Source: https://www.hhrjournal.org/2013/12/small-places-close-to-home-toward-a-health-and-human-rights-strategy-for-the-us/
Timestamp: 2019-04-21 23:10:45+00:00

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Where, after all, do universal human rights begin? In small places close to home.
Much of the discussion about “health as a human right” has centered on global health initiatives, largely ignoring the application of human rights principles to the significant socioeconomic and racial health disparities in the United States. Given the persistent gaps in insurance coverage and access to quality preventive care in the US, the health and human rights movement has primarily focused its efforts on achieving universal health care coverage. However, this focus has left unaddressed how a human rights strategy might also address the social determinants of health. As Americans’ health continues to worsen—the US Institute of Medicine recently reported that the US now fares worse in nine areas of health than 16 peer high-income democracies—a broader social determinants approach is warranted. This article explores the application of international human rights principles, including a “right to health” to the US context, and analyzes how existing domestic law may be used to advance health as a human right for America’s most vulnerable populations. It demonstrates that an effective health and human rights strategy must build partnerships among health care providers, public health professionals, and lawyers to identify rights violations, hold officials and systems accountable, and mobilize communities to advocate for systems and policy change.
Yet much of the discussion of health and human rights has centered on global health initiatives, mostly ignoring the application of human rights principles to the United States. Discussion of “health as a human right” in the US has focused primarily on the movement for universal health care coverage. This is hardly surprising given the enormous inequities in access to care that continue to plague the US. The Patient Protection and Affordable Care Act of 2010 (PPACA, henceforth ACA), while significantly expanding coverage to the uninsured, will not end the debate in America about the need for the realization of the right to health care.
Nonetheless, the focus on health care has left unaddressed how a human rights strategy might also address the role of the social determinants of health in creating health disparities in the US. Recent studies indicate that US health outcomes continue to worsen in comparison to other wealthy nations. The US Institute of Medicine recently reported that the US now fares worse in nine areas of health than 16 peer high-income democracies.4 Another study found that while overall population health in the US improved from 1990 to 2010, “[m]orbidity and chronic disability now account for nearly half of the health burden in the United States”5…and “[i]mprovements in population health in the United States have not kept pace with advances in population health in other wealthy nations.”6 Recent literature also points to the well-documented social gradient in health in the US that runs the spectrum from those at the top to those of the bottom of the income scale.7 Understanding how social factors, such as income level and social status, contribute to worsening morbidity, disability, and chronic disease in the US and how these factors lead to health disparities across groups is fundamental to improving the public’s health.
This article explores the application of human rights principles, including the right to health to the US context. In order to answer Mann’s fundamental question, “What must be done?” to respond to poverty as a root cause of illness, it is important to explore not only the application of international human rights law, but also how existing domestic law may be used to advance health as a human right for America’s most vulnerable populations.
The article begins with a discussion of international human rights laws that promote the right to health, followed by an analysis of their potential for guiding a health and human rights agenda in the US. It then explores the potential for developing a multilevel strategy for framing a right to health in the US. Components of such a strategy could feature the use of international human rights principles to frame national health policy, state constitutional and legislative efforts based on human rights law, and finally, the enforcement and strengthening of existing laws that protect and promote the health of vulnerable populations. To successfully frame a health and human rights strategy in the US, it is essential that the health care, public health, and legal communities unite to effect change at the community as well as the state and national levels.
Article 25 explicitly recognizes that health and well-being are inextricably tied to the social conditions in which people live, the opportunities that they have, and the distribution of resources in their community.10 In interpreting this right, the question of what standard of living is “adequate” to protect health and well-being is complex. As will be discussed later, this question is particularly relevant for any discussion of the human right to health in the US where there is strong disagreement about whether or not all citizens enjoy, or at least have access to, an “adequate” standard of living for health.
