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New book honours UN women who made HERstory

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Eleanor Roosevelt of the United States holding a Declaration of Human Rights poster in English. (November 1949). UN Photo

Raising awareness of women’s contributions is critical to correcting historical imbalances that have undervalued their presence, the United Nations Secretary-General said on Wednesday.

António  Guterres was speaking at an event at UN Headquarters in New York to launch a book that pays tribute to women’s participation in the development of the global organization.

HERstory: Celebrating Women Leaders in the United Nations is an initiative by Colombia and Qatar, and builds on an exhibition held two years ago.

The initiative shines a spotlight on pioneers and trailblazers such as Lucille M. Mair, the first woman to serve at the rank of Under-Secretary-General: the title given to officials who oversee UN Departments; and Margaret Anstee, who was the first woman to head a peacekeeping operation.

“The history we learn at school, that is celebrated in public monuments and events, tends to be a very partial history. It is the history of men,” Mr. Guterres said.

“Raising awareness of women’s contributions is an essential part of correcting the imbalance in our culture that has historically undervalued women’s contributions and women’s work.”

Mr. Guterres reminded the audience of the “enormous progress” in women’s rights achieved during more than seven decades since the founding of the UN.

But he also recalled that women comprised just six of the 278 delegates at the 1945 conference that established the Organization: a story told in a recent UN News podcast.

And while such paltry participation could not happen today, the UN chief reported that practically every week he still encounters diplomatic delegations that do not include a single woman.

The issue is also a concern in-house, Mr. Guterres said, adding that the UN has had to work at ensuring its own events do not feature “manels”—that is, all-male panels.

The Secretary-General has made gender parity a top priority, pushing for greater women’s representation at the UN, including at the senior management level.

“This is not simply about the fight for gender equality,” he stated.  “From peace and security to development to human rights, greater inclusion is the key to our success – bringing new perspectives, different leadership styles, greater innovation and, ultimately, a more effective organization.”

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New Social Compact

Athletes knock the legs from under global sports governance

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Sports governance worldwide has had the legs knocked out from under it. Yet, national and international sports administrators are slow in realizing the magnitude of what has hit them.

Tectonic plates underlying sports’ guiding principle that sports and politics are unrelated have shifted, driven by a struggle against racism and a quest for human rights and social justice.

The principle was repeatedly challenged over the last year by athletes as well as businesses forcing national and international sports federations to either support anti-racist protest or at the least refrain from penalizing athletes who use their sport to oppose racism and promote human rights and social justice, acts that are political by definition.

The assault on what is a convenient fiction started in the United States as much a result of the explosion of Black Lives Matter protests on the streets of American cities as the fact that, in contrast to the fan-club relationship in much of the world, US sports clubs and associations see fans as clients, and the client is king.

The assault moved to Europe in the last month with the national soccer teams of Norway, Germany, and the Netherlands wearing T-shirts during 2022 World Cup qualifiers that supported human rights and change. The Europeans were adding their voices to perennial criticism of migrant workers’ rights in Qatar, the host of next year’s World Cup.

Gareth Southgate, manager of the English national team, said the Football Association was discussing with human rights group Amnesty International tackling migrant rights in the Gulf state.

While Qatar is the focus in Europe, greater sensitivity to human rights appears to be moving beyond. Formula One driver Lewis Hamilton told a news conference in Bahrain ahead of this season’s opening Grand Prix that “there are issues all around the world, but I do not think we should be going to these countries and just ignoring what is happening in those places, arriving, having a great time and then leave.”

Mr. Hamilton has been prominent in speaking out against racial injustice and social inequality since the National Football League in the United States endorsed Black Lives Matter and players taking the knee during the playing of the American national anthem in protest against racism.

In a dramatic break with its ban on “any political, religious or personal slogans, statements or images” on the pitch, world soccer governing body FIFA said it would not open disciplinary proceedings against the European players. “FIFA believes in the freedom of speech and in the power of football as a force for good,” a spokesperson for the governing body said.

