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Paradox Lost? The Waning Health Advantage among the U.S. Hispanic Population

2023; National Institute of Environmental Health Sciences; Volume: 131; Issue: 1 Linguagem: Inglês

10.1289/ehp11618

1552-9924

Wendee Nicole,

Food Security and Health in Diverse Populations

Vol. 131, No. 1 FocusOpen AccessParadox Lost? The Waning Health Advantage among the U.S. Hispanic Population Wendee Nicole Wendee Nicole Published:6 January 2023CID: 012001https://doi.org/10.1289/EHP11618AboutSectionsPDF ToolsDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InReddit AbstractFor decades epidemiologists have puzzled over an intriguing phenomenon: Hispanic Americans are healthier than might be expected, given their having, on average, lower socioeconomic status (SES) than non-Hispanic White populations.1,2 Low SES is almost unequivocally associated with worse population health and higher death rates around the globe.3 Yet studies have found that people of Hispanic origin living in the United States have better health outcomes than other racial and ethnic groups, including non-Hispanic White populations, for cardiovascular disease,4 various cancers,5 infant mortality,6 stroke,7 bronchitis,7,8 and emphysema.7 They also live an average of 3–4 years longer than non-Hispanic White populations.9Often called the Hispanic paradox in the scientific literature, the reasons behind this population's health and longevity advantages have remained the subject of intense research—and curiosity—for decades; in 2013, a group of authors observed, "[T]he current status of the Hispanic mortality paradox can best be described as one of great interest with significant logistical confusion."10Although often grouped under the catchall heading "Hispanic," Latino immigrants—those from countries throughout Central America, South America, and the Caribbean—have very different cultural backgrounds. This reality is reflected on the current U.S. census form, which allows Hispanic respondents to identify as Mexican/Mexican American/Chicano; Puerto Rican; Cuban; or "other Hispanic, Latino, or Spanish origin." Those who respond "other" are then asked to write in their country of origin. Acknowledging how complex a person's origin and self-identity can be, the Census Bureau expanded this write-in field from 30 characters to 200 for the 2020 census.67 Image: Public domain via Environmental Health Perspectives.Even as researchers are making progress on explanations for the paradox, their findings indicate that the health advantage is waning in Hispanic communities. Why is this so?What Causes the Immigrant Advantage?Studies have documented similar health advantages with African11 and Italian12 immigrants to the United States, Turkish immigrants to Germany,13 and immigrants from several regions to Canada.14 Most of the work on such advantages, however, has focused on U.S. immigrants from Mexico and Central and South America. Researchers have extensively studied the phenomenon in different generations of immigrants; approximately one-third of the U.S. Hispanic population is foreign-born.15The selective migration (or healthy migrant) advantage is one of the most well-supported hypotheses behind the paradox.16–18 Beatriz Tapia, assistant dean of faculty development at the University of Texas Rio Grande Valley Medical School, explains that Hispanic immigrants typically fall into one of two groups. Immigrants with visas tend to have higher education and income levels and are more likely to return to their home country. Those without visas, on the other hand, tend to be both hardy enough to take on hard jobs and invested in the goal of creating a better life in the United States.19 "People [who] migrate are going to be stronger, healthier, and younger," Tapia says. "Sick people either won't come or they'll die trying."First-generation immigrants—those who themselves came to the United States—are generally healthiest when they first arrive. By the second generation, their health status and mortality decline to rates that are much closer to U.S.-born individuals.19 One possible explanation is that toward the end of their lives, many older immigrants return to their home country, which reduces Hispanic mortality statistics in the United States.20 However, this explanation does not completely explain the mortality advantage of U.S. Hispanic populations.20,21In research published in 2013,22 Andrew Fenelon, an assistant professor of public policy and sociology at Pennsylvania State University, identified a single factor that may explain a substantial amount of the Hispanic health advantage: smoking, or the lack thereof. "A lot of Latino immigrants to the United States, especially folks from Mexico, have very low rates of cigarette smoking, compared to native-born U.S. White individuals," he explains. Those who smoke tend to smoke less, even after arriving in the United States. Fenelon posits that this could be due to differences between immigrants' home and U.S. cultures, or even to the relative costliness of cigarettes in Mexico.22 In his 2013 analysis,22 which was based on data from the National Health Interview Survey (NHIS), Fenelon estimated that at least half, and in some cases more than 70%, of the mortality advantage among Mexican Americans could be attributed to differential smoking levels between them and non-Hispanic White people.Another major explanation proposed for the mortality advantage involves familism, or strong social and family networks, which is a core value for many Hispanic families.23–25 According to Karina Corona, a postdoctoral scholar at the University of Southern California (USC), people who highly value familism tend to prioritize family over self. "Familism emphasizes the strong attachment that people build with each other," she says, "how they identify not only with the nuclear family, but also with extended family."Research supports the protective role of familism in Hispanic immigrant health. "In a new place, people will try to recreate that family feeling even if family members are not near," says environmental health professor Ana Navas-Acien. "You can easily see it in New York City through the public parks, how large 'families' meet every weekend just to spend time together." Image: © Getty Images/Al Bello.Corona found in one study that Hispanic Americans with high levels of familism