Abstract

From a citizens’ perspective, global health is an integrated approach of research and development of global actions that aims to give full meaning and implementation to a vision of health as a state of bio-psycho-social well-being and as a fundamental human right. Dealing with global health means preventing and reducing inequalities and fostering harmonious and sustainable development. It means overcoming the perspectives and interests of individual countries, thus taking a holistic view, and paying special attention to the most fragile and poor populations with the primary objective of guaranteeing a dignified quality of life for each individual. It is crucial that health as a human right returns to the center of global debates and goals, a process that cannot be achieved without a proper focus on social justice, equality, and equity.

The results emerged from a one-year research/action and in-depth discussions led to the development of thirteen rights, which are at the basis of the global health concept, and, subsequently, of 60 concrete actions to implement to make these rights enforceable. The following paper presents, at the international level, the activity promoted in Italy by Cittadinanzattiva [1], a civic organization dedicated to the protection of citizens’ rights, which drafted and promoted the first “Civic Charter of Global Health” [2], presented below.

Keywords: Global Health; European union; Patients’ rights; Right to health; Environment; Civic Participation; Social justice.

Citation: Moccia F, Ciriello C, Cardillo M. 13 rights and 60 actions to promote global health from a civic perspective: The civic charter of global health. J Clin Images Med Case Rep. 2023; 4(8): 2551.

Introduction

The meaning of global health

The World Health Organization (WHO) estimates that more than 25 percent of illnesses in adults and more than 33 percent in children under the age of five are due to avoidable environmental causes, and that approximately 13 million deaths are attributable to environmental exposures annually, of which more than 7 million are related to air pollution alone [3].

The COVID-19 pandemic we have been experiencing for the past two years or so also taught us how inescapable the relationship between the individual and the planet is, and how necessary it is to practice a broader and more interconnected approach to health.

The World Health Organization defined health in 1948 as ‘a state of complete physical, mental, and social wellbeing - and not merely the absence of disease’. Today, more than 70 years later, the WHO definition is as relevant as ever. The global pandemic in fact confirms the need to recognize a broader scope to health, which is no longer the result of a few, circumscribed variables, but the fruit of multi-sectoral and global variables. The pandemic has highlighted the weaknesses and peculiarities of the individual health systems in the world and at the same time has brought out the inequalities of people in terms of response and possibilities for health protection. On the other hand, the pandemic has also been and continues to be an opportunity to provide answers and reinvent a health model that is more harmonized with the real needs of people and the planet.

This because the Covid-19 health emergency is the result of a globalized world, which now lives in a dimension of the entire planet. It has highlighted how the health of humans, animals and the environment are increasingly interconnected, yet still fragile and vulnerable. It is thus the time to adopt a long-term One Health vision that we can no longer do without and, above all, cannot think of postponing, because it is now clear that ‘no one saves himself’. This is where we must start again to rethink the concept of health, with a holistic approach that considers all the social, cultural, environmental, and economic determinants that are essential for the well-being of each individual and reinvent an interconnected global governance of One health. This single concept of health, as circular and interconnected, a unicum therefore, manifests full awareness of being part of a planet in which we are all guests, as individuals, animals, plants, ecosystem.

The popularity of the term global health and the “health for all” approach can presumably be linked to the advent of economic globalization in the 1980s. In Italy, the 1990s-2000s were marked by the growing relevance of globalization processes and their impact on living and health conditions, especially in the global south, as well as the growing inequalities between north and south. The right to health, and even more so the right to global health, concerns the existence and enjoyment of public goods, from access to clean water and sanitation to the adequate supply of healthy and nutritious food, from freedom from violence and discrimination to health information and services, which can only be provided and used through collective action; the collective right to health can be seen as a pathway that enables a group of realizing the well-being of its members through the progressive attainment of all civil, political and welfare rights [4].

