On October 30, the Program on Human Rights (PHR) at Stanford's Center on Democracy, Development and the Rule of Law (CDDRL) held a day-long conference to examine health and human rights. The conference was held to discuss how a rights-based approach to health services can impact the delivery of effective health interventions and advance other socio-economic and cultural rights in developing regions. The conference titled, “Why We Should Care: Health and Human Rights” was divided into five panels with presenters from diverse backgrounds and professions including lawyers, doctors, public health experts, students and activists.

The Program:

The conference started with a welcoming address by Helen Stacy, director of the Program on Human Rights. CDDRL Director Larry Diamond introduced the keynote speaker Paul H. Wise, professor of child health and society and pediatrics at Stanford University’s School of Medicine, and director of the Center for Policy, Outcomes and Prevention. Wise's opening remarks began on a somber note, “The language of rights means very little to a child stillborn, an infant dying in pain from pneumonia or a child desiccated by famine.” In his address, Wise emphasized the need for an aligned and integrated rights-based approach that does not undermine effective and efficient medical interventions. “We need to fill the gap between the worlds of child health and child rights so that our programs and policies are both effective and just,” he stressed.

Following the keynote address, the conference presenters shared their work according to a geographic or thematic focus. The first panel brought together three generations of speakers from Stanford - a faculty member, a pre-doctoral fellow and a recent graduate - in a unique opportunity to share ideas and discuss possibilities of health work in Africa. Rebecca Walker, clinical instructor in emergency medicine at Stanford School of Medicine, presented her impressions and reactions on Mindy Roseman’s study of forced sterilization in Namibia. Roseman, academic director of the Human Rights Program and lecturer on law at Harvard Law School, was unable to attend due to flight complications after hurricane Sandy hit the East Coast.

Eric Kramon, 2011-2012 pre-doctoral fellow at CDDRL, spoke about the political sources of ethnic inequality in health outcomes in Africa.  Kramon’s work in Kenya illustrated how politics plays a determinant role in ethnic inequalities and consequently in access to health and health outcomes. Jeffrey Tran, a 2011 Stanford graduate in human biology, described the vision behind the launch of the Project of Emergency First Aid Responder in Western Cape Province, South Africa that he helped implement. Tran explained, “Individuals and communities are an integral part of the solution and we work with the communities to develop first aid training programs that are taught and eventually run by community members.”

Panel two was dedicated to the health impact of drones in Pakistan and in Gaza. Based on research by the Stanford International Clinic on Human Rights and Conflict Negotiation in Pakistan, Professor James Cavallaro and Stanford law school student Omar Shakir, explained that drones are not only responsible for deaths of civilians but also constitute a constant disturbance to social life and mental health of ordinary people, including their relations with children and the elderly. Drones impact other rights as well - such as the right to education - as children are prevented from attending schools for fear of drone strikes. Rajaie S. Batniji, resident physician in internal medicine at Stanford and a CDDRL affiliate, explained the clinical diagnosis of traumatic disorders that result from constant surveillance and insecurity. He cited the work of Jonathan Mann in defining dignity and the devastating effects on physical, mental, and social well-being when these senses are violated. Batniji explained that populations in Gaza are prevented from living life with dignity and respect because they live under constant threat to their security and intrusion into their homes and communications.

Vivek Srinivasan, manager of the Program on Liberation Technology at CDDRL, presented his experience on the Right to Food Campaign in India. He believes that this campaign has led to the mobilization for rights and the provision of services. “Not all demands are confrontational. Communities begin demanding something that is perceived as small in scope but have ramifications that extend to other rights such as the right to education, the right to housing and the right to work.” According to Srinivasan, the Right to Food Campaign in India has had a tremendous impact in putting hunger on the policy agenda. Suchi Pande, an activist-researcher who worked on the Right to Information Campaign in India for over seven years and was the secretary for the National Campaign for People’s Right to Information from 2006 to 2008, supported Srinivasan’s argument of strong correlation in achievements and right-based mobilization. However, Pande pointed out that despite successes in the Right to Food Campaign, other economic and social rights including the right to health in India continues to be a non-issue for politicians and the government. She is optimistic and believes that rural public hearings, the role of the right to information and its supporting mechanisms will facilitate access to public health in rural India.

