Introduction

According to the Universal Declaration of Human Rights (UDHR), human rights serve as the foundation for freedom, justice and peace in the world [1]. Neglect or violations of these rights, whether civil, political, economic, social or cultural in character, may have profound effects on health [2]–[8]. Currently, nearly half of the world's people live on less than $U.S. 2.00 per day with their health and well-being jeopardized by food insecurity, unsafe drinking water, inadequate sanitation, and poor access to education and basic health services [9]. These conditions are amplified by war, forced migration, violence and torture, ecological instability, and denial of access to basic education and to the benefits of scientific progress [10], [11]. Social and economic policies that result in extreme global inequality eclipse the right to the basic necessities of human survival and may have profound effects on health status.

The conceptualization of human rights as essential conditions for health was first articulated in the mid-1990's [2], [3]; since then, health professionals have increasingly recognized the importance of human rights in the protection and promotion of individual and global health [4], [12]–[16]. The importance of human rights in medical and health practices has been recognized in a number of statements and publications by professional health organizations [17]–[20]. In 2000, the United Nations (UN) provided a detailed elaboration of state responsibilities to protect, promote and fulfill the right of individuals to the “highest attainable standard of physical and mental health” contained in Article 12 of the International Covenant on Economic, Social and Cultural Rights [21]. In its General Comment 14, the UN recognizes that health is a product of respect for many human rights, including “the rights to food, housing, work, education, human dignity, life, non-discrimination, equality, the prohibition against torture, privacy, access to information, and the freedoms of association, assembly and movement,” among others [22]. In 2002, the UN Commission on Human Rights appointed a Special Rapporteur on the Right to Health, who is charged with the duty of reporting on the status of the right to health around the world and making recommendations on appropriate measures to promote and protect this right [23]. In 2005, the UN Educational, Scientific and Cultural Organization (UNESCO) developed a Universal Declaration on Bioethics and Human Rights, which, among other goals, aims to promote respect for human dignity and protect human rights by ensuring “respect for the life of human beings, and fundamental freedoms, consistent with international human rights law” [24].

The importance of human rights as conditions for health is also evident from the UN Declaration of Commitment on HIV/AIDS, which acknowledges that the full realization of human rights is an essential element in all areas of the global response to the epidemic, and sets out specific goals and actions to realize those rights [25]. Together, health professionals and human rights advocates have developed a World Health Organization (WHO) Framework Convention on Tobacco Control, one of the most widely supported treaties in the history of the UN, to address the growing global epidemic of tobacco-related diseases [26]. In addition, physicians and other health practitioners and scientists who have applied their knowledge and skills for the protection and promotion of health and human rights (HHR) [27] have been awarded the Nobel Peace Prize [28], [29].

In 1999, The World Medical Association stated that medical ethics and human rights are an “integral part of the work and culture of the medical profession” and therefore the “teaching of Medical Ethics and Human Rights [should] be included as an obligatory course in their curricula” [30]. Despite the growing understanding of the significance of human rights in the protection and promotion of health and recognition of the need to teach human rights in health professional curricula, formal human rights education is lacking in schools of medicine (SOMs) and public health (SPHs). In 1996, a survey of all U.S. SOMs reported that approximately half of the schools included at least one of 16 human rights issues in their required bioethics courses [31]. The study may have overestimated the inclusion of human rights in medical school curricula as only 6 of the 16 issues pertained directly to human rights (10 pertained to bioethics) and the extent to which human rights and bioethics topics were addressed in the required bioethics courses was not assessed. It is important to distinguish bioethics from human rights: bioethical principles are codes of conduct that regulate clinical encounters with individual patients. They do not attempt to define health and well-being, nor do they indicate possible causes of human suffering [32], [33]. Human rights, however, encompass a broader concept that considers the social, economic, cultural, and political conditions that promote health and respect human dignity. In a survey of all 28 U.S. SPHs in 1996, five schools (17%) reported offering a HHR course [34]. In a 2002 assessment, 19% of American SPHs and 2% of SOMs were found to offer coursework in human rights [32].

The current status of HHR education and challenges to its inclusion in medical and public health curricula is not well known. We therefore conducted a cross-sectional survey among deans of all accredited allopathic medical and public health schools in the United States and Puerto Rico with the following aims: 1) to determine the nature and extent of HHR education among schools of medicine and public health; 2) to identify perceived barriers to implementing HHR curricula; 3) to learn about deans' interests and attitudes toward HHR education, and; 4) to identify factors associated with offering HHR education.

Methods

Anonymous surveys were mailed to deans of the 125 accredited allopathic SOMs and 37 SPHs in the United States and Puerto Rico. Deans were given the option of designating a representative to complete and return the survey which could be returned via fax, post, or email.

Deans were contacted at least three times between June 2006 and May 2007 to request their completion of the survey, which was adapted from previous studies on HHR education [31], [32]. The following definition of “human rights” was used in the survey cover letter to deans:

Human Rights seek to promote the inherent dignity of all people without distinction of any kind and, according to the Universal Declaration of Human Rights, serve as the foundation for freedom, justice and peace in the world. In recent years, many have recognized human rights as essential conditions for health. These include civil and political rights (i.e. freedom from arbitrary deprivation of life, torture and ill treatment, freedom of thought, conscience, religion, opinion, expression, peaceful assembly, association, movement, and rights to equality before the law, due process and to participate in government, among others) which are interdependent and indivisible with economic, social and cultural rights (i.e. the right to work, fair wages, social security, basic education, and standards of living adequate for health and well-being, and freedom from hunger, among others).