It took thousands of years for the world’s population to reach one billion, but then it took only a couple of centuries to reach 8 billion today. According to recent estimates, the world’s population will reach around 10 billion in 2050, thanks mainly to the general improvement in the medical and health framework, which has on the one hand reduced premature and infant mortality, and on the other hand increased life expectancy at birth to 72.8 years globally in 2019, an improvement of almost 9 years compared to 1990 [5]. This development, however, has not been without consequences, and the environment has paid a heavy price: About 20 per cent of the Amazon rainforest has been destroyed in the last fifty years; the current global average temperature is almost one degree Celsius higher than the average at the end of the 19th century [6]; about 200 living species are becoming extinct every day due to habitat loss and the alteration of the composition of the atmosphere and the climatic and chemical balance of the oceans [7]; more than two billion people in the world live in countries with water supply probproblems [8].

It is thus more than ever evident the significance of global health as a concept that approaches health closely interconnected with the world population, the spread of diseases, the phenomenon of globalization, but also with the distribution of resources and the health of the planet. Health is influenced by various determinants and circumstances that the human being, as an individual and as an institution, has the responsibility to govern in a consonant and sustainable manner to be able to guarantee a true right to global health. As outlined in the Ottawa Charter [9], fundamental conditions and resources of health include: peace, housing, education, food, income, a stable eco-system, continuity of resources, justice, and social equity.

The creation of the Global Health Civic Charter

In 2015, the Rockefeller Foundation and The Lancet coined the term ‘Planetary Health’, whose vision is of a planet that nurtures and sustains the diversity of life with which we co-exist and on which we depend, with the aim of creating a movement for planetary health. The correct functioning of our planet, ensuring a healthy environment, low pollution, and mitigation of climate change play a leading role in the well-being and health of populations. For this reason, it is crucial to develop a global strategy for health, environment, and climate change, which envisages a convergent, multi-sectoral approach to ensure safe and accessible environments according to principles of equity and sustainability. We need cooperative and democratic action at all levels of society whose founding principle is to conserve, sustain, and make resilient the planetary and human systems on which health depends, prioritizing the well-being of all [10].

From a citizens’ perspective, global health is an integrated approach of research and development of global actions that aims to give full meaning and implementation to a vision of health as a state of bio-psycho-social well-being and as a fundamental human right. Dealing with global health means preventing and reducing inequalities and fostering harmonious and sustainable development. It means overcoming the perspectives and interests of individual countries, thus taking a holistic view, and paying special attention to the most fragile and poor populations with the primary objective of guaranteeing a dignified quality of life for each individual. It is crucial that health as a human right returns to the center of global debates and goals, a process that cannot be achieved without a proper focus on social justice, equality, and equity.

In this innovative approach, it is our duty to look at health in this direction with a more concrete and demanding approach. Hence an inevitable awareness that health should not have a health-centric meaning, but rather health-centric with the primary objective of the bio-psycho-social well-being of the person. We are realizing, perhaps belatedly, that health is to be found first and foremost in our daily lives, in our social places, in our work contexts, in our homes with the food we eat and the lifestyle we follow, with the shopping we do, with the place we live in and the air we breathe, as the director of the World Health Organization also recently observed. This motivates us even more to change the way we are and act, and above all to demand those rights that are already in place so that they do not remain only on paper.

It is from these premises that Cittadinanzattiva has launched its new project aimed at drawing up a Global Health Charter in a “civic” key, with the aim of building a health-conscious reading of health and contributing to providing effective solutions to the crisis and the health needs of each individual [11]. Cittadinanzattiva, considering the current social, health, environmental and economic context, senses that it is time to draw up a first Global Health Civic Charter and does so through a multi-stakeholder engagement process, involving some of the main health and environmental actors. The Civic Charter of Global Health stems from the experience of the European Charter of Patients’ Rights [12], promoted in 2002 by Cittadinanzattiva and the civic organizations of 15 European countries, and is set in the perspective of the 2030 Agenda [13] and the Universal Declaration of Human Rights [14]. The aim is to build a shared and participatory vision on the health rights of the individual, as an individual and as a community, through the drafting of a Global Health Charter, from the bottom up.

Thus, the Charter wishes to function as a tool to represent on the one hand the rights that already exist, and are therefore enforceable, and on the other hand new rights, linked to the current socio-environmental-economic context.

Methodology

The process leading to the Global Health Civic Charter

The Global Health Civic Charter drafted in 2022 is the result of a multistakeholder engagement process, which involved some of the leading experts and actors in the world of health and the environment.

