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To the editor
We read with interest the article by Büyüm AM, Kenney C, Koris A, et al. (Decolonising
global health: if not now, when? BMJ Global Health 2020;5:e003394. doi:10.1136/
bmjgh-2020-003394) Although it is not contested that Black, Indigenous and People of Color are most disadvantaged by structural oppression, we would argue that a human rights-based approach is a more inclusive approach to global health inequity than decolonising global health.
The economic impacts of COVID mediated by the structural determinants will see recent gains in poverty reduction lost (1). Structural determinants within key service institutions such as the police service, prison system as well as those affecting gender will result in widespread suboptimal health. For example, black people are 40 times more likely to be stopped and searched in the UK under powers that allow officers to search people if serious violence is anticipated (2). In the US, a study examining all fatalities resulting from the use of lethal force by on-duty law enforcement officers between 2009 to 2012 across 17 U.S. states found that while whites were killed more frequently, the fatality rate was 2.8 times higher among blacks than whites (3). In the US, the First Step Act prison reforms have resulted in some benefits for prisoners, but ironically, highlighted the disproportionate incarceration of blacks (38%) who comprises 13% of the US population (4). There is evidence COVID disproportio...
The economic impacts of COVID mediated by the structural determinants will see recent gains in poverty reduction lost (1). Structural determinants within key service institutions such as the police service, prison system as well as those affecting gender will result in widespread suboptimal health. For example, black people are 40 times more likely to be stopped and searched in the UK under powers that allow officers to search people if serious violence is anticipated (2). In the US, a study examining all fatalities resulting from the use of lethal force by on-duty law enforcement officers between 2009 to 2012 across 17 U.S. states found that while whites were killed more frequently, the fatality rate was 2.8 times higher among blacks than whites (3). In the US, the First Step Act prison reforms have resulted in some benefits for prisoners, but ironically, highlighted the disproportionate incarceration of blacks (38%) who comprises 13% of the US population (4). There is evidence COVID disproportionately affects women (who are often managing unpaid work, including caretaking responsibilities, while continuing to engage in paid work), migrant workers, asylum seekers, and other marginalized groups (5). Global health organisations are often run by leaders who came from high-income countries and it is difficult for them to accept civil society representation on their boards (6). Even if they have diverse representation, many of those appointed do not have decision-making privileges (6). These are the “discriminatory social arrangement(s) that, when encoded into laws, policies and norms, unduly privileges some social groups while harming others” to which Buyum et al refer.
However, recent observations suggest that a human rights approach is needed in order to achieve equity for all. In September 2020 in Melbourne, Australia a man experiencing an exacerbation of severe mental illness was intentionally hit by a police car and kicked in the head by a police officer as he struggled on the ground (7). The police officers involved have been suspended on full pay pending criminal investigations but this excessive use of force is symptomatic of state-sanctioned violence within the Australian police force. An Australian nationwide survey of more than 6000 international students and other temporary migrants conducted during the pandemic found systemic racism against international students in Australia (8). The study revealed the depth of Australia’s racist COVID policies (8). Although there is anti-racist rhetoric in Australia, (e.g. the National Anti-Racism Strategy) (9), there are many cases of racial discrimination against Asian students, particularly during the pandemic (9). In early June, the Chinese Ministry of Culture and Tourism warned Chinese citizens about a significant rise in racial discrimination and violence against Chinese and Asian people in Australia as an impact of the COVID-19 pandemic (10). In addition, in many countries around the world the small progress that has been made in ensuring girls receive an education is predicted to be undone by the COVID shelter at home restrictions (11). Increased “household responsibilities, child labour, early marriage and teenage pregnancy may prevent many girls from returning to school” (11). Other structural determinants include prioritisation of funding to other economic activities, instead of education, as countries emerge from the pandemic. Among those girls who do return to school post COVID, gender norms may inhibit their ambition. Education for women is consistent with part of the solution posed by Buyum et al namely a ‘knowledge shift’ which makes education widespread, bi-directional, and inclusive of new learning.
A human rights-based approach is a conceptual framework that can be applied to a broad range of program areas, including health. It is informed by international human rights law (12). The approach asserts that the integration of human rights law and principles should be visible in all activities and should contribute directly to the realization of human rights. Key elements of a human rights-based approach include participation, accountability, non-discrimination, empowerment, linkage to rights and sustainability. Applying this to the case of police brutality against people with mental illness suggests police be called on to view those with mental illness as human beings first with entitlements rather than letting the stigmatization of mental illness drive their actions. Police brutality to a marginalized group with little accountability is discriminatory, disempowering and dislocated from international human rights. It is unsustainable, and is unacceptable. In the case of maternal education a human rights-based approach would recognize the right of girls to an education. It would recognize there are no human rights, as enshrined in the Universal Declaration of Human Rights and other humanitarian instruments, without their universal application, irrespective of gender, ethnicity, occupation, country of birth. More broadly a human rights-based approach to structural determinants would re-orientate key public services and structures across multiple jurisdictions to ensure equity in participation and treatment irrespective of human characteristics.
Dismantling structural oppression is indeed key to improving global health. A human rights-based approach for addressing structural violence is a way of achieving this.
Aarya Desai MPH Student
Sundeep Manoth MPH Student
John Oldroyd MPH Co-ordinator
Australian Catholic University, Fitzroy, Australia.
(1) The World Bank Project poverty impacts of COVID 19. 2020 Available from: https://www.worldbank.org/en/topic/poverty/brief/projected-poverty-impac....
(2) Mark Townsend Black people ‘40 times more likely’ to be stopped and searched in UK The Guardian 2018 Available from: https://www.theguardian.com/law/2019/may/04/stop-and-search-new-row-raci...
(3) DeGue et al Deaths Due to Use of Lethal Force by Law Enforcement Findings From the National Violent Death Reporting System, 17 U.S. States, 2009–2012 Am J Prev Med. 2016 Nov; 51(5 Suppl 3): S173–S187.
(4) Ashley Nellis The color of Justice: racial and ethnic disparities in State Prisons The Sentencing Project 2016 Available from: https://www.sentencingproject.org/publications/color-of-justice-racial-a...
(5) Neeta Kantamneni The impact of the COVID-19 pandemic on marginalized populations in the United States: A research agenda J Vocat Behav. 2020 Jun; 119: 103439.
(6) Think Global Health. (2020). Silenced Voices in Global Health | Think Global Health. Retrieved 20 September 2020 Available from: https://www.thinkglobalhealth.org/article/silenced-voices-global-health
(7) Matilda Boseley Video shows Victoria police car knock man to ground before officer appears to stomp on his head The Guardian 14th September 2020 Available from: https://www.theguardian.com/australia-news/2020/sep/14/video-shows-victo...
(8) "As if we weren't humans": Australia's global reputation damaged as humanitarian despair of international students and temporary migrants deepens 2020 Available from: https://www.medianet.com.au/releases/191624/
(9) National Anti-Racism Strategy and Racism. It Stops with Me Campaign. Australian Human Rights Commission. Humanrights.gov.au. 2020. Available from: https://humanrights.gov.au/our-work/race-discrimination/projects/nationa...
(10) COVID-19 Coronavirus Racism Incident Report. Surveymonkey.com. 2020. Available from: https://www.surveymonkey.com/r/AsianAustralian
(11) Malala Yousafzrai After Covid-19, millions of girls may not return to the classroom. We can help them The Guardian 14th September 2020 Available from: https://www.theguardian.com/commentisfree/2020/sep/14/covid-19-global-ed...
(12) FXB Center for Health and Human Rights. Health and human rights resource guide 2020 Available from: https://www.hhrguide.org/153-2/