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The International Health Regulations, 2005 revision; IHR (2005) govern how countries address collective threats in global solidarity; yet international travel bans can drive countries apart through economic isolation, trade disruptions, discriminatory restrictions and rights violations. This editoria discusses under which conditions travel restrictions can be legally justified.

In imposing travel restrictions against China during the current outbreak of 2019 novel coronavirus disease (COVID-19), many countries are violating the IHR. We—16 global health law scholars—came to this conclusion after applying the interpretive framework of the Vienna Convention on the Law of Treaties and reaching a jurisprudential consensus on the legal meaning of Article 43 of the International Health Regulations (2005).

The Independent Panel on Pandemic Preparedness1 released on 11 May adds to the mounting calls for a new Pandemic Treaty that would address gaps in the global governance of threats to global health security. The emerging debate has quickly turned to focus on questions of structure and forms—a United Nations treaty or a framework convention under the auspices of the WHO, and verification and enforcement mechanisms—as well as on issues of process regarding who will have voice and how the negotiations will proceed.2 3 But we must not lose sight of its purpose and key objectives, and what we mean by ‘global health security’. Indeed, the treaty discussions provide an opportunity and an imperative to rethink the paradigm of global health security that has shaped the current international response to the COVID-19 pandemic. The prevailing paradigm is antithetical to the core purpose of global pandemic preparedness and response for five reasons. First, global health security needs to focus on the security of people, not national borders. The concept of ‘global health security’ emerged with the increasing transnational spread of disease in the late 20th century in the context of neoliberal economic globalisation, the rise in biosecurity threats, and increased migrations due to climate change, instability and armed conflicts.4 5 It led to a reframing of infectious diseases as a national security threat, bringing the language and thinking of the security sector, concerned with defending national borders, not human health. As Senators …

Goran Tomson and colleagues argue that our ability to control pandemics requires global action to counter inequalities from demographic, environmental, technological, and other megatrends

Amid frenzied national responses to COVID-19, the world could soon reach a critical juncture to revisit and strengthen the International Health Regulations (IHR), the multilateral instrument that governs how 196 states and WHO collectively address the global spread of disease.1, 2 In many countries, IHR obligations that are vital to an effective pandemic response remain unfulfilled, and the instrument has been largely side-lined in the COVID-19 pandemic, the largest global health crisis in a century. It is time to reimagine the IHR as an instrument that will compel global solidarity and national action against the threat of emerging and re-emerging pathogens. We call on state parties to reform the IHR to improve supervision, international assistance, dispute resolution, and overall textual clarity.

Overcoming continuing polarization regarding judicial enforcement of health rights in Latin America requires clarifying divergent normative and political premises, addressing the lack of reliable empirical data, and establishing the conditions for fruitful inter-sectoral, inter-disciplinary dialogue. Fil: Yamin, Alicia Ely. Harvard University; Estados Unidos Fil: Pichón-riviere, Andres. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Bergallo, Paola. Universidad Torcuato Di Tella; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina

At the December, 2018, Partnership for Maternal, Newborn, and Child Health (PMNCH) Partners' Forum in Delhi, India, accountability was recognised as a key pillar of achieving the goals of the UN Secretary General's Global Strategy for Women's, Children's and Adolescents' Health (Global Strategy). Nevertheless, accountability continues to be used in different ways within the Every Woman, Every Child ecosystem and across the many global health initiatives in the UN Sustainable Development Goals (SDGs). Given that efforts to advance universal health coverage (UHC) and other global health agendas, such as non-communicable disease, are now considering separate accountability mechanisms, lessons gleaned from 3 years of work by the UN Secretary-General's Independent Accountability Panel (IAP) are relevant to understanding what accountability means and why it matters for the Global Strategy, and for UHC.