In all its projects and activities, Cittadinanzattiva strives to involve all the health actors in the discussion (from the scientific world to the institutional world and representatives of patients’ associations and civic organizations, etc.) and does so by convening multi-stakeholder boards that at the end of a process allow various points of view to be collected and summarized in order to formalize a timely and effective interlocution also on the basis of evidence.

The drafting process thus began with the establishment of a Scientific Committee that played a guiding role in the entire shared process [15]. Three themes emerged from the Scientific Committee’s discussions: health and well-being, health of the planet, and social justice. The work then started from a survey carried out by Cittadinanzattiva at the national and European level, thanks to its European branch Active Citizenship Network (ACN) [16], which involved citizens and associations from 24 different countries to sound out their level of awareness and perception on the issue of global health and to be able to delimit a perimeter of macro areas in order to decline the Charter as effectively as possible.

From the survey, it emerged that access to health for all citizens (76.7 percent), combating social inequalities (61.4 percent), psychophysical well-being (51.4 percent), fair distribution of wealth (36.5 percent), and the pursuit of sustainability (22 percent) are the five issues that citizens of European countries indicate as priorities for a strategy to ensure global health.

With a view to participation, the process continued with the organization of a multi-stakeholder workshop [17] which, through specific thematic sessions inspired by the three central themes, led to the evidence well expressed in the Charter. The thematic sessions were led by a scientific [18] and a civic coordination [19].

The participatory processes concluded with the drafting of the first Global Health Civic Charter, which was joined by the members of the Scientific Committee, national and European stakeholders involved in the various project phases. The Charter is addressed to the attention of civil society, national and European institutions, citizens, as individuals and as a community, and anyone else interested in contributing, through concrete and responsible actions, to the protection of the declared rights.

Results

The purpose, rights, and actions of the Global Health Civic Charter

The Charter proclaims 13 rights that aim at guaranteeing each person, in the interest of the individual and the community, a ‘global’ health understood as bio-psycho-physical well-being interconnected with biological, economic, and social, political, cultural, environmental, and commercial determinants. It aims to promote awareness among citizens and institutions and identify concrete actions to protect global health as a state of biological, psychological, and social well-being and as a fundamental human right [20].

In the area of health and well-being, measures are suggested to expand universal access to care and strengthen pandemic preparedness, ensuring global access to vaccines, drugs, and therapies, transferring technologies and skills to low-income countries as well as suspending their patents. Actions are needed to make places and cities healthier, with dedicated resources, including organizational ones, and with professional figures such as the Health City manager; facilitating everyone’s access to cultural heritage and practices of art, culture, and beauty in the logic of new cultural welfare for physical and mental health.

At the same time for the health of the planet, there are plans among others to implement water and air quality regulations, reclaim, and redevelop polluted areas, redevelop real estate and unused areas to curb land consumption, encourage sustainable mobility, and support the European policies envisaged by the European Green Deal and the Circular Economy Action Plan.

Finally, for greater social justice, it is necessary to guarantee basic health care for the most fragile and invisible people, untying it from registry residence and regularity of residence, implement national prevention and screening campaigns in urban suburbs and Roma camps, and provide an absolute ban on pregnant women entering prison.

With these dutiful premises, the 13 rights of the first Global Health Civic Charter are the following:

1. Right to global health: Everyone has the right to demand health, understood as bio-psycho-social well-being, which is more sustainable and interconnected with biological, economic, and social, political, cultural, and environmental, and commercial determinants, in order to reduce social inequalities among the most fragile and poor populations.

2. Right to well-being: Everyone has the right to live in a clean, healthy and sustainable environment and in harmony with an economy of well-being, in order to develop an integrated policy for health promotion, disease prevention and well-being, which is able to ensure the person - as an individual and as a community - a better quality of life, more equitable, dignified and inclusive and succeed in time to counter the obvious inequalities between populations. Everyone also has the right to be able to freely access and enjoy public green areas and cultural heritage places, nurturing the wellbeing and balance of the individual.

3. Right to sustainability: Everyone has the right to satisfy and develop their health and well-being needs in a fair, sustainable and responsible manner without compromising the ability of future generations to realize their own. In particular, all conditions must be ensured to avoid wastage of materials and materials by innovating the current market system.

