WHO’s Contribution to the · Intolerance WHO’s Contribution to the Health & Human Rights Publication Series Issue No. 2, August 2001 ... English • Distribution: General World

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

World Health Organization

Health and freedom from discrimination


WorldConference Against Racism, Racial Discrimination, Xenophobia and Related Intolerance

WHO’s Contribution to the


Health & Human RightsPublication Series Issue No. 2, August 2001

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


20, avenue Appia – 1211 Geneva 27 – Switzerland

Tel. (41) 22 791 2523 – Fax: (41) 22 791 4726

E-mail: [email protected]

“Vulnerable and marginalized groups in society bear an undueproportion of health problems. Many health disparities arerooted in fundamental social structural inequalities, which areinextricably related to racism and other forms of discriminationin society... Overt or implicit discrimination violates one of thefundamental principles of human rights and often lies at theroot of poor health status.”

The World Health Organization’s contribution to the WorldConference Against Racism, Racial Discrimination, Xenophobiaand Related Intolerance urges the Conference to consider thelink between racial discrimination and health, noting inparticular the need for further research to be conducted toexplore the linkages between health outcomes and racism,racial discrimination, xenophobia and related intolerance.

Cristina Torres Parodi

Regional Advisor in Health Policies Development

Public Policy and Health Program

Division of Health and Human Development

Pan American Health Organization/World Health Organization

525 23rd street, N.W.

Washington, D.C. 20037

Tel: 202-9743217

Internet: [email protected]

This document was produced by the World HealthOrganization: Department of Health and Development,Sustainable Development and Healthy EnvironmentsCluster, 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.

H e a l t h a n d f r e e d o m f r o m d i s c r i m i n a t i o n

© World Health Organization, 2001

This document is not a formal publication of the World Health Organization (WHO), and all rightsare 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 withcommercial 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


World Conference Against Racism, Racial Discrimination, Xenophobia and Related Intolerance:




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1. Introduction page 5

2. Background2.1 Health, human rights and discrimination page 62.2 Inequalities in health due to discrimination page 7

3. Determinants to inequalities in health3.1 Health sector determinants page 83.2 Socioeconomic determinants page 11

4. Conclusions page 12

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

Table of contents

Photo: WHO/PAHO/Carlos Gaggero

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(1) Basic documents. Forty-third edition.Geneva, World HealthOrganization, 2001. The Constitution was adopted by theInternational HealthConference in 1946.

(2) Id. Preamble.

1 - The Constitution of the WorldHealth Organization (WHO) of1948 declares that “[t]he enjoymentof the highest attainable standard ofhealth is one of the fundamentalrights of every human being” 1. Itdefines health as “a state of com-plete physical, mental and socialwell-being and not merely theabsence of disease or infirmity” andprohibits discrimination in itsenjoyment. 2

2 - The World Health Organizationrecognizes the World Conferenceagainst Racism, Racial Discrimination,Xenophobia and Related Intoleranceas presenting a unique opportunityfor the development and adoptionof a new approach to addressingthe health impact of racism, racialdiscrimination, xenophobia andrelated intolerance.

1 - Introduction



6


2.1 Health, human rights and discrimination

3 - Vulnerable and marginalizedgroups in society bear an undueproportion of health problems.Many health disparities are rootedin fundamental social structuralinequalities, which are inextricablyrelated to racism and other forms ofdiscrimination in society. Mortalityand health in general rarely divergefar from economics and social rela-tions, which leads to the conclusionthat to eliminate differentials inhealth outcomes requires address-ing the underlying social inequali-ties that so reliably produce them.

4 - Human rights provide a usefulframework to identify, analyze andrespond directly to the societaldeterminants of health. Vulnerabil-ity to ill-health can be reduced bytaking steps to respect, protect andfulfil human rights. Governmentefforts towards meeting their humanrights obligations must be deliber-ate, concrete and targeted as clearlyas possible.