This distinction is particularly important for any discussion of human rights or the right to health in the US, since it is a signatory but not a party to the ICESCR. Table 1 shows international human rights treaty bodies and US obligations under them. Even for party states, the legal obligation for the state to “respect, protect and fulfill” the right to health in its own borders is couched in the idea of the “progressive realization,” rendering it difficult to determine when a state has breached its obligation.18 While international human rights laws articulate a shared value about the right to health, a value that the US claims to endorse, it is important to evaluate what role these laws, if any, can play in advancing health equity in the US, without the teeth of enforcement.
The recent history of US engagement in international human rights represents a relinquishment of the leadership role Americans once had in bringing nations together to establish universal human rights principles, including positive social and economic rights. Despite US leadership in drafting the UDHR after World War II, the political and social context of the postwar years led to a focus on civil and political rights and an abandonment of the promotion of social and economic rights. Scholars have cited three historical developments as critical here: the geopolitical divide created by the Cold War, the rise of American exceptionalism, and the fierce opposition to scrutiny of legalized racial discrimination in the US during the Jim Crow era against international human rights standards. 19,20 While it is beyond the scope of this article to detail the history of human rights policy in the US, understanding these historical foundations is critical to the discussion of a right to health in the US.
Exploring the right to health in the US as it relates to social determinants of health requires first addressing the lack of a right to health care coverage. The US is the only industrialized nation in the world without a plan providing universal health care coverage and a legal recognition of the right to care.27 There is no constitutional right to health care and the federal statutory rights to health care coverage for the poor, elderly, and disabled (Medicare and Medicaid) are limited to those who are deemed “deserving” and are far from universal.28 Because eligibility is categorical (based on a particular status—age, disability, or income level), these programs are premised on the notion that health care coverage should be provided by the government only when an individual deserves help—for example, because she or he is elderly, disabled, or poor—not because government should afford coverage to all citizens as a right.
While the ACA is a significant step forward in expanding health insurance coverage and offering federal oversight and funding to improve health care quality and efficiency, the failure to extend universal and uniform coverage means that the US still falls far short of fulfilling a human right to health care. In fact, by remaining a market-based health care system, the US continues to treat “health care as a market commodity to be bought and sold for profit rather than as a human right.”32 Nonetheless, as will be discussed later, some of the ACA’s provisions may offer important opportunities and resources for states and localities to address the social determinants of health.
Hence, as the following section describes, promoting the right to health in the US must not solely depend on international human rights law arguments in US courts; rather, a human rights strategy must include efforts close to home, which challenge US social and legal policies that permit the violation of economic and social human rights.
While, as noted above, American lawyers and other advocates have encountered strong resistance when they have defined their efforts as human rights work, several factors point to momentum for a health and human rights strategy in the US.
First, with the growing attention to the social determinants of health and the need for a global health and human rights framework, it would be illogical (and would completely bow to the idea of American exceptionalism) to exclude the poor health outcomes and entrenched socioeconomic and racial health disparities in the US from this dialogue. Second, the ACA, despite its expansions and reforms, will not offer a panacea to the health care crisis in the US. Recent studies document that income gradients in health have persisted despite universal health care coverage in the UK.48 This persistence illustrates the significance of social and economic factors in health and the need for a broader strategy to address health disparities.
Recent Supreme Court decisions acknowledging international human rights norms have raised hopes among human rights advocates that these arguments may be gaining traction in domestic courts.50 While the Supreme Court has been careful to assert that use of international human rights law in its decisions is not dispositive, and the cases where the court has cited international law principles have focused on civil rights, not social or economic rights, there is reason to be encouraged. The Court’s willingness to acknowledge arguments based on international law opens a small window for application of human rights law in the US. It is important to point out, however, that lawyers are turning to international human rights law for support, in part, because of the narrowing of civil rights and constitutional protections in the US over the past decade.51 Arguments based on human rights principles interpreting the US Constitution have rarely succeeded, and have never succeeded with regard to positive social and economic rights.