Driven by the need to better understand the full and intergenerational toll of maternal mortality (MM), a mixed-methods study was conducted in four countries in sub-Saharan Africa to investigate the impacts of maternal death on families and children. The present analysis identifies gender as a fundamental driver not only of maternal, but also child health, through manifestations of gender inequity in household decision making, labor and caregiving, and social norms dictating the status of women. Focus group discussions were conducted with community members, and in depth qualitative interviews with key-informants and stakeholders, in Tanzania, Ethiopia, Malawi, and South Africa between April 2012 and October 2013. Findings highlight that socially constructed gender roles, which define mothers as caregivers and fathers as wage earners, and which limit women's agency regarding childcare decisions, among other things, create considerable gaps when it comes to meeting child nutrition, education, and health care needs following a maternal death. Additionally, our findings show that maternal deaths have differential effects on boy and girl children, and exacerbate specific risks for girl children, including early marriage, early pregnancy, and school drop-out. To combat both MM, and to mitigate impacts on children, investment in health services interventions should be complemented by broader interventions regarding social protection, as well as aimed at shifting social norms and opportunity structures regarding gendered divisions of labor and power at household, community, and society levels.

A key and distinctive feature of Latin America is the explicit discourse around the right to health. Many countries have translated this commitment into practice by incorporating rights principles and standards in constitutions and legislation, together with health policies and programmes, to treat health as an asset of citizenship rather than a market commodity, and to promote an equitable path to universal health coverage. Human-rights-based approaches (HRBAs) are characterised by a focus on the underlying social determinants of health and an emphasis on the principles of accountability, meaningful participation, transparency, and equality and non-discrimination. Understanding governments as duty bearers and health system users as claims holders has been fundamental to holding governments to account with respect to achieving aspects of universal health coverage equitably in Latin America, a region marked by profound social inequality, which is reflected in health disparities.

Applying a robust human rights framework would change thinking and decision-making in efforts to achieve Universal Health Coverage (UHC), and advance efforts to promote women’s, children’s, and adolescents’ health in East Africa, which is a priority under the Sustainable Development Agenda. Nevertheless, there is a gap between global rhetoric of human rights and ongoing health reform efforts. This debate article seeks to fill part of that gap by setting out principles of human rights-based approaches (HRBAs), and then applying those principles to questions that countries undertaking efforts toward UHC and promoting women’s, children’s and adolescents’ health, will need to face, focusing in particular on ensuring enabling legal and policy frameworks, establishing fair financing; priority-setting processes, and meaningful oversight and accountability mechanisms. In a region where democratic institutions are notoriously weak, we argue that the explicit application of a meaningful human rights framework could enhance equity, participation and accountability, and in turn the democratic legitimacy of health reform initiatives being undertaken in the region.

In 2011, the UN Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) issued a groundbreaking decision in the case of Alyne da Silva Pimentel Teixeira versus Brazil involving the maternal death of a young Afro-Brazilian woman. The CEDAW addressed systemic failures in the Brazilian health system that combined to violate Alyne's rights to life, health, and access to maternal health services. Almost 5 years later, after significant back and forth between the concerned parties, a technical follow-up commission was created with the support of the Center for Reproductive Rights, and was welcomed by the government of Brazil. The technical follow-up commission was precedent-setting, seeking to move beyond identifying gaps in "compliance" and concentrate instead on issues that might catalyze re-engagement by national level stakeholders, both governmental and non-governmental, with the aim of advancing CEDAW's recommendations through not only the creation, but also the effective implementation, of policies and programs that promote women's sexual and reproductive rights in practice, including their rights to safe motherhood. Here, the human-rights-based framework of the technical follow-up commission is described, in addition to their findings related to legal and policy frameworks, evidence-based programing, and monitoring and oversight of providers.

As health policy-makers around the world seek to make progress towards universal health coverage they must navigate between two important ethical imperatives: to set national spending priorities fairly and efficiently; and to safeguard the right to health. These imperatives can conflict, leading some to conclude that rights-based approaches present a disruptive influence on health policy, hindering states’ efforts to set priorities fairly and efficiently. Here, we challenge this perception. We argue first that these points of tension stem largely from inadequate interpretations of the aims of priority setting as well as the right to health. We then discuss various ways in which the right to health complements traditional concerns of priority setting and vice versa. Finally, we set out a three-step process by which policy-makers may navigate the ethical and legal considerations at play.

In the last few years there have been several critical milestones in acknowledging the centrality of human rights to sustainably addressing the scourge of maternal death and morbidity around the world, including from the United Nations Human Rights Council. In 2012, the Council adopted a resolution welcoming a Technical Guidance on rights-based approaches to maternal mortality and morbidity, and calling for a report on its implementation in 2 years. The present paper provides an overview of the contents and significance of the Guidance. It reviews how the Guidance can assist policymakers in improving women's health and their enjoyment of rights by setting out the implications of adopting a human rights-based approach at each step of the policy cycle, from planning and budgeting, to ensuring implementation, to monitoring and evaluation, to fostering accountability mechanisms. The Guidance should also prove useful to clinicians in understanding rights frameworks as applied to maternal health.

