Expanding the role of paralegals: supporting realization of the right to health for vulnerable communities.

BACKGROUND: All around the world, the paralegal program prepares members of marginalized communities to face the legal system. Having a common background with their clients and being capable of conducting flexible work, paralegals' role moves beyond enlarging the beneficiaries of legal aid to addressing intersectional issues around health-related rights. This study assesses the health and other impacts of paralegals recruited by Lembaga Bantuan Hukum Masyarakat (LBHM), a human rights organization which provides legal assistance and operates in Jakarta, Indonesia. The positive results these paralegals can bring in the specific context can contribute to the development of community-based paralegals elsewhere. METHODS: This mixed methods research was carried out in 2016-2018. In 2016, a quantitative survey was administered to LBHM-trained paralegals and a sub-set of paralegals who completed the survey were then also interviewed. Quantitative data were analysed using SPSS, and, for the qualitative data, thematic analysis was conducted. RESULTS: The paralegals make important contributions to health-related rights in four distinct ways. Firstly, most of the paralegals checked their clients' health in all stages of detention, especially regarding their drug dependency status and checking for signs of torture. Secondly, paralegals help clients to be more aware of their health-related rights, especially regarding their rights to obtain health services inside detention. Thirdly, paralegals can ensure that their clients obtain health services by taking medicines directly to the clients or encouraging the law enforcement agencies to refer the clients to health services. Lastly, in drug cases, paralegals help their clients to obtain alternative sentences besides imprisonment. CONCLUSIONS: These four contributions verify the positive impacts paralegals, recruited from marginalized communities, can deliver for community members facing criminal justice processes. The shifting role of paralegals from merely an intermediary between clients and lawyers to champions of the health-related rights of their clients can happen as a result of adequate training, support, and networks with other agents in criminal justice system.

Police-Related Deaths and Neighborhood Economic and Racial/Ethnic Polarization, United States, 2015-2016.

OBJECTIVES: To estimate the association between rates of police-related deaths and neighborhood residential segregation (by income, race/ethnicity, or both combined) in the United States. METHODS: We identified police-related deaths that occurred in the United States (2015-2016) using a data set from the Guardian newspaper. We used census data to estimate expected police-related death counts for all US census tracts and to calculate the Index of Concentration at the Extremes as a segregation measure. We used multilevel negative binomial models for the analyses. RESULTS: Overall, police-related death rates were highest in neighborhoods with the greatest concentrations of low-income residents (vs high-income residents) and residents of color (vs non-Hispanic White residents). For non-Hispanic Blacks, however, the risk was greater in the quintile of neighborhoods with the highest concentration of non-Hispanic White residents than in certain neighborhoods with relatively higher concentrations of residents of color (the third and fourth quintiles). CONCLUSIONS: Neighborhood context matters-beyond individual race/ethnicity-for understanding, preventing, and responding to the occurrence of police-related deaths. Public Health Implications. Efforts to monitor, prevent, and respond to police-related deaths should consider neighborhood context, including levels of segregation by income and race/ethnicity.

'We are not infertile': challenges and limitations faced by women in same-sex relationships when seeking conception services in São Paulo, Brazil.

The use of reproductive technologies has expanded beyond cases of infertility, and opportunities for individuals of different sexual orientations to use such technologies for conception have increased. The authors examined the challenges and limitations faced by women in same-sex relationships seeking conception services in São Paulo, Brazil. They interviewed 16 women in same-sex relationships who conceived children using reproductive technologies. Access to public health services for conception remains limited and exclusive to infertile heterosexual couples. Women in same-sex relationships are forced to select between costly medical treatments in the private sector, or self-insemination with sperm from a known donor. In this study, individuals reported that they experienced adverse effects of treatments; were treated with technologies for infertility when they were, in fact, fertile; and were exposed to unnecessary and invasive interventions. Growing political conservatism and the reduction of investment in public health services are factors that can directly affect sexual and reproductive health, including that of lesbians. Public policies that enable same-sex couples to conceive have yet to be developed in many countries, and a clearer articulation of the right to evidence-informed, rights-based care, consistent with national and international guidelines is a much-needed next step.

"In transition: ensuring the sexual and reproductive health and rights of transgender populations." A roundtable discussion.

