Should clinicians boycott Australian immigration detention?

Australian immigration detention has been called state sanctioned abuse, cruel and degrading and likened to torture. Clinicians have long worked both within the system providing healthcare and outside of it advocating for broader social and political change. It has now been over 25 years and little, if anything, has changed. The government has continued to consolidate power to enforce these policies and has continued to attempt to silence dissent. It was in this context that a boycott was raised as a possible course of action. Despite discussions among the healthcare community about the merits of such action, a number of questions have been overlooked. In this article, I will examine whether a boycott is both ethical and feasible. Taking into account the costs and benefits of current engagement and the potential impact of a boycott, more specifically the potential it has to further harm those detained, I conclude that under current circumstance a boycott cannot be justified. This however does not mean that a boycott should be dismissed completely or that the status quo should be accepted. I discuss potential ways forward for those seeking change.

Conflict, Complicity, and Challenges: Reflections on the South African Truth and Reconciliation Commission Health Sector Hearing.

PURPOSE: This article describes the work of the South African Truth and Reconciliation Commission (TRC) in examining the role of the health sector in human rights violations in the protracted conflicts during apartheid. ORGANIZING CONSTRUCT: The enabling legislation contained in the Promotion of National Healing and Reconciliation Act of 1995 allowed for in-depth examination of violations and complicity in human rights abuses. We provide an overview of the process of the public hearings, soliciting submissions, examining evidence of abuse, personal testimony of conflict in situations of dual accountability, and ultimately the recommendations made by the TRC. The article also outlines the responses of various health professional training institutions to the TRC's recommendations, the implementation of university health and human rights courses, and some current challenges post-TRC. CONCLUSIONS: The health sector hearings of the TRC provided a window into the structural unequal access, racial discrimination, prejudice, and abuse in the health services under the apartheid regime. Examination of past violations perpetrated by an abusive regime and by those such as health workers operating in such a system is imperative to ensure that these abuses are not repeated in the future. CLINICAL RELEVANCE: In delivering comprehensive, compassionate, and ethical care, healthcare professionals have accountability to respect and promote the human rights of their patients. Training in human rights and its relationship to health should be incorporated into all health professional programs.

Rights as Relationships: Collaborating with Faith Healers in Community Mental Health in Ghana.

This paper explores the ways in which mental health workers think through the ethics of working with traditional and faith healers in Ghana. Despite reforms along the lines advocated by global mental health, including rights-based legislation and the expansion of community-based mental health care, such healers remain popular resources for treatment and mechanical restraint and other forms of coercion commonplace. As recommended in global mental health policy, mental health workers are urged to form collaborations with healers to prevent human rights abuses and promote psychiatric alternatives for treatment. However, precisely how such collaborations might be established is seldom described. This paper draws on ethnographic research to investigate how mental health workers approach working with healers and the moral imagination which informs their relationship. Through an analysis of trainee mental health workers' encounters with a Prophet and his patients, the paper reveals how mental health workers attempt to negotiate the tensions between their professional duty of care, their Christian faith, and the authority of healers. I argue that, rather than enforcing legal prohibitions, mental health workers seek to avoid confrontation and manouver within existing hierarchies, thereby preserving sentiments of obligation and reciprocity within a shared moral landscape and established forms of sociality.

Expanding the agenda for addressing mistreatment in maternity care: a mapping review and gender analysis.

