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Wednesday, February 1, 2023

Incitement to genocide

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Incitement_to_genocide
 
Audience makes a Nazi salute during Adolf Hitler's speech of 30 January 1939, in which he threatened "the annihilation of the Jewish race in Europe!"

Incitement to genocide is a crime under international law which prohibits inciting (encouraging) the commission of genocide. An extreme form of hate speech, incitement to genocide is considered an inchoate offense and is theoretically subject to prosecution even if genocide does not occur, although charges have never been brought in an international court without mass violence having occurred. "Direct and public incitement to commit genocide" was forbidden by the Genocide Convention in 1948. Incitement to genocide is often cloaked in metaphor and euphemism and may take many forms beyond direct advocacy, including dehumanization and "accusation in a mirror". Historically, incitement to genocide has played a significant role in the commission of genocide, including the Armenian genocide, the Holocaust and the Rwandan genocide.

Definitions

"Direct and public incitement to commit genocide" is forbidden by the Genocide Convention (1948), Article 3(c). If genocide were to be committed, then incitement could also be prosecuted as complicity in genocide, prohibited in Article 3(e), without the incitement necessarily being direct or public.

Incitement

Incitement means encouraging someone else to commit a crime, in this case genocide. The Genocide Convention is generally interpreted as requiring intent to cause genocide for incitement prosecutions.

"Direct"

"Direct" means that the speech must be both intended and understood as a call to take action against the targeted group, which may be difficult to prove for prosecutors due to cultural and individual differences. Wilson notes that "direct" does not inherently exclude euphemisms (see below), "if the prosecution can show that the overwhelming majority of listeners understood a euphemistic form of speech as a direct (rather than circuitous, oblique or veiled) call to commit genocide". American genocide scholar Gregory Gordon, noting that most incitement does not take the form of imperative command to kill the target group (see below), recommends that a "glossary of incitement techniques should be woven into judicial pronouncements".

The International Criminal Tribunal for Rwanda and International Criminal Tribunal for the former Yugoslavia came to different conclusions on the prosecution of incitement. According to ICTR, incitement did not require an explicit call for violence against the targeted group or causally connected subsequent violence. ICTY came to the opposite conclusion in Prosecutor v. Kordić, because "hate speech not directly calling for violence... did not rise to the same level of gravity" as crimes against humanity.

"Public"

Incitement is considered "public" "if it is communicated to a number of individuals in a public place or to members of a population at large by such means as the mass media". However, the Genocide Convention never defines the term "public" and it is unclear how the criterion would apply to new technologies, such as Internet-enabled social media. Jean-Bosco Barayagwiza was convicted by the International Criminal Tribunal for Rwanda for speeches made at a roadblock, but on appeal it was ruled that these speeches were not considered public.

Causation

Incitement to genocide is an inchoate crime as it is technically prosecutable even if genocide is never committed. However, Gordon writes that "no international court has ever brought an incitement prosecution in the absence of a subsequent genocide or other directly-related large-scale atrocity". Wilson noted that the judgement against Jean-Paul Akayesu "seemingly elevated causation to a legal requirement to prove incitement" as it stated "there must be proof of a possible causal link" between the alleged incitement and murders. Tribunals asserted that the incitement led to violence, even when this was not conclusively proven by the prosecution.

Davies details four benefits of an inchoate and separate approach to prosecuting incitement, instead of prosecuting incitement as part of the crime of genocide:

  1. obviating the difficult task of proving a causal connection between incitement and violence,
  2. allowing people to be charged with aiding and abetting incitement,
  3. allowing incitement to genocide to be prosecuted even when the resulting violence cannot be proven to have been genocidal (e.g. rather than war crimes or crimes against humanity), and
  4. enabling the prevention of genocide by prosecuting incitement thus acting as a deterrent to genocide.

Free speech issues

Defining incitement to genocide is important because it can be in tension with the protection of freedom of expression. In the Léon Mugesera case, a Canadian federal appeals court found that his 1992 speech claiming that Hutus were about to be "exterminated by inyenzi or cockroaches" was protected free speech and that the speech's themes were "elections, courage and love". Subsequently, the Canadian Supreme Court ruled that "reasonable grounds exist to believe that Mr. Mugesera committed a crime against humanity". Some dictators and authoritarian leaders have used overly broad interpretations of "incitement" or speech crimes in order to jail journalists and political opponents.

Gordon argued that the benefits of free speech do not apply in situations where mass violence is occurring because "the 'marketplace of ideas' has been likely shut down or is not functioning properly." Therefore, it is justified to restrict speech that would not ordinarily be punishable. Susan Benesch, a free speech advocate, concedes that free speech provisions are intended to protect private speech while most or all genocide is state-sponsored. Therefore, in her opinion, prosecution of incitement to genocide should take into account the authority of the speaker and whether they are likely to persuade the audience. Richard Ashby Wilson observed that those prosecuted for incitement to genocide and related international crimes "have gone beyond mere insult, libel and slander to incite others to commit mass atrocities. Moreover, their utterances usually occur in a context of an armed conflict, genocide and a widespread or systematic attack on a civilian population."

Alternate definitions

Alternate definitions and interpretations have been proposed by various authors. In Benesch's six-pronged "reasonably probable consequences" test, a finding of incitement to genocide would require violence as a possible consequence of the speech, which is compatible with existing jurisprudence. Carol Pauli's "Communications Research Framework" is intended to define situations where freedom of speech can be justifiably infringed by broadcast interference and other non-judicial measures to prevent genocide. Gordon has argued for "fixing the existing framework" by reinterpreting or changing incitement, direct, public, and causation elements. Gordon favors removing the requirement to be public, because "[p]rivate incitement can be just as lethal, if not more, than public."

Types

Susan Benesch noted that "Inciters have used strikingly similar techniques before genocide, even in times and places as different as Nazi Germany in the 1930s and Rwanda in the 1990s." The following types have been classified by Gordon.

Direct advocacy

Gordon notes that "direct calls for destruction are relatively rare". In May 1939, Nazi propagandist Julius Streicher wrote "A punitive expedition must come against the Jews in Russia. A punitive expedition which will provide the same fate for them that every murderer and criminal must expect. Death sentence and execution. The Jews in Russia must be killed. They must be exterminated root and branch." On 4 June 1994, Kantano Habimana broadcast from RTLM: "we will kill the Inkotanyi and exterminate them" based on their alleged ethnic characteristics: "Just look at his small nose and then break it". Gordon considers Iranian president Mahmoud Ahmadinejad's 2005 comments that Israel "must be wiped off the map" an example of direct advocacy.

Predictions

In the Rwandan Media Case, some broadcasts of the Radio Télévision Libre des Mille Collines (RTLM) that "foretold elimination of the inyenzi or cockroaches" were found to constitute incitement to genocide. An example is the following statement by Ananie Nkurunziza on RTLM on 5 June 1994: "I think we are fast approaching what I would call dawn ... dawn, because—for the young people who may not know— dawn is when the day breaks. Thus when day breaks, when that day comes, we will be heading for a brighter future, for the day when we will be able to say “There isn't a single Inyenzi left in the country.” The term Inyenzi will then be forever forgotten, and disappear for good."