Additionally, according to some analysts, the growing body of international law interpreting the enforceability of social and economic rights, particularly recent holdings of the South African Constitutional Court, may provide useful guidance for US courts, including state courts.61 The South African court’s decisions in Republic of South Africa v. Grootboom (interpreting the state’s obligations with regard to the right to housing) and Minister of Health v. Treatment Action Campaign (interpreting the state’s responsibility to undertake reasonable measures to ensure access to health care) provide examples of the justiciability of constitutional protections for social and economic rights. While state courts have yet to impose an affirmative governmental duty to enforce a state constitutional provision asserting a right to health, the willingness of some courts to look abroad for guidance may offer some key opportunities.
Of course, a state-by-state approach to human rights represents a slow and incremental approach to a human rights advocacy agenda for the US. Nonetheless, as is evident from the marriage equality movement, state actions can serve to inspire change in other states; once one state takes a chance, other states often follow suit. A state constitutional or legislative strategy is only one aspect of a health and human rights strategy. Reframing the role of lawyers and legal aid programs in the US to move beyond single issue advocacy and to explicitly address the social determinants of health using law as remedy is also a critically important health and human rights approach.
Though critically important, the federal government is “just one out of the complexity of the nearly 88,000 governments in the United States federal system.”73 Local and state governments provide and administer social and economic goods and services. Many human rights abuses in the US occur due to daily indignities experienced by vulnerable people in their interactions with unresponsive systems. Often, these daily struggles follow from the failure to enforce laws intended to provide a safety net, safe and habitable housing, an adequate education, and protection from violence for poor and disenfranchised people. Federal, state, and local laws and regulations governing the distribution of basic needs may not be adequate, but access to justice in the US also plays a large role in what can be described as social and economic human rights issues.
One of the dangers of focusing a health and human rights strategy solely on international law or litigation is that of losing sight of the differential enforcement of existing laws and policies experienced in neighborhoods and communities every day. Failure to enforce housing standards, restraining orders, Individual Education Plans, workplace protections, as well as rights to public benefits and health care, are the “bread and butter” issues affecting the standard of living, opportunities, and health of vulnerable people.75 But clearly a strategy of case-by-case advocacy is also insufficient as a health and human rights agenda.76 The ultimate goal is systems accountability and change. This will only come with lawyers and health care providers partnering with and empowering communities to enforce and articulate their rights as human rights.
While Maru is speaking to the international human rights context, his argument is equally applicable to the US. Human rights advocacy depends on a range of strategies, including community legal education, fact-finding, documentation, and media campaigns, as well as litigation and legislative advocacy to promote more sustainable systems changes.78 As some legal aid programs move toward a more holistic, community-lawyering approach, the time is ripe for shifting focus to legal empowerment based on human rights advocacy tactics.79 But what has also been missing from much legal aid work in the US is “social accountability practitioners’ use of aggregate data as a catalyst for community action.”80 Public health law research represents an important example of social accountability through methodologies that collect data about the health effects of particular laws and policies. The goal of this research is to effectively connect data to community-based advocacy strategies through partnerships between lawyers and public health practitioners. Linking these efforts to community mobilization and advocacy efforts will be a critical next step for this approach.
A systemic health and human rights strategy should be built upon interdisciplinary partnerships among health care providers, public health practitioners, lawyers, and community organizers. It should be founded on three principles: bearing witness to human rights violations within the community context; tracking systemic failures through data collection and monitoring; and broad-based legal strategies which include both individual and policy advocacy in a given community. This type of partnership is explored below.
Because health care providers bear witness daily to what might be defined as human rights abuses in the US—homelessness, childhood hunger, the failure of the government to protect victims from domestic violence—they are indispensable in articulating how these violations impact the right to health. “Health workers have long acknowledged the societal roots of health status; the human rights linkage may help professionals engage in specific and concrete ways with the full range of those working to promote and protect human rights and dignity in each society.”81 Health care providers concerned with human rights often experience enormous frustration in their own inability to remedy their patients’ poor social conditions. Health care workers who practice in low-income communities often see an unrelenting flood of patients who go without basic services. Enforcement of legal rights is beyond the scope of their practice; to advocate effectively for their patients’ basic needs, therefore, they need to partner with community and legal advocates. Nonetheless, their voices are critical in documenting human rights violations and advocating for policies that secure basic human needs.
