Legal Barriers, Stigma and Discrimination Drive TB Among Migrants

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Image: radiocampuslorraine.com


Globally, the number of international migrants continues to increase. Yet, gaping health barriers continue to impede the realization of their right to health and undermine efforts in the fight against TB. In 2017 there were 258 million international migrants, an increase of 49% since 2000.[1]

Migrants face many barriers accessing health services, including TB prevention, testing, treatment and support, during transit and upon arrival in the destination country.[2] They are often also exposed to conditions which significantly increase their risk of TB, including detention in immigration centers, where they may not have access to adequate nutrition, sanitation, ventilation and TB testing and treatment.

Social and economic inequality and discrimination in law, policy and practice impedes migrants’ ability to safeguard their health, lives and well-being. Many migrants arrive in the destination country with low socioeconomic status, and may have insecure working arrangements (e.g., domestic workers), lack meaningful legal protection from occupational and safety hazards (e.g., miners), increasing their risk of acquiring TB and imposing challenges accessing health services.[3] Stigma, xenophobia and language and cultural barriers may lead to exclusion from and avoidance of health systems, including discriminatory treatment by health workers. Given these and other barriers, it is unsurprising that migrants experience disproportionately high rates of TB.

While most of the available research focuses on TB and migration from low- to high-income countries and not migration between low-income countries, the available data highlights the need to strengthen continuity of care across borders and ensure that legal frameworks enable migrants to access TB-related health services, including beyond initial entry into the destination country. A few relevant statistics:

  • In 2005, two-thirds of the TB cases in Norway were among immigrants; TB rates were 7-9 times the general population.[4]
  • A 2013 study of high-income countries found that foreign-born individuals made up over half of all TB cases with incidence rates 8.7-18.4 times that seen in the local-born population.[5]
  • In 2014, more than half (62.4 %) of all TB patients in Germany were immigrants.[6]
  • TB rates declined only gradually among Somali immigrants in Denmark during the first seven years,[7] highlighting the ongoing barriers faced by migrants and the need to address migrant’s determinants of health.

While legal barriers and discrimination impedes migrants’ ability to access health services, enabling laws provide an environment which safeguards their right to health. Not all legal frameworks are clear cut–in some countries the extent to which the law protects the right to health of migrants is unclear and/or not meaningfully enforced in practice.

The legal status of migrants in the destination country and lack of documentation are significant barriers, particularly for undocumented migrants who may also fear deportation, detention, or other punitive or adverse immigration implications if they seek health services.[8] Insufficient legal protection against discrimination, lack of clear provision in law guaranteeing the right to TB and other health services for migrants, lack of/non-realization of labour protections and occupational and safety standards, among other legal and policy barriers, create a situation in which migrants are at high risk of TB; yet are simultaneously excluded from public health systems.

In the lead up to the UN High-Level Meeting on Tuberculosis this September and beyond, and to meet Sustainable Development Goals to end TB by 2030, countries should review their immigration-related, public health, criminal, constitutional, non-discrimination and other relevant laws and policies against human rights standards, ensuring that they are enabling rather than punitive and discriminatory including by:

  1. Repealing laws which are discriminatory, punitive or have adverse immigration consequences for people with TB and/or communicable diseases (i.e. laws prohibiting entry or allowing for detention or deportation of migrants with TB, laws impeding the right to health services on the basis of legal status and/or having documentation); and
  2. Enacting, implementing and enforcing laws and policies which enable migrants to meaningful realize the right to the highest attainable standard of physical and mental health, inter alia, that:
    • clearly provide for a justiciable right to health and access to health services for migrants;
    • facilitate coordination of TB services across borders to ensure migrants have continuity of care;
    • clearly provide for labour protections for migrants, including occupational health and safety standards, without adverse immigration or other consequences;
    • address social determinants of health that increase the risk of TB for migrants including education, employment, housing, nutrition, sanitation and poverty, among others; and
    • address language and cultural barriers within health systems.





[1] https://www.un.org/development/desa/publications/international-migration-report-2017.html.