Dehumanization

Jews killed during the Warsaw Ghetto uprising, described in the Stroop Report as "bandits destroyed in battle"

According to Gordon, "verminization, pathologization, demonization, and other forms of dehumanization" can be considered incitement to genocide. Verminization classifies the target as something "whose extermination would be considered normal and desirable", which is why Hutu leaders frequently described Tutsis as inyenzi (cockroaches). RTLM propagandist Georges Ruggiu pled guilty to incitement to genocide, admitting that calling Tutsis "inyenzi" meant designating them "persons to be killed". Gordon writes that like dehumanization, demonization is "sinister figurative speech but is more phantasmagorical and/ or anthropocentric in nature... [centering] on devils, malefactors, and other nefarious personages." Pathologization means designating the target as a disease. According to genocide scholar Gregory Stanton, this "expropriates pseudo-medical terminology to justify massacre [and it] dehumanizes the victims as sources of filth and disease, [propagating] the reversed social ethics of the perpetrators". Stanton identified dehumanization as third in the eight stages of genocide, noting that "Dehumanization overcomes the normal human revulsion against murder." While Stanton and others have contended that dehumanization is a necessary condition for genocide, Johannes Lang has argued that its role is overstated and that forms of humiliation and torture which occur during genocide occur precisely because the victims' humanity is recognized.

"Accusation in a mirror"

"Accusation in a mirror" is a false claim that accuses the target of something that the perpetrator is doing or intends to do. The name was coined by an anonymous Rwandan propagandist in Note Relative à la Propagande d’Expansion et de Recrutement. Drawing on the ideas of Joseph Goebbels and Vladimir Lenin, he instructed colleagues to "impute to enemies exactly what they and their own party are planning to do". By invoking collective self-defense, propaganda justifies genocide, just as self-defense is a defense for individual homicide. Susan Benesch remarked that while dehumanization "makes genocide seem acceptable", accusation in a mirror makes it seem necessary.

Kenneth L. Marcus writes that the tactic is "similar to a false anticipatory tu quoque" (a logical fallacy which charges the opponent with hypocrisy). The tactic does not rely on what misdeeds the enemy could plausibly be charged with, based on actual culpability or stereotypes, and does not involve any exaggeration but instead is an exact mirror of the perpetrator's own intentions. The weakness of the strategy is that it reveals the perpetrator's intentions, perhaps before he is able to carry it out. This could enable intervention to prevent genocide, or alternatively be "an indispensable tool for identifying and prosecuting incitement". According to Marcus, despite its weaknesses the tactic is frequently used by genocide perpetrators (including Nazis, Serbs, and Hutus) because it is effective. He recommends that courts should consider a false accusation of genocide by an opposing group to satisfy the "direct" requirement, because that is an "almost invariable harbinger of genocide".

Euphemism and metaphor

Perpetrators often rely on euphemisms or metaphors to conceal their actions. During the Rwandan genocide, calls to "go to work" referred to the murder of Tutsis. In Prosecutor v. Nyiramasuhuko, et al. (2015), two defendants had asked others to "sweep the dirt outside". The Trial Chamber of the International Criminal Tribunal for Rwanda (ICTR) held that this was incitement to genocide, because listeners "understood the words ... 'sweeping dirt', to mean they needed to kill Tutsis". Similarly, in Nazi Germany euphemisms such as Final Solution, special treatment, and "resettlement to the East" were used to refer to mass murder. According to William Schabas, "The history of genocide shows that those who incite the crime speak in euphemisms."

Justification

Justifying ongoing atrocities may be considered incitement to genocide. For example, Nazi propagandists repeatedly emphasized to potential perpetrators that "massacres, torture, death marches, slavery, and other atrocities" were carried out in a "humane" way. According to W. Michael Reisman, "in many of the most hideous international crimes, many of the individuals who are directly responsible operate within a cultural universe that inverts our morality and elevates their actions to the highest form of group, tribe, or national defense".

Praising past violence

Praising the perpetrators of completed atrocities can be a form of incitement. RTLM announcer Georges Ruggiu thanked the "valiant combatants" supposedly fighting a "battle" against Tutsi civilians. Eliézer Niyitegeka, transport minister, thanked militias for their "good work".

Asking questions

In the Rwandan genocide, Simon Bikindi's loudspeaker broadcasts to militia asking "have you killed the Tutsis here?" were held to contribute to a finding of incitement to genocide.

Conditional advocacy

In January 1994, Hassan Ngeze wrote an article stating that if Tutsi militias attacked, there would be "none of them left in Rwanda, not even a single accomplice. All the Hutu are united". The ICTR found that this was incitement to genocide, even though it was conditional.

Target–sympathizer conflation

During genocide, members of the majority group who help or sympathize with the targeted group are also persecuted. For example, during the Holocaust, non-Jews who hid Jews or simply opposed the genocide were murdered. In Rwanda, Hutus who opposed the genocide were labeled "traitors" and murdered. Mahmoud Ahmadinejad also threatened sympathizers with Israel, stating "Anybody who recognizes Israel will burn in the fire of the Islamic nation's fury".

Causing genocide

According to Susan Benesch, the strongest evidence for a causal connection between incitement and genocide is found in cases where there is widespread civilian participation in killings (as in Rwanda or the Nazi Holocaust) and where the target group lives alongside a majority group, requiring the acquiescence of that group for genocide to occur. Frank Chalk and Kurt Jonassohn wrote that "in order to perform a genocide the perpetrator has always had to first organize a campaign that redefined the victim group as worthless, outside the web of mutual obligations, a threat to the people, immoral sinners, and/or subhuman."

Larry May argues that incitement to genocide is proof of genocidal intent, and that inciters (along with planners) are more responsible for the resulting genocide than mere participants in the killing. He believes that incitement should be prosecuted more harshly than non-leadership participation for this reason, and because "the crime in question is not merely the individual act of killing or harming, but rather the mass crime of intending to destroy a protected group."

History

Armenian genocide

During the Armenian genocide, Ottoman propaganda described Armenians as "traitors, saboteurs, spies, conspirators, vermin, and infidels". At a meeting of the Committee of Union and Progress in February 1915, a speaker argued that "It is absolutely necessary to eliminate the Armenian people in its entirety, so that there is no further Armenian on this earth and the very concept of Armenia is extinguished." The party "envisioned the Armenian as an invasive infection in Muslim Turkish society", and CUP propagandist Ziya Gökalp promoted the idea that "Turkey could only be revitalized if it rid itself of its non-Muslim elements". This propaganda led directly to the murder of over a million Armenians.

The Holocaust

Wochenspruch der NSDAP, displayed 7–13 September 1941, quotes Hitler's prophecy speech on 30 January 1939: "If international finance Jewry inside and outside Europe should succeed in plunging the nations once more into a world war, the result will be not the Bolshevization of the earth and thereby the victory of Jewry, but the annihilation of the Jewish race in Europe."