The statement constituted an implicit acknowledgement that standing up for human rights and social justice was inherently political. It raises the question of how FIFA going forward will reconcile its stand on human rights with its statutory ban on political expression.

It makes maintaining the fiction of a separation of politics and sports ever more difficult to defend and opens the door to a debate on how the inseparable relationship that joins sports and politics at the hip like Siamese twins should be regulated.

Signalling that a flood barrier may have collapsed, Major League Baseball this month said it would be moving its 2021 All Star Game out of Atlanta in response to a new Georgia law that threatens to potentially restrict voting access for people of colour.

In a shot across the bow to FIFA and other international sports associations, major Georgia-headquartered companies, including Coca Cola, one of the soccer body’s longest-standing corporate sponsors, alongside Delta Airlines and Home Depot adopted political positions in their condemnation of the Georgia law.

The greater assertiveness of athletes and corporations in speaking out for fundamental rights and against racism and discrimination will make it increasingly difficult for sports associations to uphold the fiction of a separation between politics and sports.

The willingness of FIFA, the US Olympic and Paralympic Committee (USOPC) and other national and international associations to look the other way when athletes take their support for rights and social justice to the sports arena has let a genie out of the bottle. It has sawed off the legs of the FIFA principle that players’ “equipment must not have any political, religious or personal slogans.”

Already, the US committee has said that it would not sanction American athletes who choose to raise their fists or kneel on the podium at this July’s Tokyo Olympic Games as well as future tournaments.

The decision puts the USOPC at odds with the International Olympic Committee’s (IOC) staunch rule against political protest.

The IOC suspended and banned US medallists Tommie Smith and John Carlos after the sprinters raised their fists on the podium at the 1968 Mexico City Olympics to protest racial inequality in the United States.

Acknowledging the incestuous relationship between sports and politics will ultimately require a charter or code of conduct that regulates the relationship and introduces some form of independent oversight akin to the supervision of banking systems or the regulation of the water sector in Britain, alongside the United States the only country to have privatized water as an asset.

Human rights and social justice have emerged as monkey wrenches that could shatter the myth of a separation of sports and politics. If athletes take their protests to the Tokyo Olympics and the 2022 World Cup in Qatar, the myth would sustain a significant body blow.

Said a statement by US athletes seeking changes to the USOPC’s rule banning protest at sporting events: “Prohibiting athletes to freely express their views during the Games, particularly those from historically underrepresented and minoritized groups, contributes to the dehumanization of athletes that is at odds with key Olympic and Paralympic values.”

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Disability policies must be based on what the disabled need

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Diversity policies, especially when it comes to disabled people, are often created and implemented by decision makers with very different life experiences to those who their policies affect most.

We would never expect economic policy to be crafted without input from economists and bankers. We should demand the same for disability policies, if we want to create the change needed to produce inclusive societies.

Starting in 2017, I was humbled to be given an opportunity to develop the first multi-media, audio dictionary translating Bangla to English. As a disabled individual who is visually impaired, I was uniquely placed to design such a programme, based on my lived experience. The principle of entrusting service design to those who have the most experience in that area is a logical, common-sense approach to policy, yet many governments can do more in this area. 

This has been particularly true throughout the pandemic, where it has been even more important to respond quickly and appropriately to the needs of citizens. 

For example, school children have been failed in many countries through poor or non-existent education provision. Medical professionals have been let down due to poor access to PPE.

This begs the question, why haven’t teachers created public policy regarding schools? Why haven’t Doctors and nurses been a bigger part of public policy with regards to hospital management and equipment? 

Those who have direct, lived experience should be able to formulate policy. I’m grateful that in Bangladesh and other nations, this is what is increasingly happening, with some groundbreaking results. 

If nothing else, this approach is consistent with other professions: When applying for a job, an employer will always demand evidence of past experience. There is no reason why this should not apply to policy and politics. 

You would never hire a builder to work on your house if they had never set foot on a building site: at most, you could hire an experienced interdisciplinary project manager if he or she was relying on the expertise of seasoned builders. 