[2] http://stoptb.org/assets/documents/resources/publications/acsm/KP_Mobile_Spreads.pdf.

[3] http://stoptb.org/assets/documents/resources/publications/acsm/KP_Mobile_Spreads.pdf.

[4] https://academic.oup.com/ije/article/34/5/1005/645880

[5] https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0595-5.

[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754836/.

[7] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2730343/.

[8] http://stoptb.org/assets/documents/resources/publications/acsm/KP_Mobile_Spreads.pdf.

Posted in Global Health, Human Rights, TB; Tagged: , .


Rethinking Obstetric Violence: Is Criminalization Really the Only Way Forward?

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Image courtesy of http://www.may28.org/

This post was written by Isabel Barbosa and Rebecca Reingold in honor of the International Day for Maternal Health and Rights.

Obstetric violence is disrespectful, abusive, and neglectful treatment by health providers during the provision of health care related to pregnancy, childbirth, and the post-partum period in both public and private settings. Experiences of obstetric violence include: physical abuse; humiliation or verbal abuse; coercive or unconsented practices; refusal of treatment or admission to a health facility; unnecessary use of medication; failure to maintain confidentiality or obtain informed consent; detention in facilities for failure to pay; discrimination based on race, ethnic or economic background, age, HIV status, gender non-conformity, etc; among others.

Such practices can be a powerful disincentive for women to seek and use maternal health care services and may have direct adverse consequences for both the mother and infant. They also result in violations of not only ethical principles that guide health providers’ behavior but also women’s human rights, including their rights to health, integrity, autonomy, equality, freedom from discrimination, and information.

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Posted in Human Rights; Tagged: , , , , , , .


O’Neill Institute Co-Sponsors Oral Health Convening Focusing on Children with Special Health Care Needs

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A few weeks ago I posted a blog about Deamonte Driver, a twelve year old boy who died of a toothache in Maryland in February 2007. It is hard to believe a child can die in the United States from an untreated cavity, especially so close to the nation’s capital. While Deamonte’s death sparked outrage and change in Maryland, much still needs to be done in the District, especially for children with special health care needs.

Americans face barriers to accessing dental health care. This is especially true for those that are uninsured, low-income families, communities of color, and people with disabilities. Over 48 million people live in areas in the United States with dentist shortages. While 72 million children and adults rely on Medicaid and the Children’s Health Insurance Program (CHIP), only about one-third of dentists accept public insurance.

Last week with generous support from the George E. Richmond Foundation, Georgetown University’s Health Justice Alliance, the O’Neill Institute, and the Harrison Institute for Public Law hosted a convening focusing on barriers to accessing oral health care for children with special health care needs in Washington, DC. The event gathered professionals and scholars working in health care and oral health to bring awareness to the lack of access to oral health care for children with special health care needs, particularly those from low-income areas in Washington, DC.

The convening served two purposes: (1) to draw attention to the fact that there are a number of barriers to accessing oral health care for children with special health care needs in Washington, DC; and (2) to identify possible solutions to these barriers.

One of the highlights of the day was the morning panel, which set the stage for the day and consisted of two parents of children with special health care needs—Jana Monaca and Eva Scheer—and Dr. Grant-Anamelechi, a practicing dentist. The panelists shared their personal experiences and identified some of the barriers to accessing oral health care in the Washington, DC area.

Jana Monaco is an advocate and a mother of four, two of which have a rare inborn metabolism called Isovaleric Acidemia. Her son, Stephen, 20, suffered severe brain damage at the age of 3 ½ leaving him with severe disabilities and complex medical issues due to a lack of comprehensive newborn screening at birth. Eva Scheer, has two sons. Her son Cade, 17, has autism and attends high school in Montgomery Country’s autism program.

These women shared powerful stories of how they advocate for their children and the importance of oral health for the overall well-being of their children. They shared anecdotes of both good and bad experiences taking their sons to the dentist. Going to the dentist can be a scary experience for any child, but this is especially true for children with physical and/or mental disabilities. One particular example Eva shared is that the use of a weighted blanked really helped her son Cade feel safer and more secure at the dentist. They shared how noises can be very distracting and scary for children with disabilities, especially at the dentist.