Gordon identifies three strategies that the Nazi leadership employed in order to spread hate propaganda about Jews: statements by Nazi leaders, the Ministry of Propaganda, and destruction of the independent press. American historian Jeffrey Herf has argued that the role of euphemisms in Nazi propaganda has been exaggerated, and in fact Nazi leaders often made direct threats against Jews. The German dictator Adolf Hitler was the most important Nazi propagandist. His speeches and statements against the Jews were broadcast on the radio and reprinted on the front pages of the party newspaper Völkischer Beobachter, as well as other major newspapers. Goebbels' Ministry of Propaganda achieved "wholesale control of the mass media", and from 4 October 1933, all independent media was required to report to Otto Dietrich's Reich League of the German Press, which fined or censored newspaper editors who failed to follow Nazi ideology.

According to Nazi propaganda, an international Jewish conspiracy controlled the Allies and started World War II to "Bolshevize" the world; Germany fought back with a "war against the Jews". Nazi propagandists repeatedly accused "international Jewry" of plotting the extermination (Ausrottung) or annihilation (Vernichtung) of the German people and threatened to do the same to the Jews. As evidence, the obscure self-published American book Germany Must Perish!, which advocated the compulsory sterilization of all Germans, was repeatedly emphasized in Nazi propaganda. Hitler's prophecy, found in a 1939 speech which blamed Jews for the war and predicted their annihilation in that event, was frequently quoted during the killings of Jews and was another means of arguing for genocide. Jews inside Europe were presented as a fifth column and saboteurs who posed a serious threat to the German war effort, even as mass deportations to extermination camps were ongoing.

Another tactic used to incite genocide against Jews was to portray them as subhumans (Untermenschen). According to Nazi propaganda, Jews were "parasites, plague, cancer, tumour, bacillus, bloodsucker, blood poisoner, lice, vermin, bedbugs, fleas and racial tuberculosis" on the German national community, which was allegedly threatened by "Jewish disease". Goebbels described Jews as "the lice of civilized humanity". Nazi jurist Walter Buch wrote in the legal journal Deutsche Justiz: "the National Socialist has recognized...[that] the Jew is not a human being". By excluding Jews from humanity, it became justified to kill them.

The Grand Mufti of Jerusalem and Nazi collaborator Amin al-Husseini has also been described as inciting genocide, stating in a 1944 radio address for Bosnian Muslims, "Kill the Jews wherever you find them. This pleases God, history, and religion."

Bosnian genocide

In 1991, the state of Yugoslavia (which had consisted of Serbs, Croats, Bosniaks, Slovenes, Albanians, Slavic Macedonians, and Montenegrins) broke apart and fell into ethnic violence, which began with the secession of Croatia and Slovenia from the Serbian-led government in Belgrade. Bosnia-Herzegovina, an ethnically divided region with a plurality of Bosniaks as well as large Serbian and Croatian minorities, declared independence in March 1992. Serbs in Bosnia were represented by Serb Democratic Party (SDS), whose leader, Radovan Karadžić, had already threatened Bosniaks with genocide: supporting independence "might lead Bosnia into a hell and [cause] one people to disappear". Serbs did not recognize Bosnian independence and instead started the Bosnian War. Serbian forces committed many war crimes during the conflict, which included ethnic cleansing of non-Serbs, mass rapes, imprisonment in internment camps and the Srebrenica massacre.

Alongside the Serb military campaign, there was also a Serb propaganda campaign which aimed to instill "mutual fear and hatred and particularly inciting the Bosnian Serb population against the other ethnicities", according to the judgement in Prosecutor v. Brđanin. Because of the propaganda, people who had lived peacefully together turned against each other and became murderers. In 1991, Wolves of Vučjak and other Serb militia groups helped the SDS seize control of the TV stations, which were subsequently used for pro-Serb propaganda. According to this propaganda, which became more virulent as the war continued, Bosniaks and Croats would commit genocide against the Serbs unless they were eliminated first. The most extreme broadcasts, according to Brđanin, "openly incited people to kill non-Serbs".

Rwandan genocide

Human skulls at the Nyamata Genocide Memorial

Incitement to genocide attracted attention due to its occurrence prior to and during the Rwandan genocide in 1994. The pro-genocide media, especially RTLM, was referred to as "radio genocide", "death by radio" and "the soundtrack to genocide", and its causative role was recognized by international commentators. Rwanda, a former Belgian colony, included Hutu (84%) and Tutsi (15%) populations. Under colonial rule, Tutsi were favored to the exclusion of Hutus, leading to a buildup of ethnic resentment. After majority rule began in 1962, Hutus unleashed violence against Tutsis which led many of the latter to flee to neighboring countries. In 1987, these exiles created Rwandan Patriotic Front (RPF), which invaded Rwanda in 1990. In 1993, international pressure caused the Hutu government under Juvénal Habyarimana to sign the Arusha Accords with the RPF, but Hutu hardliners took to the media to denounce the agreement, Belgium, and Tutsis.

The state-controlled Radio Rwanda was taken over by Hutu extremists for broadcasting hate propaganda. A tabloid newspaper, Kangura, was also responsible for incitement, juxtaposing a picture of a machete with the question "What shall we do to complete the social revolution of 1959?" At Ferdinand Nahimana's behest, in 1992 Radio Rwanda broadcast a fabricated "hit list" supposedly drawn up by Tutsis as Hutu militias were being bussed to the target area. The militiamen killed hundreds of Tutsi civilians in the Bugesera massacres, which proved to be a "dress rehearsal" for the 100 days of murder that began in April 1994. Also in 1992, Léon Mugesera called for Tutsi to be sent "back to Ethiopia" via the non-navigable Nyabarongo River, which had been previously used to dispose of the bodies of Tutsis murdered in ethnic violence. The Rwandan Minister of Justice soon filed incitement charges against him, causing Mugesera to flee to Canada. After Nahimana was sacked from Radio Rwanda due to his role in the Bugesera massacres, he and others set up a private radio station, RTLM, which played the key role in inciting the genocide. Gordon describes four categories of RTLM broadcasts before the genocide. The first type criticized Tutsis based on alleged characteristics (such as wealth, similar to antisemitism, or physical traits). Another type of broadcast generalized all Tutsis as "inyenzi" (cockroaches) and Inkotanyi, a dangerous feudal warrior. The RTLM also acknowledged its reputation for inciting racial hatred, and denounced specific Tutsis (on 3 April, a doctor in Cyangugu was mentioned in a broadcast; he was murdered on 6 April.)

The genocide began on 6 April 1994 with the assassination of Habyarimana, whose plane was shot down over Kigali. Hutu extremists organized death squads which assassinated Tutsi and moderate Hutu politicians. A unit of Belgian peacekeepers were also murdered, in order to encourage the UN to withdraw its peacekeeping mission.

Hamas

Hamas, an Islamist Palestinian militant group that has controlled the Gaza Strip since 2007, has fired thousands of rockets indiscriminately into Israeli civilian areas and orchestrated a suicide bombing campaign aimed at Israeli civilians. Several statements by Hamas officials have been described as incitement to genocide.

Iran

Iranian men wear headbands which read "Death to Israel".