This paper explores the intended and unintended consequences of the selection of MDG 5 as a global goal, together with its respective targets and indicators, and places what happened to MDG 5, and sexual and reproductive health and rights more broadly, into the context of the development model that was encoded in the MDGs. Over the last decade, as the MDGs increasingly took centre stage in development and their use evolved, they were inappropriately converted from global goals into national planning targets. This conversion was particularly detrimental in the case of MDG 5. It not only created a narrowing in terms of policies and programming, but also had an enormous impact on the discourse of development itself, reshaping the field in terms of the organization and dissemination of knowledge, and underscoring that the process of setting targets and indicators is far from neutral but encodes normative values. Looking forward, it is not adequate to propose an MDG+ framework based on the same structure. Sexual and reproductive health and rights must be placed back into the global discourse, using development to empower women and marginalized populations, and to address structural inequalities that are fundamental to sustained social change. The new development framework should include a strong narrative of social transformation in which fit-for-purpose targets and indicators play a role, but do not overtake or restrict the broader aims of advancing social, political, and gender justice.

Domestic litigation has become a principal strategy for realizing international treaty obligations for the human right to health, providing causes of action for the public’s health and empowering individuals to raise human rights claims for HIV prevention, treatment, and care. In the past 15 years, advocates have laid the groundwork on which a rapidly expanding enforcement paradigm has arisen at the intersection of human rights litigation and HIV/ AIDS policy. As this enforcement develops across multiple countries, human rights are translated from principle to practice in the global response to HIV/AIDS, transforming aspirational declarations into justiciable obligations and implementing human rights through national policies and programs. Yet despite this national progress in creating accountability for health-related rights, there is scarce empirical research on the scope, content, and effect of legal claims pursuant to these human rights standards. As judicial enforcement has increased, rising to the forefront of a budding health and human rights movement, both proponents and opponents of rightsbased policy have questioned the limits of this litigation strategy and the impact of litigation on global HIV/AIDS efforts. Reflecting on this growing back lash, there arises an imperative for interdisciplinary analysis — to survey these rights-based claims, compare divergent legal strategies conducive to the realization of human rights, and assess the effects of this litigation on public health outcomes. This article sketches the evolving interaction between human rights case law and HIV/AIDS policy. To clarify the need for such analysis, this article discusses the promise of human rights litigation in providing accountability for state public health commitments. Given the promise of this litigation in realizing public health outcomes, this article reviews the origins and development of human rights jurisprudence for HIV/AIDS. With this enforcement movement facing increasing criticism for distorting the global health governance agenda, the authors examine the backlash against this human rights jurisprudence in setting HIV/AIDS policy. This article concludes that scholars and practitioners must engage in comparative analyses of these rights-based litigation strategies and empirical research on their public health impacts.

The full impact of a maternal death includes consequences faced by orphaned children. This analysis adds evidence to a literature on the magnitude of the association between a woman's death during or shortly after childbirth, and survival outcomes for her children. The Ifakara and Rufiji Health and Demographic Surveillance Sites in rural Tanzania conduct longitudinal, frequent data collection of key demographic events at the household level. Using a subset of the data from these sites (1996-2012), this survival analysis compared outcomes for children who experienced a maternal death (42 and 365 days definitions) during or near birth to those children whose mothers survived. There were 111 maternal deaths (or 229 late maternal deaths) during the study period, and 46.28 % of the index children also subsequently died (40.73 % of children in the late maternal death group) before their tenth birthday-a much higher prevalence of child mortality than in the population of children whose mothers survived (7.88 %, p value