Dr. Grant-Anamelechi is the owner of Children’s Choice Pediatric Dentistry and Orthodontics in New Carrollton, MD. She practiced for a number of years prior to opening her own practice. Dr. Grant was recently named one of America’s Top Pediatric Dentists by Consumers’ Research Council of America. Her patients range in age from five days old to twenty-six years old. Dr. Grant has an acute awareness of her patients’ needs, and this extends to her patients with special health care needs. During the panel she shared some of the tools she has implemented at her practice to ensure a safe and enjoyable dental experience for children with special needs and their parents. This starts from scheduling the appointment, where her staff asks about special accommodations or requests that will help make her patients feel more comfortable. Dr. Grant spoke to the importance of being aware of when a child enjoys stimulation versus when a child does not. For some of her patients that are bothered by noises, she implements a quiet time right before the child arrives for his or her appointment that lasts until the patient leaves. This includes shutting off the television or any music that may be playing in the waiting room or dental suite. Another tool Dr. Grant has found useful is creating a PowerPoint presentation for her patients with photos of her staff and the office so her patients can become familiar with the people and the environment prior to their dental visit. For many of her patients, this helps ease tension and anxiety about going to the dentist.

The morning panel was followed by breakout sessions where participants had opportunities to delve deeper into five main barriers related to accessing oral health care. The five breakout session topics were: (1) transportation, (2) case management oversight, (3) financial incentives, (4) scope of practice, and (5) school-based health centers.

Following the breakout sessions was the afternoon panel titled Where to Go from Here: Improving Oral Health in the District and Beyond, which included two dentists and public health experts, Dr. Joan I. Gluch (UPenn Dental) and Dr. Jay Balzer (Dental Public Health, NYU Langone Hospital and Medical School in New York) who discussed their experiences working in oral health in their cities. They recommended policy solutions that have been utilized in their respective communities including engaging both the private and public spheres and universities to help ensure access to oral health services for children with special health needs. Dr. Gluch shared her experiences of integrating a mobile oralhealth unit as well as training health care workers to provide certain oral health treatments which helped increase access to oral health care and cut costs in Philadelphia. Dr. Balzer emphasized the importance of bringing oral health facilities to the people that need them the most, rather than forcing patients to find their way to dentists themselves, which is burdensome for low-income individuals and people with disabilities.

The day ended on an optimistic note with promises of continuing this important conversation long after the convening. The participants were highly engaged in the day’s events and the organizers hope to build on this momentum to make positive policy changes to ensure improved access to oral health care for children with special health care needs in the District and beyond.

Posted in Health reform, National Healthcare, Resources; Tagged: , , .


Human Rights in Global Health: Rights-Based Governance for a Globalizing World

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This article was written by Benjamin Mason Meier, Associate Professor of Global Health Policy, University of North Carolina at Chapel Hill, and Lawrence Gostin, Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University. 

Human rights impact global health.  By advancing human rights under international law as a basis for public health, international human rights law offers global standards by which to frame government responsibilities and evaluate health policies.  An evolving “health and human rights” movement has grown to become a powerful force for promoting those human rights that underlie global health.  Yet despite the dramatic growth of this movement, human rights scholarship and advocacy has focused largely on national governments, neglecting the global governance institutions that structure the realization of rights.  These institutions matter for the advancement of human rights in global health, raising an imperative to understand the implementation of human rights law through global health governance.

Cover, Human Rights in Global Health: Rights-Based Governance For a Globalizing WorldLaunching this blog series to engage with the forthcoming volume on Human Rights in Global Health: Rights-Based Governance for a Globalizing World (Oxford University Press, 2018), our introductory post frames the human rights responsibilities of institutions of global health governance.  Global governance has been instrumental to the development of human rights under international law, and these governing institutions are now essential to implementing human rights in organizational policies, programs, and practices. This edited volume is the first to systematically examine the role of these global institutions in operationalizing human rights for global health.