Since the 1979 Islamic Revolution, Iran is controlled by an Islamic government. Iran has attempted to develop nuclear weapons and uses proxy terrorism (via Hamas, Hezbollah, and Islamic Jihad) to attack and threaten Israeli civilians. Incendiary statements calling for the destruction of Israel are common in Iranian politics. President Mahmoud Ahmadinejad has called for Israel to be "wiped Israel off the map". Gregory Gordon and some other legal scholars contend that Ahmadinejad is guilty of incitement to genocide, although Benesch disagrees. In December 2006, the Conference of Presidents of Major American Jewish Organizations and the Jerusalem Center for Public Affairs hosted a symposium "Bring Ahmadinejad to Justice For Incitement to Genocide". The resulting petition, authored by Irwin Colter, has been signed by Elie Wiesel, Former UN High Commissioner for Human Rights Louise Arbour, and the former Swedish Deputy Prime Minister Per Ahlmark, and historian Yehuda Bauer. In 2007, the United States House of Representatives passed a resolution calling on Ahmadinejad to be investigated for inciting genocide.

Islamic State

The Islamic State (IS) has incited genocide against Yazidi people by dehumanizing them as "Satanists" and "devil worshippers" and issuing fatwas which recommend the sexual slavery of Yazidi women. According to IS propaganda, Yazidis' "continual existence to this day is a matter that Muslims should question as they will be asked about it on Judgement Day." Mohamed Elewa Badar argues IS has incited genocide, not just against Yazidis but against all those deemed kafir (infidels) in their extremist interpretation of Islam. IS advocates the "partial or total eradication of non-Muslim groups", and has committed genocide against the Yazidis.

International treaties

Based on the precedent of Nazi propagandist Julius Streicher, who was convicted of crimes against humanity by the International Military Tribunal in 1946, "[d]irect and public incitement to commit genocide" was forbidden by the Genocide Convention (1948), Article 3. During the debate on the convention, the Soviet delegate argued that "[i]t was impossible that hundreds of thousands of people should commit so many crimes unless they had been incited to do so" and that inciters, "the ones really responsible for the atrocities committed", ought to face justice. Several delegates supported a provision that would criminalize hate propaganda even if it did not directly call for violence. The Secretariat Draft called for the criminalization of "[a]ll forms of public propaganda tending by their systematic and hateful character to provoke genocide, or tending to make it appear as a necessary, legitimate or excusable act". However, the United States was reluctant to criminalize genocide incitement due to concerns over freedom of the press, and opposed any provisions that were seen as overly broad and likely to infringe on freedom of speech.

The International Convention on the Elimination of All Forms of Racial Discrimination (1965) prohibits "all dissemination of ideas based on racial superiority or hatred, incitement to racial discrimination, as well as all acts of violence or incitement to such acts against any race or group of persons of another colour or ethnic origin". One of the most widely ratified treaties, International Covenant on Civil and Political Rights (1966) also prohibits "propaganda for war" and "advocacy of national, racial or religious hatred that constitutes incitement to discrimination, hostility or violence" (which arguably conflicts with a separate article calling for freedom of speech). However, according to Wilson, many countries signed these treaties to maintain a façade of respect for human rights while violating their provisions and there is little effective international enforcement of human rights outside of the European Court of Human Rights. No more trials for incitement to genocide were held until nearly fifty years after the ratification of the Genocide Convention.

Since 1998, incitement to genocide is also forbidden by Article 25(3)(e) of the Rome Statute of the International Criminal Court. According to the Rome Statue, incitement is not "a crime in its own right" and an inchoate offense, as it was considered in previous prosecutions, but simply one possible "mode of criminal participation in genocide". Thomas Davies contends that this change makes it less likely that a perpetrator will be held accountable for incitement.

Case law

Nuremberg trials

Streicher at the 1938 Nuremberg rally before the destruction of Hans-Sachs-Platz synagogue

Julius Streicher, the founder, editor, and publisher of Der Stürmer, was found responsible for antisemitic articles referring to Jews as "a parasite, an enemy, and an evil-doer, a disseminator of diseases" or "swarms of locusts which must be exterminated completely". He continued to publish antisemitic articles even after learning of the mass murder of Jews in the occupied Soviet Union. The prosecution argued that "Streicher helped to create, through his propaganda, the psychological basis necessary for carrying through a program of persecution which culminated in the murder of six million men, women, and children." Because Streicher's articles "incited the German people to active persecution" and "murder and extermination", he was convicted of crimes against humanity by the IMT in 1946.

Hans Fritzsche was the Chief of the German Press Division of Joseph Goebbels' Reich Ministry of Public Enlightenment and Propaganda from 1938; in this position he issued instructions to German newspapers telling them what to report. According to the IMT prosecution, he "incited and encouraged the commission of War Crimes by deliberately falsifying news to arouse in the German People those passions which led them to the commission of atrocities". Fritzsche was acquitted because the court was "not prepared to hold that [his broadcasts] were intended to incite the German people to commit atrocities on conquered peoples". Nuremberg prosecutor Alexander Hardy later said that evidence not available to the prosecution at the time proved Fritzsche not only knew of the extermination of European Jews but also "played an important part in bringing [Nazi crimes] about", and would have resulted in his conviction. Fritzsche was later classified as Group I (Major Offenders) by a denazification court which gave him the maximum penalty, eight years' imprisonment.

Otto Dietrich was not tried at the main Nuremberg trial, but was convicted of crimes against humanity at the Ministries Trial, one of the subsequent Nuremberg trials. According to Hardy, Dietrich "more than anyone else, was responsible for presenting to the German people the justification for liquidating the Jews". Hardy noted that Dietrich not only controlled Der Stürmer but another 3,000 newspapers and 4,000 periodicals with a combined circulation over 30 million. The judgement against him noted that he conducted "a well thought-out, oft-repeated, persistent campaign to arouse the hatred of the German people against Jews" despite the lack of direct calls for violence made by him.

International Criminal Tribunal for Rwanda

The ICTR indicted three people for incitement to genocide in the so-called Rwanda Media Case: Hassan Ngeze, Ferdinand Nahimana, and Jean-Bosco Barayagwiza. All were convicted. The judges asserted that "The power of the media to create and destroy fundamental human values comes with great responsibility. Those who control such media are accountable for its consequences". They noted that "Without a firearm, machete or any physical weapon, you caused the deaths of thousands of innocent civilians". Prosecutors were able to prove that "direct" calls to genocide were made despite the use of euphemisms such as "go to work" for murdering Tutsi. After an appeal, the conviction of Barayagwiza was vacated because he had not been in control of the media while the genocide was occurring. However, Barayagwiza was still guilty of "instigating the perpetration of acts of genocide" and crimes against humanity.

International Criminal Tribunal for the former Yugoslavia

The ICTY has focused on prosecuting crimes other than genocide, because it is believed that the hate speech that occurred during the Bosnian genocide did not meet the legal standard of incitement to genocide. Serb politician Vojislav Šešelj was indicted for crimes against humanity, including "war propaganda and incitement of hatred towards non-Serb people". Serbian politician Radovan Karadžić was convicted of "participating in a joint criminal enterprise to commit crimes against humanity on the basis of his public speeches and broadcasts". Dario Kordić and Radoslav Brđanin were also convicted of crimes based on instigating violence in public speeches.

