center for analysis and research in human rights

Lines of work

Six lines of work are defined by CARDH: (i) research; (ii) capacity building and partnership; (iii) promotion and advocacy; (iv) monitoring and defence; (v) support to the democratic transition; (vi) contribution to the United Nations.

1. Research

CARDH organizes conferences and carries out research and studies for the advancement of human rights, publishing books , academic articles and reports . These publications address central themes of public interest and provide analyses and, where appropriate, recommendations to the various actors active in the promotion and enjoyment of human rights.

2. Capacity building and partnership

CARDH contributes to the capacity building of State and civil society actors and works with other partner organisations.  

2.1. State officials

CARDH launches various initiatives adopting a human rights-based approach with various public administration officials. These have included working sessions with election candidates, as well as inter-ministerial programmes on the analysis of a national budget, in all its phases of elaboration. The latest initiative consists of a sectoral table with human rights organizations and the Haitian National Police (PNH), aimed at bringing these two entities together in promoting human rights.

2.2. Non-state actors and civil society

2.2.1.  Training

CARDH also participates in civil society capacity building. Training sessions are organized for academics, human rights organizations and other non-state actors. CARDH also conducts training sessions for grassroots community organizations in certain areas known as « lawless zones » through its « ti celil dwa moun » program.

2.2.1. Platform: Founding member of ECC (Together Against Corruption)

Together with other human rights and civil society organizations, CARDH founded a new platform called «  Together Against Corruption  » (ECC). This will help define common action in the fight against corruption.

2.2.3. Electoral Observation

CARDH is part of the Coalition for Election Observation (COE). This coalition of human rights and civil society organizations monitors the elections and contributes to the search for solutions to the Haitian electoral crisis.  

3. Promotion and advocacy

CARDH also carries out activities to promote and mainstream human rights.

3.1. Human Rights Fair

In order to facilitate exchanges between State officials, civil society leaders and international cooperation partners on human rights, in 2017 CARDH established an annual space, the Human Rights Fair .

3.2. Public policies and Human rights

This pillar seeks to raise awareness of the Executive and Legislative Branches of the need to develop, adopt and advance public policies capable of improving the living conditions of the population, especially the most vulnerable.

3.3. Ratification of the International Covenant on Social, Economic and Cultural Rights

Since 2009, CARDH has been promoting the International Covenant on Social, Economic and Cultural Rights ratified in February 2012 by the Haitian Parliament. « (…) its vote by Haiti is greatly welcomed, particularly by human rights defenders, such as the Executive Director of the Centre for Analysis and Research in Human Rights (CARDH), Mr. Gédéon Jean, for whom this vote is an important step in the efforts to promote respect for human rights in Haiti, while at the same time demonstrating the will of the State to achieve this ». See United Nations Stabilization Mission in Haiti .

3.4. Participation in radio and television broadcasts

CARDH participates in numerous radio and television analysis programmes on human rights and related areas such as the rule of law and democratic governance.

4. Monitoring and defence

CARDH monitors human rights violations. In addition to regular reports and press releases denouncing abuses when they occur, CARDH produces annual reports on   the human rights situation in Haiti , outlining the key issues of the past year, as well as recommendations to the various actors active in the protection and promotion of human rights.

See massacre of La Saline

5. Support to the democratic transition

Three decades after the departure of the Duvalier dictatorship (1986), Haiti still fails to be a society that respects human rights and the principles of the rule of law, in accordance with the Constitution, adopted on February 7, 1987. The institutions that should assume the role of « guardian of the rule of law » are weak and unable to play their part. Beyond its actions directly related to the work of a civil society human rights organization, CARDH provides its expertise, which is often called upon to help resolve political and social crises.

5.1. Post-assassination crisis of President J. Moïse

5.1.1. Meeting with the high-level US delegation made up of Brian Nichols, Assistant Secretary for Western Hemisphere Affairs, and Juan Gonzalez, Senior Director of the National Security Council

Following the resignation of Daniel Foote on September 22 , a high-level American delegation, made up of Brian Nichols, Assistant Secretary for Western Hemisphere Affairs, and Juan Gonzalez, Senior Director of the National Security Council, traveled to Haiti to listen to stakeholders (civil society-politicians-authorities) in their approach to the crisis and participate in it. Thus, a meeting with civil society actors was held on Thursday, September 30 at 11:45 a.m. in the premises of the Embassy of the United States of America during which said actors gave their point of view and underlined works undertaken for a solution. At the end of the visit, the delegation gave a press conference concluding that the actors should merge the different agreements and reach a single agreement, such as N ap # Mache Pou La Vi (March for life), which CARDH is a member, had proposed during the meeting (documents were given to the delegation).

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5.1.2. Meeting with the mission led by the Under-Secretary of State for Civil Security, Democracy and Human Rights, Ms. Uzra Zeya, October 13, 2021

Following Nichols’ mission, a delegation led by the Under Secretary of State for Civil Security, Democracy and Human Rights, Uzra Zeya, visited Haiti from October 11 to 13, 2021. To begin with, CARDH brought to her attention that insecurity and criminality constitute the first problem to be tackled if one wants to set the conditions for the realization of the elections. In considerable increase, insecurity and crime affect the entire population, particularly the middle class, decapitalized, and the most vulnerable groups living on a daily basis, victims of more than 90% of kidnappings followed by rape (women), physical and moral tortures …

From January to September, the crime observation cell recorded at least 628 kidnappings, including 29 foreign nationals from three countries. At least 221, including 31 for the month of July, 73 for August and 117 for September, an increase of almost 300%. Note that these data are only indicators and not the exact number.

For the population, these missions will be important if the American government concretely helps the police and the Haitian government to resolve this problem. By tackling insecurity, among others, the following results will be achieved: i) increasing confidence in the police; ii) the population will participate in the solution; iii) the population whose interest is on the lips of politicians and the international community will take an interest in the political processes, including elections.

On governance, it is important to resolve the political crisis in the dynamic of the rule of law and respect for human rights. For CARDH, member of N ap #Mache Pou La Vi (March for Life), no single accord can guarantee stability.

The trials of the massacres and other spectacular assassinations: Monferrier Dorval, Antoinette Duclair, Diego Charles… must receive close attention like the case of President Jovenel Moïse. Strengthening justice with new perspectives is needed.

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5.1.3. Meeting with Daniel Foote, United States’ Special Envoy for Haiti

In order to facilitate the search for a solution to the new crisis engendered by the assassination of President Jovenel Moïse on July 7, 2021, President Joe Biden appointed, on July 22, Ambassador Daniel Foote as special envoy of the States United for Haiti. A meeting was held with him, accompanied by the Ambassador of the United States in Haiti, Madam Michele J. Sison, to gain the understanding of the Center for Analysis and Research in Human Rights on the crisis. See the summary document .

5.1.4. Inclusive Working Group (CTI) : Comparative analysis of proposals of an exit to the crisis and perspectives for a unique proposal

Given the difficulties of political actors and civil society to reach a single agreement after the signing of that of August 30, 2021 of the Citizen’s Commission for a Haitian Solution to the Crisis (CCSHC), N ap #Mache Pou Lavi (March for life), a civil society group to which CARDH is a member, proposed the establishment, as soon as possible, of an Inclusive Working Group (CTI) made up of six (6) personalities: one (1) representative of the National Memorandum of Understanding (PEN); one (1) representative of the August 30 agreement; one (1) representative of the remaining third of the Senate; one (1) representative of the de facto Prime Minister; one (1) representative of non-signatories; one (1) representative of N ap #Mache Pou Lavi (March for Life). This work could be carried out, by consensus, under the gaze of three personalities chosen from the media, the Federation of Haitian Bars and the Louis Joseph Janvier Chair. Within eight (8) days at most, the Inclusive Working Group (ITC) must reach the one-stop deal the country so badly needs.

Political, institutional and civil society entities have expressed their interest in the approach aimed at the Inclusive Work Group (CTI) for a final agreement. Thus, N ap # Mache Pou La Vi (March for Life) offers this document entitled «  Comparative analysis of proposals for ending the crisis and perspectives for a unique proposal »

This document presents a summary of the various proposals in three axes: policy; economy; Justice and social security, their convergences and divergences. In addition, it suggests what actors should focus on: i) Type of Executive: Prime Minister & President or Prime Minister only; ii) Duration of transition: 18 months or 24 months; iii) Upstream consensus on the sharing of responsibilities or use of mechanisms to achieve it: 1. Government; 2. CEP & Justice, 3. Government control; 4. Restoration of public finances.

However, to get there, they must be in good faith and willing to make sacrifices necessary to get the country out of the deadlock.

5.2. Crisis born of the dysfunction of Parliament and the end of the mandate of President J. Moïse

5.2.1. Political agreement of June 5, 2021

Together with other groups and personalities, the Center for Analysis and Research in Human Rights (CARDH) formed the civil society structure called N ap # Mache PouLavi (March for Life) having carried out a vast campaign against human rights violations and the dictatorial inclination of President Jovenel Moïse. Initiated on December 10, 2020, on the occasion of International Human Rights Day, the campaign continued, on July 14 and 28, 2021, then on March 28 and 29, 2021. N’ap # Mache PouLavi (March for Life) worked for nearly three months (March to May) with groups and political parties, which allowed them to conclude the agreement of June 5, 2021.