Human rights have become central to global health practice, offering universal frameworks for the advancement of justice in public health. As a basis for global justice under international law, human rights codify normative standards by which to articulate government duties and assess national practices.  This rights-based analysis shifts the policy debate in health from political aspiration to legal accountability.  Drawing from the birth of a human right to health in the Constitution of the World Health Organization, the United Nations has advanced public health obligations through the development of an expansive and reinforcing set of international standards.  Health-related human rights have thereby evolved under international treaty law, establishing norms and principles over a wide range of determinants of health.

Where human rights treaty ratification alone is insufficient to realize public health outcomes, it becomes necessary to consider the processes by which human rights are implemented.  Following from the groundbreaking development of human rights, the United Nations has shifted from the development of human rights under international law to the implementation of those rights through public policy.  In this “era of implementation,” the United Nations now looks beyond state duty-bearers to implement health-related human rights, assigning responsibilities to institutions of global governance.

Global governance has sought to realize the broader social, economic, and political determinants that underlie global health. Consequently, this global health governance landscape encompasses a proliferating range of intergovernmental organizations, funding agencies, and international bureaucracies working across an expanding range of economic, social, and cultural fields.  Structuring public health in a globalizing world, these global governance institutions are not party to human rights treaties; however, they recognize their essential role in securing the realization of health-related human rights.

This larger global health governance landscape is necessary to implement human rights for global health. These global institutions assist states in implementing human rights, providing states with the international norms, technical assistance, and accountability mechanisms to support the realization of rights. Beyond support for state duty-bearers, these organizations have independent responsibilities—as embodiments of the global community—to implement human rights through their institutional policies, programs, and practices. Yet, human rights scholarship has long neglected institutional theory and organizational practice.  Given the evolving development of human rights under international law and the parallel proliferation of global institutions for public health, it is imperative that we understand the implementation of human rights law through global health governance.

This blog series explores the relationship between human rights, global governance, and public health – examining an array of governance institutions that exercise their organizational mandate in ways that influence global health. The contributing authors will examine institutional dynamics to mainstream human rights in organizational actions and analyze institutional factors that facilitate or impede human rights mainstreaming for public health advancement. Following the structure of Human Rights in Global Health, this blog series examines distinct organizational approaches to human rights in:

  • The World Health Organization – describing the evolution of the World Health Organization’s (WHO’s) efforts to develop human rights for public health, current efforts to mainstream human rights in the Geneva Secretariat and regional offices, and the future of WHO’s rights-based role in an expanding global health governance landscape.
  • Inter-Governmental Organizations – surveying the diverse ways in which United Nations (UN) specialized agencies and ancillary organizations have mainstreamed human rights to promote an expansive set of underlying determinants of health through the United Nations Children’s Fund (UNICEF), the International Labor Organization (ILO), the United Nations Educational, Scientific and Cultural Organization (UNESCO), the United Nations Population Fund (UNFPA), the Food and Agriculture Organization of the United Nations (FAO), and the Joint United Nations Programme on HIV/AIDS (UNAIDS).
  • Global Economic Governance and Global Health Funding Agencies – recognizing the influence of a human right to development and a rights-based approach to development on global health through the World Bank, the World Trade Organization, national foreign assistance programs, and the Global Fund to Fight AIDS, Tuberculosis and Malaria.
  • Global Health in Human Rights Governance – considering how global health has been advanced by the UN human rights system through the Office of the UN High Commissioner for Human Rights (OHCHR), UN special procedures mandate holders, the UN human rights treaty bodies, and the UN Human Rights Council’s Universal Periodic Review (UPR).

The contributing authors represent an unprecedented collection of experts on a range of global governance institutions that operationalize human rights to promote global health, and their respective analyses of organizational policies, programs, and practices provide a basis to understand how global health governance is constituted by health-related human rights.

