Losing progress on human rights

Gavin and Jessamy are joined by Mandeep Dhaliwal, Director of UNDP’s HIV, Health and Development Group, to discuss the access to health and freedom of the most vulnerable people around the world. Are we maintaining progress on rights, or are we in danger of backsliding?

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello and welcome to The Lancet Voice. It's July 2024 and I'm Gavin Cleaver. I'm joined as ever by my co host, Jessamy Bagnall. In this episode, we're focusing on the critical importance of protecting the rights and health of vulnerable populations. And we're honored to be joined by Amandeep Dhaliwal, Director of the HIV Health and Development Group at the United Nations Development Programme, the UNDP.

We're going to discuss the direction of travel in legislation to protect vulnerable people, talk about the challenges faced by marginalized populations, and how the health community can help advocate for human rights. So please enjoy our conversation now with Mandeep Dhaliwal.

We are joined by Mandeep Dhaliwal, who's the director of HIV health and development at the UNDP. Mandeep, thank you so much for joining us. It's a real pleasure to have you. 

Mandeep: It's a pleasure to be with you. Thank you. 

Gavin: You've got a lot of specific interests in your role at UNDP, but I thought perhaps we could start off by just walking through the current global landscape, particularly when it comes to health and human rights of a Marginalized communities, which you do a lot of work in. What is the current, what's the current global landscape? 

Mandeep: Thanks so much, and I think a really important question Unfortunately in spite of years of progress in terms of increasing access to services for marginalized populations, people living with HIV, we see that we're still not making progress in terms of reducing new infections in these populations.

You're going to hear at the upcoming AIDS conference with the launch of a new report that the majority of new infections are in key populations including in, in Africa. And so we're not doing well in terms of removing the kinds of barriers that prevent to improve prevention outcomes for marginalized and key populations.

So infections are going up. Access to pre exposure prophylaxis is not being scaled up sufficiently. And you have laws Policies and practices which are violating their human rights, which make it more difficult for them to access HIV prevention and treatment. We are in a state where things are not where they should be.

I think part of the issue, really, is that we've, we're seeing a very well organized, funded Push back on human rights on gender equality and on civic space and civil society in particular have been critical, especially community groups in outreach in support and in access to services for marginalized populations.

So around the world countries are facing multiple crises and pushback on gender equality, human rights and civic space. And this has devastating consequences for particularly marginalized communities and including those affected by HIV. 

Gavin: What sort of time frame would you say this is operating in? In the sense of, if we take a long view, are things actually backsliding the last few years?

Mandeep: Indeed, things are backsliding. I think we started to see important progress on human rights in the context of the HIV response in the early days where human rights was at the core of everything that UNAIDS spoke about in terms of HIV responses, everything from the greater involvement of people living with HIV and AIDS, to the removal of stigma and discrimination, to removal of punitive discriminatory laws and laws which criminalize the very populations that you need to reach with services and support.

We were making progress, and I'll cite the landmark report of the Global Commission on HIV and the Law, which UNDP convened on behalf of UNAIDS, where we started to really get some serious attention Both at the global level and at the country level on the need to remove laws which are really costing lives in the context of, and wasting money in the context of HIV responses.

Since then, 90 countries had been working, governments working together with civil society, with communities with academia and really taking a hard nosed look at their laws and making changes in their legal environments to facilitate laws which support HIV responses, which support rather than punish.

Over the last few years, we are seeing a really, as I said, a well organized pushback on human rights, gender equality, and civic space. And, UNDP publishes its flagship human development report. Starting as early as 2022, we started seeing that rising insecurity and polarization were preventing the kind of solidarity and collective action that we need to tackle the world's greatest challenges like HIV.

I think there's a broader context of, insecurity, polarization, a lack of trust, erosion of trust in which it is really marginalized populations and affected communities who are paying the price. Because in that context it becomes very easy to target otherwise marginalized populations.

And, just for, I'll give you an example, sex workers during the COVID pandemic due to the lockdowns were couldn't make an income. And were, deprived of basic human rights increased stigma and discrimination towards them. Similarly, LGBTI people and, during during the lockdowns, were not able to access services.

I think there's in a context where there's stress, polycrisis erosion of trust, and an organized, coming together with an organized, funded pushback on human rights, gender equality, and civic space, is making for a toxic mix for the very populations that we need to be reaching if we're going to get to the end of AIDS by 2030.

Jessamy: Thanks so much for that. And I just wondered whether for our listeners, you touched on it there, but just for people who maybe don't have the same context as you do with your kind of deep expertise, but what are the types of laws that we're talking about here? And how do they impact people's health?

