exclu salud en chiapas, méxico ded la situación …...excluded people, eroded communities...

EXCLUDED PEOPLE, ERODED COMMUNITIESRealizing the Right to Health in Chiapas, Mexico

A report by:Physicians for Human Rights

El Colegio de la Frontera Sur

Centro de Capacitación en Ecología ySalud para Campesinos-Defensoría delDerecho a la Salud

PUEBLOS EXCLUIDOS, COMUNIDADES EROSIONADASLa situación del derecho a lasalud en Chiapas, México

Un informe de:Physicians for Human Rights

El Colegio de la Frontera Sur

Centrode Capacitación en Ecología ySalud paraCampesinos-Defensoría delDerecho a la Salud

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EXCLUDED PEOPLE, ERODED COMMUNITIESRealizing the Right to Health in Chiapas, Mexico

© 2006 Physicians for Human Rights, El Colegio de la Frontera Sur, Centro de Capacitación en Ecología y Saludpara Campesinos-Defensoría del Derecho a la Salud All rights reserved.Printed in the United States of America. ISBN: 1-879707-49-7Library of Congress Control Number: 2006905229Cover Photo: José Angel RodríguezDesign: Glenn Ruga, Visual Communications, www.vizcom.org

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Maps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv

Glossary of Terms and Acronyms . . . . . . . . . . . .v

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . .vii

I. Executive Summary . . . . . . . . . . . . . . . . . . . . . . .1

II. Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Chiapas and the Study Area Historical Context: Pre-1994Post-Uprising: The Emergence of Civil Resistance1995-2000: The Government’s Response 2000-2005: Change in the Government and More ofthe Same

III. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Identification of Study PopulationSamplingConsent Questionnaires and SurveyStatistical Analysis

IV. Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Selected Demographic, Socio-economic and Ethno-linguistic Indicators Selected Social Determinants of Health

EducationShelter and Housing ConditionsWater and Sanitation

Maternal HealthPrenatal CareUse of Delivery Care ServicesMaternal Mortality in the Previous Two Years

Child HealthChildhood MalnutritionInfant MortalityVaccination

Pulmonary Tuberculosis among Persons Age Fifteen and OlderAvailability, Accessibility, Acceptability, Quality and Use of Health Services for Self-reported Illness in the Month Prior to the Study Limitations and Implications for Interpretation of Findings

V. The Framework of the Right to Health . . . . . .41under International and Domestic LawIntroduction to International Norms and Status ofMexico’s ObligationsPrinciples Characterizing a Human RightsApproach to Health and How They Apply to theConflict Zone in Chiapas

Non-retrogression and Adequate ProgressNon-discrimination and EquityMeaningful Popular ParticipationMulti-sectoral Strategies Accountability

VI. Recommendations to the . . . . . . . . . . . . . . . . .55Mexican Government

Appendix: San Andrés Accords . . . . . . . . . . . .57

CONTENTS

MAPS

Areas of Chiapas in which Study Occurred(“conflict zone”)

Chiapas, in Relation to Mexico (with conflict zoneenlarged)

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GLOSSARY OF TERMS AND ACRONYMS

Autonomous Councils: Governing councils of the“autonomous” EZLN-supporting communities.

Campesino: Rural worker, typically agricultural, oftentranslated as “peasant.”

CCESC: Center for Training in Ecology and Health forCampesinos (Centro de Capacitación en Ecología ySalud para Campesinos).

CDHFBC: Fray Bartolomé de las Casas Center forHuman Rights.

CIEPAC: Centre for Research on Economic and PoliticalCommunity Action (Centro de InvestigacionesEconómicas y Políticas de Acción Comunitaria).

CONAPO: National Council on Population (ConsejoNacional de Población).

CONPAZ: Coordinating Body of Non-GovernmentalOrganizations for Peace (Coordinación de Organismosno gubernamentales por la Paz).

DDS: Right to Health Defense Group (Defensoría delDerecho a la Salud).

ECOSUR: The College of the Southern Border, an aca-demic and research institution (El Colegio de la Fron-tera Sur).

ENAL: National Survey on Food and Nutrition(Encuesta Nacional de Alimentación y Nutrición).

ENN: National Survey on Nutrition (Encuesta Nacionalde Nutrición).

EZLN: Zapatista Army for National Liberation (EjércitoZapatista de Liberación Nacional).

ICRC: International Committee of the Red Cross.

IMSS: Mexican Institute for “Social Security” or work-related health insurance (Instituto Mexicano delSeguro Social).

IMSS-OPORTUNIDADES: Government health programaimed at providing health care to people living inextreme poverty in rural areas. This program is admin-istered through IMSS, although it targets the uninsuredpopulation. This program was first created as IMSS-COPLAMAR and, under President Salinas, it was thenrenamed IMSS-Solidaridad in the late 1980s. PresidentFox changed the name to IMSS-OPORTUNIDADES aftertaking office in 2000.

IMSS-SOLIDARIDAD: The health branch of Solidaridad,it is managed by the Mexican Institute for Social Secu-rity and funded by general government revenues. IMSSprovides administrative direction.

INEGI: National Institute for Geographic Statistics andInformation (Instituto Nacional de EstadísticaGeografía e Informática).

ISECH: State of Chiapas Health Institute, responsible forproviding health services to the uninsured population ofChiapas (Instituto de Salud del Estado de Chiapas).

OPORTUNIDADES: Former name of PROGRESA. A gov-ernment anti-poverty program providing householdswith cash transfers linked to regular school attendanceand health clinic visits.

PAN: National Action Party, center-right political partywhich President Fox represented in the 2000 presiden-tial elections (Partido Acción Nacional).

PHR: Physicians for Human Rights.

PRD: Party of the Democratic Revolution, center-leftopposition political party (Partido de la RevoluciónDemocrática).

PRI: Institutional Revolutionary Party, party that ruledMexico for seventy-five uninterrupted years and stillgoverns in many state and local areas (Partido Revolu-cionario Institucional).

PRONASOL: National Solidarity Program (ProgramaNacional de Solidaridad), successor of COPLAMAR,was established by President Salinas in 1988 and also

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served as an umbrella organization to promote healthcare, education and basic infrastructure.

PROGRESA: Program for Education, Health and Nutri-tion for Rural and Urban Poor (Programa de Educación,Salud y Alimentación); was implemented in 1997 byPresident Zedillo’s government as a program for devel-oping the human capital of poor households.

PTB: Pulmonary Tuberculosis.

Región Altos: Mountainous region in the central high-lands of Chiapas. It has the highest concentration ofindigenous people in Chiapas and the highest levels ofpoverty in the country.

Región Norte: A mostly Chol-speaking area in thenorth of Chiapas that borders the state of Tabasco; for-merly jungle, it is now largely used for cattle grazing.

Región Selva: Region of Chiapas close to the borderwith Guatemala, which previously was almost entirelyrainforest.

Resistance: The Zapatista form of civil disobedience,which emerged after political negotiation between the

EZLN and federal government failed. In its pure form, itcalls for the refusal of collaboration with the Govern-ment and rejection of official programs, including thosefor health and education.

SSA: Ministry of Health (Secretaría de Salud).

Seguro Popular: Popular Insurance. The new federalprogram to provide health insurance coverage to theuninsured, created by the Fox administration.

SOLIDARIDAD: Solidarity for Social Well-being (Soli-daridad para el Bienestar Social) was previously theservice aspect of PRONASOL. It contained a wide rangeof programs that included education, health care,water, sewerage, and electrification projects; urban-ization improvements; and low-income housing.

UNDP: United Nations Development Programme.

UNICEF: United Nations Children’s Fund.

WHO: World Health Organization.

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ACKNOWLEDGMENTS

This report was written by: Héctor Javier SánchezPérez, PhD, Researcher at El Colegio de la Fron-tera Sur (ECOSUR); Marcos Arana Cedeño, MD,

Researcher at the Instituto Nacional de Ciencias Médi-cas “Salvador Zubirán” y Nutrición and Director of Cen-tro de Capacitación en Ecología y Salud paraCampesinos-Defensoría del Derecho a la Salud(CCESC-DDS); and Alicia Ely Yamin, JD, MPH, Directorof Research and Investigations at Physicians for HumanRights (PHR), based on a study conducted by Dr.Sánchez Pérez, Dr. Arana Cedeño, and Douglas Ford,JD, former Program Associate at PHR.

Above all, the authors and their respective institu-tions are indebted to the people and to the communityauthorities, who in the midst of a prevailing climate ofsuspicion in the conflict zone in Chiapas, gave theirtrust and participated in this study.

Mr. Ford and Kerri Sherlock, former PHR ProgramAssistant, were pivotal to the conception and develop-ment of the project as well as to the compilation of theinformation gathered. PHR, ECOSUR and CCESC-DDSare also grateful to the following individuals who con-ducted the household surveys and interviews with ded-ication and persistance, as well as the codification ofresponses, data entry and verification of consistency ofdata: Guadalupe Vargas Morales, Herlinda MéndezSantiz, Angelina Pérez Díaz, Ambrosia López Santiz,Florinda Sántiz Gómez, Hipólito Román Martínez Flo-res, Delimo López Santiz , Roberto Carlos Díaz de losSantos, Alfonso Hernández Girón, Juan Carlos NájeraOrtiz, Roberto Sólis Hernández, Julio César Arias Gar-cía, Adriana Ríos González, Jorge Alejandro FloresHernández, Blanca Coello Zepeda, Raymundo Mijan-gos, Norma Guadalupe Pérez, Veraya Estudillo andRaquel Flores Flores. Barbara Sheffels provided trans-lation and background research. Victor Penchaszadeh,MD, Professor at the Mailman School of Public Health,offered helpful guidance in initial phases. PaulaBrentlinger, MD, MPH, Clinical Assistant Professor,Department of Health Services, School of Public Healthand Community Medicine, University of Washington andMiguel Hernán, MD, PhD, MPH, MSc, Assistant Profes-sor of Epidemiology, Department of Epidemiology, Har-vard School of Public Health, together with Mark Micek,

MD, MPH, Clinical Assistant Professor of the Depart-ment of Health Services, School of Public Health andCommunity Medicine, University of Washington, playedcritical roles in the design of the survey and the analy-sis of the data. Christian Courtis, JD, Professor at theInstituto Tecnológico Autónomo de México, providedincisive comments on portions of the legal analysis. Fr.David Velasco and Lic. Luisa Pérez, of the Centro deDerechos Humanos Miguel Agustín Pro Juárez andFabián Sánchez Matus, Director of the Comisión Mexi-cana de Defensa y Promoción de los DerechosHumanos, both in Mexico City, offered crucial contex-tual information and advice. Amelia Runyon, master’sstudent at Fletcher School of Law and Diplomacy, pro-vided essential research assistance and guided thepreparation of the report. Jessica Cole, ResearchAssistant at PHR, contributed to the many details thatneeded to be addressed in the final report. Finally, thisreport would not have come to fruition but for theextreme dedication of Annis Graetz, who translateddrafts on multiple occasions and lent support to PHR,ECOSUR and CCESC-DDS at every level of substanceand process.

The report was reviewed by: Fabián Sánchez Matus,Director of the Comisión Mexicana de Defensa y Pro-moción de los Derechos Humanos; Leonard Ruben-stein, JD, PHR Executive Director; Susannah Sirkin,MEd, PHR Deputy Director; Gina Cummings, PHRDeputy Director for Operations; Barbara Ayotte, PHRDirector of Communications; Frank Davidoff, MD, for-mer editor of the Annals of Internal Medicine and PHRBoard member; Felton Earls, MD, Professor of SocialMedicine, Harvard Medical School and PHR Boardmember; Carola Eisenberg, MD, Lecturer on SocialMedicine, Harvard Medical School and PHR Boardmember; Judge Richard Goldstone, PHR Board mem-ber; Dr. Brentlinger; and Dr. Hernán. The final reportwas copyedited by Caitriona Palmer and was preparedfor publication by Ms. Ayotte.

Support for this report was provided by the GeneralServices Foundation and Ayuntamiento Barcelona,España, through the Instituto Municipal de la Salud,Programa Barcelona Solidaria.

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Physicians for Human RightsPhysicians for Human Rights (PHR) mobilizes healthprofessionals to advance the health and dignity of allpeople through action that promotes respect for, pro-tection of, and fulfillment of human rights.

Since 1986, PHR members have worked to stop tor-ture, disappearances, and political killings by govern-ments and opposition groups and to investigate andexpose violations, including: deaths, injuries, andtrauma inflicted on civilians during conflicts; sufferingand deprivation, including denial of access to healthcare, caused by ethnic and racial discrimination; men-tal and physical anguish inflicted on women by abuse;exploitation of children in labor practices; loss of life orlimb from landmines and other indiscriminateweapons; harsh methods of incarceration in prisonsand detention centers; and poor health stemming fromvast inequalities in societies.

As one of the original steering committee membersof the International Campaign to Ban Landmines, PHRshared the 1997 Nobel Peace Prize.

www.phrusa.org

El Colegio de la Frontera SurEl Colegio de la Frontera Sur is a multidisciplinary pub-lic research and post-graduate educational institution,which focuses on development and cross-borderissues on the southern border of Mexico. Its programsare oriented towards the generation of scientificknowledge, training human resources, and the designof techniques and strategies that contribute to sustain-able development.

Centro de Capacitación en Ecología ySalud para CampesinoCCESC-DDS (Centro de Capacitación en Ecología ySalud para Campesino) was created in 1985 to supportthe work of physicians and researchers during thehumanitarian emergency that followed the eruption ofthe Chichonal volcano, and to attend to the healthneeds of Guatemalan refugees and internally displacedpopulations. The Right to Health Defense Groupmerged with CCESC more recently. In 2005, CCESCreceived the Sasakawa Award at the World HealthAssembly for its more than 20 years of work on behalfof the indigenous communities of Chiapas.

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I. EXECUTIVE SUMMARY

This report analyzes health conditions and accessto care in the conflict zone in the southern state ofChiapas, taking into account the Mexican govern-

ment’s obligations to respect, protect and fulfill theright to health of all its citizens — including its mostmarginalized indigenous populations. The report foundalarmingly high rates of childhood malnutrition, pul-monary tuberculosis and maternal mortality, inade-quate living conditions, lack of access to potable waterand basic sanitation, and significant barriers to care.Ensuring the right to health in Chiapas for people of allpolitical affiliations is not a peripheral or merelyhumanitarian concern. Rather, it is a matter of justice.As the United Nations (UN) Millennium Project TaskForce Report on Child Health and Maternal Healthstates: “health claims—claims of entitlement to healthcare and enabling conditions—are assets of citizen-ship.”1 With the approach of the 2006 elections, Mexicohas a historic opportunity to confront the unacceptablehealth and social situation in the conflict zone in Chia-pas as well as to revisit reforms to enable indigenouspeople in Chiapas and elsewhere in Mexico to partici-pate as truly equal citizens in a substantive democracy.

Although the report discusses findings of a particu-lar study conducted by Physicians for Human Rights(PHR), El Colegio de la Frontera Sur (ECOSUR) and elCentro de Capacitación en Ecología y Salud paraCampesinos-Defensoría del Derecho a la Salud(CCESC-DDS) in the conflict zone, many of the findingsof this report are directly related to central humanrights issues facing Mexico today. The conflict zone inChiapas dramatically illustrates the effects of milita-rization and violence on the provision and use of healthcare services, as well as on health status. Guerrero,Oaxaca and other states of Mexico have also sufferedfrom the impact of militarization and violence. The dis-criminatory allocation and exploitation of health andother social services for political ends, which is docu-mented in this report, is not exclusive to Chiapas andcontinues to pervade Mexican society even after theend of more than seventy years of uninterrupted rule bythe PRI party. Finally, the multiple dimensions of exclu-sion faced by indigenous peoples in Chiapas are mir-

rored in the health and social conditions of indigenouspeoples across the country. This exclusion reflects thechallenges the country faces in building a genuinelyinclusive, equitable democracy.2

Historical BackgroundOn New Year’s Day in 1994, the Zapatista Army forNational Liberation (EZLN or Zapatistas) staged anarmed uprising in Chiapas, Mexico on behalf of theindigenous populations of the state whose rights, inparticular economic and social rights, they claimed tobe defending. Poor health conditions and services forthe indigenous communities of Chiapas were an under-lying cause of the Zapatista rebellion. After the intensecombat that took place between the EZLN and the Mex-ican Federal Army during the first twelve days of 1994,a low-intensity conflict evolved and essentially hasremained in force over a decade later. As documentedin PHR’s 1999 report, health care came to be heldhostage between the Zapatistas’ practice of “resist-ance,” which was a concerted policy of rejecting gov-ernmental programs, including health programs, onthe one hand, and the government’s politicized provi-sion of health services on the other. 3

In 2000-01, the Mexican institutions, El Colegio de laFrontera Sur (ECOSUR) and el Centro de Capacitaciónen Ecología y Salud para Campesinos-Defensoría delDerecho a la Salud (CCESC-DDS), joined together on acollaborative study with Physicians for Human Rights(PHR), which had issued three previous reports relatingto Chiapas since the EZLN uprising. ECOSUR, CCESC-DDS and PHR carried out a population-based study toassess health conditions, nutrition, and access to anduse of health services, as well as to evaluate how theintra- and inter- community tensions spawned by thelow-intensity conflict affected people’s health and atti-tudes about health services. It was beyond the scope of

1 “Who’s got the power: transforming health systems for women andchildren.” Millennium Project Task Force Report on Child Health andMaternal Health; 2005. 11.

2 See e.g. Lozano R, Zurita B, Franco F, Ramírez T, Hernández P, Tor-res JL. “Mexico: Marginality, Need, and Resource Allocation at theCountry Level.” In: Evans T, Whitehead M, Diderichsen F, Bhuiya A,Wirth M, eds. Challenging Inequities in Health: From Ethics toAction. New York: Oxford University Press; 2001:271-295.

3 Yamin AE, Penchaszadeh V, Crane T, Health Care Held Hostage:Violations of Medical Neutrality and Human Rights in Chiapas, Mex-ico. Boston: Physicians for Human Rights, 1998.

2 R E A L I Z I N G T H E R I G H T T O H E A L T H I N C H I A P A S , M E X I C O

this study to determine the precise impact of the conflictper se on health status. Subsequently, data collected inthe study has been supplemented by more recentnational statistics, human rights and policy informationto help examine health conditions, as well as availabilityand use of services, in light of Mexico’s obligationsunder international law with respect to the right tohealth. 4

Allocation of Health Resources andHealth IndicatorsMexico is a middle-income country and a member ofthe Organization for Economic Cooperation and Devel-opment (OECD). However, Mexico’s total health spend-ing accounted for 6.2% of Gross Domestic Product(GDP) in 2003, which places it among the OECD coun-tries with the lowest expenditure on health. Of all OECDcountries, Mexico has the second lowest share ofhealth spending paid for by public sources, whichmeans that people are paying out-of-pocket for theirhealth care.5 Moreover, Mexico is highly unequal interms of both income distribution and allocation ofhealth resources. For example, Mexico is ranked as the15th most unequal country in the world according to theUnited Nations Development Programme’s GINI index,which makes it more unequal than Mali, Niger andZambia.6

The country’s allocation of health resources, ratherthan alleviating inequities, is inversely correlated withpoverty and marginality.7 Other studies have found thatpublic health expenditures are as much as twelve timeshigher per capita for the insured—who are formallyemployed—than the uninsured in Mexico.8

Chiapas is the Mexican state that receives the lowestamount of health resources per capita.9 Apart from thefederal district, where tertiary care hospitals dramati-cally increase health care per capita spending, thereare stark differences between Chiapas (581 pesos percapita) and other states, such as, Baja California Sur(2255 pesos per capita).10 Chiapas also has the lowestnumber of inhabitants covered by some form of socialsecurity (i.e., employment-related health insurance):barely 17.6% versus 40.1% for the entire country.11 Inthis study, the proportion of inhabitants without anyinsurance was over 92% for all types of communitiesstudied.

In Chiapas, which is one of the poorest states in thecountry as well as one of the most highly indigenous,marginalization and lack of health care resources arereflected in poor health indicators. According to officialgovernment statistics, Chiapas ranks toward the bot-tom among all Mexican states in terms of both infantand child mortality and has the country’s highestmaternal mortality ratio and the highest proportion ofmortality due to infectious diseases.12 Sixty-eight per-cent of the population lives without access to potablewater and 62.3% does not have adequate sanitation. In2003, Chiapas had the highest mortality (among bothwomen and men) associated with diarrheal diseases,acute respiratory infections, and pulmonary tuberculo-

8 Lozano R, Zurita B, Franco F, Ramírez T, Hernández P, Torres JL.“Mexico: Marginality, Need, and Resource Allocation at the CountryLevel.” In: Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M,eds. Challenging Inequities in Health: From Ethics to Action. NewYork: Oxford University Press; 2001:271-295.9 Lavielle B, Lara G, Diaz D, Curitas para la Salud: El mapa de lainequidad. Fundar. 2001: 48-62.10 Numbers reflect entire health “Función 08” federal spending, The“Ramo 33” federal spending within Función 08 is also highlyinequitable. Lavielle, B, Lara G, Diaz D, Curitas para la Salud: Elmapa de la inequidad , Fundar. 2001: 48-62, at 49, 52.11 Sánchez-Pérez HJ. Tuberculosis pulmonar en zonas de alta mar-ginación socioeconómica de Chiapas, México: Problemas y retos asuperar: El caso de la Región Fronteriza. Doctoral thesis. Barcelona:Universidad Autónoma de Barcelona, 1999; Consejo Nacional dePoblación (CONAPO). 2001. Available at: http://www.conapo.gob.mx.Accessed November 7, 2005. 12 Rankings are done according to least mortality to greatest andtherefore, Chiapas ranks among the worst states. PerspectivaEstadística. Chiapas. September 2005. Available at:http://www.inegi.gob.mx/lib/buscador/busqueda.asp?s=inegi&texto=mortalidad%20de%20ni%F1os&seccionB=docit&i. AccessedNovember 6, 2005.

4 While this report emphasizes the violations of the right to health ofall the indigenous people living in the conflict zone, articles based ona more in-depth review of the study findings have been published.:Sánchez Pérez HJ, Hernán M, Ríos-González A, Arana-Cedeño M. etal. “Malnutrition among children under five years of age in conflictzones of Chiapas, Mexico.” American Journal of Public Health. forth-coming 2006; Brentlinger P, Sánchez-Pérez HJ, Arana-Cedeño M,Vargas HG, Hernán MA, Micek M, Ford D. “Pregnancy Outcomes, Siteof Delivery, and Community Schisms in Regions Affected by theArmed Conflict in Chiapas, Mexico; A Community-based Survey.”Social Science and Medicine. 2005;61:1001-1014.5 It was 46.4 percent in 2003, after the United States. See “OECDHealth Data 2005: How Does Mexico Compare?“ OECD Health Data2005: Statistics and Indicators for 30 Countries. June 8, 2005. Avail-able at: http://www.oecd.org/dataoecd/16/2/34970198.pdf. AccessedMarch 15, 2006. 6 “Inequality in Income or Consumption.” Human DevelopmentReports 2005. United Nations Development Programme. Availableat: http://hdr.undp.org/statistics/data/indicators.cfm?x=148&y=2&z=2. Accessed March 15, 2006.7 Lavielle B, Lara G, Diaz D, Curitas para la Salud: El mapa de lainequidad. Fundar. 2001, pp. 48-62; Lozano R, Zurita B, Franco F,Ramirez T, Hernandez P, Torres JL. “Mexico: Marginality, Need andResource Allocation at the County Level.” In: Evans T, Whitehead M,Diderichsen F, Bhuiya A, Wirth M, eds, Challenging Inequities inHealth: From Ethics to Action. New York: Oxford University Press;2001:277-295, 290.; Hernandez-Peña P, Zapata O, Leyva R, Lozano R.“Equidad y salud: necesidades de investigación para la formulaciónde una política social.” Salud Pública de México. 1991;33:9-17.

E X E C U T I V E S U M M A R Y 3

sis, as well as among women with cervical cancer.13

Virtually a quarter (24.5%) of people die without receiv-ing medical care. Chiapas, together with Oaxaca, rankhighest in this regard.14 As this report shows, however,the regions of Chiapas most affected by the conflicthave fared even worse than the rest of Chiapas state.

The investigation in the conflict zone consisted of ahousehold survey and in-depth structured question-naires for community leaders. The household surveyyielded information on health indicators (includingmortality, morbidity, nutrition) and the access and useof health services for 2,997 households from forty-sixcommunities in the Altos, Selva, and Norte regions ofChiapas. The study compared health conditions, accessto health services, and attitudes about health servicesamong three types of communities: 1) opposition com-munities, 2) pro-government communities, and 3)divided communities fragmented along political linesrelated to the conflict, which contained both oppositionand pro-government groups. The results of the twosurveys of households and community leaders werecombined with other qualitative data to provide a pic-ture of the health conditions in the areas that have beenmost affected by the conflict in Chiapas.

The study drew on information from human rightsand non-governmental organizations, churches, news-papers, and official sources to identify the political affil-iation of all the communities with between 300 and2,500 inhabitants in the designated regions. From thislist, eighteen opposition communities, eighteen pro-government communities, and eighteen divided com-munities were randomly selected from each region,yielding a sample of fifty-four communities. In addition,eighteen additional communities were randomly cho-sen to serve as alternates for communities that mightrefuse to participate. Ultimately, forty-six communitiesin the three aforementioned regions participated in thestudy. Within the selected communities, householdswere chosen according to two criteria: one randomlysystematic (one out of every three), and the other based

on the households identified with possible cases of pul-monary tuberculosis or where a death had occurred inthe two years prior to the study.15 In all, informationfrom 17,931 individuals was obtained from 2,997households surveyed.

FindingsThe findings of the study that are included in this reportand analyzed in regard to Mexico’s right to health obli-gations relate to selected demographic and socio-eco-nomic conditions, selected social determinants ofhealth, maternal health (including prenatal care,obstetric care and maternal mortality), child health(including vaccination coverage and malnutrition), pul-monary tuberculosis in persons aged fifteen and above,and the availability and use of health services for self-perceived morbidity in the month prior to the study.

Demographics/EducationThe population of the regions studied is very young, with47% under age fifteen. Between 80% and 99% of thepeople are indigenous and nearly half of them do notspeak Spanish. Of the population surveyed, 36% did notknow how to read or write. Among the population thatwas of school age when the conflict began, only one outof five had gone beyond primary school. Females overfifteen had an average of 2.68 years of education andalmost half of women and girls over fifteen (43%) had noschooling at all. In contrast, national statistics claimthat 88.6% of women in Mexico are literate.16

Living ConditionsDwelling conditions were precarious in all three

groups, although certain negative characteristics suchas greater crowding and dirt floors were more preva-lent in the divided communities. Half of the oppositioncommunities lacked access to clean water, while one inthree lacked this service in the other two types of com-munities.

Vaccination SchemesIn the conflict zone, 23% of the children have not

completed their vaccination schemes, a number farhigher than the official figures, which is under 5%. Thisdisturbingly low coverage is attributable to lack of

13 Secretaría de Salud (SSA), Dirección General de Información enSalud. “Estadísticas de mortalidad en México: muertes registradasen el año 2003.” Salud Pública de México 2005;47(2):171-178. Thecomparisons between Chiapas and the national averages are telling.The rates for women (per 100,000) were as follows: diarrheal dis-eases: national (5.0) v. Chiapas (17.8); acute respiratory infections:national (15.6) v. Chiapas (23.7); pulmonary tuberculosis: national(2.2 ) v. Chiapas (6.7); cervical cancer: national (11.2) v. Chiapas(18.5). The rates for men (per 100,000) were as follows: diarrheal dis-eases: national (5.6) v. Chiapas (22.5); acute respiratory infections:national (21.0) v. Chiapas (32.0); pulmonary tuberculosis: national(5.1) v. Chiapas (11.1).14 Secretaría de Salud (SSA), Dirección General de Información enSalud. “Estadísticas de mortalidad en México: muertes registradasen el año 2003.” Salud Pública de México 2005;47(2):171-178. Oaxacahad 23.0 percent.

15 All households were asked about members exhibiting certainsymptoms and those identified households were then surveyed withrespect to PTB.16 Instituto Nacional de Estadística Geografía e Informática (INEGI).XII Censo General de Población y Vivienda, 2000. Tabulados BásicosNacionales y por Entidad Federativa. Base de Datos y Tabulados dela Muestra Censal. Aguascalientes: INEGI 2001. Available at:http://www.inegi.gob.mx/est/contenidos/espanol/rutinas/ept.asp?t=medu25&c=3293. Accessed November 7, 2005.


knowledge about the importance of vaccinations, lackof access to health services, and for almost one quarterof the respondents, distrust towards governmenthealth services or reasons related to the conflict. Inaddition, 4% cited the government’s placing of condi-tions on the granting of health services.

MalnutritionThe overall rate of malnutrition according to the

height-for-age index (stunting) was an alarming 54.7%,which is among the highest found in any study withinthe country and places the area studied in line with lowhuman development countries.17 According to theweight-for-age index (underweight), the level of malnu-trition was 21%. The overall rate of wasting (weight-for-height) was 3%.

Maternal HealthWith respect to maternal health, the investigation

documented the death of eight women in the previoustwo years. The gross estimated rate of maternal mor-tality was 607 per 100,000 live births, a number at leastseven times higher than that calculated by the healthsector for Chiapas and for the whole country. This highmaternal mortality ratio can be considered an indicatorof the inadequate organization and operation of healthservices in the region, as well as the marginalization ofwomen.

The majority of women (60%) only received prenatalcare from traditional birth attendants. Approximatelyone-third sought prenatal care by some form of per-sonnel in the health system, and 6.5% either receivedno prenatal care whatsoever or were attended by per-sons other than health personnel. Only 16% of all child-births occurred in public health facilities, while 74%were attended by traditional birth attendants, 7% byfamily members or neighbors, and 1.4% delivered ontheir own. Women in divided communities used govern-ment health services the least. Nearly nine out of tendeliveries took place in women’s homes (85%). Thehigh rate of home birth is due not only to cultural rea-sons, but also to obstacles to care related to the conflictand to the perception of the low quality of care in healthservices. The study found nine cases in which healthservices refused to attend births (0.7%).

Pulmonary TuberculosisIn the forty-six studied communities, pulmonary

tuberculosis (PTB) was detected in 29 people, of whomonly 13, or fewer than half, had been identified by healthservices and were being treated. The unadjusted overallrate of PTB for the population, taking into account esti-mated total inhabitants, was at least 85.3 per 100,000and 161.2 for those age 15 and older, almost three timesthe rate reported for the entire state.

Of the 29 PTB-positive cases identified, four had notreceived any medical care. Of the 25 who had receivedit, 22 had done so in government health services andthree in private services. Of these 25 cases, 10 had notreceived any diagnosis,13 had been diagnosed withPTB, and two had received a diagnosis other than PTB.Of the 13 cases which had been diagnosed by healthservices, one had not received any anti-tuberculosistreatment, six were receiving it, and six had stoppedcompliance with their anti-TB treatment. In short,severe deficiencies were found in the detection andanti-tuberculosis treatment of PTB patients.

Access to Health CareIn cases of self-reported illness within the last

month, three out of every ten persons did not seek anyhealth care (government or other), while six out ofevery ten sought government-provided health care. Asto the reasons for not using government health facili-ties, members of opposition communities most oftenmentioned lack of medicines and problems related tothe conflict, such as receiving treatment only if certainconditional demands were met, or being denied treat-ment all together. People in pro-government commu-nities repeatedly noted their distrust of services aswell as the lack of care and transportation. In dividedcommunities, economic constraints on using anyhealth service were most often mentioned. The investi-gation determined that communities divided by theconflict have diminished capacity to respond collec-tively to serious health needs, such as arranging fortransportation for women in the event of obstetricemergencies.

Social Polarization and MarginalizationThe findings of the study suggest that during the first

six years of the conflict, the politicization of governmentservices, including those related to health, on the onehand, and the civil resistance, on the other, functionedin unfortunate synergy to create ever greater socialpolarization within regions, communities, organiza-tions, and even families. Profound divisions increas-ingly arose within and among hundreds of communitiesin Chiapas, which had previously been distinguished fortheir high level of social cohesion and organization.Among other things, the use or rejection of specifichealth services presupposed a specific political sympa-

17 The UN Development Programme Human Development Report for1995-2003 shows that Mexico has 18% of children under height fortheir age. Mexico lags behind Libya (15%), Thailand (16%), andUnited Arab Emirates (17%), scores the same as Algeria, and comesin just ahead of Congo (19%). Available at: http://hdr.undp.org/ sta-tistics/data/indicators.cfm?x=66&y=1&z=1. Accessed November 6,2005.


thy or militancy. As the report discusses, this erosion ofcommunities has persisted and intensified throughoutthe duration of the conflict.18

Social erosion in communities in Chiapas illus-trates the effect of national policies that excludeentire sectors of the Mexican population from partici-pation in democratic decision-making, including deci-sions on health services. On the macro-level, theinformation reported in this study reflects the pro-found degree of marginalization of the overwhelm-ingly indigenous people residing in the conflict zone.This marginalization can be found elsewhere in thecountry, which has been documented by others.19 Thistrend of marginalization, in turn, reflects failures ofgovernance and democracy.20 According to the UNDP:“Participating in the rules and institutions that shapeone’s community is a basic human right and part ofhuman development. More inclusive governance canbe more effective. When local people are consultedabout the location of a health clinic, for example, thereis a better chance it will be built in the right place.”21

Human and economic development in Chiapas willrequire meaningful participation by all citizens,including improved health conditions, that recognizeindigenous autonomy and self-determination. Suchinclusiveness and democratic participation is requiredby international instruments to which Mexico has vol-untarily bound itself.

Compliance with Right to HealthObligationsCurrently, the Mexican government is not meeting itsobligations under international law with respect to theright to health. Realizing the right to health requiresnot only avoiding retrogression but deliberate steps tomake adequate progress. It also demands non-dis-crimination and equality; meaningful popular partici-pation in all levels of decision-making about health,

accountability and multi-sectoral strategies that linkquestions of health to sustainable development andactive citizenship.