The benefit of applying lived experience to problem-solving has long been established in business – governments should follow suit. 

The founders of the ‘Lean methodology’ are a great example of this, where they developed a process of continuous improvement and waste elimination that saw a failing car production company, Toyota, turn into a global market leader. 

This methodology’s pioneers, Kiichiro Toyoda and Taiichi Ohno, would demand that those working on the camper van, for example, would travel themselves in the vans they were trying to improve. This enabled them to uncover the sources of discomfort created through poor design, in a way that would have been impossible in a design office in Tokyo. 

This cannot be directly applied to disability policy – it would be unethical and impossible to ask someone to be ‘blind’ for a period of time, in order to develop better policy.

The next best thing is for policy makers to engage with those who have the experience. 

This isn’t about denigrating the policymaking experience of those in government, but it is about helping them empathise with those whom their decisions impact. When public services are not designed with empathy for the people who use them, they are useless, or even potentially harmful. 

The a2i empathy training programme, for example, arranges for relatively senior government officers to act as secret shoppers and visit citizens’ access points for services outside of their ministry or area of expertise. This exercise puts them in “citizens’ shoes” since they are forced to navigate public systems without any official or intellectual privileges. This experience helps participants develop a critical eye that they use to scrutinise their own agency’s delivery systems and improve the overall quality of services. 

This kind of real-world experience (either through engaging with service users, or by putting policy makers’ in service users’ shoes), as well as high-level expertise, should be part of governance as we move towards a ‘new normal’. 

There is no reason why Ministers for health shouldn’t be ex-Doctors, and Ministers for education can’t be ex-teachers. And there is no reason why disability policy cannot be informed by disabled people.

Public service is not rocket science, but if it was, it would make sense to entrust it to the rocket scientists. 

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Reform of mental health services: An urgent need and a human rights imperative

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Already in the early stages of the COVID-19 pandemic, the World Health Organisation (WHO) was warning that substantial investment in mental health services was necessary to avert a mental health crisis. The evidence for the devastating impact of the pandemic on mental health is now overwhelming. The reasons for this are clear: the pandemic caused fear and anxiety for everyone, and many of us had to face illness, grief over lost family members, insecurity and loss of income. In addition to this extraordinary burden placed on our mental health, we were cut off from our usual support networks, friends and families, while the pandemic was also disrupting the delivery of existing mental health services themselves.

Not everyone has been affected in the same way by the pandemic, and mental health is no exception here. Among others, the mental health of certain demographics such as older persons, children and adolescents, and women, as well as that of disadvantaged groups such as persons with disabilities, LGBTI people and migrants has been affected more compared to the general population. For example, in a statement I co-signed with the UN Independent Expert on Sexual Orientation and Gender Identity and numerous other human rights experts, we alerted states to increasing mental health problems for LGBTI people, in particular youth, notably as a result of having to shelter with family members who were unsupportive of or hostile towards their LGBTI identity.

I recently published an Issue Paper entitled “Protecting the right to health through inclusive and resilient health care for all” in which I set out twelve recommendations. These include universal health coverage (of which mental health services are an essential component), more equality and dignity for patients, more participation and empowerment in relevant decision-making, the promotion of transparency and accountability throughout policy cycles, and better health communication policies. Since the right to health is defined as the right to the highest attainable standard of physical and mental health, these recommendations naturally apply to mental health care as well. Some recommendations, however, are more specific to mental health, such as those related to the need to ensure that mental health services are accessible to all when needed, of appropriate quality and affordable, to transition from an institutional to a community-based model and to eliminate coercive practices in mental health services.

Mental health systems: a longstanding source of human rights violations

While the additional strain generated by the pandemic is new, the mental health situation and lack of services has been a neglected human rights crisis in Europe for a long time. Despite the suffering and economic burden caused by mental health problems, mental health spending in the WHO European region was estimated to amount to only 1% of total health expenditure in 2019, and the majority of that expenditure was channelled towards mental health hospitals. In a very important report in 2017, the UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health was already raising the alarm over the fact that “the arbitrary division of physical and mental health and the subsequent isolation and abandonment of mental health has contributed to an untenable situation of unmet needs and human rights violations”.