5 - Freedom from discrimination onaccount of race and ethnicity, sexand gender roles, and language andreligion, is an overarching and fun-damental norm relevant to allaspects of public life. While theInternational Covenant on Eco-nomic, Social and Cultural Rightsprovides for progressive realizationand acknowledges the constraintsdue to the limits of availableresources, it also imposes variousobligations of immediate effect. Ofparticular importance in this regardis the “undertaking to guarantee”

that relevant rights “will be exer-cised without discrimination...”.

6 - Overt or implicit discriminationviolates one of the fundamentalprinciples of human rights and oftenlies at the root of poor health status.Discrimination against women; theelderly; ethnic, religious and lin-guistic minorities; persons with dis-abilities; indigenous populationsand other marginalized groups insociety both causes and magnifiespoverty and ill-health.

7 - The observance of human rights ispermeated and characterized by theprinciple of freedom from discrimi-nation. Governmental responsibilityfor nondiscrimination includes ensur-ing equal protection and opportuni-ty under the law, as well as de factoenjoyment of rights such as the rightto public health, medical care, socialsecurity and social services. TheInternational Convention on theElimination of All Forms of RacialDiscrimination places an obligationon States parties to prohibit and toeliminate racial discrimination in allits forms and to guarantee the rightof everyone without distinction as torace, colour of the skin or national orethnic origin, and equality before thelaw, notably in the enjoyment of theabove-mentioned rights.

2-Background


7


(4) See Annex:Variations in healthand service accessindicators: A regionalperspective.

(5) Bhopal R. Spectreof racism in healthand health care:lessons from historyand the UnitedStates. Britishmedical journal, 27 June 1998, 316(7149):1970–1973.

(6) Kurland J. Publichealth in the newMillennium II. Socialexclusion,July/August 2000,115(4):298–301

(3) General commenton the right to healthadopted by theCommittee onEconomic, Social andCultural Rights on 11May 2000, paragraph18. (E/C.12/2000/4,CESCR Generalcomment 14, 4 July2000.)

8 - A general comment on the right tothe highest attainable standard ofhealth, recently adopted by theCommittee which monitors theInternational Covenant on Economic,Social and Cultural Rights, enumer-ates the grounds for non-discrimi-nation in health by proscribing “anydiscrimination in access to healthcare and the underlying determi-nants of health, as well as to meansand entitlements for their procure-ment, on the grounds of race, colour,sex, language, religion, political orother opinion, national or social ori-gin, property, birth, physical ormental disability, health status(including HIV/AIDS), sexual ori-entation, civil, political, social orother status, which has the intentionor effect of nullifying or impairingthe equal enjoyment or exercise ofthe right to health”. 3

2.2 Inequalities in health due to discrimination

9 - Research has shown that inequali-ties in the health and health care ofethnic and racial groups 4 are evi-dent and that racism is the most dis-turbing of the explanations forthese inequalities. 5 It has thus beensuggested that attention be devotedto gender, ancestry and ethnicity,socioeconomic status, disability,sexual orientation and rural livingaffecting health outcomes as well asthe health effects that institutions,laws, policies and programmesmay have on ethnic and racialgroups. 6

10 - Gender is a cross-cutting theme inall matters concerning health anddevelopment which concerns howpolices and programmes impact dif-ferently on women and men. Anoth-er important dimension to consideris how racial discrimination com-bines and multiplies in relation toother grounds for discrimination,such as sex and gender roles; age(children and the elderly); sexualorientation; religion; political affilia-tion; physical and mental disability;and other health status. For exam-ple, the combination of racial andgender discrimination has resultedin increased vulnerability forwomen of African descent, many ofwhom are subjected to sexualexploitation and trafficking in theWestern hemisphere. In many coun-tries of Latin America, HIV/AIDSincidence is high among Afro-LatinAmerican men and women. Thisrequires special attention to theadded difficulties resulting frommultiple discrimination.

Respect for human rights, thestandards of which are contained innumerous international human rightsinstruments, is an important tool forprotecting health. It is those who are mostvulnerable in society—women, children,the poor, persons with disabilities, theinternally displaced, migrants andrefugees—who are most exposed to therisk factors which cause ill-health.Discrimination, inequality, violence andpoverty exacerbate their vulnerability.

It is therefore crucial not only to

defend the right to health but to ensure

that all human rights are respected and

that the root economic, social and

cultural factors that lead to ill-health are

addressed.