BACKGROUND: This paper responds to the global call to action for respectful maternity care (RMC) by examining whether and how gender inequalities and unequal power dynamics in the health system undermine quality of care or obstruct women's capacities to exercise their rights as both users and providers of maternity care. METHODS: We conducted a mapping review of peer-reviewed and gray literature to examine whether gender inequality is a determinant of mistreatment during childbirth. A search for peer-reviewed articles published between January 1995 and September 2017 in PubMed, Embase, SCOPUS, and Web of Science databases, supplemented by an appeal to experts in the field, yielded 127 unique articles. We reviewed these articles using a gender analysis framework that categorizes gender inequalities into four key domains: access to assets, beliefs and perceptions, practices and participation, and institutions, laws, and policies. A total of 37 articles referred to gender inequalities in the four domains and were included in the analysis. RESULTS: The mapping indicates that there have been important advances in documenting mistreatment at the health facility, but less attention has been paid to addressing the associated structural gender inequalities. The limited evidence available shows that pregnant and laboring women lack information and financial assets, voice, and agency to exercise their rights to RMC. Women who defy traditional feminine stereotypes of chastity and serenity often experience mistreatment by providers as a result. At the same time, mistreatment of women inside and outside of the health facility is normalized and accepted, including by women themselves. As for health care providers, gender discrimination is manifested through degrading working conditions, lack of respect for their abilities, violence and harassment,, lack of mobility in the community, lack of voice within their work setting, and limited training opportunities and professionalization. All of these inequalities erode their ability to deliver high quality care. CONCLUSION: While the evidence base is limited, the literature clearly shows that gender inequality-for both clients and providers-contributes to mistreatment and abuse in maternity care. Researchers, advocates, and practitioners need to further investigate and build upon lessons from the broader gender equality, violence prevention, and rights-based health movements to expand the agenda on mistreatment in childbirth and develop effective interventions.

The "hot potato" topic: challenges and facilitators to promoting respectful maternal care within a broader health intervention in Tanzania.

In recent years, mistreatment during childbirth has captured the public health and maternal health consciousness as not only an affront to women's rights but also a formidable deterrent to the uptake of facility-based childbirth - and thus to reductions in maternal mortality. The challenge ahead is to determine what can be done to address this public health problem. A modest but growing body of research has demonstrated that interventions to foster Respectful Maternity Care (RMC) can enact change, albeit in the relatively controlled context of a trial or study. Herein we describe our experiences in weaving elements of RMC across tiers of an existing maternal and newborn health program. As a commentary, this document does not outline program results, but instead highlights challenges and facilitators to promoting RMC within a large-scale, multi-district health platform. We conclude with lessons learned during the process and urge that others share their program learning experiences in an effort to strengthen the knowledge base on what works and what does not work in terms of addressing this complex, context-sensitive issue.

Too afraid to go: fears of dignity violations as reasons for non-use of maternal health services in South Sudan.

BACKGROUND: South Sudan has one of the worst health and maternal health situations in the world. Across South Sudan, while maternal health services at the primary care level are not well developed, even where they exist, many women do not use them. Developing location specific understanding of what hinders women from using services is key to developing and implementing locally appropriate public health interventions. METHODS: A qualitative study was conducted to gain insight into what hinders women from using maternal health services. Focus group discussions (5) and interviews (44) were conducted with purposefully selected community members and health personnel. A thematic analysis was done to identify key themes. RESULTS: While accessibility, affordability, and perceptions (need and quality of care) related barriers to the use of maternal health services exist and are important, women's decisions to use services are also shaped by a variety of social fears. Societal interactions entailed in the process of going to a health facility, interactions with other people, particularly other women on the facility premises, and the care encounters with health workers, are moments where women are afraid of experiencing dignity violations. Women's decisions to step out of their homes to seek maternal health care are the results of a complex trade-off they make or are willing to make between potential threats to their dignity in the various social spaces they need to traverse in the process of seeking care, their views on ownership of and responsibility for the unborn, and the benefits they ascribe to the care available to them. CONCLUSIONS: Geographical accessibility, affordability, and perceptions related barriers to the use of maternal health services in South Sudan remain; they need to be addressed. Explicit attention also needs to be paid to address social accessibility related barriers; among others, to identify, address and allay the various social fears and fears of dignity violations that may hold women back from using services. Health services should work towards transforming health facilities into social spaces where all women's and citizen's dignity is protected and upheld.

HIV, prisoners, and human rights.

Worldwide, a disproportionate burden of HIV, tuberculosis, and hepatitis is present among current and former prisoners. This problem results from laws, policies, and policing practices that unjustly and discriminatorily detain individuals and fail to ensure continuity of prevention, care, and treatment upon detention, throughout imprisonment, and upon release. These government actions, and the failure to ensure humane prison conditions, constitute violations of human rights to be free of discrimination and cruel and inhuman treatment, to due process of law, and to health. Although interventions to prevent and treat HIV, tuberculosis, hepatitis, and drug dependence have proven successful in prisons and are required by international law, they commonly are not available. Prison health services are often not governed by ministries responsible for national public health programmes, and prison officials are often unwilling to implement effective prevention measures such as needle exchange, condom distribution, and opioid substitution therapy in custodial settings, often based on mistaken ideas about their incompatibility with prison security. In nearly all countries, prisoners face stigma and social marginalisation upon release and frequently are unable to access health and social support services. Reforms in criminal law, policing practices, and justice systems to reduce imprisonment, reforms in the organisation and management of prisons and their health services, and greater investment of resources are needed.

