A/HRC/35/21 Decisions to use coercion are exclusive to psychiatrists, who work in systems that lack the clinical tools to try non-coercive options. The reality in many countries is that alternatives do not exist and reliance on the use of coercion is the result of a systemic failure to protect the rights of individuals. 65. Coercion in psychiatry perpetuates power imbalances in care relationships, causes mistrust, exacerbates stigma and discrimination and has made many turn away, fearful of seeking help within mainstream mental health services. Considering that the right to health is now understood within the framework of the Convention on the Rights of Persons with Disabilities, immediate action is required to radically reduce medical coercion and facilitate the move towards an end to all forced psychiatric treatment and confinement. In that connection, States must not permit substitute decision-makers to provide consent on behalf of persons with disabilities on decisions that concern their physical or mental integrity; instead, support should be provided at all times for them to make decisions, including in emergency and crisis situations.43 66. The Special Rapporteur takes note of the concerns of various stakeholders, particularly within the medical communities, regarding the absolute ban on all forms of non-consensual measures. 44 He acknowledges that their radical reduction and eventual elimination is a challenging process that will take time. However, there is shared agreement about the unacceptably high prevalence of human rights violations within mental health settings and that change is necessary. Instead of using legal or ethical arguments to justify the status quo, concerted efforts are needed to abandon it. Failure to take immediate measures towards such a change is no longer acceptable and the Special Rapporteur proposes five deliberate, targeted, and concrete actions as follows: (a) Mainstream alternatives to coercion in policy with a view to legal reform; (b) Develop a well-stocked basket of non-coercive alternatives in practice; (c) Develop a road map to radically reduce coercive medical practices, with a view to their elimination, with the participation of diverse stakeholders, including rights holders; (d) Establish an exchange of good practices between and within countries; (e) Scale up research investment and quantitative and qualitative data collection to monitor progress towards these goals. H. Underlying and social determinants of mental health 67. The right to health is an inclusive right to both health care and the underlying and social determinants of health. Public health has individual and collective dimensions, which are essential in securing the right to the enjoyment of the underlying and social determinants of health. 45 Given the deep connections between mental health and the physical, psychosocial, political and economic environment, the right to determinants of health is a precondition for securing the right to mental health. Under international human rights law, States must act on a range of underlying determinants, such as violence, supportive family environments and discrimination, to secure in particular the right to health of children and women 46 and persons with disabilities. 47 In short, respecting, 43 44 45 46 47 Hans Joachim Salize and Harald Dressing, “Coercion, involuntary treatment and quality of mental health care: is there any link?”, Current Opinion in Psychiatry, vol. 18, No. 5 (October 2005). Guidelines on article 14 of the Convention, para. 22. See Melvyn C. Freeman and others, “Reversing hard won victories in the name of human rights: a critique of the general comment on article 12 of the UN Convention on the Rights of Persons with Disabilities” The Lancet Psychiatry, vol. 2, No. 9 (September 2015). International Covenant on Economic, Social and Cultural Rights, art. 12 (2), and Committee on Economic, Social and Cultural Rights, general comment No. 14, para. 37. Convention on the Rights of the Child, art. 24, and Convention on the Elimination of All Forms of Discrimination against Women, art. 12. Convention on the Rights of Persons with Disabilities, art. 25 (a) and (b). 15