More than 13,500 asylum seekers remain trapped on the Greek islands in deplorable conditions as winter begins on December 21, 2017. Greece, with support from its European Union partners, should urgently transfer thousands of asylum seekers to the Greek mainland and provide them with adequate accommodation and access to fair and efficient asylum procedures.

Author: Human Rights Watch, Human Rights Watch
Posted: January 1, 1970, 12:00 am

(New York) – The latest revisions to China’s Criminal Law impose up to seven years in prison for “spreading rumors” about disasters, Human Rights Watch said today. The revised law, which took effect November 1, 2015, does not clarify what constitutes a “rumor,” heightening concerns that the provision will be used to curtail freedom of speech, particularly on the Internet.

“The revised Criminal Law adds a potent weapon to the Chinese government’s arsenal of punishments against netizens, including those who simply share information that departs from the official version of events,” said Sophie Richardson, China director at Human Rights Watch. “The authorities are once again criminalizing free speech on the Internet, which has been the Chinese people’s only relatively free avenue for expressing themselves.”

The National People’s Congress Standing Committee approved the addition of a provision to article 291(1) of the Criminal Law (Criminal Law Amendment Act (9)), which states that whoever “fabricates or deliberately spreads on media, including on the Internet, false information regarding dangerous situations, the spread of diseases, disasters and police information, and who seriously disturb social order” would face prison sentences – with a maximum of seven years for those whose rumors result in “serious consequences.” The vagueness of the provision means that individuals doing nothing more than asking questions or reposting information online about reported local disasters could be subject to prosecution.

In the past, the Chinese government has detained netizens who questioned official casualty figures or who had published alternative information about disasters ranging from SARS in 2003 to the Tianjin chemical blast in 2015, under the guise of preventing “rumors.”

The revision was made in the context of a wider effort to rein in online freedom since President Xi Jinping came to power in 2013:

  • In August 2013, the authorities waged a campaign against “online rumors” that included warning Internet users against breaching “seven bottom lines” in their Internet postings, taking into custody the well-known online commentator Charles Xue, and closing popular “public accounts” on the social media platform “WeChat” that report and comment on current affairs;
  • In September 2013, the Supreme People’s Court and the Supreme People’s Procuratorate (the state prosecution) issued a judicial interpretation making the crimes of defamation, creating disturbances, illegal business operations, and extortion applicable to expressions in cyberspace. The first netizen who was criminally prosecuted after this took effect was well-known blogger Qin Huohuo, who was sentenced to three years in prison in April 2014 for allegedly defaming the government and celebrities by questioning whether they were corrupt or engaged in other dishonest behavior;
  • In July and August 2014, authorities suspended popular foreign instant messaging services, including KakaoTalk, claiming the service was being used for “distributing terrorism-related information”;
  • In 2015, government agencies such as the State Internet Information Office issued multiple new directives, including tightening restrictions over the use of usernames and avatars, and requiring writers of online literature in particular to register with their real names;
  • In 2015, the government has also shut down or restricted access to Virtual Private Networks (VPNs), which many users depend on to access content blocked to users inside the country and also help shield user privacy;
  • In March 2015, authorities also deployed a new cyber weapon, the “Great Cannon,” to disrupt the services of, an organization that works to document China’s censorship and facilitate access to information;
  • In July 2015, the government published a draft cybersecurity law that will requires domestic and foreign Internet companies to increase censorship on the government’s behalf, register users’ real names, localize data, and aid government surveillance; and
  • In August 2015, the government announced that it would station police in major Internet companies to more effectively prevent “spreading rumors” online.

Activists in China are regularly prosecuted for speech-related “crimes,” Human Rights Watch said. The best known of these crimes is “inciting subversion,” which carries a maximum of 15 years in prison. But authorities have also used other crimes such as “inciting ethnic hatred,” as in the case of human rights lawyer Pu Zhiqiang, who has been detained since May 2014 for a number of social media posts questioning the government’s policies towards Uighurs and Tibetans.

While providing the public with accurate information during disasters is important, the best way to counter inaccurate information would be to ensure that official information is reliable and transparent, Human Rights Watch said.

Above all, journalists should have unimpeded access to investigate and inform the public about these events, and the wider public should have the freedom to debate and discuss disaster response.

“The casualties of China’s new provision would not be limited to journalists, activists and netizens, but the right of ordinary people and the world to know about crucial developments in China,” Richardson said. “The best way to dispel false rumors would be to allow, not curtail, free expression.”

Posted: January 1, 1970, 12:00 am

Human Rights Watch launched a public campaign on January 19, 2018, calling for an end to Lebanon’s waste crisis.

© 2018 Human Rights Watch

(Beirut) – Human Rights Watch will launch a billboard and online campaign on January 19, 2018, to end the waste management crisis in Lebanon, Human Rights Watch said today. The campaign calls for an end to the dangerous practice of open burning of waste and for parliament and the cabinet to adopt a national waste management law and strategy that cover the entire country and comply with environmental and public health best practices and international law. The petition is online here.
In December 2017, Human Rights Watch issued a 67-page report, “‘As If You’re Inhaling Your Death’: The Health Risks of Burning Waste in Lebanon,” finding that authorities’ lack of action to end open burning of waste across Lebanon is posing serious health risks for nearby residents, violating their right to health under international law. Children and older people are at particular risk. Open burning of waste is a dangerous and avoidable consequence of the government’s decades-long failure to manage solid waste in a way that respects environmental and health laws designed to protect people.
“Through this campaign we want to raise awareness about the ongoing danger open burning poses to families across Lebanon, and of the need for urgent action to stop open burning and adopt a sustainable long-term strategy,” said Lama Fakih, deputy Middle East director at Human Rights Watch. “Open burning is one symptom of the larger waste management crisis in Lebanon and is a serious threat to public health.” 
On January 9, the health minister ordered the inspection of open dumps across Lebanon for violations, stressing the prohibition on open burning. On January 11, the cabinet approved a waste management plan, presented by the Environment Ministry, that outlines a decentralized waste management system; stresses reduction, sorting, and recycling; and calls for gradually closing and rehabilitating open dumps. The Environment Ministry is developing a detailed national strategy on the basis of this plan. 

People living near open burning said they were unable to spend time outside, had difficulty sleeping because of air pollution, or had to vacate their homes when burning was taking place. 

