Baldwin-Ragaven, Laurel

Kalebi, Ahmed

Kasolo, Josephine

London, Leslie

Maart, Soraya

Petersen, Lucretia

English

South African Medical Journal (SAMJ)

December 2007, Vol. 97, No. 12  SAMJHuman rights are social or material entitlements which are recognised universally in national and international law and that address fundamental human needs. They inhere in all people by virtue of their humanity, and represent a standard to which governments can be held accountable. Not surprisingly, South Africa’s Truth and Reconciliation Commission (TRC), following its investigation into health sector complicity in human rights abuses under the apartheid system, recommended that human rights training be made central to the mission of institutions responsible for educating future generations of health professionals.1-3 Subsequently, the increasing complexity of delivering quality health care to all South Africans has posed additional challenges as to how health professionals must work, particularly as social justice and equity become essential to ongoing efforts to redress past and present inequalities.4For such reasons, the Health and Human Rights programme of the School of Public Health and Family Medicine at the University of Cape Town (UCT) co-hosted a conference in July 2006 in Cape Town to deliberate Core Competencies in Human Rights for Health Professionals.5 Nearly 90 participants from a wide range of health NGOs and community groups, national and provincial departments of health, professional organisations, statutory councils, and the research and academic community, discussed the graduate competencies in human rights that should be expected of nurses, doctors and other health professionals. Delegates from South and East Africa provided regional perspectives on the discussions. The conference drew heavily on actual experiences of health professional educators, particularly those who had attended the Train-the-Trainer short course in health and human rights conducted at UCT over the past 9 years.6One theme to emerge consistently throughout the July 2006 conference is that most students have minimal awareness of how human rights issues relate to the practice of health care and, moreover, may have little insight into their own obligations regarding the protection and promotion of human rights. Although this lacuna may be traced to the inadequacy of human rights content in most undergraduate curricula, what is more important would appear to be the limited understanding of human rights by health professionals generally and those teaching students, in particular. It follows that, particularly in clinical settings, if there is an absence of appropriate role models and if human rights fail to be put explicitly into practice in interactions with patients, any formal teaching in human rights will be undone and students may internalise the notion that patients’ rights are not their responsibility.Furthermore, the institutional culture or pervading ethos in many settings tends to cast human rights as being ‘political’, confrontational or ‘unnecessary to professional practice’, thereby creating and reinforcing a stigma against learning in this area. In addition, professional hierarchies among the different health professions (for example, the historical dominance of medicine over other health professions) may reinforce values antithetical to the human rights principles of equality and respect. Likewise, the manner in which faculties of health sciences are organised and governed in South Africa is a reflection of how human rights are understood and applied as much as the content of formal courses. If teachers do not manifest human rights in their own practice, how can students then be expected to ‘learn’ human rights? These and other examples of obstacles posed by the ‘hidden curriculum’7 have unintended consequences for efforts to introduce human rights in teaching and practice, and were illustrated by a range of presentations at the conference.What also emerged is that missed opportunities to learn human rights in experiential ways abound within the health and educational systems. Deliberate and purposive adoption of a rights-based approach, as proposed in the United Nations World Programme for Human Rights Education,8 could be an important strategy to ameliorate the situation. This would imply engaging with human rights not only at tertiary levels but also in early schooling in order to prepare students to comprehend that this is an essential part of training and practice in the health professions. Thus, a culture of human rights would be as ingrained as much as hygiene and infection control have in biomedicine over the past century.Another aspect is where to place human rights in the curriculum; evidence is that teaching of human rights is most effective when integrated across the curriculum rather than being taught in isolation. Bedside teaching provides enormous – yet so far untapped – potential for highlighting health and human rights scenarios such as access to adequate food, housing and medication, and the consequences of violence towards spouses, partners and family members. A distinct, related problem is that of the substitution, or sublimation, of human rights within bioethics teaching. It has not been uncommon for participants to report that those responsible for curriculum development assumed that, because bioethics or professional ethos is already being taught, human rights need not receive additional allocation; or that there was no space in curricula because of existing ethics teaching. The conflation of bioethics and human rights requires more attention, as does the need for research into what each discipline can uniquely provide to the training of health professionals in the current South African context.Developing human rights competencies for South African health professional graduatesEDITORIALPg 