National case law

In 2016, Léon Mugesera was convicted of incitement to genocide and inciting ethnic hatred by a Rwandan court based on his 1992 speech.

Countering incitement

Inclusion of incitement in the Genocide Convention was intended to prevent genocide. As the judgement of Prosecutor v. Kalimanzira stated, "The inchoate nature of the crime allows intervention at an earlier stage, with the goal of preventing the occurrence of genocidal acts." Irwin Cotler stated that efforts to enforce the Genocide Convention in inchoate incitement cases "have proven manifestly inadequate". Alternately, prosecution for incitement after the genocide had concluded could have deterrent effect on those planning to commit the crime, but the effectiveness of international criminal trials as a deterrent is disputed. However, deterrence is less effective when the definition of the crime is contested and undefined.

Besides prosecutions, non-judicial interventions (called "information intervention") is possible against incitement, such as jamming broadcasting frequencies used to disseminate incitement or broadcasting counterspeech advocating against genocide. Genocide-inciting social media accounts and websites (such as those used by Islamic State to spread propaganda) can be shut down and taken offline. However, propagandists can circumvent these methods by creating new accounts or moving to a different hosting service. As an alternative to outright censorship, Google developed a "Redirect Method" which identifies individuals searching for IS-related material and redirects them to content which challenges IS narratives.

Race and health

From Wikipedia, the free encyclopedia

Race and health refers to how being identified with a specific race influences health. Race is a complex concept that has changed across chronological eras and depends on both self-identification and social recognition. In the study of race and health, scientists organize people in racial categories depending on different factors such as: phenotype, ancestry, social identity, genetic makeup and lived experience. "Race" and ethnicity often remain undifferentiated in health research.

Differences in health status, health outcomes, life expectancy, and many other indicators of health in different racial and ethnic groups are well documented. Epidemiological data indicate that racial groups are unequally affected by diseases, in terms or morbidity and mortality. Some individuals in certain racial groups receive less care, have less access to resources, and live shorter lives in general. Overall, racial health disparities appear to be rooted in social disadvantages associated with race such as implicit stereotyping and average differences in socioeconomic status.

Health disparities are defined as "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations". According to the U.S. Centers for Disease Control and Prevention, they are intrinsically related to the "historical and current unequal distribution of social, political, economic and environmental resources".

The relationship between race and health has been studied from multidisciplinary perspectives, with increasing focus on how racism influences health disparities, and how environmental and physiological factors respond to one another and to genetics.

Racial health disparities

Health disparities refer to gaps in the quality of health and health care across racial and ethnic groups. The US Health Resources and Services Administration defines health disparities as "population-specific differences in the presence of disease, health outcomes, or access to health care". Health is measured through variables such as life expectancy and incidence of diseases.

For racial and ethnic minorities in the United States, health disparities take on many forms, including higher rates of chronic disease, premature death, and maternal mortality compared to the rates among whites. It is important to note that this pattern is not universal. Some minority groups—most notably, Hispanic immigrants—may have better health outcomes than whites when they arrive in the United States. However this appears to diminish with time spent in the United States. For other indicators, disparities have shrunk, not because of improvements among minorities but because of declines in the health of majority groups.

In the U.S., more than 133 million Americans (45% of the population) have one or more chronic diseases. One study has shown that between the ages of 60 to 70, racial/ethnic minorities are 1.5 to 2.0 times more likely than whites (Hispanic and non Hispanic) to have one of the four major chronic diseases specifically Diabetes, cancer, cardiovascular disease (CVD), and chronic lung disease. However, the greatest differences only occurred among people with single chronic diseases. Racial/ethnic differences were less distinct for some conditions including multiple diseases. Non-Hispanic whites trended toward a high prevalence for dyads of cardiovascular disease (CVD) with cancer or lung disease. Hispanics and African Americans had the greatest prevalence of diabetes, while non-Hispanic blacks had higher odds of having heart disease with cancer or chronic lung disease than non-Hispanic whites. Among non-Hispanic whites the prevalence of multimorbidities that include diabetes was low; however, non-Hispanic whites had a very high prevalence of multimorbidities that exclude diabetes. Non-Hispanic whites had the highest prevalence of cancer only or lung disease only. 

Between 1960 and 2005 the percentage of children with a chronic disease in the United States quadrupled with minority having higher likelihood for these disease. The most common major chronic biases of youth in the United States are asthma, diabetes mellitus, obesity, hypertension, dental disease, attention deficit hyperactivity disorder (ADHD), mental illness, cancers and others. This results in Black and Latinx adult patients facing a disproportionate amount of health concerns, such as asthma, with treatment and management guidelines not developed with studies based on their populations and healthcare needs.

Although individuals from different environmental, continental, socioeconomic, and racial groups etc. have different levels of health, yet not all of these differences are always categorized or defined as health disparities. Some researchers separate definitions of health inequality from health disparity by preventability. Health inequalities are often categorized as being unavoidable i.e. due to age, while preventable unfair health outcomes are categorized as health inequities. These are seen as preventable because they are usually associated with income, education, race, ethnicity, gender, and more.

Defining race

Definitions of race are ambiguous due to the various paradigms used to discuss race. These definitions are a direct result of biological and social views. Definitions have changed throughout history to yield a modern understanding of race that is complex and fluid. Moreover, there is no one definition that stands, as there are many competing and interlocking ways to look at race. Due to its ambiguity, terms such as race, genetic population, ethnicity, geographic population, and ancestry are used interchangeably in everyday discourse involving race. Some researchers critique this interchangeability noting that the conceptual differences between race and ethnicity are not widely agreed upon.

Even though there is a broad scientific agreement that essentialist and typological conceptions of race are untenable, scientists around the world continue to conceptualize race in widely differing ways. Historically, biological definitions of race have encompassed both essentialist and anti-essentialist views. Essentialists have sought to show that racial groups are genetically distinct populations, describing "races as groups of people who share certain innate, inherited biological traits". In contrast, anti-essentialists have used biological evidence to demonstrate that "race groupings do not reflect patterns of human biological variation, countering essentialist claims to the contrary".

Over the past 20 years, a consensus has emerged that, while race is partially based on physical similarities within groups, it does not have an inherent physical or biological meaning. In response, researchers and social scientists have begun examining notions of race as constructed. Racial groups are "constructed" from differing historical, political, and economic contexts, rather than corresponding to inherited, biological variations. Proponents of the constructionist view claim that biological definitions have been used to justify racism in the past and still have the potential to be used to encourage racist thinking in the future. Since race is changing and often so loosely characterized on arbitrary phenotypes, and because it has no genetic basis, the only working definition we can assign it is a social construct. This is not to say race is imaginary or non-existent. It is an important social reality. However to say that the concept of race has any scientific merit or has a scientific foundation can lead to many issues in scientific research, and it may also lead to inherent racial bias.