First, the Mexican government is not complying withminimum core obligations or making adequateprogress toward the realization of the right to the high-est attainable standard of physical and mental health.The deplorable health conditions and egregiousinequities that in some ways gave rise to the Zapatistauprising are still in effect. The largely indigenous peo-ple in the study are often deprived of available, accessi-ble, acceptable, and quality health facilities, goods andservices, including preconditions to health. Providingaccess to such health services and goods constitutestate obligations in accordance with General Comment14 issued by the United Nations Committee on Eco-nomic, Social and Cultural Rights.22 Governmentalhealth programs have not adequately addressed thesefailures, and for the majority of the population in theconflict zone, whether engaged in resistance or not,health conditions remain alarmingly sub-standard.

Second, the study highlighted some of the effects ofdiscrimination and structural inequalities faced by thelargely indigenous populations in the conflict zone. Thefragmentation of communities and politicization of careand other governmental services over the years sincethe conflict began has had grave implications for theaccessibility and utilization of health services in theregion. The investigators also learned of repeated alle-gations of individual health practitioners discriminatingagainst patients on the basis of political affiliation and,more frequently, on the basis of indigenous ethnicity.Indeed, the investigation reveals that the health statusand conditions of all of the communities in the conflictzone are far worse than national averages, which is inpart attributable to inequitable patterns of health careresource allocation which are tied to ethnicity, as wellas insurance status.23 Further this inequality affects thepre-conditions for health as well as to access to care —particularly living conditions, food security, educationalopportunities, basic sanitation and water. Theseinequitable conditions directly affect people’s healthand have a devastating affect on child health and nutri-tion, which are documented in this report. Women inthese communities also experience gender discrimina-tion, as evidenced by the lack of attention to women’shealth priorities in the region.

Third, Mexican law and institutions do not provide for

18 In some areas of Chiapas, as is the case in the Altos region, thissituation is exacerbated even further by religious conflicts betweenCatholics and evangelical churches, making the social problem evenmore difficult.19 CONAPO (1998). La situación demográfica de México 1998. México:2a.ed. CONAPO (1995). Índices de Marginalidad, 1995. México:CONAPO, 1995.20 In 2002 the UN Development Report noted that “studies in a rangeof countries and regions hold weak governance responsible for per-sistent poverty and lagging development” which is evidenced in partin poor public services. United Nations Development Programme(UNDP). Human Development Report 2002: Deepening Democracy ina Fragmented World. New York: Oxford University Press; 2002:51.Available at: http://hdr.undp.org/reports/global/2002/en/. AccessedJanuary 8, 2006.21 Id., UNDP. 2002:51. Emphasis added.

22 UN CESCR. “General Comment 14.” August 2000; para 12.23 See also Lozano R, Zurita B, Franco F, Ramírez T, Hernández P,Torres JL. “Mexico: Marginality, Need, and Resource Allocation atthe Country Level.” In: Evans T, Whitehead M, Diderichsen F, BhuiyaA, Wirth M, eds. Challenging Inequities in Health: From Ethics toAction. New York: Oxford University Press; 2001:271-295.


adequate accountability in the event of violations of theright to health. National and local human rights com-missions do not have the capacity or the authority tosanction violators or enforce recommendations to insti-tutions. Article 60 of the General Health Law fails toprovide for claims regarding the accessibility or ade-quacy of health services as an institutional or systemicissue. Moreover, the amparo (protection writ) which iscommonly used in civil and political rights violationscases, currently does not provide people and groupswith a collective remedy; nor does it establish prece-dent for other related cases. Even in individual cases,Mexican judges have been inappropriately reluctant touse the amparo to enforce the right to health under theapparent misconception that “programmatic” rightsare not actionable. Although aspects of the right tohealth entail programmatic obligations, violations ofspecific regulations relating to the government’s obli-gations with respect to health give rise to individualrights and should be enforced according to the samecriteria as other constitutionally protected rights.24

Fourth, although Mexico’s General Health Law setsout an integrated, multi-sectoral approach to health, inpractice this does not occur. 25 The alarmingly highrates of malnutrition that this study found among alltypes of communities are the result of a failure of theMexican government to institute coherent rural devel-opment and food security policies, which incorporatehealth concerns. The investigation also found inade-quate living conditions, lack of access to sufficient safedrinking water, lack of access to basic sanitation fordisposal of excreta, lack of access to educationalopportunities (especially for women) across all com-munities in the study. The process of fragmentation anddispersion exacerbates difficulties in establishing basicpreconditions of health, such as adequate water,sewage and housing.26

Finally, the government has not granted indigenouscommunities, including but not limited to oppositioncommunities, meaningful rights to participate in the

design and management of their health care services,as set forth under relevant international law. The Mexi-can government is a party to international instrumentscalling for genuine participation of indigenous people’sin their own affairs, including health. The San AndrésAccords, which the federal government agreed to withthe EZLN in 1996, but never implemented,would haveprovided some self-determination. Mexico, however, incontrast to other states in the region, has neveradopted national legislation to incorporate its interna-tional obligations into domestic law. Nor has it recog-nized some meaningful degree of autonomy forindigenous communities, including those in opposition,in relation to the organization and delivery of socialservices.27

Demands for social participation and control overthe decisions affecting health and well-being are at thecore of the conflict in Chiapas and underlie the Zap-atista resistance. The devolution of some meaningfuldecision-making power to the communities whosewell-being is at stake is a precondition to realizing theright to health in Chiapas, as well as fostering opportu-nities to resolve the conflict. As has been noted before,it is also fundamental to the fulfillment of human rightsand democracy more broadly.28

Yet in the conflict zone in Chiapas, the ability to par-ticipate in collective decision-making on health mattersor to effectively assert health claims through the healthsystem are glaringly absent, especially in divided com-munities. In communities in resistance, disease may betreated as everyone’s problem; in pro-governmentcommunities, it is the government’s problem, but individed communities, it is essentially no one’s problem.

24 Ley General de Salud. (Mexico General Health Law). Art. 60. Feb-ruary 7, 1984. In this vein, the Constitutional Court of Ecuador, e.g.,has stated that “positive social rights … are norms to be enforcedimmediately with full juridical effect and are binding on the authori-ties who have obligations in their capacity as obligors; [they are alsorights that must] be implemented by courts such as this one forwhich the defense of human dignity is a fundamental mainstay ofcontemporary constitutional development.” “Jofre Mendoza et al v.Minister of Health,” Ecuador (Constitutional Court of Ecuador (2003)[failure to consistently provide full triple cocktail of ARVs in accor-dance with Ministry of Health regulations could produce viral resist-ance and lead to opportunistic infections and eventually death]. 25 Title III, ch 4, Art. 60. Ley General de Salud. (Mexico General HealthLaw). February 7, 1984.26 CESCR Concluding Observations, 1999, para 27.

27 In the 1990s, Colombia, Bolivia and Paraguay reformed their con-stitutions to incorporate the rights of indigenous peoples, in keepingwith ILO Conventions 107 and 169 and as a part of the standardsincluded in the International Convention on the Elimination of AllForms of Racial Discrimination. The movements for constitutionalreforms later inspired similar efforts in Ecuador, Peru andVenezuela. 28 Immediately before Mexico’s last national elections in 2000, Erica-Irene Daes, the Chairperson-Rapporteur of the UN Working Groupon Indigenous Populations issued a report in which she “welcomedthe good functioning in certain areas of self-administered indige-nous communities…” but expressed concern over “allegations ofgovernmental interference in other areas, particularly in Chiapas…including the removal of indigenous authorities and their replace-ment by others selected by the government…” Daes considered“genuine participation by indigenous communities in the political lifeof the country to be crucial for their own development and for Mex-ico’s development, and for democracy overall.” Erica-Irene Daes,Chairperson-Rapporteur of the Working Group on Indigenous Popu-lations. “Human Rights of Indigenous Peoples.” UN DocumentE/CN.4/Sub.2/2000/40. United Nations: Geneva; 3 August 2000. para12. Available at: http://www.unhchr.ch/ Huridocda/Huridoca.nsf/0/c13d59b7cd0997b0c1256990004abe0e?Opendocument. AccessedJanuary 8, 2006.


Recommendations to the MexicanGovernment 1. The government should encourage a broad dialogue

at the local, state, and national levels about themeaning of an inclusive democracy in Mexico, whichfully recognizes its multiple constituent cultures.The dialogue should examine how health servicesshould be designed and delivered and how theindigenous population’s health needs could beaddressed. Such a dialogue would need to be sup-ported by and include non-governmental actors andcivil society, as well as relevant governmentalactors.

2. The Mexican government should take immediatesteps to implement the San Andrés Accords, as wellas its obligations under international law, includingILO Convention 169. This would confer some degreeof autonomy on indigenous communities, includingopposition communities, with respect to the organi-zation of their affairs and health services.

3. The government should permit and promote the cre-ation of local health care systems in the autonomousregions in Chiapas. These systems should be struc-turally independent and capable of responding to thespecific health care needs of each community, butoperationally coordinated with the state and nationalhealth system to provide vaccinations, medicines,and patient referrals. An autonomous technical sup-port system, based at least in part on universities,could promote communication among all partiesand facilitate better relations.

4. All federal, state, and municipal government activi-ties related to health should be carried out withoutdiscrimination. All levels of government should dis-play the highest degree of coordination and commit-ment to prevent programs and activities fromprovoking or aggravating internal conflicts. Pro-grams that are functioning well in terms of reducingcommunal conflict and improving health statusshould be supported and expanded. As part of thiscommitment, all clinics should be required toattend to all members of a community, regardlessof political affiliation or religion.

5. The government should improve its surveillanceand detection systems, and should collect healthdata on a disaggregated basis, so that disparitiesbased on gender, socioeconomic indicators, andethnicity may be detected and addressed. When thebest available evidence indicates the importance ofprocess indicators, such as the availability and useof essential obstetric care, the government shouldcollect such indicators to be able to review its

progress in addressing maternal health on an ongo-ing basis.

6. The government should establish an autonomousinstitution, made up of independent experts, tomonitor governmental compliance with indigenouspeoples’ economic, social, and cultural rights,including their health rights, in Chiapas and beyond.This institution should be equipped to promote edu-cation and dialogue among groups and actors insociety. It should also be authorized to receive andact upon individual and collective complaints and tohold the government accountable for violations.

7. The government should initiate amendments toMexican law to allow the amparo mechanism (writof protection) to provide for adequate remedies andaccountability in the event of violations of the rightto health, including providing for collective reme-dies and binding precedents. Lawyers and judgesshould be sensitized and trained in the enforcementand enforceability of the right to health.

8. Government social programs such as the Oportu-nidades program should actively foster and incorpo-rate meaningful community participation in thedesign, implementation, and evaluation of activities,which includes providing communities with author-ity in allocating resources and auditing projects.

9. The government should increase and re-allocatehealth resources per capita to and within Chiapasbased on the best evidence available of priorityhealth needs for the populations affected.

10. The Program of Tuberculosis Prevention and Con-trol should be re-structured to include investmentin more resources, sensitizing, training, supervis-ing, and evaluating a comprehensive DOTS programin Chiapas and beyond. The emphasis in this pro-gram should be placed on universality and freeaccess without conditionality, as well as mecha-nisms to ensure follow-up of patients in accordancewith international standards.

11. In keeping with the fulfillment of its obligationsunder the International Covenant on Economic,Social and Cultural Rights, the government shouldtake the following steps to improve the availability,accessibility, acceptability and quality of healthfacilities, goods and services in Chiapas:

a. train health personnel at all levels about humanrights and the principles of medical neutralitywith respect for cultural differences;

b. incorporate a basic working knowledge of thelocal indigenous language as part of the prereq-uisites for working in indigenous regions;


c. promote and reinforce community-based mech-anisms for the management of health-relatedissues;

d. foster community-based mechanisms for moni-toring and addressing health conditions, includ-ing rotating funds for obstetric emergencies;

e. develop intensive campaigns regarding the rightto health in Spanish and the principal indigenouslanguages;

f. broaden and diversify options with respect tofamily planning methods for indigenous womenand men, and ensure informed consent as wellas their right to decide freely the number andspacing of their children;

g. revise and restructure the activities of foodassistance and nutritional monitoring in accor-dance with local conditions and the consumptionhabits of the population;

h. provide available and accessible emergencyobstetric care to the population in the conflictzone;

i. improve the mechanisms of patient referral andtransfer to hospitals, especially in obstetricemergencies;

j. promote greater structural and functional inte-gration of services of the different governmentinstitutions (Ministry of Health and the IMSS-Oportunidades program), which provide medicalcare to the majority of the population in the studyarea;

k. improve the supply of medicines to health facili-ties; and

l. modify staffing policies to avoid frequent andlong absences of health personnel, in particular

physicians, from rural facilities and ensuingruptures in relations with communities, due torotations, attendance at meetings, participationin courses, paperwork, and the like.

12. Fragmented federal and state nutrition programsshould be integrated to establish a stable policy ori-ented toward promoting the population’s capacityfor self-sufficiency in food production and foodsecurity. In the context of these three regions in theconflict zone, this includes the following:

a. providing secure conditions so that the popula-tion, independent of their political or religiousaffiliation, can move about freely and engage intheir productive activities;

b. providing guarantees for an honorable andsecure return of displaced people to their com-munities and agricultural lands;

c. promoting local production and regionalexchange through a policy that stimulates theproduction and consumption of local productsand avoids the “dumping” effect, which resultsin the widespread distribution of food acquiredoutside the region;

d. establishing regional supply centers to regulatethe availability and price of food in less accessi-ble regions; and

e. implementing a program of nutritional monitor-ing in the most vulnerable communities, with theparticipation of community members as well ascivil society institutions to promote arrange-ments for the care of malnourished children,and foster local capacities.

C O N T E X T 9

More than ten years after the Zapatista Army forNational Liberation (EZLN, or Zapatistas)launched their New Year’s Day rebellion, Chia-

pas continues to be one of the most backward states inMexico in terms of the economic, social, political, andhealth conditions of the majority of its heavily indige-nous population. However, after the first years follow-ing the 1994 uprising that generated widespreadpublicity and attention to the Zapatista movement aswell as to Chiapas, the lives of the people residing inthe so-called conflict zone—those areas of the statemost affected by the initial armed combat between theEZLN and the army, as well as the ensuing paramilitaryviolence and low-intensity conflict—faded from nationaland international attention. Further, there was virtuallyno systematic information about how the familiestrapped in the protracted conflict and tension hadfared, or the conditions affecting their children.

In October 2000, PHR, together with El Colegio de laFrontera Sur and CCESC-DDS, undertook the first com-prehensive population-based health study in the con-flict zone, which took fourteen months to complete duein large measure to the ongoing tensions and climate ofmistrust. A primary purpose of the study was to docu-ment the health status, conditions, and access to healthservices in communities exposed to the ongoing mili-tary presence, the tensions and divisions between andwithin communities, and the civil resistance of Zap-atista sympathizers. The study also sought to analyzethe findings in light of the populations’ rights to healthunder international law.29 Quantitative and qualitativedata gathered during this study have been supple-mented with updated national and local statistics,together with direct observation and recent policy andhuman rights information, in order to provide a more

complete picture of the state of the right to health in theconflict zone.

Chiapas and the Study AreaMexico is a middle-income country with a per capitaGDP of close to $10,000 USD30 and is a member of theOrganization for Economic Cooperation and Develop-ment (OECD). It is however a country of extreme incomeinequality. According to the UNDP’s GINI Index, Mexicoranks 115 out of 124 in terms of income equality, mak-ing it more similar in that respect to countries such asZimbabwe and Zambia than any other OECD country.31

Mexico’s total health spending (6.2% of GDP in 2003)is also significantly lower than any other OECD country.Its total health spending per capita is only 25% of theOECD average (adjusted for purchasing power parity).32

Further, the public share of health spending in Mexicois well below the OECD average, meaning that privatefinancing—overwhelmingly in the form of out-of-pocketpayments—is required to fund most health care.33

The progress that Mexico has made in its nationalhealth indicators demonstrates that improvements in thepreconditions of health as well as in access to care arenot only possible but can be significant in terms of pro-ducing better outcomes. However, as Lozano et al write,

The allocation of health resources in Mexico isinversely related to marginality and to county

29 While this report emphasizes the violations of the right to health ofall the indigenous people living in the conflict zone, other journalarticles based on the study findings analyze in greater depth differ-ences among communities in terms of health status. See e.g.Sánchez Pérez HJ, Hernán M, Ríos-González A, et al. “Malnutritionamong Children Under Five Years of Age in Conflict Zones of Chia-pas, Mexico.” American Journal of Public Health. forthcoming 2006;Brentlinger P, Sánchez-Pérez HJ, Arana-Cedeño M, Vargas HG,Hernán MA, Micek M, Ford D. “Pregnancy Outcomes, Site of Delivery,and Community Schisms in Regions Affected by the Armed Conflictin Chiapas, Mexico; A Community-based Survey.” Social Science andMedicine. 2005;61:1001-1014.

30 2005 estimate according to the CIA World Factbook. Available at:http://www.cia.gov/cia/publications/factbook/geos/mx.html.Accessed March 23, 2006.31 GINI Index: “Inequality in income or consumption.” Human Devel-opment Report 2005. United Nations Development Programme,2006. Available at: http://hdr.undp.org/statistics/data/indicators.cfm ?x=148&y=2&z=2 Accessed March 15, 2006.; and“OECD Health Data 2005: How Does Mexico Compare?“ OECD HealthData 2005: Statistics and Indicators for 30 Countries. June 8, 2005.Available at: http://www.oecd.org/dataoecd/16/2/34970198.pdf.Accessed March 15, 2006. 32 $583 USD compared with $2,307 USD. “OECD Health Data 2005:How Does Mexico Compare?“ OECD Health Data 2005: Statistics andIndicators for 30 Countries. June 8, 2005. Available at:http://www.oecd.org/dataoecd/16/2/34970198.pdf. Accessed March15, 2006. 33 46.4 percent, see “OECD Health Data 2005: How Does MexicoCompare?“ OECD Health Data 2005: Statistics and Indicators for 30Countries. June 8, 2005. Available at: http://www.oecd.org/dataoecd/16/2/34970198.pdf. Accessed March 15, 2006.

II. CONTEXT

1 0 R E A L I Z I N G T H E R I G H T T O H E A L T H I N C H I A P A S , M E X I C O

GNP in Mexican counties. Physicians concentratein areas with little deprivation and higher percapita wealth [ ] and are relatively scarce [ ] invery high marginality counties [ ]. The moredeprived or poorest counties also have fewer pub-lic hospital beds (1 bed per 10,000 in marginalizedcounties compared with 12 beds per 10,000inhabitants in better off counties)…Hence, healthresources appear to increase in proportion to percapita GNP in Mexican counties.34

Another study showed that public health expendi-tures are twelve times higher per capita for theinsured—who are formally employed—than the unin-sured in Mexico.35 At the same time, indigenous per-sons in Mexico disproportionately live in rural andmarginalized areas and are uninsured. A study by Her-nandez-Peña found that these disadvantages are cou-pled with a lower availability of health care resources inhighly indigenous communities.36

The state of Chiapas lies in the southeast of Mexicoand extends over an area of 75,634 square kilometers.Its population in the 2000 census was 3,920,892 inhabi-tants, distributed among 19,453 communities, locatedin 118 municipalities (seven of which were created bythe Chiapas government after 1994).37 For administra-tive purposes, the state is divided into nine regions,three of which—the Altos, Selva, and Norte regions—were the most directly affected by the armed conflict.The study was conducted in these three regions, all ofwhich have important ethnographic, social, and histori-cal characteristics.38

The Altos region lies in the center of the state and itsname derives from its location at altitudes greater than1,600 meters above sea level. This region has thelargest concentration of the indigenous population inChiapas and has been an administrative and commer-cial enclave since the colonial period. Its principal city,San Cristóbal de Las Casas, was founded in 1528 and,in many ways continues to be symbolic of Spanish andsubsequent ladino39 dominance in a predominantlyindigenous area. The Altos region also has the greatestnumber of municipalities in Chiapas in conditions ofextreme poverty. The combination of enormous demo-graphic pressure, along with political and religiousissues and a system of subsistence agriculture in thisregion has led to the occurrence of inter- and intra-community conflicts, migrations, and expulsions sincethe second half of the twentieth century.

Moreover, during the last forty years the conversionof the population to religions other than Catholicismhas accelerated. Conflicts over land and economic andpolitical control have been expressed through the lensand rhetoric of religious intolerance, and have becomeincreasingly violent. Since 1970, more than 35,000indigenous people from the Altos region have been vio-lently expelled from their communities as a result ofpower conflicts that evolved into religious divisions.40

Although Mexico is an overwhelmingly Catholiccountry, Chiapas is one of the least Catholic states inMexico and the Altos region has been particularlyaffected by religious divisions. Conversion to other reli-gions (in particular, Protestant churches) has disruptedcommunal activities, such as the appointment of localleaders to political and administrative positions, theconsumption of alcohol for medicinal and ritualisticpurposes, the participation in civil acts and religiousevents (e.g. those tied to the harvest cycles). In turn,

34 Lozano R, Zurita B, Franco F, Ramírez T, Hernández P, Torres JL.“Mexico: Marginality, Need, and Resource Allocation at the CountryLevel.” In: Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M,eds. Challenging Inequities in Health: From Ethics to Action. NewYork: Oxford University Press; 2001:290-291.35 Hernandez-Peña P, Zapata O, Leyva R, Lozano R. “Equidad y salud:necesidades de investigación para la formulación de una políticasocial.” Salud Pública de México. 1991;33:9-17 cited in Lozano R,Zurita B, Franco F, Ramírez T, Hernández P, Torres JL. “Mexico:Marginality, Need, and Resource Allocation at the Country Level.” In:Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M, eds. Chal-lenging Inequities in Health: From Ethics to Action. New York: OxfordUniversity Press; 2001:291.36 Hernandez-Peña P, Zapata O, Leyva R, Lozano R. “Equidad y salud:necesidades de investigación para la formulación de una políticasocial.” Salud Pública de México. 1991;33:9-17, cited in Lozano R,Zurita B, Franco F, Ramírez T, Hernández P, Torres JL. “Mexico:Marginality, Need, and Resource Allocation at the Country Level.” In:Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M, eds. Chal-lenging Inequities in Health: From Ethics to Action. New York: OxfordUniversity Press; 2001:291.37 INEGI. XII Censo General de Población y Vivienda, 2000. TabuladosBásicos Nacionales y por Entidad Federativa. Base de Datos y Tabu-lados de la Muestra Censal. Aguascalientes: INEGI; 2001. Availableat: http://www.inegi.gob.mx/est/default.asp?c=703. AccessedNovember 5, 2005.

38 As described more fully in the section on methods, communitieswere chosen to participate in the study after thorough consultationswith human rights groups, governmental institutions (including theMinistry of Health, Ministry of Public Works, Ministry of Education),and non-governmental organizations in the region as well as news-paper reports. The consultations provided information on communi-ties in which one or more of the following events had occurred sincethe beginning of the conflict: combat between the EZLN and the Mex-ican army; paramilitary activities; assassinations of leaders or fami-lies of campesinos associated with the EZLN; displacement ofpersons due to presumed affiliation with the EZLN or with paramili-tary groups; and public protests and organized appearances by theEZLN. Consultations proved that the vast majority are located in theAltos, Selva, and Norte regions.39 Ladino is a term used to refer to non-indigenous people.40 Martínez-Velasco G. “Apreciaciones generales sobre la situacióndel desplazamiento en Chiapas.” In Regional seminar on internaldisplacement in the Americas, Mexico City, Mexico, February 18–20,2004. Washington, DC: Brookings Institution–SAIS Project on Inter-nal Displacement; 2004.

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traditional Catholic community leaders have rejectedthese new religions and have expelled members ofnon-Catholic sects from their communities, arguingthat these religions disrupt participation in communalactivities. Property abandoned by the expelled familiesor groups is then allocated among those who remain.Each religious group has developed ways to entice con-version as well as to punish those who choose not tofollow.41

The Selva region was for centuries the least knownand least populated region of Chiapas. For the Spaniardsit was “the great desert populated by the Lacandón Indi-ans,”42 and until the 1960s it was a vast area of nationalterritory covered by tropical rain forest with a few Indiancommunities.43 For over a century, the presence of non-indigenous people was limited to representatives of for-eign logging companies. As a result of the greatdemographic pressure in the Altos region, the govern-ment actively promoted the colonization of nationallands in the Selva region in the 1960s. By offering land inthis area, the government sought to alleviate agrarianpressure and conflicts in the Altos and other regions inChiapas, as well as elsewhere in the country.44

As a result, the Selva region experienced accelerateddemographic growth and became a vast multiethnicarea. For many years it was neglected by governmentsocial programs. Life in this region turned out to beexceedingly difficult for indigenous campesinos arriv-ing from more temperate climates, both because of thepresence of many unknown tropical diseases andbecause of the difficulties involved in growing their tra-ditional foods. These difficulties forced the new arrivalsto unite in very well-organized, cohesive communities,which became a fundamental characteristic of thisregion up until the beginning of the armed conflict. TheSelva region also emerged as the destination of manynon-Catholics expelled from their communities in theAltos region. However, as there was less conflict overland in the Selva region, there was also less conflictamong members of different religions. In the twodecades prior to the Zapatista uprising, strong inde-pendent campesino organizations were formed in this

region and became decisive in the expansion of theEZLN.

The Norte region is an area, which extends from thehighlands of Chiapas to the plains of the state ofTabasco. It is made up of municipalities that were previ-ously covered by dense vegetation (originally rainforest),which gave way to agricultural activity and ranching. Asanother preferred destination for migrants from theAltos region, it became an area where different ethnicgroups, including the Chol who were the original settlersof these lands, came into contact with each other andwere forced to coexist, though not always peacefully.

Although the state’s largest cities have greatlyincreased in size, more than half (54.3%) of Chiapas’population continues to live in a rural environment, ingreat contrast to 25.4% for all of Mexico.45 In theseoverwhelmingly rural areas, farming small parcels ofcollectively owned land or working as day laborers onlarger plots offers a poor and precarious existence formost residents. Historically people have lived in smallvillages of 2,500 inhabitants or less, and dependence onsocial support from the community has been a distin-guishing factor of life.

The enduring conflict has greatly eroded these smallcommunities. The number of rural settlements (popula-tion less than 2,500) has dramatically increased sincethe conflict erupted. In 1990, there were 16,422 settle-ments;46 in 2000 the number had increased to 19,453;47

and according to various sources,48 there were morethan 22,000 settlements by 2003. These numbers reflectthe process of dispersion and fragmentation that therural population of the state of Chiapas is undergoing.This process has accelerated since 1994 and has beenstrongly influenced by the polarization of communitiesaround political as well as religious affiliations.

In addition to tensions between different political

41 Id., Martínez-Velasco G. 200442 Ballinas J. El desierto de los lacandones. Tuxtla Gutiérrez: Ateneode Ciencias y Artes de Chiapas, Gobierno del Estado de Chiapas;1951; García de León A. Resistencia y utopía. México: Era; 1985.43 De Vos J. Oro verde. La conquista de la Selva Lacandona por losmadereros tabasqueños, 1822-1949. México: Fondo de CulturaEconómica, Instituto de Cultura de Tabasco; 1988. 44 Arana-Cedeño, M. “Educación y gestión ambiental en la selva deChiapas.” In: Leff E, Carabias J. Recursos naturales, técnica y cul-tura. Cuadernos de Centro de Investigaciones Interdisciplinarias enHumanidades de la UNAM. México: Universidad Nacional Autónomade México; 1990.

45 INEGI. XII Censo General de Población y Vivienda, 2000. TabuladosBásicos Nacionales y por Entidad Federativa. Base de Datos y Tabu-lados de la Muestra Censal. Aguascalientes: INEGI; 2001. Availableat: http://www.inegi.gob.mx/est/default.asp?c=703. AccessedNovember 5, 2005.46 INEGI. XI Censo General de Población y Vivienda,1990. TabuladosBásicos Nacionales y por Entidad Federativa. Base de Datos y Tabu-lados de la Muestra Censal. Aguascalientes: INEGI; 1990. Availableat: http://www.inegi.gob.mx/est/contenidos/espanol/proyectos/coesme /programas/ficha.asp. Accessed November 6, 2005.47 INEGI. XII Censo General de Población y Vivienda, 2000. TabuladosBásicos Nacionales y por Entidad Federativa. Base de Datos y Tabu-lados de la Muestra Censal. Aguascalientes, Mexico: INEGI; 2001.Available at: http://www.inegi.gob.mx/est/default.asp?c=703.Accessed November 5, 2005.. 48 Defensoría del Derecho a la Salud. “La atomización demográficaen Chiapas, un obstáculo para el ejercicio de los derechos económi-cos, sociales y culturales,” in Mexican Human Rights NGOs ShadowReport to the United Nations Comittee on Economic, Social andCutural Rights, 2006 (on file with authors).


and religious groups, harassment by armed paramili-tary groups and the presence of the Federal Army havebeen important factors in accelerating the dispersionand fragmentation of communities. For decades, expul-sion has been an extreme form of expressing religiousas well as political intolerance, and expulsions areoften conducted in a violent manner. As a result of reli-gious and political conflicts, families and groups areforcibly displaced from communities. Without countingthe more than 20,000 people estimated to have beendisplaced for religious reasons,49 conservative esti-mates for those displaced by the conflict at differenttimes have ranged between 10,000 and 20,000.50 Thus,forced displacement has played a significant role in thehigh degree of population and small rural settlementdispersion in the state of Chiapas, and in the study areain particular.

The federal and state programs to buy land for thepopulation affected by the conflict are also a centralcause of population resettlement in Chiapas. Between1994 and 1999, as a way of curbing the Zapatista move-ment, the Chiapas government invested 764 millionpesos (US$76.4 million) to buy and distribute more than260,000 hectares of land to 1,430 campesino groups.51

For example, ranchers who owned land that had beeninvaded by Zapatista supporters were compensatedand the land was re-distributed to campesino groupssympathetic to the government. In her 2000 report tothe Commission on Human Rights, the Chairperson-Rapporteur of the Working Group on Indigenous Popu-lations specifically noted her concern over indigenouscommunities being deprived of their traditional landsand of indigenous lands being fragmented in a situationthat has often created tension and conflict, includingwithin and between indigenous communities.52

Besides fostering direct conflicts, this communityfragmentation has inevitable social, economic, andenvironmental costs. The growth of health and educa-tional services and infrastructure lags far behind theincrease in need. Consequently, the number of commu-

nities in extreme poverty without such services is grow-ing. At the same time, the destruction of forests to clearlands for dwellings and agriculture accelerates defor-estation, puts pressure on natural resources, and con-tributes to environmental degradation.53

According to official government statistics, todayChiapas ranks among the states with poorest indicatorson child and infant mortality, and ranks worst in termsof maternal mortality.54 Over two-thirds (68%) of thepopulation lives without access to potable water and62.3% does not have adequate sanitation. In 2003, Chia-pas ranked 1st in mortality (among both women andmen) associated with diarrheal diseases, acute respi-ratory infections, pulmonary tuberculosis, as well asamong women in cervical cancer.55

The majority of the overwhelmingly impoverishedpopulation in Chiapas is treated by the two main institu-tions responsible for providing health services to theuninsured population: the Ministry of Health (SSA) andthe IMSS-Oportunidades (previously IMSS-Solidaridad)program. In Chiapas, 80% of the population lackshealth insurance and in rural communities the figure isover 95%. However, evidence indicates that access tohealth care is inadequate. According to official statis-tics, virtually a quarter (24.5%) of people die withoutreceiving medical care, which makes Chiapas, togetherwith Oaxaca, rank highest in this regard.56

As this report demonstrates, the regions of Chiapasmost affected by the conflict have fared even worsethan the rest of Chiapas. The population in the conflictzone is overwhelmingly indigenous and their margin-

49 Martínez-Velasco G. “Apreciaciones generales sobre la situacióndel desplazamiento en Chiapas.” In Regional seminar on internaldisplacement in the Americas, Mexico City, Mexico, February 18–20,2004. Washington, DC: Brookings Institution–SAIS Project on Inter-nal Displacement; 2004. 50 Centro de Investigaciones Económicas y Políticas de AcciónComunitaria (CIEPAC). Hidalgo O, Gustavo C. Población desplazadaen Chiapas. Chiapas: CIEPAC; 1999.51 This action was part of the programming of a short-lived governmen-tal institution called “Vocalía de Compromisos por la paz” which wasformed by the federal government during the first dialogue with theEZLN. Shortly after the peace talks failed, this body was dismantled.52 Daes EI. “Human Rights of Indigenous Peoples.” 2000. para 8.

53 Villafuerte Solís D. La cuestión ganadera y la deforestación: viejosy nuevos problemas en el trópico y Chiapas. Tuxtla Gutiérrez: Uni-versidad de Ciencias y Artes del Estado de Chiapas, Gobierno delEstado de Chiapas; 1997:182.54 Perspectiva Estadística. Chiapas. September 2005. Available at:http://www.inegi.gob.mx/lib/buscador/busqueda.asp?s=inegi&texto=mortalidad%20de%20ni%F1os&seccionB=docit&i+ AccessedNovember 6, 2005.; Secretaría de Salud (SSA), Dirección General deInformación en Salud. Salud Publica Mex 2005; 47(2)171-187.55 Secretaría de Salud. Dirección General de Información en Salud.“Estadísticas de mortalidad en México: muertes registradas en elaño 2003.” Salud Pública de México 2005;47(2):171-187. The com-parisons between Chiapas and the national averages are telling. Therates for women (per 100,000) were as follows: diarrheal diseases:national (5.0) v. Chiapas (17.8); acute respiratory infections: national(15.6) v. Chiapas (23.7); pulmonary tuberculosis: national (2.2) v. Chi-apas (6.7); cervical cancer: national (11.2) v. Chiapas (18.5). The ratesfor men (per 100,000) were as follows; diarrheal diseases: national(5.6) v. Chiapas (22.5); acute respiratory infections: national (21.0) v.Chiapas (32.0); pulmonary tuberculosis: national (5.1) v. Chiapas(11.1).56 Secretaría de Salud (SSA), Dirección General de Información enSalud. “Estadísticas de mortalidad en México: muertes registradasen el año 2003.” Salud Pública de México 2005;47(2):171-187. Oaxacahad 23.0 percent.