In panel four, Sarah MacCarthy showed results that suggest that counseling and testing services for HIV-positive pregnant women remain limited, insufficient or lacking in quality in Salvador, Brazil. “While Brazil’s HIV/AIDS program has been internationally acclaimed, national practice still fails to meet national and global guidelines,” she explained. Calling attention to the regional discrepancies in the HIV/AIDS policy and program implementation in Brazil, Nadejda Marques, manager of the Program on Human Rights at CDDRL,, expressed concerns about the implementation of an HIV/AIDS program in a context of limited resources. “In Angola, counseling and voluntary testing units for HIV/AIDS don’t have drinking water or sanitary conditions to receive patients. They lack basic equipment for testing and data collection, there is a generalized shortage of doctors, and health care providers have no specific training on HIV/AIDS.” Despite this alarming situation, Marques explained that advocating for the rights of persons living with HIV/AIDS in Angola has put in evidence the failure of a heath system unable to provide even the most basic services to its population and has enabled mobilization in a context where human rights are routinely violated.

Ami Laws, adjunct associate professor of medicine at Stanford, described how a physician can provide services in collaboration with the judicial system to advance human rights. Laws is an expert witness on cases of torture survivors that require asylum status in the U.S. and has worked mainly with victims of torture in the Punjab region in India. Everaldo Lamprea, a JSD candidate at Stanford Law School and an assistant professor at Los Andes Law School in Bogotá, Colombia, spoke about his recent comparative study on health litigation in low and middle-income countries. The escalation of right-to-health litigation in these countries can have unexpected and harmful consequences to healthcare reforms and the enforceability of the right to health. In part, this is because significant financial resources are allocated to the litigation processes and not to the health system. In addition, while litigation can highlight gaps that exist in the health system that need regulation, countries have been very slow to adapt and adjust to these signals.

Next Steps:

A number of key ideas, questions and insights emerged from the conference including:

. How to identify an effective intervention that will also mobilize communities to advocate for its implementation?

. How to provide services to the more vulnerable populations without alienating a contingent that has access to basic health care services?

. What instruments can be used to share best practices among national healthcare systems?

. How do global priorities adapt to contexts of limited financial resources and human capital?

. How can punctual achievements in rights that guarantee access to health be expanded for the achievement of other social, economic and cultural rights?

The Program on Human Rights at CDDRL will continue to pursue a research agenda examining health and human rights following the conference and announced that it will be the thematic focus of the Sanela Diana Jenkins Speakers Series in 2014. The PHR is also actively seeking support for research projects that include a right to health component at the core of its academic investigation for the 2012-2013 academic year.

In an opinion piece for Al Jazeera, Rajaie Batniji uncovers the role of medical professionals involved in acts of torture. With a lens to the unrest in Syria, Batniji calls for an international body to identify, monitor, and disqualify those complicit in torture and genocide.

In an opinion piece for Al Jazeera, Rajaie Batniji uncovers the role of medical professionals involved in acts of torture. With a lens to the unrest in Syria, Batniji calls for an international body to identify, monitor, and disqualify those complicit in torture and genocide.

Doctors have a long history of complicity in torture, but the torture of political dissidents holds a privileged place.  In Saddam Hussein's Iraq, surgeons removed the ears of men who failed to report for military service or defected from the army. In the Soviet Union, psychiatrists held political dissidents in mental hospitals with false diagnoses, in order to isolate and punish them. It is in this tradition of medical torture of dissidents that the Syrian healthcare establishment may be heading.

A July 6 report by Amnesty International documents the treatment of Wassim, a 21-year-old protester in the Syrian town of Talkalakh. After an injury from a soldier's bayonet, Wassim was taken to al-Bassel hospital, which had been occupied by Syrian security forces. As he reported: "The nurses, men and women […] swore at me and beat me hard and one female nurse punched me repeatedly with all her strength on my chest. Some were taking off their shoes and slapping me with them. I could hear many voices asking: 'You want freedom, eh?'" The report states he later had his wounds stitched without anesthesia, before being beaten on these wounds by hospital staff.  

Wassim's is not an isolated incident. In May, Reuters documented the case of a protester who had lost sensation in his legs who requested to see a doctor in jail. He told the news agency: "The doctor hit my knees with his legs, and asked: 'There, is it better now?' and then he slapped me". Most pervasively, reports suggest that even when doctors have not been involved in direct abuse, they have falsified the causes of injuries and released information about patients to the Syrian regime's security forces. The result is a public distrust of hospitals, and a clear incentive for injured protestors to avoid the healthcare system. 

