The Health of the Indigenous Population in Mexico Carlos Zolla COMISIÓN NACIONAL PARA EL DESARROLLO DE LOS PUEBLOS INDÍGENAS – MEXICO, 2004

INDIGENOUS POPULATION IN MEXICO TOTAL POPULATION IN MEXICO, ,438,412 TOTAL POPULATION IN MEXICO, ,438,412 Population 5 years and older that speaks Population 5 years and older that speaks an Indigenous language (HLI) 6,044,547 an Indigenous language (HLI) 6,044,547 Population ages in homes where family head Population ages in homes where family head or partner speaks an Indigenous language 1,233,455 Do not speak an Indigenous language but feel Do not speak an Indigenous language but feel they are Indigenous (self-declared)(Sampling) 1,103,312 they are Indigenous (self-declared)(Sampling) 1,103,312 TOTAL REGISTERED INDIGENOUS POPULATION 8,381,314 TOTAL REGISTERED INDIGENOUS POPULATION 8,381,314 TOTAL ESTIMATE, INDIGENOUS POPULATION12,403,000 TOTAL ESTIMATE, INDIGENOUS POPULATION12,403,000

DISTINCTIVE CHARACTERISTICS OF THE INDIGENOUS POPULATION IN MEXICO The most numerous population in Latin America: 12,403,000. The most numerous population in Latin America: 12,403,000. Strong cultural and linguistic diversity: 86 languages and dialects are spoken in Mexico. Strong cultural and linguistic diversity: 86 languages and dialects are spoken in Mexico. 80% of the population lives in the Central-South- Southeastern states. 80% of the population lives in the Central-South- Southeastern states. There are big ethno-linguistic groups (nahuas, mayas, mixtecos, zapotecos, otomíes, tzeltales, tzotziles: between 1,400,000 y 300,000), and small groups: kiliwas, paipai, cochimí, kukapás, kikapús, with less than 500 people each. There are big ethno-linguistic groups (nahuas, mayas, mixtecos, zapotecos, otomíes, tzeltales, tzotziles: between 1,400,000 y 300,000), and small groups: kiliwas, paipai, cochimí, kukapás, kikapús, with less than 500 people each.

DISTINCTIVE CHARACTERISTICS OF THE INDIGENOUS POPULATION IN MEXICO The highest marginalization ratios in the country and a strong territorial dispersion. The highest marginalization ratios in the country and a strong territorial dispersion. They live in regions with important mining, touristic, biological, hydric, forestal, and eolic. Relevant handicrafts and a solid ancient culture. They live in regions with important mining, touristic, biological, hydric, forestal, and eolic. Relevant handicrafts and a solid ancient culture. Notably rich medical flora (the world’s second or third largest) and ample knowledge on traditional and home medicine. Notably rich medical flora (the world’s second or third largest) and ample knowledge on traditional and home medicine. Intense regional, national and international migration in the last years. Intense regional, national and international migration in the last years.

RURAL-URBAN DISTRIBUTION OF THE INDIGENOUS POPULATION IN MEXICO, % of the HLI live in rural areas (locations with less than 2,500 inhabitants) 65% of the HLI live in rural areas (locations with less than 2,500 inhabitants) 19% live in semi-urban areas (locations with more than 2,500 and less than 15,000 inhabitants) 19% live in semi-urban areas (locations with more than 2,500 and less than 15,000 inhabitants) 16% in urban areas (locations with more than 15,000 inhabitants) 16% in urban areas (locations with more than 15,000 inhabitants)

THE INDIGENOUS PEOPLES AND THEIR HABITAT Traditional rural areas Traditional rural areas Mexican cities Mexican cities Agroindustrial areas and their surroundings Agroindustrial areas and their surroundings Rural areas and cities in the United States of America and Canada Rural areas and cities in the United States of America and Canada

DISTRIBUTION OF THE INDIGENOUS POPULATION. Locations Locations with 70% and more of indigenous population: 17,436 Locations with 70% and more of indigenous population: 17,436 Locations with 70% and more of indigenous population and less than 100 inhabitants: 8,263 Locations with 70% and more of indigenous population and less than 100 inhabitants: 8,263 Locations with 40% - 69% of indigenous population and less than 100 inhabitants: 1,255 Locations with 40% - 69% of indigenous population and less than 100 inhabitants: 1,255 Locations with less than 40% of indigenous populaton and less than 100 inhabitants: 8,088 Locations with less than 40% of indigenous populaton and less than 100 inhabitants: 8,088 Total of locations with indigenous population and less than 100 inhabitants: 16,351 Total of locations with indigenous population and less than 100 inhabitants: 16,351 SOURCES: (CONAPO, INI, 2000a. ORDPI-INI, SSa, 2001a. SSa, 2001b. SERRANO CARRETO et al., 2002)