Sowing the seeds of transformative practice to actualize women's rights to respectful maternity care: reflections from Kenya using the consolidated framework for implementation research.

BACKGROUND: Despite years of growing concern about poor provider attitudes and women experiencing mistreatment during facility based childbirth, there are limited interventions that specifically focus on addressing these issues. The Heshima project is an evidence-based participatory implementation research study conducted in 13 facilities in Kenya. It engaged a range of community, facility, and policy stakeholders to address the causes of mistreatment during childbirth and promote respectful maternity care. METHODS: We used the consolidated framework for implementation research (CFIR) as an analytical lens to describe a complex, multifaceted set of interventions through a reflexive and iterative process for triangulating qualitative data. Data from a broad range of project documents, reports, and interviews were collected at different time points during the implementation of Heshima. Assessment of in-depth interview data used NVivo (Version 10) and Atlas.ti software to inductively derive codes for themes at baseline, supplemental, and endline. Our purpose was to generate categories of themes for analysis found across the intervention design and implementation stages. RESULTS: The implementation process, intervention characteristics, individual champions, and inner and outer settings influenced both Heshima's successes and challenges at policy, facility, and community levels. Implementation success stemmed from readiness for change at multiple levels, constant communication between stakeholders, and perceived importance to communities. The relative advantage and adequacy of implementation of the Respectful Maternity Care (RMC) resource package was meaningful within Kenyan politics and health policy, given the timing and national promise to improve the quality of maternity care. CONCLUSION: We found the CFIR lens a promising and flexible one for understanding the complex interventions. Despite the relatively nascent stage of RMC implementation research, we feel this study is an important start to understanding a range of interventions that can begin to address issues of mistreatment in maternity care; replication of these activities is needed globally to better understand if the Heshima implementation process can be successful in different countries and regions.

Which will Trump: human rights and professional ethics, or torture redux?

Recent political developments in the United States raise concerns about the potential return of aggressive interrogation strategies, particularly in the event of another large-scale terror attack on the U.S. mainland. This essay reviews various legal, ethical and policy responses to revelations of torture during the Bush administration. It asks whether they improve the prospect that, in future, human rights will trump torture, not vice versa. The essay argues that physicians could help prevent further abuses - especially given their access, social status and expertise - but that insufficient steps have been taken to empower them to do so.

The ongoing violence against women: Female Genital Mutilation/Cutting.

Female Genital Mutilation/Cutting (FGM/C) comprises different practices involving cutting, pricking, removing and sometimes sewing up external female genitalia for non-medical reasons. The practice of FGM/C is highly concentrated in a band of African countries from the Atlantic coast to the Horn of Africa, in areas of the Middle East such as Iraq and Yemen, and in some countries in Asia like Indonesia. Girls exposed to FGM/C are at risk of immediate physical consequences such as severe pain, bleeding, and shock, difficulty in passing urine and faeces, and sepsis. Long-term consequences can include chronic pain and infections. FGM/C is a deeply entrenched social norm, perpetrated by families for a variety of reasons, but the results are harmful. FGM/C is a human rights issue that affects girls and women worldwide. The practice is decreasing, due to intensive advocacy activities of international, national, and grassroots agencies. An adolescent girl today is about a third less likely to be cut than 30 years ago. However, the rates of abandonment are not high enough, and change is not happening as rapidly as necessary. Multiple interventions have been implemented, but the evidence base on what works is lacking. We in reproductive health must work harder to find strategies to help communities and families abandon these harmful practices.

[Enforceability of the right to health protection in obstetric services in Mexico]. / Exigibilidad del derecho a la protección de la salud en los servicios de obstetricia en México.

