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December 2016, No. 4 Vol. LIII, Human Rights

Anniversaries are useful occasions for taking stock. The fiftieth anniversary of the adoption of the two implementing covenants of the Universal Declaration of Human Rights¡ªthe International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on Economic, Social and Cultural Rights (ICESCR), both adopted by the United Nations General Assembly in 1966¡ªis one such occasion. Whereas the Universal Declaration was aspirational, a statement of collective intent to build a better world after the devastation wreaked by ¡°barbarous acts [that] ... outraged the conscience of mankind¡±,¹?the Covenants were intended to serve as tools to promote the implementation of the rights they articulated.

This ambitious, transformative goal explains the delay in moving from the Declaration to the Covenants: eighteen years were needed to garner sufficient agreement to proceed and to devise a framework that catered to the bipolar world order that had taken shape. Instead of a unitary implementing document following the structure of the Declaration, two instruments were needed, reflecting the split between a liberal capitalist block focused on upholding civil and political rights, and a socialist block committed to the primacy of realizing social and economic rights. This implementing architecture developed unevenly, with much greater investment dedicated to building capacity to enforce civil and political rights than to advancing economic and social rights.?

Treaties and Rights

It took decades to evolve effective strategies for implementing the International Covenant on Economic, Social and Cultural Rights to improve the performance of States parties. Indeed, the extent to which ratification of the Covenant (or of any other human rights instrument) impinges on rights realization remains a controversial topic. Some suggest that States only ratify human rights conventions to court the approval of other States rather than because they intend to implement their provisions; they point to the widespread violation of human rights obligations by States parties as evidence. Others argue that States ratify human rights treaties when they transition from authoritarian to democratic rule to lock in rights obligations as a guarantee against future backsliding; they point to rapid treaty ratification by South Africa and former socialist States in Eastern Europe as cases in point.

A recent systematic, empirical study by Beth A. Simmons on the impact of human rights treaty ratification on subsequent state conduct paints a more complex and nuanced picture. The study suggests that treaty ratification does in some but not all cases clearly correlate with improved human rights implementation. The Convention on the Rights of the Child (CRC), for example, the most rapidly and widely ratified United Nations human rights treaty, sets out state obligations in respect of the recruitment of child soldiers and the promotion of health, prohibiting the former and mandating the latter. How effective has it been? According to the study, CRC had a statistically significant impact on the rate of recruitment of child soldiers but not on the rate of anti-measles vaccinations.²?Treaty ratification thus cannot be assumed to produce rights enforcement; whether it does or not depends on implementation strategies and on a complex set of other interconnected factors.

The Right to Health

The right to health is a cardinal social and economic right. According to article 12 of ICESCR, ¡°The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health¡±.

A few preliminary observations are in order. First, like most other human rights obligations, this right applies to ¡°everyone¡±, without regard to legal or other status. Undocumented migrants, prisoners and homeless populations are all covered. Second, like other social and economic rights, the right to health is one of progressive realization. ?Ratifying States must ¡°take steps¡±, ¡°by all appropriate means, including particularly the adoption of legislative measures¡±, to achieve the many aspects of this right progressively, ¡°to the maximum of its available resources¡±.³

These phrases are complex terms, susceptible to a range of interpretations. At minimum, they commit States to monitoring the progress of their policies and taking steps to improve their service provision.⁴?ICESCR takes note of the fact that implementation of social and economic rights may presuppose complex and sophisticated delivery systems, endowed with skilled personnel; extensive infrastructure; in the case of health, specialist products including pharmaceutical drugs; and operating and investigative machinery. Such systems cannot be built by legislative fiat alone, but require cumulative investment, expertise, research and finance. Accordingly, the core obligation is to progressively improve on the service provided in specified areas, expanding its reach, deepening its quality and strengthening its impact in proportion to the State¡¯s own fiscal and technical capabilities. In the case of the right to health, ICESCR identifies both physical and mental health, and various key domains, including the healthy development of the newborn and the child, public health measures to promote environmental health and to prevent ¡°epidemic, endemic, occupational and other diseases¡±. I will focus on evidence related to the implementation of the right to health for one of the most vulnerable target populations, children, understood as all persons under the age of 18.⁵

Progress

Under-Five Mortality

Implementation of the right to health for young children has increased dramatically. According to the United Nations Children's Fund (UNICEF) State of the World¡¯s Children 2016 report, ¡°the world has made tremendous progress in reducing child deaths, getting children into school and lifting millions out of poverty¡±. Many of the interventions behind this progress¡ªsuch as vaccines, oral rehydration salts and better nutrition¡ªhave been practical and cost-effective.¡±⁶?One of the most dramatic strides has been in the reduction of under-five mortality. Not only has it been cut by 53 per cent since 1990,⁷?but the rate of reduction between 2000 and 2015 was more than double that achieved in the 1990s. Between 2000 and 2015, every region registered major progress in child survival.⁸?Some of the world¡¯s poorest countries have made extraordinary progress, with 24 low-income and lower-middle-income countries achieving the Millennium Development Goals (MDG) target of a two-thirds reduction in under-five mortality between 1990 and 2015.⁹