So when you were talking about countries reviewing, the different sort of legal and Status, what are the, what are they looking at and what are they changing? 

Mandeep: So we're looking at laws which have been on the books for years, which criminalize same sex relationships laws, which criminalize sex work laws, which criminalize the possession of small amounts of drugs for personal use or paraphernalia for drug use.

We're looking at laws which criminalize exposure, non disclosure, transmission of HIV. So these are the kinds of laws which actually are further marginalizing and pushing people away from services and underground. So those are the kinds of laws that countries are looking at. Today, a third of all countries criminalize same sex relationships, and in just last year, in 2023, anti LGBTIQ plus discriminatory legislation surged in some parts of it.

But at the same time, we're also seeing countries do the right thing. So there are countries that have decriminalized also. 2022, more countries removed same sex laws than in any single year in the past 25 years. But still, we are being confronted by this pushback, which is quite problematic.

moved 

Jessamy: in the right direction? Maybe we can come to that in just one minute but I just wanted to say, with the countries where we're seeing this backtracking and we know we're trying to aim towards a kind of state where everybody has the same access to health from a public health point of view we want everybody to be healthy.

So in these countries and geographies where there's a kind of backtracking of some of these laws which are actively excluding people from the health systems, what are the types of interventions that you are involved in or that you're aware of that can work in those situations that can be get arounds or can help people to access the care that they need when there are you know, large scale legal barriers to them doing that, that, those kind of things.

Mandeep: There's a lot of, there's a range of different solutions. So I'll give you the example of Botswana, for example, where despite the criminalization of sex work, the law in the books the president at that time, President Festus Mohi issued an executive order saying that the police should not arrest sex workers.

So everything from legislation, executive executive orders to arrangements for people to access services, community based services are critical. So sex worker supported programs for outreach to provide services are critical in those kinds of contexts. That is super important. Training of healthcare providers as well as police on stigma, discrimination and human rights is also vital in these kinds of contexts.

Jessamy: From an NGO point of view or, from an international kind of multilateral situation where you're working in countries which have a very different legal framework beyond those kind of executive orders and what the government can do, what are the practicalities of. of how those types of organizations are working in these settings?

Mandeep: As I said, I think the community led responses and the investments in That's investing 

Jessamy: in the community. 

Mandeep: Investing in the community, investing in the community's capacity to challenge these structural barriers is critical. And UNDP with the support of of partners is working to In 44 with 44 key population organizations or organizations of marginalized populations to remove these kinds of structural barriers in 21 countries.

And we see that the most effective thing in this kind of a situation is to invest in the capacity of these, Community led organizations led by sex workers, people who use drugs, men who have sex with men, transgender people living with HIV, to challenge the structural barriers.

And I'll just come back to the Global Commission on HIV and the law. What was really powerful about this commission was the fact that UNDP convened communities directly with lawmakers. So we got communities together with parliamentarians, judges, police decision makers to talk about the impact of law.

positive or negative protective or punitive on their lives. And that was incredibly powerful. That's an amazing. Yeah. And I think those are the kinds of things which shift norms and practices, which facilitate access to services. So that's why I think rather than having multilaterals and academics on their own, Talking to decision makers and lawmakers.

It is really a very powerful to bring communities together with decision makers, policymakers, and it works on the flip side as well. We've been supporting the secretariat of a judicial forum in Africa. This is judges from Francophone, Anglophone, and Lusophone Africa who get together to talk about jurisprudence, the latest jurisprudence on, on HIV LGBTI inclusion and rights and the law.

And it's very interesting to hear them say actually, it's through meeting the community and meeting my peers that I understood that I had these these implicit biases or that, I didn't understand a particular issue and it's by this kind of gathering and convening that I'm able to confront my biases and do a better job at applying the law fairly and more justly.

So I think this kind of convening of community with with lawmakers, with judges, with parliamentarians is really the way to to help shift some of these things in a way that's very powerful. 

Jessamy: Yeah, that absolutely must be the way forward. And as let's go back to where you wanted to go before about some exemplars of countries and geographies that Yeah, 

Mandeep: exactly.

Yeah. Exactly. And I think we've heard, we've heard a lot about legislation, punitive legislation in countries, but we don't hear as much about the good news. Yeah. Good news, if, for example, in Dominica they have a law decriminalizing consensual same sex relations, which was brought to the courts by a gay man.

And, which followed efforts by local and regional civil society groups. Similarly, we've got a, we've got for the first time in the UN Commission on Narcotics, Narcotic Drugs, we have a resolution which recognizes harm reduction. South Africa is making positive movements towards sex work decriminalization.