Structured survey instruments were used to collect information on school location, size of the student body, HHR education status and format, and barriers to offering HHR education. Additionally, the survey explored deans' interest in developing future HHR education for students, their beliefs on the most appropriate format for educating students about HHR, their attitudes toward the importance of HHR education within their school, and attitudes toward the importance of health professionals' knowledge of HHR for use in their careers. Deans were requested to select one answer for most questions; however, they were allowed to check all options that applied when asked about the format of their current HHR curriculum, their beliefs of the most appropriate type of HHR curriculum, and barriers to HHR education. Out of 162 schools contacted, deans of 115 schools responded and seven deans of SOMs declined participation for a final sample size of 108 and a participation rate of 67% (SOM = 65%, 81/125; SPH = 73%, 27/37). Written informed consent was obtained prior to participation in the survey. This study was approved by the Committee for the Protection of Human Subjects at the University of California, Berkeley.

Since our study represents a large proportion of the target population of deans of all SOMs and SPHs, p-values for all statistical analyses are adjusted using a finite population correction. For count data, we applied the second-order correction developed by Rao and Scott [35], [36]. The corrected chi-squared (χ²) is then transformed into an F statistic by dividing χ² by its degrees of freedom of d₀ = (R−1)(C−1) where R is the number of rows and C is the number of columns. The F statistic is then taken to have numerator degrees of freedom equal to d₀ and denominator degrees of freedom equal to (n−1)d₀. We also used multiple logistic regression models to identify factors associated with offering HHR education. The dependent variable was defined as offering any HHR education including an elective or required course or seminar, or one or more modules of an elective or required course. Independent variables included school type (SOM versus SPH), funding source (public versus private) and two variables assessing attitudes towards HHR education; these variables were determined based on responses to the following questions: 1) “How important do you feel it is to offer a human rights course or module in your Medical/Public Health curriculum?” and 2) “How important do you feel it is for students to understand the role of human rights in their future health practice?” Each variable was coded continuously as 0 = not at all important; 1 = somewhat important; 2 = important; and 3 = very important. Models were adjusted for school size (<200, 200–500, >500 students) and location as determined by U.S. census categories (Northeast, Midwest, South, West). A finite population correction equal to was also applied to coefficients obtained by multiple logistic regression.

Statistical analyses were performed using STATA version 10.0 (StataCorp, College Station, TX). Two-tailed finite population corrected p-values<0.05 were considered statistically significant.

References were identified through a search in PubMed using the key words health and human rights, with education, curriculum, global health, or bioethics.

Results

Discussion

Approximately one-third of deans of SOMs and SPHs reported that some form of human rights education was offered at their institutions during the past year. The number of institutions offering required or elective HHR courses overall is considerably lower (22%). Approximately 66% of SOMs and 46% of SPHs do not currently offer HHR courses, and only 34% of all schools currently not offering HHR education are interested in incorporating it into their curricula in the future. HHR education may be even less common than these numbers suggest as deans of schools offering HHR education or interested in offering it may have been more likely to respond to our survey. Participants may also have over reported human rights education at their institutions. This is supported by the fact that the number of elective and required HHR courses in SPHs and SOMs reported in this study are approximately two and three times higher, respectively, compared to that reported in 2002 [32]. In addition, less than two-thirds of the elective and required HHR courses or seminars reported by the deans in this study are available in an updated listing of HHR courses offered by SOMs (5 courses) and SPHs (8 courses) reported by a consortium of health and human rights educators [37]. Although prospective participants received a detailed definition of HHR education, it is possible that they considered bioethics courses as human rights courses since both are concerned with respect for human dignity.

The most common barrier to HHR training reported by deans of SOMs and SPHs was competition for time in students' schedules. Other barriers identified were lack of qualified instructors, funding, administrative support and curriculum board support. The results of our multiple regression model suggest that lack of funding may be an important determinant of whether HHR training is offered as private schools were significantly more likely to offer HHR education compared with public schools. In addition, 42% of schools not offering HHR training and 50% of SPHs not offering HHR training reported funding as a barrier. These barriers can and should be addressed, as evidence suggests that there is strong student interest in HHR education. For example, students have initiated chapters of Physicians for Human Rights in nearly half (45%, 56/125) of all medical schools over the past 8 years, the majority of which were established in the past 2 years [38]. During the past year alone, students at 11 of these medical schools initiated HHR education electives, journal clubs and conferences independent of their curriculum [38]. In addition, 18 student groups have accessed online health and human rights course materials developed by the Human Rights Center at the University of California, Berkeley. A survey conducted in 46 countries, including the United States, demonstrated that medical students had a clear interest in human rights education; 55% of respondents believed a HHR framework should be compulsory, and even more believed that it was the duty of health professionals to be actively involved in the promotion of human rights [39]. In addition, other studies have shown that student interest in similar topics such as global health, health disparities, and vulnerable populations is at unprecedented levels [40], [41].

Deans of SOMs and SPHs reported favorable attitudes toward HHR education. Despite recognition of the importance of human rights in the promotion of health in medical and public health journals, by health professional organizations including the WHO and the UN, by deans of SOMs and SPHs, and by medical and public health students, there is no formal mandate for HHR education in professional health schools. While various barriers to HHR education exist, we found that deans' attitudes toward the importance of HHR training are the single most important factor associated with HHR education in U.S. SOMs and SPHs.

Supporting Information