The medical torture of political dissidents holds a privileged place because it can be perversely justified. The torture of dissidents may be seen as an act of loyalty to the state. Doctors acting on behalf of the state, such as military doctors, have what is called "dual loyalty" - loyalty to both their patient and a third party.

In addressing the issue of dual loyalty, Physicians for Human Rights has proposed guidelines that physicians not be present when torture takes place, and calls on them to report all human rights violations, especially when they interfere with their loyalty to patients. Like the medical professionals from the US recently implicated in the torture and abuse of prisoners at Guantánamo Bay and Iraq, some Syrian doctors may have valued their contribution to the security of the state more than their adherence to the norms of their profession. 

But, in their pursuit of perceived enemies of the state, have these physicians become enemies of the profession? Doctors involved in torture should be pursued as enemies of medicine: their crimes documented, their professional credentials revoked, and their ability to practice internationally thwarted.

Identifying and disqualifying doctors involved in torture

While it is exceedingly unlikely that Bashar al-Assad, an ophthalmologist, will go back to correcting cataracts in London - where he trained - if his regime is overthrown, other physicians culpable in his regime's torture will seek to continue clinical practice abroad.

Even with continued instability, it is likely that physicians and other elites will seek to emigrate. Could doctors involved in abuse head to Europe, North America or neighbouring Arab countries and continue to operate? How will they be identified? Critically, the majority of Syrian physicians that have not been complicit with abuses must be distinguished from those who have. 

Unfortunately, the medical profession has no method for identifying or punishing doctors complicit in torture. We rely on human rights organisations to provide sporadic documentation of medical torture.

With limited access and competing priorities - such as being able to provide medical care while working in countries where torture occurs - these organisations have a narrow scope for documenting the occurrence of torture. In an excellent Lancet article, Len Rubenstein and Melanie Bittle argue that the World Health Organization is best positioned to play a leading role in documenting attacks on medical functions in conflict, and this should include those attacks committed by physicians.

Among the suggestions put forth by Rubenstein and Bittle are a UN Security Council resolution providing a mandate for the WHO to pursue investigations, and the use of mobile devices for securely and quickly transmitting information about abuse. By documenting medical complicity in torture, we give physicians under incredible pressures incentive to oppose orders from their superiors and the state.

The greatest challenge, however, is enforcement, and the punishment of physicians complicit in torture. No international body retains information on professional qualifications. Like most other professions, medicine has proclaimed a need to be self-regulating, yet it has no system in place to disqualify or sanction physicians on a global level (national licensing bodies exist in most countries, but there is little to no international coordination). To this day, investigations continue of Rwandan doctors now practising in Europe and Africa, accused of involvement in the 1994 genocide.

Of course, their crimes were far more widespread than those in Syria today, as doctors oversaw the killing of hundreds of patients and staff in their hospitals, but the challenge of enforcement is nearly identical. Even if medical complicity in torture does not warrant imprisonment, it ought to warrant professional disqualification - and as of yet, no institution or process is in place to disqualify a physician from practising internationally. 

Honouring the heroism of Syrian doctors

Attacks on the healthcare system are common - perhaps inevitable - in modern war, but doctors don't always become complicit. In Bahrain, the Salmaniya medical centre was raided, and its doctors beaten and jailed for treating protesters. In Libya, Misurata hospital came under fire, deterring the sick from seeking care and endangering staff and patients.

Despicable as these attacks are, they have come to be expected as a feature of conflict. Attacks on the healthcare system have been documented in almost all recent conflicts including in Afghanistan, Kosovo, Nepal, Iraq, and the occupied Palestinian territories. In most cases, doctors have acted admirably, and sometimes heroically: seeing the sick in their homes, in secretive and makeshift clinics, risking their lives to provide care. Under oppressive regimes, doctors may be risking their lives just by refusing to be complicit in torture. 