In my Issue Paper on health, I called on governments to pay attention to the essential social determinants of health in order to rebuild more inclusive and resilient health care systems, notably social protection, living conditions, working environment and education. These are all the more relevant for mental health, since mental well-being is determined not only by individual attributes but also by the social environment which can prevent, cause or aggravate mental health problems. In recent decades, a human rights-based, holistic and psychosocial understanding of mental health has been emerging, but this approach still faces a lot of resistance in many of our member states, where a reductionist, biomedical paradigm remains prevalent. Further problems identified in the aforementioned report of the Special Rapporteur are power asymmetries in mental health policies and services, and the biased use of evidence in mental health. In combination, these reinforce a vicious cycle of stigmatisation, disempowerment, social exclusion and coercion.

In order to rise to the challenge posed by the pandemic for mental health services, it is essential to reform them, as well as relevant laws and policies, urgently and from the ground up. As with health policy generally, the imperative to prevent human rights violations must be the guiding principle behind these reforms.

The human rights of persons with mental health problems or psychosocial disabilities (i.e. disabilities arising from the interaction between a person with a mental health condition and their environment) are routinely violated in two significant ways. Firstly, their human rights continue to be violated by mental health services themselves, notably because they often display a tendency towards paternalism, coercion and institutionalisation. Secondly, affected patients may not have access to the care they need to achieve the highest attainable standard of health. In this connection, we should bear in mind that this right depends on the realisation of many other human rights, notably those enshrined in the UN Convention on the Rights of Persons with Disabilities (CRPD).

Coercion: a persistent source of human rights violations

In a recent report on its visit to Bulgaria, the European Committee for the Prevention of Torture (CPT) documented how patients in psychiatric hospitals were subjected to widespread and systematic ill-treatment at the hands of staff: they were slapped, pushed, punched, kicked, beaten with sticks, chained to beds and medicated without consent. While this example is particularly horrific, we should not forget that similar institutions, and the underlying approach taking coercion for granted, are still common in the majority of our member states, as demonstrated, for example, in recent exposés on the situation of psychiatric hospitals in Malta. My own Office has addressed human rights violations caused by such institutions in a large number of member states, including in an intervention before the European Court of Human Rights.

Why is this still accepted in 2021? Historically, fear, rejection and isolation have been our default response to persons with mental health problems. The ingrained fear and stigma of mental illness is still very strong, fuelling prejudice and the narrative that persons with mental health problems pose a danger to themselves and to society, against all available statistical evidence to the contrary – persons with mental health problems are in fact far more likely to be victims of violence than perpetrators. Mental health laws that normalise closed institutions and forced treatment confirm and reinforce these prejudices. Furthermore, while there is ample evidence that coercive treatment may lead to substantial trauma and that fear of coercion can actually deter persons experiencing mental ill-health from seeking help, there appears to be little scientific evidence to substantiate the supposed benefits of forced treatment.

In 2019, the Parliamentary Assembly of the Council of Europe unanimously adopted a groundbreaking Resolution calling on member states to end coercion in mental health, pointing to the fact that the number of persons subjected to coercion was still growing in Europe. It noted that so-called safeguards to prevent excessive use of coercion had not reduced but, on the contrary, seemed to have increased coercion, for example in France following a reform in 2011: what is defined as last resort in legislation often becomes the default approach, especially when resources are scarce. The corresponding report presented to the Parliamentary Assembly also reflects my observations concerning the marked differences in the level of involuntary placements between countries, but also between different regions of the same country or even from one hospital to another, suggesting that the main cause of coercion is not the inherent dangerousness of persons or therapeutic necessity, but an institutional culture that confines more out of prejudice or habit. This interpretation is supported by research.

