World Conference Against Racism, Racial Discrimination, Xenophobia

WHO/SDE/HDE/HHR/01.2 • Original: English • Distribution: General

WHO’s Contribution to the WorldWorld ConferenceConference AgainstAgainst Racism,Racism, RacialRacial “Vulnerable and marginalized groups in society bear an undue proportion of health problems. Many health disparities are rooted in fundamental social structural inequalities, which are inextricably related to racism and other forms of discrimination Discrimination,Discrimination, in society... Overt or implicit discrimination violates one of the fundamental principles of human rights and often lies at the root of poor health status.” XenophobiaXenophobia The World Health Organization’s contribution to the World Conference Against Racism, Racial Discrimination, Xenophobia and Related Intolerance urges the Conference to consider the and Related link between racial discrimination and health, noting in and Related particular the need for further research to be conducted to explore the linkages between health outcomes and racism, racial discrimination, xenophobia and related intolerance. IntoleranceIntolerance Health and freedom from discrimination

Health & Human Rights Publication Series–Issue No. 2 For more information, please contact: Helena Nygren-Krug Health and Human Rights Globalization, Cross-sectoral Policies and Human Rights Department of Health and Development World Health Organization Health & Human Rights 20, avenue Appia – 1211 Geneva 27 – Switzerland Publication Series Tel. (41) 22 791 2523 – Fax: (41) 22 791 4726 E-mail: [email protected] Issue No. 2, August 2001 World Health Organization Health and freedom from discrimination

This document was produced by the World Health Organization: Department of Health and Development, Sustainable Development and Healthy Environments Cluster, WHO Headquarters, Geneva, together with the Public Policy and Health Program, Pan American Health Organization (PAHO), WHO Regional Office for the Americas, Washington, D.C.

© World Health Organization, 2001 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors.

Designer: François Jarriau, SCM7 Cover photo: WHO/PAHO/Armando Waak WHO/SDE/HDE/HHR/01.2 • Original: English • Distribution: General

WHO’s Contribution to the World Conference Against Racism, Racial Discrimination, Xenophobia and Related Intolerance: Health and freedom from discrimination

World Health Organization

Health and freedom from discrimination Table of contents

1. Introduction page 5

2. Background 2.1 Health, human rights and discrimination page 6 2.2 Inequalities in health due to discrimination page 7

3. Determinants to inequalities in health 3.1 Health sector determinants page 8 3.2 Socioeconomic determinants page 11

4. Conclusions page 12

Annex: Variations in health and service access indicators: A regional perspective page 15

Photo: WHO/PAHO/Carlos Gaggero

Health and freedom from discrimination

1-Introduction

1 - The Constitution of the World Health Organization (WHO) of 1948 declares that “[t]he enjoyment of the highest attainable standard of health is one of the fundamental 1 rights of every human being” . It Photo: WHO/PAHO/Carlos Gaggero defines health as “a state of com- plete physical, mental and social 2 - The World Health Organization well-being and not merely the recognizes the World Conference absence of disease or infirmity” and against Racism, Racial Discrimination, prohibits discrimination in its Xenophobia and Related Intolerance 2 (1) Basic documents. enjoyment. as presenting a unique opportunity Forty-third edition. Geneva, World Health for the development and adoption Organization, 2001. of a new approach to addressing The Constitution was adopted by the the health impact of racism, racial International Health Conference in 1946. discrimination, xenophobia and (2) Id. Preamble. related intolerance.

Photo: WHO/PAHO/Carlos Gaggero

5 Health and freedom from discrimination 2-Background

2.1 Health, that relevant rights “will be exer- human rights cised without discrimination...”. and discrimination 6 - Overt or implicit discrimination violates one of the fundamental 3 - Vulnerable and marginalized principles of human rights and often groups in society bear an undue lies at the root of poor health status. proportion of health problems. Discrimination against women; the Many health disparities are rooted elderly; ethnic, religious and lin- in fundamental social structural guistic minorities; persons with dis- inequalities, which are inextricably abilities; indigenous populations related to racism and other forms of and other marginalized groups in discrimination in society. Mortality society both causes and magnifies and health in general rarely diverge poverty and ill-health. far from economics and social rela- tions, which leads to the conclusion that to eliminate differentials in health outcomes requires addressing the underlying social inequalities that so reliably produce them.