Immunization

Another area of dramatic improvement has been in the delivery of routine life-saving vaccinations to children. UNICEF reported that ¡°86% of the world¡¯s children received the required 3 doses of diphtheria-tetanus-pertussis containing vaccines (DTP3) in 2015, a coverage level that has been sustained above 85% since 2010. As a result, the number of children who did not receive routine life-saving vaccinations has dropped to an estimated 19.4 million, down from 33.8 million in 2000¡±.¹⁰

Malaria

Malaria remains a pervasive threat to the survival and health of children. ¡°Children under five still represent 78 per cent of global malaria deaths¡ªor 456,000 per year. This means over 1,200 children die every day from malaria¡ªabout 50 children every hour.¡±^11?Nevertheless, enormous strides have been made. Deaths of children from malaria have fallen by 40 per cent since 2000, and 4.3 million lives have been saved by improved access to malaria prevention, diagnosis and treatment between 2001 and 2013.¹²

Persistence of Serious Challenges

The Continuing and Inequitable Impact of Preventable Diseases

Despite the encouraging benchmarks listed above, millions of the world¡¯s children still lack access to a robust right to health and great inequities remain. ¡°In 2015, an estimated 5.9 million children died before reaching age 5, mostly as a result of diseases that can be readily and affordably prevented and treated.¡±¹³?UNICEF estimates that one million children aged 0¨C14 fall ill with tuberculosis every year. More than 67 million children are infected and could develop active disease at any time.¹⁴

Neonatal Deaths

Another worrying trend is the rise in the share of under-five mortality that occurs within the neonatal period. In 2015, neonatal deaths (i.e. deaths within the first 28 days of life) ¡°accounted for 45 per cent of total deaths, 5 per cent more than in 2000¡±.¹⁵

Man-Made Threats to the Health of Children

Detracting from the advances in global child health are the increasing health threats, especially for the most vulnerable populations such as children, that are generated by preventable human conduct. UNICEF has projected that ¡°approximately 250,000 additional deaths will occur annually through 2030 from malnutrition, malaria, diarrhea and heat stress attributable to climate change¡±.¹⁶

As the devastating impact of continuing conflict in several areas has dramatically highlighted, war and related violence constitute major threats to the enjoyment of a right to health for affected populations, particularly those sections who are most vulnerable. According to UNICEF, damage to health systems threatens children¡¯s lives in countries affected by conflict. For example, prior to the current conflict in the Syrian Arab Republic, that country had made impressive progress in reducing under-five mortality. In 2015, the United Nations Inter-agency Group for Child Mortality Estimation reported that since 1990, the under-five mortality rate fell from 37 to 13 deaths per 1,000 live births. Since 2012, however, the country¡¯s excess crisis mortality attributable to crisis conditions was estimated at one to two deaths per 1,000 live births.¹⁷

Adolescence and the Right to Health

One of the most dramatic challenges in the realization of the right to health for children is the large gap between the health achievements with respect to young children and the health failures with respect to adolescents. As child mortality has decreased, adolescent mortality has risen, cancelling out in some countries and regions the gains made for children in their first decade of life. Several factors have contributed to this troubling and urgent situation.

HIV and AIDS

One of the most acute factors contributing to adolescent morbidity and mortality is the unchecked spread of HIV/AIDS among young people. In?2014, WHO reported?that AIDS was the leading cause of death among adolescents (aged 10¨C19 years) in Africa, and?was the second most common cause of death among adolescents globally.¹⁸?The rate of morbidity is dramatic, particularly given the rapid decline in AIDS-related deaths in other groups. Adolescents between 15 and 19 years of age continue to be outliers. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that, in 2015, 29 adolescents acquired HIV every hour. Some 250,000 (180,000¨C340,000) new HIV infections occurred among adolescents, with girls accounting for 65 per cent of the newly infected.¹⁹

One of the reasons for this serious situation is a failure in global health policy. ¡°Global efforts to end the HIV epidemic have so far largely overlooked adolescent girls. In 2013, two thirds of the 250,000 new HIV infections among adolescents between the ages of 15 and 19 were among girls.¡±²⁰?Other factors relate to the complexity of addressing HIV infection, a complexity that mere distribution of condoms does not address. As health experts have long recognized, behavioural change, particularly in the intimate domain of gender norms and sexual relations, is an elusive and challenging action target. The legacy of failure in this sphere is writ large. It is the product of a failure to invest in robust sexual and reproductive health rights, to develop and sustain health services that are youth-friendly; guarantee confidentiality and non-stigmatizing treatment; and offer comprehensive sexuality education, vaccination against human papillomavirus and appropriate advice in case of gender-based violence.