In Syria, a group known as the "Damascus Doctors" has been organising on Facebook to provide hidden clinics in areas of protest, as reported by CNN. These doctors are upholding a tradition of professionalism and protest that existed since at least 1980, when more than 100 healthcare professionals were arrested for striking to demand the lifting of Syria's state of emergency, in place since 1963 (as of 1990, at least 90 of them remained missing). These doctors, like many others who have opposed the regime, were subjected to gruesome physical and psychological torture. 

The overwhelming majority of Syrian physicians have likely been acting heroically. It is in their honour that we should pursue aggressive international efforts to document and disqualify those physicians complicit in torture. This will require emboldened international institutions, cooperation among national licensing bodies, and the courage of doctors, journalists, activists and human rights organisations in documenting and reporting medical torture. 

In reaction to the arrest of Dominique Strauss-Khan for allegations of rape in May, Kavita Ramdas and Christine Ahn argue in a piece for Foreign Policy in Focus that gender bias is embedded in the global policies and practices at the IMF, which unfairly target women. Kavita Ramdas is the former president and CEO of the Global Fund for Women and a visiting scholar at the Center on Democracy, Development, and the Rule of Law.

In reaction to the arrest of Dominique Strauss-Khan for allegations of rape in May, Kavita Ramdas and Christine Ahn argue in a piece for Foreign Policy in Focus that gender bias is embedded in the global policies and practices at the IMF, which unfairly target women. Kavita Ramdas is the president and CEO of the Global Fund for Women and a visiting scholar at the Center on Democracy, Development, and the Rule of Law.

As Dominique Strauss-Kahn, head of the world’s most powerful financial institution, the International Monetary Fund (IMF), spends a few nights in Rikers Island prison awaiting a hearing, the world is learning a lot about his history of treating women as expendable sex objects. Strauss-Kahn has been charged with rape and forced imprisonment of a 32-year-old Guinean hotel worker at a $3,000-a-night luxury hotel in New York.

While the media dissects the attempted rape of a young African woman and begins to dig out more information about Strauss-Kahn’s past indiscretions, we couldn’t help but see this situation through the feminist lens of the “personal is political.” 

For many in the developing world, the IMF and its draconian policies of structural adjustment have systematically “raped” the earth and the poor and violated the human rights of women. It appears that the personal disregard and disrespect for women demonstrated by the man at the highest levels of leadership within the IMF is quite consistent with the gender bias inherent in the IMF’s institutional policies and practice.

Systematic Violation of Women’s Human Rights

The IMF and the World Bank were established in the aftermath of World War II to promote international trade and monetary cooperation by giving governments loans in times of severe budget crises. Although 184 countries make up the IMF’s membership, only five countries—France, Germany, Japan, Britain, and the United States—control 50 percent of the votes, which are allocated according to each country’s contribution.

The IMF has earned its villainous reputation in the Global South because in exchange for loans, governments must accept a range of austerity measures known as structural adjustment programs (SAPs). A typical IMF package encourages export promotion over local production for local consumption. It also pushes for lower tariffs and cuts in government programs such as welfare and education. Instead of reducing poverty, the trillion dollars of loans issued by the IMF have deepened poverty, especially for women who make up 70 percent of the world’s poor.

IMF-mandated government cutbacks in social welfare spending have often been achieved by cutting public sector jobs, which disproportionately impact women. Women hold most of the lower-skilled public sector jobs, and they are often the first to be cut. Also, as social programs like caregiving are slashed, women are expected to take on additional domestic responsibilities that further limit their access to education or other jobs.

In exchange for borrowing $5.8 billion from the IMF and World Bank, Tanzania agreed to impose fees for health services, which led to fewer women seeking hospital deliveries or post-natal care and naturally, higher rates of maternal death.  In Zambia, the imposition of SAPs led to a significant drop in girls’ enrollment in schools and a spike in “survival or subsistence sex” as a way for young women to continue their educations.

But IMF’s austerity measures don’t just apply to poor African countries. In 1997, South Korea received $57 billion in loans in exchange for IMF conditionalities that forced the government to introduce “labor market flexibility,” which outlined steps for the government to compress wages, fire “surplus workers,” and cut government spending on programs and infrastructure. When the financial crisis hit, seven Korean women were laid off for every one Korean man. In a sick twist, the Korean government launched a "get your husband energized" campaign encouraging women to support depressed male partners while they cooked, cleaned, and cared for everyone.