4 - Human rights provide a useful framework to identify, analyze and respond directly to the societal determinants of health. Vulnerabil- ity to ill-health can be reduced by Photo: WHO/PAHO/Carlos Gaggero taking steps to respect, protect and fulfil human rights. Government 7 - The observance of human rights is efforts towards meeting their human permeated and characterized by the rights obligations must be deliber- principle of freedom from discrimi- ate, concrete and targeted as clearly nation. Governmental responsibility as possible. for nondiscrimination includes ensuring equal protection and opportuni- 5 - Freedom from discrimination on ty under the law, as well as de facto account of race and ethnicity, sex enjoyment of rights such as the right and gender roles, and language and to public health, medical care, social religion, is an overarching and fun- security and social services. The damental norm relevant to all International Convention on the aspects of public life. While the Elimination of All Forms of Racial International Covenant on Eco- Discrimination places an obligation nomic, Social and Cultural Rights on States parties to prohibit and to provides for progressive realization eliminate racial discrimination in all and acknowledges the constraints its forms and to guarantee the right due to the limits of available of everyone without distinction as to resources, it also imposes various race, colour of the skin or national or obligations of immediate effect. Of ethnic origin, and equality before the particular importance in this regard law, notably in the enjoyment of the is the “undertaking to guarantee” above-mentioned rights.

6 Health and freedom from discrimination

Respect for human rights, the standards of which are contained in numerous international human rights instruments, is an important tool for protecting health. It is those who are most vulnerable in society—women, children, 8 - A general comment on the right to the poor, persons with disabilities, the the highest attainable standard of internally displaced, migrants and health, recently adopted by the refugees—who are most exposed to the Committee which monitors the risk factors which cause ill-health. International Covenant on Economic, Discrimination, inequality, violence and Social and Cultural Rights, enumer- poverty exacerbate their vulnerability. ates the grounds for non-discrimi- It is therefore crucial not only to nation in health by proscribing “any defend the right to health but to ensure discrimination in access to health that all human rights are respected and care and the underlying determi- that the root economic, social and nants of health, as well as to means cultural factors that lead to ill-health are and entitlements for their procure- addressed. ment, on the grounds of race, colour, sex, language, religion, political or Mary Robinson, UN High Commissioner other opinion, national or social ori- for Human Rights, 9th International gin, property, birth, physical or Congress of the World Federation of (3) General comment mental disability, health status Public Health Associations, Beijing, on the right to health (including HIV/AIDS), sexual ori- adopted by the 2–6 September 2000 Committee on entation, civil, political, social or Economic, Social and Cultural Rights on 11 other status, which has the intention May 2000, paragraph 18. (E/C.12/2000/4, or effect of nullifying or impairing CESCR General the equal enjoyment or exercise of 10 - Gender is a cross-cutting theme in comment 14, 4 July 2000.) the right to health”. 3 all matters concerning health and development which concerns how polices and programmes impact dif- ferently on women and men. Anoth- er important dimension to consider is how racial discrimination com- 2.2 Inequalities bines and multiplies in relation to in health due other grounds for discrimination, such as sex and gender roles; age to discrimination (children and the elderly); sexual orientation; religion; political affilia- 9 - Research has shown that inequali- tion; physical and mental disability; ties in the health and health care of and other health status. For exam- ethnic and racial groups 4 are evi- ple, the combination of racial and (4) See Annex: Variations in health dent and that racism is the most dis- gender discrimination has resulted and service access indicators: A regional turbing of the explanations for in increased vulnerability for perspective. these inequalities. 5 It has thus been women of African descent, many of (5) Bhopal R. Spectre of racism in health suggested that attention be devoted whom are subjected to sexual and health care: to gender, ancestry and ethnicity, exploitation and trafficking in the lessons from history and the United socioeconomic status, disability, Western hemisphere. In many coun- States. British medical journal, sexual orientation and rural living tries of Latin America, HIV/AIDS 27 June 1998, 316 (7149):1970–1973. affecting health outcomes as well as incidence is high among Afro-Latin (6) Kurland J. Public the health effects that institutions, American men and women. This health in the new Millennium II. Social laws, policies and programmes requires special attention to the exclusion, may have on ethnic and racial added difficulties resulting from July/August 2000, 115(4):298–301 groups. 6 multiple discrimination.