Framing a new field of inquiry at the intersection of health and human rights, such comparative experiences provide a research base for institutionalizing human rights in global health.  Through such a comprehensive survey of human rights in global health governance, it is possible to recognize varied approaches to human rights mainstreaming, analyze underlying determinants of human rights implementation, and develop an empirical basis to assess the effects of human rights in global health institutions.  Comparative analysis across these institutions can elucidate the causal pathways linking international human rights law to rights-based policy implementation through organizational practice, highlighting generalizable institutional factors that structure the operationalization of human rights in global health.  These institutional factors provide evidence of institutional strength for human rights implementation as a basis for global health advancement, renewing the promise of global governance in the face of unprecedented political challenges and engaging scholars, practitioners, and advocates to advance rights-based governance for global health.

Benjamin Mason Meier is an Associate Professor of Global Health Policy and the Zachary Taylor Smith Distinguished Professor of Public Policy at the University of North Carolina at Chapel Hill. To contact: bmeier@unc.edu

Lawrence O. Gostin is the O’Neill Chair in Global Health Law, Director of the O’Neill Institute for National and Global Health Law, and Director of the WHO Collaborating Center on National and Global Health Law at Georgetown University. To contact: gostin@law.georgetown.edu

Human Rights in Global Health: Rights-Based Governance for a Globalizing World (2018) is now available from Oxford University Press or Amazon.com.

Posted in Global Health;


Elimination Without Prevention — Mission Impossible

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This article was written by Thelma Thiel, Founder and Chair of the Liver Health Initiative. Viewpoints included in this article do not necessarily reflect those of the O’Neill Institute, the Hepatitis Policy Project or its sponsors. 

All the media attention highlighting the dramatic increase in opioid and other drug addition, as well as the rising rates of hepatitis and related liver cancer, obesity, and diabetes fails to mention that all these diseases are liver related and preventable.  Individuals could prevent the occurrence of these diseases by managing their own health care by developing healthier food and lifestyle behaviors.  However, to do so, the missing piece is the absence of effective educational information and initiatives to motivate them.

For decades, we have failed to provide basic information about the importance of the liver, the organ that is under attack, in sustaining one’s health and of life itself.  Few people know that this non-complaining, complex organ and its millions of liver cells perform mini miracles 24/7 in converting everything we eat, breathe, and absorb through our skin into hundreds of life-sustaining body functions.

Individuals need to understand how unhealthy food and lifestyle choices can lead to irreparable liver cell damage called cirrhosis. Misuse and abuse of drugs and alcohol, obesity, fatty liver, early onset diabetes, and atherosclerosis lead to cardiovascular diseases, high blood pressure, high cholesterol, hepatitis and liver cancer.  Providing the rationale for acting on what they have learned depends on their understanding the “why” and “how” to protect their miraculous life-sustaining liver.

Unless liver information about taking responsibility for protecting their internal life support system and chemical converter is provided in schools, government employees and military agencies, these chronic illnesses will continue to have devastating impact on the health and wellbeing of millions and will result to decreased life expectancy and increasing burden on our healthcare system. All while caring for chronic illnesses that could have been prevented.

It is discouraging that there is little promotion of primary prevention/liver education initiatives at the federal level, in schools or in the military, despite having been urgently recommended by over 30,000 liver specialists, nurses, healthcare providers and other members of professional organizations working on the front lines and caring for victims of liver related preventable illnesses.

Prevention, a buzz word that has lost much of its meaning, appears in numerous programs with no specific action identified. Primary prevention is essential in efforts to control the misuse and abuse of drugs and all the other liver-related illnesses.  It depends on everyone making informed and healthy decisions to protect their miraculous, life-sustaining liver.

Tragically, if we fail to actively promote primary prevention that includes liver information on the national agenda, millions of individuals will continue being victims of these liver-related, preventable diseases. Precious lives will be lost, and healthcare costs will increase exponentially.

The Liver Health Initiative, whose mission is to promote healthier food and lifestyle behaviors, has developed broadly acclaimed teaching tools, brochures, a coloring book, DVDs for various age groups and a Liver Health Curriculum with “motivational soundbites”.  LHI also provides Liver Health Education Training Sessions via Webinars for healthcare providers, teachers, counselors and parents.  All materials are available on LHI’s website   www.liver-health.org.

Posted in Hepatitis C, Uncategorized; Tagged: .


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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

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