Mary Robinson, UN High Commissioner

for Human Rights, 9th International

Congress of the World Federation of

Public Health Associations, Beijing,

2–6 September 2000

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3.1 Health sector determinants

11 - The most pertinent factors, whichrelate to the health sector, to explainthe discrepancies in the health situa-tion and service access indicators are:

◆ Access to health services. Barriersto health service access are a key fac-tor in differential health outcomesamong different population groupswithin a society. There are severalpractical reasons for these, includinglocation and cost. Historically, physi-cal segregation on the basis of raceand ethnicity has been operative inneighbourhoods and/or regions.Coincidentally, public services inthese areas, including health services,may be of lower quality and less effi-cient. For example, physicians, equip-ment, and services are highly concen-trated in urban areas. Critical servicesare needed to ensure access to healthservices such as subsidized transport.

General comment on the right to the high-

est attainable standard of health adopted

by the Committee which monitors the

International Covenant on Economic,

Social and Cultural Rights, May 2000:

“Health facilities, goods and services must

be accessible to all, especially the most

vulnerable or marginalized sections of the

population, in law and in fact, without dis-

crimination on any of the prohibited

grounds. These include the requirement

that they be within safe physical reach for

all sections of the population. Accessibility

also implies that medical services and

underlying determinants of health, such as

safe and potable water and adequate san-

itation facilities, are within safe physical

reach, including in rural areas.”

◆ Cultural sensitivity. There areother exclusionary factors associat-ed with language and cultural val-ues. The cosmic vision of health anddisease are part of belief systems,which vary with each ethnic group.According to some, disease can becaused by human beings withpotent powers, by supernaturalforces, or by accidents, excesses ordeficiencies. These beliefs can makepeople reluctant to use modernhealth services grounded in sci-ence. In these cases, traditionalmedicine plays an important role indisease prevention and cure. Theprovision of modern health servic-es thus need to carefully account fordifferent cultural beliefs in order tobe sufficiently culturally sensitiveso as not to limit access of ethnicminorities for this reason.

The ILO Convention (No. 169) concerning

Indigenous and Tribal Peoples in Inde-

pendent Countries, 1991, obligates ratify-

ing governments to ensure that:

1. Adequate health services are made

available to the peoples concerned, or

shall provide them with resources to

allow them to design and deliver such

services under their own responsibility

and control, so that they may enjoy the

highest attainable standard of physical

and mental health.

2. Health services shall, to the extent pos-

sible, be community-based. These services

shall be planned and administered in coop-

eration with the peoples concerned and

take into account their economic, geo-

graphic, social and cultural conditions, as

well as their traditional preventive care,

healing practices and medicines.

3 - Determinants to inequalities in health

9


3. The health care system shall give pref-

erence to the training and employment of

local community health workers, and

focus on primary health care while main-

taining strong links with other levels of

health care services.

4. The provision of such health services

shall be coordinated with other social,

economic and cultural measures in the

country

◆ The quality of services is anotheraspect that must be considered toaccount for the differences betweenthe health indicators of majorityand minority groups. Two dimen-sions of the quality of care shouldbe analyzed. First, the relationshipbetween physician and patient, inwhich the ideological biases of thestaff and the services can come intoplay, leading to differences in thequality of care within the sameinstitutional health service provider.Second, the training and size of theprofessional team and the avail-ability and use of technology, inaddition to the health modelemployed by the health team:practices geared to disease preven-tion and health promotion (or thelack thereof) lead to differences inhealth indicators.

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 appro-

priate and of good quality. This requires,

inter alia, skilled medical personnel, sci-

entifically approved and unexpired drugs

and hospital equipment, safe and potable

water, and adequate sanitation.

◆ The timeliness of access to ser-vices is another relevant aspect toconsider. People may have access tohealth services but can only takeadvantage of them late in somecases, making successful medicaltreatment impossible. This couldaccount for the differential indica-tors. The reasons why individualsor groups delay consultation are inpart related to the aspects men-tioned above—cost, location andlanguage. However, they are alsorelated to people’s understandingof the health/disease process andto the knowledge and informationavailable to them on the role of dis-ease prevention and health promo-tion. People will seek assistancemore readily when the health sectorhas an expanded comprehensive,ethnic and sensitive perspective inthe way that services are organizedand delivered.