Thailand became the first country in Southeast Asia to recognize same sex relationships. The recent judgment from Namibia. A legal case brought to the high court by a gay Namibian man has led to this colonial anti LGBTIQ plus legislation being struck down. So I think we're seeing that there is definitely a movement towards equality, towards justice, towards being towards inclusion and being able to access, populations being able to access services.

But we are being confronted in a way that I have not seen in the four decades of the HIV response that I've been involved in. I have not seen this kind of an organized, funded pushback on human rights. on gender equality in civic space. So we have a big challenge. We have progress, but there's an extreme challenge that 

Jessamy: we need to deal with.

Do you see people in the health community people that are going to be listening to this podcast, people that, read the Lancet, are we doing enough? Are we alive enough to this topic? And what would you like to see happening? 

Mandeep: I think the Lancet just convened a commission on human rights and health.

You did? And so I think you are, you're doing the right thing. You're heading in the right direction. But I would like to see Maybe 

Jessamy: even from our listeners, from the jobbing clinician, to the person that's working in public health, to the community health worker. Are we as a kind of broad collective group of professionals doing enough in this space?

Mandeep: I think in the same way that we've seen the greater engagement of the health sector and the health community and health professionals in the fight against climate change, we need to be as vocal, as explicit about human rights, that without human rights, there cannot be health and being for all.

And that, Human rights violations are as much of a problem as any disease. It's a disease unto itself and human rights violations are, lead to poor health outcomes. We have lots of evidence. So I think it's time for the health sector to, and this is why I love the Lancet, to get more political.

Good, we're always up for that. Yeah, I absolutely think that is very important. And I think we have big political challenges, right? We have we have political challenges around human rights in relation to new net, new technologies the impact of The impact of the use of new technologies on health versus, how the positive versus the negative certainly, HIV, which is, the job is nowhere near done the human rights challenge is central at this point, and we have to bring it back into the center of the response if we're going to get to the end of AIDS by 2030.

Unfortunately, I think what's happened is that, Human rights became like a programming stream like we it became about services rather than about the fundamental the fundamentals of the response. So I think we need to get back to that. We need to keep Rick calling out The impact of discriminatory policies on health and HIV.

55 percent of all new infections in 22, 2022, occurred among key populations and their sexual partners. Gender equality, inequality is one of the biggest risks for women in Sub Saharan Africa. We still have 9 million people who don't have access to antiretroviral therapy. Science is delivering the most incredible advances in terms of new technologies for pre, for prevention.

But, are they going to be delivered to people in need? We've got clinical trials for Lenacapivir, amazing for PrEP. But at 42, 000 a, a pop, who's going to be able to afford that? So we need to also get back and we need the health community and health providers to be, on the streets around access to PrEP and access to new health technologies, making sure that everybody has access everywhere.

Gavin: This does bring me on quite nicely actually to the question I was going to ask, which is, we've been talking about backsliding. And new barriers and you mentioned quite compellingly how this sort of movement against human rights is not something that you had seen in your time working in the area So do you think there's a sort of we've in high income countries We've been in a sort of consensus of the positivity and usefulness of human rights for health for a few decades now.

But do you think there is a danger this consensus could actually be not swept away, but quite damaged by the political forces swirling around the world at the moment? 

Mandeep: I think so, because I want to come back. I think often about, the levels of mistrust, lack of trust, the uncertainty, just the unhappiness that we see in across the high income countries as well, and I do think we cannot take human rights for granted in that kind of, in that kind of environment.

Because it becomes very easy to target and to other people in that kind of an environment. And then before you know it, you are backsliding on the rights of transgender people, the rights of people living with HIV, the rights of men who have sex with men. So I think there's a real threat. In a world that is deeply polarized, where, technology is used to drive and deepen divisions where there's increasing uncertainty and increasing conflicts around the world.

I think, yeah, we can't take it for granted anymore. 

Gavin: How do you think we can best uphold this consensus? 

Mandeep: I think the health sector has an important role to play. Just as the health sector. is compelling, is a very compelling voice in the fight against climate change. I think it, it is a very compelling voice in, in the fight for health and being for all.

And I really, I was delighted to see that this commission was convened by the Lancet because I think the health sector, health professionals need to be more vocal about the importance of protecting and promoting rights for health. And at a time where things are feeling under threat, that's the time to be even more vocal and not shy away from it.

So I almost want to see a doubling down in the health community, in the HIV community on the need to promote and protect rights. 

Gavin: I think particularly across the U. S. at the moment, it must feel very difficult for people who are living in states that are quite Republican dominated. And there seems to be an incredible amount of legislature coming out of states at the moment targeted at vulnerable populations.

