The notion of health as a fundamental human right was articulated as far back as 1946 in the Constitution of the World Health Organization: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”

Despite this early recognition of the importance of the link between health and human rights, the right to health has been neglected in comparison with other rights, even though it has the same international legal status as freedom of religion or the right to a fair trial. As a result of this neglect, the right to health is not as widely recognized as civil and political rights even though it is cited in numerous conventions. These include the Universal Declaration of Human Rights (1948), the International Covenant on Economic, Social and Cultural Rights (1976), the Convention on the Rights of the Child (1989), the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) (1979), and the International Convention on the Elimination of All Forms of Racial Discrimination (1965).

The claims of human beings on society and government arise from their inalienable rights as human beings and not because of any special favor or privilege that may be conferred or withheld on the grounds of “race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status,” in the words of Article 2 of the Universal Declaration of Human Rights.

Proclaimed by the United Nations General Assembly in 1948, the Universal Declaration of Human Rights states that “all people are born equal in dignity and rights” and governments are expected to respect, promote, and protect the human rights of all citizens regardless of their differences. Statements of principle are one thing, and the implementation and protection of rights another. For example, while human rights theoretically cannot be conferred or withheld on the grounds of sex, there is overwhelming evidence that they are. Women continue to occupy a subordinate social position globally, and their status as full human beings from a rights perspective has not yet been realized (7). The need to redress this situation and to articulate gender-specific rights more fully inspired the development of CEDAW.

Many human rights frameworks respond with difficulty to issues of concern for women because they focus on the behavior of government actors rather than private parties. Some of the most critical violations of women’s rights occur within the private sphere of the home. The more recent Declaration on the Elimination of Violence against Women (1993) overcomes this difficulty by including
as a rights violation violence that occurs within the family, in addition to that which occurs in the community or that which is perpetrated or condoned by the State.

A clear overlap exists between the objectives of human rights and health (8). The linkage between health and human rights derives from “the deep complementarity of the public health goal to ensure the conditions in which people can be healthy and the human right goal of identifying, promoting, and protecting the societal determinants of human well-being” (8, p. 179).

For this reason, public health policies, programs, and practices are uniquely placed to promote and protect people’s human rights in the context of their health. Conversely, health policies, programs, and practices can, through the exercise of deliberate or inadvertent discrimination, place an additional burden on the health of the public—especially those segments of the population that are marginalized and vulnerable. These are the groups who may be “overlooked” in the framing of health policies for the general population unless care is taken to include them. Human rights violations can have direct and immediate as well as long-term negative effects on human health, as illustrated by the health impacts of torture on human health. While the violation of any right can be conceived as exerting measurable impacts on physical, mental, and social well-being, it has been suggested that the health effects arising from human rights violations remain “in large part, to be discovered and documented” (9, p. 445).

It can equally well be asserted that there is already a considerable body of evidence regarding the impact of human rights violations on women’s mental health, even though this evidence was not collected with the explicit goal of identifying or documenting the mental health effects of human rights violations. Human rights offer a societal level framework for identifying and responding to the underlying societal determinants of health. As such, a rights perspective is a valuable addition to existing conceptions of the social model of health and to the measurement of social position.

To elucidate gender disparities in mental health, an understanding of gender as a social construct and analytic category is obviously essential. Gender has the analytical power to identify and explain differences between men’s and women’s susceptibility and exposure to specific risks to mental health. Gender is crucially related to the differential power men and women have to control their lives. It also impinges powerfully on the ability to respond and to cope with health risks. Access to health care can also be constrained on gender grounds. The rise of “user pays” medical care ensures that the cost burden falls most heavily on the most economically disadvantaged, namely women. Without the concept of gender, it is not possible to begin to ask questions about how the social categories occupied by women and men differentially affect how they see, experience, and understand the society in which they live and how they are likely to be regarded and treated within that society.

The Global Burden of Disease reveals that 5 of the 10 leading causes of disability worldwide are neuropsychiatric disorders (10). Depression, besides being the most prevalent psychiatric condition, makes an increasingly heavy contribution to the global disease burden. Depression is the most frequently encountered women’s mental health problem and accounts for more than 1 in 10 years of life
lived with disability. By 2020, depression is predicted to be the second leading cause of disease burden and the leading cause of disability burden.

As noted, earlier attempts to explain the gender difference in depression proceeded largely as if it is a sex difference and exhaustively investigated possible biologic reasons for the difference. The dominant place given to biologic factors resulted in hasty and erroneous interpretation of epidemiologic evidence.