7 Health and freedom from discrimination 3 - Determinants to inequalities in health

3.1 Health sector determinants Cultural sensitivity. There are other exclusionary factors associat- 11 - The most pertinent factors, which ed with language and cultural val- relate to the health sector, to explain ues. The cosmic vision of health and the discrepancies in the health situa- disease are part of belief systems, tion and service access indicators are: which vary with each ethnic group. According to some, disease can be Access to health services. Barriers caused by human beings with to health service access are a key fac- potent powers, by supernatural tor in differential health outcomes forces, or by accidents, excesses or among different population groups deficiencies. These beliefs can make within a society. There are several people reluctant to use modern practical reasons for these, including health services grounded in sci- location and cost. Historically, physi- ence. In these cases, traditional cal segregation on the basis of race medicine plays an important role in and ethnicity has been operative in disease prevention and cure. The neighbourhoods and/or regions. provision of modern health servic- Coincidentally, public services in es thus need to carefully account for these areas, including health services, different cultural beliefs in order to may be of lower quality and less effi- be sufficiently culturally sensitive cient. For example, physicians, equip- so as not to limit access of ethnic ment, and services are highly concen- minorities for this reason. trated in urban areas. Critical services are needed to ensure access to health services such as subsidized transport. The ILO Convention (No. 169) concerning Indigenous and Tribal Peoples in Inde- pendent Countries, 1991, obligates ratify- General comment on the right to the high- ing governments to ensure that: est attainable standard of health adopted by the Committee which monitors the 1. Adequate health services are made International Covenant on Economic, available to the peoples concerned, or Social and Cultural Rights, May 2000: shall provide them with resources to allow them to design and deliver such “Health facilities, goods and services must services under their own responsibility be accessible to all, especially the most and control, so that they may enjoy the vulnerable or marginalized sections of the highest attainable standard of physical population, in law and in fact, without dis- and mental health. crimination on any of the prohibited grounds. These include the requirement 2. Health services shall, to the extent pos- that they be within safe physical reach for sible, be community-based. These services all sections of the population. Accessibility shall be planned and administered in coop- also implies that medical services and eration with the peoples concerned and underlying determinants of health, such as take into account their economic, geo- safe and potable water and adequate san- graphic, social and cultural conditions, as itation facilities, are within safe physical well as their traditional preventive care, reach, including in rural areas.” healing practices and medicines.

8 Health and freedom from discrimination

General comment on the right to the highest attainable standard of health adopted by the Committee which monitors the International Covenant on Economic, Social and Cultural Rights, May 2000:

As well as being culturally acceptable, health facilities, goods and services must also be scientifically and medically appropriate and of good quality. This requires, Photo: WHO/PAHO/Dana Downing inter alia, skilled medical personnel, scientifically approved and unexpired drugs 3. The health care system shall give pref- and hospital equipment, safe and potable erence to the training and employment of water, and adequate sanitation. local community health workers, and focus on primary health care while main- taining strong links with other levels of health care services. The timeliness of access to services is another relevant aspect to 4. The provision of such health services consider. People may have access to shall be coordinated with other social, health services but can only take economic and cultural measures in the advantage of them late in some country cases, making successful medical treatment impossible. This could account for the differential indica- The quality of services is another tors. The reasons why individuals aspect that must be considered to or groups delay consultation are in account for the differences between part related to the aspects men- the health indicators of majority tioned above—cost, location and and minority groups. Two dimen- language. However, they are also sions of the quality of care should related to people’s understanding be analyzed. First, the relationship of the health/disease process and between physician and patient, in to the knowledge and information which the ideological biases of the available to them on the role of dis- staff and the services can come into ease prevention and health promo- play, leading to differences in the tion. People will seek assistance quality of care within the same more readily when the health sector institutional health service provider. has an expanded comprehensive, Second, the training and size of the ethnic and sensitive perspective in professional team and the avail- the way that services are organized ability and use of technology, in and delivered. addition to the health model employed by the health team: WHO’s measurement of health systems’ practices geared to disease preven- responsiveness recognizes prompt attention and health promotion (or the tion as “immediate attention in emergen- lack thereof) lead to differences in cies, and reasonable waiting times for health indicators. non-emergencies”.

9 Health and freedom from discrimination

In addition, international human rights principles include the obligation of governments to respect the right of individuals to seek, receive and impart information and ideas concerning health issues. The provision of and access to health- related information is also considered an “underlying determinant of health” and, as such, an integral part of the realization of the right to the highest attainable standard of health.

Discrimination in the health Photo: WHO/PAHO/Carlos Gaggero system. Finally, the effect of the segregation and discrimination practised against minority patients by the health services themselves. 12 - Discrimination has caused social This is an area less explored in the exclusion and marginalization of available literature. However, it is specific population groups. This possible that in some instances, process can, in turn, increase these health systems may also engage in groups’ vulnerability to poverty the same stereotyping found in the and ill-health. Thus, often rooted society at large, thus reinforcing in discrimination, these broader discrimination or even exacerbat- determinants of health generated ing it. In this regard, there is from the historical, cultural and increasing recognition of the need socioeconomic development, which to sensitize and train health profes- has introduced biases in the equal- sionals about human rights, with ity of opportunity for individuals particular emphasis on freedom from minority and indigenous from discrimination, and how to populations. 7 address this in all its dimensions in practical situations.

(7) Thomas, VG. Explaining health Article 1, International Convention on disparities between the Elimination of All Forms of Racial African-American and white populations: Discrimination: Racial discrimination means Where do we go from here? Journal of the “any distinction, exclusion, restriction or National Medical Association, 1992, preference based on race, colour, descent, or 84(10):839-840; national or ethnic origin” which has the pur- Navarro V. Race or class versus race and pose or effect of nullifying or impairing the class: Mortality differentials in the recognition, enjoyment or exercise of human United States. Lancet, 1990, rights, including the right to health care, 336:1238–1240. education, work and adequate housing.

10 Health and freedom from discrimination

3.2 Socioeconomic determinants

13 - Research shows that mortality rates affected by lifestyle factors such as are higher for the poor than for the diet, substance abuse (tobacco, alco- rich at all ages. The differential is par- hol, and drugs), and social behaviour ticularly high during infancy and (violence and accidents). childhood. 8 15 - The educational situation has an 14 - Segregation relegates certain seg- impact not only in terms of the limits ments of the population to neigh- it imposes on equitable access to the bourhoods with fewer resources, job market and the perpetuation of poorer services and a degraded poverty but also of its consequences human and physical environment. for health. Studies show that the Populations subjected to discrimina- mother’s education is an important tion are more likely than others to factor in family health care (births in inhabit areas affected by environ- an institutional setting, medical mental pollution and degradation, check-ups, etc.). and are more likely to be negatively

It is no coincidence that the idea to establish a world health organization emerged from the same process that identified the universal value of human rights. WHO’s mandate is also universal. Our constitution…stat[es] that “the enjoyment of the highest attainable

Photo: WHO/H. Anenden standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social con- dition.”