4. Right to innovation: Every individual, even in situations of greater fragility and exclusion, has the right to benefit from technological innovations aimed at including and fostering fair and timely access to care and programs for the promotion of health with an impact on individual and collective wellbeing, with the ultimate goal of enabling a better quality of life in balance with the health needs of our Planet. Likewise, the right to innovation must be guaranteed in the planning and programming of environmental measures that foster greater resilience of territories and the ability to respond to current emergencies, starting with the climate crisis.

5. Right to access: Every individual has the right to access the health and social services that his or her state of health and bio-psycho-social well-being requires, in respect and harmony with the environment in which he or she lives and with an environmental sustainability that is essential to foster full and equal inclusion. Health and social services must be able to guarantee equal access to everyone, without any discrimination in terms of available financial resources, place of residence, level of education, social context.

6. Right to a life with dignity: Everyone, in relation to his or her state of health and wellbeing, has the right to lead a life appropriate to the needs he or she expresses, so as to achieve a level of quality and wellbeing that represents his or her individual and collective personality.

7. Right to information: Everyone has the right to access, in a correct and conscious manner, all information concerning his or her state of health and bio-psycho-social well-being and the health of the surrounding environment in which he or she lives and performs his or her individual and collective personality.

8. Right to empowerment: Every individual has the right to take action to increase his or her competences in order to renew the social and political environment in which he or she lives and performs his or her individual and collective personality, and to participate - as an individual or as a community - in the decisions/choices that affect his or her own state of health and bio-psycho-social well-being and to be a spokesperson for a fair and quality health for his or her own life and that of the community in the social context to which he or she belongs.

9. Right to transparency: Everyone has the right to acquire the data necessary to be able to demand the right to health, both individual and collective. Information must be made available by agencies and institutions in a clear, constant, and easily accessible manner.

10. The right to share data while respecting privacy: Everyone has the right to access the wealth of information derived from data streams, in disaggregated form and in full compliance with privacy regulations and, by implementing a harmonized approach to big data, foster its use in order to weave together all levels of information for research and treatment purposes.

11. Right to participation: Everyone has the right to actively participate, as an individual and as an associate, in the decision-making processes put in place, at various levels, by institutions in order to define, implement and evaluate the implementation of all those policies that affect people’s health. These also include choices that determine the transformation of the environment, the use of natural resources and climate change mitigation and adaptation policies.

12. The right to social visibility: Every individual, even in the most fragile situations in the social, legal and relational spheres, often marked by invisibility to institutions and social-welfare pathways, has the right to be considered in his or her identity in relation to his or her own health and well-being needs and to the surrounding environment in which he or she lives and performs his or her individual and collective personality.

13. Right to a human relationship: Everyone has the right to create a proactive and effective relationship oriented as much as possible to the person, in relation to his or her bio-psycho-social health status, guaranteeing natural spaces and public green spaces in cities, as privileged gathering places where to cultivate everyone’s well-being.

The Charter also puts forwards 60 actions to follow to make the rights concrete and enforceable in these three areas. For example, it begins by recommending for the dissemination and application of the contents of this Charter, together with a monitoring of its implementation, to take place at the ‘Glocal’ level: from the national to the European level.

On information and empowerment, the Charter should be used as a tool for informing and creating awareness in citizens - as individuals or as a community - to sensitize them on issues and indispensable rights. The Charter could be the subject of education and awareness-raising campaigns to be implemented in partnership with institutions within schools. It could be disseminated through media channels, institutions and organizations related to global health. The Charter could also be disseminated in schools, universities, and all social gathering places.

Regarding accession, forms of support and subscription to the Charter could be gathered from all health actors, civic organizations, scientific societies, and environmental protection associations, cultural or architectural or sustainable development realities. Those who subscribe to the charter could make specific commitments for its implementation within the context of the reference framework.

Finally, the Charter could be used to launch activities to protect citizens’ rights with a view to health promotion. The Charter should ensure continuous engagement with stakeholders already involved in the drafting process, while also involving new actors who can create added value over time. The charter could be the output from which to activate advocacy and call for health promotion policies in practice.