Lebanon does not have a solid waste management law or strategy for the entire country. In the 1990s, the central government arranged for waste collection and disposal in Beirut and Mount Lebanon but left other municipalities to fend for themselves without adequate oversight, financial support, or technical expertise. As a result, dumping flourished across the country, with open burning of waste taking place at 150 dumps every week according to the Environment Ministry. The open burning disproportionately takes place in lower income areas, Human Rights Watch found.
Lebanon’s cabinet approved a draft law in 2012 that would create a single Solid Waste Management Board, headed by the Environment Ministry, responsible for national-level decision-making and waste treatment, while leaving waste collection to local authorities. However, parliament has not passed the bill. The joint committees of parliament considered an amended draft of that law on January 9, and returned it to the environment committee for further amendments.
The Environment Ministry says that open burning violates Lebanon’s own environmental protection laws. The government’s lack of effective action to address the issue also violates Lebanon’s obligations under international law, including the government’s duties to respect, protect, and fulfill the right to health. Human Rights Watch found that the Environment Ministry lacks the necessary personnel and financial resources for effective environmental monitoring.
According to researchers at the American University of Beirut, 77 percent of Lebanon’s waste is either openly dumped or sent to landfills even though they estimate that more than 80 percent could be composted or recycled.
Recent discussions around a long-term plan for waste management in Lebanon have focused on the use of incineration plants. Human Rights Watch does not take a position on the particular waste management approach that Lebanon should pursue so long as it complies with environmental and public health best practices and international law. But some public health experts and activists in Lebanon have opposed the use of incineration, citing concerns about independent monitoring, potential emissions, and high costs. 
The public campaign launched today was made possible by generous support from Pikasso.
“Although the government moved the garbage off the streets of Beirut, the more than 900 open dumps across the country continue to pose environmental health risks,” Fakih said. “The government needs to show leadership on this issue and put in place a solution that respects people’s right to health.”
Posted: January 1, 1970, 12:00 am

Smoke billows behind a building in the Yemeni capital Sanaa on December 3, 2017, during clashes between Houthi rebels and supporters of Yemeni ex-president Ali Abdullah Saleh. 

© 2017 Getty Images

(Beirut) – Lawless armed conflicts in the Middle East and North Africa (MENA) morphed into disastrous trends for the region in 2017, Human Rights Watch said today in releasing its 2018 World Report.

“Failed leadership, failed governments, and failed policies have brought nothing but catastrophe for the youth and future generations of the Middle East caught up in the region’s wars,” said Sarah Leah Whitson, Middle East and North Africa director at Human Rights Watch. “The legacy of these wars will be recorded as the ‘shame of the century’ for the Middle East.”

In the 643-page World Report, its 28th edition, Human Rights Watch reviews human rights practices in more than 90 countries. In his introductory essay, Executive Director Kenneth Roth writes that political leaders willing to stand up for human rights principles showed that it is possible to limit authoritarian populist agendas. When combined with mobilized publics and effective multilateral actors, these leaders demonstrated that the rise of anti-rights governments is not inevitable.

The top five trends in the region’s wars included:

  1. Chemical and Other Banned Weapons as the New Normal: The Syrian government, backed by its Russian allies, has used banned chemical weapons, and in Yemen, the United States-supported Saudi-led coalition has used widely banned cluster munitions. Human Rights Watch documented dozens of instances in which the Syrian government used chemical weapons in Syria, including littering Aleppo with chlorine-filled barrel bombs. The Islamic State (also known as ISIS) also used chemical weapons in both Syria and Iraq. The Russian government effectively blocked the only body whose job it was to attribute responsibility and pave the way for sanctions against Syria for using chemical weapons by vetoing the Joint Investigative Mechanism’s Mandate at the United Nations Security Council. Human Rights Watch also documented the Saudi-led coalition’s repeated use of cluster munitions in Yemen – including those made in the US and Brazil. Houthi-Saleh forces made wide use of anti-personnel landmines, despite repeated promises not to use this weapon, which leaves behind unexploded bomblets that harm civilians for generations.

“While the world moves to end the scourge of chemical weapons, cluster munitions, and landmines, the Middle East has made these disgusting weapons the new normal in warfare,” Whitson said. “It’s repellent that arms manufacturers continue to profit off the sale of banned weapons.”

  1. Starving Children During War: Beyond bombing homes, schools, hospitals, and irreplaceable cultural architecture in the region, the Syrian government and Saudi-led coalition have each resorted to blocking aid and impeding critical supplies from reaching starving children. The Syrian government imposes sieges in various regions of Syria, including in so-called “de-escalation zones” such as Ghouta, severely restricting access to food and medical care for the civilian population. The Saudi-led coalition imposed a nation-wide blockade on all of Yemen’s ports and airspace, in a country where malnutrition, cholera, and diphtheria were already ravaging children and have now reached epidemic levels. The UN secretary-general placed the Saudi-led coalition on his annual “List of Shame” for violations against children, despite extraordinary threats and bullying by the Saudi government to be taken off the list.

“It is deeply disturbing that Arab governments are deliberately starving Arab children during wartime,” Whitson said. “The cruelty and barbarism on display in the Middle East should lead to a collective hanging of heads in shame in the region.”

  1. Unlawful Video Executions by Warlords, National Armies Alike: It’s not just ISIS that has promoted itself with gruesome acts of violence and savagery. Human Rights Watch documented Iraqi army soldiers and Khalifa Hiftar-aligned Libyan militias proudly recording depraved acts of torture and executions of detainees. The Egyptian army and police in Sinai staged “shoot-outs” to cover up such executions. Governments failed to investigate, condemn, or appropriately punish repeated unlawful acts by their forces, despite sometimes promising to do so. 

“It’s difficult to square the global outrage against ISIS horrors in the face of national armies and militias that mimic their tactics but receive military assistance from various foreign governments,” Whitson said.

  1. Ran Out of Men, Let’s Use Children: Houthi-Saleh forces resorted to recruiting children to help fight in Yemen. The UN secretary-general placed Houthi forces, as well as other parties in Yemen, on his annual “List of Shame” for their persistent recruitment of children. Human Rights Watch also documented the use of child soldiers in the Syrian conflict by multiple parties, including Kurdish armed groups and Iran’s Islamic Revolutionary Guard Corps. Iran actually recruited Afghan immigrant children to fight in support of Syrian government forces.

“As if slaughtering and starving the region’s children is not bad enough, some are now despicably dragging children to fight and die on the battlefield,” Whitson said.

  1. Arabs Flee the Arab World En Masse: Many people in the Middle East voted with their feet, fleeing their countries in record numbers over the past five years. Millions of Syrians escaped Syria, while the hundreds of thousands who sought refuge in Europe faced a widespread backlash against refugees. Libyans, Iraqis, Yemenis, and Egyptians joined the ranks of millions of refugees and internally displaced in the Middle East who have lost their homes, livelihoods, and communities.