5.3. Proposal for an end to the crisis (2015)

Faced with the politico-institutional crisis of 2015, CARDH made a proportional proposal   to the crisis.

5.4. Electoral Evaluation and Verification Commission (CEEI) in 2015 and the Independent Electoral Evaluation and Verification Commission (CIEVE) in 2016,

In this respect, CARDH participated in the Electoral Evaluation and Verification Commission (CEEI) in 2015 and the Independent Electoral Evaluation and Verification Commission (CIEVE) in 2016, the latter with the aim of restoring confidence and truthfulness in the electoral process.

Download Report

5.5. Committee to coordinate the reception of returnees, formed following the wave of deportation made by the Dominican Republic in 2015.

The organization is also a member of the Joint Committee to Coordinate the Reception of Returnees, formed following the wave of deportations by the Dominican Republic in 2015. This committee is made up of leading figures from civil society and members of the government.

6. Contribution to United Nations 

Holding tnly consultative status with the Economic and Social Council (ECOSOC) of the United Nations, CARDH responds to calls for input from special procedures and the Office of the High Commissioner for Human Rights (OHCHR) on issues related to its sphere of action. It also participates in the examinations of the Republic of Haiti by the Human Rights Council (HRC) and treaty bodies. See Works .

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Carr Center for Human Rights Policy

The Carr Center for Human Rights Policy serves as the hub of the Harvard Kennedy School’s research, teaching, and training in the human rights domain. The center embraces a dual mission: to educate students and the next generation of leaders from around the world in human rights policy and practice; and to convene and provide policy-relevant knowledge to international organizations, governments, policymakers, and businesses.

About the Carr Center

Since its founding in 1999, the Carr Center has dedicated the last quarter-century to human rights policy.  

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• Ethel Waters, first Negro star of TV sitcom
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• Chuck Cooper, Nathaniel Clifton, and Earl Lloyd, first Negro NBA players McLaurin v. Oklahoma State Regents – Supreme Court rules against  discrimination
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Privacy Overview

Human rights methodology and institutions are undergoing a transformation, as the international human rights regime founded in the post-WWII era adapts to a changed and changing world. Advocates and scholars are reaching beyond the silos shaped by the field’s historical roots in law and journalism. As a result, methods of human rights investigation, research, and persuasion are becoming increasingly interdisciplinary, influenced by fields as diverse as forensics, anthropology, environmental science, public health, economics, data science, statistics, communications, and the arts.

Rapid growth in communication and information technologies have opened up new frontiers for data collection, analysis, and exchange that have the potential to revolutionize approaches to human rights work. International human rights institutions have rarely been at the vanguard of these changes; their operations and procedures are evolving at a far slower pace. Increasing public scrutiny and questions regarding the legitimacy of human rights bodies historically dominated by the Global North, however, have prompted efforts to diversify and decentralize the human rights work performed by both intergovernmental and civil society institutions.  .

Thanks to its unique blend of in-house expertise, CHRGJ has been on the cutting edge of this methodological and institutional renaissance. Most faculty and senior staff at the Center have degrees or prior experience in fields beyond the law, including sociology, anthropology, political science, international development, philosophy, literature, and journalism. Their commitment to cross-disciplinary approaches to their research, scholarship, and advocacy has been applied in a wide range of contexts. These include: sociological analysis of how international law influences states; anthropological studies of the vernacularization of human rights; critical and constructive examination of fact-finding methods; theorizing and pioneering of techniques for applying social science methodologies to human rights research; investigation of the use of data visualization in human rights advocacy; and exploration of how new technologies, such as satellite imagery, crowd-sourced eyewitness accounts, and algorithms may strengthen the credibility and capacity of human rights reporting and advocacy, or conversely pose new threats to rights-holders.

The Center has trained this same creative and critical eye onto international human rights institutions. Using their platforms as United Nations independent experts, academics, and advocates, Center faculty and staff have challenged the structure and procedures of various human rights institutions, in efforts to enhance their accessibility and accountability to the people whose rights they aim to protect, and to encourage their adaptation to a modernizing world.

For a complete record of CHRGJ faculty and staff work relating to human rights methodology and institutions, visit our searchable  Document Center  and  News  and  Events  archives.

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The State of Civil and Human Rights in the United States

In testimony submitted to a Senate Judiciary Committee subcommittee, the Brennan Center outlined ideas to reform the nation’s voting system, strengthen voting protections, reform the criminal justice system, and protect national security.

The Brennan Center submitted written testimony to a Senate Judiciary Committee subcommittee hearing on “The State of Civil and Human Rights in the United States.” The testimony highlights how the Brennan Center’s work to advance voting rights, end mass incarceration, and protect civil liberties is critical to advancing civil rights in America.

The testimony outlines three ways to advance and protect civil and human rights:

1.)    Modernize the nation’s voting system and strengthen voting protections to ensure a stronger democracy.

2.)    Reform the nation’s criminal justice system.

3.)    Secure our national security while balancing the need to protect civil and human rights.

[Download the PDF]

Brennan Center Testimony- The State of Civil Rights

Informed citizens are democracy’s best defense

Read our research on: Gun Policy | International Conflict | Election 2024

Regions & Countries

Human rights, how covid-19 restrictions affected religious groups around the world in 2020.

Nearly a quarter of countries used force to prevent religious gatherings during the pandemic; other government restrictions and social hostilities related to religion remained fairly stable.

How Global Public Opinion of China Has Shifted in the Xi Era

The Chinese Communist Party is preparing for its 20th National Congress, an event likely to result in an unprecedented third term for President Xi Jinping. Since Xi took office in 2013, opinion of China in the U.S. and other advanced economies has turned more negative. How did it get to be this way?

Negative Views of China Tied to Critical Views of Its Policies on Human Rights

Large majorities in most of the 19 countries surveyed have negative views of China, but relatively few say bilateral relations are bad.

Fast facts about views of China ahead of the 2022 Beijing Olympics

Here are recent findings about Americans’ views of the diplomatic boycott and how people in the U.S. and around the world see China.

More adults approve than disapprove of U.S. diplomatic boycott of Olympics; few have heard much about it

About nine-in-ten U.S. adults (91%) say they have heard little (46%) or nothing at all (45%) about the diplomatic boycott of the Olympics.

How the political typology groups compare

Pew Research Center’s political typology sorts Americans into cohesive, like-minded groups based on their values, beliefs, and views about politics and the political system. Use this tool to compare the groups on some key topics and their demographics.

Large Majorities Say China Does Not Respect the Personal Freedoms of Its People

Unfavorable views of China also hover near historic highs in most of the 17 advanced economies surveyed.

Pressing China on human rights – even if it hurts economic relations – has Americans’ bipartisan support

Unlike with other China-related issues, there is little partisan difference on this question, a February survey found.

Most Americans Support Tough Stance Toward China on Human Rights, Economic Issues

Fewer adults have confidence in Joe Biden to handle the U.S.-China relationship than other foreign policy issues.

International Cooperation Welcomed Across 14 Advanced Economies

The United Nations is broadly credited with promoting peace and human rights as younger adults are more supportive of cooperation with other countries.

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About Pew Research Center Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of The Pew Charitable Trusts .

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The WCCHR is actively seeking clinical research professionals to spearhead research efforts in collaboration with interested medical students. All WCCHR client data collected since 2010 is stored in a secure, de-identified, HIPAA-compliant REDCap database that can be utilized for retrospective analysis. 

We regularly consult our colleagues in the Division of Medical Ethics at the medical college to ensure that we do not infringe upon our clients’ rights in any way. In addition, the WCCHR makes clear to every client that declination or participation in research will have zero bearing on their forensic evaluation, medical affidavit, and immigration proceedings.  

Please see below for a list of our past projects.

Past Projects:

Milewski AR, Cox M, Huynh S, Kaur G, Pryor KO, Tabaie S. (2021).  Sexual health knowledge in female asylum seekers living in New York City: a single-center, cross-sectional study over one year .  Journal of Global Health Reports .  