Dr Gro Harlem Brundtland, Director- General, World Health Organization, Paris, France, 8 December 1998 Fiftieth Anniversary of the Universal (8) Gwatkin, 1999, World health report, Declaration of Human Rights Geneva, World Health Organization, 1999.

11 Health and freedom from discrimination 4-Conclusions

16 - The fundamental principles of 19 - National policies and programmes equality and freedom from dis- need to be planned and imple- crimination have been identified mented with due regard for the as key components in all matters legitimate interests of persons concerning health. This includes belonging to minorities. 9 This non-discrimination in access to includes respect for the beliefs, health facilities, goods and servic- knowledge and language of the es, paying partic- beneficiaries, as well as attention to ular attention to their right to participate in matters the most vulner- concerning their health and devel- able or marginal- opment. In addition, health policy ized sections of instruments and programmes need the population. to be developed by health sector It also means authorities with an intersectoral that, to the extent perspective for effective targeting possible, health on indigenous peoples and ethnic facilities, goods minority communities in order to

Photo: WHO/armando Waak and services must reduce health inequalities and in be within safe physical reach for all the light of international human parts of the population. They rights obligations which are should also be culturally appropri- addressed to government as a ate — that is respectful of the cul- whole as prime duty-bearer. ture of individuals, minorities and indigenous populations — and 20 - WHO notes with interest recommen- sensitive to gender and life-cycle dations relating to discrimination requirements. and health, addressed to governments, which have emerged from 17 - The differences in the health situa- the preparatory process of the World tion of minority and indigenous Conference. Notably, WHO wishes groups, compared to the general to draw attention to the following: population, are related to structural factors such as poverty, to factors The importance of increased directly attributable to the organi- research into the impact of dis- zation of health services and their crimination on access to health care. quality, and to the level of informa- Routine monitoring of the situation tion available to the public regard- of marginalized racial and ethnic ing health and health care. groups could be instituted through periodic sampling and compilation 18 - Biases in the treatment of indigenous of statistical information disaggre- and ethnic minorities should be cor- gated by race or ethnic group, par- rected through systematic efforts ticularly with regard to such funda- (9) Article 5, Declaration on the and a variety of mechanisms such as mental heath indicators as infant Rights of Persons Belonging to training, skill-building and aware- mortality rate, life expectancy and National or Ethnic, Religious or ness-raising among health profes- access to health services. In this Linguistic Minorities, sionals of the human rights implica- regard, WHO concludes that fur- Adopted by General Assembly resolution tions of their work, all of which ther research be conducted to 47/135 of 18 December 1992, The should be backed up with appropri- explore the linkages between health General Assembly. ate policies and legislation. outcomes and racism, racial dis-