Both quantitative and qualitative studies that monitor population health outcomes and systems delivery (within the health care sector and outside of it) are needed to carry out a health and human rights strategy that targets social determinants. Health care providers’ voices are critical to data collection.
As Maru writes above, lawyers are trained to “squeeze justice out of dysfunctional systems.” Working in partnership with health care providers and public health practitioners, they can effectively build an arsenal of evidence to challenge the systems which deny basic human rights. In partnership with health care providers, they can use a range of advocacy strategies on behalf of individual clients who are denied justice through failure to enforce their legal rights. They can work directly with health care providers to document abuses and advocate for systems changes. With the help of public health practitioners and health care providers, lawyers can collect and use data to document systemic failures.
Finally, lawyers, health care providers, and public health practitioners can work together with affected communities to mobilize advocacy efforts drawing on principles of human rights and dignity that are often lacking from single-issue campaigns.
The medical-legal partnership (MLP) movement in the US exemplifies a community-based health and human rights strategy that implements a legal advocacy and social accountability approach by connecting lawyers, health care providers, and public health practitioners. The MLP model, first established in a safety-net hospital pediatrics department in 1993, now exists in over 500 legal and medical institutions in the US. The model is also being adopted in both Australia and Canada.
MLP reframes traditional legal services for low-income clients to specifically address the legal needs that implicate social determinants of health. Table 2 provides examples of legal needs that affect health. By defining legal rights based on access to basic human needs—income/insurance, housing and utilities, education and employment, legal status, and personal and family stability—MLP is a human rights approach to health.
In “From Principle to Practice: Moving from Human Rights to Legal Rights to Ensure Child Health,” MLP pioneers Barry Zuckerman, Ellen Lawton, and Samantha Morton argue that legal advocacy focused on social determinants is critical to a health and human rights approach: “[A]s we continue to push for rights-based laws around the world, we also encourage an active strategy of promoting enforcement of existing laws….”84 Placing lawyers in community safety-net health care institutions in partnership with health care providers can result in early detection of rights violations. Hence, MLP is both preventive law and preventive medicine. It explicitly moves the enforcement of legal rights affecting health upstream by screening patients for social needs, thus identifying potential legal action before the patient/client is in crisis.
Importantly, MLP also extends far beyond enforcement of individual legal rights. In addition to reframing legal services to address social determinants, MLP transforms health care practice by training frontline health care providers to incorporate social and legal needs screening into their practice and to partner with lawyers to remedy these injustices. MLPs also create institutional structures which enable the tracking of rights violations and systemic failures affecting patient health outcomes in a given community. MLPs have successfully utilized data mapping to link poor community health outcomes with rights violations, thus incorporating public health strategies for addressing the social determinants of health.
A recent study by Beck and colleagues exemplifies how MLPs identify rights violations and lead to improved living conditions for a low-income community. 85 An initial MLP case involved a family with two children served by the Pediatric Primary Care Center (PPCC) at Cincinnati Children’s Hospital Medical Center. Both children had been diagnosed with asthma and one child was diagnosed with an elevated lead level. The family was referred to the MLP lawyers “after reporting pest infestation, peeling paint and water leakages during a visit for well-child care.” As additional housing conditions cases were referred, the MLP team identified a pattern of substandard housing conditions for a cluster of children living in units in six Cincinnati building complexes owned by one firm.