This roundtable discussion is the result of a research symposium entitled In Transition: Gender [Identity], Law & Global Health where participants took up the challenge to engage with the question: What will it take to ensure the sexual and reproductive health and rights (SRHR) of transgender populations across the globe? The barriers to overcome are fierce, and include not only lack of access to health services and insurance but also stigma and discrimination, harassment, violence, and violations of rights at every turn. Transgender people must of course lead any sort of initiatives to improve their lives, even as partnerships are needed to build capacity, translate lived experience into usable data, and to make strategic decisions. The SRHR of transgender people can only be addressed with attention to the social, cultural, legal, historical, and political contexts in which people are situated, with social, psychological, medical, and legal gender affirmation as a key priority shaping any intervention. Bringing together nine diverse yet complementary perspectives, our intent is to jumpstart a global and multigenerational conversation among transgender activists, lawyers, policy-makers, programmers, epidemiologists, economists, social workers, clinicians and all other stakeholders to help think through priority areas of focus that will support the needs, rights, and health of transgender populations. Making the changes envisioned here is possible but it will require not only the advocacy, policy, programmatic and research directions presented here but also struggle and action locally, nationally, and globally.

Quantifying underreporting of law-enforcement-related deaths in United States vital statistics and news-media-based data sources: A capture-recapture analysis.

BACKGROUND: Prior research suggests that United States governmental sources documenting the number of law-enforcement-related deaths (i.e., fatalities due to injuries inflicted by law enforcement officers) undercount these incidents. The National Vital Statistics System (NVSS), administered by the federal government and based on state death certificate data, identifies such deaths by assigning them diagnostic codes corresponding to "legal intervention" in accordance with the International Classification of Diseases-10th Revision (ICD-10). Newer, nongovernmental databases track law-enforcement-related deaths by compiling news media reports and provide an opportunity to assess the magnitude and determinants of suspected NVSS underreporting. Our a priori hypotheses were that underreporting by the NVSS would exceed that by the news media sources, and that underreporting rates would be higher for decedents of color versus white, decedents in lower versus higher income counties, decedents killed by non-firearm (e.g., Taser) versus firearm mechanisms, and deaths recorded by a medical examiner versus coroner. METHODS AND FINDINGS: We created a new US-wide dataset by matching cases reported in a nongovernmental, news-media-based dataset produced by the newspaper The Guardian, The Counted, to identifiable NVSS mortality records for 2015. We conducted 2 main analyses for this cross-sectional study: (1) an estimate of the total number of deaths and the proportion unreported by each source using capture-recapture analysis and (2) an assessment of correlates of underreporting of law-enforcement-related deaths (demographic characteristics of the decedent, mechanism of death, death investigator type [medical examiner versus coroner], county median income, and county urbanicity) in the NVSS using multilevel logistic regression. We estimated that the total number of law-enforcement-related deaths in 2015 was 1,166 (95% CI: 1,153, 1,184). There were 599 deaths reported in The Counted only, 36 reported in the NVSS only, 487 reported in both lists, and an estimated 44 (95% CI: 31, 62) not reported in either source. The NVSS documented 44.9% (95% CI: 44.2%, 45.4%) of the total number of deaths, and The Counted documented 93.1% (95% CI: 91.7%, 94.2%). In a multivariable mixed-effects logistic model that controlled for all individual- and county-level covariates, decedents injured by non-firearm mechanisms had higher odds of underreporting in the NVSS than those injured by firearms (odds ratio [OR]: 68.2; 95% CI: 15.7, 297.5; p < 0.01), and underreporting was also more likely outside of the highest-income-quintile counties (OR for the lowest versus highest income quintile: 10.1; 95% CI: 2.4, 42.8; p < 0.01). There was no statistically significant difference in the odds of underreporting in the NVSS for deaths certified by coroners compared to medical examiners, and the odds of underreporting did not vary by race/ethnicity. One limitation of our analyses is that we were unable to examine the characteristics of cases that were unreported in The Counted. CONCLUSIONS: The media-based source, The Counted, reported a considerably higher proportion of law-enforcement-related deaths than the NVSS, which failed to report a majority of these incidents. For the NVSS, rates of underreporting were higher in lower income counties and for decedents killed by non-firearm mechanisms. There was no evidence suggesting that underreporting varied by death investigator type (medical examiner versus coroner) or race/ethnicity.

Correction: Quantifying underreporting of law-enforcement-related deaths in United States vital statistics and news-media-based data sources: A capture-recapture analysis.

[This corrects the article DOI: 10.1371/journal.pmed.1002399.].

Killed by Police: Validity of Media-Based Data and Misclassification of Death Certificates in Massachusetts, 2004-2016.

