The Right To Health Fifty Years On - Still Sceptical?

Date: 14 December 1998
Author: The Hon Justice Michael Kirby AC CMG Justice of the High Court of Australia
Type: Speech
Subject: Human Rights
Event: Harvard University, School of Public Health, Francois-Xavier Bagnoud Centre for Health and Human Rights
Location: Boston, Massachusetts

The Hon Justice Michael Kirby AC CMG^*

JONATHAN MANN REMEMBERED

In his closing remarks to the Second International Conference on Health and Human Rights, Professor Jonathan Mann, as was his wont, threw down a gauntlet:

This is a lecture about Jonathan Mann - a Luther of public health - who translated theory about universal human rights into practical action. As befits an occasion that remembers the adoption, fifty years ago, of the Universal Declaration of Human Rights, it is also a lecture about where we have come from: the origins of the legal expression of the human right to health. In the field in which Jonathan Mann worked with such effect, HIV/AIDS, it is a lecture about the abiding lessons which he taught and their ongoing importance. In new fields of public health, which are revealing puzzling dilemmas, it asks the question whether real inroads have been made into the "widespread scepticism about health and human rights" which Jonathan Mann described a year ago.

I dedicate these remarks to the memory of this remarkable leader in the field of health and human rights who lost his life on 2 September 1998. Typically, he was on his way to the headquarters of the World Health Organisation (WHO) in Geneva, once again to address the link between health and human rights. He was killed with his second wife, Professor Mary Lou Clements-Mann, of the Johns Hopkins University School of Public Health. Their deaths, like those of all on board the flight, are a human loss to their families and friends. But in their cases they are a profound loss to public health and human rights in every land.

I first met Jonathan Mann in a series of international meetings at the end of the 1980s. The conferences were called to address the urgent ethical and legal implications of the HIV/AIDS epidemic. Soon afterwards, he secured my appointment to the WHO Global Commission on AIDS. I worked with him and with a remarkable collection of scientists (including Montagnier and Gallo), public health experts (including June Osborn) and ethicists. Typically, Jonathan Mann insisted that two members of the Commission, a man and a woman, should be acknowledged people living with HIV/AIDS.

We, who knew Jonathan Mann, soften our pain by recalling his many gifts: his high intelligence, his dynamism, his creativity, his imagination, his talent in answering fiendishly difficult, and loaded, questions alternatively in English or French. I always thought that, in his dedication to non-discriminatory strategies in the field of HIV/AIDS, and in his public commitment to the linkages of health and human rights, he drew, in equal strength, upon his American and his Jewish identification. American, because of this nation's commitment, from the start, to ideals of human rights, even when falling short in their attainment. Jewish, because of the special role which the Jewish people have played in interpreting the notion of God to individual human beings. And because of the suffering they underwent in living memory as a result of irrational discrimination which helped call forth the world's post-War commitment to universal human rights.

In happy mixture, these were the driving forces which carried Jonathan Mann to his work in Zaire, then as first director of the Global Programme on AIDS of WHO, in his function establishing the François-Xavier Bagnoud Center for Health and Human Rights at this great University, in his editorial leadership of the Journal of Health and Human Rights and in his courageous work, large and small, to translate human rights theory into reality. In Australia, we honour Jonathan Mann's work in the field of HIV/AIDS and human rights. I am hopeful that we will mark his contribution in permanent, tangible and lasting ways. Under successive governments, we have observed his enlightened instruction on tackling the HIV/AIDS epidemic. The reward has been that human lives have been saved. Loss and pain has been avoided. Since September 1998 there have been many memorial occasions to honour Jonathan Mann, his children, his first wife, Marie-Paule Bondat and family, the colleagues who mourn and the friends who are angry at such a premature and apparently pointless loss of a person young in years, with much promise still to come. His death is like a metaphor for HIV/AIDS itself. Although you have heard such words before, they provide the necessary text for my address. If we are to celebrate the first half century of the achievement of the Universal Declaration of Human Rights, it is not the paper or the words we memorialise. It is the commitment and the action of leaders such as Professor Jonathan Mann. By their conduct words become deeds. Aspirations become reality.