While the US does not have a strong track record of applying international human rights principles within its own borders, particularly those that promote social and economic rights, recent developments—passage of the ACA, acknowledgment of international human rights laws by state and federal courts, and legislative achievements like that in Vermont explicitly defining health care as a human right—offer some hope that a human rights framework can advance a broader health and human rights movement. Recent studies documenting the declining health status of Americans as compared to other countries and the growing body of research demonstrating the significant role that social determinants play in poor health outcomes suggests that a broader health and human rights agenda is warranted.
In addition to promoting equitable access to health insurance and health care, a health and human rights agenda must include measures for combatting harmful social determinants and promoting environmental, economic, and social conditions beneficial to health. This type of advocacy necessarily evokes a discussion of the role of social and economic rights in health, such as individual and family economic stability, safe and affordable housing, equal access to educational opportunity, and freedom from domestic and community violence.
While advocates should continue to promote broad human rights principles at the state and federal levels in furtherance of better health outcomes, enormous strides can be made close to home by partnerships among health care providers, public health professionals, and lawyers to identify rights violations, hold officials and systems accountable, and advocate for systems and policy change. To be an effective human rights strategy, however, advocates must engage and mobilize affected individuals and communities to give voice to the indignities and rights violations that occur every day across the US and to challenge the social conditions which harm their health.
The author wishes to thank Jeffrey Sheehan and Joscelyne Kravitz for their assistance with research for this paper. I also wish to thank Joel Teitelbaum and Martha Davis for their helpful comments on early drafts.
Elizabeth Tobin Tyler, JD, MA, is Clinical Assistant Professor of Family Medicine at the Warren Alpert Medical School of Brown University and Clinical Assistant Professor of Health Services, Policy and Practice at the Brown University School of Public Health in Providence, Rhode Island, USA.
Please address correspondence to Elizabeth Tobin Tyler, the Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, Rhode Island, 02903, USA, email: Elizabeth_Tobin-Tyler@brown.edu.
1. J. Mann, “Health and human rights: Protecting human rights is essential for promoting health,” British Medical Journal 312 (1996), p. 924.
2. The World Health Organization Commission on Social Determinants of Health (CSDH) defined social determinants as “[t]he complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world.” CSDH, “Closing the gap in a generation: Health equity through action on the social determinants of health,” CSDH final report (Geneva: WHO, 2008).
3. See P. Braveman, S. Gruskin, “Policy and practice: Poverty, equity, human rights, and health,” Bulletin of the World Health Organization 8/7 (2003), pp. 539–542; P. Braveman, “Social conditions, health equity, and human rights,” Health and Human Rights: An International Journal 12/2 (2010), p. 10. Available at http://www.hhrjournal.org/2013/08/26/social-conditions-health-equity-and-human-rights.
4. US Institute of Medicine of the National Academies, U.S. health in international perspective: Shorter lives, poorer health (Washington, DC: Institute of Medicine, 2013), pp. 1–4; See also, S. Bezruchka, “American experiences,” in D. Raphael (ed), Tackling health inequalities: Lessons from international experiences (Toronto: Canadian Scholars Press, 2012), pp. 33–62.
5. C. J. Murray, J. Abraham, M. K. Ali, et al., “The state of US health, 1990–2010: Burden of diseases, injuries, and risk factors,” Journal of the American Medical Association 310/6 (2013), p. 598.
7. See M. Marmot, “Social determinants of health inequalities,” Lancet 365 (2005), pp. 1099–1104; J. Banks, M. Marmot, Z. Oldfield, et al., “Disease and disadvantage in the United States and in England,” Journal of the American Medical Association 295/17 (2006), pp. 2037–2045.
8. P. Aka, “Analyzing U.S. commitment to socioeconomic human rights,” Akron Law Review 39 (2006), p. 423.
9. Universal Declaration of Human Rights (UDHR), G.A. Res. 217A (III) (1948), Art. 25. Available at http://www.un.org/en/documents/udhr/index.shtml.
10. See B. Meier, “Global health governance and the contentious politics of human rights: Mainstreaming the right to health for public health advancement,” Stanford Journal of International Law 46 (2010), pp. 4–5.