WHO’s measurement of health systems’

responsiveness recognizes prompt atten-

tion as “immediate attention in emergen-

cies, and reasonable waiting times for

non-emergencies”.

Photo: WHO/PAHO/Dana Downing

1 0


In addition, international human rights

principles include the obligation of gov-

ernments to respect the right of individu-

als to seek, receive and impart informa-

tion 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 healthsystem. Finally, the effect of thesegregation and discriminationpractised against minority patientsby the health services themselves.This is an area less explored in theavailable literature. However, it ispossible that in some instances,health systems may also engage inthe same stereotyping found in thesociety at large, thus reinforcingdiscrimination or even exacerbat-ing it. In this regard, there isincreasing recognition of the needto sensitize and train health profes-sionals about human rights, withparticular emphasis on freedomfrom discrimination, and how toaddress this in all its dimensions inpractical situations.

Article 1. International Convention on

the Elimination of All Forms of Racial

Discrimination: Racial discrimination means

“any distinction, exclusion, restriction or

preference based on race, colour, descent, or

national or ethnic origin” which has the pur-

pose or effect of nullifying or impairing the

recognition, enjoyment or exercise of human

rights, including the right to health care,

education, work and adequate housing.

12 - Discrimination has caused socialexclusion and marginalization ofspecific population groups. Thisprocess can, in turn, increase thesegroups’ vulnerability to povertyand ill-health. Thus, often rootedin discrimination, these broaderdeterminants of health generatedfrom the historical, cultural andsocioeconomic development, whichhas introduced biases in the equal-ity of opportunity for individualsfrom minority and indigenouspopulations. 7

(7) Thomas, VG.Explaining healthdisparities betweenAfrican-American andwhite populations:Where do we go fromhere? Journal of theNational MedicalAssociation, 1992,84(10):839-840;Navarro V. Race orclass versus race andclass: Mortalitydifferentials in theUnited States.Lancet, 1990,336:1238–1240.



(8) Gwatkin, 1999,World health report,Geneva, World HealthOrganization, 1999.

Photo: WHO/H. Anenden

3.2 Socioeconomicdeterminants

13 - Research shows that mortality ratesare higher for the poor than for therich at all ages. The differential is par-ticularly high during infancy andchildhood.8

14 - Segregation relegates certain seg-ments of the population to neigh-bourhoods with fewer resources,poorer services and a degradedhuman and physical environment.Populations subjected to discrimina-tion are more likely than others toinhabit areas affected by environ-mental pollution and degradation,and are more likely to be negatively

affected by lifestyle factors such asdiet, substance abuse (tobacco, alco-hol, and drugs), and social behaviour(violence and accidents).

15 - The educational situation has animpact not only in terms of the limitsit imposes on equitable access to thejob market and the perpetuation ofpoverty but also of its consequencesfor health. Studies show that themother’s education is an importantfactor in family health care (births inan institutional setting, medicalcheck-ups, etc.).

It is no coincidence that the idea toestablish a world health organizationemerged from the same process thatidentified the universal value of humanrights. WHO’s mandate is also univer-sal. Our constitution…stat[es] that “theenjoyment of the highest attainablestandard of health is one of the funda-mental rights of every human beingwithout 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

Declaration of Human Rights

1 1

1 2


16 - The fundamental principles ofequality and freedom from dis-crimination have been identifiedas key components in all mattersconcerning health. This includesnon-discrimination in access tohealth facilities, goods and servic-

es, paying partic-ular attention tothe most vulner-able or marginal-ized sections ofthe population.It also meansthat, to the extentpossible, healthfacilities, goodsand services must

be within safe physical reach for allparts of the population. Theyshould also be culturally appropri-ate — that is respectful of the cul-ture of individuals, minorities andindigenous populations — andsensitive to gender and life-cyclerequirements.

