Alicia Ely Yamin is the Director of the Global Health and Rights Project and a lecturer at Harvard Law School. She’s also an adjunct senior lecturer on health policy and management at the Harvard T.H. Chan School of Public Health and a Senior Advisor on Human Rights and Health Policy at Partners in Health.

Alicia is known globally for her work on the right to health, economic and social rights, and reproductive justice. She has spent much of her professional life in Latin America and East Africa, including co-founding a health and human rights program with the Asociación Pro Derechos Humanos in Lima in 1999.

She has served in major UN and global expert roles, including as one of 10 experts appointed by the UN Secretary-General to the Independent Accountability Panel from 2016 to 2021. Alicia has edited and authored over a dozen books and UN reports, and close to 200 articles. Her most recent book, When Misfortune Becomes Injustice: Evolving Human Rights Struggles for Health and Social Equality, was published in a revised and expanded second edition by Stanford University Press in 2023, with a Spanish edition forthcoming in 2026.

Today, we’re bringing her human rights lens to our international mental health systems, including what she’s seeing in debates around accountability, consent, and institutional power.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Justin Karter: Alicia, thank you so much for coming to the Mad in America podcast. It’s wonderful to have you here.

Alicia Ely Yamin: Thank you so much. It’s great to be here. I’m a fan.

Karter: To start, I’d love to back up and get a sense of how you found your way into this work. How did your own history, your intellectual journey, lead you into human rights law, and then into public health and international human rights work?

Ely Yamin:  I grew up between Argentina and the United States. My mother’s family is from Argentina. I likely would have grown up there, except that there was a pretty brutal military dictatorship. I really grew up in the United States, but I had maintained close ties.

On the other side of my family, my father’s father was a labor activist, a union organizer. So I really was growing up very aware of human rights issues, but more as political and social demands.

I went to college at a time when the United States was invading Central America. I was obviously very aware of the U.S. role in the Southern Cone in Latin America.

It wasn’t until law school that I really found human rights as kind of a way to channel those passions and ethical commitments into a professional career. After law school, I graduated from Harvard Law School, and I had a fellowship that took me to Mexico to do pretty traditional human rights work on torture, extrajudicial executions, and police abuses.

But while I was there, and really in law school, my desire was to use human rights to promote social justice, economic justice.

While I was in Mexico, I decided, for a variety of reasons, to focus on health, which, I think, is a very acute reflection of patterns of justice and injustice. Actually, it was in Mexico that I met Eric Rosenthal, who, later, with the same fellowship I had at the time, founded what was originally called Mental Disability Rights International. It’s now called Disability Rights International.

Karter: You said something really interesting there. You said, “Health is a reflection of patterns of justice and injustice.” That’s a powerful conception of health that differs from maybe our standard definition. I wonder if you could just say a little bit more about what you mean by that.

Yamin: I mean, in public health and epidemiology, we talk about the distribution and determinants of population health. But from a legal or human rights lens, many of those determinants are, in fact, legal or institutional. They then discriminate against certain populations or marginalize certain populations. Sometimes the way health systems are structured can exclude or punish certain kinds of populations. That’s really what I have been focused on for my entire career.

Karter: You take this conception of health and human rights, and then you begin moving into the mental health sphere. Can you tell us a little bit about your first forays into the mental health world, and then some of your early field work?

Yamin: Actually, it began before my professional work. My brother, growing up, I have an older brother, and he struggled with pretty severe mental health struggles and had been in and out of institutions. Growing up, I was really acutely aware, primarily I would say as a child, of the stigma associated with these mental health struggles, but also what he was going through, and the suffering and the pain that affects the entire family.

Then, when I met Eric Rosenthal in Mexico after law school, I became involved in Mental Disability Rights International and did quite a bit of field work with him in different countries, investigations, and served on the Board for quite a while. Some of that field work really, one, gave me kind of normative frameworks for understanding why mental health care was so terrible and what needed to be done, and brought me up close into the abuses that were happening in many of these psychiatric institutions, primarily in Latin America.

Karter: Well, our listeners will be familiar with some of the abuses, but I’m wondering if you could speak to some of the particular moments that stick with you, things you saw in your field work, things you saw in institutions and outside of institutions?