Data from national surveys can be used to compare population-based rates of depression over the life span. The gender difference in depression first emerges in early puberty (11) and declines from midlife onward (12). These changes in rates of depression over the female life cycle were taken as strong evidence that corresponding changes in female sex hormones were responsible. However, while the gender difference in depression is most marked during the reproductive years, strenuous research efforts have not succeeded in tying this difference to changes in sex hormones related to pregnancy, the use of oral contraceptives, or the use of hormone replacement therapy in menopause or natural hormonal changes during menopause (12). Other factors in women’s lives also change over time and have proved to be important in explaining depression. For example, some of the methodologically strongest research on depression and menopause has reported that multiple interacting factors best explain why some women experience depression at this time and others do not. Research undertaken by Kuh and colleagues (13) to consider the complex range of factors that impinge on mental health in midlife is reported here in some detail. Factors from childhood, adolescence, and adult life were all examined in relation to psychological distress among women in midlife. Participants in this research on midlife health and menopause were part of the larger Medical Research Council National Survey of Health and Development (MRCNSHD), a prospective cohort study of a representative sample of the British population born in 1946 and subsequently followed. The psychological symptoms on which data were collected when participants were aged between 47 and 52 years included anxiety and depression, irritability, tearfulness, and feelings of panic and a composite psychological symptom score. A very large number of risk factors across the life course were included. Risk factors belonged to six clusters: family background, characteristics of the child, adult health, adult socioeconomic circumstances, social support and life style, and current life stress. The study investigated the nature of links between mental health in midlife and experiences in childhood or in adolescence and early adult life. Pathways through which such risk factors as cumulative losses, social adversity, negative events, and experiences over the course of women’s lives influenced their psychological health in midlife were carefully evaluated.

Importantly, no variation in psychological symptoms in midlife was found according to menopausal stage, a finding that is in keeping with the results of the majority of other studies. However, past psychological distress was predictive of current distress, and many of the classical social determinants of depression and poor mental health were found to play a highly significant role in women’s mental health in midlife. These included social position in childhood and adult life (lower social class, having lived in council housing, lower educational qualifications, parents who had divorced), negative life events, behavioral risk factors (smoking and being overweight), and marital status, with divorced or separated women having higher symptom scores than those who were married or single (13). A graded relationship was reported between the number of adverse changes in participants’ family and work life each year between 47 and 52 years of age
and systematic increases in symptom scores over the same time span. Higher social support, including emotional support, good social networks, and access to help in a crisis, positively mediated the likelihood of psychological symptoms. This research underlines the importance of taking a life course approach to women’s mental health and employing methodologies capable of eliciting markedly different life course trajectories.

The critical importance of social environment and social position for health has been demonstrated repeatedly. Variations in both mortality and morbidity rates by social class are a consistent finding of epidemiology (17). Adverse mental health outcomes such as depression are 2 to 2.5 times higher among those experiencing the greatest social disadvantage compared with those experiencing the least. Women experiencing such disadvantage have the highest rates of all (12,15,18).

Studies in countries of different income levels have confirmed the existence of what has come to be called the social gradient in health—significant differences in both mortality and morbidity extend from the top to the bottom of the social hierarchy (15,17,19). So strong is the relationship between socioeconomic status (SES) measured by such indicators as income, education, and employment status and a wide range of poor health outcomes that SES is typically accorded the status of a research control variable in order to facilitate the evaluation of other risk factors to health. As a result, little detailed research into socioeconomic status as an etiologic factor in its own right has occurred (19).

Mann (9) asserts that the biomedical foundation of public health, with its concepts and language borrowed from notions of disease, is ill suited to understanding societal level determinants of health and detracts from analyzing and responding to the underlying social conditions responsible for poor health. He is also critical of researchers, program administrators, and policy makers who ostensibly seek to improve public health but attempt to do so by designing behavioral risk reduction programs that assume high-risk health behaviors such as drinking, smoking, and unhealthful dietary choices are under the complete control of the persons who engage in them. Ironically, such programs tend to ignore differences in the social contexts that help to explain variations in rates of these same behaviors.

There is abundant evidence that poverty and material disadvantage are critical predictors of poor mental health. Other dimensions of social position that are important include environmental stressors such as adverse life events and chronic psychosocial difficulties that are more common among people living in poverty and are significantly associated with the lower socioeconomic class predominance for nonpsychotic psychiatric disorders like depression and anxiety. Less access to supportive social networks, at both an immediate personal, contextual level and a broader, societal level, has also been linked with higher levels of morbidity, including higher rates of depression and anxiety (5).