“Is there any greater evidence of just how inhospitable the Middle East has become than the reality of millions of its people fleeing, or trying to flee, disastrous wars – caused by disastrous leadership?” Whitson said.

Posted: January 1, 1970, 12:00 am

North Korean leader Kim Jong-un participates in the opening of the 5th Conference of Cell Chairpersons of the Workers' Party of Korea (WPK) in Pyongyang, in this undated photo released by North Korea's Korean Central News Agency (KCNA) in Pyongyang on December 22, 2017.

© 2017 KCNA

(Seoul) – Kim Jong-un intensified repressive measures against his own people even while grabbing world attention through aggressive weapons testing throughout the year. The government tightened travel restrictions, hunted down fleeing refugees with the help of China, punished its citizens for contact with the outside world, and continued to deny human rights violations, Human Rights Watch said today in its World Report 2018. North Korea remains one of the most repressive states in the world.

In the 643-page World Report, its 28th edition, Human Rights Watch reviews human rights practices in more than 90 countries. In his introductory essay, Executive Director Kenneth Roth writes that political leaders willing to stand up for human rights principles showed that it is possible to limit authoritarian populist agendas. When combined with mobilized publics and effective multilateral actors, these leaders demonstrated that the rise of anti-rights governments is not inevitable.

“Kim Jong-un sits at the helm of a state built on horrific rights abuses and complete intimidation of its population,” said Phil Robertson, deputy Asia director. “Since the North Korean people are silenced, it falls to the international community to step up and press the country’s leaders on human rights, and to ensure that protecting human rights remains at the center of all international dealings with Pyongyang.”

Kim Jong-un sits at the helm of a state built on horrific rights abuses and complete intimidation of its population.

Phil Robertson

Deputy Asia Director

North Korea restricts all basic civil and political liberties for its citizens, including freedom of expression, religion and conscience, assembly, and association. It prohibits any organized political opposition, independent media, independent civil society, or free trade unions. The judicial system is totally controlled by the ruling Workers Party of Korea and the government.

The government uses collective punishment, including torture in custody, forced labor in detention facilities that are essentially gulags, as well as public executions to maintain fear and control over the populace. North Korea is continually bolstering its efforts to prevent people from leaving North Korea without permission by increasing the number of border guards, CCTV cameras and monitoring systems, and barbed wire fences. China also increased checkpoints on roads leading from the border. During the summer and autumn of 2017, Chinese authorities also intensified crackdowns on both North Koreans fleeing through China and the networks guiding them.

In 2017, North Korea refused to cooperate with the United Nations Seoul field office and the UN special rapporteur on the situation of human rights in North Korea, Tomás Ojea Quintana. The government also continually denied the findings of the UN Commission of Inquiry (COI) report on human rights in the Democratic People’s Republic of Korea (DPRK) that North Korea committed crimes against humanity. However, in 2017, the DPRK engaged with two UN human rights treaty bodies, the Convention to Eliminate Discrimination Against Women (CEDAW) and the Convention on the Rights of the Child (CRC), and invited the UN special rapporteur on the rights of persons with disabilities, Catalina Devandas-Aguilar, who visited the country in May 2017, making her the first-ever UN Human Rights Council special rapporteur allowed into the country. Yet despite this uptick in engagement, North Korea still regularly refuses to acknowledge its own rights violations.

In March 2017, the Human Rights Council adopted without a vote a resolution that authorizes the hiring of “experts in legal accountability” to assess cases and develop plans for the eventual prosecution of North Korean leaders and officials responsible for crimes against humanity. On December 11, 2017, for the fourth consecutive year, the UN Security Council discussed North Korea’s egregious human rights violations as part of its formal agenda, addressing the widespread and systematic rights violations as a threat to international peace and security.

“The sad reality is North Korea’s countless human rights victims have few options: either take their fate into their own hands by running the gauntlet in North Korea and China to get to a third country, or suffer in silence and hope governments around the world will step up to demand justice for them,” said Robertson. “It is crucial the international community not let the North Korean people down, and ensure accountability by building the case for criminal responsibility against the leadership.”

Posted: January 1, 1970, 12:00 am

People living near open burning said they were unable to spend time outside, had difficulty sleeping because of air pollution, or had to vacate their homes when burning was taking place. 

“It’s like there’s fog across the whole town,” said Othman, a resident of Kfar Zabad in the Bekaa Valley. “We’re coughing all the time, unable to breathe, sometimes we wake up and see ash in our spit.”

Othman was describing the effects of the open burning of garbage, which takes place regularly near his home. Open burning of waste across the country is a dangerous and unreported part of Lebanon’s waste management crisis.

In December 2017 Human Rights Watch released a report on the health risks of Lebanon’s waste management crisis. We found that the open burning of solid waste at more than 150 dumps across the country poses serious health risks to nearby residents and that the authorities’ inaction to end this open burning of waste was violating their right to health. Those living near dump sites which are burned reported an array of health problems consistent with frequent and sustained inhalation of smoke. Children and older people are at particular risk and these dumps are disproportionately located in lower-income areas.

The government has failed to meet other basic obligations toward residents to inform them about the impact of the crisis on their health and environment. This lack of information has taken a heavy psychological toll. In particular, parents told us they worry about the potential impact burning has on their children. There is no excuse for the government’s failure to monitor the air quality and provide this basic information to the public. People have a right to know about the health risks in their environment. They should demand it.

But burning trash is not just a health or environmental issue. Just like torture, freedom of speech, or women’s rights, it is also a human rights issue—and therefore triggers Lebanon’s obligations under international law.

Although the Universal Declaration of Human Rights splits civil and political rights (such as the right to life or freedom from torture) and economic, social, and cultural rights (such as the right to health or education) into two separate international treaties, human rights are indivisible. Rights have an equal status—no group of rights is more important than another—and the denial of one right frequently impedes the enjoyment of others.

While state obligations around civil and political rights are often absolute and immediate, states are generally required to strive for realization of economic, social, and cultural rights. This distinction is rooted in the perception that greater resources are often required to achieve such rights. But that does not give Lebanon a free pass. Both sets of rights are binding and authorities are required to show that they are taking appropriate steps to fulfill economic, social, and cultural rights.

The Lebanese government has long found hollow excuses to not fulfill these obligations, pointing to a lack of money or political instability to justify its inaction.  Lebanon’s civil war ended almost 30 years ago, and the state today has the wealth, know-how, and international support to make progress on providing education, health, and basic services. But as time passes without improvement, residents have turn to private initiatives, allowing the government to shirk its obligations. The country has settled into a cycle of low expectations and meager results when it comes to basic rights.

To get back on track, Lebanon needs to do more to fulfill its binding commitment to respect, protect and fulfil rights such as the right to health and education. This would encourage citizens to demand action from their government, require the government to guarantee a minimum level of protection, and introduce accountability for government failures.

