In 2000, the question, “Is this person Spanish/Hispanic/Latino?” emerged on the U.S. census, grouping these populations for the first time on a national scale. Prior to this, there was no consistent or comprehensive way to collect data on the Hispanic/Latino community, making it difficult to understand their demographics, needs, and trends. This question provided policymakers, researchers, and community organizations with data to make informed decisions regarding education, health care, employment, and social services. The merger may have had unintended consequences on population health studies that were likely not accounted for.
Health surveys often follow the same trend of fitting multiple people into a single box. Doing so can make data collection and analysis more efficient, avoids the challenges of defining and classifying the diversity of ethnic groups, and reduces the risks of discrimination and stigmatization of specific groups. However, this approach also has significant limitations and drawbacks. The 2000 census’s unifying classification implies that “All Hispanics/Latinos are the same,” which is not even remotely true. The term “Latino” is typically given to a person with origins from Latin America (Mexico, Central, and South America) and the Caribbean. “But they all speak Spanish.” Are we forgetting about Portuguese-speaking Brazilians? “Hispanics” refers to a person with ancestry from a country whose primary language is Spanish, including Spanish-speaking Latin America and Spain. When people from multiple ethnicities are grouped into a single box, it can lead to cultural erasure and obscure important differences about the unique cultural and social factors contributing to health outcomes.
The Hispanic Paradox, first coined by Kyriakos Markides in 1986, referred to the paradoxical phenomenon that despite facing significant socioeconomic challenges, Hispanics in the U.S. live longer than non-Hispanic whites. Today, this is also known as the Latino Epidemiological Paradox. In 2015, the Centers for Disease Control and Prevention (CDC) Vital Signs report found the same conclusion as Dr. Markides, Hispanics in the U.S. had a 24% lower all-cause mortality than their non-Hispanic white counterparts, with lower risk for nine of the fifteen leading causes of death, including cancer and heart disease.
While the Latino Epidemiological Paradox may seem like good news, it is essential to remember that it is not universal. The same CDC Vital Signs report found that Hispanics had a higher prevalence of diabetes mellitus and obesity and higher mortality from diabetes than non-Hispanic whites. Moreover, as more extensive databases are being compiled with more minority participants being included (Hispanics/Latinos, too), new studies emerge, refuting the validity of the paradox. A recent study used the All of Us Research Program database. It included more than 40,000 self-reported Hispanic/Latino people and found age-adjusted cardiovascular disease rates to be significantly higher amongst this population than non-Hispanic whites. This begs the question, “So do Hispanics/Latinos have better health status, or do they not?” This study does not debunk the decades-long mystery, but it certainly provides a strong counterpunch.
“All Hispanics and Latinos enjoy this health benefit.” Even as a naïve teenager, I would have contested this point. Growing up Cuban-American in Miami, the “Capital of Latin America,” I would go to friends’ houses, who were from various countries in Latin America, and notice similarities in their families to mine: we spoke Spanish at home, and our families immigrated in pursuit of the American Dream. However, in many ways, the similarities stopped there. The food we ate, our alcohol consumption and tobacco usage, and our families’ physical activity levels were all different. There are irrefutable cultural distinctions between a family from Spain and a Dominican or Nicaraguan, or Venezuelan family.
Previously there was a paucity of robust data to effectively stratify Hispanic/Latino health outcomes by country of origin. For instance, the widely used National Health and Nutrition Examination Survey (NHANES) classifies Hispanics into two subgroups, “Mexican American” and “Other Hispanics.” This discrepancy can lead to inaccurate conclusions and false overgeneralizations about the health status of these “Other Hispanics.” New study cohorts, however, may allow us to have a more nuanced discussion in the years to come. For example, the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) created a cohort of 16,415 Hispanic/Latino participants from four large metropolitan cities with sufficient power to analyze health metrics by country of origin. One study using HCHS/SOL found diabetes mellitus prevalence significantly differed by Hispanic background: South Americans (10.2%), Cubans (13.4%), Central Americans (17.7%), Dominicans (18.1%), Puerto Ricans (18.1%), and Mexicans (18.3%).
Recognizing that cultural variations in health risk factors among different Hispanics/Latinos may contribute to differences in chronic disease prevalence and health outcomes may be the tip of the iceberg. Failing to acknowledge these differences can lead to inaccurate and incomplete data, resulting in unnoticed and unaddressed health disparities. Using a one-size-fits-all approach may not be practical for everyone and can have severe consequences for public health policy and resource allocation. Moreover, these vast generalities can mislead practitioners when evaluating individual patients. As a health care provider, the community you practice in will determine the type of patients you will encounter, with practitioners in Miami, New York City, Chicago, Los Angeles, Dallas, and so forth, caring for different Hispanics/Latinos.
Therefore, a lack of better subgroup data can lead to a lack of cultural sensitivity and competency in health care delivery and an inability to appropriately apply the available data to the population you serve.
While the mortality benefit for Hispanics/Latinos may still hold true today, the increasing rates of diabetes mellitus and obesity disproportionately affecting Hispanics/Latinos may soon close the gap. We must shift our focus from applauding Hispanics/Latinos for defying what we know about the social determinants of health to instead putting our efforts into studying the differences in health outcomes by the Hispanic/Latino country of origin. The framework and make-up of each community’s Hispanic/Latino population vary across the U.S. Thus, having Hispanic/Latino subgroup data would help inform individual community-based intervention and disease prevention strategies, and ultimately allow health care providers to personalize care, account for ethnic distinctions in risk behaviors and disease prevalence, and reduce health disparities.
Matthew B. Alonso is a medical student.