Background The consequences of maternal mortality on orphaned children and the family members who support them are dramatic, especially in countries that have high maternal mortality like Ethiopia. As part of a four country, mixed-methods study (Ethiopia, Malawi, South Africa, and Tanzania) qualitative data were collected in Butajira, Ethiopia with the aim of exploring the far reaching consequences of maternal deaths on families and children. Methods We conducted interviews with 28 adult family members of women who died from maternal causes, as well as 13 stakeholders (government officials, civil society, and a UN agency); and held 10 focus group discussions with 87 community members. Data were analyzed using NVivo10 software for qualitative analysis. Results We found that newborns and children whose mothers died from maternal causes face nutrition deficits, and are less likely to access needed health care than children with living mothers. Older children drop out of school to care for younger siblings and contribute to household and farm labor which may be beyond their capacity and age, and often choose migration in search of better opportunities. Family fragmentation is common following maternal death, leading to tenuous relationships within a household with the births and prioritization of additional children further stretching limited financial resources. Currently, there is no formal standardized support system for families caring for vulnerable children in Ethiopia. Conclusions Impacts of maternal mortality on children are far-reaching and have the potential to last into adulthood. Coordinated, multi-sectorial efforts towards mitigating the impacts on children and families following a maternal death are lacking. In order to prevent impacts on children and families, efforts targeting maternal mortality must address inequalities in access to care at the community, facility, and policy levels.

One of the most significant transformations to occur in the landscape of struggles for health justice since this journal was originally launched relates to the increasing judicialization of health-related rights, and economic, social, and cultural rights (ESC rights) more broadly. Indeed, the articles in this issue go far toward debunking outdated conceptions about health rights as merely "programmatic rights," which are not justiciable. Over the last 20 years, and increasingly in the last decade, we have seen that health and related rights are in fact being enforced by courts around the world, from South America to South Asia, Eastern Europe to East Africa. And increasingly, even in low-income countries, important demands for health-related entitlements are being framed in terms of legally enforceable claims.

BackgroundLittle is known about the interconnectedness of maternal deaths and impacts on children, beyond infants, or the mechanisms through which this interconnectedness is established. A study was conducted in rural Tanzania to provide qualitative insight regarding how maternal mortality affects index as well as other living children and to identify shared structural and social factors that foster high levels of maternal mortality and child vulnerabilities.Methods and findingsAdult family members of women who died due to maternal causes (N = 45) and key stakeholders (N = 35) participated in in-depth interviews. Twelve focus group discussions were also conducted (N = 83) among community leaders in three rural regions of Tanzania. Findings highlight the widespread impact of a woman's death on her children's health, education, and economic status, and, by inference, the roles that women play within their families in rural Tanzanian communities.ConclusionsThe full costs of failing to address preventable maternal mortality include intergenerational impacts on the nutritional status, health, and education of children, as well as the economic capacity of families. When setting priorities in a resource-poor, high maternal mortality country, such as Tanzania, the far-reaching effects that reducing maternal deaths can have on families and communities, as well as women's own lives, should be considered.

The case of Haiti's devastating earthquake and the reactions it has elicited sharply illustrate an array of seemingly dichotomous ways of understanding obligations of "international assistance and cooperation," which are taken up by authors in this issue. First, there is a tension between dealing with immediate humanitarian needs and addressing underlying structural causes. Second, there is the related dichotomy between compassion/charity and the accountability for legal obligations that a human rights approach to health and development demands. Third, within a framework for accountability, there is a tension between an ahistorical understanding of international responsibility - based purely on the self-evident need of fellow human beings - and a contextually-rooted accountability. Finally, the situation of Haiti begs the question of whether we can address immense human suffering in the world through a strongly statist model or whether we require a more cosmopolitan understanding of ethical and legal obligations across borders. Drawing on the Critical Concepts articles in this issue, this essay briefly explores some of these tensions, and the potential contributions and limitations of applying a human rights framework to advance global health.

Accountability is a central feature of any rights-based approach to health because it converts passive beneficiaries into claims-holders and identifies states and other actors as duty-bearers that can be held responsible for their discharge of legal, and not merely moral, obligations. This article reviews what we mean by accountability, how courts and other mechanisms are being engaged to promote accountability, and what we should understand as the central obligations of states and other actors if we are concerned with obligations of progressive realization relating to health and development goals. The first part of the article sets out a number of mutually-reinforcing dimensions of accountability, examines different duty-bearers, and discusses mechanisms for enforcement, with a focus on courts. The second part of the article explores how we might define the obligations of progressive realization for which we seek accountability. I argue that there are three aspects of accountability with which a human rights approach to health as a social policy and development issue should be concerned: (1) what the state is doing; (2) how much effort the state is expending; and (3) how the state is going about the process. Although the focus is on national obligations, I argue that donor states and other actors have parallel obligations.

