TY - JOUR AU - Tanyag, Maria AB - As the feminist adage goes, ‘the personal is political’. In the same vein, Alicia Ely Yamin opens her book with two stirring personal anecdotes—her grandmother’s protracted labour that left forceps scars on her mother’s forehead, and her own miscarriage. These stories foreground her life devoted to advancing sexual and reproductive health and rights (SRHR) as an academic and activist. The book itself, according to Yamin, was birthed in anger and indignation over the countless preventable deaths of women and girls especially from the Global South (p xii). In Power, Suffering and the Struggle for Dignity, the many personal encounters Yamin shares as part of a long career in health and human rights attest to the global inequalities that significantly constrain individual life chances. Indeed, as she points out, ‘statistics are, of course, necessary to illustrate trends and probabilities, and to place individual stories in context. However, by sharing stories of real people and places throughout this book … the dilemmas and issues faced in the field will feel more immediate for many readers’ (p 10). Health, which is fundamental to human dignity, is not only shaped by biological and behavioural factors, but also by global and national distributions of privilege, obligations, and resources within society. The human stories interspersed within Yamin’s analysis of key issues such as gender, neo-liberal governance, and health systems, help to substantiate this important point. This book, therefore, carries a strong personal tone through which she uniquely offers an empathetic investigation of how and why a human rights-based approach (HRBA) to health matters. It will be of interest to readers from various disciplines and professions, especially health practitioners who want to learn about the intersecting inequalities that undermine the capacity of many individuals and communities to live lives of dignity, health, and well-being. Importantly, its concrete discussions will benefit those who are working to bridge the gap between theory and practice on the right to health. Yamin addresses both how an HRBA matters, and why this approach matters, in two main parts of her book. In the first part, consisting of four chapters, she discusses the ‘starting points’ to a HRBA to health, and demonstrates how the recognition of equal dignity for all human beings may radically transform institutions, policies, and deeply embedded cultural norms.1 Such an approach, Yamin argues, progressively reveals instances of suffering that ultimately constitute the denial of the human worth for particularly vulnerable groups, such as those with disabilities or those who belong to indigenous groups. Using the example of torture and cruel, inhumane and degrading treatment (CIDT), in Chapter 1 she destabilises the rigid distinctions between ‘public’ sphere (for example, state-perpetrated, highly visible, and politically motivated) and ‘private’ sphere violence (as perpetrated within families or communities, often invisible, and gradual harms).2 These forms of violence interrelate and in some cases overlap. They fundamentally manifest as incursions on bodily autonomy and integrity perpetrated by state agents including public health personnel, as well as internalised by individuals themselves. Yamin explores the ongoing implications of this public-private divide for the right to health in the remaining chapters of this part.3 She notes that in practice, civil and political rights take precedence over economic, social, and cultural rights, instead of being conceived as interdependent and indivisible. And yet, as she effectively demonstrates, ‘health is a pre-condition to exercising basic self-government’ (p 57). The full capacity of individuals to exercise their civil and political rights is contingent on eliminating various structural and symbolic barriers to individual agency. These health barriers are typically gendered in that they disproportionately undermine the political and economic participation of women and girls. Focusing on SRHR, Yamin rightly claims that: No global health issue may more acutely capture the culmination of conspiring inequities within, as well as between, countries than maternal mortality. And it is likely that no global health issue more graphically illustrates the role of health systems, their potential both for promoting greater democracy and for reinforcing exclusion and discrimination along gender, class, racial, and ethnic lines, which further marginalizes certain groups (pp 232–33). A key contribution of this book, therefore, is in revealing the vested interests that inform, under certain circumstances, a deliberate neglect of the right to health by states, especially those from the Global North. In the second part of the book, Yamin delves further into the strategies that can be deployed to translate HRBA in practice.4 This includes challenging top-down decision-making processes that do not meaningfully contribute to social transformations. She substantiates her case in Chapters 5–8, using examples as diverse as formalistic legal tools applied by courts to paternalistic aid delivery.5 A key theme in this part is in reframing health from a matter of charity to one of accountability. According to Yamin, the distinct contribution of a HRBA to health is in legitimising accountability measures when duty-bearers fail to meet their obligations (p 133). Importantly, accountability is not about ‘naming and shaming’ individual perpetrators of violence and abuse, who are usually the front-line health workers. Rather, HRBA to health suggests equal attention to systemic failures that incorporate a range of actors at different levels from community service providers to parliamentarians and policymakers, as well as development and aid organisations. Yamin makes a compelling case for a HRBA to health, but she leaves some important questions