Mandeep: I think this is what I was saying more generally about, when you have people who are struggling in their daily lives, as many people are across the world when you have polarization, when you have division. And uncertainty and a lack of trust in institutions it is difficult, it is very challenging and it becomes easier to, to target someone that's seen as being on the margins of society.

So we're creating a, an environment where this backlash is growing roots and I think that's really the challenge and that's why the voice is to call it out. And the voice and, the credibility of the health sector, I think, is really important to bring to the table. And we have, as health professionals, an important role to play to say that, to highlight that stigma, discrimination and criminalization.

Deny people their dignity and rights, but it doesn't just affect those people it affects everyone So there's a need to renew and strengthen commitment to health and human rights and especially in this environment So in the same way as the climate is deteriorating The health sector is reaffirming and renewing and strengthening commitment to health and climate.

We need to do exactly the same for health as a health community. 

Gavin: I think that's a very interesting comparison. You mentioned that it's been a sort of unprecedented time for backsliding on human rights. Is there a particular incident or moment that sticks out to you in your role, something that you came across that you really thought, wow.

Mandeep: I don't think there's a moment per se, but I do feel it's the frequency that I monitor, how often do I get up in the morning? And the first thing I need to do is deal with an email where a country office is saying, Oh actually we have to help these community groups that are being thrown in jail, or the frequency of those kinds of things.

of things is increasing. So it's not just the odd place here and there, it's now every region pretty much, and it's happening much more frequently. 

Gavin: Thinking about it from a kind of global health architecture sense, is there anything you can think of that would make the work of kind of NGOs a multi lateral?

Easier given what we've talked about, what sort of frameworks need to be in place to better support the sort of work that you do and help support? 

Mandeep: I think they, one of the things that I think is critical is that, when we talk about member states in the multilateral system, often that is.

interpreted as meaning just government. And I think what's really important is to have civil society and communities at the table, involved centrally in the governance. And that would, that I think would really give teeth to the kind of convening I was discussing earlier, where we bring community and civil society together with different parts of of the executive and and judicial branches of government.

So I actually think that as a multilateral, it's important for us to think about how we can. More meaningfully and more systematically and consistently involve civil society and communities in, in governance. And that could help to shift. Convening, convening civil society and community, creating that space, creating safe spaces for that kind of engagement in the meantime is very important.

Gavin: Yeah, what are some kind of good methods of creating that space? 

Mandeep: I think, just making it implicit to the methodology of what you do. So if we're putting out a, we the Global Commission, I think was an ex, was an extraordinary exemplar, we brought, we had a series of regional dialogues where for each region, we were able to bring activists, criminalized people, together with lawyers, judges, parliamentarians, police, and for them to be able to hear about the impact of laws.

And for the communities to hear, the considerations that, you know, that the policy makers were dealing with, the decision makers were dealing with. I think creating that kind of policy dialogue and using the, using the convening power of the multilateral system is a very good way of doing these things, particularly on issues that are very challenging, where people wouldn't otherwise be able to talk to each other.

Gavin: Absolutely. Finally, then, what's on your wish list for the next few years? What sort of What action would you like to see happen and I guess to stop this backsliding to to get us moving in a positive direction again? 

Mandeep: I'd like to, I would like for people, I'd like to see a greater understanding of the role that human rights and particularly human rights in the area of health can play in rebuilding trust in societies and in institutions.

In really creating more social cohesion and reducing the kind of division that and polarization that we see in our societies. And I would love to see the health sector. and health professionals speaking out as passionately about health and human rights as they do now, as they're starting to do now about health and climate.

So for me, I think the engagement of the health community is really super important. I would like to see a stop A moratorium on laws criminalizing the most marginalized people in our societies who actually need access to services. To sustain the fight against HIV, we need to uphold the dignity of the very people who are on the margins of society.

And we need to have a rights based and people centered approach to do that. And that requires investment. We need investment. In communities, in, particularly in communities of marginalized populations, for them to be able to dismantle these structural barriers. Otherwise we are not going to get to the end of AIDS by 2030.

Gavin: Yeah, I think that's a lot for our listeners to to think about. And I really like the message of equivalence between campaigning for health and, action on the climate. With health and human rights. Mandeep dhaliwal. Thank you so much for joining us It's been a really enlightening chat and we really appreciate your time.

Mandeep: Thank you very much. Thank you. It's been a pleasure to speak with you

Gavin: Thanks so much for listening to this episode of The Lancet Voice, and remember, you can subscribe to The Lancet Voice wherever you usually get your podcasts. We'll see you again back here next time.