Yamin: In one case, DRI, what was then MDRI, brought very important litigation in the inter-American system regarding the National Neuropsychiatric Hospital in Asunción, Paraguay, which was a facility for adults that was massively overcrowded. But we had been tipped off to the presence of two adolescent boys in this facility, and went to do an investigation.

Then I continued to be involved in the legal and advocacy part of that. But one of those boys who was held in this facility was locked in a tiny cell 23 hours a day, naked, eating food with his hands, with feces surrounding him, and holding, shaking the bars really violently because he was obviously so upset at being caged that way. He had just this very forlorn expression in his eyes that actually reminded me very much of an expression I had seen in my brother’s eyes.

It’s that kind of moment of — but for all of the layers of privilege with which my family and I walked through this world, my brother very well could have ended up in a similar situation. I’m not saying that there aren’t similar situations in the United States. That’s one that really, really sticks with me.

Another one that really sticks with me was in Uruguay, where I was living with my family at the time. I had — my two children were small at that time. We came across a really young boy, again, caged in a windowless little closet with just bars on this tiny part of the door, zero stimulation whatsoever, and because I had small children at the time, I was wrecked confronting this.

I happened to constantly have the habit of carrying around little toys for my own kids. I passed a Thomas the Tank Engine through the bars in the door. The kid just had his eyes lit up, and he grabbed that, and he had a huge smile. It was just very, very emotional.

That is another kind of moment that sticks with me, but there are many.

Karter: Thank you for sharing that with us. You said in your previous answer that some of what happened during this time, during your field work, was also encountering frameworks that helped you make sense of why this was happening. I wonder if you could speak to how you were wrestling with it at the time. What is going on here? Why is this happening? How is this allowed to happen?

Yamin: Well, when I started with DRI, it was before the Convention on the Rights of Persons with Disabilities, but DRI was really advocating for deinstitutionalization and many, many of the things that then — and the standards in the CRPD that later came to fruition.

But there were some principles on the treatment of people with mental disabilities. I started reading those documents and seeing the enormous gap between those documents and what was going on in practice.

I also began really kind of processing: why is this, right? Why do we — and to say that we warehouse people with psychosocial disabilities is, I think, overly benign. I mean, the treatment that I have seen is, in many cases, worse than what I’ve seen in prisons.

Karter: How do we make sense of that gap between what’s rights on paper and what’s happening in practice? What’s driving this discrepancy?

Yamin: Well, so some of it is, of course, political will, and a lack of accountability mechanisms at the national level. But over time — and this is something that I’ve done in my own human rights work and health-related work and economic and social rights — is really to focus on evolving political economies, and to see how privatization of facilities, the austerity policies that are affecting health systems in general and social determinants of health, but mental health systems also in particular, have really been barriers to having the quite progressive and landmark standards in, for example, the Convention on the Rights of Persons with Disabilities actually implemented in practice, so people have effective enjoyment of those rights.

The same is true of health rights in general, I should say, right? It’s not just mental health, but it certainly is mental health. As important as the work that DRI was doing, I began to think beyond the naming and shaming and look at the structural drivers of these situations.

Karter: I know we’re going to be getting to the institutional corruption framework and how that undermines human rights and mental health care. I want to come back to your story. I’m thinking about when you encounter the things that you’ve described, where do you go from there? What did you do next? You said you’re seeing these things, you’re documenting them, you’re realizing that sort of naming and shaming them isn’t enough. What was the next step for you?

Yamin: I was working with DRI at the time, which was MDRI at that time. In the Paraguay case, they brought the case to the Inter-American Commission on Human Rights, which, for the first time in history, issued what are called precautionary measures in the case of a psychiatric institution. And then MDRI and the Paraguayan government entered into a long, protracted series of negotiations, with the kind of — not threat, but leverage — hanging over the government that that case could always be reactivated if they didn’t agree to the terms of the negotiated settlement.

That was that — and litigation is super important, and I think that there were positive outcomes as a result of that. But it certainly didn’t overhaul the system, right?

In other cases, the field investigations results in reports that then NGOs use in publicity and advocacy. Sometimes there’s shadow reporting to UN committees. MDRI has done very well using video and somewhat non-traditional forms of human rights documentation. But that, again, I kind of — in other dimensions of my life — looked more into health systems and how they’re financed and organized and how priorities are set.