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alization reflects the extreme exclusion faced byindigenous populations across Mexico. In Mexico,there are fifty-six officially recognized ethnic groupsconcentrated in four states, including Chiapas. In acountry that boasts over a 90% national literacy rate,astoundingly almost half of the indigenous populationis illiterate. Studies have estimated that municipali-ties with over 70% indigenous populations containapproximately 80% of the population living below thepoverty line.57

Yet, the indigenous groups represented in the con-flict zone face even greater degrees of poverty thanothers.58 For example: 58% of the Mixtec population (inCentral Mexico) lives in municipalities classified ashaving “very high” marginalization, compared with93% of the Tseltal population in Chiapas. Similarly, in1995, the infant mortality rate for speakers of Tojolabaland Tsotsil in Chiapas was 87 and 81, respectively, per1,000 live births, compared with forty for Chinantecaand Zapotec groups, and thirty-three among the Chon-tal population, who are from other states in Mexico.59

Historical Context: Pre-1994Health—and the lack of health care infrastructure andpublic health services—has long been a symbol of theMexican state’s historic neglect of the largely indige-nous rural population of Chiapas. In the 1980s and early1990s, independently organized social service groups inthe state, in particular in the Selva region, sprang upand began to play important roles. The growth of thesesocial organizations was accompanied by the develop-ment of independent campesino political organizations.Health was a central priority for these organizations, asit later became for the EZLN.

Thus, when the Mexican state began to establishhealth services in the most remote regions of Chiapas,health programs were already in place which had beenpromoted by churches, non-governmental serviceorganizations (NGOs), universities and other highereducational institutions, as well as by political organi-

zations.60 The governmental programs to extend thecoverage of health services to isolated regions rarelycoordinated with existing non-governmental programsand often forced the population to choose between thestate health services and those provided by the churchor another civic organization. These “choices” were, inturn, heavily politicized, which only served to exacer-bate polarization within the communities.61

Expansion of government health services favoredpopulations with greater affinity to the state govern-ment and to the then-ruling Institutional RevolutionaryParty (PRI). As former New York Times Mexico corre-spondents, Sam Dillon and Julia Preston wrote, the PRIexercised “an oppressive hold on every aspect of Mexi-can life [which] made it the world’s longest-ruling polit-ical organization.”62 Health services, and thepossibilities that they offered for patronage, were noexception.

During the years prior to the Zapatista uprising in1994, health was one of the issues that the EZLN pro-moted most actively, in order to establish a relationshipwith the indigenous communities and gain their trust. Ithas been suggested that the EZLN leader himself, Sub-comandante Marcos, first arrived in Chiapas in order toparticipate in a course for health providers.63 Theexpectation of improving the health and nutritional sta-tus, as well as the living conditions of the population,were central driving forces behind the widespread par-ticipation in the Zapatista uprising.

In the First Declaration of the Lacandón Jungle,which was made public on January 1, 1994, the EZLNdeclared war against the Mexican Army and announceda military advance toward Mexico City. In that docu-ment, the EZLN points to hunger and death from cur-able illnesses as the principal reasons that gave rise tothe armed uprising and mentions in their basicdemands, health and nutrition, as well as labor condi-

57 See E.g., Psacharopoulis G, Patrinos H. Indigenous People andPoverty in Latin America: An Empirical Analysis. Washington, DC:World Bank: 1994 cited in Lozano R, Zurita B, Franco F, Ramírez T,Hernández P, Torres JL. “Mexico: Marginality, Need, and ResourceAllocation at the Country Level.” In: Evans T, Whitehead M, Diderich-sen F, Bhuiya A, Wirth M, eds. Challenging Inequities in Health: FromEthics to Action. New York: Oxford University Press; 2001:271-295,280. 58 Secretaría de Salud (SSA), Instituto Nacional Indigenista (INI). Lasalud de los pueblos indígenas. México: SSA, INI, 1992; ConsejoNacional de Población (CONAPO). La situación demográfica de Méx-ico, 1998. 2a edición. México: CONAPO, 1998.59 CONAPO. La situación demográfica en México, 1998. 2ª. edición.México: CONAPO; 1998.

60 For example, beginning in 1980, el Instituto Politécnico Nacional(National Polytechnic Institute) developed the Plan Tojolabal and thePlan de la Selva health programs, which, in coordination with theComitán General Hospital (public hospital run by Ministry of Health),created an extensive network of community health services andtraining for health promoters. The Universidad Autónoma Metropoli-tana, also had successful training programs relating to humanresources in health, which contributed to the medical care of popula-tions in extreme poverty.61 Arana-Cedeño M, Loyola E. “Transición epidemiológica en lapoblación de la Selva Lacandona, Chiapas.” In: Vázquez-SánchezMA, Ramos Olmos MA, eds. Reserva de la Biósfera de MontesAzules, Selva Lacandona. Investigación para su conservación. Méx-ico: Publicaciones especiales ECOSFERA 1992;1:322-341.62 Preston J, Dillon S. Opening Mexico: The Making of A Democracy.New York: Farrar, Strauss and Giroux; 2004: ix.63 Tello-Díaz C. La rebelión de las cañadas. Mexico City: Editorial Caly Arena; 1995.


tions, land, education, autonomy, democracy, justice,and peace with dignity.64

Post–Uprising: The Emergence of CivilResistanceThe military actions in January 1994 lasted only twelvedays, but the fighting was only the first phase of a pro-tracted conflict. Throughout 1994 and early 1995, morethan 6,000 people were evacuated from their communi-ties by the Mexican military. At the same time, the gov-ernment emptied the schools and health clinics of thosecommunities that had been supportive of the Zapatistas.This displacement, which was promoted as a “protectivemeasure,” facilitated the identification of those whosympathized with the EZLN and those who did not.65

By June 1994, after numerous violent clashes withthe military and the failure of the dialogue with the gov-ernment, the EZLN adopted a posture and strategy of“resistencia” (resistance). In the Second Declaration ofthe Lacandón Jungle, issued in June 1994, the EZLNemphatically called upon its sympathizers to refuse allcollaboration with the government and to reject all offi-cial programs, including those for health:

…We will accept nothing that comes from the rot-ten heart of the bad government, not a singlecoin, nor a medicine, nor a stone, nor a grain offood, nor a crumb from the handouts that it offersin exchange for our dignity. We will take nothingfrom the supreme federal government. Even ifour pain and our grief deepen, though death maystill be with us, at the table, in the land, and on theroof; though we may see that others sell them-selves to the hand that oppresses them; thougheverything might ache and grief weeps even fromthe stones, we will take nothing from the govern-ment. We will resist . . .66

Resistance came to be a central element of the Zap-atistas’ political stance as well as of their strategy.

Civil resistance went beyond health care to othersocial services, such as education which was expressed

through the rejection of public schools. At the beginningof the conflict, a large proportion of schools had closedtheir doors. During 1994, nearly all public school activityin the regions affected by the conflict ceased. After Feb-ruary 1995, schools gradually reopened and the childrenwho returned to these schools were from families hostileto the EZLN, and those who had not been displaced dur-ing the first year of the conflict. The opposition commu-nities rejected the official teachers from the state andfederal government. Gradually, in some regions,national and international civil society organizationsdeveloped (and continue to maintain) primary and sec-ondary education programs for the boys and girls of theZapatista movement as well as their sympathizers. TheEZLN’s negotiating power quickly grew stronger throughtheir capacity to maintain resistance, rather thanthrough military activity.67 Although resistance was aresponse to governmental policies, one consequence ofthis strategy was to foster further polarization betweencommunities that were aligned with the resistance—andtherefore the EZLN—and those that were not.

1995-2000: The Government’sResponse In February 1995, the Mexican Army engaged in a majoroffensive to re-take portions of territory under Zap-atista control and re-settle pro-government villagers,effectively displacing thousands of Zapatistas to moreremote and inaccessible areas. Following intense pub-lic outcry about the military offensive, the governmententered into negotiations with the Zapatistas andapproximately one year later, on February 16, 1996, theEZLN and the federal government, jointly issued the“San Andrés Accords.” These Accords did not specifi-cally address the organization of health care but theydid set out a new “inclusive social contract based on aconsciousness of the fundamental plurality of Mexicansociety and the contribution of indigenous peoples tonational unity.”68 The Accords also recognized indige-nous peoples’ rights to “free determination” as setforth in Convention 169 of the International Labor Orga-nization, to which Mexico is a party, and asserted thatautonomy in the organization of their affairs was theconcrete expression of such free determination. Insigning the San Andrés Accords, the governmentassumed a core commitment to improve the healthconditions and care of the indigenous peoples of Chia-

64 EZLN. “Segunda Declaración de la Selva Lacandona.” In Primera ysegunda “Declaración de la Selva Lacandona:” Comunicados del 1de enero al 23 de marzo de 1994. Mexico City: EZLN; 1994. Availableat: http://www.ezln.org/documentos/1994/19940610.es.htm.Accessed November 6, 2005. 65 Centro de Derechos Humanos Fray Bartolomé de Las Casas(CDHFBC). “Informe para el Relator Especial de la Organización delas Naciones Unidas para los Derechos Humanos y las LibertadesFundamentales de los Indígenas.” Chiapas: CDHFBC. San Cristóbalde Las Casas; June 12, 2003. 66 EZLN. “Segunda Declaración de la Selva Lacandona.” 1994. Avail-able at: http://www.ezln.org/documentos/1994/19940610.es.htm.Accessed November 6, 2005.

67 The efficacy of this strategy largely rests on the incapacity of thefederal, state and local governments to confront or control it. TheEZLN was thus able to reframe the terms of the confrontation.68 Global Exchange. “The San Andrés Accords.” 2004. para 2. Avail-able at: http://www.globalexchange.org /countries/americas/mex-ico/SanAndres.html Accessed November 6, 2005.

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pas, in accordance with the principles of self-determi-nation and autonomy.69 However, this vision was neverto materialize. Then-President Zedillo took no steps toimplement the San Andrés Accords and by Septemberof 1996, peace talks had collapsed.

During and after the negotiations, far from the auton-omy called for under the San Andrés Accords, the Mexi-can army was heavily involved in providing health andother social services within the small rural communi-ties that lay in the conflict zone. The army has repeat-edly justified its presence in indigenous communities aspart of its “social work,” which in large measure con-sists of medical care and public health services. Investi-gations, including PHR’s previous report on the subject,have found, however, that this social work in the contextof low-intensity warfare, promotes distrust of healthservices generally, as well as social polarization.70 Anypopulation that rejected the military’s medical servicesor any other activities was automatically labeled Zap-atista and became subject to suspicion.71 In its 1999review of Mexico’s compliance with its obligations underthe International Covenant on Economic, Social andCultural Rights (ICESCR), the United Nations Commit-tee on Economic, Social and Cultural Rights (ESC RightsCommittee) stated that it was particularly concernedabout “the presence of numerous military and paramili-tary forces within the indigenous communities of Chia-pas, and in particular about the allegations made by civilsociety organizations that these elements interfere withthe supervision and implementation of developmentprograms and the distribution of economic and socialassistance, and about the lack of consultations with thecommunities concerned.”72 In 2000, in part as aresponse to pressure from civil society organizationsthat followed up on the ESC Rights Committee’s recom-mendations, Federal Army health posts were removed,although testimonies indicate that there are residualeffects on social polarization which remain.

Coinciding with the heightened military presence incommunities during 1995 and 1996, further internaldisplacements were provoked by fear of burgeoningirregular armed forces which the army promotedamong campesinos opposed to the EZLN. It is nowknown that members of the Mexican military financed,

armed, and trained these “paramilitary” groups, asthey later came to be called, with the aim of containingthe Zapatistas. These groups have been and continue tobe the main perpetrators of human rights violations inthe region.73

The government has also turned to other tactics toundermine social cohesion in Zapatista communities.For example, since 1995, both the federal military andother groups opposing the EZLN have promoted themassive introduction of alcoholic beverages to under-mine Zapatista resistance. EZLN communities are“dry”, which is a policy that has garnered widespreadsupport from women in those communities who claimthat this policy has led to a reduction in domestic vio-lence.74 The systematic introduction of alcoholic bever-ages has aggravated divisions and conflicts in theregion.

As documented in PHR’s previous report, HealthCare Held Hostage, the civilian health sector in Chiapaswas itself deeply politicized in the years following theEZLN uprising. Health Care Held Hostage revealed thatpatients were routinely asked politically motivatedquestions at public health care centers affiliated withIMSS-Solidaridad as well as the Ministry of Health. Zap-atista sympathizers alleged persistent discrimination by

69 Global Exchange. “The San Andrés Accords.” 2004. Available at:http://www.globalexchange.org/countries/americas/mexico/SanAn-dres.html Acessed November 6, 2005.70 Yamin AE, Penchaszadeh V, Crane T, Health Care Held Hostage:Violations of Medical Neutrality and Human Rights in Chiapas, Mex-ico. Physicians for Human Rights, Boston: 1998; 25-26, 31.71 Arana-Cedeño, M. “La labor social del ejército.” La Jornada: Feb-ruary 20, 1998.72 CESCR, Concluding Observations: Mexico, E/C.12/1/Add.41.CESCR Session February, 21 1999. para 25.

Soldiers outside of a primary school in the municipality ofChenalhó, in the Altos region, where a military medicalpost was installed as part of the “social work” of the Federal Army (1998).

73 Hidalgo O, Castro G. Militarización y paramilitarización en Chia-pas. Chiapas: Centro de Investigaciones Económicas y Políticas deAcción Comunitaria (CIEPAC). San Cristóbal de Las Casas, Chiapas,December 1997.74 Misión Civil Nacional e Internacional de Observación por la Paz.San Cristóbal de las Casas, Chiapas, December, 1997.75 At the time of PHR’s previous report, this program was calledIMSS-Solidaridad and it was subsequently named IMSS-Oportu-nidades for a short time. Yamin AE, Penchaszadeh V, Crane T, HealthCare Held Hostage: Violations of Medical Neutrality and HumanRights in Chiapas, Mexico. Physicians for Human Rights, Boston:1998; 25-29.


individual providers and institutions managed by bothIMSS-Solidaridad and the Ministry of Health.75 The find-ings of that study were corroborated by other studies.76

After the Acteal massacre on December 22, 1997, inwhich PRI-aligned paramilitary gunmen killed forty-five unarmed people, including two infants and sixteenother children, as they were praying, the governmentfurther shifted its counterinsurgency strategy, withnotable implications for health. According to severalsources, then-President Zedillo and Labastida, his newSecretary of Government, developed a two-prongedstrategy: to entice indigenous communities back “intothe fold” by investing $3.5 billion pesos in Chiapassocial programs while destroying the Zapatistas’autonomous municipalities one by one.77

Within these social programs, health care and publichealth figured prominently. In 2003, Chiapas was stillreceiving the greatest share of national funds for theIMSS-Oportunidades program (22%), although its shareof the overall health budget was small.78 Accountabilityfor how the monies were spent or ensuring non-dis-crimination was virtually non-existent. For example,through programs such as the “Cañadas DevelopmentProgram” (Programa de Desarrollo de las Cañadas),the government funded some social programs, such asPaz y Justicia (“Peace and Justice”)79 which had strongties with the Federal army, and operated as a paramili-tary wing that conducted activities in the Norte regionof Chiapas.80

During these years, the EZLN and its autonomouscommunities became increasingly insular. As Prestonand Dillon write of this period:81

the Zapatistas, seeing that the Zedillo govern-ment was determined to destroy their alternativeforms of self-rule, went into a defensive with-drawal. Their autonomous authorities went intohiding, and they closed the townships to most vis-itors. The differences between the priista andZapatista villagers hardened into hatred. The gov-

ernment’s strategy also forced new privations onthe Zapatistas who remained dedicated to theirtownships. Besieged by army troops, the townswere cut off from regional commerce, and theflow of international aid was large but not reliableenough to compensate. Since the Zapatistasrefused to pay taxes, the authorities cut off theirelectricity, which was supplied by a state-ownedcompany.

Construction of water distribution systems and otherbasic services, as well as access to government credits,were also systematically terminated. For their part, theZapatistas blocked the construction of roads that mightfacilitate commerce, arguing that they would give thearmy access. The communities in resistance refusedmany directly provided governmental health services,including vaccinations.

2000-2005: Change in the Governmentand More of the Same

On July 2, 2000, Vicente Fox, the candidate of theNational Action Party (Partido de Acción Nacional, orPAN) was elected president of Mexico, breaking theover 70-year PRI stranglehold on the Mexican presi-dency. The election of Fox was hailed as a “real openingof the political system” in Mexico and a chance forauthentic democracy.82 Among other things, Fox prom-ised to seek a negotiated solution to the conflict withthe Zapatistas, which at the time he estimated wouldtake fifteen minutes.83

During the first months of Fox´s administration,public expectations rose that a solution to the conflictwas near. A Zapatista delegation marched peacefully toMexico City, attracting a vast participation of civil soci-ety and left wing political parties. The climactic momentof the march came when an indigenous woman, theComandante Esther,84 gave a speech addressing theNational Congress about the rights of the indigenouspeople and autonomy. Over the course of the followingdays, President Fox introduced a bill that recognizedthe autonomy of indigenous people, the most criticalaspect of the San Andrés Accords. This bill had beendrafted by a non-partisan Congressional commission(COCOPA).85

However, the national Congress passed this law with

81 Preston J, Dillon S. Opening Mexico: The Making of A Democracy.New York: Farrar, Strauss and Giroux; 2004: 455.82 Id., Preston J, Dillon S. 2004: 19.83 Gómez M. Fox “Frente a Chiapas y a los pueblos indígenas” La Jor-nada, June 1, 2000: p.3.84 “Discurso de la Comandante Esther ante el Congreso” La JornadaMarch 29, 2001:p.5.

76 Arvide I. “La guerra de los espejos: La desconfianza en institu-ciones oficiales, se traduce en enfermedad y muerte.” México:Océano;1998:140-144.77 See e.g., Preston J, Dillon S. Opening Mexico: The Making of ADemocracy. New York: Farrar, Strauss and Giroux; 2004:454.78 Secretaría de Salud (SSA), Dirección General de Información enSalud. “Estadísticas de recursos financieros públicos para la saluden México, 2003.” Salud Pública de México. 2005;47:90-98, 91.79 Paz y Justicia is an elite paramilitary group active in the Altos andin the northern part of the Selva region of Chiapas. It serves as a pilotprogram in the paramilitary-counterinsurgency project. 80 Fazio C. “La guerra invisible.” La Jornada. February 14, 2005; Mar-iano Granados Chapa Miguel Ángel. “Chiapas, todavía.” DiarioReforma: February 13, 2005.

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a number of amendments that distorted the originalaim of the concept of autonomy included in the SanAndrés Accords. The EZLN broke ties with the Party ofthe Democratic Revolution (PRD) and other left-wingparties as some of their representatives had taken partin passing what the EZLN perceived as a betrayal of theintent of the San Andrés Accords. This debacle usheredin a period of renewed tensions together with a radical-ization of EZLN resistance.86 Consequently members ofcommunities that supported the EZLN were con-demned to a stance of permanent opposition withrespect to the pro-government communities in order toretain their identity. Maintaining such a stance createdever greater tensions and consumed ever greaterresources of the communities involved.

In 2000 an agreement was signed between the Mexi-can government and the Office of the High Commis-sioner for Human Rights (OHCHR) for theestablishment of a sustained presence of the OHCHR inMexico. The OHCHR felt such a presence was neces-sary for several reasons: the Mexican government wasat an impasse on the implementation of the San Andrésaccords; the human rights conditions of the indigenouspeoples in Chiapas and other states had not improvedand many people still lived in conditions of “extremepoverty and marginalization” and forced migration; theincreasing militarization of the region; and the land dis-putes in which indigenous peoples were being deprivedof their land and livelihoods. Daes, the Chairperson-Rapporteur of the OHCHR Working Group, also sig-naled the need for independent monitoring of thesituation.87

At the state level, the 2001 election of the alliancecandidate Pablo Salazar Mendiguchía as governor ofChiapas appeared to bring about more openness andremedial actions, such as the dismantling of various

former PRI programs, including the above-mentioned“Cañadas Development Program.”88 As a result of thisgovernmental shift, numerous civic organizations andcommunities that had maintained a posture of resist-ance progressively reinitiated participation in some ofthe government’s health and development programs.Others, however, have continued to follow the strategyof resistance and have become increasingly radicalized.Consequently, those communities and groups support-ing a hard-line Zapatista resistance position havepulled away from those who have assumed a more flex-ible attitude with respect to the government. In someinstances, violent confrontations have occurredbetween groups that were allies until recently.89

Forms of resistance, such as the non-payment ofelectricity bills, have also created confrontations. Inmany cases, the government-owned electricity com-pany has responded by cutting the supply of electricityto opposition communities. As an effort to expandresistance, the EZLN has called upon other politicaland social organizations to adhere to the non-paymentof electricity bills.90

Although tensions between the state governmentand the EZLN have decreased, evidence suggests thatinternal community divisions and confrontationsremain almost unchanged and are still potentially dan-gerous. Despite the fact that the number of cases hasdeclined since 2001, human rights organizations stilldenounce cases of arbitrary arrests, extrajudicial exe-cutions and military invasions of community lands.Indeed, the violence that pervades the conflict zone haspersisted and even worsened in recent months.91

At the same time, communities have increasingly

85 Comission on Concordance and Pacification, (Comisión de Concor-dia y Pacificación, COCOPA). 86 After issuing a press release stating that it refused to recognizethe new law, the EZLN broke off talks with the government andmaintained a public silence for almost twenty months. 87 OHCHR. “Human Rights of Indigenous Peoples.” Submitted byErica-Irene A Daes, Chairperson-Rapporteur of the Working Groupon Indigenous Populations. E/CN.4/Sub.2/2000/CRP.1. August 3,2000; paras 1, 2, 6, 8, 10. Available at: http://www.hri.ca/forthere-cord2000 /documentation/commission/e-cn4-sub2-2000-40.htm.Accessed November 8, 2005. 88 Salazar was the candidate of a seven-party coalition, including thePartido de la Revolución Democrática (PRD, Party of the DemocraticRevolution), Partido Acción Nacional (PAN, National Action Party),Partido del Trabajo (PT, Work Party), Partido Verde Ecologista deMéxico (PVEM, Green Ecologist Party), Convergencia para la Democ-racia (CD, Democratic Convergence), Partido de la SociedadNacionalista (PSN, National Society Party), Partido del CentroDemocrático (PCD, Center Democratic Party), and Partido de laAlianza Social (PAS, Social Alliance Party).

89 Numerous violent confrontations have occurred between EZLNsupporters and PRD members in recent years, some of which haveled to fatalities, including those in Pasté, San Juan Chamula, SanIsidro and Nuevo San Rafael. Ambushes, assassinations and incur-sions by armed men also occur frequently. The government has alsocontinued to cut electricity to opposition communities, such asmunicipalities of Yajalón, Flor de la Alianza, Tumbalá, Tila andSabanilla. There have been arbitrary arrests, extrajudicial execu-tions and military invasions of community lands, such as in the ZonaNorte of Chiapas, zona baja de Tila, Ejido Emiliano Zapata; and SanJosé Bascán, municipio de Salto de Agua. See e.g. www.enlace-civil.org.mx. Accessed January 10, 2006. 90 Diario Reforma, Jan. 9, 2006.91 See e.g. allegations of reactivation of militarization and paramilita-rization by the Centro de Derechos Humanos Fray Bartolomé de lasCasas. Boletín Informativo Diario de la Comisión Mexicana deDefensa y Promoción de los Derechos Humanos, January 15, 2006.In other events, on February 17, 2005 in an operation in the munici-pality of Tila, in the Norte region of Chiapas, police beat and arbitrar-ily detained at least 54 people according to Heriberto Cruz Vera, theparish priest of Tila. On March 20, 2005, the Center for HumanRights, Fray Bartolome de las Casas, received word that at least oneperson had been assassinated in the community of Masojá Grande in


shifted from being in opposition to being politicallydivided. However, this has not fostered a solution to the“insurgency”; on the contrary, it has led to the map ofthe conflict zone being covered with ever increasingnumbers of divided communities, with ensuing healthconsequences.92

Divided communities lose the capacity to speak withone voice, or through a particular leader or spokesper-son, and are unable to respond collectively as needed.Building or maintaining a water distribution system,transferring a woman with an obstetric emergency tothe hospital, identifying children with malnutrition, ormaking sure that health services function adequately,are only a few of the important activities that requirecommunities to respond collectively. These activitiesare difficult or impossible when there are no mecha-nisms of communication and collaboration. The nega-tive impact of divided communities range from onefaction of the population blocking another’s use of serv-ices, to pressuring medical personnel to deny care tothe opposing group. Moreover, the atmosphere ofpolarization and division in communities causes a cli-mate of permanent tension that affects a large numberof health conditions.93

State health authorities in Chiapas have acknowl-edged in recent years that community divisions poseenormous difficulties in implementing programs. Theyhave initiated a limited number of programs on healthand nutrition that emphasize the importance of socialinclusion of all the population, regardless of their polit-ical or religious affiliation. However, the positive effectsof this new strategy have been stymied due to the lack

of resources, restricted coverage, and the limitationson training health personnel for these programs.94

After a long period of relative silence, on June 21,2005, the EZLN declared a “Red Alert” to call attentionto the ongoing tensions in the conflict zone. The EZLNthen published the Sixth Declaration of the LacandónJungle, in which it proposed a national program forpeaceful struggle to attain a “new constitution thatreincorporates the demands of the people” includinghealth, independence, democracy, justice, liberty, andpeace. In order to achieve this goal, the Zapatistas pro-posed the creation of what they called the “Other Cam-paign”–alluding to the presidential campaign and otherpolitical campaigns already underway. On January 1,2006, the “Other Campaign” was formally launched inSan Cristóbal de Las Casas, Chiapas.

the municipality of Tila. On March 21, gunfire was heard on the out-skirts of the community of Nuevo Limar which is also in the munici-pality of Tila. Following the disturbances, there were heightenedrumors regarding people connected to the paramilitary group Paz yJusticia (Peace and Justice) and to the PRI (Institutional Revolution-ary Party) in Tila. The rumored paramilitaries were believed to bemeeting in various communities and carrying firearms. The dis-placed communities in Tila have expressed concern about the Tilaassassination, particularly since the leaders of these communities inrecent months have received threats and have been subject to intim-idation. Available at: http://www.laneta.apc.org/cdhbcasas/Boletines/2005/062905_tortura_yabteclum.htm. Accessed February10, 2006.92 For example, on the morning of November 25, 2005, members ofthe Junta de Buen Gobierno (Junta for Good Government) de la Real-idad accused Zapatistas from the community Lucha Campesina,Altamirano, of firing on members of the Central Independiente deObreros Agrícolas y Campesinos (CIOAC, Independent Central ofAgricultural Workers and Peasants), leaving six dead and severalbadly wounded. The Junta de Buen Gobierno was closely affiliatedwith the Partido Revolucionario Democrático (PRD). Shortly afterpublishing the accusation, the JBG corrected itself, stating that thereare no Zapatistas in the community where the shooting took placeand that the incident occurred between people not connected to the

EZLN. By November 30, the JGB had researched the problem andidentified the shooters as other PRD affiliates. Furthermore, theyalleged that a former PRD deputy had falsely accused the Zapatistasfor the incident. This incident marks the decline in good relationsbetween former allies in the Zapatista struggle. Available at:http://www.jornada.unam.mx/2005/11/27/016n1pol.php andhttp://www.jornada.unam.mx/2005/11/30/025n1pol.php. AccessedDecember 13, 2005.93 Although this study did not explicitly address the consequences formental health, many manifestations of fear, insecurity, and depres-sion suffered by inhabitants in the conflict zone were observed dur-ing fieldwork. For example, an extremely worrisome indicator of thedisruption of the social tissue in the communities affected by thepolarizing effects of the conflict is suicide. Eight cases of suicidewere found in the study (seven men and one woman). Seven of thesedeaths were caused by the ingestion of paraquat (Gramoxone), apowerful herbicide widely used by Chiapas peasants who work onlarge farms. In the eighth case, death was caused by hanging. Five ofthese suicides occured in divided communities. 94 See e.g., Programa “Vida Mejor para las mujeres, las niñas y losniños de Chiapas” Available at: http://www.dsocial.chiapas.gob.mx/Vida_Mejor.htm. Accessed December 20, 2005.

1 9

Given that poor health conditions and care were anunderlying source of the Zapatista uprising, thestudy measured a set of leading health indicators

in the conflict zone. The principal research questionsincluded in this report were: 1) What is the maternalmortality ratio (measured by maternal deaths/100,000live births)? 2) What is the infant mortality rate (deaths ofchildren under one year/1,000 live births)? 3) What is theprevalence of childhood malnutrition? 4) What is theprevalence of smear-positive pulmonary tuberculosis?and 5) Are there significant differences between keyhealth indicators for the study population and for the pop-ulations of Chiapas (as a whole) and/or Mexico?95 Second,the study set out to examine if there is an associationbetween health status (as represented, e.g., by infant andmaternal mortality, malnutrition prevalence, and tuber-culosis prevalence), access to and utilization of healthservices, and conflict-related factors (in particular, politi-cal-party affiliations and intra-community division in theareas of Chiapas most affected by the conflict); and ana-lyze the human rights implications of those findings.

Identification of Study PopulationBased upon exhaustive consultations with humanrights groups, governmental institutions (including theMinistry of Health, Ministry of Public Works, and Min-istry of Education), non-governmental organizations inthe region, churches, and newspaper reports,96 munici-palities were identified as “severely affected by the con-flict” when one or more of the following events hadoccurred: combat between the EZLN and the Mexican

army; paramilitary activities; assassinations of leadersor families of campesinos associated with the EZLN;displacement of persons due to presumed affiliationwith the EZLN or with paramilitary groups; and publicprotests and organized appearances by the EZLN. Vir-tually all of the identified municipalities fell within theAltos, Norte and Selva regions of the state. Within thesethree regions, a list was compiled of all communitieswith populations between 300 and 2,499.97 Informationfrom the above-mentioned sources was then used toidentify the political affiliation of all the communities onthe list. Community status was classified as:

1. Opposition communities sympathizing with theEZLN (some of which were “in resistance”),

2. Pro-government communities (sympathetic to thegovernment), and

3. Divided communities (which according to availableinformation contained two or more groups whosepositions toward the EZLN differed).

Fifty-four communities were randomly selected from atotal of 524: eighteen in each of the three regions (six oppo-sition, six pro-government, and six divided in each region).Six additional communities from the three regions werealso randomly chosen as alternates (two opposition, twopro-government, and two divided communities).

Although multiple political, religious, and other localexperts were consulted in order to classify all communi-ties by political affiliation (opposition, pro-government,and divided communities), there was no “gold standard”census with which the investigators could confirm theopinions of local experts. As it would not have been polit-ically, logistically, and financially feasible to visit everycommunity in the study area to determine its politicalaffiliation before the selection of study sites, after theprocess of classification and random selection of com-munities to be included in the study sample, communityleaders were approached about enrollment in the study.At this stage, investigators determined that the current

97 INEGI. XII Censo General de Población y Vivienda, 2000. TabuladosBásicos Nacionales y por Entidad Federativa. Base de datos y tabu-lados de la muestra censal. Aguascalientes: INEGI; 2001.;http://www.inegi.gob.mx.; INEGI. Chiapas. Conteo de población yvivienda, 1995. Resultados definitivos. Tabulados básicos. México:INEGI; 1996. Available at: http://www.inegi.gob.mx/est/ contenidos/espanol/proyectos/coesme/programas/ficha.asp. AccessedNovember 6, 2005.

III. METHODS

95 Not all of the study questions or domains of inquiry are presentedin this report, which focuses on violations of the right to health; addi-tional areas of study are discussed in journal articles publishedbased on the findings of the study. See: Brentlinger P, Sánchez-Pérez HJ, Arana-Cedeño M, Vargas MG, Hernán MA, Micek M, FordD. “Pregnancy Outcomes, Site of Delivery, and Community Schismsin Regions Affected by the Armed Conflict in Chiapas, Mexico. ACommunity-based Survey.” Social Science and Medicine2005;61:1001-1014; Sánchez-Pérez HJ, Hernán M, Ríos-González A.et al. “Malnutrition among Children under Five Years of Age in Con-flict Zones of Chiapas, Mexico.” American Journal in Public Health.forthcoming 2006. Other issues as vaccination, overall mortality,among others, are in preparation.96 National newspapers consulted: La Jornada, El Financiero, andReforma; Chiapas newspapers consulted: Cuarto Poder and, in SanCristóbal de las Casas, El Tiempo.

political affiliation of the selected communities wassometimes different than what the experts had believed.

Based on interviews with community authorities andobservations made in the field, of fifty-four selectedcommunities, fourteen (26%) differed from their origi-nal classification: five pro-government communitieshad become either opposition or divided, five dividedcommunities had become pro-government, and fouropposition communities had become either pro-gov-ernment or divided. Of the eighteen alternate commu-nities, three (17%) did not correspond to their originalclassification: two divided communities had becomepro-government communities, and one pro-govern-ment community suffered division.

Of the fifty-four selected communities, thirty-seven(68.5%) agreed to participate in the study, twelve(22.2%) refused, and five (9.3%) were not visited for thefollowing reasons: three for lack of contact with theEZLN “autonomous governing councils,”98 one for rea-sons relating to the security of the field team,99 and oneno longer existed when the study took place.100

Given the non-response rates of opposition anddivided communities, four other communities werepurposively selected to be included in the sample tocreate comparative sample sizes among types of com-munities: one opposition and three divided. In the threedivided communities, the opposition faction partici-pated in the survey only under the condition that the“other” faction would not.101

The overall non-response rate at the community levelwas 23.6% without including the four non-randomly-selected communities. The highest non-response ratecame from opposition communities (41.1%), while thelowest negative response rate came from the divided

(9.1%). At the household level, non-response was negli-gible; the members of only twenty households refusedto provide any information for the study.

Consequently, the study was carried out in forty-sixcommunities: thirty-seven chosen randomly, five ran-domly-selected alternates, and four purposivelyselected.102 Of these, twenty were pro-government, sixopposition, and twenty divided. Of these twenty dividedcommunities, the political affiliation of householdscould only be determined in twelve.103

SamplingWithin each community, two procedures were used toselect households for the study. First, one out of every threehouseholds was randomly selected to participate in thecross-sectional survey. The field team went to each com-munity and drew up a census and map of its households.

Second, under the following circumstances, addi-tional people were surveyed:

• When there had been a pregnancy, birth or a death ina household during the two years prior to the study.

• When there was someone age fifteen and older witha chronic cough (lasting more than fifteen days atthe time of the study), or when the possibility of PTBwas suspected.