FIFTY YEARS ON

There is little point in searching for the origins of the global movement for human rights. We have it on the authority of Isaiah Berlin that the notion of human rights was absent from the legal conceptions of the Romans and the Greeks and missing from the Chinese and all other ancient civilisations, on the basis that you needed an idea of individualism and legalism to give substance to the concept of human rights. There is no value in exploring national claims to be the origin of the notion of the limited state - whether in England's Magna Carta of 1215, its Bill of Rights of 1689, the American Declaration of Independence in 1776 or the French Declaration of the Rights of Man and of the Citizen of 1789. Certainly, the last-mentioned was the first document of its kind to have referred to what we would now call social, economic and cultural rights: rights to education, work, property and social protection being reflected in earlier and in later drafts. But out of the successive English, French and American revolutions arose an international movement which is now unstoppable. It bears out Lord Acton's statement that, ultimately, the "single confused page" of the French Declaration was to have a more lasting impact than all of Napoleon's armies.

In the middle of the nineteenth century, the European powers, revolted by the excesses of war, began the slow and imperfect process of framing rules of war which would prohibit excess and oblige humane treatment of the wounded. Yet during the last century, and for much of this, the movement towards human rights was "spasmodic and unorganised".

It took the triple horrors of the Second World War, the Holocaust and the flash brighter than a thousands suns at Hiroshima to propel our species, and its leaders, into action. The story begins in January 1941 when President F D Roosevelt sketched his vision for the post-War world. It would be a world which guaranteed freedom of speech, of worship, from want and fear. For many Americans who supported these ideals, they were not goals for attainment in a distant millennium but quickly, as an insurance against repeated wars. Roosevelt's aspirations were adopted in August 1941 in the Atlantic Charter. Britain and the United States left them open to ratification by other nations. They make a point, sometimes overlooked, that the Western powers, and not simply the socialist countries, were committed to human welfare as an integral aspect of human rights.

In January 1942, the United Nations, being the Allies ranged against the Axis powers, included amongst their war objectives the preservation of human rights and justice in their own lands as well as in all lands. As the tide of the war turned, the meeting of the United States, the United Kingdom, the Soviet Union and China at Dunbarton Oaks in 1944 agreed to establish an international system for peace and security, one purpose of which would be the protection of human rights. At first it was expected that the Charter of the proposed new world body would itself include a Bill of Rights. However, that idea was abandoned by the United States in 1944. To the great regret of many closely involved in its drafting, the Charter omitted a statement of fundamental rights as a precondition to membership of the United Nations. But it included, as one of the purposes of the new body, the promotion and encouragement of respect for human rights and for fundamental freedoms for all without discrimination. Picking up amendments which, ironically, were proposed by General Smuts of South Africa, the Charter recognised specifically that international peace and security were inter-dependent with protection of human rights and economic progress.

At the San Francisco conference in 1945, President Truman promised that an international Bill of Rights would be drawn up. The General Assembly of the United Nations quickly established a Third Committee on Social, Human and Cultural Affairs and committed to it and, in 1946, to the Economic and Social Council (ECOSOC), the question of whether an international instrument should be adopted on that topic and, if so, in what terms. New impetus was given to the idea by the revelations, before the International War Crimes Tribunals, of the horrors which had been perpetrated by the defeated powers. Amongst the most gruesome evidence before these bodies was that of harmful and involuntary experimentation performed by doctors in the name of a distorted notion of public health.

In January 1947, the Commission on Human Rights, established by ECOSOC therefore undertook the preparation of a global human rights instrument as its principal task. Mrs Eleanor Roosevelt, widow of the late President, was elected chairman of the Committee. The bureau worked on drafts prepared by its officers and by the Government of the United Kingdom. Contemporaneous with these developments was the establishment by the United Nations in July 1946 of WHO, whose Charter came into force in April 1948. Yet for much of its life, WHO was to be relatively isolated from the world movement of human rights law which was going on around it.