OBJECTIVES: To assess the validity of demographic data reported in news media-based data sets for persons killed by police in Massachusetts (2004-2016) and to evaluate misclassification of these deaths in vital statistics mortality data. METHODS: We identified 84 deaths resulting from police intervention in 4 news media-based data sources (WGBH News, Fatal Encounters, The Guardian, and The Washington Post) and, via record linkage, conducted matched-pair analyses with the Massachusetts mortality data. RESULTS: Compared with death certificates, there was near-perfect correlation for age in all sources (Pearson r > 0.99) and perfect concordance for gender. Agreement for race/ethnicity ranged from perfect (The Counted and The Washington Post) to high (Fatal Encounters Cohen's κ = 0.92). Among the 78 decedents for whom finalized International Classification of Diseases, 10th Revision (ICD-10), codes were available, 59 (75.6%) were properly classified as "deaths due to legal intervention." CONCLUSIONS: In Massachusetts, the 4 media-based sources on persons killed by police provide valid demographic data. Misclassification of deaths due to legal intervention in the mortality data does, however, remain a problem. Replication of the study in other states and nationally is warranted.

Engaging Human Rights in the Response to the Evolving Zika Virus Epidemic.

In late 2015, an increase in the number of infants born with microcephaly in poor communities in northeast Brazil prompted investigation of antenatal Zika infection as the cause. Zika now circulates in 69 countries, and has affected pregnancies of women in 29 countries. Public health officials, policymakers, and international organizations are considering interventions to address health consequences of the Zika epidemic. To date, public health responses have focused on mosquito vector eradication, sexual and reproductive health services, knowledge and technology including diagnostic test and vaccine development, and health system preparedness. We summarize responses to date and apply human rights and related principles including nondiscrimination, participation, the legal and policy context, and accountability to identify shortcomings and to offer suggestions for more equitable, effective, and sustainable Zika responses.

Monitoring HIV-Related Laws and Policies: Lessons for AIDS and Global Health in Agenda 2030.

The National Commitments and Policy Instrument (NCPI) has been used to monitor AIDS-related laws and policies for over 10 years. What can be learnt from this process? Analyses draw on NCPI questionnaires, NCPI responses, the UNAIDS Law Database, survey data and responses to a 2014 survey on the NCPI. The NCPI provides the first and only systematic data on country self-reported national HIV laws and policies. High NCPI reporting rates and survey responses suggest the majority of countries consider the process relevant. Combined civil society and government engagement and reporting is integral to the NCPI. NCPI experience demonstrates its importance in describing the political and legal environment for the HIV response, for programmatic reviews and to stimulate dialogue among stakeholders, but there is a need for updating and in some instances to complement results with more objective quantitative data. We identify five areas that need to be updated in the next iteration of the NCPI and argue that the NCPI approach is relevant to participatory monitoring of targets in the health and other goals of the UN 2030 Agenda for Sustainable Development.

Reproductive justice and the pace of change: socioeconomic trends in US infant death rates by legal status of abortion, 1960-1980.

US infant death rates for 1960 to 1980 declined most quickly in (1) 1970 to 1973 in states that legalized abortion in 1970, especially for infants in the lowest 3 income quintiles (annual percentage change = -11.6; 95% confidence interval = -18.7, -3.8), and (2) the mid-to-late 1960s, also in low-income quintiles, for both Black and White infants, albeit unrelated to abortion laws. These results imply that research is warranted on whether currently rising restrictions on abortions may be affecting infant mortality.

Sound and Fury--engaging with the politics and the law of sexual rights.

Although past resistance to sexual rights in global debates has often been grounded in claims to culture, nation and religion, opposition voices are now using, rather than rejecting, the frame of international human rights. This Commentary argues that, despite opponents' attempts to defeat sexual rights with other rights claims, a careful understanding of the principles of international human rights and its legal development exposes how the use of rights to oppose sexual rights should, and will ultimately, fail. The Commentary briefly takes up three kinds of "rights" claims made by opponents of sexual rights: limiting rights to protect rights, textual basis, and universality, and explores the rationales and impact of their application to countering sexual rights. Because sexuality and reproduction intersect as well as diverge in the opposition they face, this struggle matters intensely and plays out across advocacy, programmatic and policy worlds. Underpinning this Commentary is the understanding that opposition to sexual and reproductive health rights uses common arguments about rights principles that must be understood in order to be countered.

Sexual rights as human rights: a guide to authoritative sources and principles for applying human rights to sexuality and sexual health.

This Guide seeks to provide insight and resources to actors interested in the development of rights claims around sexuality and sexual health. After engaging with the vexed question of the scope of sexual rights, it explores the rules and principles governing the way in which human rights claims are developed and applied to sexuality and sexual health, and how that development is linked to law and made a matter of state obligation. This understanding is critical to policy and programming in sexual health and rights, as it supports calling on the relevant range of human rights, such as privacy, non-discrimination, health or other universally accepted human rights, as well as demanding the action of states under their international and national law obligations to support sexual health.

Roundtable discussion on the Third Global Symposium on Health Systems Research: why prioritise talk over aid in the midst of the Ebola crisis?