12 Health and freedom from discrimination

crimination, xenophobia and related intolerance. Such research would inform and form the basis for countries to take appropriate action. It would also help to differentiate the Photo: WHO relative contribution of race versus States. To that end, the develop- poverty in the causation of poor ment of participatory strategies for health outcomes. these communities in the processes of collecting and using information The need for comprehensive leg- need to be devised. On the basis of islation, specifically prohibiting all existing statistical information, the forms of discrimination and provid- importance of establishing national ing civil and criminal penalties and programmes, including affirmative remedies in all spheres of public life, action measures. including in relation to health and health care. In addition, the need to The urging that measures be strengthen the capacity of govern- taken to eliminate disparities in ments to review health-related laws health status experienced by disad- and policies to determine whether vantaged racial and ethnic groups on their face or application there is by the year 2010, including dispari- inherent discrimination. Similarly, ties pertaining to health issues such governments should be supported as malaria, tuberculosis, HIV/ in developing national health legis- AIDS, cancer, cardiovascular dis- lation which conforms with their ease, diabetes, tobacco, maternal human rights obligations. health, food safety, mental health, safe blood and health systems. The need for central government, together with health sector authori- The special emphasis to be put on ties, to allocate sufficient financial gender issues and gender discrimi- resources in the national budget to nation, particularly the multiple ensure adequate health prevention, jeopardy that occurs when gender, promotion and care programmes class, race and ethnicity intersect and which target indigenous peoples the importance of public policies and ethnic minority communities. being adopted which give impetus to programmes on behalf of indige- The importance that institutions nous women and ethnic minority responsible for providing statisti- women, with a view to promoting cal information on the population their civil, political, economic, social take explicit account of the exis- and cultural rights; to putting an end tence of indigenous peoples, people to this situation of disadvantage for of varying descent and other ethnic reasons of gender; to dealing with groups, capturing the component urgent problems affecting them in parts of their diversity according to health, including reproductive their needs and characteristics, health and gender-based violence; designing strategies to evaluate the and to ending the situation of aggra- human rights policies concerning vated discrimination they suffer as ethnic groups, and exchanging women in manifestations of racism experiences and practice with other and gender discrimination.

13 Health and freedom from discrimination

The need to consider situations of representatives and minority com- children subjected to racial discrim- munities to exercise their rights to ination, especially those who find participation. This requires skill- themselves in circumstance of par- building in how to negotiate, as ticular vulnerability, such as aban- well as how to access social and doned children; political processes. The right of children who live individuals and groups to active, or work in the free and meaningful participation street; child vic- in setting priorities, making deci- tims of traffick- sions, planning, implementing and ing and econom- evaluating programmes that may ic exploitation; affect their development is an inte- sexually-exploit- gral component of a rights-based ed children; chil- approach to health. dren affected by armed conflict, and child victims 21 - WHO looks forward to participating of poverty, and, in the World Conference Against in this context, Racism, Racial Discrimination, the importance of Xenophobia and Related Intolerance Photo: WHO/PAHO/Carlos Gaggero collecting and in South Africa and urges the Con- analysing statistical data to assess ference to consider the link between how policy and legislation affect racial discrimination and health. children’s lives. In all matters con- Overall in the conference docu- cerning health and discrimination ments, WHO stresses the impor- of children, the best interests of the tance of including health whenever child shall prevail. other economic, social and cultural rights are mentioned, such as educa- The need to adopt measures to tion, work and housing. provide a proper environment for disadvantaged groups, including action to reduce and eliminate We inhabit a universe characterized industrial pollution that affects by diversity. There is not just one planet them disproportionately, to take or one star, there are galaxies of differ- measures to clean and redevelop ent sorts, a plethora of animal species, contaminated sites located in or different kinds of plants, and different near where they live and, where races and ethnic groups. How can one appropriate, to relocate, on a volun- have a soccer team if all the members tary basis and after consultation of the team are goalkeepers? How with those affected, racially and could it be an orchestra if all members ethnically disadvantaged groups to played the French horn? other areas when there is no other practical alternative for ensuring Archbishop Desmond Tutu speaking their health and well-being. at the Special Debate on Tolerance and Respect during the 57th Session Public and private sector efforts of the United Nations Commission are required to strengthen the on Human Rights, March 2001. capacity of indigenous peoples’