The human toll of inaction is easy to see. Last year, HRW found that more than 250,000 Syrian refugee children are not going to school. Despite the efforts of the Ministry of Education, families are facing serious barriers that violate Lebanon’s obligation to provide an education in a nondiscriminatory manner.

Discrimination within Lebanon’s education system is not limited to Syrian refugees. We have also found that schools in Lebanon systematically discriminate against children with disabilities, and do not adequately accommodate them in the classroom. Although Lebanon adopted a law in 2000 guaranteeing access to inclusive education for people with disabilities, the government has done little to implement the law. Few Lebanese public and private schools offer any form of inclusive education. This, too, is a human rights issue: the exclusion of children with disabilities discriminates against them and denies them their right to an education.

Lebanon of course deserves international support as it struggles to host the highest number of refugees per capita in the world. But this is not just a humanitarian or development issue—each of these children has a right to an education. Access to free and universal primary education is so fundamental that it is immediately binding—in other words, trying to address the problem over time is not acceptable. Every week without an education harms each child who is out of school. The denial of that right will have serious consequences for the children, their families, and the future of Lebanon and Syria.

After decades of sub-par basic services and governmental intransience, there is a widespread lack of faith in the government to make progress on these issues. But in failing to move forward to fix these problems, the government is not only failing the Lebanese people and their basic needs, it is also violating its obligations under international law.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

In 2016, more than 6,000 Floridians died of an opioid overdose, a 35 percent increase from the year before. Governor Rick Scott has declared the opioid crisis a public health emergency, and is promoting numerous bills designed to tighten restrictions on prescription opioids. But overdose deaths from non-prescription opioids are increasing at alarming rates – in Florida, deaths from fentanyl increased 97 percent in 2016.

The Governor should support the one bill that gets to the heart of the public health crisis – SB800/H579, the Infectious Disease Elimination Pilot Programs Act (IDEA) – that would permit Florida counties to establish syringe exchange pilot programs for people who use drugs in their communities.

Syringe exchange programs have a proven record of reducing HIV and Hepatitis C infection, preventing overdose, and bringing people into treatment without raising rates of drug use or crime. One year into its operations, Florida’s only current program, in Miami, has enrolled more than 600 clients, removed 100,000 dirty needles from the streets, conducted hundreds of tests for HIV and Hepatitis C, and linked more than 80 people to treatment. These are frontline public health services desperately needed in many other counties throughout the state.

Posted: January 1, 1970, 12:00 am

Syringe exchange programs have a proven record of reducing HIV and Hepatitis C infection, preventing overdose, and bringing people into treatment without raising rates of drug use or crime. 

Julia Negron’s house in Venice, Florida is home to her busy family of kids and grandkids. It’s also on the front lines of the state’s overdose epidemic.

Julia, a former heroin user who lost her daughter-in-law to an overdose, started Suncoast Harm Reduction Project to provide overdose prevention and other essential services to people who use drugs in her community. Working beside her are other moms like Jan Spring, whose son Derek died of overdose just two weeks after his 18th birthday. Julia and Jan are working hard, but they know they could be doing much more, and are looking to Florida lawmakers for help.

In 2016, more than 6,000 Floridians died of an opioid overdose, a 35 percent increase from the year before. Governor Rick Scott has declared the opioid crisis a public health emergency, and is promoting numerous bills designed to tighten restrictions on prescription opioids. But overdose deaths from non-prescription opioids are increasing at alarming rates – in Florida, deaths from fentanyl increased 97 percent in 2016.

The Governor should support the one bill that gets to the heart of the public health crisis – SB800/H579, the Infectious Disease Elimination Pilot Programs Act (IDEA) – that would permit Florida counties to establish syringe exchange pilot programs for people who use drugs in their communities.

Syringe exchange programs have a proven record of reducing HIV and Hepatitis C infection, preventing overdose, and bringing people into treatment without raising rates of drug use or crime. One year into its operations, Florida’s only current program, in Miami, has enrolled more than 600 clients, removed 100,000 dirty needles from the streets, conducted hundreds of tests for HIV and Hepatitis C, and linked more than 80 people to treatment. These are frontline public health services desperately needed in many other counties throughout the state.

In a video released today, Julia, Jan, and other advocates say they are ready to go to work saving lives by providing the array of health services offered by syringe exchange programs. By passing the IDEA bill, the legislature can give them the green light to get started.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

© 2009 Romano

I thought I had grown accustomed to being blindsided by bad news – headlines detailing how the United States government is chipping away at human rights. But yesterday morning, I was newly shocked and outraged when I heard that the US Environmental Protection Agency (EPA) may roll back federal standards that ban children under 18 from working with toxic pesticides.

This move may just be another one of the Trump administration’s sweeping attempts to undo regulations enacted under former President Barack Obama. But undoing or weakening these safeguards could leave many children in the US vulnerable to pesticide exposure.

Children younger than 18, who are in a critical stage of growth and development, are especially susceptible to toxic pesticides. The American Academy of Pediatrics (AAP) has said there’s a clear link between childhood exposure to pesticides and “pediatric cancers, decreased cognitive function, and behavioral problems.” Child health experts, including the AAP and the Children’s Environment Health Network, have supported a minimum age of 18 for children to handle pesticides. 

I’ve interviewed more than 100 child farmworkers in the US while researching child labor in agriculture. Far too many of them described being exposed to pesticides and getting sick while they worked. One 16-year-old boy said he used a backpack sprayer to apply an insecticide on a tobacco farm in Virginia, adding that, “I got home and felt dizzy and started puking.”

The EPA announced that it is considering changing the standards in two notices published in the federal register in late December. One of the safeguards on the chopping block, a revision to the Worker Protection Standard enacted in 2015, bans children under 18 from handling pesticides on farms, forests, nurseries, and greenhouses where they work and from re-entering fields where pesticides have recently been sprayed. The second rule bans kids under 18 from handling or applying high-risk pesticides – known as restricted use pesticides, or RUPs – in, on, or around schools, homes, farms, and other workplaces like golf courses.

These are common sense measures to protect children’s health, based on solid research. Yet even so, it took decades of fighting by advocates to get these protections passed, and they were only adopted after the EPA extensively reviewed the literature and analyzed public comments.

The EPA should advance its mission of protecting human health and the environment and drop this callous and harmful proposal.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am
It wasn’t until the 1980s, after a series of nervous breakdowns, that Bo Laurent—then in her 30s—set out to investigate the source of her deep distress.