Discussion and conclusion

This Charter represents a fundamental step for the citizens’ right to health and to access health services. The link between health and the environment is perhaps one of the best-known aspects of the global health approach; alongside this, there has been a growing awareness of how the mental and physical health status of individuals is closely linked to people’s enjoyment of civil and social rights and socio-economic and educational levels, and how inequalities weigh in the achievement of populations’ health goals. Government policies must increasingly take into account the interconnectedness of these variables: from attention to the mental well-being of the younger generations to health prevention and health promotion even of the invisible, from the quality of life in cities to the health of those in prison and illegal foreigners, the Charter aims to be a tool to design and implement new measures aimed at the health of all.

As declared by experts [21], the COVID-19 infodemic (an excessive amount of information about a problem that is typically unreliable, spreads rapidly, and makes a solution more difficult to achieve) showed that low health literacy of a population is a globally underestimated public health problem. For example, in Europe, nearly half of the adults reported having problems with health literacy and lacked relevant skills to take care of their health and the health of others [22]. For this reason, it is crucial a stronger commitment by international institutions to invest in the health literacy of the population and to include, as a heritage of the pandemic, the concept of global health as a priority common good and as a term to be highlighted among the health literacy programs.

At the European level, it is important, right after the next 2024 European elections, to prioritize the concept of global health among the multi-annual EU Health Program, starting from a greater commitment of both the newborn European Health Emergency preparedness and Response Authority (HERA) [23] and the EU Parliament’s Subcommittee on Public Health [24].

From our side, Cittadinanzattiva/Active Citizenship Network confirms its commitment to promote and encourage the endorsement of the Charter among the civil society, but also in the framework of the MEPs Interest Group “European Patients’ Rights and Cross-border Healthcare” [25], established in 2014 by Active Citizenship Network as a concrete example of cooperation between civic societies and patient organizations together with the Members of the EU Parliament to strengthen the protection of patients’ rights in the European framework.

Declarations

Each of the authors confirms that this manuscript has not been previously published by another international peer-review journal and is not under consideration by any other journal. Additionally, all the authors have approved the contents of this paper and have agreed to the submission policies of the journal.

Authors’ contribution: Each named author has substantially contributed to conducting the underlying research and drafting this manuscript. Additionally, to the best of our knowledge, the named authors have no conflict of interest, financial or otherwise.

Conflict of interest: The authors listed on the first page declare that they do not have any conflict of interest.

Acknowledgements: The Global Health Charter is promoted by Cittadinanzattiva with the nonconditional contribution of Janssen Italia, a pharmaceutical company of the Johnson & Johnson Group.

Cittadinanzattiva thanks all the experts that took part in the Scientific Committee, the Multistakeholder Workshop, the Scientific Coordination, and the Civic Coordination.

In particular, special thanks to: Walter Ricciardi, president of the World Federation of Public Health Association (WFPHA); Stefano Vella, Adjunct Professor, Global Health, Catholic University of Rome; Marco Frey, President of Global Compact Italy Foundation; Anna Rita Cosso, President of Cittadinanzattiva.

For all phases of the project, a project team was set up by Cittadinanzattiva, coordinated by Claudia Ciriello and composed of: For the Health area of Cittadinanzattiva: Claudia Ciriello, Etty Escalante, Valeria Fava, Cristiana Montani Natalucci, Alessia Squillace; for the General Secretariat of Cittadinanzattiva: Annalisa Mandorino and Francesca Moccia; for the European area of Cittadinanzattiva: Maira Cardillo, Maddalena D’Urso, Bianca Ferraiolo, Mariano Votta; for the Press and Communication area of Cittadinanzattiva: Aurora Avenoso, Lorenzo Blasina, Alessandro Cossu, Luana Salvatore Zuccarello; for the institutional relations area of Cittadinanzattiva: Valentina Condò, Riccardo Giannini, Cristiano Tempesta; for the Events organization area: Elisa Blasucci and Marianna Sarruso; for the Territory and Environment area of Cittadinanzattiva: Adriano Paolella and Raniero Maggini; for the Justice for Rights area of Cittadinanzattiva: Valentina Ceccarelli and Laura Liberto; for the School area of Cittadinanzattiva: Adriana Bizzarri and Marilù Pacetta; for the Consumers area: Cinzia Pollio and Tiziana Toto.

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