14 Health and freedom from discrimination Annex

Variations higher concentrations of Afro- that by 1986, 39% of Hispanics in in health and Peruvians, such as Piura (93 per the USA had no coverage, a fig- 1000 live births), Lambayeque (68 ure three times higher than that service access per 1000), and Tacna (64 per of whites and double that of indicators: 1000), while the lowest rates are African-Americans.8 In Guatemala, A regional found in Lima and El Callao more than 70% of Guatemalan perspective (with 45 and 41 per 1000 respec- women receive some form of care tively).4 In Panama, the probabil- at the time of delivery, but while ity of dying before completing 50% of Latino women are cared the first year of life is 3.5 times for by physicians, only 14.46% higher among indigenous chil- of indigenous women receive WHO Regional Office for the dren than among non-indige- medical care. Moreover, 87% of Americas has examined the ques- nous children.5 Infant mortality indigenous women give birth in tion of variations in health and in Brazil, estimated with 1996 the home, at an average age of 20 service access indicators among data, reveals sharp disparities: 62 to 25. In most of the Latin Ameri- the different ethnic groups in the per 1000 live births for the Afro can and Caribbean (LAC) Region, Americas in the light of available group and 37 per 1000 among health services are highly con- empirical information.1 whites.6 Infant mortality indica- centrated. In the outlying neigh- tors speak volumes: 16% of bourhoods of Caracas and Mara- 1. Studies in the USA indicate health disparities among the dif- women over the age of 15 have caibo, the Afro-Venezuelan pop- ferent ethnic groups.2 For exam- lost at least one child born alive. ulation lacks services; health ple, mortality is higher among When analysed by ethnic group, workers, in turn, do not want to African-Americans than among the distribution is as follows: 33% work in the neighbourhoods the white population: the two of indigenous women over age where this population lives leading causes of death in the 15 have lost at least one child, because of violence and a lack of 9 USA are cancer, with a ratio of 1:2, whereas this figure was 19% security. Other examples of lack and cardiovascular diseases with among black women and 12.83% of services and isolation concern a ratio of 1:6. African-Americans among white women. black communities on the Pacific also have higher infant mortality Coast of Colombia, in the Valle del rates and higher mortality from 3. In Guatemala, the data illus- Chota or Esmerardas Province of diabetes, homicide and HIV/ trate that mortality among Ecuador and in the Garífuna and AIDS. These studies also show indigenous children is higher. Criollo communities of the South evidence of higher mortality Neonatal mortality, mortality in Atlantic Autonomous Region from selected diseases in the children aged 0 to 1 year and mor- (RAAS) of Nicaragua. African-American population than tality in children under 5 are high- in other minority groups such as er among the indigenous popula- 5. Other significant statements Native Americans and Hispanics. tion (32 per 1000, 64 per 1000 and can be made regarding access to Another U.S. study recently con- 94 per 1000) than for the Latino modern health technologies. firmed higher mortality among population (27 per 1000, 53 per Compared to elderly white peo- African-Americans in 107 cities 1000 and 69 per 1000). With ple, elderly African-Americans in across the country. 3 respect to total under-5 mortality, the USA see fewer specialists, 67.6% of these deaths correspond receive less preventive care 2. The information is not as to the indigenous population and (mammograms, Pap smears) and consistently available for the rest 32% to the non-indigenous popu- poorer quality hospital services, of the Region, and the studies are lation, attributable to limited and lack access to sophisticated more sporadic. However, the access to health services. 7 technologies (for cardiovascular results coincide. For example, problems, orthopaedic condi- studies in Peru reveal high infant 4. Concerning access to insur- tions, kidney transplants) and to mortality rates in provinces with ance services, the studies show intensive treatment programmes

15 for prostate cancer, immunodefi- ciencies and depression. These disparities are also evident in other minority groups.10 There is no scientific evidence that these differences are due to genetic causes.11 Poverty, distance to services and lack of information are Photo: WHO/PAHO/Armando Waak possible explanations to these disparities. These factors may, in turn, be rooted in racial discrimination.