11. Braveman (2010, see note 3), p. 10.
12. G. MacNaughton, “The human right to health care in the United States: Health care for all,” Clearinghouse Review: Journal of Poverty Law and Policy 45/5–6 (2011), p. 210; G. Backman, P. Hunt, R. Khosla, et al., “Health systems and the right to health: An assessment of 194 countries,” Right to Health 372 (2008), p. 2048. Available at http://www.who.int/medicines/areas/human_rights/Health_System_HR_194_countries.pdf.
13. J. Ruger, Health and social justice (Oxford: Oxford University Press, 2010), p. 119.
14. See generally, Braveman (see note 3).
15. S. Gruskin, E. Mills, and D. Tarantola, “History, principles, and practice of health and human rights,” Lancet 370 (2007), p. 450. Available at http://globalhealth.usc.edu/en/Research And Services/Pages/~/media/6B72A0A151174FB1B9E7D4A836A0B000.ashx.
16. World Health Organization, A conceptual framework for action on the social determinants of health (Geneva: WHO, 2010).
17. S. Burris, “Introduction: Merging law, human rights, and social epidemiology,” Journal of Law, Medicine, and Ethics 30/4 (2002), p. 501.
18. L. Gostin, “Meeting basic survival needs of the world’s least healthy people: Toward a framework convention on global health,” Georgetown Law Journal 96 (2008), p. 382.
19. The term “American exceptionalism” has taken on multiple meanings in political and social discourse. Michael Ignatieff describes three elements of exceptionalism that are helpful to the discussion here: “First, the United States signs on to international human rights and humanitarian law conventions and treaties and then exempts itself from their provisions by explicit reservation, nonratification, or noncompliance. Second, the United States maintains double standards: judging itself and its friends by more permissive criteria than it does its enemies. Third, the United States denies jurisdiction to human rights law within its own domestic law, insisting on the self-contained authority of its own domestic rights tradition.” M. Ignatieff, American exceptionalism and human rights (Princeton, NJ: Princeton University Press, 2005), p. 3.
20. W. Henderson, “Advancing human rights and justice for all,” Clearinghouse Review: Journal of Poverty Law and Policy, 45/5–6 (2011), p. 254; H. Lewis, “‘New’ human rights? U.S. ambivalence toward the international economic and social rights framework,” in C. Soohoo, C. Albisa, M. F. Davis (eds), Bringing human rights home: A history of human rights in the United States (Westport, CT: Praeger, 2008), vol. 1, pp. 115–119.
21. P. Alston, “Putting economic, social, and cultural rights back on the agenda of the United States,” in W. Schulz (ed), The future of human rights: U.S. policy for a new era (Philadelphia: University of Pennsylvania Press, 2008), p. 129, citing remarks by Public Delegate Marc Leland, ‘‘Item 10: Economic, social and cultural rights,’’ at the 60th Session of the United Nations Commission on Human Rights, March 29, 2004.
22. See ibid., pp. 128–132.
23. Lewis (see note 20), p. 119.
24. E. Tars and D. Bhattari, “Opening the door to the human right to housing: The universal periodic review and strategic federal advocacy for a rights-based approach to housing,” Clearinghouse Review: Journal of Poverty Law and Policy 45/5–6 (2011), p. 202.
25. C. Lopez, D. Finger, M. Jain, et al., “Redefining human rights lawyering through the lens of critical theory: Lessons for pedagogy and practice,” Georgetown Journal of Poverty Law and Policy 18 (2011), p. 395.
26. Tars (see note 24), pp. 204–205.
27. A. Yamin, “The right to health under international law and its relevance to the United States,” American Journal of Public Health 95/7 (2005), p. 1157.
28. D. Orentlicher, “Rights to health care in the US: Inherently unstable,” American Journal of Law and Medicine 38/326 (2012), pp. 326–347.