Karter: I’m coming back to the public health and human rights framing. One of the reasons I wanted to underline that earlier is that it’s different than the mainstream, maybe even hegemonic, conception of mental distress in psychiatry and psychology. In that view, there’s some underlying biological mechanism in an individual that leads to distress. It might present differently cross-culturally, but it’s ultimately the same disorder, or something like that.

Conceptualizing distress at the population level as arising from access to or denial of human rights is a very different framing. I wonder if you could speak to the tension between those models.

Yamin: The Convention on the Rights of Persons with Disabilities really was transformative in this respect, because it conceptualized disability, not just psychosocial disability or mental disability, but all disability, as the product of an interaction between physical or mental impairments and the social, cultural, institutional environment. That was really huge, and an enormous step forward.

That’s also, in some ways, the way we think about health in a human rights framework. You can’t have a right to something that is purely stochastic, or purely biological and individual. You have rights to things that require institutional arrangements.

You don’t have a right to be the best piano player or the best soccer player in the world, which is a talent or a gift. But rights, when we think about education or political participation or due process, and also health, are a byproduct, an artifact, of social relationships and institutional arrangements. Human rights kind of pushes in that direction always.

What I found interesting when I started really working with colleagues who do more on disability is that, often, the argument in mental health would be that these kinds of what I would call abuses or coercive practices were necessary to uphold the person’s right to health. That, to me, struck me as really kind of odd, because a right to health is not just access to care. That’s super important, and equal access to care. But there’s also a part of the right that is the right to refuse care, certainly to refuse non-consensual care or treatment. That has struck me, and I’ve done a little bit of writing on that.

Karter: You recently led a special issue for the Harvard Health and Human Rights Journal, Institutional Corruption and Rights-Based Mental Health (MIA coverage here). I wonder if, for our listeners, you could explain what institutional corruption is and how it helps us understand the barriers to rights-based mental health approaches?

Yamin: Actually, it came out of reading Lisa Cosgrove’s work and Robert Whitaker’s work, because they talk about how there has been this relationship between the organized psychiatric profession and the pharmaceutical industry, in the sense of having driving incentives for prescribing more and more psychotropic medications.

They begin by tying the real inflection point there to the DSM-III in 1980, which changed the emphasis of mental health to treating diseases of the brain, basically. That elevated psychiatrists and the psychiatric profession enormously, because previously, the psychiatric profession had been associated with these horrific abuses in institutions. There was really not a ton of data or evidence that they could do any better than people who were not prescribing meds.

But after 1980, you see the proliferation of pharmaceutical interventions. What really struck me was how non-evidence-based it was, right? Non-evidence-based here, and then I started reading other studies from the UK and elsewhere in Europe.

That’s also part of human rights, right? The states are obligated to take appropriate measures and to ensure that if there are private actors involved, they are being regulated, so the appropriate measures are taken to advance population health, or in this case, mental health.

I continued to have many conversations with Lisa and Bob Whitaker, and then with other colleagues. I have done a lot of work on globalization and what kind of neoliberalism did to health systems in the global south. Of course, 1980 was the period of Ronald Reagan here, of Margaret Thatcher, a decade in which structural adjustment programs swept across the world. Thereafter, in 1995, the World Trade Organization was founded and really, really unleashed a zeal for trade liberalization that greatly, greatly benefited pharmaceutical companies and intellectual property.

I wanted to put this together and think about how the neoliberal paradigms, which had spread austerity and privatization in health systems, the so-called public-private partnership model in many countries, also fit with this greater pharmaceuticalization.

In doing the research, it was really quite interesting to see the ways in which being able to just prescribe a pill is so appealing in that neoliberal framework, because you don’t need to address all those other social causes of distress. You don’t need to keep people in psychiatric treatment for that long. You just hand out pills.

It’s become so normalized over the last 40-odd years that it’s just taken for granted. Psychiatrists who are trained on this Western, largely US-based model replicate this around the world.

That’s really what this special issue was about, and highlighting it. It’s kind of a call to action to rethink, on the one hand, the paradigms that are used in mental health systems around the world, but also for advocacy: it’s not going to be enough just to talk about the norms in the Convention on the Rights of Persons with Disabilities. We do have to think about these political economy forces that are shaping possibilities for people to enjoy these rights in practice.