It was in September 1947 that Mrs Roosevelt submitted the draft of the Universal Declaration to the General Assembly. That body referred the draft to the Third Committee which undertook 81 meetings, considering 168 amendments before the final text was submitted. It is interesting to observe the debates which surrounded the content of the Universal Declaration. The Chinese delegate declared that the task of the drafters was to reconcile Confucius with Thomas Aquinas. Already the "Cold War" was poisoning the relations of the victorious Allies. The Soviet delegate, Andre Vyshinsky, declared that civil rights were fully practised in the Soviet Union and what was needed was the inclusion of socialist proposals - to provide against discrimination; to permit rebellion against autocracy; to ensure self-determination of colonial peoples; to uphold workers' rights to engage in street demonstrations; and to limit the enjoyment of civil rights where necessary to prevent the re-emergence of Fascism.

It was no easy task to marry the objectives of the Western countries, including my own, to ensure the universal protection of civil rights with the objectives of the socialist block, and other countries, to reflect concerns about social and economic rights. The world was fortunate, fifty years ago, that the Chairman of the Committee was Mrs Roosevelt. She could draw upon her husband's programme of social rights in the United Sates to find empathy with the notion that such matters should find their way into the Declaration. Many saw it, perhaps she did herself, as a way of achieving on the global stage FDR's ideals about social equity in the United States.

The proposal that reference should be made in the Universal Declaration to a right to health was put to the Drafting Committee by Mr Amado of Panama. As recorded, this was the way in which he said the matter should be dealt with:

Gradually the idea of including such notions gained acceptance. So it was that on 10 December 1948, the Universal Declaration of Human Rights was adopted by the General Assembly. In the chair was Dr H V Evatt, President of the Assembly and chief delegate for Australia. He was a past Justice of the High Court of Australia who had left judicial office to serve as Attorney-General and Foreign Minister in the wartime Government of Australia. His niece, Justice Elizabeth Evatt, currently serves as a member of the United Nations Human Rights Committee.

The Universal Declaration was accepted by the affirmative vote of 48 nations. No votes were cast against. Eight nations abstained, being the Soviet Block, South Africa and Saudi Arabia. There were two absentees. As finally adopted, the text of the Universal Declaration dealing with health is found in Article 25. It reads:

The struggle to express international human rights norms, including in relation to health, did not conclude with the hortatory words of the Universal Declaration. It was followed by regional conventions in Europe, the Americas and Africa, establishing, as each one of them does, machinery for individual complaints and for the determination of allegations that the signatory nations have not complied with their duties. In due course, the aspiration of an International Bill of Rights was taken further by the adoption of the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights in December 1966. These Covenants moved beyond the expression of ideals and principles into legal obligations which are assumed by the States that become parties to them.

The treaty provision in relation to the right to health is found in Article 12 of the Economic, Social and Cultural Rights Covenant. In addition to specific steps to which the states parties commit themselves, that article contains a general statement:

Covenant

At first, this requirement appeared to be a statement of hope rather than of legal obligation. However, in 1987 the Committee on Economic, Social and Cultural Rights was established. It was to receive reports upon state compliance with their obligations under the Covenant. That Committee is itself obliged to report to ECOSOC on the efforts taken to realise the rights recognised in the Covenant. In addition to receiving and commenting on national reports, including in relation to national policies of public health, the Committee undertakes other consultations designed to identify, at the level of the United Nations, the interaction between fundamental human rights and national policies of public health. At one of the meetings organised by the Committee a statement, described as "rather provocative", is attributed to a certain Mr Jonathan Mann of Harvard University to the effect that "males pose a threat to public health". As reported, the statement was elaborated by reference to the vulnerability of women to sexually transmitted diseases, to sexual abuse, physical maltreatment, religious rites (eg female circumcision) and deep-rooted socio-economic repression which, Mr Mann asserted, had "detrimental effects on the health of women".