Early Marriage and Pregnancy

The deleterious impact of early marriage on adolescent girls¡¯ health has long been incontrovertible. Nevertheless, little progress has been made in reducing the incidence of early marriage among poor or conflict-ridden communities, particularly in the developing world. The United Nations Population Fund, in a 2012 report on early marriage, stated that by the time a girl reaches the age of 15, there is a one in nine chance she will be married.²¹?If she is married, she faces overwhelming likelihood of forced sex and early childbearing, as well as increased risk of sexually transmitted infections and physical and emotional abuse.²²

One of the most detrimental consequences of early marriage is pregnancy among very young girls, a known health hazard to both mother and baby. Fortunately, there has been some progress in reducing the incidence of teen age pregnancy over the past half-century. The United Nations Population Fund (UNFPA), in its report entitled Girlhood, Not Motherhood: Preventing Adolescent Pregnancy, states that, in the world¡¯s poorest regions, ¡°birth rates for 15-19 year olds in 1950¨C55 averaged 170 births per 1000 girls ...; in 2010 it was 106. But 106 per 1000 is still four times higher than in the high-income regions of the world.¡±²³

Mental Health

One of the most urgent unmet child health needs is mental health treatment for adolescents, particularly girls. In 2016, UNFPA reported?that suicide is now the second leading cause of death for adolescent girls between the ages of 10 and 19 at the global level, and the leading cause of death for those between the ages of 15 and 19.²⁴?A relevant factor contributing to this epidemic is their extraordinarily high exposure to violence: one in three girls experience violence during their lifetime, many during adolescence. On average, globally, an adolescent girl dies every 10 minutes as a result of violence. Small wonder that debilitating depression and anxiety take an enormous toll on the mental health of adolescent girls, morbidity that is still very largely ignored and neglected by medical professionals. According to UNFPA:

As [a girl] ages, reality begins to sink in: impending marriage, leaving school and embarking on a life of servitude and, often, destitution. ¡­ These painful realizations can negatively affect her mental health, and are manifested in the increased anxiety, depression, self-harm and suicide. Girls who survive to 20 become more vulnerable to unintended pregnancy and to fatal complications from pregnancy and childbirth.²⁵

Addiction

Another noteworthy indicator of poor adolescent well-being is the very extensive prevalence of addiction, with both alcohol and drug abuse starting in the early teenage years. Alcohol use has devastating consequences for the health of children in their second decade of life, and is an increasing concern in many countries. WHO reports that 14 per cent of adolescent girls and 18 per cent of boys aged 13¨C15 years in low- and middle-income countries are reported to use alcohol, 5 per cent of all deaths of young people between the ages of 15 and 29 are attributable to alcohol use.²⁶?Drug addiction has a different geographical incidence but is an equally powerful morbidity factor for individuals in their late teens and early adulthood.

Conclusion

Significant strides have been made globally in the realization of the right to health for children, with dramatic improvements reported in some key areas. The overall picture, however, is less encouraging for two reasons. Even within the areas where improvements have taken place, sizeable income and regional disparities persist, with discriminatory impact on the most vulnerable and marginalized communities. Age discrimination also severely affects access to a right to health. While young children have benefited from concerted attention, including in the MDGs, the problems experienced by adolescents have received much less recognition. Acute morbidity and mortality persist, including as a result of preventable diseases and conditions.? If the laudable and ambitious health goals of the International Covenant on Economic, Social and Cultural Rights are to be realized in time for its centenary celebrations, much more vigorous and inventive efforts will be needed, to ensure that every child and young person does indeed enjoy ¡°the highest attainable standard of physical and mental health¡± throughout their lifetime.

I am grateful to Krista Oehlke for excellent research assistance.

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Notes

1?Universal Declaration of Human Rights, Preamble.

2 Beth A. Simmons, Mobilizing for Human Rights: International Law in Domestic Politics (Cambridge, Cambridge University Press, 2009), pp. 332; 337 - 348.

3 United Nations, Treaty Series, vol. 993, No. 14531, Art.2(1).

4 Philip Alston and Gerard Quinn, ¡°The nature and scope of States Parties¡¯ obligations under the International Covenant on Economic, Social and Cultural Rights¡±, Human Rights Quarterly, vol. 9, No. 2 (May 1987), pp. 156 -229.?