MARGINALIZATION OF THE INDIGENOUS POPULATION IN MEXICO, 2000 Total of indigenous municipalities or where indigenous population is present: 871 (100%) Total of indigenous municipalities or where indigenous population is present: 871 (100%) Indigenous municipalities with VERY HIGH MARGINALIZATION: 300 (37.4%) Indigenous municipalities with VERY HIGH MARGINALIZATION: 300 (37.4%) Indigenous municipalities with HIGH MARGINALIZATION: 407 (50.7%) Indigenous municipalities with HIGH MARGINALIZATION: 407 (50.7%) Indigenous municipalities with MEDIUM MARGINALIZATION: 79 (9.8%) Indigenous municipalities with MEDIUM MARGINALIZATION: 79 (9.8%) Indigenous municipalities with LOW MARGINALIZATION: 12 (1.5%) Indigenous municipalities with LOW MARGINALIZATION: 12 (1.5%) Indigenous municipalities with VERY LOW MARGINALIZATION: 3 (0.4%) Indigenous municipalities with VERY LOW MARGINALIZATION: 3 (0.4%)

MARGINACIÓN DE LA POBLACIÓN INDÍGENA. Vivienda Total of homes: 2,051,444 Total of homes: 2,051,444 Indigenous homes with tap water: 64.0% (National: 84.3%). Indigenous homes with tap water: 64.0% (National: 84.3%). Durango; 32.3%. Veracruz: 35.1%. San Luis Potosí: 36.2% Indigenous homes with electricity: 83.1% (National: 95.0%). Indigenous homes with electricity: 83.1% (National: 95.0%). Durango: 31.6%. Chihuahua: 31.9%. Nayarit: 51.1% Indigenous homes with dirt floor: 43.7% (National: 13.2%). Indigenous homes with dirt floor: 43.7% (National: 13.2%). Guerrero: 75%. Chiapas: 71.0%. San Luis Potosí: 70.9%. Indigenous homes with exclusive sanitary service: 73.6% (National: 85.9%). Indigenous homes with exclusive sanitary service: 73.6% (National: 85.9%). Guerrero: 36.8%. Nayarit: 37.5%. Durango: 46.3% Homes that cook with wood fire: 62.4 (Nacional: 17.2%). Homes that cook with wood fire: 62.4 (Nacional: 17.2%). San Luis Potosí: 85.8%. Chiapas: 85.7%. Guerrero: 83.8%.

MARGINALIZATION OF THE INDIGENOUS POPULATION. Income Monetary income of the indigenous population as a result of working (SMM: Monthly Minimum Wages)* Does not get paid for work: 25% Does not get paid for work: 25% Receives up to 2 SMM: 56% Receives up to 2 SMM: 56% Receives more than 2 SMM: 19% Receives more than 2 SMM: 19% * 1, pesos = dollars

MARGINALIZATION OF THE INDIGENOUS POPULATION. Illiteracy in municipalities with indigenous population Percentage of illiteracy amongst people 15 years and older: 25% Women: 32% Women: 32% Men: 18% Men: 18% Illiterate HLI women: 43.3% Illiterate HLI women: 43.3% Non illiterate HLI women: 10.4% Non illiterate HLI women: 10.4% Illiterate HLI men: 23.4% Illiterate HLI men: 23.4% Non illiterate HLI men: 6.7% Non illiterate HLI men: 6.7%

MARGINALIZATION OF THE INDIGENOUS POPULATION. Backwardness in Education

MARGINALIZATION OF THE INDIGENOUS POPULATION. Health Life expectancy seven years less than the rest of the population (69/76) Life expectancy seven years less than the rest of the population (69/76) High chronic malnutrition ratios High chronic malnutrition ratios Predominant infectious diseases (intestinal infections, influenza, pneumonia, pulmonary tuberculosis) Predominant infectious diseases (intestinal infections, influenza, pneumonia, pulmonary tuberculosis) General, childhood, preschool, school-age and maternal mortality higher than in national population General, childhood, preschool, school-age and maternal mortality higher than in national population Persistence of the so-called residual diseases (for example tracoma, in Chiapas) Persistence of the so-called residual diseases (for example tracoma, in Chiapas) Predominant “poverty pathology” (Cholera, malaria, dengue fever, lepra, etc) Predominant “poverty pathology” (Cholera, malaria, dengue fever, lepra, etc)

