Racism and discrimination in the care of Totonaca women in Veracruz, Mexico: the need for intercultural competencies


  • Niels Michael Dörr Physician. Department of General, Visceral and Vascular Surgery, BG Bergmannstrost Hospital, Halle (Saale), Germany.
  • Gunther Dietz Anthropology. Full time researcher and professor, Research in Education Institute, Universidad Veracruzana, Xalapa, Veracruz, Mexico.


Target. Racism is a health inequality that has been neglected. The objective is to examine maternal health in rural Mexico with respect to the different forms of discrimination. Material and methods. The research is based on anthropological fieldwork carried out in the Sierra del Totonacapan region in Veracruz, Mexico. Results. We empirically distinguish and document omissions and violations of human rights, before analyzing the sources of racism from an intersectional perspective, according to which gender, class and race constitute closely linked sources of discrimination. Conclusions. Finally, we propose an intercultural competence approach to confront racism at its confluence with other ideologies. This approach is aimed at professionals as conscious, reflective and transforming actors of intercultural interactions.

Author Biography

Niels Michael Dörr, Physician. Department of General, Visceral and Vascular Surgery, BG Bergmannstrost Hospital, Halle (Saale), Germany.

Physician. Department of General, Visceral and Vascular Surgery, BG Bergmannstrost Hospital, Halle (Saale), Germany.


Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med 2009;32(1):20–47. doi: 10.1007/s10865-008-9185-0.

Johnstone M-J, Kanitsaki O. The Neglect of Racism as an Ethical Issue in Health Care. J Immigr Minor Heal 2010;12(4):489–95. doi: 10.1007/s10903-008-9210-y.

Horton R. Offline: Racism-the pathology we choose to ignore. Lancet 2017;390(10089):14. [Consultado 2020 agosto 8]. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/28677545.

Bhopal RS. Intertwining migration, ethnicity, racism, and health. Lancet 2017;390(10098):932. doi: 10.1016/S0140-6736(17)32143-8.

Barnes LL, De Leon CFM, Wilson RS, Bienias JL, Bennett DA, Evans DA. Racial Differences in Perceived Discrimination in a Community Population of Older Blacks and Whites. J Aging Health 2004;16(3):315–37. doi: 10.1177/0898264304264202.

Karlsen S, Nazroo JY. Relation between racial discrimination, social class, and health among ethnic minority groups. Am J Public Health 2002;92(4):624–31. [Consultado 2020 agosto 8]. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/11919063.

Larson A, Gillies M, Howard PJ, Coffin J. It’s enough to make you sick: the impact of racism on the health of Aboriginal Australians. Aust N Z J Public Health 2007;31(4):322–9. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/17725009.

Harris R, Tobias M, Jeffreys M, Waldegrave K, Karlsen S, Nazroo J. Racism and health: The relationship between experience of racial discrimination and health in New Zealand. Soc Sci Med 2006;63(6):1428–41. doi: 10.1016/j.socscimed.2006.04.009.

Kung H-C, Hoyert DL, Xu J, Murphy SL. Deaths: final data for 2005. Natl Vital Stat Rep 2008;56(10):1–120. [Consultado 2020 agosto 8]. Disponible en: https://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf.

Osorio RM. Eduardo L. Menéndez (2002), La parte negada de la cultura. Relativismo, diferencias y racismo. Región y Soc 2008;20:337–45. [Consultado 2020 agosto 8]. Disponible en: http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S1870-39252008000400012.

Menéndez EL. De racismos, esterilizaciones y algunos otros olvidos de la antropología y la epidemiología mexicanas. Salud Colect 2009;5(2):155. [Consultado 2020 agosto 8]. Disponible en: http://revistas.unla.edu.ar/saludcolectiva/article/view/258.

Pan American Health Organization. Ethnicity and Health. 132nd session of the executive committee. Wasinghton (DC): PAHO; 2003. [Consultado 2020 agosto 8]. Disponible en: http://www.paho.org/English/gov/ce/ce132-16-e.pdf

Roldán JA, Álvarez MA, Carrasco M, Guarneros N, Ledesma J, Cuchillo-Hilario M, et al. Marginalization and health service coverage among Indigenous, rural, and urban populations: A public health problem in Mexico. Rural Remote Health 2017;17(4). [Consultado 2020 agosto 8]. Disponible en: https://www.rrh.org.au/journal/article/3948.

Perreira KM, Telles EE. The color of health: skin color, ethnoracial classification, and discrimination in the health of Latin Americans. Soc Sci Med 2014;116:241–50. doi: 10.1016/j.socscimed.2014.05.054.