5 United Nations, Treaty Series, vol. 1577, No. 27531, Art. 1.

6 United Nations Children¡¯s Fund (UNICEF), The State of the World¡¯s Children 2016, Report (New York, 2016), p. vi. Available from .

7 United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), ¡°Levels and trends in child mortality,¡± Report 2015, (New York, UNICEF, September 2015), p. 3. Available from .

8 United Nations Children¡¯s Fund, ,¡± p. 12.

9 .

10 World Health Organization (WHO), Global and regional immunization profile. 18 November 2016. Available from ;?World Health Organization (WHO), WHO-UNICEF estimates 2015 revision, for 194 WHO Member States. Available from ;?United Nations Department of Economic and Social Affairs, Population Division, World Population Prospects, the 2015 Revision. The twenty-fourth round of official United Nations population estimates and projections. Available from (accessed 17 January 2017); The data is reproduced in a slide ¡°Progress and challenges with achieving universal immunization coverage: 2015 estimates of immunization coverage: WHO/UNICEF estimates of national immunization coverage (Data as of July 2016)¡±, prepared by Immunization Vaccines and Biologicals, (IVB), World Health Organization. Available from .

11 United Nations Children¡¯s Fund, ¡°Malaria kills 1,200 children a day: UNICEF¡±, Fact Sheet, 23 April 2015. Available from .

12 Ibid.

13 United Nations Children¡¯s Fund,?, p. 3;?, ¡°Levels and trends in child mortality,¡± p. 3.?

14 United Nations Children¡¯s Fund, ¡°Strengthening community and primary health systems for TB: a consultation on childhood TB integration¡± (New York, 2016), p. 3. Available from .

15 United Nations Children¡¯s Fund,?, p. 10; United Nations Children¡¯s Fund, Committing to Child Survival: A Promise Renewed, Progress report 2015 (New York, 2015), p. 35. Available from .?

16?United Nations Children¡¯s Fund,?The State of the World¡¯s Children 2016, p. 5; World Health Organization, Quantitative Risk Assessment of the Effects of Climate Change on Selected Causes of Death, 2030s and 2050s (Geneva, 2014), p. 13. Available from . ?

17 , ¡°Levels and trends in child mortality,¡± p. 24; United Nations Children¡¯s Fund, , p. 10.

18 World Health Organization, Mortality, morbidity and disability in adolescence, Health for the world¡¯s adolescents: a?second chance in the second decade. An interactive online report. 2014. Available from ; Joint United Nations Programme on HIV/AIDS (UNAIDS), ¡°Ending the AIDS epidemic for adolescents, with adolescents: a practical guide to meaningfully engage adolescents in the AIDS response (Geneva, 2016), p. 2. Available from .

19 Ibid, p. 6.

20 United Nations Population Fund (UNFPA), How Our Future Depends on a Girl at This Decisive Age: The State of the World Population 2016 (New York, 2016), p. 32. Available from .

21 United Nations Population Fund (UNFPA), Marrying Too Young: End Child Marriage, Report (New York, 2012), p. 10. Available from ; United Nations Population Fund (UNFPA), , p. 33.

22 The Lancet Commissions, ¡°Our future: a Lancet commission on adolescent health and wellbeing¡±, The Lancet, vol. 387, No. 10036 (May 2016), pp. 2423-2478 (2430). Available from .?United Nations Population Fund (UNFPA), , p. 33.

23 United Nations Population Fund (UNFPA),?Girlhood, Not Motherhood: Preventing Adolescent Pregnancy?(New York, 2015), p. 7. Available from?; United Nations Department of Economic and Social Affairs, Population Division, World Population Prospects, the 2015 Revision. The twenty-fourth round of official United Nations population estimates and projections. Data Query.?Available from (accessed 17 January 2017).

24?United Nations Population Fund (UNFPA),?,?p. 24;?World Health Organization, Global Health Observatory visualizations, Adolescent health: mortality and DALYs in adolescents by WHO region, 2000 and 2012, aged 10-19 years. 2016. Available from (accessed 22 June 2016);?

25?United Nations Population Fund (UNFPA),?,?p. 34;??The Lancet Commissions, ¡°Our future: a Lancet commission on adolescent health and wellbeing¡±, The Lancet, vol. 387, No. 10036 (May 2016), pp. 2423-2478;?

26 World Health Organization, School and youth health, School health and youth health promotion: facts. 2017. Available from (accessed 17 January 2017); Office of the Secretary-General¡¯s Envoy on Youth, #YouthStats, ¡°Substance abuse¡±. Available from (accessed 20 December, 2016); World Health Organization, ¡°Fact sheet on adolescent health¡±, July 2015. Available from .? ?

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