1269-1270.indd   1269 11/27/07   3:46:42 PMEDITORIALLastly, the problem of dual loyalty (or role conflict), where a health professional’s obligation to a third party (often the State) subjugates the patient’s human rights, remains a central dilemma to health professional practice.9 Recent events have highlighted the tensions between health workers who bring to public scrutiny concerns about the inadequacies of health policies and the vulnerabilities of their patients, and government which attempts to silence such criticisms.10,11 Greater emphasis therefore must be placed on inclusion of human rights in the curriculum so as to equip students to deal with these challenges after graduation.Arising from these themes, conference participants identified a range of competencies that should be considered as part of a graduate’s profile.5 These relate to areas of knowledge (e.g. what constitutes human rights; the implications of domestic and international human rights legislation and conventions; national policies and their impact on health and human rights; etc.), skills (e.g. how to identify potential and actual human rights violations in health settings) and attitudes or values (e.g. why human rights are important for health professional practise, cultivating a willingness to engage in advocacy and support colleagues who speak out against human rights abuses). Furthermore, health professionals need to have the tools to both prevent and redress human rights abuses. For example, if patients have a right of access to health care, it implies that not only should health professionals treat patients with dignity and respect, but also that they should avoid becoming instruments through which the State can deny patients access to health care.At present, the Health Professions Council of South Africa (HPCSA) has embarked on a process to ensure that competencies in ethics, human rights and health law become part of the criteria for accreditation of undergraduate programmes in South Africa.12 Such an initiative should go a long way towards providing an institutional imperative to implement effective human rights teaching. Moreover, it will create health professionals who, unlike the doctors who attended to Steve Biko prior to his death in detention,13 will be able to identify human rights abuses in the making and take appropriate action to end it. As experience in expanding access to antiretroviral treatment by those living with AIDS illustrates,14 we need practitioners who will recognise that human rights violations span the full spectrum of civil and political as well as socio-economic rights. We envisage that the HPCSA’s and other initiatives will give rise to a new generation of health care providers who will not only be advocates for expanding the protection of vulnerable groups but will also champion their rights of access to health care and attain the underlying social and economic conditions necessary for health.Leslie LondonSchool of Public Health and Family MedicineUniversity of Cape TownLaurel Baldwin-RagavenTrinity CollegeHartford, USAAhmed KalebiUniversity of the Witwatersrand & National Health Laboratory ServicesJohannesburgSoraya Maart Lucretia PetersenSchool of Health and Rehabilitation SciencesUniversity of Cape TownJosephine KasoloFaculty of MedicineMakerere UniversityKampalaUgandaCorresponding author: L London (leslie.london@uct.ac.za)  1.  Truth and Reconciliation Commission Report. Volume Four, Chapter Five; Institutional Hearings: The Health Sector. Cape Town: Truth and Reconciliation Commission, 1998: 109-164.  2.  Baldwin-Ragaven L, de Gruchy J, London L. An ambulance of the wrong colour. Health professionals, human rights and ethics in South Africa. Cape Town: University of Cape Town (UCT) Press, 1999.  3.  Baldwin-Ragaven L, London L, de Gruchy J. Learning from our apartheid past: Human rights challenges for health professionals in contemporary South Africa. Ethnicity and Health 2000; 5(3): 227-241.  4.  Braveman P. Health disparities and health equity: concepts and measurement. Ann Rev Public Health 2006; 27: 167-194.  5.  University of Cape Town. Conference on Core Competencies in Human Rights for Health Professionals. Final report 15th December 2006.  (http://www.hhr.uct.ac.za/conferences/conferences.php) (accessed 26 October 2007).  6.  Baldwin-Ragaven L. Prioritising human rights training for health professionals (reportage) S Afr Med J 1998; 88: 1377.  7.  Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med 1998; 73: 403-407.  8.  World Programme for Human Rights Education. General Assembly Resolution 59/113B. United Nations document published 14 July 2005. http://www.ohchr.org/english/issues/education/training/reports.htm (accessed 26 October 2007).  9.  London L. Dual Loyalties; Health Professionals and HIV Policy in South Africa. S Afr Med J 2002; 92: 882-883.10. Ngalwa S. Frere doctor rebuked for ‘breach of protocol’. Cape Argus 9 August 2007.11. Bamford H. Balfour sues jail doctor for speaking out. Cape Argus 4 August 2007.12.  Health Professions Council of South Africa. Proposed Core Curriculum on Human Rights, Ethics and Medical Law for Health Care Practitioners. Pretoria: HPCSA, 2007.13.  Rayner M. Turning a Blind Eye: Medical Accountability and the Prevention of Torture in South Africa. Washington: AAAS, 1987.14.  London L. Human Rights and Public Health: Dichotomies or Synergies in Developing Countries? Examining the Case of HIV in South Africa. Journal of Law, Medicine and Ethics 2002 30: 677-691.December 2007, Vol. 97, No. 12  SAMJPg 1269-1270.indd   1270 11/27/07   3:46:43 PM

Developing Human Rights competencies for South African health professional graduates

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Developing Human Rights competencies for South African health professional graduates

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South African Medical Journal (SAMJ)