Karter: In the institutional corruption framework, one of the benefits is that it helps us think beyond bad apples, as Lisa says, right? Of course, there are bad apples, but we also understand that behaviors occur within systemic constraints and that perverse incentive structures make it much easier to engage in certain behaviors and interventions, and much harder to pursue others.

From that understanding, when somebody walks into the ICU for a psychiatric disorder in the United States, what are some of the incentive structures in the room, for all the players involved, that get in the way of that person’s human rights being accounted for and being treated with dignity?

Yamin: : I mean, everybody is overwhelmed. Maybe it’s late at night and they’re exhausted. There are 30 other people waiting to be seen. They have — I don’t know how many minutes they’re supposed to do a lot per patient — I mean, all of that interferes, right? Sometimes there are physical space concerns too. And that’s in the United States, right? You can imagine what happens in other places.

Karter: You have to bill an insurance company, so there needs to be a diagnosis that’s billable. Certain medications you can bill more for monitoring because they’re high-risk medications.

Yamin: Oh, of course, yes, absolutely.

Karter: The long-term outcome is maybe not the primary concern of the immediate team, who needs to sort of stabilize in some way.

Yamin: Stabilize and move on, right?

Karter: Right. And our system not being a national system, there isn’t a really clear way to see that we’re losing money long-term on providing short-term solutions that increase chronicity, or cause other health issues down the road, right? Because other payers, at other hospitals and other public health systems, pick up the tab for that, or the individual does. But it’s not necessarily — it’s not part of the decision-making there in the moment, in the same way it might be in another system. Is that fair to say?

Yamin: Well, I think it exacerbates that in our system, because when you have sort of cradle-to-grave coverage, like in the United Kingdom or something, there is more communication and follow-up. But I think in these situations there’s a lot of stabilize and move on, and it’s not my problem. It’s much more costly, right? The transaction costs in the United States on healthcare are astronomical.

Karter: When you came, as a human rights and public health expert, into these pretty intense debates in the mental health field — around what is mental illness, how is it best treated, and how do we care for people who are potentially unhoused, or perhaps denying care but not doing well individually on their own, and potentially becoming sick, more sick, by being exposed to illness, things like that — how did your framing illuminate those debates differently than the stuck debates the field is having?

Yamin: Yeah, they are kind of stuck debates, with very, very heated positions, right? A little bit is what I was just saying about how I think that that is a misreading of the right to health and what it entails.

I’ve done a lot of work talking about how, in the kind of medical system that all of us are so familiar with — to use a word, kind of the biomedical model — physicians, doctors, are imbued with this specific kind of technical expertise. They have this magical power that allows them to diagnose and name whatever the problem is in the individual’s body or mind. The way the model is set up makes it almost an unchallengeable authority.

A lot of what human rights has been about in this field is saying that’s not actually right, and that we have to pay more attention to the lived experience of patients, of people who use the health systems.

My own background: I’ve worked mostly in reproductive health and sexual health. The same thing is very, very true in obstetrics and gynecology.

I do think it’s, in a way, particularly problematic in psychiatry, because the cloak of technical expertise and scientificity masks real, serious problems in the classification systems and replicability. It’s not as though you can point to, well, that’s this kind of tumor, right? It’s a very different kind of medicine, which poses a lot of additional problems, I would say.

Karter: You said the cloak of science covers up a lot of gray area — in terms of how do we know that this person has X condition, and that this treatment is likely to be successful. And I imagine that comes into the equation when you’re trying to say someone is likely to benefit from this treatment, even if forced, more so than from this lack of treatment. Could you say a little bit about how that changes the equation once you take back that cloak?

Yamin: Right. Well, once you take away that cloak and actually give greater equality to the different voices, then the medical provider is forced to justify their decisions.

In many of these situations, that can be through supported decision-making, where the patient, who may be in some distress, is not alone but can have help navigating it, which would also kind of equalize the situation.

But again, in the political economy, we’re both speaking from Eastern Massachusetts and the Boston area, where there is a very high ratio of hospitals to people. Nonetheless, if you are taken to an emergency room in the Boston area while you’re in crisis, it’s going to be very overcrowded.