The foundational princple of human rights is that all human beings are equal in rights, dignity, and worth. Yet we live in a world ravaged by social inequalities both within and between countries, which have profound implications for the distribution of population health as well as the unequal enjoyment of economic and social rights and of human rights generally. It is far from clear that we have a consensus in the human rights community about which inequalities in health constitute inequities or how egalitarian a society must be to conform to the requirements of a social order in which all human rights can be realized. Further, the conversations in the world of human rights have largely been divorced from those in the worlds of development and public health. In this article, I attempt to bring those two conversations together. I first set out how concepts of formal and substantive equality and non-discrimination are defined under international law and might be applied in practice to questions we face in public health today. I argue that the application of these concepts is far from formulaic; interpretations of equality and non-discrimination necessarily reflect deeply held understandings about justice, power, and how we are the same and different from one another. I then explore how far a human rights framework can guide us in terms of some of these underlying questions in health and development polity, particularly in relation to how much priority should be given to the worst off in society, what kind of equality we should be seeking from a human rights perspective, and how we should evaluate who is worst off in terms of health. In conclusion, I argue that the great power of applying a human rights framework to health lies in denaturalizing the inequalities that pervade our societies and our world and in establishing that all people--by virtue of being human--have both a claim for redress when they are treated unfairly and a right to participate in determining what equity and equality require in a given context.

Alicia Ely Yamin and Oscar Parra-Vera discuss the case of Colombia, where a recent constitutional court decision demonstrates the involvement of the court in protecting fundamental rights to health.

Health professionals view medical ethics as a discipline that provides the basis for more adequate patient care. In recent years the concepts of quality of care and human rights - with their attending discourses - have joined the concept of medical ethics among the paradigms to consider in care for humans both at the individual and health policy levels. The current study seeks to analyze such paradigms, based on a case study of sexual and reproductive health policies in Peru in the last 10 years.

Background Maternal mortality in South Africa is high and a cause for concern especially because the bulk of deaths from maternal causes are preventable. One of the proposed reasons for persistently high maternal mortality is HIV which causes death both indirectly and directly. While there is some evidence for the impact of maternal death on children and families in South Africa, few studies have explored the impacts of maternal mortality on the well-being of the surviving infants, older children and family. This study provides qualitative insight into the consequences of maternal mortality for child and family well-being throughout the life-course. Methods This qualitative study was conducted in rural and peri-urban communities in Vulindlela, KwaZulu-Natal. The sample included 22 families directly affected by maternal mortality, 15 community stakeholders and 7 community focus group discussions. These provided unique and diverse perspectives about the causes, experiences and impacts of maternal mortality. Results and discussion Children left behind were primarily cared for by female family members, even where a father was alive and involved. The financial burden for care and children’s basic needs were largely met through government grants (direct and indirectly targeted at children) and/or through an obligation for the father or his family to assist. The repercussions of losing a mother were felt more by older children for whom it was harder for caregivers to provide educational supervision and emotional or psychological support. Respondents expressed concerns about adolescent’s educational attainment, general behaviour and particularly girl’s sexual risk. Conclusion These results illuminate the high costs to surviving children and their families of failing to reduce maternal mortality in South Africa. Ensuring social protection and community support is important for remaining children and families. Additional qualitative evidence is needed to explore differential effects for children by gender and to guide future research and inform policies and programs aimed at supporting maternal orphans and other vulnerable children throughout their development.