6. Data related to lifestyle and African-American.14 In general, (1) Equity in Health: from an Ethnic Perspective, Dr. Cristina Torres, Regional Policy Advisor, ethnicity also shows significant Brazilian data on the health pro- WHO Regional Office for the Americas. impact on health. With regard to fession, such as physicians, den- (2) U.S. Department of Health, 1991; Nickens HW. Race/ethnicity as a factor in health and death attributable to violence in tists and other specialists, reveals health care. Health services research, 1995, Brazil, the figure is 23.4% in the the following distribution: 82.93% Part II; 151–177. (3) Williams D. Race, socioeconomic status, black population (second leading are white, 12.42% brown, and and health: The added effects of racism and discrimination. Annals of the New York cause of death), while it is the 1.01% black. For medical auxil- Academy of Sciences, 1999, 986:173–188; fourth leading cause of death in iaries, the participation of minori- Williams D. Race and health: Trends and policy implications (paper). Conference: the white population, or less than ty groups increases: 59.09% white, Income on Equality, Socioeconomics Status 12 and Health, Washington, D.C., 2000; Williams half (11.4%). 32.79% brown, and 7.6% black. D, House J. Understanding and reducing socioeconomic and racial/ethnic disparities in health, Atlanta, Institute of Medicine of the 7. In Guatemala, the 1998 9. Finally, traditional medicine National Research Council, 2000. National Survey on Maternal and (4) Cowater International Inc. Comunidades has an important role to be consid- de Ancestria Africana en Costa Rica, Honduras, Child Health revealed chronic ered within the ethnic groups. For Nicaragua, Argentina, Colombia, Ecuador, Perú, Uruguay y Venezuela. Washington, D.C., and acute malnutrition among example, in Petit Goave (Haiti) half Banco Interamericano de Desarrollo, 1996. indigenous children under 5. The of the population uses traditional (5) Id. (6) FOASE. Housing, services, child health all survey showed chronic malnutri- healers (herbalists, midwives or lag far behind. Latin news (12):2000. tion (height-for-age) of 67.8% sorcerers who practise voodoo). In (7) Valladares R, Barillas E. Inversiones en salud, equidad y pobreza: Guatemala. The among the indigenous popula- this zone, there are 15 healers for World Bank, PNUD y PAHO, 1998. tion, while the corresponding fig- every 1000 people, while the ratio (8) Bollini, Siem. No real progress towards equity: Health of migrants and ethnic ure for the Latino population of physicians to population is 15 minorities on the eve of the year 2000. Social group was 36.7%. Acute malnutri- per 10000. 15 science medicine, 1995, (41)6:819–828. (9) Cowater International Inc. Comunidades tion (weight-for-age) is 34.6% de Ancestria Africana en Costa Rica, Honduras, Nicaragua, Argentina, Colombia, Ecuador, among the indigenous popula- Perú, Uruguay y Venezuela. Washington, D.C., tion, while it is 20.9% among Lati- Banco Interamericano de Desarrollo, 1996. (10) Fiscella K et al. Inequality in quality: nos. Moreover, the percentage of Addressing socioeconomic, racial and ethnic low birthweight is 9.94% for disparities in health care. Journal of the American Medical Association, 2000, indigenous children and 8.94% 283(19):2579–2584. for Latino. 13 (11) Lillie-Blanton M, LaViest T. Race/ethnicity, the social environment and health. Social science and medicine, 1996, 43(1): 83–91. 8. In the context of examining (12) Barbosa, da Silva MI. Racismo e saúde. São Paulo, Tese de doutorado, 1998. health disparities among ethnic (13) Valladares R, Barillas E. Inversiones en salud, equidad y pobreza, Guatemala. The groups, it is interesting to note World Bank, PNUD y PAHO, 1998. also that they are underrepre- (14) This information was provided by the Association of Black Cardiologists (ABC), sented within the medical profes- Washington, D.C. sion. For example, only 2% of (15) Clerismé C. Medicina tradicional y moderna en Haití, Boletin de la Oficina cardiologists in the USA are Sanitaria Panamericano OPS/OMS, Washington, D.C., Mayo 1985, 98:5,431–439.

16 Health and freedom from discrimination

Designer: François Jarriau, SCM7 Cover photo: WHO/PAHO/Armando Waak WHO/SDE/HDE/HHR/01.2 • Original: English • Distribution: General