The person who is in mental distress is very unlikely to get supported decision-making. They’re going to be taking sharps away from you, possibly isolating you, or sedating you against your will.

That’s not — some of it may be indifference or lack of training, or possibly ill will or something, or misguidedness — but a lot of it is the way our hospital systems work, our health systems work.

Karter: I want to go back to what you said about the connection to obstetrics, because I think it’s really illuminating. Can you say more about what you mean by that — that there are similar logics operating in psychiatry and obstetrics? Are you talking about paternalism?

Yamin: Certainly paternalism, yes, certainly paternalism. I mean, obstetrics has a pretty dark history. Often in obstetrics, women are completely ignored, treated as unreliable narrators of their own experience, even when they’re going through labor pains, right?

But throughout pregnancy, or when they’re reporting an event — an unwanted pregnancy, for example — they’re reduced to sort of fields on which obstetricians are the protagonists who exercise their decisions, often thinking that the beneficiary of those decisions is not the woman, but the fetus or the eventual child.

It’s not just women — I should say the pregnant person, because trans men can also have kids — but completely instrumentalized, right, and dehumanized.

I think there is a connection to psychiatry where the person who is experiencing whatever they’re experiencing is often disregarded. I mean, there are historical connections, right? Women were diagnosed as hysterical, right?

It’s very, very common that an obstetrician will make a decision to tie a woman’s tubes during labor and delivery because she’s not capable of making a decision about childbirth spacing thereafter. She may have some condition or whatever.

Similarly, in psychiatry, there is, I would say, a tendency to be paternalistic and to make decisions without fully informed consent from patients.

Karter: And what you’re describing also touches a darker throughline, the eugenics history of controlling reproduction, especially for disabled and other marginalized people.

Yamin: Yes, there’s a very dark connection to eugenics histories. Forced sterilization is a horrific problem among women and girls with disabilities, as it is with other marginalized populations too.

Karter: These two fields really come together in one of your recent papers with Lisa Cosgrove, where you’re writing about the new medications being brought to market for postpartum depression (MIA coverage here). Can you tell us a little bit about that project and the research that you’re doing? You used the term obstetric violence in that paper. I’d be interested if you could unpack that for us, what that means.

Yamin: Obstetric violence is saying it’s not just that obstetricians can be disrespectful or abusive, or touch you in inappropriate ways without consent. It’s that making pregnancy and childbirth into a pathology that needs to be managed and controlled by the physician — instead of making the pregnant woman, the delivering person, the protagonist of this natural process — is a kind of violence.

It’s very connected to ideas of structural violence. It’s not just a question of what the provider does to the woman. It again connects to the idea that structural factors cause psychological and physical harm.

That concept started in Latin America with humanized childbirth and has now spread widely. It’s very, very contested in the United States. In the United States, obstetricians really, really strongly reject it, and talk about specific cases of maybe bad apples and mistreatment, and don’t want to acknowledge the structural drivers.

This had been largely applied, as I said, in pregnancy and delivery, so kind of forced episiotomies, which is to cut open and make it easier to deliver the babies, things like that.

But Lisa and I took — we were playing around with these ideas — and thought it could be extended into the postpartum period, because some of the same dynamics are at work. Of course, she has done a lot of work on the prescription of various pharmaceuticals, and sometimes on the misprescription of them.

This sertraline was first injectable, and then it became a pill, the first pill to treat postpartum depression.

The argument we make in the piece is, first of all, postpartum depression sits at kind of the intersection of mental health and reproductive health. There are all kinds of tropes about the good mother and the punitive attitudes toward mothers who are not absolutely perfectly content with their newborn children.

At the same time, there is much more diagnosed postpartum depression in this country than there is in other countries, such as high-income countries like Western Europe.

If you don’t focus just on a pill to relieve immediate distress, but you zoom out and you think, well, why would that be, you find that those other countries, for example, have much more generous family and medical leave policies, much more generous social protection and social support policies, protections on people not being fired or evicted, often mandatory policies that send doulas or midwives to houses after birth.

If you imagine somebody who is in a precarious economic situation, who doesn’t have personal family financial support, has to give up their job when they have a child — that is always stressful, to have a newborn child, right? The child may be colicky, or may have other serious issues — and they’re alone, without those protections for employment and housing and food security. It’s natural that you might expect more distress.