17 - The differences in the health situa-tion of minority and indigenousgroups, compared to the generalpopulation, are related to structuralfactors such as poverty, to factorsdirectly attributable to the organi-zation of health services and theirquality, and to the level of informa-tion available to the public regard-ing health and health care.

18 - Biases in the treatment of indigenousand ethnic minorities should be cor-rected through systematic effortsand a variety of mechanisms such astraining, skill-building and aware-ness-raising among health profes-sionals of the human rights implica-tions of their work, all of whichshould be backed up with appropri-ate policies and legislation.

19 - National policies and programmesneed to be planned and imple-mented with due regard for thelegitimate interests of personsbelonging to minorities. 9 Thisincludes respect for the beliefs,knowledge and language of thebeneficiaries, as well as attention totheir right to participate in mattersconcerning their health and devel-opment. In addition, health policyinstruments and programmes needto be developed by health sectorauthorities with an intersectoralperspective for effective targetingon indigenous peoples and ethnicminority communities in order toreduce health inequalities and inthe light of international humanrights obligations which areaddressed to government as awhole as prime duty-bearer.

20 - WHO notes with interest recommen-dations relating to discriminationand health, addressed to govern-ments, which have emerged fromthe preparatory process of the WorldConference. Notably, WHO wishesto draw attention to the following:

◆ The importance of increasedresearch into the impact of dis-crimination on access to health care.Routine monitoring of the situationof marginalized racial and ethnicgroups could be instituted throughperiodic sampling and compilationof statistical information disaggre-gated by race or ethnic group, par-ticularly with regard to such funda-mental heath indicators as infantmortality rate, life expectancy andaccess to health services. In thisregard, WHO concludes that fur-ther research be conducted toexplore the linkages between healthoutcomes and racism, racial dis-

4-Conclusions

(9) Article 5,Declaration on theRights of PersonsBelonging toNational or Ethnic,Religious orLinguistic Minorities,Adopted by GeneralAssembly resolution47/135 of 18December 1992, TheGeneral Assembly.

Photo: WHO/Armando Waak


crimination, xenophobia and relat-ed intolerance. Such research wouldinform and form the basis for coun-tries to take appropriate action. Itwould also help to differentiate therelative contribution of race versuspoverty in the causation of poorhealth outcomes.

◆ The need for comprehensive leg-islation, specifically prohibiting allforms of discrimination and provid-ing civil and criminal penalties andremedies in all spheres of public life,including in relation to health andhealth care. In addition, the need tostrengthen the capacity of govern-ments to review health-related lawsand policies to determine whetheron their face or application there isinherent discrimination. Similarly,governments should be supportedin developing national health legis-lation which conforms with theirhuman rights obligations.

◆ The need for central government,together with health sector authori-ties, to allocate sufficient financialresources in the national budget toensure adequate health prevention,promotion and care programmeswhich target indigenous peoplesand ethnic minority communities.

◆ The importance that institutionsresponsible for providing statisti-cal information on the populationtake explicit account of the exis-tence of indigenous peoples, peopleof varying descent and other ethnicgroups, capturing the componentparts of their diversity according totheir needs and characteristics,designing strategies to evaluate thehuman rights policies concerningethnic groups, and exchangingexperiences and practice with other

States. To that end, the develop-ment of participatory strategies forthese communities in the processesof collecting and using informationneed to be devised. On the basis ofexisting statistical information, theimportance of establishing nationalprogrammes, including affirmativeaction measures.

◆ The urging that measures betaken to eliminate disparities inhealth status experienced by disad-vantaged racial and ethnic groupsby the year 2010, including dispari-ties pertaining to health issues suchas malaria, tuberculosis, HIV/AIDS, cancer, cardiovascular dis-ease, diabetes, tobacco, maternalhealth, food safety, mental health,safe blood and health systems.

◆ The special emphasis to be put ongender issues and gender discrimi-nation, particularly the multiplejeopardy that occurs when gender,class, race and ethnicity intersect andthe importance of public policiesbeing adopted which give impetusto programmes on behalf of indige-nous women and ethnic minoritywomen, with a view to promotingtheir civil, political, economic, socialand cultural rights; to putting an endto this situation of disadvantage forreasons of gender; to dealing withurgent problems affecting them inhealth, including reproductivehealth and gender-based violence;and to ending the situation of aggra-vated discrimination they suffer aswomen in manifestations of racismand gender discrimination.