unasked. Notably, her critical, theoretical as well as practical discussions give little attention to current debates on religious fundamentalisms and multiple crises to understand fully the critical juncture where global and national decision-making over health and rights are increasingly situated. First, despite the special focus on SRHR in the book, her analysis elides the highly contentious nature of SRHR, as well as the great diversity by which women’s right groups have made pragmatic bargains even using religious discourses in order to promote key legislations on sexual and reproductive freedoms. For example, she does not unpack how, unlike other components of health, SRHR has had tremendous backlash against and threats of backsliding globally.6 Hence, even as she acknowledges the politics around the right to health, Yamin’s analysis seems to imply a linear or incremental progress to human rights when, historically and at present, the status of SRHR is far from accepted and has been fraught with contestations and rollbacks despite existing international frameworks, due to the policy influence of religious fundamentalist forces.7 Secondly, Yamin could have taken the issue of accountability further by situating this crucial point within the increasingly prevalent occurrence of global health pandemics which can intersect with other human security crises such as economic recessions, armed conflicts, and environmental disasters. By taking into account the causal role of broader threats to security, she could have problematised new ways by which health is being securitised and the implications this has for the application of human rights frameworks and effective health service delivery in particular.8 This book would then be even more useful to health practitioners operating within humanitarian, conflict or emergency spaces. Lastly, Yamin’s analysis adeptly navigates what she calls the ‘sophistry’ that underlies the limited application of human rights norms that do not lead to social justice (pp 10, 235). However, the problem, as Fiona Robinson argues, is that ‘the dominant conceptions of human rights and human security are widely based on an ontology of atomistic individualism that privileges the norms of self-sufficiency and neglects the relational nature of human existence and the fundamental nature of the human need to give and receive care’.9 By deploying the same discourse or language of human rights, Yamin’s analysis falls within this trap even as her own rich accounts of interactions in the field highlight the web of human relationships that define health outcomes. According to Robinson, ‘feelings of security and insecurity are not experienced by individuals as isolated agents, but rather as beings-in-relation with others – family members and communities’.10 That is, the multi-layered and interconnected relations of care and vulnerability, manifesting through health outcomes, are not adequately captured by a human rights approach, which obscures the mutual dependence among humans, communities, and states at large, especially during times of crisis. On the contrary, by starting with practices of care, eliminating health inequalities as forms of human insecurities shaped by gender, class, religion, and race/ethnicity is folded within a broader social justice project. Such an approach begins by asking, what are the conditions needed for sustainable and mutual human flourishing? How can we build caring societies including health systems that are not depletive, exploitative, or self-sacrificing especially for marginalised women and girls? This same normative goal is, in fact, shared by Yamin as she concludes with relentless optimism in the face of tremendous suffering. She emphasises throughout her book that ‘applying a meaningfully empowering human rights framework to health calls on us to create difference in the world, to make a different world, and to make ourselves different in the process’ (p 249). Readers of this book will surely be moved by Yamin’s captivating stories but also, hopefully as I was, will be encouraged to ask more questions about the relevance of human rights frameworks to health. Footnotes 1 ‘Part I. Starting Points’. 2 ‘Dignity and Suffering: Why Human Rights Matter’. 3 ‘The Powerlessness of Extreme Poverty: Human Rights and Social Justice’, ch 2; ‘Redefining Health: Challenging Power Relations’, ch 3; ‘Health Systems as “Core Social Institutions”’, ch 4. 4 ‘Part II. Applying Human Rights Frameworks to Health’. 5 ‘Beyond Charity: The Central Importance of Accountability’, ch 5; ‘Power and Participation’, ch 6; ‘Shades of Dignity: Equality and Nondiscrimination’, ch 7; ‘Our Place in the World: Obligation Beyond Borders’, ch 8. 6 See eg L Chappell, ‘Contesting Women’s Rights: Charting the Emergence of a Transnational Conservative Counter-network’ (2006) 20 Global Society 491. 7 Association for Women’s Rights in Development (AWID), The Devil is in the Details: At the Nexus of Development, Women’s Rights, and Religious Fundamentalisms (2016) accessed 7 January 2017. 8 See eg SE Davies and S Rushton, ‘Public Health Emergencies: A New Peacekeeping Mission? Insights from Unmil’s Role in the Liberia Ebola Outbreak’ (2016) 37 Third World Quarterly 419. 9 F Robinson, ‘Feminist Care Ethics and Everyday Insecurities’ in J Nyman and A Burke (eds), Ethical Security Studies: A New Research Agenda (Routledge 2016), online resource, 125. 10 ibid 129. © The Author 2017. Published by Oxford University Press; all rights reserved. For Permissions, please email: journals.permissions@oup.com TI - Alicia Ely Yamin, Power, Suffering, and the Struggle for Dignity: Human Rights Frameworks for Health and Why They Matter JF - Medical Law Review DO - 10.1093/medlaw/fwx015 DA - 2017-04-01 UR - https://www.deepdyve.com/lp/oxford-university-press/alicia-ely-yamin-power-suffering-and-the-struggle-for-dignity-human-4ZWlxTU0Es SP - 352 EP - 355 VL - 25 IS - 2 DP - DeepDyve ER -