Through a description of the four major challenges faced by Latin American human rights groups and the strategies that they have adopted to overcome these challenges, this article seeks to incorporate the perspective of human rights activists into the discussion of how to make health a universally recognized human right. The ill-defined normative content of the right to health, the lack of precedents and procedures for enforceability, and the lack of consciousness of health as a right have presented major obstacles to the implementation of the right in the region. Also, Latin American human rights groups must move beyond traditional legal methods and expertise to work in an interdisciplinary fashion with health professionals and grassroots health groups. Despite the obvious obstacles, Latin American human rights groups cannot afford not to become involved in advocacy on the right to health. /// Par une description des quatre principaux defis majeurs auxquels sont confrontes les groupes de defense des droits de la personne en Amerique Latine et les strategies qu'ils ont adoptees pour surmonter ces defis, cet article cherche a incorporer la perspective des activistes des droits de la personne dans la discussion sur la maniere de faire de la sante un droit universellement reconnu. Le contenu normatif mal defini du droit a la sante, le manque de precedents et de procedures en matiere d'applicabilite et l'absence de conscience de la sante en tant que droit, ont eu pour effet de presenter des obstacles majeurs a la mise en œuvre du droit dans la region. De meme, les groupes de defense des droits de la personne en Amerique Latine doivent aller au-dela des methodes legales traditionnelles et se former au travail pluridisciplinaire avec les professionnels de la sante et les groupes de sante a la base. En depit des obstacles evidents, les groupes de defense des droits de la personne d'Amerique Latine ne peuvent pas se permettre de ne pas s'engager dans la defense du droit a la sante pour tous. /// A traves de una descripcion de los cuatro retos mayores enfrentados por grupos de derechos humanos latinoamericanos y las estrategias que han adoptado para vencerlos, este articulo busca inyectar algo de las perspectiva de los activistas de derechos humanos en el debate de como hacer que la salud sea reconocida como un derecho humano universal. El contenido mal definido de la norma del derecho a la salud, como la falta de precedentes y procedimientos para su cumplimiento, y la falta de conciencia sobre la salud como derecho han presentado grandes obstaculos para la implementacion del derecho en la region. Ademas los grupos de derechos humanos latinoamericanos tendran que ir mas alla de los metodos legales y las estrategias tradicionales de trabajo en una forma inter-disciplinaria con profesionales de salud y grupos de organizaciones de base de salud. A pesar de los obstaculos tan obvios, los grupos de derechos humanos latinoamericanos no pueden darse el lujo de no estar involucrados en la abogacia sobre el derecho a la salud.

Alicia Yamin argues that applying human rights frameworks and approaches to maternal health offers strategies and tools to address the root causes of maternal morbidity and mortality within and beyond health systems, in addition to addressing other violations of women's sexual and reproductive health and rights. Please see later in the article for the Editors' Summary.

One case of a surgical procedure that led to the death of a woman where one of the charges was a failure to obtain fully informed consent was debated at length by the UK General Medical Council last year. What about a quarter of a million cases? Between 1996 and 2000 more than 250 000 women the overwhelming majority poor and from the remote rural areas of the Andean sierra and Peruvian Amazon underwent sterilisation without a proper consent process during the implementation of a family planning public-health policy in Peru. The Peruvian government was found responsible by the Inter-American Human Rights Commission in one emblematic case in which Mamerita Mestanza Chavez had been forcibly sterilised and died as a result of the operation. Clearly the promotion of the right to health requires different approaches for different audiences and actors but analysis of specific cases such as that of reproductive health in Peru can play a part in advancing this agenda. (authors)

In a rights framework, participation is inextricably related to power. Through effective participation, we can challenge political and other forms of exclusion that prevent people from having power over the decisions and processes that affect their lives and health. Yet concepts of power are as contested as notions of participation. Thus, I argue here that, far from there being a formula for what participation means in a rights-based approach to health, the way in which we conceptualize the role of participation is closely linked to how we understand power and, in turn, the purpose and meaning of human rights themselves. I outline three ways of thinking about domination and participation-as-empowerment. In a liberal understanding of how power operates, there is an overarching concern for ensuring processes of participation that enable competing groups to express their voices on the proverbial level playing field, so that no one group may impose its will on the others. Critics of this approach assert that it ignores the power relations in which participatory processes are embedded, which determine which of the issues that affect health get decided--and which issues are never brought to the table because they are systematically blocked. If a second dimension of power entails deciding what gets decided, participatory approaches need to challenge the definition of what is "up for contention," or they risk merely legitimating social control. A third dimension of power entails securing compliance from oppressed groups by shaping their perceptions of their own interests. A human rights-based approach concerned with the effects of this form of domination on people's health calls for developing critical consciousness before there can be any truly "empowering" participation. I conclude by arguing that much is at stake in defining participation in a human rights framework to health, because in defining what we are calling for, we will determine how relevant human rights are to the daily struggles of people around the world for well-being.