Milewski, A. R. (2020).  Assisting Asylum Seekers: The Unique Expertise of Anesthesiologists.ASA Monitor , 85, 2, 6-7. Gu, F., Chu, E., Milewski, A. R., Taleghani, S., Maju, M. Kuhn, R., Richards, A., & Emery, E. (2020). Challenges in Founding and Developing Medical School Student-Run Asylum Clinics.Journal of Immigrant and Minority Health , 23, 179-183. Aguirre, N. G., Milewski, A. R., Shin, J., & Ottenheimer, D. (2020).  A coding tool and abuse data for female asylum seekers. Data in brief , 31, 105912. Aguirre, N. G., Milewski, A. R., Shin, J., & Ottenheimer, D. (2020).  Gender-based violence experienced by women seeking asylum in the United State: A lifetime of multiple traumas inflicted by multiple perpetrators.  Journal of Forensic and Legal Medicine, 72, 101959. Ackerman, K., Habbach, H., Hampton, K., Rosenberg, L., Stoughton, S., & Shin, J. (2019).  There Is No One Here to Protect You: Trauma Among Children Fleeing Violence in Central America. Physicians for Human Rights. Geynisman-Tan, J., Milewski, A. R., Dahl, C., Collins, S., Mueller, M., Kenton, K., & Lewicky-Gaupp, C. (2019).   Lower Urinary Tract Symptoms in Women With Female Genital Mutilation. Female Pelvic Medicine and Reconstructive Surgery, 25(2), 157–160. Sharp, M. B., Milewski, A. R., Lamneck, C., & McKenzie, K. (2019).  Evaluating the Impact of Student-run Asylum Clinics in the US from 2016–2018. Health and Human Rights, 21(2), 309–323. Chelidze, K., Milewski, A. R., & Freeman, E. E. (2017).  Assessing and assisting asylum seekers. Dermatology World, 7(26), 40–42. Dubin, K., Milewski, A. R., Shin, J., & Kalman, T. P. (2017).  Medical Students’ Attitudes toward Torture, Revisited. Health and Human Rights, 19(2), 265-277. Chelidze, K., Sirotin, N., Fabiszak, M., Gallen-Edersheim, T., Clark, T., Villegas, L., . . . Ahola, J. (2015).  Documenting Torture Sequelae: The Weill Cornell Model for Forensic Evaluation, Capacity Building, and Medical Education. In B. Lawrance & G. Ruffer (Eds.), Adjudicating Refugee and Asylum Status: The Role of Witness, Expertise, and Testimony (pp. 166-179). Cambridge: Cambridge University Press. Emery, E., Stellar, C., Dubin, K., Clark, T., Duncan, A., Lopez, A., . . . Sirotin, N. (2015).  Student Leadership in the Creation and Operation of an Asylum Clinic. Health and Human Rights Journal, Perspectives.

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Center for Human Rights Science

Statistics and Human Rights Program

We apply statistical methods to complex problems, using data to identify and understand when abuses occur and what to do about them.

We do more than make pretty graphs. We bring a wealth of training in statistical methods to understand what a given dataset can tell us—and what it can’t. We help our partners expand their capabilities, providing analysis and insight to groups with expertise in investigation and service delivery.

Currently, we are collaborating with the Pennsylvania Prison Society to assess how people die in correctional facilities and develop indicators of prison health. We’re also working with Megan Price , the executive director of the Human Rights Data Analysis Group on a book of case studies of statistical analyses in human rights investigations.

Want to work with us?

Meet Robin Mejia, Director of the Statistics and Human Rights Program .

You can email her at  [email protected] .

Recent projects

Conflict deaths and events.

Carnegie Mellon statisticians worked to develop rigorous methods to estimate conflict deaths and other conflict events. The work involved both matching records from disparate sources and estimating the number of unrecorded deaths.  Much of this work was carried out through a partnership between CHRS, the  Human Rights Data Analysis Group  (a nonprofit think tank based in San Francisco, CA) and the  Carter Center’s Conflict Resolution Program .

Population Needs and Perceptions

When a conflict ends and peace accords are signed, national and international actors invariably have ideas about what is needed to move forward. This project focuses on understanding the perceptions of the population that has suffered under conflict. A joint project with the   Harvard Humanitarian Initiative , which has been conducting surveys in the Eastern Democratic Republic of Congo, this project studies the perception of the population over time, using repeated cross sectional survey data.

Center for Human Rights

http://jsis.washington.edu/humanrights/

The University of Washington Center for Human Rights is committed to interdisciplinary excellence in the education of undergraduate and graduate students in the field of human rights; promoting human rights as a core area of faculty and graduate research; and engaging productively with local, regional, national, and international organizations and policymakers to advance respect for human rights.

Core Services Offered

We publish a weekly newsletter listing human rights events and opportunities of interest in the Puget Sound area. In addition, we work with campus and community groups to help plan human rights events on and off campus.

Funding Information

Jackson Foundation 2011 Laird Norton Family Foundation 2011

Reporting Structure

Judy Howard, Divisional Dean of Social Sciences

Related UW Entities

College of Arts & Sciences: Jackson School of International Studies, Department of Law, Societies, & Justice, Department of Psychology, Department of Political Science, Department of Sociology, Department of Comparative History of Ideas, Department of History, Department of Geography, Department of Anthropology, Disability Studies, Latin American Studies, Department of Comparative Literature School of Social Work College of Education School of Law Evan’s School of Public Affairs Department of Philosophy and Public Affairs Information School School of Medicine: Department of Pediatrics UW Tacoma: Interdisciplinary Arts & Science UW Bothell: Interdisciplinary Arts & Sciences

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• Abshire-Inamori Leadership Academy
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The CSIS Human Rights Initiative, launched in 2014, promotes a proactive, resilient global human rights agenda that reinforces democratic values as a central component of a comprehensive foreign policy

Focus Areas

• Staff and Affiliates
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It seeks to generate innovative solutions for government, civil society, and the private sector to build respect for human rights and works to integrate human rights priorities across U.S. foreign policy interests. Current focus areas for the Human Rights Initiative include exploring how respect for human rights can help build sustainable and inclusive democracies; analyzing how to align and leverage private sector interests to further human rights priorities; and responding to egregious current human rights abuses.

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Meet our network of experts, staff, and non-resident affiliates who contribute to our analysis.

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Building Sustainable and Inclusive Democracy

Technology and Human Rights

Business and Human Rights

Responding to Egregious Human Rights Abuses

75 Years of the Universal Declaration of Human Rights

Featured analysis.

Photo: Artinun/Adobe Stock

Updates on the Release of the U.S. National Action Plan on Responsible Business Conduct

The updated National Action Plan for Responsible Business Conduct aims to help the government and private sector positively impact the communities in which they operate and promote business practices that are transparent, accountable, and respecting of human rights.

Critical Questions by Scott Busby and Lauren Burke — April 8, 2024

Launch of the United States Guidance for Online Platforms on Protecting Human Rights Defenders Online

Transcript — March 29, 2024

Advancing Decent Work and Labor Rights Globally

Transcript — February 21, 2024

Ukraine’s Rapid Digitalization: Human Rights Risks and Opportunities in a Postwar Environment

Report by ​Marti Flacks, Caitlin Chin-Rothmann, Lauren Burke, Julia Brock, and Iryna Tiasko — February 14, 2024

Progress and Possibility: Reflecting on 75 Years of the Universal Declaration of Human Rights: Opening Remarks

Transcript — December 6, 2023

Past Events

A Human Rights Approach to Ukraine's Rapid Digitalization

Progress and Possibility: Reflecting on 75 Years of the Universal Declaration of Human Rights

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Digital technologies are a vital resource for Human Rights Defenders (HRDs) and civic actors around the world.  Join the CSIS Human Rights Initiative as they host the U.S. Department of State's launch of their new Guidance for Online Platforms On Protecting Human Rights Defenders Online. 

Event — March 29, 2024

The   CSIS Human Rights Initiative hosted the U.S. Department of State's launch of their new Guidance for Online Platforms On Protecting Human Rights Defenders Online.

Join CSIS for an event on centering human rights values within Ukraine's post-war digitalization.

Event — February 22, 2024

Join the Human Rights Initiative for a discussion of the impact of the global labor rights movement on American workers, businesses, and consumers. 

Event — February 21, 2024

The Human Rights Initiative hosted a discussion of the impact of the global labor rights movement on American workers, businesses, and consumers.

“Ukraine’s Rapid Digitalization: Human Rights Risks and Opportunities in a Postwar Environment”: Audio Brief with Lauren Burke

A short, spoken-word summary from CSIS’s Lauren Burke on her report with Martin Flacks, Caitlin Chin-Rothmann, Julia Brock, and Iryna Tiasko, Ukraine’s Rapid Digitalization: Human Rights Risks and Opportunities in a Postwar Environment .

Podcast Episode by Lauren Burke — February 14, 2024

This report outlines four strategies to center human rights values within Ukraine's post-conflict digital governance framework as the government of Ukraine and its international partners begin planning for reconstruction.

Join the CSIS Human Rights Initiative for an event commemorating the 75th anniversary of the Universal Declaration of Human Rights and reflecting on the future of U.S. engagement on human rights issues. 

Event — December 6, 2023

CSIS's Marti Flacks delivered opening remarks as CSIS commemorated the 75th anniversary of the Universal Declaration of Human Rights.

Center for Human Rights and International Justice

https://humanrights.stanford.edu/

Where Generative AI Meets Human Rights

Experts in technology, law, and human rights debate the unique implications of this technology and how we might best direct its potential to benefit humanity.

In November 2022, OpenAI released ChatGPT. Less than 18 months later, the subject of generative AI dominates almost every sphere of life, public and private. Policymakers talk about it; economists talk about it; social scientists, parents, teachers, and investors talk about it.