Thus, although the health survey was fully con-ducted in one of every three households, the fieldwork-ers were instructed to inquire in all householdswhether either of the aforementioned circumstancesapplied to anyone there. This information was comple-mented with data obtained in an in-depth interview withthe authorities in order to limit, as much as possible,the possibility of under-reporting cases of interest (i.e.,pregnancies, deaths, and probable cases of PTB). Oncethe information on these aspects had been gathered,either through an in-depth interview with communityauthorities or through the household survey, the field-workers proceeded to verify whether all the reportedcases of deaths, pregnancies, or possible PTB had beenincluded in the study.

For the identification of cases of PTB, persons iden-tified with chronic cough were given an additional ques-tionnaire and asked to provide three sputum samplesfor the purposes of detecting PTB through acid-fastsmears and cultures. The sensitivity of such testsvaries according to the quality and quantity of samplesobtained and the quality of the processing and readingperformed. In Mexico, acid-fast smears have been esti-

102 Thirteen from the Altos; sixteen from the Selva; and seventeenfrom the Norte regions, respectively.103 For reasons of safety, the research team did not ask for the polit-ical affliation of some of those surveyed.

98 In autonomous municipalities, opposition communities are guidedby the ordinances of autonomous councils, which have replaced offi-cially designated authorities. 99 A few days prior to conducting the study, a murder had occurred inthe community.100 It is important to mention that in some cases of refusal, the denial toparticipate in the study did not come from the inhabitants of the vil-lages, but from the autonomous councils. In one case of refusal, thecommunity, in a meeting of the authorities and inhabitants, had alreadyagreed to the study, but a group of five inhabitants did not accept thestudy. Consequently, a decision was taken not to proceed with the studyin order to avoid any confrontation within the community.101 However, these were not the only communities in which only onepolitical faction was surveyed. In one divided community, for exam-ple, one of the two groups in the community refused to participate inthe study because shortly before the survey, a man had been mur-dered and another had been wounded. Both of the victims (EZLNsupporters) belonged to the group in the community that partici-pated in the study, while the aggressors belonged to the group thatnot participated. The study was conducted only among the group thathad suffered the aggression, amid considerable fear of furtherattacks against its members as well as the field team.


M E T H O D S 2 1

mated to permit detection of approximately 70% of pos-itive PTB cases.104 In the case of Chiapas, various stud-ies have shown that the sensitivity of the test isdrastically reduced in highly marginalized populations(as low as 44%).105 The stigma associated with admittingto symptoms of PTB, combined with the likelihood offalse negatives, suggests that reported numbers ofPTB cases are almost certainly underestimated.

In cases of self-reported illnesses in the month priorto the study, an additional questionnaire was also givento identify possible barriers of access to health servicesas a consequence of the conflict.

To ascertain the nutritional status of the under-fivepopulation—the 2,704 young children recorded in thehousehold census—weight and height were measuredto determine height-for-age, weight-for-age, andweight-for-height parameters.106 The field team wasgiven intense training to standardize the measure-ments and data recording. This process was conductedin a theoretical and practical manner, using the stan-dardization exercises developed by Habitch and Mar-torell.107 To ensure data quality, a new set ofstadiometers and Salter weight scales were employed,which were calibrated before each measurement.

In the forty-six communities studied, informationwas obtained from 17,931 individuals in 2,997 house-holds: 1,477 households (49.2%) from pro-governmentcommunities, 256 (8.6%) from opposition communities,and 1,264 (42.2%) from divided communities (496 pro-government, 168 opposition, and 600 of undeterminedpolitical affiliation).

ConsentAt the time the study was conducted, there was no func-tioning institutional ethical review committee in Chiapas.

However, the protocol was approved by a panel ofexperts assembled by PHR, and all research was carriedout in accordance with the Declaration of Helsinki.108

Consent for conducting the study in the selectedcommunities was obtained in stages, and is itselfreflective of the extreme degrees of mistrust that existsin the conflict zone. First, authorization was obtainedfrom community leaders and institutions of authority.These institutions, for the most part, are made up of acommunity’s general assembly or the assembly’s rep-resentatives, such as health and education commit-tees. Once permission had been obtained from thecommunity authorities, a meeting was convened atwhich the study was presented to the entire adult popu-lation of each community. Finally, authorization fromeach head of the household was solicited in order tobegin the survey.

Community authorities were shown the question-naires to familiarize themselves with the questions tobe asked in the households, and they were given theopportunity to delete any they considered inappropri-ate. The authorities of six communities (all in the Altosregion) recommended refraining from asking questionsabout religion. For reasons of security, in eight of thedivided communities, household members were notasked about their political affiliation.

In addition to the project co-directors representingECOSUR and DDS-CCESC and the fieldwork coordina-tor, the field-work team comprised nine interviewers,four men and five women, who were hired based ontheir previews work experience with campesinos andcommunity health promotion, as well as their languageskills: two spoke Tseltal, two spoke Tsotsil, two spokeboth of these languages.

No financial incentive or compensation was providedto the participants, except for the wages paid to thecommunity guides who had knowledge of the locationof households in communities, and who helped eitherwith the translation of the questions and answers dur-ing the survey, or in the collection of samples to identifypossible cases of PTB.

Questionnaires and SurveyThe design of the household survey was partially basedon surveys that had been used in a series of previousstudies conducted in other parts of the state of Chia-pas.109 Specific questions were added that related to con-ditions resulting from the armed conflict and resistance.The household survey included the following sections,which are discussed in this report: demographic and

104 Llaca Díaz JM. “La baciloscopia y el cultivo en el diagnóstico de laTuberculosis Extrapulmonar.” RESPYN. 2003:4(3).105 Sánchez-Pérez HJ, Hernán M, Hernández-Díaz S, Jansá JM,Halperin D, Ascherio A. “Detection of Pulmonary Tuberculosis in Chi-apas, Mexico.” Annals of Epidemiology 2002;12(3):166-172.;Sánchez-Pérez HJ, Flores-Hernández JA, Jansá JM, Caylá JA,Martín-Mateo M. “Pulmonary Tuberculosis in Areas of High Levels ofPoverty in Chiapas, Mexico.” International Journal of Epidemiology.2001;30:386-393. 106 Birthdates were obtained and corroborated, whenever possible,with a birth certificate or a vaccination record. In keeping with thepopulation’s limited access to services, only 65 percent of the chil-dren were able to verify their date of birth through documentation.The consistency of the findings for these indicators demonstratedthat despite the aforementioned difficulties, the data obtained wereadequate for making an evaluation of the nutritional status of chil-dren under five.107 Habitch JP, Martorell R. “Anthropometric Field Methods: Criteriafor Selection in Human Nutrition.” In: DG Jeliffe, Edwards EP, eds.Nutrition and Growth. New York: Plenum Lublishing Corporation;1979;2:365-387.

108 World Medical Association (WMA). Declaration of Helsinki. Ethicalprinciples for medical research involving human subjects. Edin-burgh, Scotland: WMA, 2000.

socioeconomic characteristics of all inhabitants; house-hold health census (pulmonary tuberculosis, pregnancyoutcomes in the last two years, childhood vaccinationrates, and nutritional status of children under age five;self-perceived morbidity in the prior month and mortal-ity in the previous two years; and questions about utiliza-tion of health services for self-perceived morbidity,vaccination, pre-natal and delivery care, and chroniccough (cough of more than 15 days duration).

In carrying out the survey, interviews were con-ducted primarily with heads of household and theirspouses. However, for a large portion of the interviews,multiple adults in the household participated and fieldworkers were trained in making adjustments for sucharrangements.

In addition to the survey, an in-depth, structuredquestionnaire was designed for the authorities of thecommunities studied, including legal representatives ofmunicipalities, administrators of communal lands,group representatives, and those in charge of health andeducation committees. These interviews gathered infor-mation on the following aspects of the communities:

1. Demographic: languages spoken, number of inhab-itants, number of families, and the births anddeaths (including maternal) during the two yearsprior to the study.

2. Socioeconomic: religions present, whether internaldivisions existed and if so on what basis, whether thearmed conflict of 1994 caused the displacement ofinhabitants to other communities or if people hadcome or returned there from other communities, andthe availability, quality, and coverage of basic serv-ices and programs for the community and improve-ment of dwelling conditions; and bias in provision ofbasic services (e.g. provision of services only tomembers of one faction in a divided community).

3. Health: main health problems in the view of com-munity leaders, cases of deaths and injuries

(wounds or accidents) in the community within thelast two years, and cases of chronic cough in per-sons age fifteen and older or with PTB.

4. Health Services: availability, characteristics, andcoverage (including the supply of medicines andvaccines) of community health services, along withthe distances and problems involved in gettingpatients to hospitals for treatment. Information wasalso collected on the presence of midwives in thecommunity, whether there were any training pro-grams for the community health providers or mid-wives, and whether the institutional health servicesoffered any kind of assistance.

Statistical AnalysisInformation obtained in the surveys was organized indatabases using the program Fox-Pro Version 6.0. Forstandardization and subsequent inclusion of informa-tion, a specific process was developed. For each of thevariables analyzed, a manual of coded responses wascreated. Once entered, data were verified through sev-eral procedures: First, a simple frequency analysis (todetect coding errors) was performed using StatisticalPackage of Social Sciences (SPSS), version 10.0. Sec-ond, data were verified by physically comparing themagainst the questionnaires. Finally, programs weredesigned to verify the congruence and consistency ofdata using vector methodology, that is, the correlationof two or more variables of interest.

Statistical analysis of the data was done with SPSSand Stata Version 7.0 (College Station, TX: Stata Corp.,2001) to obtain frequencies, proportions, means, andtests of significance (mainly chi-square and t-tests). Inall bivariate analyses, statistical significance wasdefined as p<0.05.

Children’s anthropometric data was entered intodatabases using the program Fox-Pro Version 6.0 andthen copied into the program Epi Info.110 This was doneto calculate the anthropometric indicators by compar-ing the values measured for the population studied,with the NCHS reference values included in Epi Info. Inorder to compare this study with others and to conductbivariate and multivariate analysis, children were clas-sified in two categories: not malnourished (those con-sidered normal or with mild malnutrition, its mean,with less than -1 to at most -2 standard deviationpoints) and malnourished (those with moderate andsevere malnutrition, with Z-scores of –2 or less ).111

110 Epi Info 6, Version 6.04. Centers for Disease Control and Preven-tion, Atlanta, Georgia, and Geneva, Switzerland: January 2001.111 National Center of Health and Statistics (NCHS), World HealthOrganization (WHO). Growth Charts. Rockville: NCHS, Dew Publica-tions, 2000.

109 Sánchez-Pérez HJ, Ochoa-Díaz López H, Navarro y Giné A, andMartín Mateo M. “La atención del parto en Chiapas, México: ¿dónde yquién los atiende? Salud Pública de México. 1998;40(6):494-502.Available at: http://www.insp.mx.salud/40/406-6.pdf. AccessedNovember 8, 2005; Sánchez-Pérez HJ, Flores-Hernández JA, JansáJM, Caylá JA, and Martín Mateo M. “Pulmonary Tuberculosis in Areasof High Poverty in Chiapas, Mexico.” International Journal of Epi-demiology. 2001;30(2):396-393. Available at: http://ije.oupjournals.org. Accessed November 8, 2005; Ochoa-Díaz López H, Sánchez-Pérez HJ, Ruiz-Flores M, and Fuller M. “Social Inequalities andHealth in Rural Chiapas, Mexico: Agricultural Economy, Nutrition,and Child Health in La Fraylesca Region.” Cadernos Saúde Pública.1999;15(2):261-270. Available at http://www.scielosp.org/scielo.php?script= sci_arttext&pid=S0102-311X1999000200011. AccessedNovember 8, 2005; Palacios-Blanco JC, Sánchez-Pérez HJ, Nieves-Escudero A, Ochoa-Díaz H. “Uso de servicios de salud ante morbili-dad percibida en niños menores de cinco años en Chiapas, México.”Bol Med Hosp Infant Mex 2002;59:6-20.


2 3

Selected Demographic, Socio-economicand Ethno-linguistic Indicators

The populations of the regions studied are veryyoung, with 47% under the age of fifteen. The pro-portion of inhabitants under age fifteen, both

overall (47.2%) and by community type, was muchhigher than figures recorded in the last national popu-lation census carried out in 2000 for the studied regions(42%), Chiapas (38%), and all of Mexico (33.4%).112 Chia-pas has the second lowest median age (nineteen)among the Mexican states, compared with the medianage of twenty-two for the whole country.113 In this study,the median age of those studied in each of the threecommunity types was approximately sixteen. The highyouth population calls to attention the need for childand adolescent health interventions, reproductivehealth care, education and housing. In a broader sense,it highlights current and future pressure on the region’seconomy and the over-exploitation of naturalresources.

Between 80% and 99% of the population in the con-flict zone are indigenous,114 and nearly half (48.4%) donot speak Spanish. Across the three regions, monolin-gualism in adults is nearly twice as high amongfemales (61%) as males (36%). The communities in theconflict zone belong to various ethno-linguistic groups.In the Altos region, the main languages spoken areTsotsil and Tseltal; in the Selva region, Tseltal and Tojo-labal; and in the Norte region, Chol.

On the other hand, with the exception of the Selvaregion, the regions affected by the conflict also have ahigh demographic density. In spite of this, more than75% live in settlements of fewer than 2,500 inhabitants

(Table 1). This dispersion, which has greatly increasedover the last ten years, indicates the difficulty of provid-ing adequate social services to these populations.

The high proportion of inhabitants of the conflictzone who do not speak Spanish, particularly women,means in practice that these people have few possibili-ties to participate in social and economic decisions andprocesses. Almost all public services (health, educa-tional, etc.) are provided in Spanish, in spite of interpre-tations of international law calling for such services,and past efforts to develop programs. Virtually no doc-

tors in the formal health system speak the indigenouslanguages (although some health promoters and non-professional health providers do). This lack of lan-guage-appropriate health services constitutes anenormous cultural barrier for people to access healthcare.115 As noted above, women are more often mono-lingual and are ordinarily in greater contact with thehealth system for reproductive and child health care.The lack of language-appropriate health services oftendeprives them of the ability to effectively communicatetheir health needs and choices.

Economic barriers to care are also significant. Morethan 90% of the studied population did not have any

IV. FINDINGS

FIGURE 1

79.9%

94.2%

81.2%

26.4%

57.0%

7.5%

Study Area Chiapas Mexico

100

90

80

70

60

50

40

30

20

10

0

% Indigenous

% Without SocialSecurity

112 INEGI. XII Censo General de Población y Vivienda, 2000. Tabula-dos Básicos Nacionales y por Entidad Federativa. Base de datos ytabulados de la muestra censal. Aguascalientes: INEGI; 2001.113 CONAPO (Consejo Nacional de Población). 2001. Available at:http://www.conapo.gob.mx. Accessed March 9, 2005.114 In order to make this study comparable with others conducted inMexico, those individuals age five and older whose first languagewas not Spanish were considered indigenous. Government popula-tion studies and analyses have considered municipalities or commu-nities eminently indigenous if 40 percent or more of their populationage five and older speak an indigenous language. With 80% of thosespeaking an indigenous language, one can say that all the communi-ties have a predominantly indigenous population.

115 Similarly, bilingual teachers do not always work in communitiesthat speak their own languages. During the survey, the field teamobserved that several teachers who were Tseltal speakers, wereworking in Tojolabal communities in the Selva region, and did notspeak the language of this community.

form of health insurance. In fact, Chiapas is the Mexi-can state that receives the lowest amount of healthresources per capita and has the lowest number ofinhabitants covered by some form of social security(i.e., employment related health insurance): approxi-mately 17% versus 40.1% for the entire country.116 Inthis study, the proportion of inhabitants without anyinsurance averaged 94.2%.

Selected Social Determinants of Health

EducationThere may be no social determinant of greater impor-tance to health status than education. Female literacyin particular has been linked to better reproductive andmaternal health status as well as improved child healthoutcomes.117 Education is critical to enabling people tonavigate health and other social systems, makeinformed choices, and participate in discussions andplans that may affect their health and well-being, aswell as other decisions about their lives.

117 Garza C, de Onis M. “Justificación para la elaboración de unanueva referencia internacional de crecimiento.” Food and NutritionBulletin. The United Nations University; 2004;25(1):6-11.


116 Sánchez-Pérez HJ. Tuberculosis pulmonar en zonas de alta mar-ginación socioeconómica de Chiapas, México: Problemas y retos asuperar: El caso de la Región Fronteriza. Doctoral thesis. Barcelona:Universidad Autónoma de Barcelona; 1999; Consejo Nacional dePoblación (CONAPO). 2001: http://www.conapo.gob.mx. AccessedNovember 7, 2005.

TABLE 1. Socio-demographic indicators in Mexico, Chiapas and the studied regions, 2000.

Indicator* Altos Selva Norte Study Area Chiapas México

Population density (per km2) 109.2 17.7 103.6 76.8 51.8 49.6

% residing in communities of 75.6 76.2 87.1 79.6 54.3 25.4fewer than 2,500 inhabitants

% age five and older who are 98.8 54.3 86.5 79.9 26.4 7.5indigenous

% monolingual Indigenous 62.9 32.1 35.3 40.9 61.2 16.6

% illiteracy (15 years and over) 50.3 66.9 61.5 59.5 22.9 9.5

% population without 92.2 94.9 95.6 94.2 81.21 57.0social security

Average number of inhabitants 5.3 5.5 5.4 5.4 4.8 4.4per household

% households with running water 39.2 57.3 76.3 57.6 74.4 88.7

% households with dirt floors 89.2 58.8 76.8 74.9 38.4 14.8

% households burning 98.3 84.9 92.1 91.8 54.5 17.5wood for cooking

% households with electricity 75.7 71.6 75.9 74.4 87.9 95.0

Degree of marginalization of its VH=13 VH=7 VH=12 VH=32 VH=44 VH=386municipalities2 H=2 H=4 H=10 H=16 H=65 H=906

L=1 L=0 L=1 L=2 M=6 M=486L,VL=2 L,VL=66

4

Source: Instituto Nacional de Estadística, Geografía e Informática (INEGI). XII Censo General de Población y Vivienda, 2000. Tabulados BásicosNacionales y por Entidad Federativa. Base de datos y tabulados de la muestra censal. Aguascalientes, México: INEGI, 2001.

* In all indicators analyzed, p<0.05 (x2 among three groups).1 Calculation based on the number of total inhabitants, and the number of people with social security.2 According to: Consejo Nacional de Población (CONAPO). Indicadores socioeconómicos e índice de marginación municipal, México, 1990.México: CONAPO, 1993; and CONAPO/PROGRESA. Índices de marginación. México: CONAPO, 1998.

Degrees of marginalization: VH = very high, H = high, M = medium, L = low, VL = very low.

Chiapas, along with the states of Oaxaca and Guer-rero, has the highest levels of illiteracy in the country.The illiteracy rate among the population studied, how-ever, was even higher than the rate recorded for thestate as a whole; according to official statistics, 23% ofthe population of Chiapas age fifteen and older has nothad any schooling, compared to over 30% among thethree groups studied. The difference between the studypopulation and the national average is, however, farmore striking; official government statistics claim thatMexico has a national illiteracy rate of 9.5%.118 Of thepopulation surveyed, 36% did not know how to read orwrite. The average number of years of schooling wasfound to be 3.4, which is functionally illiterate.

Gross gender inequalities were reflected in the edu-cation level data. The average number of years of studyfor men over fifteen in the study population was 4.19;22.3% had no schooling whatsoever. Females over fif-teen, in contrast, had an average of 2.68 years of educa-tion and almost half of women and girls over fifteen(43%) had no schooling at all. In contrast, national statis-tics claim that 88.6% of women in Mexico are literate.119

By specifically analyzing educational indices for thechildren who were of school age during the first years ofthe conflict, the investigation observed how this popula-tion was affected by the closing of schools and subse-quent re-opening only for pro-government communitiesand families. For the children who were age seven in1994, at the time of the study (2000–2001) six to sevenyears later, nearly 9% still had no schooling, and only22% had any post-primary education. Children fromdivided and pro-government communities were the mostaffected, with 7% and 11% of their children, respectively,without any schooling and only one in five having gonebeyond primary school. Children in opposition communi-ties appear to have been the least affected, with nonewithout schooling, and nearly 37% with some secondaryeducation or beyond. For the rest of age groups, thesame trends were observed: opposition communitieshad higher percentages of children having some form ofschooling or reaching a post-primary school level,although they were never more than 50%.

The seemingly better educational conditions (lowerilliteracy, greater access to post-primary studies)observed in opposition communities, with respect to

the other two groups, may be attributable to one ormore of the following reasons: 1) opposition groupsarose from populations with higher educational levels,and the difference has been preserved during the con-flict; 2) the lack of participation in this study of commu-nities with highest levels of resistance, where it is likelythat less favorable educational conditions exist becauseof their oppositional stance;120 and, 3) the non-govern-mental educational systems developed by oppositioncommunities are having a positive impact on their pop-ulation. This differentiates them from pro-governmentand divided communities which, despite having govern-mentally-provided educational services, exhibit a lackof resources and reflect the abandonment of the educa-tion sector in the state of Chiapas.121

Shelter and Housing ConditionsDwelling conditions were observed to be inadequate inall three groups, although certain negative characteris-tics such as greater overcrowding and dirt floors weremore prevalent in the divided communities. (See Table 2).

The study found overcrowding among all threegroups, which is a contributing factor in the spread of

infectious diseases such as tuberculosis. A significantlyhigher than average number of inhabitants per house-hold (5.9) was found in the three groups studied. Thisfigure was higher than the official statistics reported

118 INEGI. Estadísticas a propósito del día internacional de la alfabet-ización: datos nacionales. Available at: www.inegi.gob.mx/inegi/con-tenidos/espanol/prensa/contenidos/estadisticas/2002/alfabeti02.pdf.Accessed November 7, 2005; The illiteracy rates for men and womenare 8% and 11%, respectively. UNFPA, State of the World’s Popula-tion 2005: The Promise of Equality; Gender Equity, ReproductiveHealth and the Millennium Development Goals. 2005:110. 119 INEGI. XII Censo General de Población y Vivienda. 2001. Availableat http://www.inegi.gob.mx/est/contenidos/espanol /rutinas/ept.asp?t=medu25&c=3293. Accessed November 7, 2005.

F I N D I N G S 2 5

FIGURE 2: Percentage of Homes with Dirt Floors

74.4%

34.4%

14.8%


80

70

60

50

40

30

20

10

0

120 As previously mentioned, based on observations conducted in thefield, it is quite feasible that this type of community has less advanta-geous socioeconomic indicators (including education) than the restof the groups.121 In different educational evaluations, Chiapas has the worst levelsof education in the country. See for example: Periódico Reforma,Janurary 17, 2006; p.1.122 INEGI. “XII Censo General de Población y Vivienda”. Available athttp://www.inegi.gob.mx. Accessed November 6, 2005.

for the entire state (4.8) and for the entire country(4.4).122 Further, these figures are likely to underratethe disparities with the rest of the country, as most ofhouses in the studied population have only one room,whereas that is not the case on the national level.

The proportion of homes with dirt floors in the studyarea (74.4%) is nearly two times as high as for theentire state of Chiapas (38.4%), and five times as highas for all of Mexico (14.8%).123 In rural communities,having a dirt floor (as opposed to a cement or otherfloor) is an indicator of the lack of purchasing poweramong the population.124 Having a dirt floor is alsoassociated with higher incidences of parasitic diseases(such as hookworm) and anemia.125

Water and SanitationWater and sanitation are among the most importantconditions that enable people to be healthy. Almost athird of studied households (28.5%) lacked runningwater in the household. Opposition communities hadthe highest proportion (39%) of households withoutrunning water, while pro-government and divided com-munities had a lower percentage without this service(27%). Having access to running water in the householdmakes it far more likely that families can meet the

World Health Organization (WHO) recommendation ofat least 20-40 liters per person per day for drinking,cooking and bathing. Having running water in thehousehold has gender implications because it is usu-ally women who must fetch water for cooking, cleaningand consumption if it is not running in the home. “Run-ning water” does not, however, guarantee the WHO’sminimum recommendation with respect to “potable,”which is defined as less than 10 fecal coliforms per 100ml of water. Indeed, other studies have documentedthat there are significant problems relating to poorquality and bacteriological content of drinking water inareas with high poverty levels in Chiapas.126

With respect to sanitation, almost two thirds of thestudied population (64%) uses latrines. However, eventhough pro-government communities had the highestproportion of toilets or septic tanks (15%), they also hadthe highest proportion without any sanitation system. Inthe opposition and divided communities, the proportionof households using latrines was more than 70%, com-pared to 54% in pro-government communities. What ismost important to note however, is that almost a quar-ter of the entire population surveyed had no sanitationsystem whatsoever (23.6%). This is in a country whichclaims to be at the verge of achieving high humandevelopment according to its national indicators.127 Aspoor sanitation is one of the greatest sources of fecal-

126 Sánchez-Pérez HJ, Morales-Vargas G, Méndez-Sánchez JD. “Cal-idad bacteriológica del agua para consumo humano en zonas de altamarginación socioeconómica de Chiapas: ¿apta o no apta?” SaludPublica Mex 2000;42:397-406.127 United Nations Development Programme (UNDP). Human Devel-opment Report, 2005. New York: UNDP. Oxford University Press;2005:255.

123 Id., INEGI.124 Secretaría de Desarrollo Social (Sedeso). Indicadores de mar-ginación por comunidad. Tuxtla Gutiérrez, Chiapas: SEDESO, 2003.125 Dávila-Gutierrez C, Trujillo-Hernandez B, Vazquez C et al. “Preva-lencia de parasitosis intestinales en niños de zonas urbanas delestado de Colima, México.” Bol Med Hosp Infant Mex 2001;58(4)34-47; Marcos L, Maco V, Terashima A. et al. “Parasitosis intestinal enpoblaciones urbana y rural en Sandia, Departamento de Puno,Perú.” Parasitol. Latinoam 2003;58(1-2):35-40.


TABLE 2. Indicators of shelter and housing conditions by political affiliation of communities.

Indicator* Pro-Govt. Opposition Divided Total

Number of studied households 1,477 256 1,264 2,997

Average number of inhabitants per household (SD) 5.86 (2.53) 6.34 (2.77) 6.10 (2.61) 5.98 (2.59)

% with dirt floors 67.9 74.5 81.9 74.4

% without indoor access to water 27.7 38.8 27.3 28.5

% using wood for cooking 93.2 96.1 98.2 95.5

% without electricity or any type of artificial lighting 10.2 3.9 12.9 10.8

Type of disposal excreta system:

% with toilet / septic tank 14.9 7.8 10.3 12.3

% with latrine 54.1 76.1 73.2 64.0

% without any type (“at ground level”) 31.0 16.1 16.5 23.6

* In all indicators analyzed, p < 0.05 (X2 among three groups)

oral contamination and the spread of numerous dis-eases, including various gastrointestinal diseases, theWHO has recommended that a national policy on basicsanitation would aim to provide at least one latrine perhousehold.

Maternal Health

Prenatal CareThe investigation documented a total of 1,223 pregnan-cies for the two years prior to the study, eight (0.7%) ofwhich ended in the mother’s death. Of the 1,221 womenfor whom data was gathered,128 over half (53.9%) wereseen only by a traditional birth attendant (TBA). Of theremaining women, 8.6% were attended by both a TBAand governmental providers in public health services;29.7% by government health services exclusively; 1.3%by other services (private or non-governmental), 2.6%by non-health agents (family members, neighbors), and3.9% did not receive any prenatal care.

Surprisingly, a significantly greater number ofwomen in those opposition communities surveyedreceived prenatal care from a combination of govern-mental health services and TBAs (63.9%) than in gov-ernmental or divided communities (35.3% and 36.4%,

respectively), although this may be an anomaly due tothe high rate of non-participation by communities inmore hard-line resistance. Furthermore, qualititativeinformation suggests that prenatal consultations in thisgroup are generally done with TBAs while women go topublic health facilities to secure certain medicines.

Among the women who did not utilize governmenthealth services for prenatal care, the principal reasonsfor not going were, in descending order: the remotenessof services from their communities (22%), a preferencefor going to TBAs (21.6%), lack of time, which is relatedto remoteness as well as household obligations (21.4%),and distrust of these services (including mistreatmentand poor care, among others, 20.6%). Of course, poortreatment, among other factors, is also reflected inwomen’s preferences for being attended by TBA’s.

Use of Delivery Care ServicesOf the women studied, almost three quarters (74%)were attended by TBAs during childbirth. These resultsconfirm the outcomes of other studies in Chiapas,which found that a large proportion of pregnancies anddeliveries are assisted by TBAs, who in most cases, donot have a support team for the diagnosis and adequatetreatment of possible obstetric complications.129 For

129 Sánchez-Pérez HJ, Ochoa-Díaz López H, Navarro i Giné A,Martín-Mateo M. “La atención del parto en Chiapas, México: ¿dóndey quién los atiende?” Salud Publica Mex 1998;40:494-502.

128 It was not possible to obtain any information about prenatal carefor two of the pregnancies.

F I N D I N G S 2 7

TABLE 3. Provider of delivery care during the latest pregnancy in the previous two years.


Number of women age 12–49 with a pregnancy 582 108 533 1,223terminated in the two years prior to the study

Agent attending birth: (%) (%) (%) (%)

Governmental 17.0 22.2 13.7 15.5

Non-Governmental 0.7 0.0 0.2 0.4

Private 1.4 0.9 0.2 0.8

Traditional birth attendant 74.3 63.9 76.3 74.2

Non-Health 5.4 9.3 8.5 7.1

None 1.2 3.7 1.1 1.4

Site of delivery: (%) (%) (%) (%)

Governmental 13.4 20.4 8.3 11.8

Private 1.6 0.9 0.2 0.9

Home of the Woman 80.6 74.1 85.9 82.3

Home of the traditional birth attendant 2.3 2.8 2.1 2.2

Home of a relative 2.3 1.9 3.6 2.85

* In the two indicators analyzed, p<0.05 (x2 among three groups).

these reasons, TBAs are not considered skilled birthattendants according to the WHO, World Bank or inter-national standards.

Only 16% of overall births were attended by govern-ment health personnel. Of the remaining births, 7% wereattended by non-health personnel (family members orneighbors), and 1.4% were not attended by anyone.

Almost nine of every ten births (87.3%) occurred atthe home of the woman, the woman’s relative or of theTBA, rather than in a health facility. Only 11.8% of birthstook place in governmental health services. Among the1,034 women who did not use government services fortheir delivery, the main reasons they cited were: prefer-ring a TBA (28%), lack of time to get to a health facility(22%), lack of nearby health facility (20%), and distrustof services (16%). However, mistreatment and poorcare were cited by 30.5% and 21.4% of women in pro-government and divided communities, respectively, asreasons for not delivering in public health services,compared with 1.9% in opposition communities. On theother hand, “distrust” of services was cited far morecommonly by women in opposition communities(14.2%). A number of studies have documented cases offorced sterilization in the region, which may have con-tributed to women’s mistrust of health careproviders.130

The percentage of women delivering in a public orprivate health facility was notably lower in divided com-munities than in either opposition or pro-governmentcommunities (8.5% versus 15% and 21.3% respec-tively).131 Despite fluctuations in community classifica-tion, the research team believes these differences to besignificant. Qualitative information that supplementsthe survey data reveals that in communities that lackhealth services and access to transportation, it isexceedingly difficult to transport women to a healthfacility with the capacity to provide essential obstetric

care. Arranging for such transportation can oftenrequire communal, rotating fund arrangements andcollective action to secure transportation. In dividedcommunities, people noted that the possibilities ofobtaining economic or material support and assistance(child care, housing, personal belongings, among otheraspects) from neighbors, as well as any vehicle able tobring a woman to a hospital (for possible obstetricalcomplications), are seriously limited.

The study also found that often women from all com-munity types who arrive at the hospital after travelingfor several hours find that there are no doctors available(especially on weekends, holidays, or at night) or thatthere are no medicines or equipment to treat obstetricemergencies. The women must then be transportedagain for several more hours under wholly unfavorableconditions and often on barely passable dirt roads. Inseveral of the communities studied similar documentedcases arose which on some occasions culminated in thedeath of the mother, the child, or both.132

Maternal Mortality in the Previous Two YearsThe investigation documented eight cases of maternaldeaths occurring in the two years prior to the study. Sixof these women were living in pro-government commu-nities and two in divided communities. All eight womenwere indigenous and had a maximum of three years ofprimary education; five were monolingual; and none ofthem had health insurance.

Further research is needed to better understand allcontributing factors that affect the high maternal mor-tality in the study area, such as intra- and inter-familyrelations, use of traditional versus government serv-ices, the cultural practices and representations sur-rounding maternity among the women (especiallyindigenous women) in Chiapas, and the relative influ-ence of intra- and inter-community social, political, andreligious conflicts.

However, it is clear that three types of delays played arole in these women’s deaths.133 First, there were delaysin the decision to seek care due to lack of money, lack oftransportation, lack of a referral by a doctor or commu-nity health promoter and, related to that, lack of aware-ness of the gravity of the situation. Second, there weredelays in the time it took the women to arrive at medicalcare. Two women died en route and one died while wait-

130 In this study, a 35-year-old woman from an opposition communityin the Altos region, reported being scolded by a doctor who told herthat she must undergo surgery because “you are not an animalneeding to have so many children.” Because she did not want sur-gery or to be treated in that manner, she left the health center andwas taken to another health facility by her family. See also: Freyer-muth G. Las mujeres de humo. Morir en Chenalhó. Género, étnica ygeneración, factores constitutivos del riesgo durante la maternidad.México: Centro de Investigaciones y Estudios Superiores enAntropología Social (CIESAS), Comité por una Maternidad Voluntariay sin Riesgos, Instituto Nacional de las Mujeres, Miguel Ángel Por-rúa, 2003; Hidalgo O, Castro G. Población desplazada en Chiapas.Chiapas, México: CIEPAC; 1999; Kirsch J, Arana-Cedeño M.“Informed Consent for Family Planning for Poor Women in Chiapas,Mexico.” Lancet 1999;354(9176):419-420. Available at:http://www.thelancet.com/ Accessed November 7, 2005.131 The high percentage from opposition communities may be attrib-utable to sampling bias because the most hard-line opposition com-munities did not participate in the study.