Health systems experts from around the world discuss why they were meeting at the Third Global Symposium on Health Systems Research while people were dying of Ebola in West Africa.

Noncommunicable diseases and human rights: a promising synergy.

Noncommunicable diseases (NCDs) have finally emerged onto the global health and development agenda. Despite the increasingly important role human rights play in other areas of global health, their contribution to NCD prevention and control remains nascent. The recently adopted Global Action Plan for the Prevention and Control of NCDs 2013-2020 is an important step forward, but the lack of concrete attention to human rights is a missed opportunity. With practical implications for policy development, priority setting, and strategic design, human rights offer a logical, robust set of norms and standards; define the legal obligations of governments; and provide accountability mechanisms that can be used to enhance current approaches to NCD prevention and control. Harnessing the power of human rights can strengthen action for NCDs at the local, national, and global levels.

What's pregnancy got to do with it? Late presentation to HIV/AIDS services in Northeastern Brazil.

Despite the known benefits of early treatment initiation for individual morbidity and mortality, as well as for reducing the risk of transmission, late presentation (LP) to HIV/AIDS services remains a major concern in many countries. There is little information on LP from middle- and low-income countries and studies that do evaluate LP commonly disaggregate data by sex. It is rare, however, for researchers to further disaggregate the data by pregnancy status so it remains unclear if pregnancy status modifies the effects associated with sex. The study was conducted at the only State Reference Center for HIV/AIDS in Salvador, Brazil's third largest city. LP was defined as a patient accessing services with a CD4 < 350 cells/mm(3). Data were abstracted from the electronic medical records of 1421 patients presenting between 2007 and 2009. CD4 counts and viral load (VL) information was validated with data from the National CD4/VL Database. Descriptive and bivariate statistics were conducted to inform the multivariate analysis. Adjusted prevalence ratios (APR) were estimated using generalized linear models due to the high frequency of the outcome. Half of the sample (52.5%; n = 621) was classified as LP. Compared to the prevalence among pregnant women (21.1%), the prevalence of LP was more than twice as high among non-pregnant women (56.0%) and among men (55.4%). The multivariate analysis demonstrated no statistical difference between men and nonpregnant women (APR 1.04; 95%CI 0.92-1.19), but the APR of LP for nonpregnant women was 53% less than men (APR 0.47; 95%CI 0.33-0.68). These results highlight the importance of analyzing data disaggregated not only by sex but also by pregnancy status to accurately identify the risk factors associated with LP so that programs and policies can effectively and efficiently address LP in Brazil and beyond.

HIV and gender-based violence: welcome policies and programmes, but is the research keeping up?

The global HIV policy arena has seen a surge of interest in gender-related dimensions of vulnerability to HIV and violence. UNAIDS and other prominent actors have named gender-based violence a key priority, and there seems to be genuine understanding and commitment to addressing gender inequalities as they impact key populations in the AIDS response. In the quest for evidence-informed interventions, there is usually a strong connection between the research conducted and the policies and programmes that follow. Regarding gender, HIV and violence, is this the case? This discussion paper asks whether the relevant peer-reviewed literature is suitably representative of all affected populations--including heterosexual men, transgender men and women, women who have sex with women, and men who have sex with men--as well as whether the literature sufficiently considers gender norms and dynamics in how research is framed. Conclusions about violence in the context of heterosexual relationships, and with specific attention to heterosexual women, should not be presented as insights about gender-based violence more generally, with little attention to gender dynamics. Research framed by a more comprehensive understanding of what is meant by gender-based violence as it relates to all of the diverse populations affected by HIV would potentially guide policies and programmes more effectively.

Realigning government action with public health evidence: the legal and policy environment affecting sex work and HIV in Asia.

The HIV epidemic has shed light on how government regulation of sex work directly affects the health and well-being of sex workers, their families and communities. A review of the public health evidence highlights the need for supportive legal and policy environments, yet criminalisation of sex work remains standard around the world. Emerging evidence, coupled with evolving political ideologies, is increasingly shaping legal environments that promote the rights and health of sex workers but even as new legislation is created, contradictions often exist with standing problematic legislation. As a region, Asia provides a compelling example in that progressive HIV policies often sit side by side with laws that criminalise sex work. Data from the 21 Asian countries reporting under the UN General Assembly Special Session on HIV in 2010 were analysed to provide evidence of how countries' approach to sex-work regulation might affect HIV-related outcomes. Attention to the links between law and HIV-related outcomes can aid governments to meet their international obligations and ensure appropriate legal environments that cultivate the safe and healthy development and expression of sexuality, ensure access to HIV and other related services and promote and protect human rights.