Freyermuth G and Sesia P. La Muerte Materna. Acciones y estrategias hacia una maternidad segura: Comité Promotor por una Maternidad sin Riesgo en México. México Ciudad: CIESAS; 2009.

Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health 2000;90(8):1212–5. [Consultado 2020 agosto 8]. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/10936998.

CESCR: General comment No. 14. The right to the highest attainable standard of Health. Art. 12. Committee on Economic, Social and Cultural Rights. Geneva; 2000. [Consultado 2020 agosto 8]. Disponible en: https://www.refworld.org/pdfid/4538838d0.pdf.

Valderrama Rouy P. The Totonac. En: Sandstrom AR, García Valencia EH, editors. Native Peoples of the Gulf Coast of Mexico. Tucson: The University of Arizona Press; 2005:187–210.

Atkinson R., Flint J. Accessing Hidden and Hard-to-Reach Populations: Snowball Research Strategies. Social Research Update 2001;(33). [Consultado 2020 agosto 8]. Disponible en: http://sru.soc.surrey.ac.uk/SRU33.html.

Glaser BG, Strauss AL. The discovery of grounded theory : strategies for qualitative research. New York City: Routledge; 1999.

Dietz G. Towards a Doubly Reflexive Ethnography: A proposal from the anthropology of interculturality. AIBR. Revista de Antropología Iberoamericana 2011;11(1):3-26. [Consultado 2020 agosto 8]. Disponible en: http://www.aibr.org/antropologia/netesp/numeros/0601/060102e.pdf

Geertz C. Thick Description: Towards and Interpretive Theory of Culture. En: The Interpretation of Culture: Selected Essays; 1973:310–23.

Smith-Oka V. Unintended consequences: Exploring the tensions between development programs and indigenous women in Mexico in the context of reproductive health. Soc Sci Med 2009;68(11):2069-77. doi: 10.1016/j.socscimed.2009.03.026.

Ali MM, Sadler RK, Cleland J, Ngo T, Shah IH. Long-term contraceptive protection, discontinuation and switching behaviour. Intrauterine device (IUD) use dynamics in 14 developing countries. London: WHO, Marie Stopes International, USAID; 2011.

Kleinman A, Benson P. Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix it. PLoS Med 2006;3(10):1673–6. doi: 10.1371/journal.pmed.0030294.

Dixon LZ, El Kotni M, Miranda V. A Tale of Three Midwives: Inconsistent Policies and the Marginalization of Midwifery in Mexico. J Lat Am Caribb Anthropol 2019;24(2):351–69. doi: 10.1111/jlca.12384

Foucault M. The Birth of the Clinic: An Archaeology of Medical Perception. Vintage; 1994.

Jenkins GL. Burning bridges: policy, practice, and the destruction of midwifery in rural Costa Rica. Soc Sci Med 2003;56(9):1893–909. doi: 10.1016/S0277-9536(02)00212-5.

Maine D. Detours and shortcuts on the road to maternal mortality reduction. Lancet 2007;370(9595 ):1380–2. doi: 10.1016/S0140-6736(07)61580-3.

Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp Jr J, Lohr KN. Outcomes of Routine Episiotomy. A Systemativ Review. JAMA 2005;293(7):2141–7. doi: 10.1001/jama.293.17.2141

Dietz G. From Indigenismo to Zapatismo: the struggle for indigenous rights in twentieth century Mexico. In: Zamosc L, Grey Postero N, editors. The Struggle for Indian Rights in Latin America. Brighton: Sussex Academic Press; 2004:32–80.

Saldivar Tanaka E. Prácticas cotidianas del Estado: una etnografía del indigenismo. Mexico City: Universidad Iberoamericana; 2008.

Cortina A. Aporofobia, el rechazo al pobre : un desafío para la democracia. Paidós Ibérica; 2017.

Moreno Figueroa MG, Saldívar Tanaka E. ‘We Are Not Racists, We Are Mexicans’: Privilege, Nationalism and Post-Race Ideology in Mexico. Crit Sociol 2016;42(4–5):515–33. doi: 10.1177/0896920515591296.

Hunt P, Backman G. Health systems and the right to the highest attainable standard of health. Health Hum Rights 2008;10(1):81–92. [Consultado 2020 agosto 8]. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/20845831.

Iturriaga, E. Las élites de la Ciudad Blanca: discursos racistas sobre la Otredad. Mérida: Universidad Nacional Autónoma de México; 2016.