132 For more details, see: Brentlinger P, Sánchez-Pérez HJ, Arana-Cedeño, M, Vargas MG, Hernán MA, Micek M, Ford D. “PregnancyOutcomes, Site of Delivery, and Community Schisms in RegionsAffected by the Armed Conflict in Chiapas, Mexico. A Community-based Survey.” Social Science and Medicine 2005;61:1001-1014.133 See D. Maine et al, Safe Motherhood Programs: Options andIssues. Center for Population and Family Health. Columbia Univer-sity School of Public Health. 1991.

ing for transportation. Third, there were delays inreceiving care and a lack of capacity to resolve obstetricemergencies upon arrival at health facilities. Four of thedeaths occurred at hospitals.

Based on these eight deaths out of the 1,319 livebirths recorded for the two years prior to the study, theresearch team found the crude maternal mortality rateto be 607 per 100,000 live births (95% CI = 262–1192).Although the sample size was small, this data indicatesa maternal mortality ratio far higher than that calcu-lated by the health sector both for Mexico and for thestate of Chiapas, which itself has the highest maternalmortality ratio in the country.134

According to official figures, the maternal mortalityrate for 1999 was 53 per 100,000 live births for Mexicoand 66 per 100,000 live births for Chiapas.135 For 2001,the ratio for Mexico was 59 and for Chiapas 84 per100,000 expected births.136 In fact, while the maternalmortality ratio in Mexico remained around 47–59 per100,000 registered live births during the 1990–2001period, in Chiapas this indicator has been rising.137

Moreover, it is quite probable that this investigationhas under-estimated the maternal mortality ratio dueto: 1) an under-diagnosis of women who died early on intheir gestation from pregnancy-related causes; and 2)the lack of participation in the study of more resistantopposition communities, which have the least access toemergency obstetric care.138

While high maternal mortality is an indicator of the

marginalization of the female population, it is alsoindicative of the inadequate health systems in the area.It is now widely recognized that the keystone to pre-venting maternal deaths is available, accessible (bothphysically and economically), acceptable (both scientif-ically and culturally) and quality emergency obstetriccare.139 The lack of access to and use of emergencyobstetric care indicated by the data on mortality, use ofservices and reasons for not using services, constitutesboth a serious public health problem and a gravehuman rights issue.140

Child HealthAs children are among the most vulnerable group in apopulation, child health speaks particularly stronglyto a number of different aspects of the neglect of thepopulations in the areas studied as well as the hard-ships suffered by those living in the conflict zone. Forexample, the nutritional status of children under agefive is typically an indicator of how general living con-ditions and changes in them, whether gradual or sud-den, affect a population. Poor vaccination coverage,on the other hand, reflects failures in the health caresystem.

Childhood MalnutritionMalnutrition is largely associated with preventabledeaths in children.141 Chiapas has one of the highestmortality rates associated with nutritional deficienciesin Mexico and is the state with the highest mortalityrate for diarrheal diseases in children under age five. In2000, while the rate for the entire country was 21.4 per100,000 children under age five, in Chiapas it was morethan double that (48.5/100,000). In other states, the ratewas far lower (e.g., in Colima, the rate was only 3.8 per

134 CONAPO. “Cuadernos de Salud Reproductiva en Chiapas, Mex-ico.” Consejo Nacional de Población; 2000. See also: FreyermuthEG., Jimenez CV, Manca MC. La muerte materna en Tenejapa, SanCristobal de las Casas. Chiapas: Comité por una Maternidad Volun-taria y Sin Riesgos en Chiapas; 1999.135 SSA (Secretaría de Salud). La situación de salud en los estados,1999. Mexico City: Dirección General de Estadística e Informática,SSA: 2001.136 Id., SSA. 2001. 137 SSA. Dirección General de Estadística e Informática. Mortalidad1990; Mortalidad 1991; Mortalidad 1992; Mortalidad 1993; Mortali-dad 1994; Mortalidad 1995; Mortalidad 1996; Mortalidad 1997. Méx-ico: SSA, años 1990, 1991, 1992, 1993, 1994, 1995, 1996, 1997; SSA.La situación de salud en los estados, 1999. México: SSA, 2001; SSA,Dirección General de Información y Evaluación del Desempeño(DGIED). Coordinación de Planeación Estratégica: Mortalidad, 2001.México: SSA, DGIED, 2001.138 The proportion of obstetric emergencies that did not receive med-ical attention documented by this study was higher than in someother studies conducted in the state of Chiapas. For example, whilehalf of the eight maternal deaths documented in this study did notreceive any health care, one study conducted in the Altos regionfound that the proportion of maternal deaths that had medical atten-tion in 1998–99 was 34.5 percent (Freyermuth G. Las mujeres dehumo. Morir en Chenalhó. Género, étnica y generación, factoresconstitutivos del riesgo durante la maternidad. México: CIESAS,Comité por una Maternidad Voluntaria y sin Riesgos, InstitutoNacional de las Mujeres, Miguel Ángel Porrúa, 2003). The research

F I N D I N G S 2 9

team knows of at least two cases of women dying during pregnancyor delivery in opposition communities that were in the original sam-ple, but refused to participate in the study.139 Berer M, Sundari Ravindran TK, eds. Safe MotherhoodIssues:Critical Issues. Blackwell Science; Reproductive Health Mat-ters (1999), “Introduction” pp. 3-13.140 Although the sample size was small and results cannot be gener-alized for the entire conflict zone in Chiapas (especially for opposi-tion communities that did not allow participation in the study), inconjunction with qualitative information gathered, they do suggestserious problems regarding the access and use of obstetric servicesin the area. For an analysis of human rights obligations relating tomaternal mortality, see Yamin AE, Maine DP. “Maternal mortality asa human rights issue: Measuring compliance with internationaltreaty obligations.” Human Rights Quarterly. 1999:21(3): 563–607.141 Ávila-Curiel A, Chávez-Villasana A, Shamah-Levy T, Madrigal-Fritsch H. “La desnutrición en el medio rural mexicano: Análisis delas encuestas nacionales de alimentación.” Salud Pública de México1993;35(6):658–666. Available at: http://www.insp.mx/salud/35/356-17s.html. Accessed November 7, 2005.


100,000).142 In the conflict zone, malnutrition is evenmore dire.

The nutritional state of children under age five wasmeasured using three indicators: height-for-age,weight-for-age, and weight-for-height. The height-for-age indicator describes a chronic phenomenon. Itmeasures the combined effects impact of insufficient

food intake and repeated episodes of infectious diseasefor a prolonged period. The height of a child under agefive is also affected by illness. In the same way thatproper health conditions and adequate food intakeensure proper growth, illnesses—especially infectiousones—and insufficient food intake over long periods,also cumulatively affect growth. The stunting effect onheight, although it may be observed in all age groups, ismost evident in children between age three and fiveyears, because it is in this period of growth in which thechildren duplicate their size, and in consequence, theirnutritional requirements increases. Chronic malnutri-tion causes a child’s body to sacrifice the increase ofbody size for the more or less adequate functioning ofthe child’s organs and daily activities.

142 de la Fuente J, Limón-Rojas M, Fuentes-Alcalá M, Guerrero-Vil-lalobos G. Programa Nacional de Acción a favor de la Infancia. Sec-retaría Técnica. Serie de Documentos Técnicos No. 2, México, D.F:Secretaría de Salud, 1996; Secretaría de Salud (SSA), Dirección Gen-eral de Información y Evaluación del Desempeño (DGIED). Indi-cadores para la evaluación de los sistemas de salud. Salud Públicade México 2002;44(4):371–380. Available at: http://www.insp.mx/salud/44/ 444_11.pdf. Accessed November 7, 2005

TABLE 4. Malnutrition in children under five years of age, by political affiliation of communities.


Prevalence of overall malnutrition (all children)1

% Underweight, W/A2 21.1 (1,259) 17.7 (254) 21.2 (1,191) 20.8 (2,704)3

% Stunting, H/A 52.2 (1,236) 48.6 (249) 58.6 (1,181) 54.7 (2,666)

% Wasting, W/H 3.0 (1,248) 1.2 (253) 3.5 (1,184) 3.0 (2,685)

Rates of malnutrition in children <= age 1

% Underweight, W/A 8.3 (302) 6.6 (61) 10.4 (298) 9.1 (661)

% Stunting, H/A 24.9 (301) 21.3 (61) 31.5 (298) 27.6 (660)

% Wasting, W/H 2.0 (297) 0 (61) 4.8 (291) 3.1 (648)

Rates of malnutrition in children > Age 1 <= Age 2

% Underweight, W/A 28.9 (249) 27.3 (44) 27.4 (230) 28.1 (523)

% Stunting, H/A 62.0 (237) 55.8 (43) 67.4 (227) 63.9 (507)

% Wasting, W/H 7.4 (244) 6.8 (44) 6.8 (230) 5.0 (518)


% Underweight, W/A 26.0 (265) 22.2 (54) 26.5 (257) 25.9 (576)

% Stunting, H/A 51.5 (260) 66 (53) 63.4 (254) 58.2 (567)

% Wasting, W/H 2.3 (264) 0 (54) 1.2 (257) 1.6 (575)


% Underweight, W/A 22.6 (443) 17.9 (95) 22.2 (406) 21.9 (944)

% Stunting, H/A 65.8 (438) 53.3 (92) 70.6 (402) 66.6 (932)

% Wasting, W/H 1.6 (443) 0 (95) 2.5 (406) 1.8 (944)

* In all indicators analyzed, p<0.05 (x2 among three groups).1 The numbers in parentheses indicate the total number of studied children for each one of the analyzed indicators.2 W/A = Weight / Age; H/A = Height / Age; W/H = Weight / Height.3 The total number of children recorded in the households was 2,838. This does not include 134 (4.7%) children whose some of their anthro-pometric measures, could not be obtained.

On the other hand, changes in food intake and healthof a child under age five almost immediately translateinto changes in weight, because children can loseweight quickly when ill or starved. Thus, the weight forheight indicator is very sensitive and describes theimmediate situation.143

The weight-for-age indicator is commonly used inhealth programs in Chiapas and the rest of Mexicobecause weight measurements are easier to obtainthan those for height. Although this indicator is lessprecise, it is useful because it can be easily obtainedand can facilitate the monitoring of the child overtime.144 The presence of stunting (low height-for-age)does not exclude that of wasting (low weight-for-height), or vice versa. A child under age five who hassuffered a chronic process of malnutrition causing adeficit in height, may also suffer from an infectious ill-ness or an extreme lack of food that causes significantweight loss. In such cases, chronic malnutrition may beaggravated by a recent weight loss.

The prevalence of stunting found in this study was54.7%, which is among the highest observed in any studyin Mexico and is more than double the official nationalstatistics. On the other hand, the differences observedamong community types in the prevalence of under-weight children, both overall and by age group, were notstatistically significant, which may suggest similar levelsof unsatisfied health needs in all groups.145

Children under age one had the lowest prevalence ofstunting, as they always do, but had levels exceeding20% in the three groups studied. The prevalence ofmalnutrition increases more than twofold in all studiedgroups after children reach one year of age. Such high

levels of stunting reflect extreme levels of poverty andmarginalization and will affect this population’s healthfor at least a generation.146

The overall prevalence of wasting was 3.0%. This isconsistent with findings from other studies in Mexicoand with patterns of malnutrition elsewhere in LatinAmerica, where stunting tends to be the predominantreflection of malnutrition.147 Under the weight-for-ageindicator, the proportion of children with malnutritionunder five years of age was 21%.

Infant Mortality The infant mortality rate observed in the study area was39.4 per 1,000 live births (95% CI = 27.3–54.9), a figurealmost three times as high as the rate of 13.8 for thecountry as a whole, and 12.0 for Chiapas, estimated inyear 2000.148 Infant mortality reflects a combination ofpoor nutritional status of the mother, poor nutritionalstatus and exposure to illness of the child, and a lack ofaccess to obstetric and neonatal health care. Thesehigh rates and disparities with the rest of the state andcountry provide a clear view of the deplorable inequitiesfaced by the overwhelmingly indigenous families andchildren in the conflict zone.

147 The results (3.0% for wasting) are at an intermediary level betweenthe ENAL of 1996 (7.6%) and the ENN of 1999 (2.1% for all of Mexicoand 1.7% for the southern part, including Chiapas). The difference inresults between our study and the ENAL of 1996 may be attributed tothe fact that in 1996 the level of malnutrition was more acute becauseof the armed conflict that began in 1994. Also, some authors havedescribed the important seasonal variation of wasting in which per-centages can differ greatly during rainy season. Arana-Cedeño M.“Educación para la salud con enfoque estacional para culturas contiempo circular”. Cuadernos de Nutrición 2005;28(4)154-159; BrancaF, Pastore G, Demissie T, Ferro-Luzzi A. “The nutritional impact ofseasonality in children and adults of rural Ethiopia.” European Journalof Clinical Nutrition. 1993:47(12): 840-850.148 INEGI. Estadísticas demográficas: Cuaderno de población, no. 13.Aguascalientes: INEGI, 2001.

143 Phenomena of acute exposure to hunger are clearly identified byvariation in weight. The importance of weight and its fluctuations areproportionate to the size of the child. A fluctuation of a few hundredgrams carries a different significance in a child with a height of onemeter and a few years of age, than in a newborn. The term “wasting”is used to describe this condition.144 It is also useful for comparing results with many other studiesthat also used this indicator. In rural areas, health workers recordthis index in many communities.145 This high prevalence of underweight-for-age, according to the cri-teria of the World Health Organization, can be considered a reflectionof high levels of malnutrition and as such constitutes both a health anda human rights issue that demands urgent attention. World HealthOrganization (WHO). WHO Global Database on Child Growth and Mal-nutrition. Geneva: WHO; 2000. Available at: http://www.who.int/nut-growthdb/index.html. Accessed November 7, 2005.146 These results were similar to those in the ENAL of 1996 (45.6%for the country as a whole and 51% for Chiapas) and were also signif-icantly higher than those in the ENN of 1999, both for all of Mexico(17.8%) and just the southern part (29.2%). The prevalence of stunt-ing (according to the criteria of the World Health Organization) in thestudied area is in the highest category of malnutrition levels, which isconsistent with that found for the height-for-age indicator.

F I N D I N G S 3 1

FIGURE 3: Infant Mortality Rate in 200039.4

12.013.8


40

35

30

25

20

15

10

5

0

Per 1,000 live births

Vaccination Since the early weeks of the conflict before the Zap-atista civil resistance began, health workers were con-cerned about the continuity of services for theprevention of illnesses, and in particular immuniza-tions. In fact, this concern was reflected in the Declara-tion of the Neutrality of Health Services During theArmed Conflict in Chiapas.149 In practice, various NGOsand some university programs, who had trained com-munity health promoters to give vaccinations in iso-lated communities before the conflict, maintained andexpanded their activities. These networks permitted a

system in which vaccinations originating from officialinstitutions were delivered to the population throughcivil society organizations. This activity was expanded inan important way in early 1995, when the InternationalCommittee of the Red Cross (ICRC) and the MexicanRed Cross, established a vaccination program in theconflict zone.

However, in some opposition communities vaccina-tions were not permitted: children were not taken to bevaccinated and health workers were not allowed tocome and vaccinate in the communities.150 The investi-gators also found instances in which governmenthealth providers refused to vaccinate children becauseof the political affiliation of their parents, specificallybecause they were EZLN sympathizers. During thestudy, the field team learned of at least ten cases inwhich community authorities prohibited health person-nel from vaccinating children from a different politicalaffiliation. There were also repeated allegations ofhealth providers charging people from communitiesthat did not support the government for vaccinations. Awoman from an opposition community in the Selvaregion asked “for someone to help us vaccinate thechildren, but not from the government;”151 on otheroccasions, religious affiliation was a barrier or, attimes, more subtle barriers to vaccination wereerected. For example, people were allegedly asked tobuy the syringes,152 or health personnel did not vacci-

150 In opposition community (File 1876). 151 A 32 year-old woman residing in a resistance community (File1143). Her one year-old daughter had only received one vaccine.152 Pro-government community, the Altos Region (File 1761) .


149 Comisión Médica de CONPAZ. “Declaración por la Neutralidad delos Servicios de Salud durante el conflicto armado de Chiapas.” SanCristóbal de Las Casas, January 1994. The refusal to work in riskareas on the part of health workers and mid-level health authorities,was aggravated by some violent incidents. Worst among these wasthe attack of six nurses from the Ministry of Health who were vacci-nating children in the municipality of San Andrés Larrainzar (in theAltos region). Three of the nurses were beaten and raped by a groupof armed men near a military checkpoint in 1995. Coordination ofNon-Governmental Organizations for Peace (CONPAZ): “Serecrudece la represión en Chiapas” (Repression intensifies in Chia-pas), San Cristóbal de Las Casas, Chiapas: November 13, 1995.

The investigation documented numerous refusalson the part of health services to administer vaccina-tions. For example:

• In an opposition community in the Norte region,a 34-year-old Chol woman told the field teamthat she had taken her four-year-old son to bevaccinated, but the nurse at the clinic told hershe would not vaccinate her son, because thevaccination campaign had ended a month agoand she would have to take him elsewhere (File4351).

• A woman was refused vaccinations for her sonbecause “while she was pregnant, she did not goto the clinic for prenatal care.” When asked whyshe had not gone for check-ups, she answered“because I don’t trust them much, besides thenurses don’t treat you well and are alwaysscolding” (File 4272).

• Another 35-year-old Tsotsil woman commentedthat health personnel in the clinic would notvaccinate her son because he did not have a vac-cination booklet (File 3862).

• On two other occasions, in different dividedcommunities, the team found children who hadnot been vaccinated because the doctor had toldthem “he didn’t have time to vaccinate children”(Files 3884, 3621).

TABLE 5. Completed vaccination schemes inchildren under five years of age, by politicalaffiliation of communities.

Indicator Pro-Govt. Opposition Divided Total

(1,335) (261) (1,242) (2,838)

% of children 74.8 84.2 76.6 76.4with complete scheme of vaccination1,2

Vaccinating health agent1

Governmental 88.5 95.8 88.4 89.1

Non-Governmental 0 0 1.1 0.5

Private 0.3 0 0 0.1

None 11.2 4.2 10.5 10.21 p < 0.05 among the different studied groups.2 Includes the BCG, polio, DTP, and measles vaccines.

nate because parents were not registered in the Pro-gresa Program.153

Of the 2,838 children under age five registered in thisstudy, only 76.4% had received their complete schemesof vaccination at the time of the survey. In accordancewith WHO and Mexican vaccination schemes, childrenhad received the proper dose for their age of the vacci-nations against polio; measles; diphtheria, pertussisand tetanus; and the BCG vaccine against tuberculosis.Contrary to what might be predicted, children in oppo-sition communities had the highest proportion of com-pleted vaccination schemes (p<0.05).

Not only had almost a quarter of the populationstudied not received their complete vaccinationschemes, but the number of those who had not com-pleted their vaccination schemes was far higher thanofficial estimates. According to official figures, Chiapas’vaccination coverage for children under age five was86% in 1994 and 94% in 1998, while coverage at thenational level in these years was 95% and 97%, respec-tively.154 In 2000, the official figures for coverage ofcompleted vaccination schemes in Chiapas was 96%for children under age one, and 98.5% for childrenbetween age one and four, higher than the respectivefigures of 94.4% and 98% for all of Mexico.155

The low vaccination rates were not limited to opposi-tion communities; indeed the study found lower ratesamong pro-government and divided communities, sug-gesting that other barriers were at work as well.

Family members of children with incomplete vacci-nation schemes were asked why they did not take theirchildren to be vaccinated in government health facili-ties. Over one-fifth (21%) cited reasons relating to thephysical and economic inaccessibility of health serv-ices: lack of health services in their community, dis-tance and difficulty of obtaining transportation to get tothe nearest health clinic, etc. Close to another one-fifth(18%) stated that they distrusted the governmenthealth services. Likewise, 6.2% cited reasons attributa-ble to the armed conflict. Some parents pointed outthat they were unable to attend health clinics in othercommunities, particularly if there was a health facilityin their own community (albeit one with no health per-sonnel or vaccines). They expressed concern that doc-tors in the other communities would deny them care,

medicines, and vaccines, since “they have a healthfacility in their own community” and “they do notbelong to that clinic.” Such was the case of a Tseltalwoman who belonged to the PRI political party, whotold investigators that no one had come to vaccinatechildren in her community for approximately ninemonths. She also explained that there were no vaccinesin her local health facility and that no one could get vac-cinations in the nearest clinic.

Of those parents who did not vaccinate their chil-dren, 4% specifically noted that governmental healthservices had placed conditions on vaccinations.156 Insixty-six cases, parents recounted direct refusal on thepart of health services to vaccinate their children.Refusal to vaccinate can lead to reluctance on the partof communities to attempt future vaccinations in addi-tion to fostering antipathy toward health services gen-erally. It is also in violation of the government’sobligations to respect the right to health. The mostextreme case was found in a community in the Selvaregion, where the population was engaged in the offi-cial process of building its own health clinic. As aresult, the doctor of the clinic where they had beenreceiving care, withheld treatment and vaccinationsbecause they “did not belong to that clinic anymore.” Itis worth noting that in the case of this community, thenearest clinic was more than four hours away on foot,and at the time of the study more than nine months hadgone by without any inhabitant having received a singlevaccination.

The health services erected other administrative andeconomic barriers for the vaccination of children aswell. For example, families in different communitiescomplained that if they were not enrolled in the Pro-gresa/Oportunidades program, a government anti-poverty program that provides families with access tohealth care as well as some other services, they wereexcluded from vaccination. In the best of cases, healthpersonnel vaccinated the “Progresa” children first andonly if any vaccines were left, they were administered to

156 Other prominent reasons involved lack of time on the part of par-ents, which may be related to the amount of time it takes to get tohealth facilities, and the religious affiliation of the children’s parents.The study noted two ways in which religion influenced the vaccinat-ing of children: 1) some evangelicals (for example, in the Altosregion) did not vaccinate their children because, according to theirbeliefs, the children need not be vaccinated, they merely have to havefaith in God; and 2) the leaders of a specific religious affiliationobstructed those belonging to other affiliations from coming to theclinics, so that their children could not receive vaccinations. This sit-uation was encountered mainly in the Altos region. For example, in acommunity near San Juan Chamula, people of a religious affiliationdiffering from the one professed by the majority could not attend thelocal health clinic. If they required any form of health service, theyhad to go to another community and assume a false name so as notto be identified.

F I N D I N G S 3 3

153 This situation was observed in the three studied regions. Forexample, in the Altos (File 3026), and Norte region (Files 484, 3840), 154 Gobierno Federal y Gobierno del Estado de Chiapas. Chiapas vive,la superación del rezago social, 1995-1998. Chiapas, México: 1999.Available at http://www.ser.gob.mx/chiapas/espanol.htm. AccessedNovember 10, 2005.155 SSA. Dirección General de Información y Evaluación del Desem-peño (DGIED). Indicadores para la evaluación de los sistemas desalud. Salud Pública de México 2002;44(4): 371–80.

children who were not in program. Conversely, the fam-ilies who received assistance from Progresa/Oportu-nidades had to vaccinate their children as a condition toremain in the program.

On other occasions, health service personnel askedparents to buy syringes to vaccinate the children,which, considering the population’s limited economicresources and great difficulty getting to pharmacies topurchase them, made the vaccination of their childrenimpossible. Problems with the supply of vaccines werealso documented. In such cases, it was not establishedwhether the health services were actually out of vac-cines or if this merely was an excuse used by healthpersonnel for not administering these vaccines.

Pulmonary Tuberculosis amongPersons Age Fifteen and OlderStates party to the International Covenant on Economic,Social and Cultural Rights are expected “to take meas-ures to prevent, treat and control epidemic andendemic diseases.”157 Infectious diseases, by theirnature, have the greatest potential for causing epi-demics. However, they can also become endemic inmany places, as has occurred with pulmonary tubercu-losis (PTB) in the studied area. PTB is a disease charac-terized by its heightened appearance in populationgroups that are socially and economically disadvan-taged, as shown by the eminently social character of itsepidemiology.

From a public health perspective, PTB is a preventa-ble and curable disease. However, social inequality anddiscrimination are directly related to the distributionand prevalence of TB among populations. The poormaterial living conditions of the majority of the popula-tion in various indigenous regions of Chiapas, bringtogether the principal risk factors for the transmissionof PTB: dark and poorly ventilated homes with perma-nently humid dirt floors and high levels of crowdingwhere more than five people live in one or two rooms.Moreover, the population suffers high levels of malnu-trition, a product of a monotonous, insufficient diet, andmaintains precarious access to services of detectionand treatment.

PTB is an incapacitating disease that, if not detectedand quickly treated, condemns patients and their fami-lies to a higher level of poverty that often has a negativeimpact on their living conditions. Under such condi-tions, it is common that the inability to work reducesaccess to food, and forces other members of the familyinto the labor market, often under unsatisfactory condi-tions (e.g., children drop out of school to work). In areasof high levels of poverty, untreated PTB is commonly

fatal. Untreated PTB leads to the infection (and possibledeaths) of other persons. Inadequately or partiallytreated TB can lead to multiple drug resistant TB(MDR-TB), which greatly exacerbates treatment diffi-culties in low-resource settings.

In Mexico, PTB is one of the twenty principal causesof death, and among the adult population it is among thetop causes of death.158 Chiapas, in turn, is the state withthe highest mortality rate associated with PTB, but it isalso one of the states most lacking in health resourcesfor adequately dealing with the spread of this disease.159


158 Sánchez-Pérez HJ. Tuberculosis pulmonar en zonas de alta mar-ginación socioeconómica de Chiapas, México: Problemas y retos asuperar: El caso de la Región Fronteriza. Doctoral thesis. Barcelona:Universidad Autónoma de Barcelona, 1999.159 Sánchez-Pérez HJ, Hernán M, Hernández-Díaz S, Jansá JM,Halperin D, and Ascherio A. “Detection of pulmonary tuberculosis inChiapas, Mexico.” Annals of Epidemiology 12, no 3:2002: 166–172.Available at: http://www.sciencedirect.com/web-editions/jour-nal/10472797. Accessed November 7, 2005; Sánchez-Pérez HJ, Flo-res-Hernández JA, Jansá JM, Caylá JM, and Martín-Mateo M. 2001.“Pulmonary tuberculosis in areas of high levels of poverty in Chia-pas, Mexico.” International Journal of Epidemiology;30 (2): 386–93.

Four out of five of the PTB positive cases identified inthe study who had not been treated by governmentalhealth services cited reasons relating to the inac-cessibility (physical and economic) of health serv-ices, as well as mistreatment and denials of care:

• A 42-year-old woman had not sought treatmentat the clinic in her community because she hadpreviously been denied care there as “her nameis not on the list of patients to be treated in theclinic.” According to this person, this is the onlyplace she can go because of lack of money (File4315-02).

• A 34-year-old man had not sought treatmentbecause medical assistance had been previouslydenied when he took his son to the clinic (File596-01).

• A 20-year-old man at first went to governmenthealth services, but subsequently stoppedbecause “they do not give any treatment,” andchose to be treated by traditional healers anditinerant medicine vendors instead (File 3070-03).

• A 35-year-old woman said she had not soughttreatment because of lack of money. There is noclinic in her community and the nearest one isninety minutes away on foot because there is notransportation between the two communities(File 1685-01).

157 UN CESCR. “General Comment 14.” August 2000; para 44.

F I N D I N G S 3 5

This investigation identified serious deficiencies inboth the detection and treatment of PTB, as well asalarming conditions that expose people to risk of PTB.In forty-six communities surveyed, twenty-nine casesof smear-positive PTB were found, only thirteen ofthem (fewer than half, 45%) had been previouslydetected by health services.The overall unadjustedprevalence of smear-positive PTB calculated for thetotal population of the communities studied, was 85.3per 100,000 inhabitants, and 161.2 per 100,000 forthose age fifteen and older (Table 7).160

Of the twenty-nine PTB-positive cases identified, fourhad not received any medical care. Of the twenty-fivewho had received medical care, twenty-two had done soin government health services and three in private serv-ices. Of these twenty-five cases, ten had not receivedany diagnosis, thirteen had been diagnosed with PTB,and two received diagnosis other than PTB (asthma andthroat infections). Of the thirteen cases, which had been

diagnosed by health services, one had not received anytreatment, six were receiving anti-tuberculosis treat-ment, and six had failed to comply due to several irregu-larities and deficiencies in their treatment.161

The rate of official detection (thirteen out of twenty-nine identified by the survey) is far below the WHO rec-ommendation (which stands at a minimum of 75%) foreffective management and control of PTB cases. Inaddition, it is highly probable that the official rates ofPTB incidence in Chiapas are underestimated, in partdue to under-diagnosis. There is evidence that under-diagnosis is very high, because of the presence of for-

160 It is possible that these rates are underestimated. They were cal-culated by estimating the number of all inhabitants in the studiedcommunities. However, it is probable that there were cases of PTBthat were not detected by the study due to the stigma associated withPTB in the communities. Additionally, it is possible that cases ofcoughing may not have been identified either by the field team or byhealth services. In fact, considering only the PTB rates in the inter-viewed households, unadjusted rates of PTB would be 161.8 per100,000 for the general population and 306.5 per 100,000 populationfor persons fifteen and older.

161 Examples include one patient who only received three months oftreatment, and another whose treatment ended after four daysbecause of political reasons (e.g. in the Altos region, a 29-year-oldTsotsil woman was diagnosed with PTB in San Cristóbal de LasCasas. However, the conflicts between her community and the com-munity where the health clinic was situated made it impossible forthe paitent to follow her anti-tb treatment (File 18)). Another patient,a 30-year-old man from a divided community had a bacciloscopiesperformed in his nearest clinic, located in another community, threeweeks before the study. The clinic already had his PTB positiveresults but had not yet told the patient because the nurse was afraidto go to his house owing to the political conflicts between the com-munity where the clinic was located and where the patient resided. Inother words, under-diagnosis, poor quality care, inadequate casemonitoring, and problems associated with the conflict, led to thenon-compliance with anti-tuberculosis treatment in six of the thir-teen cases previously diagnosed by health services and kept oneknown PTB positive patient from initiating treatment.

TABLE 6. Rates of Pulmonary Tuberculosis (PTB) Overall and Among Persons aged 15 and older,by Political Affiliation of Communities.

C O M M U N I T Y T Y P E

Pro-Govt. Opposition Divided TotalEstimated total population for the 17,258 3,154 13,592 34,004studied communities1

Estimated population age fifteen and older 9,129 1,680 8,985 17,994estimated for the studied communities2

Number of PTB positives3 14 1 14 29

Unadjusted PTB Rate per 100,000 persons in the 81.1 31.7 103.0 85.3estimated total overall Population3 IC95% IC95% IC95% IC95%

[44.40-271.10] [0.00-176.50] [56.30-172.80] [57.10-122.50]

Unadjusted PTB Rate per 100,000 persons 15 years 153.4 59.5 155.8 161.2and over (in the estimated total population 15 and over)3 IC95% IC95% IC95% IC95%

[83.90-257.20] [0.00-331.20] [85.20-261.30] [108.00-231.40]1 From the number of recorded inhabitants and the proportion of households studied in each community.2 From the proportion of the population age fifteen and older found in each type of community.3 According to the results of acid-fast smears and cultures made from sputum samples obtained from patients age fifteen and older withproductive cough of fifteen or more days of duration (n = 22 cases, ten pro-government communities and twelve divided communities) andseven cases of patients with less that four months in treatment at the time of the study (five with negative acid fast smears, and two cases inwhich it was not possible to collect samples; four from pro-government communities, two from divided communities, and one from an oppo-sition community).

midable problems in obtaining sputum samples inorder to effectively detect bacillus through bacil-loscopy, the laboratory method upon which the systemfor epidemiological surveillance of PTB in the Mexicodepends.162 Despite carrying out the anti-tuberculosisprogram in accordance with DOTS, in practice there aremany deficiencies in its application in Chiapas.

In 2000, while Chiapas ranked ninth highest in thecountry for the incidence of PTB cases, it ranked highestin the mortality associated with this disease.163 Nearlyone out of every ten patients diagnosed with PTB inMexico lives in the state of Chiapas and more than halfof them are indigenous.164 Although it was not possibleto accurately establish deaths caused by tuberculosisbecause the majority of deaths occurred without med-ical care, the team found twelve deaths whose case sto-ries seemed highly compatible with PTB.

Interventions by national and international healthorganizations, which were intended to address the PTBproblem, too often generated fragmentation and dimin-ished coordination in the activities of PTB control andtreatment. Anti-tuberculosis treatment schedules wereprovided under differing criteria and without strictmonitoring, as set out by currently recommendedinternational norms.165

In sum, severe deficiencies were found in the diag-nosis and treatment of PTB patients. During the fieldwork, the team observed the use of expired anti-tuber-culosis drugs, shortages of medicines, and a lack offlexibility in assisting patients by bringing medicines totheir homes (when they were physically unable to get tothe clinic or lacked the economic resources to do so).Further, political tensions led to the under-diagnosis ofcases, services could not provide bacilloscopy results

and anti-tuberculosis treatment, and some patientsfailed to comply due to irregularities and inadequatemonitoring.

Availability, Accessibility, Acceptability,Quality and Use of Health Services forSelf-reported Illness in the Month Priorto the StudyChiapas has the greatest degree of poverty and thefewest health resources in Mexico, both of which com-bine to restrict access to health services. There isstrong evidence that high levels of poverty help causethe low utilization of health services and delays inseeking care.166 Chiapas state has the lowest proportionof inhabitants that have insurance through social secu-rity. In 2000, only 17.6 % of inhabitants were enrolled inany institutional or private medical service.167 Chiapashas the worst indices of any Mexican state for healthresources, manifested in an evident lack of suppliesand resources in the state health services responsiblefor treating the majority of the people (who lackingsocial security have little or no access to other types ofhealth services). Chiapas also lacks resources to prop-erly train health personnel and supervise and evaluateservices, all of which comprise key aspects for increas-ing the quality, accessibility, and use of services by thepopulation.168 Chiapas has the poorest outcome indica-tors in Mexico with respect to many health conditionsincluding maternal mortality and mortality due toinfectious diseases (e.g. tuberculosis, gastrointestinaldiseases, cervical cancer).