The truth, when it finally came, was both liberating and traumatizing: Bo discovered she had been born with atypical genitalia, which surgeons had operated on to make her look—arbitrarily—more typically female, inflicting irreversible harm on her in the process, and telling her parents that they should never reveal to Bo the surgery she had undergone as an infant.

Doctors had told Bo’s parents, and Bo herself once she found out, that her condition was so rare there was no one else like her. But after learning the truth from her medical records, and as she traveled the country telling her story, she found this was untrue. Her California mailbox began to fill with letters from people describing similar experiences.

In 1993, Bo, using the name Cheryl Chase, founded the Intersex Society of North America (ISNA) to meet and help people who, like her, were born with biological sex characteristics that fall outside typical definitions—that is, their chromosomes, gonads, or internal and external sex organs differ in some way from what science and society have long deemed to be “male” or “female.”

ISNA became an eddy of activists, a support group for traumatized people who had more questions than answers, and the birthplace of momentous historical agitations such as “Hermaphrodites with Attitude.” Their mission was to convince the medical establishment to respect intersex people’s rights to health and bodily autonomy by stopping “normalizing” surgeries on children before they were old enough to understand the procedures and consent to them.

Speaking Truth to Power

ISNA’s message was not anti-doctor, or even anti-surgery, but pro-informed consent. Operations to alter the size or appearance of children’s genitals risk incontinence, scarring, lack of sensation, and psychological trauma. Surgery to remove gonads can amount to sterilization without patients’ consent, and then require lifelong hormone replacement therapy. The procedures are irreversible, severed nerves cannot regrow, and scar tissue can limit options for future surgery.

Bo and the other early ISNA participants believed the truth would soon set them—and future generations of intersex people—free. Their thinking, as Bo told me when we first met in the fall of 2016 near her home in Sonoma county, California, was: “As soon as we get our stories out there, this will all stop. Once doctors realize the harm they’ve done, they’ll change their minds and methods.”

But it wasn’t that simple.

Convincing the medical establishment proved to be significantly more complicated than anyone expected.

A change in medical paradigms requires a shift in understanding what the medical evidence shows—in this case, an acknowledgment that, although empirical data remains incomplete, there is now substantial evidence that medically unnecessary surgery on infants and young children with intersex traits often causes significant harm. Conversely, there is little evidence of its putative benefits, and certainly no empirical basis on which to conclude that the supposed benefits are real, let alone that they outweigh its harms.

But it's not easy to suggest that doctors are engaging in practices that violate their patients’ basic rights—the white coat signals a lot. As an endocrinologist in Boston told me: “Aside from clergy, who else in our society but doctors do people listen to about the heaviest life and death, sickness and health questions?”

The Default-To-Surgery Paradigm

The medical paradigm that ISNA was up against had calcified in the US in the 1960s when John Money, a psychologist at Johns Hopkins University, theorized that gender in infants was malleable and surgical interventions could unproblematically determine lifelong gender identity. Operations on intersex bodies had been conducted sporadically around the world in prior decades, but it was Money’s infamous 1967 case of recommending female sex assignment surgery on a male baby following a botched circumcision that cemented the theory as the default medical practice.

There were no clinical trials, no consideration of the potential risks, just a hypothesis from an elite practitioner based on his marquis case—which became known as “John/Joan”—driving the theory’s momentum. The outcome was, in fact, disastrous. In 1997, the patient’s psychiatrist and a sexology professor in Hawaii exposed the trauma the boy had suffered, and how Money had knowingly distorted the truth in his publications. The child had, in fact, not grown up to identify as a woman, but a man—and transitioned in his 20s.

In 2004, the patient, David Reimer, committed suicide.

The default-to-surgery paradigm, however, had already become entrenched and, in fact, was already being exported around the world.

Despite the horrors of Reimer’s story, Bo and ISNA continued to believe there was no reason to demonize doctors. The goal was to tell the stories of people who had undergone medically unnecessary surgery at an early age, explain to the medical community the destruction these surgeries had done to intersex people, and detail how surgery had failed to deliver the supposed benefits of “normalcy” and happiness.

This was their tactic to move the needle and start advocating to help intersex adolescents and adults seek the care they actually wanted. And then, the thinking went, the non-consensual surgeries would stop, social awareness would garner acceptance, and the intersex community could flourish.

“We were naive,” Bo said 25 years later. 

Resistance and Inertia

ISNA only ever staged one public protest—in 1996 in Boston, at the annual conference of the American Academy of Pediatrics (AAP). It was a small group, and many participants were allies, but it struck a chord. The anniversary of that protest, October 26, is today marked as Intersex Awareness Day worldwide.

Although Bo herself was invited as a keynote speaker at an AAP conference as early as 2000, even having a seat at the table did not have linear impact.

“Doctors [would tell] me that the parents of intersex kids they’d operated on were happier than the parents of kids whose lives they’d saved,” Bo said, adding that most doctors could not say how the patients themselves felt about it once they reached adulthood because the doctors simply didn’t know—they had lost touch with them.  

Bo and other advocates made compromises along the way, some of which led to rifts in the community. During my research on intersex issues around the US, I heard a range of opinions, for example, on what happened in 2006 when Bo agreed to work with a group of physicians on the “Disorders of Sex Development Consensus Statement”—a collaborative paper produced at a conference in Chicago.

An intersex activist in her 60s told me she left the movement when ISNA “allowed the high priests of medicine to call us, ‘disordered.’” Another said he understood the compromise to get a seat at the table, but was disappointed it never produced results: “We’re still seen as freaks that need to be fixed 20 years later.” 

In the past decade, activists have worked to claim the space that the “DSD” consensus statement staked out. They quickly replaced “disorders” with “differences”—and today human rights bodies and even a handful of clinics use that language as well. But the default-to-surgery paradigm persists.

A father of a two-year-old child with intersex traits who is a clinical psychologist told me: “If you want to fuck somebody up psychologically, start calling a part of their body deformed and then see how that works out. The whole idea of disease and even the message the surgery sent is that there was something wrong that we had to fix.”

New Words, Same Ways

Despite shifts in terminology, and despite increasing controversy even within the medical community, the cohort of doctors who specialize in intersex treatment has largely clung to the default-to-surgery paradigm. The tone has changed: at least in their writing, doctors now mostly avoid construing surgery as a “quick fix” but rather a “legitimate option.” Teams of specialists— “DSD teams”—that sometimes include mental health providers typically meet with parents as part of the decision-making process.

But despite these advances, the surgical status quo remains largely intact. And medical justifications for cosmetic surgeries ring increasingly hollow.