The inclusion of the framework of human rights in maternal health is mentioned more and more frequently as a feasible proposal to improve the care that women receive in obstetric health care services. Despite the fact Mexico has a solid regulatory framework for obstetric care, mechanisms of enforceability are essential to ensure that health-related human rights are upheld. In addition to being in place, enforceability mechanisms should be effective and accessible to people, particularly in obstetric care, where repeated human rights violations occur that endanger women's health and lives. The objective of this article is to specify the regulatory, legal, and extralegal elements that need to be considered in order to include maternal health in a set of enforceable human rights.

Stratified reproduction, family planning care and the double edge of history.

PURPOSE OF REVIEW: There is a growing clinical consensus that Medicaid sterilization consent protections should be revisited because they impede desired care for many women. Here, we consider the broad social and ideological contexts for past sterilization abuses, beyond informed consent. RECENT FINDINGS: Throughout the US history, the fertility and childbearing of poor women and women of color were not valued equally to those of affluent white women. This is evident in a range of practices and policies, including black women's treatment during slavery, removal of Native children to off-reservation boarding schools and coercive sterilizations of poor white women and women of color. Thus, reproductive experiences throughout the US history were stratified. This ideology of stratified reproduction persists today in social welfare programs, drug policy and programs promoting long-acting reversible contraception. SUMMARY: At their core, sterilization abuses reflected an ideology of stratified reproduction, in which some women's fertility was devalued compared to other women's fertility. Revisiting Medicaid sterilization regulations must therefore put issues of race, ethnicity, class, power and resources - not just informed consent - at the center of analyses.

[International legal framework of elderly rights protection].

Aging of the population is one of the dominant trends in the XXI century. It is expected that by 2050, more than a quarter of the world's population (27%) will be 65 years or older. Increase of older persons' proportion in the population of most countries entails a change in the scale and structure of morbidity requiring higher costs for medical care, social security, including pensions. Ageing appears on the international agenda for more than 30 years. The Human Rights treaty bodies rank the elderly as a vulnerable group, who are more susceptible to various forms of discrimination. However, there is currently no any international legal instrument specifically dedicated to the problems of protection of the elderly at a time when their discrimination and stigmatization is a very common phenomenon.

Older Europeans and the European Court of Justice.

BACKGROUND: the European Court of Justice (ECJ) is considered by many to be the most important judicial institution of the European Union today. Despite the potential importance and relevance of the ECJ rulings to the lives and rights of older Europeans, no research has attempted to analyse or to study the ECJ rulings in this field. OBJECTIVE: to describe the ECJ case-law in the field of elder rights. METHODS: using a computerised search of the ECJ database, between the years 1994 and 2010, 123 cases directly dealing with legal rights of older persons were analysed. RESULTS: on average, only 1-2% of the annual ECJ case-load addresses rights of older persons. Unlike the clear trend in the increase of the total ECJ case load, there was no similar trend of increase in the number of cases directly involving older persons' rights. However, in the majority of the elder-rights cases, the ECJ decision was in support of the older person's rights. CONCLUSIONS: the ECJ can potentially serve as an important protector of rights of older Europeans, if and to the extent that these cases reach its jurisdiction.

Monitoring, reporting and addressing child rights and protection violations in 'non-listed' countries.

Children have been affected by the Israeli-Palestinian conflict for several generations. Recent reports state that they are subject to a number of grave violations, ranging from killing and maiming to detention and ill-treatment. The monitoring and reporting mechanism (MRM) for United Nations Security Council Resolution 1612 (2005), although not formally mandated in Israel and the occupied Palestinian territories (oPt), has been successfully adapted and used by humanitarian and human rights agencies to support monitoring, reporting, and responding to violations against children. However, agencies in Israel and the oPt face a number of challenges in doing so, which are common in other countries where the MRM is employed. These include limited recognition and understanding of the issues, insufficient resources, and a difficult operational environment. Despite these challenges, local adaptation of the mechanism to reflect the specific situation of children and close collaboration have enabled these agencies to monitor and respond to violations against children in a more effective manner.

Rescuing the vulnerable.

Human trafficking, such as forced prostitution and labour, affects men, women and children in the UK. Many have been brought into the country from eastern Europe and Africa. This article describes new guidance from the Department of Health that is designed to help healthcare professionals identify and support trafficked people.