Volker Türk—the United Nations High Commissioner for Human Rights—talks about it, too. “The unparalleled human rights impacts of advanced AI, including generative AI, are already being felt by vast numbers of people,” he said in a recent discussion on the subject. To ensure the benefits of AI flow to everyone, “people must be at the center of the technology.”

Türk offered  these remarks as the keynote speaker at  Human Rights Dimensions of Generative AI , a February 14 event hosted by the Center for Human Rights and International Justice and co-sponsored by the Stanford Institute for Human-Centered AI (HAI) and others. Following Türk’s comments, a panel of experts representing private and public sectors and academia discussed the implications of generative AI for human rights, democratic function, and general social cohesion. The group included:

• Eileen Donahoe, Special Envoy & Coordinator for Digital Freedom in the U.S. Department of State’s Bureau of Cyberspace and Digital Policy;
• Alex Walden, Global Head of Human Rights at Google;
• Peggy Hicks, Director of the Thematic Engagement, Special Procedures and Right to Development Division of the UN Human Rights Office; 
• Nate Persily , Co-Director of the Stanford Cyber Policy Center and James B. McClatchy Professor of Law at Stanford Law School; and
• Raffi Krikorian, Chief Technology Officer at the Emerson Collective.

Below are a few highlights from the conversation.

Why AI Is Different

Though some of the concerns over AI are conventional—it can promote disinformation or invade privacy—there are several ways in which the challenges it presents are unfamiliar to the policy world.

For one, AI is what Persily calls a keystone technology. “It is becoming fundamental to all other technologies, which makes it different,” he said. “It is everywhere already and will continue to be everywhere. It is regulating the entire future of our economy and social relations.” It is also more opaque than other technologies, and its applications are far more difficult to foresee. As one example, Persily said that the team at OpenAI, when it released ChatGPT, didn’t imagine its use in coding. “More than half of uses are now for coding,” he said.

Google’s Walden pointed to the novel speed and scale at which AI functions, as well as its ability to learn and adapt. Though platforms like Google have long been in conversation with policymakers about how to regulate content, she said, “AI makes this all much more complicated.” 

Finally, many of the foundational algorithms in AI are open source. This is central to making the tools accessible beyond corporate IP, but it is also problematic. Within the first year of ChatGPT’s release, for instance, there was an explosion of AI-generated child pornography—a result of the fact that these tools were freely available.

“In some ways, the most democratically friendly aspect of this technology also poses the greatest risk,” Persily said.

A Few Grave Concerns

All the panelists voiced concern about how AI will be—and already is being—used; three of these concerns echoed across the conversation.

First, both Krikorian and Donahoe noted how the rapid evolution of different AI tools makes it virtually impossible for the public or policymakers to keep up. “There is a big discrepancy between the development and the absorption of this technology,” Krikorian said. “In many ways this just means we’re pouring gasoline on every other problem.” Before we’ve managed to tackle the growing issue of online disinformation, for instance, AI is accelerating its dissemination.

Second, Hicks noted that, though the UN has called for a pause in the use of AI in areas where human rights violations are most likely to occur, these are precisely the realms where advances seem to be moving fastest. Legal carve-outs are being created for sectors like national security and law enforcement, where human rights practitioners have long focused their energies, often to little avail.

“We’ve been voicing these concerns since well before generative AI,” Hicks said. “And we’ve yet to make progress on that front.”

Finally, Persily suggested that the growing problem of disinformation could lead people to not only believe in falsehoods but, of greater concern, disbelieve what’s true. “The pervasiveness of artificial content gives credibility to all those who want to divide reality,” he said. “The more we distrust the evidence before our eyes, the greater the power of liars to say what is and isn’t true.”

Thoughts on Regulation

Discussion of how to effectively and fairly regulate generative AI circled around a few central points:

• The UN, through its  B-Tech initiative , has created a framework by which technology companies can fold considerations of human rights into the work that they do. This initiative has recently taken up the specific case of generative AI. “The one cross-cutting set of laws we have in place to address these colossal challenges,” Türk said, “is the international human rights framework.”
• A regulatory solution must be founded on broad participation. “One of the big concerns we have is that these conversations seem to be taking place with too much focus on the global North and English-language environments,” Hicks said. The potential problems, Donahoe seconded, are inherently transnational and, as such, solutions must be crafted inclusively.
• As much transparency as possible must be built into these tools. It may never be possible to fully understand the function of a model—why its outputs are what they are—but certain checks could outline the model’s capabilities beforehand.
• Discussion around policies and regulation must embrace nuance. Hicks suggested that most discussion of AI today is highly polarized: A product is either good or bad; it will destroy the world or save it; the private sector is the problem or government is the problem. “We have to find ways to engage in both conversations at the same time,” she said.

As the discussion came to a close, Donahoe asked each of the four panelists to answer whether they were, in general, more optimistic or pessimistic about a future with generative AI. The panelists were universally hopeful—but, one might say, reservedly so.

“I’m optimistic about the technology, but I would have to say I’m pessimistic about society right now” is how Persily put it, questioning our ability to effectively reach consensus about governing the many threats on the horizon. “If only AI had had this moment 30 years ago or if we could deal with it after first dealing with our social divisions.”

Read more on the event from the Center for Human Rights and International Justice , or watch the recording .

Stanford HAI’s mission is to advance AI research, education, policy and practice to improve the human condition.  Learn more . 

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Historic and Unprecedented: The ECtHR Upholds Positive Human Rights Obligations to Mitigate Climate Change

The three much-awaited judgments issued by the European Court of Human Rights (ECtHR) on April 9, 2024 are truly historic and unprecedented. In Verein Klimaseniorinnen Schweiz and Others v. Switzerland , the Grand Chamber established that climate change is “one of the most pressing issues of our times” and poses a threat to human rights. With this ruling, the Court confirmed that States have a positive obligation to adopt measures to mitigate climate change under Article 8 of the ECHR, the right to family and private life. According to the Court, Switzerland failed to comply with this obligation and exceeded its margin of appreciation by not meeting its past greenhouse gas (GHG) emissions reduction targets and allowing for “critical lacunae” in its regulatory framework. The Court also found a violation of Article 6 ECHR, the right of access to court. The Court declared the two other cases, Carême v. France and Duarte Agostinho and Others v. Portugal and 32 others , inadmissible on procedural grounds (no victimhood and a failure to exhaust domestic remedies). This blog post provides a quick overview of the three rulings, most notably Klimaseniorinnen, and sketches out their most important implications. It obviously does not do justice to the richness of the judgments. It is primarily written with the idea that scholars and experts will delve into all the intricacies in this blog symposium (see introduction here ) and other publications in the years to come (see already Milanovic here and Buyse and Istrefi here) .

Klimaseniorinnen : Major Substantive Take-Aways

With Klimaseniorinnen, the Court follows in the footsteps of various national courts , most notably the Dutch Urgenda ruling (see also the extensive overview of the domestic case-law in paras. 236-272 of the judgement), as well as international courts and bodies (e.g., the Inter-American Court of Human R ights and the UN Committee on the Rights of the Child). The Court can be commended for the relatively swift handling of these cases under its priority policy, involving 37 third-party interventions (including a brief by the Sabin Center) and 33 respondent States. The judgment in Klimaseniorinnen is 657 paragraphs long, and the inadmissibility decision in Duarte is not brief either at 231 paragraphs.

In their case against Switzerland, the four Swiss elderly women and the association relied on Articles 2 and 8 of the ECHR and argued that the increase in heatwaves poses a health risk to them, considering their age. They also alleged breaches of Article 6 (the right to access to court) and Article 13 of the ECHR (the right to an effective remedy) for the authorities’ failure to respond seriously to their requests and provide an effective remedy with respect to the alleged violations of Articles 2 and 8 of the ECHR.

Before delving into the procedural aspects, we will first examine various important elements related to the merits. Notably, the Court responded to (and preempted) criticism as to the undemocratic role of courts in relation to climate change (paras. 410-414 and 449-451). The UK government , for example, noted critically that the applicants are “asking the Court to act as legislator.” The Court emphasizes that judicial intervention cannot replace legislative or administrative action but that “democracy cannot be reduced to the will of the majority … in disregard of the requirements of the rule of law” (para. 412).

With respect to Article 8, the Court forcefully held that this provision encompasses the right of individuals to effective protection from serious adverse effects of climate change on their life, health, well-being and quality of life (para. 519). Particularly noteworthy is the distinction in relation to the scope of the margin of appreciation. The Court adopted a reduced margin in relation to the necessity of combating climate change, while it accorded states a wide margin as to the choice of means (para. 543). The court made clear that, in order to guarantee Article 8, States have a positive obligation to adopt, and effectively apply regulations and measures capable of mitigating the existing and potentially irreversible effects of climate change (para. 545). The Court even determined that Article 8 requires states to “undertake measures for the substantial and progressive reduction of their respective GHG emission levels, with a view to reaching net neutrality within, in principle, the next three decades” (para. 548). These principled pronouncements are groundbreaking, as also illustrated by the partly (and only) dissenting opinion of the British Judge Tim Eicke. According to Eicke, this newly created right to effective protection by the State does not have any basis in Article 8 or any other provision (para. 4). The majority of the Court disagreed.