Social views also better explain the ambiguity of racial definitions. An individual may self-identify as one race based on one set of determinants (for example, phenotype, culture, ancestry) while society may ascribe the person otherwise based on external forces and discrete racial standards. Dominant racial conceptions influence how individuals label both themselves and others within society. Modern human populations are becoming more difficult to define within traditional racial boundaries due to racial admixture. Most scientific studies, applications, and government documents ask individuals to self-identify race from a limited assortment of common racial categories. The conflict between self-identification and societal ascription further complicates biomedical research and public health policies. However complex its sociological roots, race has real biological ramifications; the intersection of race, science, and society permeates everyday life and influences human health via genetics, access to medical care, diagnosis, and treatment.

Race and disease

Diseases affect racial groups differently, especially when they are co-related with class disparities. As socioeconomic factors influence the access to care, the barriers to access healthcare systems can perpetuate different biological effects of diseases among racial groups that are not pre-determined by biology.

Some researchers advocate for the use of self-reported race as a way to trace socioeconomic disparities and its effects in health. For instance, a study conducted by the National Health Service checks program in the United Kingdom, which aims to increase diagnosis across demographics, noted that "the reported lower screening in specific black and minority ethnic communities... may increase inequalities in health." In this specific case, the lack of attention to certain demographics can be seen as a cause of increased instances of disease from this lack of proper, equal preventive care. One must consider these external factors when evaluating statistics on the prevalence of disease in populations, even though genetic components can play a role in predispositions to contracting some illnesses.

Individuals who share a similar genetic makeup can also share certain propensity or resistance to specific diseases. However, there are confronted positions in relation to the utility of using 'races' to talk about populations sharing a similar genetic makeup. Some geneticists argued that human variation is geographically structured and that genetic differences correlate with general conceptualizations of racial groups. Others claimed that this correlation is too unstable and that the genetic differences are minimal and they are "distributed over the world in a discordant manner". Therefore, race is regarded by some as a useful tool for the assessment of genetic epidemiological risk, while others consider it can lead to an increased underdiagnosis in 'low risk' populations.

Single-gene disorders

There are many autosomal recessive single gene genetic disorders that differ in frequency between different populations due to the region and ancestry as well as the founder effect. Some examples of these disorders include:

Multifactorial polygenic diseases

Many diseases differ in frequency between different populations. However, complex diseases are affected by multiple factors, including genetic and environmental. There is controversy over the extent to which some of these conditions are influenced by genes, and ongoing research aims to identify which genetic loci, if any, are linked to these diseases. "Risk is the probability that an event will occur. In epidemiology, it is most often used to express the probability that a particular outcome will occur following a particular exposure." Different populations are considered "high-risk" or "low-risk" groups for various diseases due to the probability of that particular population being more exposed to certain risk factors. Beyond genetic factors, history and culture, as well as current environmental and social conditions, influence a certain populations' risk for specific diseases.

Disease progression

Racial groups may differ in how a disease progresses. Different access to healthcare services, different living and working conditions influence how a disease progresses within racial groups. However, the reasons for these differences are multiple, and should not be understood a consequence of genetic differences between races, but rather as effects of social and environmental factors affecting.

Prevention

Genetics have been proven to be a strong predictor for common diseases such as cancer, cardiovascular disease (CVD), diabetes, autoimmune disorders, and psychiatric illnesses. Some geneticists have determined that "human genetic variation is geographically structured" and that different geographic regions correlate with different races. Meanwhile, others have claimed that the human genome is characterized by clinal changes across the globe, in relation with the "Out of Africa" theory and how migration to new environments cause changes in populations' genetics over time.

Some diseases are more prevalent in some populations identified as races due to their common ancestry. Thus, people of African and Mediterranean descent are found to be more susceptible to sickle-cell disease while cystic fibrosis and hemochromatosis are more common among European populations. Some physicians claim that race can be used as a proxy for the risk that the patient may be exposed to in relation to these diseases. However, racial self-identification only provides fragmentary information about the person's ancestry. Thus, racial profiling in medical services would also lead to the risk of underdiagnosis.

While genetics play a role in determining how susceptible a person is to specific diseases, environmental, structural, cultural, and communication messaging factors play a large role as well. For this reason, it is impossible to discern exactly what causes a person to acquire a disease, but it is important to observe how many inter-related factors relate to each other. Each person's health is unique, as they have different genetic compositions and life histories.

Race-based treatment

Racial groups, especially when defined as minorities or ethnic groups, often face structural and cultural barriers to access healthcare services. The development of culturally and structurally competent services and research that meet the specific health care needs of racial groups is still in its infancy. In the United States, the Office of Minority Health The NIH (National institutes of health) and The WHO are organizations that provide useful links and support research that is targeted at the development of initiatives around minority communities and the health disparities they face. Similarly, In the United Kingdom, the National Health Service established a specialist collection on Ethnicity & Health. This resource was supported by the National Institute for Health and Clinical Excellence (NICE) as part of the UK NHS Evidence initiative NHS Evidence. Similarly, there are growing numbers of resource and research centers which are seeking to provide this service for other national settings, such as Multicultural Mental Health Australia. However, cultural competence has also been criticized for having the potential to create stereotypes.

Scientific studies have shown the lack of efficacy of adapting pharmaceutical treatment to racial categories. "Race-based medicine" is the term for medicines that are targeted at specific racial clusters which are shown to have a propensity for a certain disorder. The first example of this in the U.S. was when BiDil, a medication for congestive heart failure, was licensed specifically for use in American patients that self-identify as black. Previous studies had shown that African American patients with congestive heart failure generally respond less effectively to traditional treatments than white patients with similar conditions.

After two trials, BiDil was licensed exclusively for use in African American patients. Critics have argued that this particular licensing was unwarranted, since the trials did not in fact show that the drug was more effective in African Americans than in other groups, but merely that it was more effective in African Americans than other similar drugs. It was also only tested in African American males, but not in any other racial groups or among women. This peculiar trial and licensing procedure has prompted suggestions that the licensing was in fact used as a race-based advertising scheme.

Critics are concerned that the trend of research on race-specific pharmaceutical treatments will result in inequitable access to pharmaceutical innovation and smaller minority groups may be ignored. This has led to a call for regulatory approaches to be put in place to ensure scientific validity of racial disparity in pharmacological treatment.

An alternative to "race-based medicine" is personalized or precision medicine. Precision medicine is a medical model that proposes the customization of healthcare, with medical decisions, treatments, practices, or products being tailored to the individual patient. It involves identifying genetic, genomic (i.e., genomic sequencing), and clinical information—as opposed to using race as a proxy for these data—to better predict a patient's predisposition to certain diseases.

Environmental factors

A positive correlation between minorities and a socioeconomic status of being low-income in industrialized and rural regions of the U.S. depict how low-income communities tend to include more individuals that have a lower educational background, most importantly in health. Income status, diet, and education all construct a higher burden for low-income minorities, to be conscious about their health. Research conducted by medical departments at universities in San Diego, Miami, Pennsylvania, and North Carolina suggested that minorities in regions where lower socioeconomic status is common, there was a direct relationship with unhealthy diets and greater distance of supermarkets. Therefore, in areas where supermarkets are less accessible (food deserts) to impoverished areas, the more likely these groups are to purchase inexpensive fast food or just follow an unhealthy diet. As a result, because food deserts are more prevalent in low income communities, minorities that reside in these areas are more prone to obesity, which can lead to diseases such as chronic kidney disease, hypertension, or diabetes.

