Hispanic paradox

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Hispanic paradox: Income may be lower but health better than most
By Juliet Chung

Los Angeles Times

Thousands of Hispanic patients stream though the East Los Angeles practice of Dr. Hector Flores and his partners each year.

The older ones go to the family practice with arthritis and hypertension, the younger ones with diabetes and asthma.

What surprises Flores, however, is not how sick they are — it is how sick they are not.

Overall, Flores said, his patients are much healthier than one would expect given their low levels of income and education, factors epidemiologists long have known are linked to poor health.

"You can predict in the African-American population, for example, a high infant-mortality rate," he said recently, "so we would think a [similarly] poor minority would have the same health outcomes.

"But they don't. They're not there," he said, referring to outcomes among Hispanics.

Why Hispanics are not sicker — a phenomenon known to health officials as the Hispanic paradox — is puzzling to public-health experts, given the link between disadvantage and high disease and mortality rates.

In overall mortality rates and infant-mortality rates, two standard measures of a population's health, Hispanics' numbers approach and sometimes surpass those of whites.

In Los Angeles County in 2003, the age-adjusted mortality rate for Hispanics was 535 per 100,000, 33 percent less than for non-Hispanic whites and 52 percent less than blacks, according to the most recent data from the county's Department of Public Health.

Nationally that year, Hispanics' mortality rate was 621, 25 percent less than whites' and 43 percent less than blacks', according to National Vital Statistics Reports, published by the Centers for Disease Control and Prevention.

Hispanics' infant-mortality rates reflect a similar pattern. In Los Angeles, the rate was 5.2 per 100,000 in 2003, 16 percent higher than whites' and 57 percent less than blacks'. The national rate was 5.7, about the same as whites' and 58 percent less than blacks'.

"It violates one of the most predictable patterns we see in most areas of the world and for most diseases," said Dr. Paul Simon, chief epidemiologist for the Public Health Department.

"The question is, 'What is the Latino population doing right?' "

The reasons for the paradox are a matter of debate. Some scholars attribute it to immigration, which may draw selectively from the ranks of the hale and hardy. Another possibility is that many immigrants return to their home countries when seriously ill, skewing mortality statistics in this country.

But increasingly, researchers are suggesting that such factors as diet, lifestyle choices and strong social-support networks are the key to Hispanics' better-than-expected health.

"They're not taking some secret Aztec herb they didn't tell you about," said David Hayes-Bautista, an early observer of the Hispanic paradox who directs the University of California, Los Angeles, Medical School's Center for the Study of Latino Health and Culture.

It's worth figuring out what is making the difference, he added, because "we could all be better off for it."

As the immigration debate heats up and the cost of health care soars, the phenomenon is attracting attention from social scientists and public-health officials. It was first noticed, though, in the 1970s and '80s by researchers looking at infant- and overall mortality rates in Texas and California.

Scholars tended to view the findings as wrong or anomalous, assuming that Hispanics' relatively disadvantaged socioeconomic status put their health status more on par with blacks'.

As data accumulated, covering broader swaths of the country and longer periods, skepticism turned to curiosity.

Kyriakos Markides, who in 1986 coined the term "Hispanic epidemiological paradox," described scholars' shift in recent years as remarkable.

"Nobody talked about it then," said Markides, a professor of sociomedical sciences at the University of Texas Medical Branch in Galveston, speaking of a generation ago. "People just ignored the data or assumed that disadvantaged populations have high mortality. Now, it's the leading theme in the health of the Hispanic population in the United States."

Studies have indicated that Hispanics drink less alcohol and smoke less than their white counterparts. However, their healthful behaviors appear to wane with greater acculturation in the United States.

Several studies have found that the children and grandchildren of foreign-born Hispanics tend to smoke, drink and use illegal drugs more than their parents and grandparents. And some research suggests that they are less likely to breast-feed and to stick to the healthier diets of their forebears.

"You can see it in obesity rates; they're very high in Mexican children," said Dr. Leo Morales, an associate professor of medicine and public health at UCLA who has written about the paradox.

"That portends high disease rates for cardiovascular disease, diabetes, all the obesity-related complications."

Ana Abraido-Lanza, an assistant professor at Columbia University's Mailman School of Public Health, cited a greater availability of fast food in the U.S. and social factors, including a more relaxed attitude toward drinking.

A yet-to-be-published study of Chicago neighborhoods found that in enclaves with high numbers of Hispanic immigrants, 5 percent of such immigrants had asthma, a lower percentage than for whites, blacks and U.S.-born Hispanics in the same area.

That figure jumped to 22 percent, higher than for all other groups, among Hispanic immigrants when they lived in neighborhoods with few of their immigrant peers, even when such factors as health insurance and poverty were accounted for.

"There seems to be something about neighborhood social context that matters," said Kathleen Cagney, a University of Chicago assistant professor and lead author of the study, which is to be published in the American Journal of Public Health.

In this case, Cagney said, she believes the trust and solidarity in their neighborhoods led foreign-born Hispanics outdoors and away from indoor irritants such as mold and cockroach infestations.

No expert offered a comprehensive explanation of the paradox, and some wondered whether one was possible. "In some ways, it's like the more you get into it, the more complex it seems," said Dr. Elena Fuentes-Afflick, a professor of pediatrics at the University of California, San Francisco.

Like Flores, she believes the truth ultimately will involve a combination of factors.

Copyright © 2006 The Seattle Times Company