Nearly 15 years later, the scenario is grim for South Korean workers, especially women. Of all OECD countries, Koreans work the longest hours: 90% of men and 77% of women work over 40 hours a week.  According to economist Martin Hart-Landsberg, in 2000, 40 percent of Korean workers were irregular workers; by 2008, 60 percent worked in the informal economy. The Korean Women Working Academy reports that today 70 percent of Korean women workers are temporary laborers.

Selling Mother Earth

IMF policies have also raped the earth by dictating that governments privatize the natural resources most people depend on for their survival: water, land, forests, and fisheries. SAPs have also forced developing countries to stop growing staple foods for domestic consumption and instead focus on growing cash crops, like cut flowers and coffee for export to volatile global markets. These policies have destroyed the livelihoods of small-scale subsistence farmers, the majority of whom are women.

“IMF adjustment programs forced poor countries to abandon policies that protected their farmers and their agricultural production and markets,” says Henk Hobbelink of GRAIN, an international organization that promotes sustainable agriculture and biodiversity. "As a result, many countries became dependent on food imports, as local farmers could not compete with the subsidized products from the North. This is one of the main factors in the current food crisis, for which the IMF is directly to blame."

In the Democratic Republic of Congo (DRC), IMF loans have paved the way for the privatization of the country’s mines by transnational corporations and local elites, which has forcibly displaced thousands of Congolese people in a context where women and girls experience obscenely high levels of sexual slavery and rape in the eastern provinces. According to Gender Action, the World Bank and IMF have made loans to the DRC to restructure the mining sector, which translates into laying off tens of thousands of workers, including women and girls who depend on the mining operations for their livelihoods. Furthermore, as the land becomes mined and privatized, women and girls responsible for gathering water and firewood must walk even further, making them more susceptible to violent crimes.

We Are Over It

Women’s rights activists around the globe are consistently dumbfounded by how such violations of women’s bodies are routinely dismissed as minor transgressions. Strauss-Kahn, one of the world’s most powerful politicians whose decisions affected millions across the globe, was known for being a “womanizer” who often forced himself on younger, junior women in subordinate positions where they were vulnerable to his far greater power, influence, and clout. Yet none of his colleagues or fellow Socialist Party members took these reports seriously, colluding in a consensus shared even by his wife that the violation of women’s bodily integrity is not in any sense a genuine violation of human rights.

Why else would the world tolerate the unearthly news that 48 Congolese women are raped every hour with deadening inaction? Eve Ensler speaks for us all when she writes, “I am over a world that could allow, has allowed, continues to allow 400,000 women, 2,300 women, or one woman to be raped anywhere, anytime of any day in the Congo. The women of Congo are over it too.”

We live in a world where millions of women don’t speak their truth, don’t tell their dark stories, don’t reveal their horror lived every day just because they were born women.  They don’t do it for the same reasons that the women in the Congo articulate – they are tired of not being heard. They are tired of men like Strauss-Kahn, powerful and in suits, believing that they can rape a black woman in a hotel room, just because they feel like it. They are tired of the police not believing them or arresting them for being sex workers. They are tired of hospitals not having rape kits. They are tired of reporting rape and being charged for adultery in Iran, Pakistan, and Saudi Arabia.

Fighting Back

For each one of them, and for those of us who have spent many years investing in the tenacity of women’s movements across the globe, the courage and gumption of the young Guinean immigrant shines like the torch held by Lady Liberty herself. This young woman makes you believe we can change this reality. She refused to be intimidated.  She stood up for herself. She fought to free herself—twice—from the violent grip of the man attacking her. She didn’t care who he was—she knew she was violated and she reported it straight to the hotel staff, who went straight to the New York police, who went straight to JFK to pluck Strauss-Kahn from his first-class Air France seat.

In a world where it often feels as though wealth and power can buy anything, the courage of a young woman and the people who stood by her took our breath away. These stubborn, ethical acts of working class people in New York City reminded us that women have the right to say “no.”  It reminded us that “no” does not mean “yes” as the Yale fraternities would have us believe, and, most importantly that no one, regardless of their position or their gender, should be above the law.  A wise woman judge further drove home the point about how critically important it is to value women’s bodies when she denied Strauss-Kahn bail citing his long history of abusing women.