30. See generally, National Federation of Independent Business v. Sebelius (2012) 132 S.Ct. 2566.
31. Congressional Budget Office, Estimates for the insurance coverage provisions of the Affordable Care Act updated for the recent Supreme Court decision (July 24, 2012).
32. MacNaugton (see note 12), p. 214.
33. The website of the Robert Wood Johnson Foundation has many such examples; see http:// www.rwjf.org.
34. S. Burris, “From health care law to the social determinants of health: A public health law research perspective,” University of Pennsylvania Law Review 159 (2011), p. 1653; See generally, L. Berkman, I. Kawachi, (eds), Social epidemiology (New York: Oxford University Press, 2000); See also, N. Krieger, Epidemiology and the people’s health: Theory and context (Oxford: Oxford University Press, 2011).
35. Braveman (2010, see note 3), p. 8.
36. Burris (see note 34).
38. See generally, R. Rector and R. Sheffield, “Understanding poverty in the United States: Surprising facts about America’s poor,” Executive summary, Backgrounder 2607 on poverty and inequality (Washington, DC: Heritage Foundation, September 13, 2011). Available at http://www.heritage.org/research/reports/2011/09/understanding-poverty-in-the-united-states-surprising-facts-about-americas-poor.
39. See generally, J. Iceland, Poverty in America: A handbook (Berkeley, CA: University of California Press, 2006).
41. Lopez et al. (see note 25), p. 358.
42. H. Shaefer and K. Edin, “Extreme poverty in the United States, 1996 to 2011,” Policy Brief 28 (Ann Arbor, MI: National Poverty Center, February 2012), pp. 2, 4.
43. See generally, L. Siegel, K. Stewart, and N. Ferrell, Human rights in the U.S.: Opinion research with advocates, journalists, and the general public (Washington, DC: Belden Russonello and Stewart for The Opportunity Agenda, 2007). Available at http://opportunityagenda.org/files/field_file/Human%20Rights%20Report%20-%202007%20public%20opinion.pdf.
45. Ford Foundation, Close to home: Case studies of humanitarian rights work in the United States (New York: Ford Foundation, 2004), p. 16.
47. See generally, Lopez et al. (see note 25).
48. M. Martinson, “Income inequality in health at all ages: A comparison of the United States and England,” American Journal of Public Health 102/11 (2012), pp. 2049–2056.
49. For a description of the concepts of legal empowerment and social accountability, see generally, V. Maru, “Allies unknown: Social accountability and legal empowerment,” Health and Human Rights: An International Journal, 12/1 (2010), pp. 83-93.
50. See Graham v. Florida (2010) 130 U.S. 2011, 2033-2034 (overturning the sentencing to life without parole of a subset of juvenile offenders); Roper v. Simmons (2005), 543 U.S. 551, 576–578 (rejecting the juvenile death penalty); Lawrence v. Texas (2003), 539 U.S. 558, 572–573 (overturning state criminalization of consensual homosexual acts).
51. Lopez et al. (see note 25), p. 345.
52. See ibid., p. 333.
53. See A. Redlich, “Who will litigate constitutional issues for the poor,” Hastings Constitutional Law Quarterly 19 (1992).
54. C. Soohoo and J. Goldberg, “The full realization of our rights: Right to health in state constitutions,” Case Western Reserve Law Review 60 (2010), p. 1001.
55. For a list of state court opinions that cite international human rights law, see Siegel et al. (see note 41), p. 5.
56. M. Davis, “The spirit of our times: State constitutions and international human rights,” New York University Review of Law and Social Change 30/359 (2006), pp. 4–7.
57. Soohoo, et al. (see note 54), p. 1036.
59. N.Y. Const. art. 17, sec. 3. Available at http://www.dos.ny.gov/info/constitution.htm.
60. N.Y. Const. art. 17, sec 1. Available at http://www.dos.ny.gov/info/constitution.htm. For an excellent discussion of the potential for using these provisions of the New York Constitution to challenge failure by the state to enforce reproductive health rights, see Davis (see note 56).