Since the celebration a decade ago of the 40th anniversary of the Universal Declaration, the debate about its impact and its importance has been refocussed. The collapse of the Soviet Union has brought within the potential scrutiny of human rights courts and committees a large number of nation states previously excluded. In Vienna, the World Conference on Human Rights in 1993 emphasised (contrary to the suggestions of some delegates) the universal character of human rights and that there was no exception for "Asian values" or for cultural derogations in Africa, Latin America or elsewhere. Those who have studied the record of the drafting of the Universal Declaration now call to notice the large part played in its formulation by delegates from countries in what is now known as the Third World.

Asian leaders rightly insist on the inter-dependence of economic, social and cultural rights and civil and political rights. Many Asian commentators point out, fairly, that perceptions of the precise content of human rights change over time. The notion of universal political suffrage did not extend in Western countries to women or to some ethnic minorities until quite recently. The recognition of the rights of homosexual and bisexual citizens to be removed from the danger of criminal prosecution for consenting adult sexual conduct is also relatively new. In this sense, the voyage of discovery which the Universal Declaration initiated is far from complete. With each new decade, new insights are gained and shared. This is where teachers and leaders, such as Jonathan Mann, are so important. They see the truth before others do. And then they want to share their insights with the rest of us.

UNIVERSAL DECLARATION: REPORT CARD

The last observations invite, fifty years on, a report card on the general achievements of the Universal Declaration. First, let me acknowledge some weaknesses:

Declaration

Universal Declaration,

Charter

Universal Declaration.

Declaration

Declaration.

Economic, Social and Cultural Covenant.

Declaration

Universal Declaration,

Conceding all the failings and weaknesses of the Universal Declaration, as viewed with the perspective of half a century, it is still fitting to celebrate its anniversary. It remains a lodestar for humanity after a particularly dark age:

So what are its abiding strengths?

Declaration

Magna Carta

Declaration

Universal Declaration

Universal Declaration,

Universal Declaration

Covenants

Universal Declaration,

Universal Declaration.

Universal Declaration

HEALTH, HUMAN RIGHTS AND HIV/AIDS

The particular human right to health is an especially important one. In my work for the United Nations in Cambodia, I found the high store placed upon this right, and on the right to work, the right to education, the right to the protection of culture and other rights not traditionally regarded as justiciable and significant to most Western lawyers. There is no mention of health and medical care in Magna Carta. It cannot be found in the American Declaration of Independence, the French Declaration or any of the other earlier efforts to expound the rights that inhere in humanity because of its human qualities. The Universal Declaration of Human Rights, was a critical point of departure in the development of notions of human rights, indeed of what human rights are. It is difficult, therefore, to overstate the importance of that departure from conventional wisdom and legal orthodoxy. But to be converted into action it needed change agents.

It is an old aphorism that human rights matter most when they are hardest to accord. So it is with the right to health. In the past, human rights when they impinged on public health, were usually discussed, as a legal concept, in terms of the right of public health authorities, acting for the state, to depart from the human rights of individuals in the name of the public health of the whole community. Terrible abuses have occurred in the observance of individual human rights in the name of the protection of public health. Only in recent times has it been appreciated that such derogations are subject to at least three controlling requirements at least (1) that they are provided and controlled by law; (2) that such law should be compatible with the requirements of a democratic society; and (3) that, to the fullest extent possible, it should accord respect to the human rights of the individuals affected.

When the HIV/AIDS epidemic came along, it would have been easy for the international community, and nation states, to have slipped into the traditional mode of responding to the epidemic, to the great disadvantage for the human rights of those infected. In many countries, to greater or lesser degree, that has happened. In the early days of the epidemic, I coined the phrase "HIL" - highly inefficient laws. There is a temptation, in the face of public pressure, to respond to a fearful new problem with ineffective and oppressive legal regulation.