Strauss-Kahn sits in his Rikers Island cell. It would be a great thing if his trial succeeds in ending the world’s tolerance for those who discriminate and abuse women. We cannot tolerate it one second longer.  We cannot tolerate it at the personal level, we must refuse to condone it at the professional level, and we must challenge it every time it we see it in the policies of global institutions like the International Monetary Fund.

Nathan Eagle, Founder and CEO of txteagle spoke at the weekly Liberation Technology Seminar Series on Dececember 2, 2010 about mobile phone usage in the developing world.

Although txteagle began in 2007 as a purely academic project, the current goal of the company and of its founder and CEO, Nathan Eagle, is to give one billion people a five percent raise. In his presentation, Eagle described the context for which txteagle was designed, how the company's focus has evolved over the past three years, and what steps the company is taking to move closer to achieving this goal in the future.

Eagle began by offering some background information to explain the initial impetus behind txteagle. Today, about 63% of global mobile phone usage takes place in the developing world, making airtime usage in emerging markets worth about $200 billion a year. Mobile phone users at the so-called "Base of the Pyramid" typically spend 10% of their income on mobile phone airtime. Through his experience living in emerging markets and teaching mobile application development in universities across sub-Saharan Africa, Eagle began to see that a significant opportunity space existed to reduce the cost of airtime for people at the base of the pyramid, in effect giving these people a raise.

Mobile applications developed as a part of MIT's Entrepreneurial Research on Programming and Research on Mobiles (EPROM) project offered some insights into the potential of mobile-based tools. In Rwanda, where electricity is a prepaid service, one of Eagle's former students quickly cornered a significant share of the market by creating scratch cards for crediting one's electricity bill via mobile phone. In Eastern Kenya, a program called SMS Blood Bank was created to enable real time monitoring of blood supplies at local district hospitals in Eastern Kenya. Although SMS reporting of low blood levels resolved the huge amount of latency in the system of local district hospitals (where responses to dips in supply had typically taken up to 4 weeks), the price of reporting blood levels via SMS represented a pay cut for local nurses; despite nurses' initial enthusiasm, SMS reporting tapered off within weeks. When the idea of sending about 10 cents of airtime to compensate nurses for each SMS report of blood level data proved a success, the model behind txteagle was born.

Designed as a means to monetize people's downtime, txteagle has grown rapidly through partnerships with over 220 mobile operators in about 80 countries around the world. In turn for helping these operators analyze their customer data, txteagle has gained access to about 2.1 billion mobile subscribers. Partnering with txteagle is a winning proposition for mobile operators, since the airtime compensation mobile subscribers receive from txteagle improves operators' Average Revenue per User (ARPU), a statistic that had been plummeting as more and more poor people became mobile phone users. By enabling people to carry out work via web browsers or SMS and compensating them via mobile money or airtime, txteagle has become a market leader at efficiently gathering data in the developing world.

Since txteagle was first created, the company has attempted to move from an outsourcing/back-office model to an emphasis on work that leverages a person's unique local knowledge and information. Typically outsourced tasks such as forms processing, audio transcription, inventory management, data cleaning, tagging, and internet search, tend to be less rewarding to the worker. By focusing on local data instead, txteagle enables unprecedented insight into emerging markets, all while optimizing engagement with local customers. Typical tasks include: maps and directions, local market prices and businesses, survey research and polling, and other forms of local knowledge gathering.

One of txteagle's central initiatives, GroundTruth, leverages this local knowledge-based model to carry out better market research. Today, global brands are already spending about $125 billion annually in emerging markets to engage the "next billion," but they typically carry out this research in a sub-optimal way. Through the txteagle platform, Eagle suggests, brands and organizations can use advertising money to design better products and services, conduct market research, and carry out brand engagement. Recent success cases include the use of txteagle to help a program of the United Nations to reach survey respondents directly and to enable the World Bank to obtain better local market price data at lower cost. 

Although txteagle's rapid growth and early successes have been encouraging, the company has ambitious goals for the next two years. The company began by focusing on outside sales through its GroundTruth market research program. Next year, the company  hopes to generate syndicated data and ultimately to create a self-source platform enabling anyone to conduct their own population-level surveys.  By continuing to focus on improving the quality of both their data and workers over time, txteagle aims to have an even greater positive impact on the incomes of the hundreds of millions of mobile phone users at the base of the pyramid.