While the Court did not find a violation of Article 2, it acknowledged that the principles developed under the right to life are “to a very large extent” similar to those under Article 8 (para. 537). Regarding Article 6, the Court gave the domestic Swiss courts a rap over the knuckles for not addressing the issue of standing of the association. The failure of the domestic courts to engage “seriously or at all” in the action brought by the applicant association, and the absence of other legal avenues, impaired the very essence of the association’s right of access to a court (paras. 636-638).

Victimhood: Welcoming Associations While Turning Down Individual Applicants

The most important procedural takeaway from Klimaseniorinnen relates to Article 34 of the ECHR. The Court allow associations to take legal action in relation to climate change. This confirms the hints that were already made by President O’Leary during the hearing in relation to the Aarhus Convention (paras. 490-501). Most importantly, the Court determined that an association does not need to show that its members or other affected individuals on whose behalf it is acting would themselves have met the victim-status requirements (para. 502). The judgment also builds on the Court’s previous case law in Mellox and Câmpeanu and the recognition of the (theoretical) possibility of environmental associations bringing climate cases in most member states (para. 234). In order to avoid “abstract complaint[s] about a general deterioration,” the Court presented three criteria mostly related to the legal position and representativeness of the association (para 501). To appreciate the implications of these considerations, it is useful to read the partly dissenting opinion of Judge Eicke. He criticizes the Court for its all-too evolutive interpretation of the victim requirement that essentially opens the door to actio popularis- type complaints.

While the Court adopted a welcoming attitude towards associations, it is more discouraging towards individual applicants. The Court declareed that the four elderly Swiss women lack victimhood and are not directly affected. In doing so, the Court upheld the high threshold of a minimum level of severity in its earlier case law (para. 472). The Court pointed out that applying a low threshold could lead to claims being brought by a huge number of persons because everyone is or will be affected by the adverse effects of climate change. Considering the exclusion of actio popularis, the Court lays down two strict criteria: (i) a high intensity of exposure to the adverse effects of climate change with significantly severe adverse consequences of governmental (in)action as well as (ii) a pressing need owing to the absence or inadequacy of reasonable measures to reduce harm. In the court’s view, the four applicants failed to satisfy these requirements as they were not in any “critical medical condition” and there was no proof of a correlation with the asthma of one of the women (para. 533). The Court also reiterated its well-established case law that future risks can “only in highly exceptional circumstances” be taken into account (para. 470). The implication of Klimaseniorinnen is that NGOs and associations may have an easier time in accessing the Court in climate cases than “lone wolves”. This approach should help to limit the potentially high number of complaints that would otherwise be lodged with the Court in Strasbourg.

Carême exemplifies a straightforward and unsurprising application of the victim requirements under Article 34 of the ECHR. Carême claimed that the government of France violated its positive obligations under Articles 2 and 8 by not taking all appropriate GHG emission reduction measures to reach the goals France has set for itself under the Paris Agreement . The Court concluded that the former mayor of Grande-Synthe lacked victimhood since he no longer lives in France. He has no relevant links with the municipality Grande-Synthe aside from the fact that his brother is living there. Furthermore, Carême has no right to lodge a complaint on behalf of the municipality of which he was the former mayor.

Duarte Agostinho : No Extraterritoriality

The Court declared the most mediagenic , high-profile, and ambitious case of Duarte Agostinho inadmissible. The six Portuguese youngsters in the case did not only bring a claim against their home State, but also against 32 other States for violating Articles 2, 3, 8, and 14 of the ECHR. The applicants had not exhausted domestic remedies in any of the respondent States.

The case raised the contentious issue of extraterritoriality. The Court followed the defending States and relied on a strict territorial test requiring effective control over the emissions. While acknowledging the peculiarity of climate change, the Court was wary of creating a “novel ground” for extraterritorial jurisdiction “by way of judicial interpretation” (para. 195). In the court’s view, this would result in “a radical departure from the rationale of the Convention protection system, which was primarily and fundamentally based on the principles of territorial jurisdiction and subsidiarity” (para. 205). The Court also pointed to “an untenable level of uncertainty for the States” when the extraterritorial jurisdiction is expanded, turning the ECHR into a global climate change treaty that can be activated by people anywhere in the world (para. 208). The Court’s approach notably differs from the UN CRC Committee and IACtHR which required merely that the harm was ‘reasonably foreseeable’ to the State Party (as analyzed here , here and here). The Court explicitly acknowledges this difference (para. 212).

The Court concluded that the Portuguese youngsters failed to exhaust domestic remedies in the only state that has jurisdiction–Portugal . According to the court, the youngsters should have started a case before the Portuguese courts. This follows from the subsidiary nature of the ECHR system, and the Court made clear that it also benefits from a prior review by national courts (para. 228). The various Urgenda -type national court cases in recent years also illustrate that this requirement is not unreasonable, considering the risk of opening the “floodgates.” The Court’s inadmissibility decision is thus not surprising and aligns with the decision of the UN CRC Committee in Sacchi et al v. Argentina et al . 

Despite the case’s inadmissibility, the Court acknowledged several points made by the applicants. For example, it recognized that States have ultimate control over private and public activities on their territories that produce GHG emissions and those emissions do impact people beyond a State’s border (para. 192).

The Impetus to Climate Litigation

The judgments will undeniably set the tone for climate litigation in the years to come. They will impact both litigation and other procedures before other international (i.e., the advisory opinions before the International Court of Justice, International Tribunal for the Law of the S ea and IACtHR ) and national courts. Formally speaking, judgments of the Court are only binding between the parties ( inter partes ). The judgments are, nonetheless, considered to contain res interpretata. This means that an interpretation by the court is part of the ECHR and is generalizable beyond the individual case at issue.

The judgments are certainly not last word on climate change from the Court in Strasbourg. Six other climate cases are still pending before the Court. The judgments will also leave their mark more broadly in the environmental area and provide a much-needed impetus considering the limitations that dominate this area. As Lambert noted in 2020: the Court “reached the end of the road with regard to environmental protection.” The Court’s approach can also be contrasted with the absence of a ‘rights turn’ in the case law of the Court of Justice of the EU, primarily resulting from restrictive standing requirements (in Carvalho ). The reliance on Aarhus by the Court could be a valuable source of inspiration for the CJEU’s locus standi requirements in relation to the action for annulment (263(4) TFEU), also considering Article 52(3) of the Charter and the EU’s ratification of the Aarhus Convention.

The question remains what the judgments imply for the ongoing discussions with respect to the recognition of the right to a clean, healthy and sustainable environment as a separate self-standing human right (e.g., the UNGA Resolution adopted in July 2022), or even a distinct right against the adverse effects of climate change (e.g. the Indian Supreme Court in March 2024). Following a resolution of the Committee of Ministers, the CDDH-ENV held its last meeting about the environment and human rights in March 2024 and sent its draft report to the CDDH for its adoption in June 2024. In Klimaseniorinnen, the Court acknowledged these developments by noted that it is not for the Court to determine whether such a right exists. Its role is to assess the Convention issues before it (para. 448). The Court’s decision highlights that the ECHR is a living instrument that enables the Court to engage with urgent issues.

Sandra Arntz

Jasper Krommendijk

Jasper Krommendijk is a professor of Human Rights Law at the Radboud University Nijmegen, holds a Jean Monnet Chair on the Rule of Law in the national and EU legal orders (EURoLNAT), and is a director of the Research Centre for State and Law (SteR).