INFANT MORTALITY RATE, BY INDIGENOUS LANGUAGE SPEAKERS, Speaks an indigenous languageDoes not speak an indigenous language / / / / / / / / / / / / 1000 Sources: CONAPO, La situación demográfica en México, 1998 y Programa Nacional de Población,

INFANT MORTALITY BY ETHNOLINGUISTIC GROUP (Deaths for each 1000) Maya37.9 Maya37.9 Otomí40.1 Otomí40.1 Zapoteco40.4 Zapoteco40.4 Mazahua44.7 Mazahua44.7 Chol47.2 Chol47.2 Náhuatl48.3 Náhuatl48.3 Tzoltzil52.6 Tzoltzil52.6 Other53.3 Other53.3 Tzeltal 53.4 Tzeltal 53.4 Huasteco53.6 Huasteco53.6 Mazateco55.6 Mazateco55.6 Mixteco56.2 Mixteco56.2 Totonaca57.0 Totonaca57.0 NATIONAL24.9 (Between 21.0 and 22.0, for 2002) NATIONAL24.9 (Between 21.0 and 22.0, for 2002) Sources: CONAPO, La situación demográfica en México, 1998 y Programa Nacional de Población,

PRESCHOOL AND SCHOOL-AGE MORTALITY IN THE INDIGENOUS POPULATION. Relative weight of deaths Pre-school mortality (1 - 5 years) Pre-school mortality (1 - 5 years) National: 12%Indigenous: 19% School age mortality ( years) School age mortality ( years) National: 1.8% Indigenous: 3.3% Source: SSa, 2001 Source: SSa, 2001

MALNUTRITION IN INDIGENOUS POPULATIONS Chronic malnutrition in girls and boys: delay in growth (small for their age) in almost half (44%) of the population (17.7% national) Chronic malnutrition in girls and boys: delay in growth (small for their age) in almost half (44%) of the population (17.7% national) Micronutrient deficiency and anaemia (36% indigenous; 27% non indigenous) Micronutrient deficiency and anaemia (36% indigenous; 27% non indigenous) Important deficiencies in iron, zinc, vitamins C and A (between 12 and 50% of the indigenous children) Important deficiencies in iron, zinc, vitamins C and A (between 12 and 50% of the indigenous children) Four of ten pregnant women have anaemia (almost twice as many than in the general population) Four of ten pregnant women have anaemia (almost twice as many than in the general population)

MORTALITY BY SELECTED CAUSES.* NATIONAL AND INDIGENOUS CAUSE NATIONALINDIGENOUS _______________________________________________________ Diabetes mellitus3616 Diabetes mellitus3616 Tumors5333 Tumors5333 Heart disease6946 Heart disease6946 Cirrhosis2423 Cirrhosis2423 Pneumonias2229 Pneumonias2229 Tuberculosis49 Tuberculosis49 Maternal414 Maternal414 Diarrhea1134 Diarrhea1134 *Rate for each 100,000 inhabitants Source: SSa, 2001

The ten main causes of health care needs referred by traditional therapists from traditional medicine in the 3,025 areas covered by the Program IMSS-COPLAMAR Cause of health care need% 1. “Mal de ojo” (witchcraft) Digestive disorders Scare-Ghost “Caída de mollera” Dysentery Air Diarrhea Sprains (musculoskeletal) Harm (witchcraft) Anginas 9.98 Source: ZOLLA, Carlos et al. Diccionario enciclopédico de la medicina tradicional mexicana, México, INI, 2000, 2 vols.

THE NATIONAL HEALTH SYSTEM - MEXICO Secretariat of Health (SSa)* Secretariat of Health (SSa)* Instituto Mexicano del Seguro Social (IMSS)* Instituto Mexicano del Seguro Social (IMSS)* Instituto de Salud y Seguridad Social para los Trabajadores del Estado (ISSSTE) Instituto de Salud y Seguridad Social para los Trabajadores del Estado (ISSSTE) Secretariat of National Defense (SEDENA) Secretariat of National Defense (SEDENA) Marine Secretariat (SEDEMAR) Marine Secretariat (SEDEMAR) Petróleos Mexicanos (PEMEX) Petróleos Mexicanos (PEMEX) * They have care schemes for “open population”, not affiliated to social security schemes. IN the case of IMSS, a through the program IMSS-Oportunidades

THE HEALTH SYSTEM AS AN ORGANIZED SOCIAL RESPONSE We perceive the health system as a kind of organized social response to face the impact of disease, accidents, imbalance or death.