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Photo: WHO

1 4


◆ The need to consider situations ofchildren subjected to racial discrim-ination, especially those who findthemselves in circumstance of par-ticular vulnerability, such as aban-

doned children;children who liveor work in thestreet; child vic-tims of traffick-ing and econom-ic exploitation;sexually-exploit-ed children; chil-dren affected byarmed conflict,and child victimsof poverty, and,in this context,the importance ofcollecting and

analysing statistical data to assesshow policy and legislation affectchildren’s lives. In all matters con-cerning health and discriminationof children, the best interests of thechild shall prevail.

◆ The need to adopt measures toprovide a proper environment fordisadvantaged groups, includingaction to reduce and eliminateindustrial pollution that affectsthem disproportionately, to takemeasures to clean and redevelopcontaminated sites located in ornear where they live and, whereappropriate, to relocate, on a volun-tary basis and after consultationwith those affected, racially andethnically disadvantaged groups toother areas when there is no otherpractical alternative for ensuringtheir health and well-being.

◆ Public and private sector effortsare required to strengthen thecapacity of indigenous peoples’

representatives and minority com-munities to exercise their rights toparticipation. This requires skill-building in how to negotiate, aswell as how to access social andpolitical processes. The right ofindividuals and groups to active,free and meaningful participationin setting priorities, making deci-sions, planning, implementing andevaluating programmes that mayaffect their development is an inte-gral component of a rights-basedapproach to health.

21 - WHO looks forward to participatingin the World Conference AgainstRacism, Racial Discrimination,Xenophobia and Related Intolerancein South Africa and urges the Con-ference to consider the link betweenracial discrimination and health.Overall in the conference docu-ments, WHO stresses the impor-tance of including health wheneverother economic, social and culturalrights are mentioned, such as educa-tion, work and housing.

We inhabit a universe characterizedby diversity. There is not just one planetor one star, there are galaxies of differ-ent sorts, a plethora of animal species,different kinds of plants, and differentraces and ethnic groups. How can onehave a soccer team if all the membersof the team are goalkeepers? Howcould it be an orchestra if all membersplayed the French horn?

Archbishop Desmond Tutu speaking

at the Special Debate on Tolerance

and Respect during the 57th Session

of the United Nations Commission

on Human Rights, March 2001.



Variations in health andservice accessindicators: A regional perspective

WHO Regional Office for theAmericas has examined the ques-tion of variations in health andservice access indicators amongthe different ethnic groups in theAmericas in the light of availableempirical information.1

1. Studies in the USA indicatehealth disparities among the dif-ferent ethnic groups.2 For exam-ple, mortality is higher amongAfrican-Americans than amongthe white population: the twoleading causes of death in theUSA are cancer, with a ratio of 1:2,and cardiovascular diseases witha ratio of 1:6. African-Americansalso have higher infant mortalityrates and higher mortality fromdiabetes, homicide and HIV/AIDS. These studies also showevidence of higher mortalityfrom selected diseases in theAfrican-American population thanin other minority groups such asNative Americans and Hispanics.Another U.S. study recently con-firmed higher mortality amongAfrican-Americans in 107 citiesacross the country. 3

2. The information is not asconsistently available for the restof the Region, and the studies aremore sporadic. However, theresults coincide. For example,studies in Peru reveal high infantmortality rates in provinces with

higher concentrations of Afro-Peruvians, such as Piura (93 per1000 live births), Lambayeque (68per 1000), and Tacna (64 per1000), while the lowest rates arefound in Lima and El Callao(with 45 and 41 per 1000 respec-tively).4 In Panama, the probabil-ity of dying before completingthe first year of life is 3.5 timeshigher among indigenous chil-dren than among non-indige-nous children.5 Infant mortalityin Brazil, estimated with 1996data, reveals sharp disparities: 62per 1000 live births for the Afrogroup and 37 per 1000 amongwhites.6 Infant mortality indica-tors speak volumes: 16% ofwomen over the age of 15 havelost at least one child born alive.When analysed by ethnic group,the distribution is as follows: 33%of indigenous women over age15 have lost at least one child,whereas this figure was 19%among black women and 12.83%among white women.