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Association analysis between an epigenetic alcohol risk score and blood pressure

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Epigenome‐wide association studies have revealed multiple DNA methylation sites (CpGs) associated with alcohol consumption, an important lifestyle risk factor for cardiovascular diseases. We generated an alcohol consumption epigenetic risk score (ERS) based on previously reported 144 alcohol-associated CpGs and examined the association of the ERS with systolic blood pressure (SBP), diastolic blood pressure (DBP), and hypertension (HTN) in 3,898 Framingham Heart Study (FHS) participants. We found an association of alcohol intake with the ERS in the meta-analysis with 0.09 units higher ERS per drink consumed per day (p<0.0001). Cross-sectional analyses in FHS revealed that a one-unit increment of the ERS was associated with 1.93 mm Hg higher SBP (p=4.64E-07), 0.68 mm Hg higher DBP (p=0.006), and an odds ratio of 1.78 for HTN (p<2E-16). Meta-analysis of the cross-sectional association of the ERS with BP traits in eight independent external cohorts (n=11,544) showed similar relationships with blood pressure levels, i.e., a one-unit increase in ERS was associated with 0.74 (p=0.002) and 0.50 (p=0.0006) mm Hg higher SBP and DBP, but could not confirm the association with hypertension. Longitudinal analyses in FHS (n=3,260) and five independent external cohorts (n=4,021) showed that the baseline ERS was not associated with a change in blood pressure over time or with incident HTN. Our findings provide proof-of-concept that utilizing an ERS is a useful approach to capture the recent health consequences of lifestyle behaviors such as alcohol consumption.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

The Agricultural Lung Health Study is supported by the Intramural Research Program of the National Institutes of Health, the National Institute of Environmental Health Sciences (Z01–ES102385, Z01–ES049030, Z01–ES043012) and the National Cancer Institute (Z01–CP010119). The KORA study was initiated and financed by the Helmholtz Zentrum München–German Research Center for Environmental Health, which is funded by the German Federal Ministry of Education and Research (BMBF) and by the State of Bavaria. The Framingham Heart Study was supported by NIH contract N01–HC–25195. The analytical component of this project was funded by the Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (D. Levy, Principal Investigator). J. Ma is supported by NIH grant R01AA028263; C. Liu is supported by R01AA028263 and R01HL15569 grants. Support for the Genetic Epidemiology Network of Arteriopathy (GENOA) was provided by the National Heart, Lung and Blood Institute (U10 HL054457, RC1 HL100185, R01 HL087660, R01 HL119443, R01 HL141292, and R01 HL133221). HRS is supported by the National Institute on Aging (NIA U01AG009740). Support for MESA is provided by contracts 75N92020D00001, HHSN268201500003I, N01–HC–95159, 75N92020D00005, N01–HC–95160, 75N92020D00002, N01–HC–95161, 75N92020D00003, N01–HC–95162, 75N92020D00006, N01–HC–95163, 75N92020D00004, N01–HC–95164, 75N92020D00007, N01–HC–95165, N01–HC–95166, N01–HC–95167, N01–HC–95168, N01–HC–95169, UL1–TR–000040, UL1–TR–001079, UL1–TR–001420, UL1TR001881, DK063491, and R01HL105756. The nutrition and omics analyses in the Rhineland Study were supported by the Diet–Body–Brain Competence Cluster in Nutrition Research funded by the Federal Ministry of Education and Research (grant numbers 01EA1410C and FKZ:01EA1809C). The Rotterdam Study is supported by the Erasmus MC University Medical Center and Erasmus University Rotterdam; The Netherlands Organization for Scientific Research (NWO); The Netherlands Organization for Health Research and Development (ZonMw); the Research Institute for Diseases in the Elderly (RIDE); The Netherlands Genomics Initiative (NGI); the Ministry of Education, Culture and Science; the Ministry of Health, Welfare and Sports; the European Commission (DG XII); and the Municipality of Rotterdam. SHIP is part of the Community Medicine Research net of the University of Greifswald, Germany, which is funded by the Federal Ministry of Education and Research (grants no. 01ZZ9603, 01ZZ0103, and 01ZZ0403), the Ministry of Cultural Affairs as well as the Social Ministry of the Federal State of Mecklenburg–West Pomerania, and the network Greifswald Approach to Individualized Medicine (GANI_MED) funded by the Federal Ministry of Education and Research (grant 03IS2061A).

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I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethics committee/IRB of National Institute of Environmental Health Science, Bavarian Medical Association, Boston Medical Center, University of Michigan, University of Mississippi Medical Center, Mayo Clinic, University of Bonn, Erasmus University Medical Center, and University of Greifswald.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Conclusion updated; author information and contribution updated to clarify.

Data Availability

All data produced in the present study are available upon reasonable request to the authors.

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• Volume 14, Issue 4
• Shanghai Community-Based Schizophrenia Cohort (SCS): a protocol for establishing a longitudinal cohort and research database of patients with schizophrenia receiving community-based mental health treatment
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• http://orcid.org/0000-0001-7891-3297 Youwei Zhu 1 ,
• Siyuan He 1 ,
• Yanli Liu 1 ,
• Chunmei Chen 1 ,
• Xiaolei Ge 1 ,
• Weibo Zhang 1 , 2 , 3 ,
• Qing Zhou 4 ,
• Yihua Jiang 5 ,
• Yanping Zhang 6 ,
• Weiyun Xu 7 ,
• Na Wang 8 ,
• Jun Cai 1 , 9 ,
• 1 Shanghai Mental Health Center , Shanghai Jiao Tong University School of Medicine , Shanghai , People's Republic of China
• 2 Shanghai Institute of Infectious Disease and Biosecurity , Fudan University , Shanghai , People's Republic of China
• 3 Mental Health Branch, China Hospital Development Institute , Shanghai Jiao Tong University , Shanghai , People's Republic of China
• 4 Shanghai Xu Hui Mental Health Center , Shanghai , China
• 5 Shanghai Min Hang Mental Health Center , Shanghai , China
• 6 Shanghai Jin Shan Mental Health Center , Shanghai , China
• 7 Shanghai Hong Kou Mental Health Center , Shanghai , China
• 8 Fudan University , Shanghai , Xuhui District , China
• 9 Shanghai Key Laboratory of Psychotic Disorders , Shanghai , China
• 10 Forensic Psychiatry , Shanghai Jiao Tong University School of Medicine Affiliated Shanghai Mental Health Center , Shanghai , China
• Correspondence to Dr Jun Cai; caijun533{at}163.com ; Dr Weibo Zhang; zhangweibo600{at}163.com ; Dr Na Wang; na.wang{at}fudan.edu.cn

Introduction Drivers for remission, relapse and violence-related behaviour among patients with schizophrenia are the most complicated issue.

Methods and analysis This study aims to recruit a longitudinal cohort of patients with schizophrenia. Two suburban districts and two urban districts were randomly selected according to health service facilities, population, geographical region and socioeconomic status. Individuals (>18 years old) who received a diagnosis of schizophrenia following the International Classification of Diseases (10th edition) criteria within the past 3 years will be invited as participants. Assessments will be carried out in local community health centres. Data will be used to (1) establish a community-based schizophrenia cohort and biobank, (2) prospectively determine the course of multidimensional functional outcomes of patients with schizophrenia who are receiving community-based mental health treatment, and (3) map the trajectories of patients with schizophrenia and prospectively determine the course of multidimensional outcomes based on the differential impact of potentially modifiable moderators.

Ethics and dissemination The study has been reviewed and approved by the Human Research Ethics Committee of Shanghai Mental Health Center (2021-67). Results of the study will be disseminated through peer-reviewed journals. If effective, related educational materials will be released to the public.

• Schizophrenia & psychotic disorders
• EPIDEMIOLOGIC STUDIES
• MENTAL HEALTH

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2023-079312

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STRENGTHS AND LIMITATIONS OF THIS STUDY

This ongoing, large-scale community-based cohort study is one of the first studies to comprehensively investigate the health profiles and prognosis of community-dwelling patients with schizophrenia in China.

The use of multidimensional outcomes and health profiles provides an opportunity to investigate predictors of relapse and recurrence and to establish a community-based prognostic model that could facilitate the development of new mental health services.

The short follow-up duration (3 years) may limit us from examining additional issues related to the long-term illness trajectory of schizophrenia rehabilitation.

This study will only recruit patients receiving community-based mental health treatment, which may limit the generalisability of the findings.

Introduction

Schizophrenia is a devastating, complex, severe mental disorder that affects approximately 1% of the global population. 1 It is characterised by several complex positive and negative symptom clusters and subcluster and cognitive impairment 2 —positive symptoms, also known as psychosis or the psychotic syndrome, common positive symptoms including delusions, hallucinations, behaviour disorder and formal thought disorders such as speech that are difficult to follow or even to the point of incomprehensibility. 3 Positive symptoms are often the main reason the patient presents to the clinician. 4 While negative symptoms mainly consist of a lack of volition, reduced speech output, diminished expression, anhedonia and asociality. 5 6

Schizophrenia leads to a tremendous public health burden worldwide, and its incidence is increasing annually. 4 Since 2016, it has become the most disabling disorder worldwide, accounting for 7.4% of disability-adjusted life years and nearly 13.4 million years of life lived with disability. 7 The life expectancy of patients with schizophrenia is approximately 15 years shorter than that of the general population. 8 In many countries, the social cost of this disease has even exceeded $20 000 per patient. 9 In China, the weighted lifetime prevalence and 12-month prevalence of schizophrenia are 0.6%, and the weighted 12-month prevalence of schizophrenia has reached 1.4% for people aged between 18 and 34 years. 10 The disease imposes a serious financial burden and considerable socioeconomic loss in this age group. 11

Schizophrenia is a longstanding mental disorder; therefore, the long-term outcomes of patients have received an increasing amount of attention. Interventions to treat relapse and prevent violence have already been implemented among patients. However, relapse is still common among this population. It is the occurrence of at least one positive symptom or two negative symptoms after a period of remission. 12 These symptoms often include the reappearance or development of auditory hallucinations, delusions and thought disorder for positive symptoms, while anhedonia, asociality, flattening of affect and demotivation for negative symptoms. 13 One systematic review of longitudinal studies estimated that the pooled prevalence rates of relapse of positive symptoms were 28% and 54% at the 1-year and 3-year follow-ups, respectively. 14 24% of patients relapse at 7–12 months despite receiving drug treatment, although this percentage is much lower than that of patients who are not receiving drug treatment. 15 Generally, continual relapse is positively correlated with detrimental long-term outcomes and irreversible progression of brain integrity. 16 There is also a subgroup of patients with a heightened risk of violent and aggressive behaviours. 17 Compared with the general population, patients with schizophrenia have more than a fourfold greater risk of exhibiting aggressive behaviours and even committing violent crimes. 18 The 1-year prevalence of violent episodes in patients with schizophrenia who are receiving stable treatment has reached 21.8%. 19