Governmental programs have failed to successfullyexpand access to health care. For example, the Seguro

166 Bindman AB, Grumbach K, Osmond D, Komaromy M, Vranizan K,Lurie N et al. “Preventable Hospitalizations and Access to HealthCare.” JAMA 1995;274:305–11; Ochoa-Díaz López H, Sánchez-PérezHJ, Martínez-Guzmán LA. “Uso de un índice de bienestar social parala planificación de la salud a nivel municipal.” Salud Pública de Méx-ico;1996;38(4):257–67. Available at: http://www.insp.mx/ salud/38/384-5.html; Andrulis, D. P. 1998. “Access to Care is the Center-piece in the Elimination of Socioeconomic Disparities in Health.”Annals of Internal Medicine. 1998;129(5):412–16. 167 Including Instituto Mexicano del Seguro Social (IMSS), Instituto deServicios y Seguridad Social para los Trabajadores del Estado(ISSSTE), public and semi-public health institutions, private institu-tions with company agreements, and other types of institutions.Instituto Nacional de Estadística, Geografía e Informática (INEGI).Perspectiva Estadística: Chiapas. Aguascalientes, México: INEGI,Septiembre 2005: 22.168 SSA, Organización Panamericana de la Salud (OPS) Situación desalud en México: Indicadores básicos, 1995. México, D.F.: SSA, OPS,1995; SSA, Dirección General de Estadística e Informática (DGEI).Boletín de información estadística. Recursos y Servicios, 1997. Méx-ico D.F.: SSA, DGEI, 1998.


162 Sánchez-Pérez HJ, Hernán M, Hernández-Díaz S, Jansá JM,Halperin D, and Ascherio A. “Detection of Pulmonary Tuberculosis inChiapas, Mexico.” Annals of Epidemiology 2002;(12)3:166-172;Sánchez-Pérez HJ, Hernández-Flores JA, Jansá JM, Caylá JA, andMateo M. Pulmonary Tuberculosis in Areas of High Poverty in Chia-pas, Mexico. International Journal of Epidemiology. 2001;30:386-393.163 SSA. La situación de salud en los estados, 1999. México: SSA,2001; SSA, Dirección General de Estadística e Informática (DGEI).Coordinación de Planeación Estratégica: Mortalidad, 2001. México,D.F: SSA, DGEI, 2001; SSA. Sistema Nacional de Vigilancia Epidemi-ológica. Epidemiología. Sistema Único de Información 2001;51(18)Semana 51, 16-22 de diciembre de 2001.164 SSA. Mortalidad, 2001. México: SSA, 2001; SSA, DGEI, 2001; SSA.Sistema Nacional de Vigilancia Epidemiológica. Epidemiología. Sis-tema Único de Información 2001;51(18) Semana 51, 16-22 de diciem-bre de 2001. 165 Lee JW, Loevinsohn E, Kumaresan JA. Response to a Major Dis-ease of Poverty: the Global Partnership to Stop TB. Bull WorldHealth Organ. 2002;80(6):428; Mitra M. “A TB Scientist Reflects onthe Continuing Struggle Against a Global Threat.” JAMA 2005; 293(22): 2708-17.

Popular is a federal program that has emerged fromnational health reform, and seeks to reduce out-of-pocket payment for health insurance. The programexpands health coverage for unemployed citizens andfamilies and citizens that do not qualify for insurancethrough social security. Seventy thousand Chiapas fam-ilies have been enrolled in this program. Participationis voluntary but not entirely free; annual fees for partic-ipants range between 600 and 1000 pesos ($55 and $92US dollars). However, the program only covers a limitednumber of conditions, treatments, and medications.This has created disparities for those who qualify forthe program and can be treated within public healthservices, and those whose conditions or needs do not.

The second principal health program, called Oportu-nidades, is a federal program that affects 549,567 fam-ilies in Chiapas, or approximately half of the state’spopulation.

In many communities there were allegations thatdoctors, instead of prioritizing care for patients basedon clinical needs, determined whether they wereenrolled in the Oportunidades program or not, treatingfirst those who were, and deferring care and medica-tions for those who were not. Further the study foundevidence that participation in Oportunidades is at timesconditional. For example, in a pro-government commu-nity in the Norte region, a 21-year-old woman reportedthat she had gone to the clinic in her communitybecause she had an infection of the uterus. The doctorthere told her that she would treat her but that “shehad to use contraception” (tenía que planificarse), thatis, to use family planning methods. In addition, she wastold that if she did not accept family planning, shewould be removed from the Progresa/Oportunidadesprogram. According to the same woman, her husbandcomplained to the area supervisor; the doctor found outabout the complaint and subsequently scolded her,saying that she would not give her a consultationbecause she had complained.169 (File 4039-02).

Availability of care is also adversely affected in thestudied communities because medical personnel rou-tinely are forced to leave their health facility in order toattend meetings, courses, deliver information, or to takevacations. The tremendous burden of administrativework forces doctors to devote more time to administra-tive matters than to clinical work. The team discoveredthat it is not uncommon to see health centers without adoctor for ten days or more out of every month. Further,interviewees asserted that clinics often close at 6 p.m.,after which time there is no available care.

Additionally, the study confirmed that many clinics inthe rural areas of Chiapas are staffed by social service

doctors who only stay in a facility for about nine to twelvemonths, or doctors who have annual contracts. This con-stant turn-over leads to problems in continuity of care,monitoring of patients (especially the chronically ill), andtracking down contacts for diseases, such as PTB.

Even services that are available are often not used.The study found a non-utilization rate of 30% of govern-ment health services for a variety of different condi-tions, ranging from vaccinations, to obstetric care toPTB treatment. Of the 2,947 persons that reported ill-ness in the month prior to the household survey, 675(23%) did not seek any medical attention. Of the 2,272who did seek care, 168 (7.4%) reported that they hadbeen denied access to care. The reasons for denial ofservices were: administrative constraints (schedule,living outside of catchment area –e.g.., “you don’tbelong to this clinic”), 44%; alleged lack of medications,33%; conditioning (political, participating in the Pro-gresa/Oportunidades program, or having to performwork in the clinic) 6%; and being charged more thanthey could pay for services, 5%.

The study could not determine the degree to whichthe conflict may have helped discourage or obstruct theuse of health services. But it does show that politicalfactors, including distrust and outright refusals of care,have played a role in such a high non-utilization rate.Qualitative information, obtained in addition to thehousehold surveys, helps shed some light on the con-flict-related and non-conflict related factors affectingutilization of government health services in the studiedcommunities. For example:

• One of the factions in a divided community in theAltos region would not let members of a nearbycommunity use their clinic, because of problemsrelated to the December 1997 massacre in Actealand the ensuing political divisions.

• A sick child in an Altos region community that didnot have a health clinic was taken by his parents tothe nearest clinic. However the doctor there wouldnot treat the boy unless his parents, who belongedto the EZLN, changed their political affiliation and“joined us.” The boy was sick for two days and wastaken to a traditional healer, but later died.

• A pro-government community in the Selva region,which had a government clinic, did not allow mem-bers of a “nearby” community (two hours away onfoot) to use the clinic’s services. The pro-govern-ment community said that if they treated peoplefrom the other community, they would not haveenough medications to take care of their own people.As there was a clinic (without a doctor) in the othercommunity, medical personnel were warned by localauthorities not to treat patients coming from otherscommunities (Files 379-04, 1690-01, 1704-01).

F I N D I N G S 3 7

169 Kirsch J, Arana-Cedeño M.” Informed consent for family planningfor poor women in Chiapas, Mexico. Lancet 1999;354(9176):419–20.


• Interviewees alleged that the presence of militarypersonnel in communities where health clinics arelocated affects access to these clinics. This is par-ticularly the case for women, as often their hus-bands will not let them go, or they do not dare goingalone (as occasionally the soldiers allegedly molestthem) and their husbands cannot always accom-pany them to the doctor.170

• Residents of several divided and opposition commu-nities in the Selva and Altos regions, complained thatin order to receive treatment in their assigned clinic,located in another community, they were asked towash sheets or cut the grass, etc. They also com-plained that if they stopped going to the clinic, theywere “erased” from the list of the Progresa/Oportu-nidades program, thereby losing all possibilities ofreceiving treatment. (Files 1876-02, 3223-01, 1116-03).171 Others forms of conditionality included: recipi-ents must be a beneficiary of the Progresa/Oportunidades program (File 181-01); and femalerecipients must accept family planning methods.

There are even greater barriers to secondary carethan to primary care clinics.172 Poverty among the popu-lation makes hospital stays problematic, not onlybecause of the costs but also the loss of earnings whileaway – earnings that provide families’ daily sustenance.Apart from the financial barriers, physical access alsois difficult. For example, the field team was informedthat problems in getting to hospitals are due to: 1) thepossibility of being “assaulted” (ranging from simplerobbery to murder) after 6 or 7 PM on the roads, and 2)during the rainy season (at least five months out of theyear), the dirt roads running in and out of remote com-munities become impassable. Mudslides, washouts,and swollen rivers often make access to certain com-munities difficult.173 Additionally, the field team learnedthat, especially in divided communities, inhabitantsfear being robbed of their household belongings when

they have to be away for several days.174

In addition to lack of accessibility, community mem-bers reported low quality care, including outright dis-crimination to cultural insensitivity. For instance, aperception exists among the study population that theywill not be fed or treated well in hospital. Hospital foodoffered to patients and their relatives is often com-pletely different to the food that they are familiar with intheir communities.175 Allegations of poor treatmentwere also common. For example, a 35-year-old Tojola-bal woman from a divided community in the Selvaregion reported that her nine-year-old daughter whohad already suffered two years of stomach pain andheadache, became much worse and was taken to thenearest health clinic for treatment. She was referredfrom there to a hospital where she was admitted. Thewoman complained that if she slept with her daughter,the nurses came and scolded her, saying that she couldnot sleep because she had to take care of her daughter.She was repeatedly reprimanded by the staff, who didnot treat or examine her daughter adequately. Duringthe time of the study, her daughter remained in illhealth, but she said that “we don’t know where to takeher for lack of economic resources, transportation, androad conditions,” and “in the nearest health clinic theyconstantly say there is no medicine” (File 1173).

The objective facts of lack of medications (or asser-tions to that effect) are often mixed with perceptions ofinadequate quality of care and mistreatment. Forexample, a 62-year-old Chol man from the EZLN,stated that after having been denied medicine andmedical attention at a clinic, three of his sons becameill, but he had not brought two of them for care becausehe knew that they would tell them “that there is nomedicine or to come back later” and when they would

170 Female members of the field work team were verbally harassedby soldiers when undertaking the survey in the conflict zone.171 These types of complaints occurred in rural medical units of theIMSS-Oportunidades program, which do not charge for treatmentbut instead ask people to support the clinic through such activities.172 One reason for not seeking secondary care is the fear of dying out-side the community. This is a significant determinant of behavior, notonly because of what it implies in juridical and administrative terms(filling out certificates, transferring the remains, etc.), but alsobecause of the importance for inhabitants to die on their land. Forexample, the field team encountered a very sick woman, whose chil-dren, despite the severity of her condition, did not allow her to go to thenearest hospital for fear that she might die outside her community.173 In order to gain access to some communities, it is necessary tocross rivers in four-wheel-drive vehicles. In the rainy season, theserivers are practically impossible to cross and in some cases requireheavy vehicles (three-ton trucks) to cross them.

174 This occurs more often in smaller households that cannot dependon relatives or social networks to take care of the children or eventhe home.175 For example, during the field work, the study team encounteredthe case of a male infant less than a year old, who was found in asevere state of malnutrition with an acute case of diarrhea. The fieldteam transported him from his community to the general hospital inSan Cristóbal de Las Casas (more than four hours away). Due to hishealth condition and age, it was necessary to bring along the infant’smother (who could not speak Spanish), father, and his four-year-oldsister. The infant needed to be kept in the hospital at least ten days tostabilize his condition, increase his weight, and treat his gastroin-testinal infection. On the third day, the parents no longer wanted tostay in the hospital, because only the sick child and the mother werebeing fed (the father and the daughter did not receive anything), thefood given to the mother was different from what she was accus-tomed, there was nobody to take care of things at their home, and theinfant’s father had no income while away from his community. Thechild was discharged from the hospital at the request of the parentsand was brought home, where a short time later he died. The deathof this child was not included in the results of the study as it occurredabout a month after the survey had been conducted.

F I N D I N G S 3 9

return the doctor would not be there or the clinic wouldbe closed. He also alleged that health workers scoldindigenous people saying that “they do not know how tocare for or clean themselves” (File 181). Similarly, a 37-year-old displaced man alleged that, in addition tobeing required to buy his medicines which he could notafford, he was discriminated against in the hospital dueto his indigenous identity and displaced status, andclaimed that non indigenous patients were treated bet-ter than indigenous patients with better quality of care,more medicines, and a shorter wait time to be treated(File 502-01).

In short, in addition to the lack of availability ofhealth care in the conflict zone, the study found severefinancial and physical barriers to care. There wasreported discrimination in access, based on politicalaffiliation as well as conditioning care based on partici-pation in the Progresa/Oportunidades Program. Thestudy documented acute problems with the quality ofcare, ranging from outright mistreatment of patients tolack of cultural considerations on the part of healthservices.

Limitations and Implications forInterpretation of Findings Biases may have been introduced at various points inthe collection of data, which present limitations to theconclusions that can be drawn from these findings.First, the classification of communities does not lenditself to replication or independent validation. This diffi-culty in replication is exacerbated by the high misclas-sification rate (approximately 25%) and subsequentreplacement of communities.

Second, the sample size of opposition communitiesis not comparable to the number of pro-government ordivided communities: 256 households versus 1,477 and1,264, respectively. Third, in reaction to the high non-response rate among opposition communities in par-ticular, four purposively selected oppositioncommunities were added to those that had been ran-domly selected, which severely limits how the resultscan be generalized . Fourth, and perhaps most serious,it was primarily the “hard-line” resistance communi-ties that declined to participate in the study. Therefore,this report cannot determine what health impacts havebeen associated with the rejection of all governmenthealth care and other social services.

Further, the political affiliation or status of a com-munity is dynamic and fluid. As evidenced to somedegree by the difficulty in taking a snapshot to classifythe communities studied, these affiliations may shiftrapidly and continually. For example, when a family orgroup of families in an opposition community begins toaccept or seek certain government services, they maybe ostracized and the community then becomes“divided.” As many of the health conditions reported onin this study are the result of long-term exposures (e.g.stunting) or are calculated over a long period in order toobtain statistically significant numbers (e.g. maternaldeaths), the fluid nature of these communities does notpermit a definitive correlation between one communitytype and any specific results obtained in any givensnapshot.

Conclusions, however, can be drawn with respect tothe health conditions in the conflict zone in general, andcomparisons can be drawn between the conflict zoneand the overall populations of Chiapas and Mexico.

4 1

When understood through the lens of interna-tional human rights law, it becomes clear thatby providing woefully substandard health serv-

ices to an overwhelmingly indigenous population, per-mitting political divisions to discourage or prevent asignificant portion of the population from taking advan-tage of existing services, and failing to assure preven-tion of disease through appropriate public healthmeasures, the government of Mexico has consistentlyviolated its obligations.

In a previous report on Chiapas, Health Care HeldHostage, PHR analyzed a wide spectrum of violations ofinternational human rights and humanitarian law by theMexican government, including freedom of movementand the right to health care and violations of medicalneutrality, as well as failures to respect medical neu-trality in Zapatista communities. Seven years later, thatanalysis is still relevant to the situation in Chiapas. Thatreport also noted that problems surrounding access to,quality of and discrimination in health care are perhapsbest understood as systematic violations of the socialright to health. Enjoyment of the right to health isdependent upon ending discrimination and securing awide variety of human rights for the indigenous peoplein Chiapas, and also requires an inclusive and effectivecitizenship without loss of identity or dignity.

Introduction to International Norms andStatus of Mexico’s Obligations The right to the highest attainable standard of physicaland mental health (referred to here as the right tohealth), which is inextricably related to the right to life aswell as other human rights, is set forth in a number ofinternational treaties to which Mexico is a party, includ-ing: the International Covenant on Economic, Social andCultural Rights (ICESCR), the Convention on the Rightsof the Child (the Children’s Convention); the Conventionon the Elimination of All Forms of Discrimination AgainstWomen (the Women’s Convention); the Convention onthe Elimination of All Forms of Racial Discrimination(Race Convention); the Additional Protocol to the Ameri-can Convention on Human Rights Protocol of San Sal-vador); and Convention 169 of the International LaborOrganization Concerning Indigenous and Tribal Peoplesin Independent Countries (ILO Convention 169).

The core provision regarding the right to health isfound in Article 12 of the ICESCR. Article 12(1) sets outthe general statement that there is a right to the “high-est attainable standard of physical and mental health.”Paragraph 2 then announces four steps states shouldtake in fulfilling the highest attainable standard ofhealth: (a) the provision for the reduction of the still-birth-rate and of infant mortality and for the healthydevelopment of the child; (b) the improvement of allaspects of environmental and industrial hygiene; (c) theprevention, treatment and control of epidemic, endemic,occupational and other diseases; and (d) the creation ofconditions which would assure to all medical serviceand medical attention in the event of sickness.

A review of international instruments shows that theright to health as it is enshrined in international lawextends well beyond health care services to includebasic preconditions for health, such as clean water andsanitation, adequate housing and nutrition.176 Thisunderstanding of the right to health is also consistentwith Mexican law. Article 4 of Mexico’s Constitutionestablishes that “every person has the right to healthprotection.”177

Numerous legal scholars have clarified the natureand purpose of the right to health protection. GonzálezFernández writes that its purpose is “to guarantee thehuman right to health, to medical care, to protection ofthe means of subsistence, and to social services neces-sary for individual and collective well-being. As aresult, the right to the protection of health for Mexicansconsists of comprehensive health care of equal quality,efficiency, and timeliness made available through theappropriate institutions.”178 According to Diego Valadés,

176 In addition to the right to health, there is a separate right to ahealthy environment. For example, the UN Working Group on Indige-nous Populations has highlighted the importance of a healthy envi-ronment to indigenous peoples. In the Inter-American System, theProtocol of San Salvador distinguishes between the right to healthand the separate right to a healthy environment.177 Title 1, ch. 1, art. 4. Constitución Política de los Estados UnidosMexicanos (Political Constitution of the United Mexican States). 13thed. Mexico: Trillas; 1997.178 González-Fernández JA. “El derecho a la salud y las garantíassociales.” Revista de investigaciones Juridicas, Escuela Libre deDerecho 6(6): 1982; 425. In: Ruiz Massieu JF, “Mexico,” in The Rightto Health in The Americas: A Comparative Constitutional Study. PanAmerican Health Organization; 1989:372-389, 379.

V. THE FRAMEWORK OF THE RIGHT TO HEALTHUNDER INTERNATIONAL AND DOMESTIC LAW


“the statement of the right to health protection includespersonal health services (preventive, curative, andrehabilitative medical care), and general or publichealth services (including environmental protection).179

The meaning of the right to health under interna-tional law has been further explained by the GeneralComment issued by the ESC Rights Committee, whichmonitors implementation of and compliance of the ICE-SCR. (“ESC Rights Committee General Comment No.14” or “General Comment”). The General Commentrecognizes that “the underlying determinants of health,such as safe and potable drinking water and adequatesanitation facilities, hospitals, clinics and other health-related buildings, trained medical and professionalpersonnel” have to be available in sufficient quantitywithin the State party.180 It specifies that health facili-ties, goods and services must be available, accessible,acceptable and of adequate quality.

Availability refers to having sufficient quantity ofhealth facilities, goods and services, including drinkingwater, sanitation, and other determinants of health.Accessibility has four overlapping dimensions: first, theprinciple of non-discrimination demands that “healthfacilities, goods and services must be accessible to all,especially the most vulnerable or marginalized sec-tions of the population, in law and in fact, without dis-crimination on any of the prohibited grounds;”181

second, physical accessibility means that “health facili-ties, goods and services must be within safe physicalreach for all sections of the population, especially vul-nerable or marginalized groups, such as ethnic minori-ties and indigenous populations…;”182 and accessibilityalso implies that “medical services and underlyingdeterminants of health, such as safe and potable waterand adequate sanitation facilities, are within safe phys-ical reach, including in rural areas.“ 183

Third, economic accessibility requires that “healthfacilities, goods and services must be affordable forall…including socially disadvantaged groups. Equitydemands that poorer households should not be dispro-portionately burdened with health expenses as com-pared to richer households.”184 Campesinos whodepend upon subsistence farming and do not have

access to cash face particular difficulties, which need tobe considered in governmental policy and practice.Accessibility also includes the “right to seek, receiveand impart information and ideas concerning healthissues,” which includes health information in indige-nous languages.185

With respect to acceptability, the ESC Rights Com-mittee states that “[a]ll health facilities, goods andservices must be respectful of medical ethics and cul-turally appropriate, i.e. respectful of the culture of indi-viduals, minorities, peoples and communities, sensitiveto gender and life-cycle requirements...”186 Culturalacceptability requires respect for traditional medicinesand practices which have not been shown to be harmfulto human health.187

Finally, “health facilities, goods and services mustalso be scientifically and medically appropriate and ofgood quality. This requires, inter alia, skilled medicalpersonnel, scientifically approved and unexpired drugsand hospital equipment, safe and potable water, andadequate sanitation.”188

Through Mexico’s General Health Law, the NationalHealth System theoretically guarantees both the avail-ability and quality of health services, particularly to so-called vulnerable groups, such as indigenouspersons.189 The 1998 reform to the Law of Fiscal Coordi-nation indicated a formula for distributing the healthbudget more equitably, with an emphasis on marginal-ized groups.190

However, in practice, the findings of this study indi-cate that health care is not sufficiently available oraccessible to many indigenous (as well as non-indige-nous) persons in Chiapas, and in particular those com-munities that are in the conflict zone. Economicinaccessibility is a tremendous barrier to use, aspatients of the health system are expected to covercosts of medications and ancillary expenses even whenservices are provided free of charge or at reduced fees.Cases of parents being asked to purchase or pay for

179 Valadés D. “El derecho a la protección de la salud y el federal-ismo.” In: Derecho constitucional a la protección de la salud. (1994)cited in Jose Francisco Ruiz Massieu, “Mexico,” in The Right toHealth in The Americas: A Comparative Constitucional Study, PanAmerican Health Organization; 1989:372-389, 379.180 UN CESCR. “General Comment 14.” August 2000; para 12 (a).181 Id.,UN CESCR. 2000; para 12 (b).182 Id., UN CESCR. 2000; para 12(b).183 Id., UN CESCR. 2000; para 12(b).184 Id., UN CESCR. 2000; para 12(b).

185 Id., UN CESCR. 2000; para 12(b).185 Id., UN CESCR. 2000; para 12(c).187 Traditional practices that have been shown to be harmful, such asfemale genital cutting, should be abolished in keeping with interna-tional human rights law. UN. Women’s Convention. 1981; Art. 5.188 UN CESCR. “General Comment 14.” August 2000; para 12(d).189 Title III, ch. 1, Art. 25. Ley General de Salud. (Mexico GeneralHealth Law). February 7, 1984.190 Ley de Coordinación Fiscal (Law of Fiscal Coordination) GobiernoFederal de la Nación. 1997 cited in Lozano R, Zurita B, Franco F,Ramírez T, Hernández P, Torres JL. “Mexico: Marginality, Need, andResource Allocation at the Country Level.” In: Evans T, Whitehead M,Diderichsen F, Bhuiya A, Wirth M, eds. Challenging Inequities inHealth: From Ethics to Action. New York: Oxford University Press;2001:292.

T H E F R A M E W O R K O F T H E R I G H T T O H E A L T H U N D E R I N T E R N A T I O N A L A N D D O M E S T I C L A W 4 3

syringes in order to have their children vaccinated werealso documented. Further, the study findings suggestthat geographic dispersion coupled with transportationexpenses pose inordinate barriers to care for theserural populations, and that lack of security also makestransportation of patients extremely difficult. Althoughsome of these obstacles are partially compensated forby kinship or other forms of culturally developed mech-anisms of sharing and solidarity, in divided communi-ties many of these traditional mechanisms of mutualsupport are lost. Across communities, the study founddistrust of government services and instances of out-right denials of care at public health facilities due tosuch factors as: political affiliation, bureaucratic argu-ments about not being on a particular clinic’s patient“list”, and non-participation in the Oportunidades Pro-gram. The lack of accessibility is reflected in the rela-tively high percentage of people who fail to utilizegovernmental health services, even for vaccinationsand obstetrical care.

Furthermore, health services are often not accept-able to local populations for various reasons, and thisfact affects the non-utilization of services across politi-cal affiliations. For example, the Special Rapporteur onthe Right to the Highest Attainable Standard of Physicaland Mental Health (Special Rapporteur on the Right toHealth) has called on governments to: make “healthfacilities, programmes and projects, and health-relatedinformation [available] in languages spoken by indige-nous peoples”; institute “training of indigenous healthworkers to conduct outreach services to and health carein indigenous communities;” and institute “training ofhealth professionals to ensure that they are aware of,sensitive to, issues of ethnicity and indigenous cul-ture.”191 Not only are these conditions not being met inChiapas today, as the report documents, indigenouspersons complain of rampant mistreatment on thebasis of their ethnicity and of health personnel makingdisparaging remarks about their habits and demeanor.

Finally, many of the programs administered by thepublic health system are of inadequate quality. Forexample, the General Health Law prioritizes maternal-child health. According to the law, maternal-childhealth includes: “(1) the care of women during preg-nancy, childbirth, and the post-partum period; (ii) thecare of the child and regard for his/her growth anddevelopment, including the promotion of timely vaccina-tions; and (iii) the promotion of the integration and well-being of the family. However, in practice, the study found

that health care for children and emergency obstetricservices have not been effectively provided to mothers inindigenous and economically marginalized areas.192

Inadequate quality is reflected, too, in the absence ofdiagnosis and appropriate treatment for pulmonarytuberculosis. Indeed, in relation to PTB, the normativerequirements of availability, accessibility, acceptabilityand quality of care should translate into a concerted planwith deliberate steps aimed at providing people with: areliable and timely diagnosis; adequate medical treat-ment and monitoring, independent of their political orreligious affiliation, their having social security or not,and their economic ability to pay; clear and adequateinformation and counseling concerning their diagnosis,the illness, its treatment, its evolution, its possible com-plications, and the possibility of infecting others; andcomprehensive treatment. The study found that reason-able steps, including the establishment of a comprehen-sive DOTS program, were not being taken toward thefulfillment of the government’s obligations.193

In addition to the ICESCR, Mexico is a party to othertreaties that are relevant for understanding its health-related obligations. Article 24 of the Children’s Conven-tion, which Mexico has ratified, adopts a similardefinitional approach to the right to health as the ICE-SCR.194 Article 12 of the Women’s Convention, whichMexico has also ratified, puts the right differentlybecause it speaks to the obligation of States parties toeliminate discrimination against women in the field ofhealth care.195 However, read in conjunction with Arti-cles 14 and 16 of the Women’s Convention, it is clear

191 Report by Paul Hunt, Special Rapporteur to the Commission onHuman Rights, on “The Right of Everyone to the Highest AttainableStandard of Physical and Mental Health,“ submitted in accordancewith Commission resolution 2004/27. UN Doc. A/59/422. October 8,2004, para 58.

192 See: Brentlinger P, Sánchez-Pérez HJ, Arana-Cedeño M, VargasMG, Hernán MA, Micek M, Ford D. “Pregnancy outcomes, site ofdelivery, and community schisms in regions affected by the armedconflict in Chiapas, Mexico. A Community-based Survey.” Social Sci-ence and Medicine 2005;61:1001-1014; Freyermuth G. Las mujeresde humo. Morir en Chenalhó. Género, étnica y generación, factoresconstitutivos del riesgo durante la maternidad. México: Centro deInvestigaciones Estudios Superiores en Antropología Social(CIESAS); Comité por una Maternidad Vountaria y sin Riesgos, Insti-tuto Nacional de las Mujeres, Miguel Ángel Porrúa, 2003.193 According to the WHO, the five elements of DOTS are: sustainedpolitical commitment; access to quality-assured TB sputummicroscopy; standard short-course chemotherapy under propercase management conditions; uninterrupted supply of quality-assured drugs; and recording and reporting system enabling out-come assessment.194 Article 24 (2)(d). United Nations. Convention on the Rights of theChild (Children’s Convention). G.A. Res. 44/25, 44 UN GAOR, Supp.No 49, UN Doc A/44/736 (1989). Mexico ratified the Convention on theRights of the Child on September 21, 1990.195 Article 14 (2)(b), United Nations. Convention on the Elimination ofAll Forms of Discrimination Against Women (Women’s Convention).Adopted December 18, 1979. GA Res 34/180, UN GAOR Supp (No 46).UN Doc/A/34/36 (1978). Reprinted in ILM 33 (1980). Entered intoforce September 3, 1981. Mexico ratified the Women’s Convention onMarch 23, 1981.


that access to health care services, including familyplanning, is part of women’s right to full participation indecisions affecting their well-being.196

Article 10(2) of the ICESCR specifically addressespregnancy when it states that “[s]pecial protectionshould be accorded to mothers during a reasonableperiod before and after childbirth.”197 The Women’sConvention provides that “States’ parties shall take allappropriate measures to eliminate discriminationagainst women in the field of health care in order toensure, on a basis of equality of men and women,access to health care services . . .”198 It too specificallyaddresses the of needs of pregnant women: “Statesparties shall ensure to women appropriate services inconnection with pregnancy, confinement and the post-natal period, granting free services where neces-sary.”199 Both the ICESCR and the Women’s Conventionassert that States parties must take all appropriatesteps or measures to “the maximum available extentof [their] resources” to assure the fulfillment of theright to health including medical attention for all inthe event of sickness (such as obstetric complica-tions) and to “eliminate discrimination in health care,including special measures for pregnant women,”respectively.200

The reduction of maternal mortality is explicitlymentioned in both the 1999 CEDAW General Recom-mendation on “Women and Health,” and in the 2000ESC Rights Committee General Comment on “the Rightto the Highest Attainable Standard of Health.” The ESCRights Committee General Comment states that, “Amajor goal should be reducing women’s health risks,particularly lowering rates of maternal mortality.”201

For its part, CEDAW states in its General Recommen-dation that States’ parties must report on the measuresthey have taken “to ensure women appropriate servicesin connection with pregnancy, confinement and thepost-natal period” and in particular should includeinformation on “the rates at which these measures

have reduced maternal mortality and morbidity in theircountries.”202

The Committees then go further by announcing thatessential obstetric services must be provided and madeaccessible to women in fulfilling a State’s obligations.The ESC Rights Committee has singled out essentialobstetric services as an important component of Statesparties’ obligations with respect to the right to health inits General Comment and has stated that the provisionof maternal health care constitutes part of a State’sessential or minimum core obligations.203 In its GeneralRecommendation “Women and Health,” CEDAW notesthat “it is the duty of States parties to ensure women’sright to safe motherhood and emergency obstetric serv-ices and they should allocate to these services the max-imum extent of available resources.”204 The alarminglyhigh maternal mortality ratio found in the study,although from a small sample, indicates that Mexico isnot complying with its obligations under internationallaw with respect to this aspect of the right to health andtherefore with ending discrimination against women inthe field of maternal health care.

Children’s health is a special concern of internationalhuman rights law. Article 24 of the Children’s Conven-tion, to which Mexico is a party, recognizes the right thatchildren have “to the enjoyment of the highest attain-able standard of health and to facilities for the treat-ment of illness and rehabilitation of health” and “tocombat disease and malnutrition,” among other things,“through the provision of adequate nutritious foods andclean drinking-water, taking into consideration the dan-gers and risks of environmental pollution”. 205

Article 12 of the ICESCR calls on States parties, suchas Mexico, to take steps to ensure the “healthy develop-ment of the child.” Further, among the minimum obliga-tions set out by the ESC Rights Committee in its GeneralComment No. 14 is the duty of States parties “to ensureaccess to the minimum essential food which is, nutri-tionally adequate and safe, to ensure freedom fromhunger to everyone [including children]”.206 Further, theHuman Rights Committee, which is the body that issuesauthoritative interpretations of the International Conven-tion on Civil and Political Rights, to which Mexico is also

196 United Nations Committee on the Elimination of DiscriminationAgainst Women (UN CEDAW). “General Recommendation No. 24:Women and Health.” 20th Session of the Committee on the Eliminationof Discrimination against Women. New York: February 2, 1999; para 2.197 UN. Cairo Programme. Chapter IV: “Reproductive Rights andHealth.” 1994; Art. 10(2).198 UN. Women’s Convention. 1981; art. 12(1).199 Id., UN. 1981; art. 12(2).200 UN. Women’s Convention. 1981. arts 1, 12; United Nations. Inter-national Covenant on Economic, Social and Cultural Rights. Geneva:3 January 1976; Arts. 1, 12.201 UN CESCR. “General Comment 14.” August 2000; paras 14 and 21.202 UN CEDAW. “General Recommendation No. 24.” 1999; para 26.

203 UN CESCR. “General Comment 14.” August 2000; paras 14 and44.204 UN CEDAW. “General Recommendation No. 24.” 1999; para 27.205 Article 24. United Nations. Convention on the Rights of the Child(Children’s Convention). G.A. Res. 44/25, 44 UN GAOR, Supp. No 49,UN Doc A/44/736 (1989). 206 UN CESCR. “General Comment 14.” August 2000; para 43.207 United Nations High Commission for Human Rights. “GeneralComment 6.” April 1982; para 5.

a party, has defined the role of states in protectinghuman life to include obligations to “reduce infant mor-tality…and to eliminate malnutrition and epidemics.” 207

The right to food should not be interpreted as the“right to food assistance”—i.e., as a hand-out, as it hasbeen interpreted in practice in Chiapas—but as theright of the population to food security through its ownfood production or remunerated work that permitsaccess to sufficient quantities of appropriate food.However, the alarming rates of malnutrition found inthe study (54.7% stunting) indicate that the Mexicangovernment has failed to provide for food security forthe population.

In paragraph 44 of General Comment No. 14, the ESCRights Committee states that an obligation of compara-ble priority to those set out in the minimum core are “toensure…child health care” and “to provide immuniza-tion against the community’s major infectious dis-eases.”208 Such immunization coverage is providedthrough a national immunization program. It furtherclarifies with respect to Article 12(2) (c) that “[t]he con-trol of diseases refers to States’ individual and jointefforts to, inter alia,…implement] or [enhance] immu-nization programmes and other strategies of infectiousdisease control.209 The study however found that almosta quarter of the children under the age of five had notreceived their full immunization schemes, as set out bythe Mexican government, and that there were sociopo-litical, economic and physical barriers to the accessibil-ity of immunization services, as well as some directrefusals by health care practitioners to immunize.