3. In Guatemala, the data illus-trate that mortality amongindigenous children is higher.Neonatal mortality, mortality inchildren aged 0 to 1 year and mor-tality in children under 5 are high-er among the indigenous popula-tion (32 per 1000, 64 per 1000 and94 per 1000) than for the Latinopopulation (27 per 1000, 53 per1000 and 69 per 1000). Withrespect to total under-5 mortality,67.6% of these deaths correspondto the indigenous population and32% to the non-indigenous popu-lation, attributable to limitedaccess to health services. 7

4. Concerning access to insur-ance services, the studies show

that by 1986, 39% of Hispanics inthe USA had no coverage, a fig-ure three times higher than thatof whites and double that ofAfrican-Americans.8 In Guatemala,more than 70% of Guatemalanwomen receive some form of careat the time of delivery, but while50% of Latino women are caredfor by physicians, only 14.46% of indigenous women receivemedical care. Moreover, 87% ofindigenous women give birth inthe home, at an average age of 20to 25. In most of the Latin Ameri-can and Caribbean (LAC) Region,health services are highly con-centrated. In the outlying neigh-bourhoods of Caracas and Mara-caibo, the Afro-Venezuelan pop-ulation lacks services; healthworkers, in turn, do not want towork in the neighbourhoodswhere this population livesbecause of violence and a lack ofsecurity. 9 Other examples of lackof services and isolation concernblack communities on the PacificCoast of Colombia, in the Valle delChota or Esmerardas Province ofEcuador and in the Garífuna andCriollo communities of the SouthAtlantic Autonomous Region(RAAS) of Nicaragua.

5. Other significant statementscan be made regarding access tomodern health technologies.Compared to elderly white peo-ple, elderly African-Americans inthe USA see fewer specialists,receive less preventive care(mammograms, Pap smears) andpoorer quality hospital services,and lack access to sophisticatedtechnologies (for cardiovascularproblems, orthopaedic condi-tions, kidney transplants) and tointensive treatment programmes

Annex

1 5

for prostate cancer, immunodefi-ciencies and depression. Thesedisparities are also evident inother minority groups.10 There isno scientific evidence that thesedifferences are due to geneticcauses.11 Poverty, distance to serv-ices and lack of information arepossible explanations to these dis-parities. These factors may, in turn,be rooted in racial discrimination.

6. Data related to lifestyle andethnicity also shows significantimpact on health. With regard todeath attributable to violence inBrazil, the figure is 23.4% in theblack population (second leadingcause of death), while it is thefourth leading cause of death inthe white population, or less thanhalf (11.4%). 12

7. In Guatemala, the 1998National Survey on Maternal andChild Health revealed chronicand acute malnutrition amongindigenous children under 5. Thesurvey showed chronic malnutri-tion (height-for-age) of 67.8%among the indigenous popula-tion, while the corresponding fig-ure for the Latino populationgroup was 36.7%. Acute malnutri-tion (weight-for-age) is 34.6%among the indigenous popula-tion, while it is 20.9% among Lati-nos. Moreover, the percentage oflow birthweight is 9.94% forindigenous children and 8.94%for Latino. 13

8. In the context of examininghealth disparities among ethnicgroups, it is interesting to notealso that they are underrepre-sented within the medical profes-sion. For example, only 2% ofcardiologists in the USA are

African-American.14 In general,Brazilian data on the health pro-fession, such as physicians, den-tists and other specialists, revealsthe following distribution: 82.93%are white, 12.42% brown, and1.01% black. For medical auxil-iaries, the participation of minori-ty groups increases: 59.09% white,32.79% brown, and 7.6% black.