For example, a 2015 article co-authored by 30 DSD healthcare providers reflecting on genital surgeries stated: “There is general acknowledgement among experts that timing, the choice of the individual and irreversibility of surgical procedures are sources of concerns.” It continued: “There is, however, little evidence provided regarding the impact of non-treated DSD during childhood for the individual development, the parents, society….”

Too often, as in the article by the 30 DSD doctors, the absence of evidence becomes part of the justification for continuing early surgery. The social hypothetical—fears of stigma for the child and chaos for family and society if surgery is delayed—continues to trump the actual harm that people who have undergone surgery suffer.

The foundational medical principle—“do no harm”—seems to dictate exactly the opposite: a moratorium on medically unnecessary cosmetic surgery on intersex children too young to consent unless and until there is evidence that the benefits outweigh the harms.

Real Risks Versus Hypothetical Happiness

There is now a growing body of outcomes data showing that early surgery can lead to physical and psychological harm, if not catastrophe, for intersex people. One of the many risks of “normalizing” surgery is assigning the wrong sex. Add to that the risk of needing additional surgeries to repair mistakes (I interviewed one person who had undergone 39 surgeries to keep his body functioning after a cosmetic operation in adolescence damaged him).

Then there’s scarring, incontinence, loss of sexual sensation and function, psychological trauma including depression and post-traumatic stress disorder, the risk of anesthetic neurotoxicity in young children, and the need for lifelong hormonal therapy.

In 2017, Dr. M. Joycelyn Elders, Dr. David Satcher, and Dr. Richard Carmona, all former US surgeons-general, wrote that they believed “there is insufficient evidence that growing up with atypical genitalia leads to psychosocial distress,” and “while there is little evidence that cosmetic infant genitoplasty is necessary to reduce psychological damage, evidence does show that the surgery itself can cause severe and irreversible physical harm and emotional distress.” They said: “These surgeries violate an individual’s right to personal autonomy over their own future.”

Despite the data, many physicians who perform the surgery continue to be unmoved. A New York urologist unabashedly published a paper in 2007 documenting how his clitoral surgeries were proven effective and “nerve sparing.” The evidence he offered was produced by inserting vibratory devices in post-operative patients—in some cases, seven-year-old girls—and asking them how strongly they felt it.

More recently, in July 2017 when a hospital in South Carolina settled a medical malpractice suit for its surgery on an intersex infant for nearly $500,000, a psychologist with more than 20 years of experience with intersex patients dug in his heels and defended the status quo. “I never question people's experiences,” he said. “What I do question is whether their experiences are generalizable to others.”

Bioethicists have documented physicians’ reluctance to change the status quo for decades. Katrina Karkazis, an ethicist at Stanford, wrote in her 2008 book on the topic a number of “folk myths” that doctors perpetuate: “[A]s increasing numbers of studies have begun to demonstrate poor surgical outcomes, some surgeons and other clinical specialists discount even these findings,” she wrote, explaining that doctors believed their surgical techniques were always improving so data from past patients was irrelevant.

Karkazis wrote: “By charging that adequate studies are impossible because they will always assess old techniques, surgeons and others deflect current as well as future scientific and anecdotal evidence of poor surgical outcomes.”

In 2015, when patient advocates and ethicists publicly resigned from the largest research initiative on intersex healthcare to date—a multi-site university hospital project funded by the National Institutes of Health—citing frustration with the continuation of medically unnecessary surgeries on intersex children, one bioethicist wrote in her resignation letter that she was finished with “being asked to be a sort of absolving priest of the medical establishment in intersex care.”

Ending Unnecessary Surgeries

The experience of those who have undergone early surgery and the principles of medical ethics suggest that doctors should weigh evident harm over hypothetical benefits. The real question doctors should be asking is how many more of their patients need to suffer before medically unnecessary surgeries end.

Medical and policy leaders have noted the need for a fundamental change in approach. United Nations human rights experts; the World Health Organization; Amnesty International; Physicians for Human Rights; every major lesbian, gay, bisexual, and transgender legal organization in the US; the American Medical Association Board of Trustees in 2016; three former US surgeons general in 2017, two US pediatrics associations later that year; and intersex-led organizations around the world have called for an end to medically unnecessary non-consensual surgeries on intersex kids.

Many providers who care for intersex children have become increasingly uncomfortable with the current paradigm, but there remains a lack of clear, centralized standards of care for intersex patients.

And so the inertia persists. ISNA has dissolved and Bo has retired from activism, but a new generation of intersex people, whose bodies were operated on decades after Bo’s, have taken up the fight. For Intersex Awareness Day 2017, activist Pidgeon Pagonis staged a protest outside the Chicago hospital where, as a child, Pidgeon’s clitoris, vagina, and gonads were all surgically altered without Pidgeon’s consent.

The hospital issued a public statement saying it was “committed to open communication with the Intersex community and fully respect the diversity of opinions that exist in affected individuals.” But a leaked internal communication struck a rather different tone, perhaps revealing why doctors continue to perform these surgeries decades after they became controversial even within the medical community. In it, the hospital called the protesters’ demands “extreme,” and said the group was targeting hospitals across the country.

Bo told me: “No one has proven that the interventions are necessary to do on an infant…. Even if you find some people who had early surgery who are happy, that doesn’t mean it’s safe or necessary…. There are probably happy people. But there are a lot of very unhappy people—ruined people.”

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

Maria Carolina Silva Flor and Joselito Alves dos Santos with their 18-month-old daughter, Maria Gabriela Silva Alves, pictured after the launch of the Human Rights Watch report Neglected and Unprotected, July 2017.

© 2017 Amanda Klasing/Human Rights Watch

Maria Gabriela Silva Alves will have no party for her second birthday today. No cake. No gifts. No celebration. Gabi, as her parents call her, has congenital Zika syndrome, and her parents simply cannot afford it.

Gabi is one of thousands of children born with congenital Zika syndrome in Brazil over the last two and a half years. I met Gabi and her family while researching the human rights impacts of the Zika epidemic in northeastern Brazil. At 8-months-old, I was struck by how tiny she was, how lovingly her mother held her. Last July, I saw Gabi again when she was a year and a half. I had the joy of holding her several times, and having her nestle into my arms under the loving gaze of her parents, Carol and Joselito.

Brazil has not addressed longstanding human rights problems that allowed the Zika outbreak to escalate, leaving the population vulnerable to future outbreaks and other serious public health risks. 

Her parents were thrust under an intense media spotlight with little government support following her birth. Doctors weren’t sure – still aren’t sure – what Gabi’s life will be like. But her parents have been doggedly seeking services and support. She has a new automated chair that allows her to move around more easily. And, after spending nearly half of Gabi’s life commuting long distances for health care, they now have appointments in their own municipality with transportation provided.