THE HEALTH SYSTEM - MEXICO ACADEMIC, MODERN OR ALLOPATHIC MEDICINE (Institutional and private) ACADEMIC, MODERN OR ALLOPATHIC MEDICINE (Institutional and private) DOMESTIC OR HOME MEDICINE DOMESTIC OR HOME MEDICINE TRADITIONAL MEXICAN MEDICINE (Traditional Indigenous Medicine) TRADITIONAL MEXICAN MEDICINE (Traditional Indigenous Medicine) HOMEOPATHIC MEDICINE HOMEOPATHIC MEDICINE ALTERNATIVE OR COMPLEMENTARY MEDICINE (Acupuncture, Naturopathy, Digitopuncture, Iridiology, etc) ALTERNATIVE OR COMPLEMENTARY MEDICINE (Acupuncture, Naturopathy, Digitopuncture, Iridiology, etc)

THE HEALTH SYSTEM IN MEXICO MA MT MD HMTCH A - D N

THE REAL HEALTH SYSTEM IN THE INDIGENOUS REGIONS IN MEXICO ACADEMIC INSTITUTIONAL OR PRIVATE MEDICINE (Secretaría de Salud, Programa IMSS- OPORTUNIDADES) ACADEMIC INSTITUTIONAL OR PRIVATE MEDICINE (Secretaría de Salud, Programa IMSS- OPORTUNIDADES) TRADITIONAL INDIGENOUS MEDICINE (Healers, midwives, herbal healers, bone healers, prayers, snake people, etc) TRADITIONAL INDIGENOUS MEDICINE (Healers, midwives, herbal healers, bone healers, prayers, snake people, etc) HOME OR DOMESTIC MEDICINE (mainly housewives) HOME OR DOMESTIC MEDICINE (mainly housewives)

THE HEALTH SYSTEM IN THE INDIGENOUS REGIONS WITH INSTITUTIONAL SERVICES Academic Medicine (MA) Traditional Medicine (MT) Home or Domestic Medicine (MT)

IT IS IMPORTANT TO OBSERVE THE RELATIONSHIP BETWEEN DOMESTIC OR HOME MEDICINE, TRADITIONAL MEDICINE AND ACADEMIC OR ALLOPATHIC MEDICINE WITHIN THE REAL HEALTH SYSTEM MA MT MD

It is the population that associates the different health models in reality and uses them as a complement. MA MT MD

Locations (17,859) Have health services: 2,064 (11.6%) Have health services: 2,064 (11.6%) Have access to health services: 6,227 (34.9%) Have access to health services: 6,227 (34.9%) Do not have access to health services: 9,559 (53.6%) Do not have access to health services: 9,559 (53.6%) Population (4,403,986) Have health services: (1,721,032): 39.1% Have health services: (1,721,032): 39.1% Have access to health services: 1,205,884 (27.4%) Have access to health services: 1,205,884 (27.4%) Do not have access to health services: 1,477,070 (33.5%) Do not have access to health services: 1,477,070 (33.5%) *Locations with 40% and more HLI **Unidades de la SSa e IMSS-Oportunidades. Se tiene acceso cuando la unidad está a menos de 2,500 m. de la localidad. PERCENTAGE OF DISTRIBUTION OF LOCATIONS AND POPULATION IN THE RURAL INDIGENOUS LOCATIONS* BY ACCESS TO HEALTH SERVICES**, 2000

PERCENTAGES OF DISTRIBUTION OF THE LAST CHILDREN BORN ALIVE BY AGENT WHO ASSISTED THE MOTHER DURING DELIVERY, BY CONDITION OF INDIGENOUS LANGUAGE Speaks an Indigenous Language Does not speak an I. L. Doctor: 25.4%64.6% Doctor: 25.4%64.6% Nurses: 2.2% 2.8% Nurses: 2.2% 2.8% Midwife: 57.2%28.7% Midwife: 57.2%28.7% Others: 2.0% 1.3% Others: 2.0% 1.3% Family or friend: 8.5% 1.4% Family or friend: 8.5% 1.4% Nobody: 4.7% 1.2% Nobody: 4.7% 1.2% Source: Encuesta de Salud Reproductiva en el Ámbito de IMSS- Solidaridad, 1999, CONAPO, 2004.