In my address to the Parliamentary Assembly prior to the adoption of this Resolution, I drew attention to how my own country work allowed me to see first-hand the vicious circles caused by a mental health approach based on coercion, which perpetuates the isolation of the very persons who need the support of their community the most, fuelling more stigma and irrational fear. The lack of community-based, voluntary mental health services also results in even more coercion and deprivation of liberty.

I have also shared my observation that safeguards supposed to protect persons from arbitrariness and ill-treatment are reduced to mere formalities because they operate in a legal system where persons with mental health problems do not even have a chance to have their voices heard, owing to the profound power asymmetry between the patient and physician in most mental health settings. Judges almost invariably follow the opinion of the psychiatrist over the wishes of the patient, when the law provides for such a possibility. At their worst, such safeguards do little more than ease the conscience of those who are in fact taking part in human rights violations.

My position on coercion in psychiatry and the Resolution of the Parliamentary Assembly should be seen against the background of a growing consensus within the international community to consider involuntary measures without the informed consent of persons with mental health problems as human rights violations, or even as possibly amounting to torture. This is in large part due to the paradigm shift operated by the CRPD when it entered into force in 2008, and the efforts of civil society, in particular of persons with lived experience of mental health problems and psychosocial disabilities, to have their say in policy-making. As a result, a growing number of relevant international and national human rights bodies are now calling for an end to coercion and its replacement by community-based treatment options based on consent. This approach is slowly making headway in the medical community as well, as can be seen in the growing body of WHO guidance to states to reduce coercion, establish community-based alternatives and integrate mental health into primary care. Similarly, the World Psychiatric Association issued a position statement on the need to reduce coercion in October 2020.

This revolution is rooted in the CRPD and it would be a mistake to cling to older Council of Europe standards that place the bar lower. In this context, it is regrettable that work is still continuing in the Council of Europe on a draft Additional Protocol to the Oviedo Convention that reflects an outdated, biomedicine-driven approach reducing mental health to mental disorders and empowering physicians to forcibly confine and treat persons without consent, with virtually no limit being set on the duration of this placement or the treatments to be used. The vagueness of the definitions in this text and the trust in the judgement of a single physician, which appears misplaced given the human rights violations we are still witnessing on a daily basis, could easily give the impression of sanctioning even the worst kinds of human rights abuses in psychiatry. The opposition of the Parliamentary Assembly, several UN bodies including the treaty body of the CRPD, the unanimous protests of representative organisations of persons with psychosocial disabilities and my own opposition to this initiative have so far been ignored.

I call on member states to stop supporting such initiatives at international level, which may create confusion and become a stumbling block to necessary progress in advancing the human rights agenda when it comes to mental health. If new international standards do not nurture the paradigm shift from institutional to community-based care, and from coercive to consent-based care, they should at least do no harm by muddying the waters.

The way forward

A number of member states have started reviewing their mental health legislation in the light of these considerations, for example in Ireland and in the UK. What I found particularly positive with these two examples is the commitment to engage with civil society, and in particular users and providers of mental health services. Initiatives by representative organisations of persons with psychosocial disabilities to promote more inclusive policy-making, for example in the ongoing trialogue in Germany, are also to be commended. The active participation of persons with lived experience of using mental health services in defining policies, in particular, is a sine qua non condition of successful mental health reform, as their exclusion from the debate so far has allowed human rights violations to continue unchecked for as long as they have. This is also a general obligation under Article 4(3) of the CRPD.

The realisation of the right to full enjoyment of the highest attainable standard of mental health depends on the realisation of many other crucial human rights. In particular, member states need to conduct the necessary reforms of their mental health legislation in parallel with reforms in two crucial areas affecting core rights enshrined in the CRPD: legal capacity (Article 12) and the right to live independently and be included in the community (Article 19). Mental health care that truly respects the autonomy, dignity, will and preferences of service users is simply not possible so long as legal systems continue to tolerate substituted decision-making or segregation in institutions. Ongoing legal capacity reforms in our member states are very important in this respect. States must ensure that persons with mental health problems or psychosocial disabilities, including children, never lose their say on decisions involving their health, if necessary by providing the appropriate supports for decision-making, in order to ensure that mental health care is provided on the basis of free and informed consent. For as long as involuntary measures remain a reality, it is also crucial to ensure full access to justice to challenge any decision, an area where there are also some good practices, for example in the Netherlands.