Walker D, DeMaria LM, Suarez L, Cragin L, Evaluating Alternative Models of Obstetric Care in Mexico Research Team. Skilled Birth Attendants in Mexico: How Does Care During Normal Birth by General Physicians, Obstetric Nurses, and Professional Midwives Compare With World Health Organization Evidence-Based Practice Guidelines? J Midwifery Womens Health 2012;57(1):18–27. doi: 10.1111/j.1542-2011.2011.00075.x.

Heart MYHB, Chase J, Elkins J, Altschul DB. Historical trauma among Indigenous Peoples of the Americas: concepts, research, and clinical considerations. J Psychoactive Drugs 2011;43(4):282–90. doi: 10.1080/02791072.2011.628913.

Flores Albornoz, D. La clínica rural en el contexto indígena: alcances y desafíos. Desacatos 2020;63(1):59-69.

Crenshaw, K. Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics. University of Chicago Legal Forum 1989;(1):139-167. [Consultado 2020 agosto 8]. Disponible en: http://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8.

Crenshaw K. Mapping the Margins: intersectionality, identity politics and violence against women of color. En: M. Fineman & R. Mykitiuk (eds.): The Public Nature of Private Violence. New York, NY: Routledge; 1994:93-118.

Molyneux M. Mothers at the Service of the New Poverty Agenda: Progresa/Oportunidades, Mexico's Conditional Transfer Programme. Social Policy & Administration 2006;40(4):425–49.doi: 10.1111/j.1467-9515.2006.00497.x.

Barber SL. Mexico's conditional cash transfer programme increases cesarean section rates among the rural poor. Eur J Public Health 2009;20(4):383–8. doi: 10.1093/eurpub/ckp184.

Lahoz Gómez D, Vázquez García V, Zapata Martelo E. Programa Oportunidades: ¿superación de la pobreza con perspectiva de género? En: E. Montero Mendoza (coord.): Género y etnicidad en los programas de salud pública: tuberculosis pulmonar en la Sierra de Santa Marta, Veracruz. Xalapa, Editorial Universidad Veracruzana; 2013:63-101.

Hogan VK, de Araujo EM, Caldwell KL, Gonzalez-Nahm SN, Black KZ. “We black women have to kill a lion everyday”: An intersectional analysis of racism and social determinants of health in Brazil. Soc Sci Med 2018;199:96–105. doi: 10.1016/j.socscimed.2017.07.008.

Hankivsky O, Reid C, Cormier R, Varcoe C, Clark N, Benoit C, et al. Exploring the promises of intersectionality for advancing women’s health research. Int J Equity Health 2010;9(5). [Consultado 2020 agosto 8]. Disponible en: http://equityhealthj.biomedcentral.com/articles/10.1186/1475-9276-9-5.

Castro R, Frías SM. Obstetric Violence in Mexico: Results From a 2016 National Household Survey. Violence Against Women, SAGE. 2019. doi: 10.1177/1077801219836732.

Tobasía-Hege C, Pinart M, Madeira S, Guedes A, Reveiz L, Valdez-Santiago R, et al. [Disrespect and abuse during childbirth and abortion in Latin America: systematic review and meta-analysis Desrespeito e maus-tratos durante o parto e o aborto na América Latina: revisão sistemática e meta-análise]. Rev Panam Salud Publica 2019;43:e36. [Consultado 2020 agosto 8]. Disponible en: http://www.ncbi.nlm.nih.gov/pubmed/31093260.

DallaPiazza M, Padilla-Register M, Dwarakanath M, Obamedo E, Hill J, Soto-Greene M. Exploring Racism and Health: An Intensive Interactive Session for Medical Students. MedEdPORTAL 2018;14:10783. [Consultado 2020 agosto 8]. Disponible en: https://www.mededportal.org/publication/10783.

Lerín-Piñón S. Antropología y salud intercultural: desafíos de una propuesta. Desacatos Rev Ciencias Soc 2004 ;0(16):111–25. [Consultado 2020 agosto 8]. Disponible en: http://desacatos.ciesas.edu.mx/index.php/Desacatos/article/view/1074.

Miller S, Cordero M, Coleman AL, Figueroa J, Brito-Anderson S, Dabagh R, et al. Quality of care in institutionalized deliveries: The paradox of the Dominican Republic. Int J Gynecol Obstet 2003;82(1):89–103. doi: 10.1016/S0020-7292(03)00148-6.






Original Research