THE REAL HEALTH SYSTEM IN INDIGENOUS REGIONS WITHOUT INSTITUTIONAL SERVICES DOMESTIC OR HOME MEDICINE TRADITIONAL MEDICINE

FACTORS THAT HAVE FOSTERED EMIGRATION OF THE INDIGENOUS POPULATION IN THE LAST 20 YEARS (I) FactorsAffected region or indigenous groups ECOLOGICAL  Low land productivity  Oaxaca, la Montaña de Guerrero, r mazahua-otomí region, and Sierra Tarahumara  Climatological phenomena: draughts, freezing, hurricanes  Sierra Tarahumara and regions close to the coast  Wasted time in the temporary agricultural cycle of the place of origin  Practically all regions  Changes in the productive quality of the soil caused by monoculture and other causes of ecological degradation  Yucatán, totonaca region in Veracruz, Huastecas, petroleum areas in Veracruz and Tabasco, and Sierra Norte de Puebla

FACTORS THAT HAVE FOSTERED EMIGRATION OF THE INDIGENOUS POPULATION IN THE LAST 20 YEARS (II) FactorsAffected region or indigenous groups LAND OWNERSHIP  Problems with agrarian distribution or lack of land ownership  Huastecas, Chiapas and Huicot area  Land used for raising cattle  Huastecas, totonaca de Veracruz and Chiapas  Forced sale of cooperative lands and change in the use of the soil with development goals (dams, railroads, factories, and roads)  Petroleum zones in Veracruz, zona nahua, mazahua and otomí, State of Mexico, Tehuantepec Isthmus, Sierra Tarahumara, zona nahua in Guerrero and Papaloapan region

FACTORS THAT HAVE FOSTERED EMIGRATION OF THE INDIGENOUS POPULATION IN THE LAST 20 YEARS (III) FactorsAffected region or indigenous groups CRISIS IN PRICES OF AGRICULTURAL PRODUCTS  Lower costs for coffee, agave fiber, sugar, tobacco, cocoa, orange, tomato, avocado and others  Chiapas, las Huastecas, chocho-mixteca- popoluca region, Sierra Norte de Puebla, region in Veracruz, nahua region in Oaxaca and Puebla, nahua region in Veracruz, chontal zone in Tabasco, Huicot region, and Yucatán Peninsula  Demand for agave fiber cancelled  Yucatán Peninsula  Lower demand for palm tree products because of products made of plastic or synthetic fibers  Montaña de Guerrero, Sierra Tarahumara, and Oaxaca  Lower demand for products that are produced at a very small scale by indigenous people: ceramics, palm tree products, regional fruit, wooden objects, regional candy, etc.  Practically all regions

STRATEGIC GUIDELINES FOR HEALTH CARE FOR AND WITH INDIGENOUS POPULATION Foster the tasks of designing, promotion and implementation of a NEW STATE POLICY specifically oriented towards improving the health situation and the living conditions of the indigenous population Foster the tasks of designing, promotion and implementation of a NEW STATE POLICY specifically oriented towards improving the health situation and the living conditions of the indigenous population Promote the implementation of an INTER-CULTURAL HEALTH CARE MODEL (MIAS) for the indigenous population Promote the implementation of an INTER-CULTURAL HEALTH CARE MODEL (MIAS) for the indigenous population Promote the creation of an INFORMATION SYSTEM that allows periodic health diagnoses of the indigenous population Promote the creation of an INFORMATION SYSTEM that allows periodic health diagnoses of the indigenous population

STRATEGIC GUIDELINES FOR HEALTH CARE FOR AND WITH INDIGENOUS POPULATION Guarantee full access to health care services for all the indigenous population (mainly SSa [Sistema de Protección Social en Salud/Seguro Popular de Salud], IMSS-Oportunidades). Guarantee full access to health care services for all the indigenous population (mainly SSa [Sistema de Protección Social en Salud/Seguro Popular de Salud], IMSS-Oportunidades). Promote and develop local resources for health, especially traditional indigenous medicine. Promote and develop local resources for health, especially traditional indigenous medicine. Formulate a MONITORING SCHEME of health actions as part of the evaluation and follow-up tasks of public action with the indigenous population, assigned by law to the Comisión Nacional para el Desarrollo de los Pueblos Indígenas. Formulate a MONITORING SCHEME of health actions as part of the evaluation and follow-up tasks of public action with the indigenous population, assigned by law to the Comisión Nacional para el Desarrollo de los Pueblos Indígenas.