9. Finally, traditional medicinehas an important role to be consid-ered within the ethnic groups. Forexample, in Petit Goave (Haiti) halfof the population uses traditionalhealers (herbalists, midwives orsorcerers who practise voodoo). Inthis zone, there are 15 healers forevery 1000 people, while the ratioof physicians to population is 15per 10000.15

(1) Equity in Health: from an Ethnic Perspective,Dr. Cristina Torres, Regional Policy Advisor,WHO Regional Office for the Americas.(2) U.S. Department of Health, 1991; NickensHW. Race/ethnicity as a factor in health andhealth care. Health services research, 1995,Part II; 151–177.(3) Williams D. Race, socioeconomic status,and health: The added effects of racism anddiscrimination. Annals of the New YorkAcademy of Sciences, 1999, 986:173–188;Williams D. Race and health: Trends andpolicy implications (paper). Conference:Income on Equality, Socioeconomics Statusand Health, Washington, D.C., 2000; WilliamsD, House J. Understanding and reducingsocioeconomic and racial/ethnic disparitiesin health, Atlanta, Institute of Medicine of theNational Research Council, 2000.(4) Cowater International Inc. Comunidadesde Ancestria Africana en Costa Rica, Honduras,Nicaragua, Argentina, Colombia, Ecuador,Perú, Uruguay y Venezuela. Washington, D.C.,Banco Interamericano de Desarrollo, 1996.(5) Id.(6) FOASE. Housing, services, child health alllag far behind. Latin news (12):2000.(7) Valladares R, Barillas E. Inversiones ensalud, equidad y pobreza: Guatemala. TheWorld Bank, PNUD y PAHO, 1998.(8) Bollini, Siem. No real progress towardsequity: Health of migrants and ethnicminorities on the eve of the year 2000. Socialscience medicine, 1995, (41)6:819–828.(9) Cowater International Inc. Comunidadesde Ancestria Africana en Costa Rica, Honduras,Nicaragua, Argentina, Colombia, Ecuador,Perú, Uruguay y Venezuela. Washington, D.C.,Banco Interamericano de Desarrollo, 1996.(10) Fiscella K et al. Inequality in quality:Addressing socioeconomic, racial and ethnicdisparities in health care. Journal of theAmerican Medical Association, 2000,283(19):2579–2584.(11) Lillie-Blanton M, LaViest T. Race/ethnicity,the social environment and health. Socialscience and medicine, 1996, 43(1): 83–91.(12) Barbosa, da Silva MI. Racismo e saúde.São Paulo, Tese de doutorado, 1998.(13) Valladares R, Barillas E. Inversiones ensalud, equidad y pobreza, Guatemala. TheWorld Bank, PNUD y PAHO, 1998.(14) This information was provided by theAssociation of Black Cardiologists (ABC),Washington, D.C.(15) Clerismé C. Medicina tradicional ymoderna en Haití, Boletin de la OficinaSanitaria Panamericano OPS/OMS,Washington, D.C., Mayo 1985, 98:5,431–439.

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Photo: WHO/PAHO/Armando Waak

This document was produced by the World HealthOrganization: Department of Health and Development,Sustainable Development and Healthy EnvironmentsCluster, 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 rightsare 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 withcommercial 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








Health & Human RightsPublication Series Issue No. 2, August 2001

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


20, avenue Appia – 1211 Geneva 27 – Switzerland

Tel. (41) 22 791 2523 – Fax: (41) 22 791 4726

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“Vulnerable and marginalized groups in society bear an undueproportion of health problems. Many health disparities arerooted in fundamental social structural inequalities, which areinextricably related to racism and other forms of discriminationin society... Overt or implicit discrimination violates one of thefundamental principles of human rights and often lies at theroot of poor health status.”

The World Health Organization’s contribution to the WorldConference Against Racism, Racial Discrimination, Xenophobiaand Related Intolerance urges the Conference to consider thelink between racial discrimination and health, noting inparticular the need for further research to be conducted toexplore the linkages between health outcomes and racism,racial discrimination, xenophobia and related intolerance.

Cristina Torres Parodi

Regional Advisor in Health Policies Development

Public Policy and Health Program

Division of Health and Human Development

Pan American Health Organization/World Health Organization

525 23rd street, N.W.

Washington, D.C. 20037

Tel: 202-9743217

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WHO’s Contribution to the · Intolerance WHO’s Contribution to the Health & Human Rights Publication Series Issue No. 2, August 2001 ... English • Distribution: General World

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