As for institutions, I refer to the longstanding recommendations of my Office to put an end to their use, starting with immediate moratoria on future placements. Experience shows the crucial importance of closing large psychiatric hospitals where persons are involuntarily placed. To take one example, Italy was a pioneer in this respect by initiating a process of gradual closure of psychiatric hospitals from 1978, replacing them with alternatives closer to the community. While Italy is also facing a number of problems regarding the use of coercive measures in psychiatric establishments that still need to be addressed, it should be thought-provoking that the rate of involuntary placements in Italy today appear to be lower, by orders of magnitude, than in neighbouring states.

Reduction of coercive practices in psychiatric services, including the use of restraints and forced medication, and their progressive elimination should be another immediate priority. As mentioned above, the institutional culture and habits largely determine the prevalence of such measures. For example, my predecessor recommended to Denmark in 2013 that recourse to coercion in psychiatry be drastically reduced, and I was happy to note that a psychiatric centre in Ballerup had managed to put an end to the use of restraints as a first in the country, by training staff on conflict management and increasing physical activity for residents, without augmenting medication, for the benefit of both patients and staff.

The ultimate goal must be to replace institutions and a coercion-based mental health system by a recovery- and community-based model, which promotes social inclusion and offers a range of rights-based treatments and psychosocial support options. These can take many different forms and many models exist including, for example, support provided by peers or a support network, patient advocates/personal ombudspersons, advanced planning, community crisis resolution or open dialogue. It is also crucial to deconstruct the lingering stigma associated with seeking help for mental health problems, whether this is done in the school environment, at the workplace or in primary healthcare centres, through targeted awareness-raising and outreach. Only then can mental health services, as an integral part of primary care, be universally available to individuals throughout the entire life cycle. Once more, true involvement of persons with lived experience in the design, implementation, delivery and monitoring of these services is crucial.

Member states can take inspiration from several compilations of promising practices at the European and global levels, as well as ongoing projects and research conducted into community-based delivery of recovery-oriented mental health services, such as the RECOVER-E project running in Croatia, Montenegro, North Macedonia, Bulgaria and Romania. I am also conscious of the potential impact of new technologies on mental health care, which represent both opportunities and serious risks for human rights, and I refer to my general recommendations concerning human rights and artificial intelligence.

In this context, I encourage states to pay special attention to the mental health of children and adolescents, not least because of the extraordinary strain that the COVID-19 pandemic has placed on them. Lockdown measures and prolonged school closures have deprived them, more than other groups, of their usual routines, while exposing them to isolation and an increase in violence and abuse. We should not forget that childhood and adolescence are crucial periods for life-long mental health. Mental ill-health experienced in the formative years of one’s life, for example as a result of adversities or trauma, affects brain development and the ability to form healthy relationships and life skills. Children and adolescents therefore need non-bureaucratic access to mental health support, as early as necessary and as least invasively as possible, without any shame attached. Institutionalisation of children, on the other hand, has a devastating impact on childhood development. We also need to bear in mind that suicide was one of the leading causes of death among adolescents in the European region even before the pandemic, which makes recent evidence of a marked increase in anxiety levels, depression and self-harm among young people particularly alarming. In order to prevent future burdens on mental health systems, it is crucial to expand our capacities for early psychosocial interventions for children by building on innovative and community-based child mental health services, rather than pursuing the worrying trend of ever-increasing use of psychotropic medication on children.

Mental health reform is an extremely challenging task for all our member states, given the complexity of the issues and the huge gap between agreed international standards and the reality on the ground. This, however, makes it all the more urgent. Let us turn the current challenge of the pandemic into an opportunity, by thoroughly transforming mental health services in Europe, with human rights as our guide and compass.

Council of Europe

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