reported better physical health, less loneliness, and less depression.26 Interestingly, the same study found Asian Americans and European Americans also saw a stress-buffering effect of familism, although familism was overall more prevalent among Asian Americans than European Americans. A separate study by Corona found that Hispanic mothers and daughters with high stress levels but also high levels of familism reported better self-esteem and subjective health compared with those who reported high stress but low familism.27"Hispanic people are not experiencing less stress than others," says Fernando Riosmena, director of the Institute for Health Disparities Research at the University of Texas at San Antonio. "However, they seem to be protected from that stress to some extent by living in places closer to family and friends."28Living in gateway cities—those with established immigrant populations—has also been thought to contribute to Hispanic populations' health and mortality advantage,29 particularly via familism. However, new research casts doubt on this hypothesis.29 Using NHIS data on Mexican immigrants specifically, Fenelon and colleagues found the mortality advantage was stronger in destinations with smaller enclaves of Mexican immigrants or areas that had more recently begun to receive these populations. One reason, he surmises, is that smaller, newer immigrant communities probably have fewer generations that have adopted less healthful U.S. dietary and lifestyle choices, compared with more established communities in gateway cities.It is important to note that some destinations may be new for one nationality but long-time gateways for others. In Miami, for example, the Hispanic population is more than half Cuban, with relatively few Mexicans, whereas in Los Angeles–Long Beach the vast majority is Mexican; other cities have majorities of Puerto Ricans, Salvadorans, or other nationalities.30 These distinctions emphasize the need for epidemiologists to break down the monolithic "Hispanic" population designation into finer categories, such as national origin, length of time in the United States, and age."It's very important to make the distinction that this is not a single group," says Ana Navas-Acien, a professor of environmental health at Columbia University. She says Hispanics tend to identify strongly with their country of origin, which affects culture, diet, and other aspects of their lives in the United States. Indeed, quite striking disparities in health outcomes have been documented between Hispanic immigrants with different birth countries, age, and immigration experience.31Research on Hispanic PopulationsAs with most other immigrant groups,32 U.S. Hispanic populations overall have less access to health care, more economic disadvantage, and more severe environmental and occupational exposures, compared with non-Hispanic Whites.33–35 The authors of a recent review published in Environmental Health Perspectives noted that environmental health is an understudied area among immigrants, with little research beyond the documentation of exposure disparities.32This girl, dressed as a popular character from the carnaval tradition of Baranquilla, Colombia, is participating in Feria de las Flores (Flower Festival) in New York City. This festival is celebrated each year by the Colombian community in Queens, recreating an iconic event of the same name in Medellín, Colombia. Although immigrant communities often have higher-than-average exposures to environmental pollutants, there is evidence that strong cultural identity has a protective effect on health. Image: © Kike Calvo/AP Images.Now, several important cohort studies are investigating how environmental exposures disproportionately harm Hispanic populations. The Mexican Immigration to California: Agricultural Safety and Acculturation (MICASA) prospective study investigates health in Hispanic farmworkers ranging from respiratory health36 to injuries.37 The Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS)38 longitudinal study is following children of Mexican farmworkers and their environmental exposures. The Maternal and Developmental Risks from Environmental and Social Stressors (MADRES) longitudinal study of more than 900 lower-income Hispanic women and their children is looking at key maternal health and child health outcomes through 5 years of age."Despite [Hispanic populations] having lower overall mortality, there are a number of adverse health outcomes that are among the highest in this group, especially among children,"39 says Tracy Bastain, director of the MADRES Center for Environmental Health Disparities at USC. "Our center was initiated on the premise that air pollution exposures are disproportionately higher in communities with predominantly Hispanic/Latino residents and that these residents also have the highest rates of childhood obesity."Air pollution and other environmental exposures are also being addressed in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), which examines the prevalence and development primarily of cardiovascular disease in Hispanic people, the role of acculturation, and risk factors that play protective or harmful roles. One HCHS/SOL ancillary project, SOLAir, involves understanding how air pollution affects diabetes risk in the populations of four locations: Miami, San Diego, Chicago, and the Bronx; another ancillary study focuses on how greenspace affects diabetes risk in San Diego and Miami.Two other studies under HCHS/SOL are examining how greenspace and sedentary behaviors influence metabolic health. "These studies enhance the environmental assessments of the cohort," says Carmen Isasi, coprincipal investigator at the HCHS/SOL Bronx field office and chair of the HCHS/SOL steering committee. "Together with rich assessments of social determinants of health, we will be able to address environmental influences from a broad perspective, that includes structural social factors, air pollution, and the built environment." This comprehensive approach, she says, is critical to understand health inequities.In addition to air pollution, Hispanic communities—along with other people of color—are also more likely to be exposed to drinking water contaminants, such as uranium, chromium, and arsenic.40–42 Both cadmium and arsenic have been linked to kidney disease,43 a health condition for which Hispanic individuals (particularly those from Puerto Rico44) have worse outcomes than non-Hispanic White people.45,46 Navas-Acien, along with lead author Anne Nigra, an assistant professor at Columbia University, recently showed that U.S. community water systems serving semi-urban areas with higher Hispanic populations were the most likely to exceed the U.S. Environmental Protection Agency maximum contaminant level for arsenic, even as other systems were actively working to reduce arsenic levels.42 In another study, their team found that systems serving semi-urban Hispanic communities were among those most likely to exceed the maximum contaminant levels for uranium, chromium, barium, and selenium.41 Their latest study, which examined metals in drinking water at the county population level, further demonstrates the exposure disparities that Hispanic communities face.40Other harmful exposures can come with the jobs that Hispanic workers often take on. Physically demanding work with long hours, including agriculture and construction, is often accompanied by exposures to extreme heat, pesticides, and disease vectors, such as ticks and mosquitoes.47,48 Hispanic women comprise a large part of the housekeeping workforce, which exposes them to hazardous cleaning chemicals for long periods of time.47–49 These physical demands and harmful exposures may partly explain why, in the United States, Hispanic individuals experience higher levels of physical disability50,51 and likelihood of dying on the job52,53 than non-Hispanic White workers.Employment in frontline jobs with little freedom to isolate or take time off meant that Hispanic workers bore a high burden of death and illness during the COVID-19 pandemic. Images, clockwise from top right: © iStock.com/davit85; iStock.com/Ivan Aaragon Alonso; © iStock.com/andresr; © iStock.com/gorodenkoff.However, few studies have directly connected their findings with the Hispanic paradox paradigm, and the area is ripe for dedicated research. For example, if Hispanic populations had the environmental advantages of non-Hispanic White populations, what would their health status look like? By reducing harmful environmental exposures, would later generations of U.S. Hispanic residents live longer, like their immigrant parents and grandparents? Because so many of the health conditions for which Hispanic populations have an advantage over non-Hispanic White populations—certain cancers,54 cardiovascular disease,55 and infant mortality56—have strong environmental health components, where is their advantage coming from, and can it be extended instead of diminished?Paradox Lost?Some researchers are projecting that the Hispanic paradox may become a thing of the past. For example, work conducted by USC postdoctoral scholar Luis Maldonado57 using nationally representative data from 1988 to 1994 suggested that children born in Mexico had much lower obesity rates than Mexican-origin children born in the United States, but the pattern changed when he used data from 2005 to 2014, when foreign- and U.S.-born Mexican children had equivalent levels of obesity. This shift has real potential to alter health and mortality estimates for Hispanic populations in the future.58,59This shift was the subject of another study, which assessed obesity rates as birth cohorts from the 1970s and 1980s aged, with modeled future trends suggesting the paradox may be lost.60 "Our big question was whether [the rise in] obesity is going to erode the paradox," says Michelle Frisco, a Pennsylvania State University professor of sociology and demography. "As obesity is going up among Hispanic [individuals], especially men, we showed that the life expectancy advantage of U.S.-born Hispanic men over U.S.-born White men is likely to decline over time, and their life expectancy is going to look more similar."Frisco adds that her research was done pre-COVID, a disease that took an enormous toll on Hispanic adults61 due to the fact they often hold frontline worker jobs62 and are often less likely to seek out health care.63,64 "COVID took three years off life expectancy for Hispanic people," she says, "and nobody's done any comprehensive analysis of what that's going to do to the paradox."65Understanding Hispanic populations' health and mortality advantages largely relies on projections and studies using past data, which are rapidly changing. "I think it's hazardous to apply old data to the present-day situation. A lot of these studies often go back to the 1980s or 1990s," says Robert Kaplan, the other coprincipal investigator of the Bronx HCHS/SOL team. "There have been enormous technological developments in terms of lifestyle, conveniences, food production, occupations, and livelihoods. So in order to understand the needs of our present-day population, you need new data."Navas-Acien points again to the crucial need for disaggregated data. "Sometimes when you use general statistics, people's race or ethnic status might not be well identified, and you might end up reaching conclusions which are not true," she says. Navas-Acien gives the example of cardiovascular disease among American Indians/Alaska Natives: "For a long time, it was believed they have a lower burden of cardiovascular disease [than other racial and ethnic groups]," she says. "However, that was totally wrong; it was just based on statistics that were incorrect." (In fact, cardiovascular disease is the leading cause of death among this population.66)Shedding light on the unique aspects of Hispanic populations' health can only help our nation reckon with its history of environmental racism and disproportionate exposures for people of color. Ultimately, a better understanding will give policy makers information to implement meaningful change. "Environmental health has a really important role to play in understanding not just the Hispanic paradox," says Fenelon, "but what policy should do about health for Hispanic people in the United States."Wendee Nicole is an award-winning science writer based in San Diego. Her work has appeared in Nature, Scientific American, and other publications.References1. Arias E, Kochanek KD, Anderson RN. 2015. How does cause of death contribute to the Hispanic mortality advantage in the United States?NCHS Data Brief no. 221. https://www.cdc.gov/nchs/products/databriefs/db221.htm [accessed 29 December 2022]. 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