This is not without costs. The family has racked up insurmountable debt caring for Gabi and her older brother, keeping food on the table and a roof over their heads. Though they receive a small financial contribution from the government, there is not enough money to keep their family healthy, much less to celebrate Gabi’s birthday.

Gabi and her family are not alone. Even as the headlines on Zika have faded, children throughout Brazil, and around the world, are growing up with congenital Zika syndrome. No longer babies, they and their caregivers need evolving support. They face difficulties buying expensive medicine, traveling to urban centers for appointments, and keeping paid work because of heavy family responsibilities. Federal and local authorities, and the broader international community, will need to address the special evolving needs of Gabi and children like her concerning their health, but also their education and other still unknown issues.

As Gabi embarks on her third year of life, I wish her and her family good health. And I hope they get the support they need.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

People living near open burning said they were unable to spend time outside, had difficulty sleeping because of air pollution, or had to vacate their homes when burning was taking place. 

Lebanon’s waste crisis gained international recognition in 2015, when garbage overflowed in the streets of Beirut. But in fact, this is just the tip of the iceberg. My organization, Human Rights Watch, found that Lebanon’s mismanagement of its waste has gone on for decades, particularly in areas outside Beirut and Mount Lebanon. One consequence has been the open burning of waste, a dangerous and avoidable practice, at more than 150 dumps across the country every week, posing health risks to nearby residents.

This is not just a nuisance. It is a legal and human rights issue. Lebanon’s failure to stop the open burning and inform residents of the risks to their health violates its obligations under international human rights law.

An extensive body of scientific research has documented the dangers smoke from the open burning of household waste poses to human health. It’s been linked to heart disease, cancer, skin conditions, and respiratory illnesses. Children and older people are at particular risk.

Our report was based on more than 100 interviews with nearby residents, doctors, environmental experts and government officials. The vast majority of residents we spoke with reported health issues consistent with prolonged exposure to smoke, such as chronic obstructive pulmonary disease, coughing, throat irritation, and asthma. One resident said: “We are coughing all the time, unable to breathe. Sometimes we wake up and see ash in our spit.”

Residents we spoke with had almost no information about the dangers of open burning or steps they should take to mitigate the risks to their health. And families said that uncertainty over whether the burning would lead to more serious health effects, such as cancer, for them and their children, was taking a heavy psychological toll.

Open burning appears to disproportionately take place in poorer parts of the country, and almost all of it takes place outside central Beirut and Mount Lebanon. We documented reports of open burning next to schools and even a hospital.

Open burning is a consequence of Lebanon’s broader waste crisis. Lebanon does not have a solid waste management plan for the entire country. Instead, it has jumped from one emergency plan to the next for decades, without putting in place long-term solutions. As a result, there are now more than 900 open dumps across the country.

There is more than enough funding and technical expertise in Lebanon to adopt a nationwide waste management plan that complies with health and environmental best practices and respects international law. The European Union alone has allocated more than 70 million euros to solid waste management in Lebanon in recent years. There are clear solutions to this problem and the only obstacle here is political will. The government should finally end the open burning of waste and put in place long term sustainable solutions that protect the health of all residents.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

U.S. Attorney General Jeff Sessions delivers remarks on the U.S. system for asylum-seekers at the Executive Office for Immigration Review in Falls Church, Virginia, U.S. October 12, 2017. © 2017 Reuters

In the United States, 142 people die of drug overdoses every day. President Donald Trump has rightly declared a public-health emergency and asked his health secretary to lead the federal response. But law-enforcement agencies also need an approach that puts a premium on public health, particularly as people are increasingly overdosing not on prescription medications but on street drugs like heroin and illicitly produced synthetic opioids such as fentanyl.

So far, however, the Justice Department is sending signals that it will be part of the problem rather than the solution.

In an announcement last month, Attorney General Jeff Sessions made it clear that he will instruct staff to prosecute anyone possessing, selling, manufacturing, or importing a substance containing fentanyl and to subject them to higher penalties than those for heroin use. This may send more people to prison for longer, but more criminal prosecutions of people who use drugs will not curb overdose deaths.

Someone is arrested every 25 seconds in the United States for possessing drugs for personal use. This criminalization of personal drug use and possession has devastated individuals, families, and communities. Punitive approaches drive people who use drugs away from health services and do not reduce injection-drug use, in the United States or globally. Drug courts, endorsed by the Justice Department as a priority, still involve criminal charges and have not been proven to reduce drug use.

But there are alternatives. Public-health-based interventions are known to work, but many of these initiatives are limited by legal barriers or lack of federal support. The Justice Department can help. Here are three steps the attorney general could take that could have a positive and immediate impact on our nation’s opioid epidemic:

1. Increase the number of law-enforcement agencies carrying naloxone.

Naloxone is a safe, generic medication that can bring a person back from an opioid overdose if administered on time. One study in 2012 conservatively estimated that one life is saved for every 164 naloxone kits. Police are often the first responders, particularly in rural areas where ambulance service is not as readily available. More police and sheriff’s departments are carrying naloxone than ever before, but these are still a small fraction of the law-enforcement agencies in the United States.

President Trump’s Commission on Combating Drug Addiction and the Opioid Epidemic recommended last month that the administration should mandate that every law-enforcement agency in the country be equipped with naloxone, and that Congress should fund the mandate. The Justice Department can ensure that federal, state, and local law enforcement has the tools, training, and support to carry out this recommendation. At the very least, the DOJ should issue a new guidance document that updates, expands, and promotes a program formed during the Obama administration to help local police and sheriffs’ departments establish a naloxone program.

2. Help states strengthen “Good Samaritan” laws.

The president’s commission also noted the importance of “Good Samaritan” laws that protect people who call emergency services in an overdose situation from arrest or prosecution related to drug use and possession. These laws are necessary because, as multiple studies have confirmed, fear of arrest reduces people’s willingness to call 911 when the person they are with overdoses. The evidence also demonstrates that these laws do encourage calls to emergency services and reduce deaths from overdose.

Most states now have some form of Good Samaritan law, but these laws vary widely and public awareness about them is low. Ten states offer no legal protection to 911 callers. In Arizona, for example, a Good Samaritan bill is pending for the 2018 legislative session. Despite 1,274 deaths from drug overdose in Arizona 2015 and the governor’s declaration of the opioid crisis as a statewide public-health emergency, local advocates expect an uphill battle in the conservative state. A Justice Department endorsement of this life-saving bill could influence Arizona lawmakers, the sheriffs’ association, business owners, and other groups key to its passage.

3. Support a pilot project for supervised-injection facilities.

Supervised-injection facilities are medically and legally sanctioned spaces designed to reduce harm from drug use for both people injecting drugs and their communities. Fearful of arrest and stigmatization, many people use drugs on the street, in cars, in abandoned buildings, and often alone, placing them at greater risk of dying from an overdose.