61. Soohoo, et al. (see note 54), pp. 1001–1002.
Every person is entitled to comprehensive, quality healthcare.
Systemic barriers must not prevent people from accessing necessary healthcare.
The cost of financing the healthcare system must be shared fairly.
The healthcare system must be transparent in design, efficient in operation and accountable to the people it serves.
As a human right, a healthcare system that satisfies these principles is the responsibility of government to ensure.
Vermont Workers’ Center, Building a grassroots movement for the human right to healthcare. Available at http://www.workerscenter.org/hchrhistory.
63. MacNaughton (see note 12).
64. A. Rudiger, “Reviving progressive activism: how a human rights movement won the country’s first universal health care law,” New Politics Online Feature (New York: New Politics, November 6, 2011). Available at http://newpol.org/content/reviving-progressive-activism-how-human-rights-movement-won-country’s-first-universal-health.
65. Ford Foundation (see note 45), pg. 9.
66. See, for example, J. Sabonis, “Using a human rights framework at the Maryland legal aid bureau,” Clearinghouse Review: Journal of Poverty Law and Policy 44/9–10 (2011), pp. 450–458.
67. Maru (see note 49), p. 89.
68. Lopez et al. (see note 25), p. 361.
69. Sabonis (see note 66).
70. See A. Houseman, “Restrictions by funders and the ethical practice of law,” Fordham Law Review 67 (1999), pp. 218–240; R. Diller, E. Savner, A call to end federal restrictions on legal aid for the poor (New York: Brennan Center for Justice at New York University School of Law, 2009), pp. 9–10.
71. Lopez et al. (see note 25), p. 352.
72. Ford Foundation, (see note 45), p. 11.
73. Aka (see note 8), pp. 439–440.
74. Maru (see note 49), p. 88.
75. Lopez et al. (see note 25), p. 347, citing M. Davis, “The pendulum swings back: Poverty law in the old and new curriculum,” Fordham Urban Law Journal 1391 (2007), pp. 1410–1411.
76. Legal aid programs that prioritize human rights, connect individual advocacy with systemic reform, as J. Peter Sabonis describes: “Beginning with the premise that clients, because of their humanity, are entitled to civil and economic rights, we hoped to trigger both systemic and individual advocacy that was characteristic of our early history: aggressive, creative, client-centered, and movement-oriented.” Sabonis (see note 66), p. 452.
77. Maru (see note 49), p. 83.
78. C. Soohoo, C. Albisa, M. F. Davis (eds), Bringing human rights home: A history of human rights in the United States (Westport, CT: Praeger, 2008), vol. 2, p. 97.
79. Lopez et al. (see note 25), p. 350.
80. Maru (see note 49), p. 84; see also, Sabonis (see note 66), p. 454, describing how, in reframing its work as human rights work, Maryland Legal Aid Bureau used data about housing supply and demand to demonstrate a lack of government accountability.
81. Burris (see note 17), p. 499.
82. Maru (see note 49), p. 88.
83. E. Lawton, M. Sandel, S. Morton, et al., “Medical-legal partnership: A new standard of care for vulnerable populations,” in E. Tobin Tyler, E. Lawton, K. Conroy, et al. (eds), Poverty, health and law: Readings and cases for medical-legal partnership (Durham, NC: Carolina Academic Press, 2011), p. 74.
84. B. Zuckerman, E. Lawton, and S. Morton, “From principle to practice: Moving from human rights to legal rights to ensure child health,” Archives of Disease in Childhood 9/2 (2007), pp.100–101.
85. A. Beck, M. D. Klein, J. K. Klein, et al., “Identifying and treating substandard housing cluster using a medical-legal partnership,” Pediatrics 130/5 (2012), pp. 831–838.
87. See generally, Beck et al. (see note 85).
89. Lawton et al. (see note 83), p. 76.

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