It was on the Global Commission on AIDS that I learned from Jonathan Mann, June Osborn and others the importance of the AIDS paradox. It took epidemiologists and public health experts to teach me, a lawyer, certain fundamental realities about human rights when it came to HIV/AIDS. The AIDS paradox teaches that the most effective ways of preventing the spread of the virus responsible for AIDS is by protecting the human rights of those most at risk. It is a paradox because it runs counter to the traditional responses to epidemics in public health. It contradicts the instinctive feelings of most citizens. It challenges the assumptions and instant reactions of most political leaders and aspirants. Yet it was the outgrowth of consideration of the particular features of this epidemic, of its vectors of transmission and of the weapons realistically available for the public health armoury to prevent its spread.

Explaining the paradox rationally is quite simple. Given the absence of effective vaccines and (for most people) effective medicines, the only means of reducing the spread of the epidemic is by the sharing of information and by the achievement of behaviour modification in those principally at risk. Anyone in my profession can tell you that behaviour modification, particularly in matters important to a person's identity and pleasure, is extremely difficult to achieve by law, certainly over a prolonged period. Alienated homosexual and bisexual citizens, drug users, so-called "promiscuous" people and sex workers were already outside the range of many public health messages in most countries when HIV/AIDS came along.

Led by Dr Mann, WHO set about the task of spreading the message about the coincidence of human rights and public health objectives. But it was not easy. Deeply entrenched resistance arose. There was religious antagonism to the education of children in schools, and in the media, about sexual behaviour. There were legal and social prohibitions on homosexuals, injecting drug users and sex workers. Condoms in suitable quantities and at affordable prices were unavailable even if legally obtainable. Women, often at greatest risk, were disempowered and unable effectively to protect themselves from infection. The political commitment to taking radical steps necessary to save lives was missing. Turning this situation around, was a Herculean challenge. But it was one taken up by Jonathan Mann in WHO with the enthusiastic support of a team of colleagues, many of whom stuck with him after his departure from Geneva. At that time, Harvard became a kind of Avignon for the alternative Pope. Fortunately many of those who remained behind in Geneva, like Dr Michael Merson (now of the Yale University) and Dr Peter Piot (now of UNAIDS) fully accepted Jonathan Mann's insights and tried to carry them forward in the work of WHO.

This is not the occasion to tell the story of the achievements and frustrations of those days. The achievements are continuing. The frustrations are certainly still there. One initiative which Jonathan Mann undertook, in cooperation with the Centre for Human Rights in Geneva, was the establishment of an international consultation on HIV/AIDS and human rights. I took part in two of these meetings. The second adopted international guidelines on HIV/AIDS and human rights. Listed were the organisational, policy and strategic programmes which were necessary to build on the AIDS paradox and to turn it into affirmative action.

The efforts to harmonise human rights and public health in the context of HIV/AIDS has been well told by Lawrence Gostin and Zita Lazzarini in their book Human Rights and Public Health in the AIDS Pandemic. Naturally, the book contains an acknowledgment to the Harvard School of Public Health and to the "inspirational" work of Jonathan Mann. Courts in every land are now confronted by the legal outfall of the HIV/AIDS epidemic and by the second epidemic of discrimination which follows close in its wake. But the biggest battle against the spread of the virus and of intractable discrimination remains to be fought in the developing world. I saw this most clearly in my work in Cambodia. Large and relatively discreet public signs, advising about AIDS and the use of condoms, were removed by elected politicians in response to puritanical civic protests. A well policed area outside Phnom Penh long used for brothels was closed, ostensibly to prevent the spread of HIV. Foreign sex workers were peremptorily deported. I endeavoured to explain to Cambodian officials the ineffectiveness of these responses and the urgency of answering the epidemic with informed programmes of education, anti-discrimination and condom distribution. Sometimes my words were heeded. More often they were not.

I reported on this and other aspects of the human rights issues of health to the United Nations Commission on Human Rights and to the General Assembly. This is the only real sanction which is available to the Special Rapporteurs and Special Representatives working in the field of human rights. No country wishes to be damned before the international community for infractions of such rights. We have come thus far. But there are no armies to enforce United Nations human rights principles in the field of health or anywhere else. Persuasion, by logic and by example, are the weapons we have. In the face of an urgent public health crisis such as HIV/AIDS, the time available for action is usually inadequate. The urgency and importance of obtaining effective responses is not equalled by the appreciation of the need for immediate action or the conviction that the advice given is right.