At supervised-injection facilities, staff provide services such as clean needles and equipment as well as testing for HIV and hepatitis C and linkage to drug-dependence treatment for those who want it. These facilities are operating in 66 cities in nine countries—only underground programs are operating here. These facilities significantly reduce the transmission of infectious disease and overdose deaths without increasing drug use or crime rates. Communities benefit from reduced public drug consumption and hazards such as discarded needles.

These public-health interventions are under consideration in at least six locations in the United States, from California to Baltimore. The Justice Department could support a pilot project in one city by working with local officials to help remove legal barriers and by increasing awareness of the evidence-based public-safety arguments in their favor.

Public safety includes public health, and the United States is in the midst of an emergency. The Department of Justice can, and should, be part of the solution to the nation’s opioid crisis.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

“My name is Amina and I am twenty years old. I grew up here in the town of Bagega. I had six children. Three have died. Each time one died, I was so distraught and I was very traumatized.” Amina, Bagega, Zamfara state, Nigeria, 2011.

© 2011 Marcus Bleasdale/VII for Human Rights Watch

Bhopal, Chernobyl, and Minamata – these environmental disasters shocked the world. Yet, pollution results not only from catastrophic accidents but also from years of silent exposure. Children’s developing bodies are particularly vulnerable. According to the World Health Organization, some 1.7 million children under 5 die each year because of the unhealthy environment around them.

In northern Nigeria, we met Amina, a tall, young woman. As she described how three of her children had died, she buried her face in her hands, visibly distraught. Amina’s children were victims of one of the worst lead poisoning incidents in history in Zamfara, northern Nigeria. More than 400 children have died there since 2010, when lead was accidentally released by small-scale gold miners.

Sadly, there are countless other examples around the world where children have been slowly poisoned with officials only acting once it was too late. Human Rights Watch has documented how governments have failed to protect children exposed to toxic chemicals from leather tanneries, artisanal gold mines, battery factories, former mines, open burning of waste, and pesticide-sprayed farms.

This week, governments are meeting for the United Nations Environment Assembly (UNEA) in Nairobi, Kenya, to discuss how to tackle pollution.

UNEA should embrace a rights-based approach to prevent pollution and promote better access for citizens to information on pollution. Specifically, UNEA should guide governments on how to better monitor children’s environmental health, and how to use this information to regulate and hold accountable polluting industries. UNEA should also call for the results of child health monitoring to be made public, so that affected citizens and the wider public can stay informed and also scrutinize government action.

Amina’s children could have been saved. Governments should act before more children die from pollution.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

Naloxone, a medicine that can reverse an opioid overdose. Massachusetts, US, August 8, 2017. 

© 2017 Reuters.
The president’s commission on combating drug addiction and the opioid crisis covered a lot of important ground in its final report on Nov. 1, but it skipped over one key issue that can make the difference between life and death. In 2016 more than 64,000 Americans lost their lives to overdose — more than 175 every day.  Many of these deaths could have been avoided if naloxone, the overdose reversal medication, were available over the counter.

Most of these deaths involve opioids such as the powerful synthetic drug fentanyl, heroin and prescription painkillers. Naloxone reverses opioid overdose, but it must be given quickly. It is easy to use and has been successfully administered for decades by lay people, saving tens of thousands of lives. But its status as a prescription medication limits its availability. Making this antidote available over the counter could be a game-changer in reducing the terrible toll of preventable opioid overdose deaths.

The commission’s report notes the importance of increased naloxone access, but focuses its recommendations on expanding access among medical first responders. While this is important, it ignores the fact that the first people on the scene of an overdose are usually not emergency workers but friends, family members, and associates of people who use drugs. In this context, these people are the true “first responders.”

Naloxone access has increased significantly in the last several years, as nearly all states now permit naloxone to be prescribed to people who aren’t themselves at risk of overdose but who may be able to help someone who is. Similarly, most states allow for “standing orders” that allow for wider distribution of naloxone through pharmacies and, in some states, other venues. While these initiatives are important, they leave behind many of the most vulnerable Americans — those who do not regularly see a health care provider or who do not have insurance.

Human Rights Watch has documented in the U.S. and around the globe, many people who inject drugs  are wary of interaction with the healthcare system because of stigma or poor treatment. Karen, whose real name has been withheld to protect her privacy, is a case in point. This 23-year-old former heroin user from Wilmington, N.C., told Human Rights Watch that talking to a pharmacist about what they need for their heroin habit is a difficult thing for lots of people. She says there is lots of fear and shame. Also, studies show that due to fears of arrest and prosecution, many people at the scene of an overdose are reluctant to call 911

Why not just put naloxone in that person’s pocket? Time is of the essence with overdoses, and empowering people who witness an overdose to reverse it can prevent a delay that can result in death or irreparable brain damage.

Some enterprising states and cities have found ways to get naloxone into the hands of laypeople, and the results are exactly as expected. A recent study in Massachusetts found that cities that have naloxone distribution programs have lower overdose death rates than those that don’t. Similarly, the North Carolina Harm Reduction Coalition has given out 52,000 naloxone kits since 2013 through their statewide grass roots network that includes syringe exchange and naloxone distribution, with more than 8,700 overdose reversals reported. Because naloxone is a prescription medication, however, these results are difficult to replicate in other states, where distribution by community groups is often not permitted by law.

There is no reason why at least some formulations of naloxone could not be made available over the counter, which would make it far easier for these types of low threshold programs to provide naloxone to those at highest risk of overdose. Designated an “essential medicine” by the World Health Organization, naloxone is not a controlled substance and has no potential for abuse. It meets the criteria for over-the-counter status established by the Food and Drug Administration, and two of the mostpopular naloxone products were specifically designed for use by lay people.

The FDA is taking a number of steps, including preparing a model label and initiating the necessary trials to ensure that naloxone can be successfully used without prior training, in anticipation of a manufacturer requesting permission to sell naloxone over the counter. To date, however, none of the companies producing naloxone has done that.

The opioid commission missed a perfect opportunity to endorse community-based naloxone distribution, a proven, evidence-based, and common-sense strategy to reducing overdose deaths. A recommendation for the FDA to intensify its efforts to make naloxone available without a prescription would have increased the pressure on naloxone manufacturers to file the necessary applications — or, failing that, for the FDA to take that step on its own. In a public health emergency, every day we wait means more preventable deaths. The time to act is now. 

Megan McLemore is a senior health researcher at Human Rights Watch. Corey Davis is a senior attorney at the National Health Law Program.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am