Furthermore, this can also occur when minorities living in rural areas undergoing urbanization, are introduced to fast food. A study done in Thailand focused on urbanized metropolitan areas, the students who participated in this study as were diagnosed as "non-obese" in their early life according to their BMI, however were increasingly at risk of developing Type 2 Diabetes, or obesity as adults, as opposed to young adults who lived in more rural areas during their early life. Therefore, early exposure to urbanized regions can encourage unhealthy eating due to widespread presence of inexpensive fast food. Different racial populations that originate from more rural areas and then immigrate to the urbanized metropolitan areas can develop a fixation for a more westernized diet; this change in lifestyle typically occurs due to loss of traditional values when adapting to a new environment. For example, a 2009 study named CYKIDS was based on children from Cyprus, a country east of the Mediterranean Sea, who were evaluated by the KIDMED index to test their adherence to a Mediterranean diet after changing from rural residence to an urban residence. It was found that children in urban areas swapped their traditional dietary patterns for a diet favoring fast food.

Genetic factors

The fact that every human has a unique genetic code is the key to techniques such as genetic fingerprinting. Versions of genetic markers, known as alleles, occur at different frequencies in different human populations; populations that are more geographically and ancestrally remote tend to differ more.

A phenotype is the "outward, physical manifestation" of an organism." For humans, phenotypic differences are most readily seen via skin color, eye color, hair color, or height; however, any observable structure, function, or behavior can be considered part of a phenotype. A genotype is the "internally coded, inheritable information" carried by all living organisms. The human genome is encoded in DNA.

For any trait of interest, observed differences among individuals "may be due to differences in the genes" coding for a trait and "the result of variation in environmental condition". This variability is due to gene-environment interactions that influence genetic expression patterns and trait heritability.

For humans, there is "more genetic variation among individual people than between larger racial groups". In general, an average of 80% of genetic variation exists within local populations, around 10% is between local populations within the same continent, and approximately 8% of variation occurs between large groups living on different continents. Studies have found evidence of genetic differences between populations, but the distribution of genetic variants within and among human populations is impossible to describe succinctly because of the difficulty of defining a "population", the clinal nature of variation, and heterogeneity across the genome. Thus, the racialization of science and medicine can lead to controversy when the term population and race are used interchangeably.

Evolutionary factors

Currently malaria-endemic countries in the eastern hemisphere
 
Currently malaria-endemic countries in the western hemisphere

Genes may be under strong selection in response to local diseases. For example, people who are duffy negative tend to have higher resistance to malaria. Most Africans are duffy negative and most non-Africans are duffy positive due to endemic transmission of malaria in Africa. A number of genetic diseases more prevalent in malaria-affected areas may provide some genetic resistance to malaria including sickle cell disease, thalassaemias, glucose-6-phosphate dehydrogenase, and possibly others.

Many theories about the origin of the cystic fibrosis have suggested that it provides a heterozygote advantage by giving resistance to diseases earlier common in Europe.

In earlier research, a common theory was the "common disease-common variant" model. It argues that for common illnesses, the genetic contribution comes from the additive or multiplicative effects of gene variants that each one is common in the population. Each such gene variant is argued to cause only a small risk of disease and no single variant is sufficient or necessary to cause the disease. An individual must have many of these common gene variants in order for the risk of disease to be substantial.

More recent research indicates that the "common disease-rare variant" may be a better explanation for many common diseases. In this model, rare but higher-risk gene variants cause common diseases. This model may be relevant for diseases that reduces fertility. In contrast, for common genes associated with common disease to persist they must either have little effect during the reproductive period of life (like Alzheimer's disease) or provide some advantage in the original environment (like genes causing autoimmune diseases also providing resistance against infections). In either case varying frequencies of genes variants in different populations may be an explanation for health disparities. Genetic variants associated with Alzheimer's disease, deep venous thrombosis, Crohn disease, and type 2 diabetes appear to adhere to "common disease-common variant" model.

Gene flow

Gene flow and admixture can also have an effect on relationships between race and race-linked disorders. Multiple sclerosis, for example, is typically associated with people of European descent, but due to admixture African Americans have elevated levels of the disorder relative to Africans.

Some diseases and physiological variables vary depending upon their admixture ratios. Examples include measures of insulin functioning and obesity.

Gene interactions

The same gene variant, or group of gene variants, may produce different effects in different populations depending on differences in the gene variants, or groups of gene variants, they interact with. One example is the rate of progression to AIDS and death in HIV–infected patients. In Caucasians and Hispanics, HHC haplotypes were associated with disease retardation, particularly a delayed progression to death, while for African Americans, possession of HHC haplotypes was associated with disease acceleration. In contrast, while the disease-retarding effects of the CCR2-641 allele were found in African Americans, they were not found in Caucasians.

Theoretical approaches in addressing health and race disparities

Public health researchers and policy makers are working to reduce health disparities. Health effects of racism are now a major area of research. In fact, these seem to be the primary research focus in biological and social sciences. Interdisciplinary methods have been used to address how race affects health. according to published studies, many factors combine to affect the health of individuals and communities. Whether people are healthy or not, is determined by their circumstances and environment. Factors that need to be addressed when looking at health and race include income and social status, education, physical environment, social support networks, genetics, health services, targeted instruction, and gender. These determinants are often cited in public health, anthropology, and other social science disciplines. The WHO categorizes these determinants into three broader topics: the social and economic environment, the physical environment, and the person's individual characteristics and behaviors. Due to the diversity of factors that often attribute to health disparities outcomes, interdisciplinary approaches are often implemented.

Interdisciplinarity or interdisciplinary studies involves the combining of two or more academic disciplines into one activity (e.g., a research project) The term interdisciplinary is applied within education and training pedagogies to describe studies that use methods and insights of several established disciplines or traditional fields of study. Interdisciplinarity involves researchers, students, and teachers in the goals of connecting and integrating several academic schools of thought, professions, or technologies—along with their specific perspectives—in the pursuit of a common task.

Biocultural approach

Biocultural evolution was introduced and first used in the 1970s. Biocultural methods focus on the interactions between humans and their environment to understand human biological adaptation and variation. These studies:

"research on questions of human biology and medical ecology that specifically includes social, cultural, or behavioral variables in the research design, offer valuable models for studying the interface between biological and cultural factors affecting human well-being"

This approach is useful in generating holistic viewpoints on human biological variation. There are two biocultural approach models. The first approach fuses biological, environmental, and cultural data. The second approach treats biological data as primary data and culture and environmental data as secondary.

The salt sensitivity hypothesis is an example of implementing biocultural approaches in order to understand cardiovascular health disparities among African American populations. This theory, founded by Wilson and Grim, stems from the disproportional rates of salt sensitive high blood pressure seen between U.S. African American and White populations and between U.S. African American and West Africans as well. The researchers hypothesized that the patterns were in response to two events. One the trans-Atlantic slave trade, which resulted in massive death totals of Africans who were forced over, those who survived and made to the United States were more likely able to withstand the harsh conditions because they retained salt and water better. The selection continued once they were in the United States. African Americans who were able to withstand hard working conditions had better survival rates due to high water and salt retention. Second, today, because of different environmental conditions and increased salt intake with diets, water and salt retention are disadvantageous, leaving U.S. African Americans at disproportional risks because of their biological descent and culture.