This is one reason why the loss of Jonathan Mann is such a devastating blow, not only for public health and epidemiology but also for human rights. As Kathleen Kay, an Australian friend, said at a memorial service for him:

We who are left must carry on, guided by his example.

RIGHT TO HEALTH: FUTURE ISSUES

The last time I saw Jonathan Mann was at a conference in San Francisco a year ago. I was attending that meeting in my capacity as a member of the International Bioethics Committee of UNESCO and the Ethics Committee of the Human Genome Organisation. My path had taken me a away from HIV/AIDS into the new and challenging issues presented by the genome. We talked about those issues. As usual, he saw immediately the human rights dimensions. Those dimensions are reflected in the Universal Declaration on the Human Genome and Human Rights adopted by the General Conference of UNESCO in November 1997. In a sense, that Universal Declaration is an appropriate marker for the passage of fifty years from the earlier, broader, Universal Declaration. The new one is designed to deal with some of the issues presented by the likely consequences of the discovery of human genes and the use of that knowledge as the foundation of medical science in the next millennium.

Apart from the general consideration of the need to uphold the inherent dignity and the equal and inalienable right of all members of the human family, which runs through the earlier Universal Declaration and the recent one dealing with the human genome, many and complex are the problems which genomic science offers to public health and to human rights. The issues range from the protection of patient rights to privacy and confidentiality to the possible impact of genetic knowledge upon conceptions of criminal culpability. They extend from questions of interference with (or if that is a loaded word, alteration of) genes in a patient or in a germline which has the potential to alter the genetic makeup of the human subject through to the vexed question of whether genetic discoveries should be subject to patent protection. They certainly include the controversial question of cloning which the UNESCO Declaration asserts in the case of reproduction to be incompatible with human dignity.

As I reflect upon the debates on bioethical concerns which have successively arisen in the past twenty-five years, considering those which involved AIH (Artificial Insemination by Husband), AID (Artificial Insemination by Donor), HTT (Human Tissue Transplants) and IVF (Invitro Fertilisation), I can only conclude that the issues for human rights, presented by advances in genetics and in technology relevant to medical care, have become more complex with each succeeding year. When a seemingly intractable problem presents, it is soon overtaken by a problem even more difficult.

Of course, there remain for consideration good old-fashioned concerns about human rights and public health. In those places which do not provide for statutory rights of access to clinical records, should judge-made law afford such rights? Addressing the realities of local hospital and doctors surgeries in the relationship with the patient, some commentators suggest that the "idea that patients have rights sits uncomfortably within the general shape of ... healthcare law" in most parts of the world. For many indigenous people in developed countries, and most ordinary patients in the Third World, notions of fundamental rights in the context of healthcare may seem to be rhetoric rather than reality. Nonetheless, reporting obligations to the United Nations, the inquisitive investigations of international relief and human rights agencies, troublesome non-government organisations at home and the political process itself can help to turn serious deprivations of the fundamental right to health into the subjects of political action. This has certainly happened in Australia in the context of the health of Aboriginal people and in particular of Aboriginal women and children.

In some areas of public health attitudes must change drastically before human rights will be accorded. At the time when slavery was socially accepted, the condition of "drapetomania" was sometimes described as a mental illness. Yet all the slaves were trying to do was, with perfect rationality, to escape from enslavement. Similarly, it was only in 1989 that homosexuality was finally deleted from the international classification of diseases. When we reflect upon such errors of the past, we are bound to ask what are the errors that remain today? I suspect that history will say that the way we have dealt with drug dependence and drug use by proceedings in courtrooms rather than as problems of public health has involved a number of most serious departures from fundamental human rights. Not the least of these is the programme of prison building which exists in the United States and other countries which have followed its lead in this regard and the huge numbers of young people, often from minority groups, undergoing incarceration in the largely ineffective effort to deal with the problem in the way we have adopted.