The International Convention on the Elimination ofAll Forms of Racial Discrimination (Race Convention),to which Mexico is also a party, calls on States partiesto eliminate racial discrimination and “guarantee theright of everyone, without distinction of race, colour, ornational or ethnic origin” the enjoyment of, amongother rights, “the right to public health, medical care,social security and social services.”

Article 25 of the ILO Convention 169, which Mexicohas ratified, most specifically addresses the rights ofindigenous persons to health: “Governments shall

ensure that adequate health services are made avail-able to the peoples concerned, or shall provide themwith resources to allow them to design and deliver suchservices under their own responsibility and control, sothat they may enjoy the highest attainable standard ofphysical and mental health.”210

At the regional level, the American Declaration onthe Rights and Duties of Man (American Declaration)mentions the right to health in Article XI.211 The Inter-American Commission and Inter-American Court onHuman Rights have both broadly interpreted the pro-tections of the right to life in the American Conventionon Human Rights (American Convention), to whichMexico is a party to include dimensions of health andwellbeing necessary to human survival andflourishing.212 Further, the Protocol of San Salvador, towhich Mexico is also a party, specifically includes theright to health in Article 10, as well as the right to ahealthy environment in Article 11.213

Mexican laws relating to health protection are foundprincipally in the General Health Law, the Organic Fed-eral Law on Public Administration, and the State HealthLaw provisions of Chiapas. The Mexican Constitutiongrants authority to the Mexican Congress to enact lawsrelated to the “general health,” and establishes a Gen-eral Health Council with authority to make general pro-visions, which are obligatory throughout the country.214

Mexican national law is also consonant with interna-tional law’s recognition of different dimensions of thestate’s obligations to guarantee the right to health: torespect, or avoid from direct infringement through, e.g.,discrimination; to protect from interference by thirdparties, e.g., through such measures as environmentalregulation; and to fulfill by adopting appropriate meansto realize the right, including providing available,accessible (economically and physically), acceptableand quality health goods and services to all.215 Never-theless, as this report details, these obligations are notbeing honored in practice in the conflict zone.

208 Id., UN CESCR. 2000; para 44(2).209 Id., UN CESCR. 2000; para 16210 Article 7(2). International Labor Organization. International LaborOrganization Convention Concerning Indigenous and Tribal Peoplesin Independent Countries (ILO Convention 169). Reprinted in Twenty-five Human Rights Documents. New York: Center for the Study ofHuman Rights, Columbia University; 1994. This article states: “Theimprovement of the …levels of health…of the peoples concerned,with their participation and cooperation, shall be a matter of priorityin plans for the overall economic development of areas they inhabit.Special projects for development of the areas in question shall alsobe designed as to promote such improvement.”


211 Article XI. American Declaration on the Rights and Duties of Man.Bogotá: 1948. Approved in the IX Inter-American Conference of theOrganization of American States (OAS).212 Article 4, para 1. OAS. American Convention on Human Rights:Pact of San José, Costa Rica. Approved at San José, Costa Rica,November 22, 1969. Available at: http://www.oas.org/juridico/eng-lish/Treaties/b-32.htm. Accessed November 8, 2005. Ratified byMexico March 2,1981.213 OAS. Additional Protocol to the American Convention on HumanRights in the Area of Economic, Social and Cultural Rights: Protocolof San Salvador. OAS Treaty Series No. 69: 1988. Entered into force1998. Mexico ratified the Protocol of San Salvador in 1996.214 Title 1, ch. 1, art. 4. Constitución Política de los Estados UnidosMexicanos. 13th ed. Mexico: Trillas; 1997.215 UN CESCR. “General Comment 14.” August 2000; para 12.


Principles Characterizing a HumanRights Approach to Health and How TheyApply to the Conflict Zone in Chiapas International human rights norms relating to the rightto health are not abstract aspirations; on the contrary,they provide a concrete set of principles by which toevaluate the design and implementation of health pol-icy-making and programming. It is widely recognizedthat a human rights-based approach to health includes,but is not limited to, the following principles: non-retro-gression and adequate progress; non-discriminationand equality; meaningful participation; accountability;and multi-sectoral strategies.

Non-retrogression and Adequate ProgressViolations of these legal obligations constitute injusticesand not simply tragedies. In language that is echoed ineconomic and social rights provisions of other treaties,the ICESCR obligates States parties such as Mexico totake steps “toward the progressive realization” of all ofthe rights contained in the Covenant to the “maximumavailable extent of its resources.”216 As a matter of law,as a party to the ICESCR, the Women’s Convention, theChildren’s Convention and the Protocol of San Salvador,Mexico is by no means free to defer taking action withrespect to such rights.217 Ten years after the EZLN upris-ing, Chiapas continues to trail the country in manyhealth and social indicators and the government’sresponse has been inadequate.

One of the principal governmental programsintended to address the health conditions of marginal-ized people in Chiapas and elsewhere is the Oportu-nidades program, which was initiated during theadministration of President Salinas under the name ofSOLIDARIDAD. The program serves individuals who arenot covered by formal health insurance, and Chiapashas received a high proportion (22%) of federal fundsfor this program. However the program has perverseincentives built into it which do not lend themselvestoward creating self-sufficiency or improving commu-nal conditions: in order to receive funding from thisprogram, individual beneficiaries must continuallydemonstrate that they live in conditions of extremepoverty. As a result, women and families receiving ben-efits from the program often reject other programsaimed at the improvement of their standard of living,which may be community-oriented, so that they cancontinue benefiting from Oportunidades Program.

In its last review of Mexico’s compliance with the

ICESCR, in 1999, the ESC Rights Committee noted howconcerned it was “that very little progress has beenachieved by the State party [ ] to reduce poverty [and] bythe increase in the number of persons living in povertyand extreme poverty. The Committee considers thatunless the structural causes of poverty are properlyaddressed, a more equitable distribution of wealthbetween the various sectors of society, between statesand between rural and urban areas will not beachieved.”218 The ESC Rights Committee further specif-ically addressed: ”the persisting plight of indigenouspopulations, particularly those of Chiapas, [ ] who havelimited access to, inter alia, health services, education,work, adequate nutrition and housing”.219

For its part, in its 1995 review of compliance with theRace Convention—shortly after the Zapatista uprisingbegan—the Committee on the Elimination of RacialDiscrimination (CERD) stated: “The situation ofextreme poverty and marginalization of the majority ofthe indigenous population in Mexico is a matter of con-cern. Such a situation has complex causes, some ofthem stemming from the impact of the encounter ofcivilizations, as well as the consequences of the recentinternationalization of the economy for social policiesin Mexico. It has been, and still is, the responsibility ofthe Government to improve the economic and socialsituation of the indigenous population of Mexico.”220

Five years later, Daes, the Chairperson-Rapporteur ofthe Working Group on Indigenous Populations reportedwith concern after her visit that “while economic, socialand cultural rights are a matter of progressive imple-mentation…it is clear that the Government of Mexico,like every government, is responsible for undertakingsustained and systematic efforts for the enjoyment ofthese rights, using both its means and if those are notadequate, through international assistance of the inter-national community…Serious challenges still exist…inthe area of economic, social and cultural rights, espe-cially in terms of malnutrition, and, in general, moreresources appear to be needed in the health area.”221

This study found that not only are more resourcesneeded, but those resources must be spent in such away as to foster self-sufficiency and reduce inequities.As noted here and confirmed by other studies in Mex-ico, health care expenditures (especially those made ona discriminatory basis) do not necessarily reduce mar-

216 Id., UN CESCR. August 2000; Art. 1. See also “Children’s Conven-tion.” Art. 4; “Protocol of San Salvador.” Art 10.217 See e.g. UN. Limburg Principles on the Implementation of the

International Covenant on Economic, Social and Cultural Rights, UNDoc. E/CN.4/1987/17. Annex reprinted in Human Rights Quarterly.1987;9:122,125.218 UN CESCR. “Concluding Observations.” 1999: para 16.219 Id., UN CESCR. 1999: para 18.220 UN CERD. “Concluding Observations: Mexico.” 1995.221 Daes: paras 10, 13.


ginality or observed inequalities.222

The ESC Rights Committee has forcefully stated thatviolations of the ICESCR occur when a state fails to sat-isfy a “minimum core obligation to ensure the satisfac-tion of, at the very least, minimum essential levels ofeach of the rights”.223 These minimum obligationsshould be viewed as priorities for states to measurewhether they are making adequate progress andinclude steps to ensure minimal nutrition levels andprevent epidemic diseases. The truly alarming levels ofmalnutrition and lack of complete vaccination schemesamong children in the study, as well as gross inadequa-cies in access to care ranging from obstetric services toanti-tuberculosis treatment, as well as in the basic pre-conditions of health, suggest that Mexico is not comply-ing with even its basic obligations regarding the right tohealth. This includes providing reproductive and mater-nal health care and conditions for the healthy develop-ment of the child, and ensuring the prevention andtreatment of epidemic diseases such as PTB, as well asnon-discrimination in all health care facilities, goodsand services.

Furthermore, courts have found that, regardless oflimited resources, states can be obligated to adopt andimplement public health strategies and plans ofaction.224 Such plans, according to the ESC Rights Com-mittee on the basis of epidemiological evidence, shouldaddress the health concerns of the whole population;“the strategy and plan of action shall be devised, andperiodically reviewed, on the basis of a participatoryand transparent process; they shall include methods,such as right to health indicators and benchmarks, bywhich progress can be closely monitored; the processby which the strategy and plan of action is devised, aswell as their content.” 225 In the case of Chiapas, notonly has the absence of such a participatory plan ofaction for health been starkly apparent, the govern-ment has used health policy in a politicized and manip-ulative fashion to undermine support for the EZLN.

Non-discrimination and EqualityNon-discrimination is a core principle for the full real-ization of the right to health, as for all human rights.The ESC Rights Committee has stated that: “By virtueof article 2.2 and article 3, the Covenant proscribes anydiscrimination in access to health care and underlyingdeterminants of health, as well as to means and enti-tlements for their procurement, on the grounds of race,colour, sex, language, religion, political or other opin-ion, national or social origin, property, birth, physical ormental disability, health status (including HIV/AIDS),sexual orientation and civil, political, social or otherstatus, which has the intention or effect of nullifying orimpairing the equal enjoyment or exercise of the rightto health.”226

In Chiapas there are discrimination and patterns ofinequity on multiple levels. First, the conflict zone ispervaded by constant tensions, which have been sys-tematically exacerbated by politicized social policies,including health programs. In the face of the EZLNuprising and resistance, the government’s social policyhas for years been one of attempting to obtain andmaintain the loyalty of communities through a combi-nation of targeting social services, land distribution,and development programs to some while cutting offservices, such as water and electricity, to others. Asdescribed in earlier sections of this report, the effectsof these discriminatory policies have been to create acycle of fragmentation and polarization among andwithin communities. Over the years, some communitiesand some families within communities chose to receiveservices and participate in governmental programswhile others resisted. All of the findings in this reportmust be understood in light of a health system func-tioning within an extremely politicized context ofchronic conflict.

Although the study found no evidence that pro-gov-ernment communities had fared better than those inresistance, it did find that the pervasive tensions anddivisions produced by these policies affected utilizationof, and access to, health care services across commu-nity types, as when the nearest clinic belonged to acommunity of a different political affiliation, for exam-ple. Further qualitative information suggests thatdivided communities face extreme difficulties inresponding collectively to their health needs, rangingfrom addressing sanitation issues to transportingwomen in obstetric emergencies.

At the micro-level, international human rights, aswell as Mexican law, dictates that individual members ofopposition communities cannot be discriminatedagainst by individual providers. As health personnel are

222 Lozano R, Zurita B, Franco F, Ramírez T, Hernández P, Torres JL.“Mexico: Marginality, Need, and Resource Allocation at the CountryLevel.” In: Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M,eds. Challenging Inequities in Health: From Ethics to Action. NewYork: Oxford University Press; 2001:271-295, 291.223 See UN CESCR. “General Comment 3: The Nature of States Par-ties Obligations.” UN doc. E/1991/23. Geneva: 14 December 1990;Annex III, para 10.224 “Minister of Health v Treatment Action Campaign.” CCT 8/02.Constitutional Court of South Africa, July 2002. Available at:http://www.tac.org.za/Documents. Accessed November 7, 2005. Thedecision of this case resulted in court-ordered extension of Nevirap-ine treatment to prevent mother-to-child transmission of HIV anddevelopment of HIV/AIDS policy meeting specific criteria to be moni-tored by court.225 UN CESCR. “General Comment 14.” August 2000; para 18. 226 UN CESCR. “General Comment 14.” August 2000; para 18.


state agents acting on behalf of state institu-tions, deliberate acts of discrimination orconditioning of care, violates internationallaw. Dozens of instances of discrimination byhealth practitioners were alleged by respon-dents, both due to political affiliation and,more frequently, due to a patient’s indige-nous ethnicity. Remedies should be providedto the victims of individual acts of discrimi-nation, when these acts result in harm.

The investigation further reveals that thehealth status and conditions of all of thecommunities in the conflict zone are farworse than national averages, which is inpart attributable to patterns of discrimina-tion based on race and ethnicity.227 It is notnecessary under international law to havethe purpose or intent of discriminatingagainst a certain group; rather, the effect ofnullifying the enjoyment of a right is enoughto indicate a violation of international law. InMexico, a conspiracy of inequities producesdiscriminatory effects on the enjoyment ofthe right to health of the largely indigenouspopulation in the conflict zone.

For example, it has previously been docu-mented that the allocation of healthresources in Mexico is inversely related tomarginality and that per capita expenditures are anastounding twelve times higher for the insured popula-tion than the uninsured population.228 Chiapas is theMexican state that gets the lowest amount of healthresources per capita.229 Apart from Mexico City, wheretertiary care hospitals dramatically increase health careper capita spending, there are stark differencesbetween Chiapas (581 pesos per capita) and otherstates, such as for example, Baja California Sur (2255pesos per capita).230 Chiapas also has the lowest num-ber of inhabitants covered by some form of social secu-rity (i.e., employment related health insurance): barely

17.6% versus 40.1% for the entire country.231 In thisstudy, the proportion of inhabitants without any insur-ance was over 92% for all types of communities studied.

Indigenous people in Mexico are not only dispropor-tionately represented among the poor and uninsured;studies have shown that the availability of health careresources increases when the proportion of indigenouspersons in a county is very low.232 The study found thatbetween 80% and 99% of the population in the conflictzone are indigenous,233 and nearly half do not speakSpanish.

CERD noted in its last review of Mexico the failure ofthe Mexican government to address persistent discrim-ination against indigenous people and economic and

227 See also Lozano R, Zurita B, Franco F, Ramírez T, Hernández P,Torres JL. “Mexico: Marginality, Need, and Resource Allocation atthe Country Level.” In: Evans T, Whitehead M, Diderichsen F, BhuiyaA, Wirth M, eds. Challenging Inequities in Health: From Ethics toAction. New York: Oxford University Press; 2001:271-295.228 E.g.,Lozano R, Zurita B, Franco F, Ramírez T, Hernández P, TorresJL. “Mexico: Marginality, Need, and Resource Allocation at the Coun-try Level.” In: Evans T, Whitehead M, Diderichsen F, Bhuiya A, WirthM, eds. Challenging Inequities in Health: From Ethics to Action. NewYork: Oxford University Press; 2001; Hernandez-Peña P, Zapata O,Leyva R, Lozano R. “Equidad y salud: necesidades de investigaciónpara la formulación de una política social.” Salud Pública de México.1991.229 Lavielle B, Lara G, Diaz D, Curitas para la Salud: El mapa de lainequidad , Fundar. 2001: 48-62.

230 Numbers reflect entire health “Función 08” federal spending, The“Ramo 33” federal spending within Función 08 is also highlyinequitable. Lavielle B, Lara G, Diaz D, Curitas para la Salud: El mapade la inequidad , Fundar. 2001: 48-62, at 49, 52.231 Sánchez-Pérez HJ. Tuberculosis pulmonar en zonas de alta mar-ginación socioeconómica de Chiapas, México: Problemas y retos asuperar: El caso de la Región Fronteriza. Doctoral thesis. Barcelona:Universidad Autónoma de Barcelona; 1999; Consejo Nacional dePoblación (CONAPO). 2001. Available at: http://www.conapo.gob.mx.Accessed November 7, 2005. 232 Hernandez-Peña P, Zapata O, Leyva R, Lozano R. “Equidad ysalud: necesidades de investigación para la formulación de unapolítica social.” Salud Pública de México. 1991.

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FIGURE 4. Budget Inequality. Health Budget perInhabitant per State, 1999

Source: Secretaría de Salud. Own estimation with data of "La Situación de la Salud1999”, www.ssa.gob.mx cited in Lavielle B, Gabriel L, Díaz D. Curitas para la Salud:El Mapa de la Inequidad. Mexico: Fundar Centro de Análisis e Investigación; 2004.


social exclusion of entire populations, which has notcontributed to the restoration of peace in Chiapas.234

CERD noted that, “Particular concern is expressed thatthe State party does not seem to perceive that perva-sive discrimination being suffered by the 56 indigenousgroups living in Mexico falls under the definition givento racial discrimination in Article 1 of the Convention.The description of their plight merely as an unequalparticipation in social and economic development isinadequate.”235

The study documented how the discrimination facedby women in the conflict zone manifests itself in,among other ways, the inattention to their health prior-ities, such as the need for accessible obstetric services.Both the ESC Rights Committee and CEDAW havecalled on States parties to eliminate “discriminationagainst women when it comes to access to health serv-ices during the life cycle, particularly regarding familyplanning, pregnancy, delivery and the post-partumperiod.”236 In the conflict zone in Chiapas, the alarm-ingly high indices of maternal mortality found in thisstudy, coupled with the lack of effective access toobstetric services, clearly reflect the marginalization ofwomen’s health concerns as well as structural prob-lems in the health system.

The Women’s Convention relates the right to healthservices to combating discrimination against women ingeneral. More particularly, it focuses on the need toensure that rural women “participate in and benefitfrom rural development and, in particular, shall ensureto such women the right . . . [t]o have access to ade-quate health care facilities, including information,counseling and services in family planning.”237 CEDAWhas specifically stated in a general recommendationthat it is discriminatory effect as well as purpose, whichtriggers a violation of the treaty. In its most recentreview of Mexico’s compliance with the Women’s Con-vention, CEDAW stated that “poverty constitutes a seri-ous obstacle to enjoyment of rights by women, who

make up the majority of the most vulnerable sectors,especially in rural and indigenous areas,” and called onMexico “to give priority to women in its poverty eradica-tion strategy, with special attention to women in ruraland indigenous areas; in this context, measures andspecific programs should be adopted to ensure thatwomen fully enjoy their rights on an equal footing[including] in the area of [] health, with special empha-sis on joint work with non-governmental organizationsand on women’s participation not only as beneficiaries,but also as agents of change in the developmentprocess.”238

According to its own law, the Mexican government isrequired to ensure that its health policies and pro-grams are designed and implemented in a non-dis-criminatory manner. Mexico’s Constitution prohibitsdiscrimination in the enjoyment of all rights, includingthe rights to health protection. The Constitution recog-nizes that “[e]very person in the United Mexican Statesshall enjoy the guarantees granted by this Constitu-tion,” and that “men and women are equal before thelaw.” Further, the Constitution explicitly acknowledgesMexico’s indigenous populations, and protects and pro-motes the development of their cultures andresources.239

Yet, in practice, this is not occurring. On the contrary,this investigation found that the dysfunctional and abu-sive health system in Chiapas is intensifying exclusion,voicelessness, and inequity while simultaneouslydefaulting on its potential—and obligation—to fulfillindividuals’ rights and contribute to the building of anequitable, democratic society.240

Meaningful Popular Participation

ParticipationThe right to health requires states to provide more

than a package of services—even a package extendingbeyond medical care. Realization of the right to healthalso entails providing individuals and communities withan authentic voice in decisions defining, determining oraffecting their well-being. Demands for social partici-pation and control over the decisions affecting theirhealth and well-being are at the core of the conflict inChiapas and underlie Zapatista resistance. The SanAndrés Accords set out a conception of pluri-culturalcitizenship—i.e., a framework of respect for the funda-

238 CEDAW Concluding Observations 2002, UN Doc A/57/38,CEDAW/C/MEX/5. August 6, 2002. part 3, paras 432-433. 239 Title 1, ch. 1, Art. 1. Constitución Política de los Estados UnidosMexicanos. 13th ed. Mexico: Trillas; 1997.240 See “Who’s Got the Power: Transforming Health Systems forWomen and Children,” Millennium Project Task Force Report onChild Health and Maternal Health;2005:12.

233 In order to make this study comparable with others conducted inMexico, those individuals age five and older whose first languagewas not Spanish were considered indigenous. Government popula-tion studies and analyses have considered municipalities or commu-nities eminently indigenous if 40% or more of their population agefive and older speak an indigenous language. With 80% of thosespeaking an indigenous language, one can say that all the communi-ties have a predominantly indigenous population234 United Nations Committee on the Elimination of Racial Discrimi-nation (CERD). Concluding Observations of the Committee on theElimination of Racial Discrimination: Mexico. CERD/C/304/Add.30.August 6, 1995.235 Id., CERD 1995, para 381.236 UN CEDAW. “General Recommendation No. 24.” 1999.237 Women’s Convention: 1981; Art. 14.


mental cultural diversity of the Mexican nation and forindigenous rights—as well as “free determination” forindigenous peoples within “national unity.” Althoughthe San Andrés Accords were never implemented,these principles are also part of international humanrights law. That is, a recognition of autonomy for indige-nous communities, including the opposition communi-ties, with respect to the organization of their healthservices among other things, is consistent with ILOConvention 169 and other international instruments towhich Mexico has voluntarily bound itself. Mexico how-ever, in contrast to other states in the region, has neveradopted national legislation to incorporate its interna-tional obligations into domestic law or to recognizesome genuine degree of autonomy of indigenous com-munities, including those in opposition, in relation tothe organization and delivery of social services.241

It is clear that participation under internationalhuman rights law requires more than using local healthpromoters to register pregnant women or assist in locat-ing children to be vaccinated. On the contrary, statesshould provide resources for indigenous peoples todesign, deliver and control their health services so thatthey may enjoy the highest attainable standard of physi-cal and mental health.242 Local communities should beable to define their own health priorities, assist in thedevelopment and implementation of programs and playa pivotal role in the evaluation of health programs. Truerights-based participation requires programs thatenable people to be active, informed and critical agentsand citizens, rather than objects of charity.243

According to the ESC Rights Committee that moni-tors the ICESCR, an “important aspect is the improve-ment and furtherance of participation of the populationin the provision of preventive and curative health serv-ices, such as the organization of the health sector, theinsurance system and, in particular, participation inpolitical decisions relating to the right to health takenat both the community and national levels.”244 The Spe-cial Rapporteur on the Right to Health has called forgovernments and other actors to make every effort toensure “the active and informed participation in the

formulation, implementation and monitoring of healthpolicies and programs.”245

Article 25 of ILO Convention 169 specifically stressesthe need for community participation in the organiza-tion of indigenous peoples’ health services: “Healthservices shall, to the extent possible, be community-based. These services shall be planned and adminis-tered in co-operation with the peoples concerned andtake into account their economic, geographic, socialand cultural conditions as well as their traditional pre-ventive care healing practices and medicines.”246 Thiscooperation with the communities has not been presentin Chiapas.

In another statement, the Special Rapporteur callsspecifically for “the active and informed participation ofindigenous people in the formulation, implementationand monitoring of health policies and programs.”247

Additionally, although not a binding treaty, Article 31 ofthe Draft Declaration on Indigenous Peoples explicitlyconnects health to self-determination: “Indigenouspeoples, as a specific form of exercising their right toself-determination, have the right to autonomy or self-government in matters relating to their internal andlocal affairs, including…health.”248

However, genuine participation of indigenous popu-lations in health decisions is starkly absent in Mexico.In her 2000 report, Daes, the Chairperson-Rapporteurof the UN Working Group on Indigenous Populationslamented that, “the genuine and full participation ofindigenous communities in the development process[including access to basic resources, education andhealth services] is still a challenge for the Governmentof Mexico. It is recommended that the competentauthorities review the process of decision-making andfully involve indigenous communities in the planning,implementation and evaluation of development projects

241 In the 1990s, Colombia, Bolivia and Paraguay reformed their con-stitutions to incorporate the rights of indigenous peoples, in keepingwith ILO Conventions 107 and 169 and as a part of the standardsincluded in the International Convention on the Elimination of AllForms of Racial Discrimination. The movements for constitutionalreforms later inspired similar efforts in Ecuador, Peru andVenezuela.242 UN CESCR. “General Comment 14.” August 2000; para 21.243 See e.g. Veneklasen L, Millar V, Clark C, and Reilly M. “Rights-Based Participation and Beyond: Challenges of Linking Rights andParticipation,” IDS Working Paper 235 (December 2004):14.244 UN CESCR. “General Comment 14.” August 2000; para 17.

245 Hunt P. “The Right of Everyone to the Enjoyment of the HighestAttainable Standard of Physical and Mental Health.” Special Rappor-teur of the Commission on Human Rights on the right of everyone tothe enjoyment of the highest attainable standard of physical andmental health. Submitted in accordance with CHR resolution2004/27, UN Doc. A/59/27: September 2004 (advance edited version);para. 58 (c-e).246 ILO Convention 169, art 25.247 Hunt P. “The Right of Everyone to the Enjoyment of the HighestAttainable Standard of Physical and Mental Health.” Special Rappor-teur of the Commission on Human Rights on the right of everyone tothe enjoyment of the highest attainable standard of physical andmental health. Submitted in accordance with CHR resolution2004/27, UN Doc. A/59/27: September 2004 (advance edited version);para. 58(b)248 United Nations Sub-Commission on Prevention of Discriminationand Protection of Minorities. “Draft Declaration on the Rights ofIndigenous Peoples.” UN Doc. E.CN.4.SUB.2.RES.1994.45. 1993; art.31.


affecting their lives. Special measures need to be takenfor the participation of women in the developmentprocesses.”249

Demands for social participation and control overthe decisions affecting their health and well-being areat the core of the conflict in Chiapas and underlie Zap-atista resistance. The implementation of the SanAndrés Accords would have been a significant steptoward clarifying Mexico’s internal law. Implementingits obligations pursuant to ILO Convention 169 would gofar towards establishing a framework to promoteindigenous people’s rights to health, including those inopposition communities. Mexico’s current law uses therhetoric of participation without truly implementing theprinciples of autonomy called for under ILO Convention169 and the 1986 Declaration on the Right to Develop-ment. For example, the General Health Law promoteseducation aimed at “public participation” in preventionof illness, public awareness of cases of illness andenvironmental hazards to health, and public orientationin the areas of nutrition, family planning, occupationalhealth, and adequate use of health services.250 Partici-pation is thus a strategy or tool used by the governmentto achieve health goals, and is not linked to the devolu-tion of control to indigenous communities, as called forunder international human rights law.

In its last review of the performance of the Mexicangovernment in 1999, the ESC Rights Committee statedthat its prior review and recommendations had notbeen heeded with respect to incorporating participationfrom civil society into social programs, includinghealth: “The Committee specifically exhorts the Mexi-can government to include civil society in general andthe assisted groups in particular in the planning, appli-cation and evaluation of the structural causes ofpoverty and programs to alleviate it.”251

However, the most important federal governmentanti-poverty programs in effect in Chiapas, Oportu-nidades, does not incorporate real participation of theaffected populations into the analysis of the structuralcauses of poverty and the design and the implementa-tion of programs to address it. Oportunidades is a verti-cal program that treats individual beneficiaries asobjects of aid. Moreover, the program contains incen-tives whereby beneficiaries have to demonstrate theirpoverty to stay in the program, thereby fostering contin-ued dependency rather than addressing the “structuralcauses of poverty.”

In short, to be in compliance with international obli-

gations, at a minimum, the Mexican government mustinitiate long-term, coherent strategies for local plan-ning of health programs. These long-term strategiesmust include input from both opposition and non-oppo-sition communities and members, NGOs and localproviders, and must include some devolution of deci-sion-making power rather than tokenistic consultation.

Access to InformationSocial participation and monitoring are impossible

without access to information. In Mexico, access toinformation on health, and transparency in handlingsuch information, are inadequate. Access to healthinformation is part of the right to health and is funda-mental for the ability of the public to monitor its imple-mentation. To comply with its obligations underinternational law, a government should collect data ona disaggregated basis and this information, togetherwith the methodologies used by the government,should be readily available to the public.252 The SpecialRapporteur on the Right to Health has explicitly calledfor “the disaggregation of health data by ethnicity, gen-der, socio-economic status, cultural or tribal affiliationand language.”253 However, census data in Mexico is notcollected or broken down in such a way as to be able toanalyze the health of indigenous people, even thoughthere is an acknowledgement that language is insuffi-cient to capture the dimensions of ethnic identity.254

Indeed, although under both the ICESCR and Women’sConvention, States parties are supposed to report dis-aggregated data to respond to the issue of misleadingnational averages that may mask discriminatory poli-cies or effects, in its most recent review of Mexico,CEDAW noted “the lack of sufficient data disaggregatedby sex in many of the areas covered by [its] report.”255

This investigation also found a consistent pattern ofunder-reporting, ranging from pulmonary tuberculosisprevalence to maternal deaths. For example, maternalmortality was detected at seven times the levels offi-cially reported by the government; pulmonary tubercu-losis was detected at three times the official state level.Although some discrepancies may be due to explain-able factors, these numbers do show the need for the

249 Daes: para 11250 Title II, Ch. 1, Art. 6(1-8) Ley General de Salud. (Mexico GeneralHealth Law). 7 February 1984.251 ESC Rights Committee. Concluding Observations 1999; paras 27, 31.

252 UN CESCR. “General Comment 14.” August 2000; para 20.253 Report by Paul Hunt, Special Rapporteur to the Commission onHuman rights, on The Right of Everyone to the Highest attainablestandard of Physical and Mental Health, submitted in accordancewith Commission resolution 2004/27. UN Doc. A/59/422. 8 October2004, para 58(a).254 Bronfman M. “La salud de los pueblos indígenas: una conquistaimpostergable.” Cuadernos de Salud. Mexico City: Secretaría deSalud, 1994.255 CEDAW Concluding Observations 2002, UN Doc A/57/38,CEDAW/C/MEX/5 (part 3, paras 447. 6 August, 2002.


Mexican government to improve the methodology withwhich it reports on these critical public health indica-tors.256 There is no reason, for example, that all deathcertificates cannot include questions about whether thewoman was pregnant at the time or that reporting ofmaternal deaths include process indicators that revealthe availability of, and access to, obstetric services.257

Furthermore, there is a lack of accessibility of healthinformation. Despite highly touted programs of “trans-parency,” this investigation found that government datais not easily accessible by the public, nor are themethodologies used shared with the public or inter-ested NGOs. Communities do not even have access tolocal health center and hospital records to be able toevaluate care and review health priorities. During thefield study, the team observed that many health workersdo not keep any medical records of their patients, espe-cially in those cases when patients come from other vil-lages. In qualitative interviews, patients complained ofnot being made aware of their most basic rights, suchas their right to their medical records or to informedconsent in all procedures, including sterilizations.

Multi-sectoral StrategiesAs noted above, the right to health goes beyond the pro-vision of medical care and indeed beyond the healthsector. Not only are adequate water and sanitation, aswell as education regarding health problems, compo-nents of the minimum core obligations set out in theICESCR, but addressing health in a rights frameworkcalls for looking at broader development, improvingadequate dwelling conditions, food security, environ-mental protection, access to arable land, and theirimpacts on health.258

Mexico’s General Health Law sets out an integrated,multi-sectoral approach to health, calling on ministriesof health, education, and labor to work jointly to, interalia, promote maternal-child health, strengthen thehealth of families, encourage occupational safety forminors and pregnant women, and take actions relatedto education, as well as access to potable water andsewage. In addition, the goals of the National HealthSystem, set forth in the General Health Law, integratethe biological and socioeconomic factors essential togood health. Specifically, the National Health Systemobjectives are to supply quality health services to all,pay special attention to preventative actions, contribute

to harmonious demographic development, collaboratethrough social assistance services toward equitableeconomic and social well-being, and give impetus tofamily and community development, including thephysical and mental growth of children.259

However, in practice this is not the case. Indeed, thehigh rates of malnutrition and other childhood diseasesof poverty found across community types in this thisstudy, are the result of a failure of the Mexican govern-ment to institute a coherent rural development policy,which incorporates health concerns. The investigationfound inadequate living conditions, lack of access tosufficient, safe drinking water, lack of access to basicsanitation for disposal of excreta, lack of access to edu-cational opportunities (especially for women) across allcommunities in the study. The process of fragmentationand dispersion only makes it more difficult to establishbasic preconditions of health, such as adequate water,sewage and housing, a point which was noted by theESC Rights Committee in its last review of Mexico’scompliance with the ICESCR.260

One program run by the state of Chiapas, Vida Mejorpara las mujeres, las niñas y los niños de Chiapas (Bet-ter Life for the Women, Boys and Girls of Chiapas), doeshave a multi-sectoral focus, and unlike the Oportu-nidades Program, is directed towards the communityas opposed to the individual. It has a far smaller scopethan Oportunidades, and is currently only covering 164small regions. Developed in the aftermath of 26 new-

256 See e.g. Wardlaw T, Maine DP. “Process Indicators for MaternalMortality Programmes.” In Berer M, Sundari Ravindram TK, eds.Safe Motherhood Initiatives: Critical Issues. Blackwell Science:Reproductive Health Matters: 1999; 24-30.257 See Maine D, Wardlaw TW, Ward V, McCarthy J, Birnbaum A,Akalin MZ, Brown JE. Guidelines for Monitoring the Availability andUse of Obstetric Services. UNCIEF/WHO/UNFPA: 1997.

258 For example, the importance of land tenure, and consequentlyagrarian reform policies, to the wellbeing and survival of indigenouspeoples cannot be overstated. In its August 31, 2001 ruling in thecase of the Mayagna (Sumo) Awas Tingni Community v. Nicaragua,the Inter-American Court of Human Rights explained that land has tobe understood in an integral fashion for indigenous peoples:

Para 149. …Among indigenous peoples, there is a communitariantradition regarding a communal form of collective property of theland, in the sense that ownership of the land is not centered on anindividual but rather on the group and its community. Indigenousgroups, by the fact of their very existence, have the right to live freelyin their own territory; the close ties of indigenous people with theland must be recognized and understood as the fundamental basis oftheir cultures, their spiritual life, their integrity and their economicsurvival.