Although existing studies have suggested that early detection and timely intervention could effectively reduce the recurrence of schizophrenia, the predictors of early relapse have not been fully elucidated. One major challenge in terms of identifying predictors of early relapse among patients with schizophrenia is the complexity of the prognosis. There is a need for research on these multidimensional issues. Previous studies have mainly focused on only a few factors, including early age of onset, substance abuse, duration of untreated psychosis, insidious onset, negative symptoms, stressful events, expressed emotions, comorbidity, violent behaviours, perceived social support, medication adherence, vocational function and household income. 20 21 However, many of these commonly analysed predictors of prognosis in schizophrenia are far from conclusive. For example, previous studies have shown that age of onset has a positive but small effect on hospitalisation, negative symptoms, relapse and social/occupational functioning among patients with schizophrenia. 22 In addition, a multicentre retrospective study showed that vocational function and household income are predictors of relapse, 23 but these two risk factors were not regarded as predictors of relapse in our studies conducted in developed countries. 24 25 Additionally, the models that have been used for predicting relapse are relatively simplistic, and little attention has been devoted to community-based patients. To advance our understanding of the pathophysiology of schizophrenia and to progress towards disease-modifying treatments and relapse prevention, it is essential to investigate schizophrenia relapse as broadly as possible in community-dwelling patients. Here, we report a cohort study of community-dwelling individuals with the aim of identifying markers for improved mental health management among patients with schizophrenia who exhibit relapse or aggressive behaviours.

Shanghai is one of the largest and most urbanised cities in China. In 2021, the life expectancy of residents reached 84.11 years (81.76 years for males and 86.56 years for females). Urbanisation and changes in lifestyle may have affected the mental health of these populations. According to the 2021 Shanghai Statistical Yearbook, the mental illness death rate was 8.83 per 100 000 individuals, which was the seventh highest among all causes of death ( https://tjj.sh.gov.cn/tjnj/20220309/0e01088a76754b448de6d608c42dad0f.html ). Long-term community-based medication is crucial for preventing mental illness. In 2001, Shanghai enacted China’s first local regulation on mental health, namely, the ‘Shanghai Mental Health Regulations’, followed by the ‘Shanghai Mental Health System Construction and Development Plan (2020–2030)’ and ‘the Shanghai Community-based Health Management Regulations for Severe Mental Disorders Service Management (2019 edition)’. These efforts all promoted the development of community-based mental health in Shanghai. From 2001 to 2020, community-based mental health services developed rapidly in Shanghai. Patients had the highest regular management rate and stable rate, 26 with a much lower Gini coefficient in China than in other countries. 27 The prevalence of schizophrenia in China has more than doubled since 2010, with particularly high rates observed in the most developed areas of modern China; moreover, the prevalence of schizophrenia is still increasing. 28 As the most populous and developed city, Shanghai provides an opportunity for studying the nature and magnitude of mental illness. Shanghai is a suitable research site for exploring the possible factors affecting the prognoses of patients receiving community-based mental health treatment in China. In addition, this community-based cohort study will provide guidance for optimising the mental health management system and for developing mental health policies.

Objectives of the study and conceptual framework

Schizophrenia is a chronic recurrent mental disorder with a high relapse rate. The purpose of this longitudinal study was to establish a cohort of patients with schizophrenia who were clinically stable, compliant with their medication and adherent to community-based appointments. The aims of this follow-up study are as follows:

To study the process and prognoses of schizophrenia among current stabilised patients.

To map the clinical trajectories and explore the predictive effects of biological, psychosocial, imaging and other indicators on patient recurrence and other events among community-dwelling patients.

To create a progression and prognosis database of community-based patients with schizophrenia, thus providing a working foundation and sample resources for subsequent related mechanistic research, drug research and intervention research.

To establish a biobank of new cases to monitor the occurrence of disease recurrence, violent behaviours and other outcome events during the whole life cycle.

Standardised multidimensional and longitudinal assessments will be routinely carried out among first-episode and multiepisode patients with schizophrenia who are receiving community-based mental health treatment in Shanghai. Key illness outcomes, including antipsychotic medication use, psychotic symptoms, social function, occupational function, physical health, stress events, aggressive violent behaviours, self-harm and suicidal-related behaviours, will be continuously measured and tracked over time.

Methods and analysis

Study setting and design.

This study is an ongoing, community-based, naturalistic longitudinal cohort study that examines potential differences in relapse risk factors, development, cognition and behaviour in community-dwelling patients with schizophrenia. The study was designed and will be conducted by the Shanghai Mental Health Center, Xu Hui Mental Health Center, Hong Kou Mental Health Center, Jin Shan Mental Health Center and Min Hang Mental Health Center in Shanghai, China. Eligible patients were informed of the study and encouraged to participate. Informed consent forms were obtained from the patients and their guardians before enrolment in the study. The ethics committee at the Shanghai Mental Health Center approved this study protocol.

Study population and eligibility criteria

Patients with schizophrenia older than 18 years will be encouraged to participate in this cohort study. The eligibility criteria are as follows: (1) received either an outpatient or inpatient diagnosis of schizophrenia in accordance with the International Classification of Diseases (10th edition) (ICD-10) criteria within the past 3 years; (2) aged between 18 and 65 years; (3) IQ >70 as measured by the short form of the Wechsler Adults Intelligence Scale-IV; and (4) clinically stable and provided informed consent. According to previous studies, a current clinically stable state was defined as no exacerbation of psychotic symptoms or less than a 50% change in the dose of any primary psychotropic medication for the previous 3 months. 29 30 The exclusion criteria will be as follows: (1) history of head injury and/or a neurological condition; (2) a history of head trauma with loss of consciousness; (3) pregnancy; (4) history of illicit drug abuse; (5) low level of proficiency with the Chinese language and lacked cooperativeness with the assessment; and (6) not living in Shanghai or planning to leave and settle down in other cities within 6 months.

Recruitment and enrolment process

The recruitment of eligible subjects started in January 2022. Recruitment and enrolment are scheduled to occur at local community healthcare centres. Enrolment and follow-up are conducted simultaneously. Enrolment will be completed when the sample size meets the requirements of our cohort study. The full cohort is anticipated to be complete when all patients complete the 3-year follow-up. Two trained psychiatrists or general practitioners will refer potential candidates to the principal investigator of the project and arrange a first prerecruitment interview in the nearest community healthcare centres. Detailed information on the project will be provided to the candidate and their guardian. Those who meet the study criteria and agree to participate will be invited to complete the demographic data questionnaire. All participants will be encouraged to continue their medication during the whole study period.

Outcome measures

Clinical efficacy is a commonly used outcome variable for schizophrenia prognosis and is usually defined as a clinically meaningful percentage of reduction in symptoms. 31 Rating scales such as the Brief Psychiatric Rating Scale (BPRS) and Positive and Negative Syndrome Scale can also be useful for measuring clinical efficacy. 32 Previous studies have revealed that a cut-off of at least a 25% reduction in the BPRS score from baseline roughly indicates minimal improvement according to Clinical Global Impressions. 33 34 Based on the above criteria, in this cohort study, the primary outcome measure is clinical efficacy, which is defined as a 25% decrease in the BPRS score compared with the last assessment.

The secondary outcomes include relapse, violent attacks, suicide, suicide attempts, suicide ideation, cognitive function, social function, disease burden and quality of life. Risk behaviours such as violent attacks, suicide, suicide attempts and suicidal ideation will be evaluated and assessed by general practitioners from community health centres. Additionally, suicide will be judged by general practitioners based on diagnostic criteria according to the ICD-10.

In our study, relapse is defined using three operational evaluation criteria based on previous study results: (1) change in antipsychotic medication use due to exacerbation of psychotic symptoms; (2) increased frequency of outpatient mental health services or rehospitalisation; and (3) patient needs intensive supervision because of self-harm, violent behaviours, suicidal/homicidal ideation or related behaviours. 23 35 Relapse outcome information will be collected through family member reports and clinical evaluations by general practitioners in the community every 3 months. Patients who meet any of the aforementioned conditions will be considered to have experienced relapse.

Data collection procedures

After providing informed consent, two standardised baseline clinical assessments are scheduled. Each enrolled participant will be invited to receive free assessments at the local community health centre. Although there are no direct monetary benefits for each participant, individuals will receive their assessment report after each assessment.