Bio social inheritance model

Similar to the biocultural approach, the bio social inheritance model also looks at biological and social methods in examining health disparities. Hoke et al. define Biosocial inheritance as "the process whereby social adversity in one generation is transmitted to the next through reinforcing biological and social mechanisms that impair health, exacerbating social and health disparities."

Controversy

There is a controversy regarding race as a method for classifying humans. Different sources argue it is purely social construct or a biological reality reflecting average genetic group differences. New interest in human biological variation has resulted in a resurgence of the use of race in biomedicine.

The main impetus for this development is the possibility of improving the prevention and treatment of certain diseases by predicting hard-to-ascertain factors, such as genetically conditioned health factors, based on more easily ascertained characteristics such as phenotype and racial self-identification. Since medical judgment often involves decision making under uncertain conditions, many doctors consider it useful to take race into account when treating disease because diseases and treatment responses tend to cluster by geographic ancestry. The discovery that more diseases than previously thought correlate with racial identification have further sparked the interest in using race as a proxy for bio-geographical ancestry and genetic buildup.

Race in medicine is used as an approximation for more specific genetic and environmental risk factors. Race is thus partly a surrogate for environmental factors such as differences in socioeconomic status that are known to affect health. It is also an imperfect surrogate for ancestral geographic regions and differences in gene frequencies between different ancestral populations and thus differences in genes that can affect health. This can give an approximation of probability for disease or for preferred treatment, although the approximation is less than perfect.

Taking the example of sickle-cell disease, in an emergency room, knowing the geographic origin of a patient may help a doctor doing an initial diagnosis if a patient presents with symptoms compatible with this disease. This is unreliable evidence with the disease being present in many different groups as noted above with the trait also present in some Mediterranean European populations. Definitive diagnosis comes from examining the blood of the patient. In the US, screening for sickle cell anemia is done on all newborns regardless of race.

The continued use of racial categories has been criticized. Apart from the general controversy regarding race, some argue that the continued use of racial categories in health care and as risk factors could result in increased stereotyping and discrimination in society and health services. Some of those who are critical of race as a biological concept see race as socially meaningful group that is important to study epidemiologically in order to reduce disparities. For example, some racial groups are less likely than others to receive adequate treatment for osteoporosis, even after risk factors have been assessed. Since the 19th century, blacks have been thought to have thicker bones than whites have and to lose bone mass more slowly with age. In a recent study, African Americans were shown to be substantially less likely to receive prescription osteoporosis medications than Caucasians. Men were also significantly less likely to be treated compared with women. This discrepancy may be due to physicians' knowledge that, on average, African Americans are at lower risk for osteoporosis than Caucasians. It may be possible that these physicians generalize this data to high-risk African-Americans, leading them to fail to appropriately assess and manage these individuals' osteoporosis. On the other hand, some of those who are critical of race as a biological concept see race as socially meaningful group that is important to study epidemiologically in order to reduce disparities.

David Williams (1994) argued, after an examination of articles in the journal Health Services Research during the 1966–90 period, that how race was determined and defined was seldom described. At a minimum, researchers should describe if race was assessed by self-report, proxy report, extraction from records, or direct observation. Race was also often used questionable, such as an indicator of socioeconomic status. Racial genetic explanations may be overemphasized, ignoring the interaction with and the role of the environment.

From concepts of race to ethnogenetic layering

There is general agreement that a goal of health-related genetics should be to move past the weak surrogate relationships of racial health disparity and get to the root causes of health and disease. This includes research which strives to analyze human genetic variation in smaller groups than races across the world.

One such method is called ethnogenetic layering. It works by focusing on geographically identified microethnic groups. For example, in the Mississippi Delta region ethnogenetic layering might include such microethnic groups as the Cajun (as a subset of European Americans), the Creole and Black groups [with African origins in Senegambia, Central Africa and Bight of Benin] (as a subset of African Americans), and Choctaw, Houmas, Chickasaw, Coushatta, Caddo, Atakapa, Karankawa and Chitimacha peoples (as subsets of Native Americans).

Better still may be individual genetic assessment of relevant genes. As genotyping and sequencing have become more accessible and affordable, avenues for determining individual genetic makeup have opened dramatically. Even when such methods become commonly available, race will continue to be important when looking at groups instead of individuals such as in epidemiologic research.

Some doctors and scientists such as geneticist Neil Risch argue that using self-identified race as a proxy for ancestry is necessary to be able to get a sufficiently broad sample of different ancestral populations, and in turn to be able to provide health care that is tailored to the needs of minority groups.

Association studies

One area in which population categories can be important considerations in genetics research is in controlling for confounding between population genetic substructure, environmental exposures, and health outcomes. Association studies can produce spurious results if cases and controls have differing allele frequencies for genes that are not related to the disease being studied, although the magnitude of its problem in genetic association studies is subject to debate. Various techniques detect and account for population substructure, but these methods can be difficult to apply in practice.

Population genetic substructure also can aid genetic association studies. For example, populations that represent recent mixtures of separated ancestral groups can exhibit longer-range linkage disequilibrium between susceptibility alleles and genetic markers than is the case for other populations. Genetic studies can use this disequilibrium to search for disease alleles with fewer markers than would be needed otherwise. Association studies also can take advantage of the contrasting experiences of racial or ethnic groups, including migrant groups, to search for interactions between particular alleles and environmental factors that might influence health.

Human genome projects

The Human Genome Diversity Project has collected genetic samples from 52 indigenous populations.

Sources of racial disparities in care

In a report by the Institute of Medicine called Unequal Treatment, three major source categories are put forth as potential explanations for disparities in health care: patient-level variables, healthcare system-level factors, and care process-level variables.

Patient-level variables

There are many individual factors that could explain the established differences in health care between different racial and ethnic groups. First, attitudes and behaviors of minority patients are different. They are more likely to refuse recommended services, adhere poorly to treatment regimens, and delay seeking care, yet despite this, these behaviors and attitudes are unlikely to explain the differences in health care. In addition to behaviors and attitudes, biological based racial differences have been documented, but these also seem unlikely to explain the majority of observed disparities in care.

Health system-level factors

Health system-level factors include any aspects of health systems that can have different effects on patient outcomes. Some of these factors include different access to services, access to insurance or other means to pay for services, access to adequate language and interpretation services, and geographic availability of different services. Many studies assert that these factors explain portions of the existing disparities in health of racial and ethnic minorities in the United States when compared to their white counterparts.

Care process-level variables

Three major mechanisms are suggested by the Institute of Medicine that may contribute to healthcare disparities from the provider's side: bias (or prejudice) against racial and ethnic minorities; greater clinical uncertainty when interacting with minority patients; and beliefs held by the provider about the behavior or health of minorities. While research in this area is ongoing, some exclusions within clinical trials themselves are also present. A recent systematic review of the literature relating to hearing loss in adults demonstrated that many studies fail to include aspects of racial or ethnic diversity, resulting in studies that do not necessarily represent the US population.

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