In the conflict zone in Chiapas, in addition to the health conditionsassociated with unchecked displacement and paramilitary violencecoupled with governmental policies of land distribution, which thisreport recounts, these have also affirmatively broken the affectedindigenous peoples’ relationship to the land. Inter-American Court ofHuman Rights, the Mayagna (Sumo) Awas Tingni Community v.Nicaragua ruling of August 31, 2001, Available at:http://www.wcl.american.edu/humright/hracademy/corteidh/seriec_ing/index.html.259 Title III, Ch 4, Art 60. Ley General de Salud. (Mexico GeneralHealth Law). February 7, 1984.260 CESCR Concluding Observations, 1999, para 27.


born deaths in December of 2001 at the General Hospi-tal of Comitán, the program was developed to providebetter attention to women during their pregnancieswithin their rural communities. With greater prenatalcare and the prevention of malnutrition, the programhas succeeded in combating prenatal morbidity andhas reduced malnutrition of children under five years ofage by 40% in its catchment areas. The program, whichis intended to create a sense of community responsibil-ity for health and diminish fragmentation within com-munities, was designed on the basis of successfulexperiences by NGOs. However, the impact of this laud-able program has been limited because it competeswith the Oportunidades Program, which providesincentives for individuals and individual families to optout in order to retain their benefits from the federalgovernment. The lack of coordination between theseprograms undermines potential progress in advancingthe affected populations’ right to health.

Coordination among sectors, such as among thehealth sector and the agricultural and social develop-ment sectors, is crucial to combat the food insecurityand deplorable conditions of housing and sanitationfound in the study. Coordination between the federaland state governments, and with local governments, isalso essential in providing programs that meet commu-nities’ health needs and adopt approaches that encour-age cooperation and capacity-building.

AccountabilityAs the right to health is more than a set of basic serv-ices, it also requires aspects of a functioning legislativeand judicial system. The ESC Rights Committee reiter-ates the importance of ratifying international instru-ments, which provide protection for the right to health,and of enacting and implementing legislation: “Theincorporation in the domestic legal order of interna-tional instruments recognizing the right to health cansignificantly enhance the scope an effectiveness ofremedial measures and should be encouraged in allcases. Incorporation enables courts to adjudicate viola-tions of the right to health, or at least its core obliga-tions, by direct reference to the ICESCR.”261

CEDAW’s General Recommendation on Women andHealth mentions specifically the enactment andenforcement of laws to provide sanctions for gender-based violence or sexual abuse of women patients byhealth care professionals, as well as laws prohibiting,inter alia, marriage of girl children, defined as beingunder the age of eighteen.262 In its latest review of Mex-ico’s compliance, CEDAW expressed its concern “at the

fact that no instances are mentioned [in Mexico’sreport] in which the Convention has been invokedbefore the courts and the lack of a compilation of judi-cial decisions in this regard.”263 For her part, the Chair-person-Rapporteur of the UN Working Group onIndigenous Populations stated in her 2000 report that“the system of administration of justice faces greatchallenges in Mexico, where indigenous people areaffected by its problems and view it with mistrust.”264

Accountability need not be purely judicial. In additionto providing remedies, the ESC Rights Committeeencourages the adoption of a framework law to opera-tionalize their right to health national strategy. Theframework law should not only incorporate interna-tional norms into domestic law but should also estab-lish national mechanisms for monitoring theimplementation of national health strategies and plansof action.265 Imbuing human rights ombuds offices withthe authority to investigate and sanction perpetrators incases of abuse is one example.

Mexico has taken some, but not all the steps, neededto provide accountability for violations. Mexico’s Gen-eral Health Law ensures health protection, and con-tains programmatic provisions, which commit the Stateto action on health matters. “The law identifies theobjectives of health protection to include physical andmental well-being, improved length and quality of life,social development, health services and social assis-tance, health education and research. Provisions of theGeneral Health Law address medical care particularlyfor the benefit of vulnerable groups, maternal childhealth, education for health promotion, nutrition, occu-pational health, and basic sanitation.”266 However, theimplementation of the right to health protectionacknowledged in the General Health Law requires Mex-ico to provide effective monitoring and oversight, aswell as remedies for the victims of violations.267

However, Mexico’s domestic law does not provideadequate enforcement mechanisms for the right tohealth protection. Article 60 of the General Health Lawdoes include a provision regarding malpractice andmedical negligence claims. Medical malpractice casesare generally brought to the National Commission onHuman Rights (CNDH), state human rights commis-sions, and the National Medical Arbitration Commis-sion (CONAMED). Although they can review negligenceclaims brought against individual providers, these insti-

263 CEDAW Concluding Observations, para 419.264 Daes: para 19.265 UN CESCR. “General Comment 14.” August 2000; para 56.266 Ley General de Salud. Art 60. (Mexico General Health Law). 7 Feb-ruary 1984.267 UN CESCR. “General Comment 14.” August 2000; para. 59.

261 UN CESCR. “General Comment 14.” August 2000; para. 60.262 UN CEDAW. “General Recommendation No. 24.” 1999; para 15.


tutions only provide mechanisms to enforce the patientrights against malpractice set out under Mexican law.Patients or their representatives can also sue in courtfor damages under Mexican law in malpractice casesinvolving “strict liability.”

More fundamentally, Article 60 fails to provide forclaims regarding the accessibility or adequacy of healthservices as an institutional or systemic issue. In orderto be truly effective, mechanisms such as the amparo,which is commonly used in civil and political rights vio-lations cases, would need to be reformed in order to: (1)provide people and groups with a collective remedy;and (2) establish precedent for other related cases.

Further, even in individual cases, Mexican judges havebeen inappropriately reluctant to use the amparo (pro-tection writ) to enforce the right to health under theapparent misconception that “programmatic” rightsare not actionable. Although aspects of the right tohealth entail programmatic obligations, violations ofspecific regulations relating to the government’s obli-gations with respect to health give rise to individualrights, and should be enforced according to the samecriteria as other constitutionally protected rights.268

268 Ley General de Salud. Art 60. (Mexico General Health Law). Feb-ruary 7, 1984. In this vein, the Constitutional Court of Ecuador, e.g.,has stated that “positive social rights … are norms to be enforcedimmediately with full juridical effect and are binding on the authori-ties who have obligations in their capacity as obligors; [they are alsorights that must] be implemented by courts such as this one forwhich the defense of human dignity is a fundamental mainstay ofcontemporary constitutional development.” “Jofre Mendoza et al v.Minister of Health,” Ecuador (Constitutional Court of Ecuador (2003)[failure to consistently provide full triple cocktail of ARVs in accor-dance with Ministry of Health regulations could produce viral resist-ance and lead to opportunistic infections and eventually death].

5 5

1. The government should encourage a broad dialogueat the local, state, and national levels about themeaning of an inclusive democracy in Mexico, whichfully recognizes its multiple constituent cultures.The dialogue should examine how health servicesshould be designed and delivered and how theindigenous population’s health needs could beaddressed. Such a dialogue would need to be sup-ported by and include non-governmental actors andcivil society, as well as relevant governmentalactors.

2. The Mexican government should take immediatesteps to implement the San Andrés Accords, as wellas its obligations under international law, includingILO Convention 169. This would confer some degreeof autonomy on indigenous communities, includingopposition communities, with respect to the organi-zation of their affairs, including the organization oftheir health services.

3. The government should permit and promote thecreation of local health care systems in theautonomous regions in Chiapas. These systemsshould be structurally independent and capable ofresponding to the specific health care needs of eachcommunity, but operationally coordinated with thestate and national health system to provide vaccina-tions, medicines, and patient referrals. Anautonomous technical support system, based atleast in part on universities, could promote commu-nication among all parties and facilitate better rela-tions.

4. All federal, state, and municipal government activi-ties related to health should be carried out withoutdiscrimination. All levels of government should dis-play the highest degree of coordination and commit-ment to prevent programs and activities fromprovoking or aggravating internal conflicts. Pro-grams that are functioning well in terms of reducingcommunal conflict and improving health statusshould be supported and expanded. As part of thiscommitment, all clinics should be required toattend to all members of a community, regardlessof political affiliation or religion.

5. The government should improve its surveillanceand detection systems, and should collect health

data on a disaggregated basis, so that disparitiesbased on gender and ethnicity may be detected andaddressed. When the best available evidence indi-cates the importance of process indicators, such asthe availability and use of essential obstetric care,the government should collect such indicators to beable to review its progress in addressing maternalhealth on an ongoing basis.

6. The government should establish an autonomousinstitution, made up of independent experts, tomonitor governmental compliance with indigenouspeoples’ economic, social, and cultural rights,including their health rights, in Chiapas and beyond.This institution should be equipped to promote edu-cation and dialogue among groups and actors insociety. It should also be authorized to receive andact upon individual and collective complaints and tohold the government accountable for violations.

7. The government should initiate amendments toMexican law to allow the amparo mechanism (writof protection) to provide for adequate remedies andaccountability in the event of violations of the rightto health, including providing for collective reme-dies and binding precedents. Lawyers and judgesshould be sensitized and trained in the enforcementand enforceability of the right to health.

8. Government social programs such as the Oportu-nidades program should actively foster and incorpo-rate meaningful community participation in thedesign, implementation, and evaluation of activities,which includes providing communities with author-ity in allocating resources and auditing projects.

9. The government should increase and re-allocatehealth resources per capita to and within Chiapasbased on the best evidence available of priorityhealth needs for the populations affected.

10. The Program of Tuberculosis Prevention and Con-trol should be re-structured to include investmentin more resources, sensitizing, training, supervis-ing, and evaluating a comprehensive DOTS programin Chiapas and beyond. The emphasis in this pro-gram should be placed on universality and freeaccess without conditionality, as well as mecha-nisms to ensure follow-up of patients in accordancewith international standards.

VI. RECOMMENDATIONS TO THE MEXICANGOVERNMENT


11. In keeping with the fulfillment of its obligationsunder the International Covenant on Economic,Social and Cultural Rights, the government shouldtake the following steps to improve the availability,accessibility, acceptability and quality of healthfacilities, good and services in Chiapas,:

a. train health personnel at all levels about humanrights and the principles of medical neutralitywith respect for cultural differences;

b. incorporate a basic working knowledge of thelocal indigenous language as part of the prereq-uisites for working in indigenous regions;

c. promote and reinforce community-based mech-anisms for the management of health-relatedissues;

d. foster community-based mechanisms for moni-toring and addressing health conditions, includ-ing rotating funds for obstetric emergencies;

e. develop intensive campaigns regarding the rightto health in Spanish and the principal indigenouslanguages;

f. broaden and diversify options with respect tofamily planning methods for indigenous womenand men, and ensure informed consent as wellas their right to decide freely the number andspacing of their children;

g. revise and restructure the activities of foodassistance and nutritional monitoring in accor-dance with local conditions and the consumptionhabits of the population;

h. provide available and accessible emergencyobstetric care to the population in the conflictzone

i. improve the mechanisms of patient referral andtransfer to hospitals, especially in obstetricemergencies;

j. promote greater structural and functional inte-gration of services of the different governmentinstitutions (Ministry of Health and the IMSS-

Oportunidades program), which provide medicalcare to the majority of the population in the studyarea;

k. improve the supply of medicines to health facili-ties; and

l. modify staffing policies to avoid frequent andlong absences of health personnel, in particularphysicians, from rural facilities and ensuingruptures in relations with communities, due torotations, attendance at meetings, participationin courses, paperwork, and the like.

12. Fragmented federal and state nutrition programsshould be integrated to establish a stable policy ori-ented toward promoting the population’s capacityfor self-sufficiency in food production and foodsecurity. In the context of these three regions in theconflict zone, this includes the following:

a. providing secure conditions so that the popula-tion, independent of their political or religiousaffiliation, can move about freely and engage intheir productive activities;

b. providing guarantees for an honorable andsecure return of displaced people to their com-munities and agricultural lands;

c. promoting local production and regionalexchange through a policy that stimulates theproduction and consumption of local productsand avoids the “dumping” effect, which resultsin the widespread distribution of food acquiredoutside the region;

d. establishing regional supply centers to regulatethe availability and price of food in less accessi-ble regions; and

e. implementing a program of nutritional monitor-ing in the most vulnerable communities, with theparticipation of community members as well ascivil society institutions to promote arrange-ments for the care of malnourished children,and foster local capacities.

5 7

JOINT PROPOSALS WHICH THEFEDERAL GOVERNMENT AND THE EZLNCOMMIT TO SEND TO THE DEBATE ANDNATIONAL DECISION AUTHORITIES, INACCORD WITH POINT 1.4 OF THE RULESOF PROCEDURE 1

February 1996

The various parties commit themselves to sending tothe Debate and National Decision Authorities the fol-lowing joint proposals upon which they have agreed:

On the basis of the new relationship between theState and the indigenous peoples it is necessary to rec-ognize, ensure and guarantee rights within anamended federalist framework. Such an objectiveimplies the promotion of reforms and addenda to theFederal Constitution and the laws emerging from it, aswell as to State Constitutions and local Judicial Dispo-sitions, to further, on the one hand, the establishmentof general foundations that may ensure unity andnational objectives; and, at the same time, allow thefederative entities the true power to legislate and act inaccordance to the particularities of the indigenousissues coming before them.

I.1. To urge a profound transformation of the State, as

well as of the political, social, cultural, and eco-nomic relationships with the indigenous peoples,which satisfies their demands for justice.

2. To urge the emplacement of an all-inclusive newsocial agreement, based on the understanding ofthe fundamental plurality of Mexican society and onthe contribution that the indigenous people canmake to national unity, beginning with the constitu-tional acknowledgement of their rights, and in par-ticular, to their right to self-determination andautonomy.

3. The legal reforms to be promoted must originate

from the principle of the equality of all Mexicansbefore the law and judicial organs, and not by thecreation of special codes of law that privilege partic-ular people; respecting the principle that the Mexi-can Nation is a pluricultural entity which isoriginally supported by its indigenous peoples.

4. The constitutional modifications represent one ofthe most important factors in the new relationshipbetween the indigenous peoples and the Statewithin the framework of reforming the State, so thattheir demands may find support within the Statelegal system.

II. 1. The creation of a judicial framework that estab-

lishes a new relationship between indigenous peo-ples and the State, based on the recognition of theirright to self-determination and the judicial, politi-cal, social, economic and cultural rights that obtainfrom it. The new constitutional dispositions mustinclude a framework of autonomy.

2. Such a judicial framework must be produced withthe recognition of the self-determination of indige-nous peoples, who, with previous societies, are theones who have suffered a historical continuation ofcolonial oppression, maintain and recognize theirown identities; and possess the will to preservethem, based on their own, distinct cultural, social,political and economic characteristics. Thoseattributes characterize them as indigenous peoples,and as such, they are constituted as subjects with aright to self-determination.

Autonomy is the concrete expression of theexercise of the right to self-determination, withinthe framework of membership in the National State.The indigenous peoples shall be able, consequently,to decide their own form of internal government aswell as decide their way of organizing themselvespolitically, socially, economically and culturally.Within the new constitutional framework of auton-omy, the exercise of self-determination of indige-nous peoples shall be respected in each of thedomains and levels in which they are asserted,being able to encompass one or more indigenous

APPENDIX

1 The Food for Chiapas Campaign. The San Andrés Accords (Agree-ments and Joint Proposals). Available at: http://www.foodforchia-pas.net/History/ezln/02_18_96implementation.html. AccessedMarch 22, 2006.


groups, according to particular and specific circum-stances in each federal entity. The exercise ofautonomy of indigenous people will contribute tothe unity and democratization of national life andwill strengthen national sovereignty.

It is appropriate to admit, as a fundamentaldemand of the indigenous peoples, their right toautonomy, insofar as they are communities with dif-ferent cultures and they have the faculty to decidetheir own local issues within the framework of theNational State. This acknowledgement is based onAgreement 169 of the OIT International Labor Orga-nization, and ratified by the Senate of the Republic.Thus, the recognition of autonomy is based on theconcept of indigenous group, which is founded onhistorical criteria and on cultural identity.

3. National legislation must acknowledge indigenouspeoples as subjects with the right to self-determi-nation and autonomy.

4. It is proposed to the Congress of the Union to recog-nize, in national legislation, these communities asentities with public rights, with the right to freeassociation in municipalities with populations thatare predominantly indigenous, as well as the rightof a group of municipalities to associate, in order tocoordinate their actions as indigenous peoples.

Competent authorities will execute the orderlyand gradual transference of resources, so that thepeople themselves may administer the public fundsassigned to them, and to strengthen the indigenousparticipation in government, negotiations andadministration in the various domains and levels. Itwill be up to state legislatures to determine, in theircase, the obligations and faculties that might betransferred.

State legislatures will be able to move forwardon the remunicipatization in the territories in whichthe indigenous villages are established, said remu-nicipalization must be based on consultation withthe towns involved.

In order to strengthen the federal contract, it isessential to revise in depth, not only the relationshipbetween the Federation and the state governments,but also the relationship between the latter and themunicipalities.

The union between townships and predomi-nantly indigenous populations is proposed, not as adifferent type of municipality, but as one which,within the framework of the general concept of thispolitical institution, may allow indigenous participa-tion in its composition and unity, while, at the sametime promoting and integrating indigenous commu-nities into the municipal government. As to what

constitutes a municipality with a predominantlyindigenous population, reaffirming the full meaningof a free municipality on which federalism is based,it is considered necessary that the organizations beconstitutionally strengthened, in such a mannerthat:

a. they may be endowed with duties that guaranteethe exercise of autonomy of the indigenous peo-ples;

b. the structure foreseen in the Municipal OrganicLaw will guide and orient them toward facing thenew challenges of development, and in particu-lar to the needs and new forms of organizationspecifically for indigenous towns.

5. It is proposed that the Congress of the Union and tothe State Legislatures acknowledge and establishthe characteristics of self-determination and thelevels and modes of autonomy, taking into consider-ation what “autonomy” means.

a. Territory. Every indigenous town is found in aterritory that covers the entire habitat occupiedor used by indigenous people in one form oranother. The territory is the material base oftheir reproduction as a people and it expressesthe inseparable unity people-land-nature.

b. Demarcation of application. Jurisdiction is thespatial, material and personal normative field ofvalidity in which the indigenous people applytheir rights. The Mexican State will acknowledgethe existence of said fields.

c. Responsibilities. There must be compatibilitywith various federal, state and municipalauthorities, as well as a distribution of political,administrative, economic, social, cultural, edu-cational, judicial resources, for the managementand protection of natural resources, with thepurpose of responding opportunely to therequirements and demands of indigenous peo-ples. Furthermore, it will be required to specifythe obligations, faculties and resources that arelikely to be transferred to the indigenous com-munities and towns under the established crite-ria in Section 5.2 of the document entitled “JointPronouncements”, as well as the various formsof participation by the communities and townsvis a vis the government authorities, so that theymay interact and coordinate their actions withthem, particularly at the municipal level.

d. Self-development. The indigenous communitiesand towns themselves must determine theirdevelopment projects and programs. For thisreason, it is considered appropriate to incorpo-

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rate, in local and federal legislation, the idealmechanisms that would promote the participa-tion of indigenous peoples in the planning fordevelopment at all levels; so that the design ofthis participation may take into considerationtheir aspirations, needs and priorities.

e. Participation in the national and state channelsof representation. Local and national participa-tion and political representation must beensured, respecting the various socio-culturalcharacteristics, in order to create a new federal-ism.

It is proposed to the Congress of the Union,the recognition, in constitutional and politicalreforms that may derive, of the rights of theindigenous woman to participate as an equalwith men in all levels of government and in thedevelopment of indigenous peoples.

6. It is proposed to the Congress of the Union and tothe State legislatures that, in acknowledging indige-nous autonomy and for the determination of all itslevels, they take into consideration the main rightsthat are the objects of said autonomy; establishingthe characteristics required to insure its free exer-cise. Among said rights, the following may beemphasized:

a. to exercise the right to develop the specificforms of social, cultural, political and economicorganization;

b. to obtain the recognition of their internal norma-tive systems for regulation and sanctions, inso-far as they are not contrary to constitutionalguarantees and human rights, especially thoseof women;

c. to agree to State jurisdiction in a better way;

d. to agree collectively to the use and enjoyment ofnatural resources, except those which fall undernational jurisdiction;

e. to promote the development of the various compo-nents of indigenous identity and cultural heritage;

f. to interact with the various levels of political rep-resentation in government and the administra-tion of justice;

g. to cooperate with other communities of theirethnicity or different groups, in joining effortsand coordinating actions for optimal use ofresources, and the initiation of regional and gen-eral development projects for the promotion anddefense of common interests;

h. to design their community and their municipalgovernment representation freely, as well as

selecting their authorities as indigenous peo-ples, in accordance with their own institutionsand traditions;

i. to promote and develop their languages and cul-tures, as well as their political, social, economic,religious and cultural customs and traditions.

III. 1. Increase in political participation and representa-

tion. Municipal strengthening. It is convenient toanticipate at the constitutional level the necessarymechanisms that:

a. Insure the adequate political participation ofindigenous communities and peoples in theCongress of the Union and local congresses,incorporating new criteria in setting the bound-aries of the electoral districts that correspond tothe indigenous communities and towns;

b. Allow participation in the electoral processeswithout requiring participation of the politicalparties;

c. Guarantee the effective participation of theindigenous peoples in the publicity and supervi-sion of those processes;

d. Guarantee the organization of internal electionor nomination processes.

e. Recognize the system assignation of officesand other forms of organization, methods ofdesignation of representatives, and the makingof decisions in the assembly and of popularconsultation. 1

f. Establish the election of municipal agents orallied figures or, when appropriate, be named bythe corresponding towns and communities.

g. Foresee in the state legislation the mechanismsthat may allow the revision, and, when appropri-ate, the modification of the names of the munic-ipalities, proposed by the population located inthe corresponding boundaries.

2. The guarantee of full access to justice. The Statemust guarantee the towns full access to the juris-diction of the Mexican State, with recognition andrespect for their own internal normative systems,guaranteeing full respect for human rights. It willpromote the recognition that positive Mexican Lawmay acknowledge the authorities, norms and inter-nal procedures for conflict resolution of towns andcommunities, will guarantee that local judgmentsand decisions are confirmed by the judicial authori-ties of the State.


The recognition of jurisdictional spaces to thedesignated authorities in the heart of the indige-nous communities, towns and municipalities stemsfrom a restructuring of the municipal charter, sothat said authorities will be able to settle internalconflicts of coexistence; their knowledge and reso-lution may imply a better acquisition and distribu-tion of justice.

The marginalization in which the indigenous peo-ple live and the conditions of disadvantage to whichthey consent in the system of granting and procuringjustice, create the need for a serious revision of thefederal and state judicial frameworks, so that effec-tive access of the indigenous peoples be guaranteed,or in place of local action, access to its members tothe State jurisdiction, and in this manner, avoidingpartial distribution of justice to the detriment of theindigenous sector of the population.

In the legislative reforms that may enrich theinternal normative systems it must be determinedthat, when sanctions are imposed upon members ofthe indigenous towns, the economic, social and cul-tural characteristics of those sanctioned must betaken into consideration, privileging sanctions otherthan incarceration. Preferably sentences may car-ried out in places that are closer to home and also,that integration into the community be favored as anessential mechanism of social readaptation.

The insertion of the norms and judicial practicesof the indigenous communities as a source of lawapplicable to procedures and resolutions of contro-versies under their authorities will be encouraged;also, in order to provide constitutional guarantees, itis strongly suggested that federal and local judg-ments in which the indigenous people are involvedbe taken into consideration.

3. Knowledge and respect of indigenous culture. It isconsidered necessary to elevate the constitutionalrank of all Mexicans by means of a pluriculturaleducation that acknowledges, disseminates andpromotes the history, customs, traditions and, ingeneral, the culture of the indigenous peoples, rootof our national identity.

The Federal Government will promote the lawsand necessary policies so that the indigenous lan-guages in each state may have the same socialvalue as Spanish, and it will promote the develop-ment of practices that deter discrimination againstthem in administrative and legal transactions.

The Federal Government commits itself to thepromotion, development, preservation and practiceof indigenous languages by providing education inthe indigenous languages; moreover, it will favorthe instruction of writing and reading in the lan-

guages themselves; and measures will be adoptedto insure that these peoples have the opportunity tolearn Spanish.

Knowledge of indigenous cultures is nationalenrichment and a necessary step to eliminate mis-understandings and discrimination toward indige-nous peoples.

4. Integral Indigenous Education. The various govern-ments commit themselves to respect the educa-tional tasks of the indigenous peoples within theirown cultural space. The allocation of financial,material and human resources must be broughtabout with fairness to plan and carry out educa-tional and cultural activities determined by theindigenous towns and communities.

The State must bring about the indigenous peo-ples’ right to a free and quality education, as well asto encourage the participation of the indigenoustowns and communities in selecting, ratifying andremoving teachers, taking into consideration crite-ria on academic and professional performance pre-viously agreed on by the indigenous peoples and thecorresponding authorities, and to form supervisorycommittees on the quality of education within theframework of local institutions.

The right to bilingual and intercultural educationof the indigenous peoples is ratified. The definitionand development of educational programs withregional content, where their cultural heritage isrecognized, are established as the jurisdiction offederative entities in consultation with the indige-nous towns. It will be possible, through educationalaction, to insure the use and development of indige-nous languages, as well as the participation oftowns and communities in conformance with thespirit of Agreement 169 of the OIT (InternationalLabor Organization).

5. The provision of basic needs. The State must set upmechanisms to guarantee the indigenous towns theconditions that may allow them to satisfactorily tendto their nourishment, health, and housing at an ade-quate level of well-being. Social policy must set uppriority programs for the improvement of the levelsof health and nourishment of children, as well assupport programs, in an egalitarian plane, for thetraining of women, increasing their participation inthe organization and the development of the familyand the community. Priority must be given to theintervention of the indigenous woman in the deci-sions regarding economic, political, social and cul-tural development projects.

6. Production and employment. Historically, develop-ment models have not taken into consideration the

A P P E N D I X 6 1

productive systems of the indigenous peoples. Con-sequently, the utilization of their potentials must beencouraged.

The Mexican judicial system, both at federal andstate levels must push for the recognition of theindigenous peoples’ right to the sustainable use andthe derived benefits of the use and development ofthe natural resources of the territories they occupyor utilize in any form, so that, in a framework ofglobal development, the economic underdevelop-ment and isolation may be overcome. This actionalso implies an increase in and reorientation ofsocial spending. The State must foster the develop-ment of the economic base of the indigenous townsand must guarantee their participation in designingthe strategies directed toward the improvement oftheir living conditions and the provision of basicservices.

7. Protection of migrant indigenous peoples. The Statemust set up specific social policies to protectmigrant indigenous people, both in the national ter-ritory as well as beyond its borders, with inter insti-tutional actions to support work and education ofwomen, and health and education for children andyouth, which, in rural regions, must be coordinatedin the areas of contribution as well as those thatattract agricultural workers.

8. Means of communication. With the purpose of cre-ating an inter cultural dialogue from the communitylevel up to the national level, that may allow a newand positive relationship between the variousindigenous groups and between these groups andthe rest of society, it is essential to endow thesetowns with their own means of communication,which are also key mechanisms for the develop-ment of their cultures. Therefore, it will be proposedto the respective national authorities, to elaborate anew communications law that may allow the indige-nous towns to acquire, operate and administratetheir own means of communication.

The Federal and State governments will pro-mote that the means of communication currently inthe hands of the Indigenists become indigenousmeans of communication, which is a demand madeby the indigenous communities and towns.

The Federal Government will recommend to therespective authorities that the seventeen INI(National Indigenist Institute) radio stations begiven to the indigenous communities in theirrespective regions, with the transference of per-mits, infrastructure and resources, when anexpressed request by the indigenous communitieshas been issued to this effect.

In the same manner, it is necessary to create anew judicial framework in the area of communica-tions that may consider the following aspects:national pluriculturalism; the right to use indige-nous languages in the media; the right to rebuttal;guarantees to rights of expression, information andcommunication; and the democratic participation ofthe indigenous towns and communities before theauthorities who decide on matters of communica-tion. The participation of interested parties in estab-lishing a civic responsibility process for thedecision-making authorities in the area of commu-nication, can be realized through the creation of acommunications Ombudsman or a citizens’ Councilof communications.

IV. THE ADOPTION OF THE FOLLOWINGPRINCIPLES, WHICH MUST GOVERNTHE NEW RELATIONSHIP BETWEENINDIGENOUS PEOPLE AND THE STATEAND THE REST OF SOCIETY: 1. Pluralism. The contact between the peoples and

cultures that constitute Mexican society must bebased on respect for their differences, and mustassume their fundamental equality. Consequently, itmust be the policy of the State to regulate its action,to promote a pluralist orientation in society, capableof actively combating every form of discrimination,and of correcting economic and social inequalities.Similarly, it will be necessary to move towards thecreation of a judicial order nourished by plurality,reflecting intercultural dialogue with common stan-dards for all Mexicans and respect for the internalsystems of law of the indigenous peoples.

2. Self-determination. The State shall respect theexercise of self-determination by indigenous peo-ples, in all fields and levels where they will try tovalidate and practice their separate autonomy,without damaging national sovereignty and withinthe new normative framework for the indigenoustowns. This implies respect for their cultural identi-ties and their forms of social organization. It willalso respect the abilities of the indigenous townsand communities to determine their own develop-ment, as long as national and public interest isrespected. The various levels of government andState institutions will not intervene unilaterally inthe affairs and decisions of the indigenous townsand communities, in their organization and forms ofrepresentation, and in their current strategies forthe use of resources.


3. Sustainability. It is necessary and urgent to safe-guard the natural areas and culture of the territo-ries of indigenous peoples. Legislation will push forthe recognition of the rights of the indigenous townsand communities to receive the corresponding ind-emnization, when the exploitation of naturalresources carried out by the State causes damagesto their habitat which may endanger their culturalsurvival. In the cases where damage has alreadyoccurred, and the towns are where damage hasalready occurred, and these towns are able to showthat the given compensation does not allow theircultural survival, the establishment of review mech-anisms will be promoted to allow the State and theaffected to jointly analyze the specific case. In bothcases the compensatory mechanisms will try toinsure the sustainable development of the indige-nous towns and communities.

In the same manner, there will be launched, incommon accord with the indigenous towns, rehabil-itation activities of those territories, and support ofinitiatives to create the conditions that may insurethe sustainability of their practices of productionand of life.

4. Consultation and Accord. The policies, laws, pro-grams, and public actions that might relate to theindigenous towns will be consulted. The State mustpromote the integrity and agreement of all the insti-tutions and levels of government that influence thelife of the indigenous towns, avoiding partial prac-tices influencing the life of the indigenous towns,avoiding partial practices that may split up publicpolicy. To insure that their action corresponds to thedistinct characteristics of the various indigenoustowns, and to avoid the imposition of uniform poli-cies and programs, their participation in all thephases of public action, including conception, plan-ning and evaluation must be guaranteed.

Similarly, there must be a gradual and orderlytransference of powers, obligations and resourcesto the municipalities and communities so that, withthe participation of the latter, the public moniesassigned to them may be distributed. As forresources, and for whatever purpose they may exist,they may be transferred to the forms of organizationand association that are anticipated in point 5.2 ofthe document of Joint Pronouncements.

Since the policies in the indigenous areas shouldnot only be conceived with the towns themselves,but implemented with them, the present indigenistand social development institutions that operatelocally must be transformed into different entitiesthat may be conceived and operated jointly and inconcert with the State and the indigenous peoples

themselves.

5. Strengthening of the Federal System and Democra-tic Decentralization. The new relationship with theindigenous peoples encompasses a process ofdecentralization of the obligations, faculties andresources of the federal and state authorities to themunicipal governments, in the spirit of point 5.2 ofthe document Joint Pronouncements, so that withthe active participation of the indigenous communi-ties and the population in general, they may assumethe initiatives thereof.

V. CONSTITUTIONAL AND LEGALREFORMS 1. The establishment of a new relationship between

the indigenous peoples and the State has, as a nec-essary point of departure, the creation of a new judi-cial framework at the national level as well as in thefederative entities. The constitutional reforms thatrecognize the rights of the indigenous towns mustbe achieved through a creative legislative spirit thatmay produce new policies and may give real solu-tions to social problems. To that effect, the researchteam proposes that these reforms must contain,among others, the following general aspects:

a. To legislate on the autonomy of the indigenouscommunities and towns, to include the recogni-tion of the communities as entities with publiclaw; their right to associate freely with munici-palities that are of predominantly indigenouspopulations; and also the right of various munic-ipalities to associate for the purpose of coordi-nating their actions as indigenous towns;

b. To legislate to “guarantee the protection of theintegrity of the lands belonging to indigenousgroups,” taking into consideration the specificsof the indigenous towns consideration thespecifics of the indigenous towns and communi-ties, in the concept of territorial integrity con-tained in Agreement 169 of the OIT (InternationalLabor Organization), as well as establishing theprocedures and mechanisms for the regulariza-tion of the various forms of indigenous propertyrights and for the promotion of cultural cohesion;

c. In issues related to natural resources, to installa preferential order that privileges the indige-nous communities in the granting of conces-sions in order to reap the benefits of theexploitation and use of natural resources;

d. Legislate on the rights of the indigenous people,men and women, to have representatives in the

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legislative entities, particularly in the Congressof the Union and in the local congresses; incor-porating new criteria to delimit the electoral dis-tricts that may correspond to the indigenouscommunities and towns, and that they beallowed to have elections in accordance to thelegislation on that matter;

e. Legislate on the rights of the indigenous townsto elect their own authorities and to exerciseauthority according to their own internal normsin their autonomous localities, guaranteeing theparticipation of women on equal terms;

f. In the content of the legislation, to take into con-sideration the pluricultural nature of the Mexi-can Nation that may be reflected in inter culturaldialogue, with common standards for all Mexi-cans and with respect for the internal normativesystems of the indigenous towns;

g. In the Constitution, to insure the obligation tonot discriminate on the basis of racial or ethnicorigin, language, gender, beliefs or social condi-tion, thus, making possible the designation ofdiscrimination as a crime. The rights of theindigenous towns to the protection of theirsacred sites and ceremonial centers, and theuse of plants and animals that are consideredsacred for strictly ritual use must also beinsured;

h. Legislate so that no form of coercion may beexercised against the individual guarantees andthe specific rights and freedoms of the indige-nous towns;

i. Legislate the rights of the indigenous towns to thefree exercise and development of their culturesand their access to means of communication.