During the first interview, information regarding sociodemographic characteristics, family medical history of mental illness, medical history, employment status, living arrangement, family and social support, and financial status is collected by two trained mental health professionals. The standard 18-item version of the BPRS will be administered for the assessment of psychopathology symptoms every 6 months during the follow-up period. The Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 and Life Event Scale (LES) will be administered to assess psychological status. The LES evaluates 48 common life events in China regarding family, occupational, academic and social communication domains. A higher LES score indicates greater psychological stress. 36 The LES was designed specifically for Chinese people and has good inter-rater reliability and internal consistency. 37 These three assessments will also be administered at baseline and every 6 months.

In the second interview, participants will be interviewed by a trained psychiatrist, and the following instruments will be administered: the Montreal Cognitive Assessment, the Perceived Social Support Scale (PSSS), the Social Disability Screening Schedule, the Modified Overt Aggression Scale, the Pittsburgh Sleep Quality Index and the WHO Quality of Life Instruments. The second interview will also be conducted every 6 months. Multimodal MRI can be used to reveal structural and functional changes in the brain. Structural and resting-state MRI data will be obtained with a Siemens 3T Primsa scanner at the Neuroimaging Core at the Shanghai Mental Health Center.

All the assessments will be administered at baseline and at the 12-month, 24-month and 36-month follow-ups except for the health history and the PSSS, which will only be assessed at baseline. Considering the workload of each subject, follow-up assessments will be scheduled in 2 days. In addition, this study specifically focuses on patient relapse-related outcomes, recurrence-related outcomes and prognosis-related events, such as an increased frequency of outpatient mental health services, rehospitalisation, relapse, violent behaviours, dangerous behaviours, and suicide-related and self-harm-related behaviours. Patients will be scheduled for follow-up every 3 months. These outcomes are assessed and evaluated by general practitioners in community health service centres.

To elucidate potential blood biomarkers of disease-specific alterations in patients with schizophrenia, peripheral blood samples will be collected at baseline, at the 1-year follow-up, at the 2-year follow-up and at the 3-year follow-up. At baseline, 7 mL of blood will be collected for proteomic and genomic studies, while at 12-month, 24-month and 36-month follow-ups, only 5 mL of peripheral blood will be collected for proteomic analyses. Risk behaviour assessments will be carried out every 3 months after recruitment. The data will be collected via telephone or face-to-face interviews according to self-reports or caregiver reports. In our study, risk behaviours include aggressive behaviours, stressful events, traumatic events, alcohol and nicotine usage, psychotic symptom recurrence, adverse reactions related to antipsychotic medication, physical disease and employment. Physical examination for weight, height, waist and hip circumference evolution, blood pressure, blood sugar, blood routine, glycosylated haemoglobin, blood lipid level and ECG tests were conducted every 6 months during follow-up. In addition, long-term follow-up will be continued if desired by the subjects, even after the 3-year follow-up. An overview of the assessments is shown in figure 1 .

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Overview of the cohort study process and data collection procedure. ICD-10, International Classification of Diseases (10th edition); WAIS-IV, Wechsler Adults Intelligence Scale.

Sample size calculation

There are multiple prognostic outcomes of schizophrenia, including remission, relapse, psychotic symptom-related violent behaviour, self-injury and suicide. We assumed that suicide has the lowest incidence and applied this to calculate the sample size; the formula is as follows:

According to contemporary studies, the suicide rate p 0 is set as 5%. 38 39 The other related parameters are set as α=0.05, β=0.1, Z α =1.96 and Z β =1.28.

Considering the need for subgroup analysis and the 20% loss to follow-up, as we increased the total sample size to 1000, a total of 1200 patients needed to be included according to a 20% loss to follow-up. This 3-year cohort study aimed to recruit at least 1200 community-dwelling patients with schizophrenia.

Data storage and analysis plan

Each participant will be assigned a unique identification number. The corresponding data will be entered into the electronic case report form platform and maintained anonymously on password-locked computers and mobile hard disks.

During the assessment, all the questionnaires will be checked by two independent personnel to minimise missing data. If more than 10% of the items are missed or have obvious logical errors, the questionnaire will be considered invalid. In these cases, we will reinvite patients to complete the questionnaire or recruit new patients. In the data imputation stage, data will be imputed and cross-checked by two independent professionals. During the analysis stage, a multiple imputation model will be applied to handle missing outcome data. Potential predictors with more than 50% missing data will be discarded from the prediction model analysis.

All the statistical analyses will be performed in line with the objective as formulated above. In general, demographic data, clinical assessments, psychological status assessment and physical examination variables will be presented as the mean±SD or median. Relationships between relapse, psychosocial and demographic variables will be analysed using multiple regression and structural equation models. Mixture models will be used to identify subgroups of participants based on their psychosocial, physical and mental health characteristics. Multivariate analysis by linear or logistic regression will be performed to identify independent predictors of primary and secondary outcome measures. Mixed models, repeated analysis of variance, Cox regression and latent class growth analysis will be applied in the longitudinal data analyses. Relapse HRs will be estimated using proportional hazard regression. Finally, based on the Transparent Reporting for Individual Prognosis or Diagnosis guidelines, a relapse prediction model will be developed using regression analysis and machine learning approaches. α=0.05 (two tailed) was set as the statistical significance level. Statistical analyses will be performed using IBM SPSS Statistics V.21 or R software.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this community-based cohort study.

Findings to date

As of 31 December 2023, we have recruited 660 participants. Baseline face-to-face interviews and clinical examinations have been conducted with all 660 participants. A total of 534 participants have completed the first follow-up assessments. The mean age of the recruited participants was 47.04±15.07 years. A total of 329 participants were female, and 264 participants were male. The average age at diagnosis was 41.33±15.58 years.

Here, we introduce the protocol for a cohort study to predict relapse and violence among patients with schizophrenia. This is the first community-based prospective cohort study examining multiple vulnerability and resiliency factors associated with the rehabilitation of patients with schizophrenia. This cohort study aims to recruit 1200 patients with clinically stable schizophrenia who are receiving community-based rehabilitation and mental health treatment. Comprehensive demographic, biological, clinical, psychological and social function data will be collected during the 3-year follow-up. Meaningful associations between outcomes and assessment measures will provide valuable information on mental health services for community-dwelling patients with schizophrenia. The results will also help to identify patients at risk of relapse and violence and might facilitate the development of interventions targeted at improving health services for these patients.

In China, when a patient’s condition stabilises after inpatient or outpatient treatment, he or she is referred to a community health service centre for further community-based mental health and rehabilitation services. These services mainly included antipsychotic maintenance treatment, behaviour therapy, social skills training, vocational rehabilitation, health education, physical examination and regular follow-up services. A mental health service team is responsible for these aforementioned services. The team members include general practitioners, psychiatric nurses, psychological therapists and rehabilitation therapists. If a patient relapses, team members refer the patient to the hospital. Currently, nearly 90% of patients with schizophrenia live and receive community mental health treatment in their communities, and a robust method of measuring disease progression among community-based patients is imperative for advancing the development of disease-modifying treatments. In addition, given the clinical and possible aetiological heterogeneity of psychotic symptoms, accurate markers of disease relapse could advance our understanding of disease mechanisms and lead to the implementation of patient-modifying interventions, especially for high-risk violent patients.

Our community-based cohort fulfils these needs and takes advantage of the linkage between hospital-based and community-based mental health services, which could have great implications for the development of high-quality mental health services, especially for community-dwelling patients.

Ethics statements

Patient consent for publication.

Consent obtained from parent(s)/guardian(s).

Acknowledgments

The authors would like to thank the psychiatrists, general practitioners from community health service centres, and social workers who participated and helped recruit and follow up patients during the study. We wish the patients speedy recovery.

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YZ and SH contributed equally.

Contributors YoZ and SH are responsible for the writing and editing of the original paper; in addition, they contributed equally to this paper. YL and SH are in charge of data quality control and data cleaning, YL also helped write and edit the revised paper. QZ, YJ, YaZ and WX are in charge of designing the subjects' recruitment and data collection plan. CC, YiZ and XG contributed to the data quality control plan. English language editing and data analysis were carried out mainly by NW and WZ. JC and BX contributed to the conception and design of this study.

Funding Health Industry Clinical Research Project of the Shanghai Municipal Health Commission (2020040362); Shanghai New Star Young Medical Talents Training Program; the Science and Technology Commission of Shanghai Municipality Research Project (19411950800); Project of the Key Discipline Construction, Shanghai 3-Year Public Health Action Plan (GWVI-10.1-XK18, GWVI-11.2-XD25); Key Project of 'Medical and Industrial Cross-Research Foundation' of Shanghai Jiao Tong University in 2024 (YG2024ZD24); Project of Science and Technology Committee of Xuhui District (SHXH202048); key discipline construction project of public health in Minhang District (MGWXK05); Project of Science and Technology Committee of Minhang District (2020MHZ009); Medical project of Hongkou District Science and Technology Committee (2201-04, 2023XKDTR05) and the fourth cycle 'Excellent Young Talents' training programme of Jinshan District Health Commission (JSYQ201915).

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

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