Now, do we treat that distress that really has social causes with a pill? As Lisa showed me and taught me, this particular pill may be a benzodiazepine type pill. It may actually be a barbiturate. It’s a little bit unclear from the advertising.

But one of the ways women bond with their babies is through nursing and breastfeeding. That would be contraindicated in that case. I think we were trying to highlight that this is complicated.

Of course, if somebody is undergoing psychosis, they need help, they need care, and medication can be part of that. But it shouldn’t be the only thing that we can offer when there are all these other things going on in people’s lives.

Karter: In some ways, calling this postpartum depression covers over all these gaps in our social system. If we were talking about it as a social failure condition — a failure to provide adequate support to a mother — it would land very differently.

Yamin: Justin, that is exactly what the human rights framework does. It says, well, these are political failures that are being treated as personal defects and we need to get to the root of the political failures.

I don’t think you can just look at the mental health system or even the health system as the starting point. I really do think that it’s in broader social determinants. What is our housing policy in this country? What are our employment and leave policies? Yes, in our health system, our medical system is a disease management system, in my view, that is very, very fragmented, very, very dependent on your own personal resources. It’s a health system that magnifies and exacerbates social inequalities in the overall society, whether those are race, gender, or class-based.

The answer is there’s no magic bullet. But the start is developing public policies that treat people, in all their diversity, as political and moral equals, and then devising social policies that put that into effect.

In the United States, we could do much, much, much better. In some other countries around the world that are shackled with sovereign debt, or are losing income through other means, they don’t have as much flexibility to address this as the political problem it is, right?

Karter: There’s been a lot of talk about the sort of mental health crisis in the Western world, in the US in particular, rising rates of diagnoses, debates about all of that. I’m curious from your point of view, from the political economy point of view, what would be at the top of your list of things that we could do politically that would change that scenario? What would make the biggest impact, maybe the top three policies that come to mind for you that would actually lower rates, lower distress among the population in the United States?

Yamin: That’s a really good and complicated question. I would say a policy that redistributes wealth and income, because I think we live in a society with such extreme wealth inequality that it’s very difficult for democratic processes to actually implement the policies necessary in specific areas.

I think that guaranteeing housing and guaranteeing healthcare, it’s fair to say that most Americans are really stressed about the cost of healthcare and the housing crisis, the lack of housing, right? I think that that’s pretty universal, even though it definitely affects brown and black people way more than white people, disproportionately more than white people.

Karter: Access to healthcare, access to housing, and then some type of redistributive financial policy.

Yamin: Yeah, I would say so.

Karter: I noticed you didn’t say more psychiatric beds and more institutionalization — and that seems to be the direction we’re heading — so I want to ask a question about that. As somebody who’s spent years working in the human rights framework around mental health, what’s it like to watch the current overall backlash against international law and human rights, and at the same time these renewed calls for institutionalization and forced treatment here in the United States?

Yamin: It’s infuriating, I guess, is one way to put it. It’s outraging. I mean, there are so many things that this administration is doing that run counter to basic respect for human rights, and this is one of them.

It does concern me that, while there are pretty well-organized coalitions working on alternatives to the CDC-revised vaccine schedule and related policies, there may be less well-organized resistance to these policies.

Karter: In the midst of all of this, it can be pretty dark. I’m wondering what keeps you going, and what keeps you from being overly cynical, and where are you putting energy right now?

Yamin: Well, I’m part of a grassroots group called Defend Public Health that is very much a part of the resistance, really fighting to stave off some of the worst abuses of this administration, but also to set out more of a vision of what we need to do after this endless assault is over, because it will be over one day.

We can’t think about going back to what we had before, which wasn’t very good.

What gives me hope, I guess, is working with colleagues who are in it with me. I’ve met a lot of new people who are just as committed.

Also, I’ve been doing this for a long time, Justin, and I’ve seen the struggle can be very ant-like, what you think you’re doing to contribute. I mean, it took decades to legalize abortion in Argentina. It took years and years to fight to convince the powers that be that people in Sub-Saharan Africa deserve antiretroviral medications.

I’ve worked on so many things that have just taken years, but I have seen change, right? I have seen change, and I’ve seen people’s lives transformed. And I get to work with amazing, committed people, so that keeps me hopeful.

 

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