Since this journal was first published, rights-based approaches to health have prolferated in the health and development communities. At the same time, human rights advocacy organizations, courts, and UN actors have increasingly been engaged in applying rights norms in health contexts. Together with others in this issue, this article is a call not to lose sight of the radical potential of using a human rightsparadigm to promote health--even as we go about the pragmatic work of translating rights frameworks into practice in our research, advocacy, litigation strategies, program planning, and service delivery. Drawing together points made in other pieces in this issue, the article describes certain conceptual and practical implications of a transformative engagement between health and human rights. It argues that an appropriate starting point is to take suffering seriously; in so doing, approaches in both health and rights will necessarily shift. A human rights approach challenges biological individualism in both clinical medicine and public health, and builds on work in social epidemiology by providing frameworks for accountability. At the same time, using rights to advance the health of marginalized peoples around the world requires critiquing and expanding limited approaches to human rights, in theory and practice.

Mental health is perhaps the most neglected area of health policy and programming. According to the 2001 World Health Report, “some 450 million people suffer from a mental or behavioral disorder, yet only a small minority of them receive even the most basic treatment” [1]. More than 40% of countries have no mental health policy and over 30% have no mental health program. Over 90% of countries have no mental health policy that includes children and adolescents [1]. According to the World Health Organization (WHO), mental and behavioral disorders are estimated to account for 12% of the global burden of disease, yet the mental health budgets of the majority of countries constitute less than 1% of their total health expenditures [1]. The relationship between disease burden and disease spending is clearly disproportionate. Those few who do receive services often fare just as badly. Mental Disability Rights International (MDRI; Washington, D.C., United States), a human rights group dedicated to the promotion of rights of the mentally disabled, has documented how, in many countries, severely mentally disabled individuals become targets of stigma, discrimination, and other human rights abuses. Routinely, children and adults with mental disabilities are arbitrarily detained in psychiatric facilities, social care homes, orphanages and other closed institutions. Out of public view, they are subject to the most extreme forms of inhuman and degrading treatment experienced by any population (Figure 1). In Kosovo, MDRI learned that women were raped in psychiatric facilities in plain view of local staff and international humanitarian relief workers [2]. In Hungary and Paraguay, MDRI found people locked in cages [3,4]. In Turkey, Peru, and Bulgaria, MDRI investigators learned of a practice called “unmodified ECT”—the use of without any form of anaesthesia or muscle relaxants—a practice that is both painful and dangerous [5,6]. Figure 1 Bathroom in the Men's Chronic Ward of Larco Herrera Hospital, a Government-Supported Psychiatric Hospital in Lima, Peru

The debate section of the September 2001 issue was dedicated to the complex issue of globalisation.1–5 All the authors note the polarisation of the current debate and the importance of finding specific strategies to move forward. Our point here is not to take sides as to the results of globalisation but to address the question of why these debates are so polarised. That is, precisely part of the problem is that there is no true “debate” occurring here because there is no level playing field between rich and poor countries, between the winners and the losers of …

Background: Maternal mortality remains the leading cause of death and disability for reproductive-age women in resource-poor countries. The impact of a mother’s death on child outcomes is likely severe but has not been well quantified. This analysis examines survival outcomes for children whose mothers die during or shortly after childbirth in Butajira, Ethiopia. Methods: This study uses data from the Butajira Health and Demographic Surveillance System (HDSS) site. Child outcomes were assessed using statistical tests to compare survival trajectories and age-specific mortality rates for children who did and did not experience a maternal death. The analyses leveraged the advantages of a large, long-term longitudinal dataset with a high frequency of data collection; but used a strict date-based method to code maternal deaths (as occurring within 42 or 365 days of childbirth), which may be subject to misclassification or recall bias. Results: Between 1987 and 2011, there were 18189 live births to 5119 mothers; and 73 mothers of 78 children died within the first year of their child’s life, with 45% of these (n=30) classified as maternal deaths due to women dying within 42 days of childbirth. Among the maternal deaths, 81% of these infants also died. Children who experienced a maternal death within 42 days of their birth faced 46 times greater risk of dying within one month when compared to babies whose mothers survived (95% confidence interval 25.84-81.92; or adjusted ratio, 57.24 with confidence interval 25.31-129.49). Conclusions: When a woman in this study population experienced a maternal death, her infant was much more likely to die than to survive—and the survival trajectory of these children is far worse than those of mothers who do not die postpartum. This highlights the importance of investigating how clinical care and socio-economic support programs can better address the needs of orphans, both throughout the intra- and post-partum periods as well as over the life course.