the Next Big Question project. More recently I was asked to be a youth participant for the first round table on illicit drugs, held in January. This was an excellent experience and I believe that we have made real progress by getting the tough issue of illicit drugs back on the political radar.

I am studying a Bachelor of Chemical Engineering in a double degree with Finance at the University of Adelaide. However currently I am in the middle of a semester long exchange to the National University of Singapore - which has not been all work as you can see in this photo of me exploring the volcanoes of Indonesia. It has been a great experience studying in Asia and thanks to technology (Skype) I have been able to continue to be an active participant in Australia21.

Since March I have been involved in a diverse range of discussions and projects. One of my primary contributions has been online through our website and social media. We have completely redesigned our website, making it much more user friendly and engaging. We have also begun to expand our presence into the social media space, which I see as a vital tool for not for profit organisations. We have progressed substantially, however still have a long way to go.

Another important issue for Australia21 is youth engagement. It is important not just to ensure diversity of opinions but also for the longevity of the organisation. I am currently involved in developing policies and strategies that will allow us to further engage youth in the organisation.

So far being an honorary advisor for Australia21 has been a challenging but very rewarding and interesting experience. The board members have been extremely supportive and encourage my input at every opportunity. A lot has happened since March and with some big projects under way I am very excited about the upcoming months.

Vivienne Moxham-Hall

Since my appointment as an honorary advisor to Australia21 I have been a guest at the monthly Board teleconferences, gained skills with media and met some outstanding thinkers. The role of honorary advisor is to allow youth to have a voice in the controversial polices and questions that Australia is and will be facing in the twenty-first century.

In this process I have learnt so much about the contemporary issues Australia is facing: The real research and facts of Climate Change and how much the War on Drugs has affected society. I found it astounding, the numerous impacts young people have experienced from prohibition and the damage such knee-jerk policies can have on every day people. The issue of drug prohibition is one which got me so involved in Australia21 and passionate about the work they do. The experience of being an advocate for reform you truly believe in and knowing that there are some of the greatest minds who can mentor, help and educate you, as a young person is so exciting. It has been one of the most enlightening experiences of my life and is such a privilege. I look forward to continuing to work with Australia21 with eagerness and an anticipation about what we can all achieve together.

I am completing my Master of Health Policy and in my spare time I volunteer for St John Ambulance Australia and am a volunteer Surf Lifesaver at Stanwell Park Beach. The photo here is of me and my father on our patrol.

Comment from Australia21 Chairman Paul Barratt

The honorary advisers initiative has been a great success, and I would like to thank Vivienne and Tom for the valuable new perspectives they have shared with the Board.

The next step is to talk with a wider group of young people about the best ways of working with them. We want the voices of young people to be heard in all aspects of our work, and we expect to introduce new and practical ways of achieving this in the coming year.