If these issues are not exotic enough, reports in the United States suggest that more extra-ordinary problems lie in waiting. One of these may be decorporation, allegedly as a means of affording a better life and mobility to quadriplegics. Scientists in the United States are experimenting with transplantation of monkey heads to a full state of consciousness and patents have been awarded for a device for perfusing an animal's head. We may treat these issues with scorn. But the lesson of this century has been how quickly science fiction becomes reality.

Virtually every society is grappling with the issues of euthanasia or assisted suicide. In Australia, legislation of the Northern Territory was, exceptionally, disallowed by the Federal Parliament because the procedures for physician-assisted suicide were considered unacceptable. Other legislation along the same lines may yet ensue. For some patients, the ultimate human right is that of controlling the end of their existence and, in particular, if they face unrelieved pain and loss of human dignity.

CONCLUSIONS

In such an exciting world of old and new problems it may be hoped that Centers such as this will continue to explore the frontiers, push forward the boundaries of understanding and throw light on the linkages of health and human rights. It may also be hoped that WHO will prove more responsive to those linkages in the future than it sometimes has in the past.

Many commentators, both before and after Jonathan Mann's experience, have referred to the need for greater involvement of WHO in the implementation of the right to health reflected in Article 25 of the Universal Declaration and Article 12 of the Economic, Social and Cultural Rights Covenant. A representative of WHO told a meeting organised by the Committee on the Covenant in 1993 that it was only after the mid-1970s that WHO started to acknowledge the importance of socio-economic circumstances in general health conditions. This drew the comment that WHO has been historically ambivalent about defining health in terms of a human right. Unlike the International Labor Organisation, WHO has "not yet taken the initiative to formulate international binding standards articulating the obligations of States in the area of health". Why should this be? It is probably because of the conservatism of the public health tradition, the suspicion which most health care workers have of lawyers and a degree of caution and scepticism which is the residue of a professional attraction to a different and more paternalistic principle, sometimes described by the phrase "Nanny knows best".

The new Constitution of WHO in its Preamble, idealistically declares intrinsic and inherent values:

The Preamble also stresses the responsibility of States "in the promotion and protection of health" and of Governments for "the provision of adequate health and social measures". The constitutional formulae are there, reinforced by the terms of the Universal Declaration and the International Covenant. The experience should also be there after the involvement of WHO in the AIDS epidemic, the imperative need which this occasioned for inter-agency dialogue, including in the field of human rights, and the acceptance by all leaders in that field of the essential inter-connections between human rights and public health which Jonathan Mann taught.

One must express the hope that Jonathan Mann's message will gain fresh attention with the new leaders of WHO. Only then will there be the "lasting legacy" for their work which the Secretary-General of the United Nations promised at the Memorial Service for the United Nations personnel who died on that fateful flight. Rightly, the Secretary-General placed those who died in the company of others, including one of his predecessors, Dag Hammarskjöld, who had given their lives on behalf of the United Nations "and in the cause of building a better world". Their loss, he assured us, "will not have been in vain".

Those words must also be translated into action. Jonathan Mann was a believer in power of words and of ideas. But he was a man of action. At the end of his contribution at the Second International Conference on Health and Human Rights, speaking of the interconnection to which he had brought such sharp insights he said:

We, Jonathan Mann's multitude, must learn from this unique teacher. As we remember his work in the context of the half century of the Universal Declaration of Human Rights we should draw an ultimate lesson: Noble sentiments are not enough. We must be active for reform. Out there in the world ordinary people yearn for rights - including the right to health. There are oppressors, autocrats and apathetic, antagonistic and indifferent officials. Look at what Mrs Roosevelt and her colleagues set in train. Look at what, fifty years later, Jonathan Mann inaugurated. With a sense of impatience and idealism, with "modesty" and "boldness", we should go and do likewise.