Jonah Garcia is a social worker with what may be one of the toughest gigs in the country.
Garcia is a program director at La Clinica de Familia Doña Ana Healthy Start in the U.S.-Mexico border community of Las Cruces, N.M., where she helps mothers deliver healthy babies. In the county the program serves, about 5 percent of children arrive after their mothers have received no prenatal care, according to an agency report.
A little more than half of the children born in the county have mothers who have not graduated from high school, and the median income there was just $35,541 last year, according to Census data. That combination of low income and little formal education creates what many public health experts would describe as the conditions for elevated infant mortality. But in Doña Ana County, the number of children who die before age one is lower than the national average. And in the 11 years that Garcia's program has worked with some of the county's highest-risk cases, she says just one client's child has died.
"I'd like to say that we just work darn hard," said Garcia.
In the United States, the prevailing wisdom is that people with better education and higher incomes have better health. But when it comes to several key indicators such as infant mortality and longevity, Latinos in the United States defy this paradigm. A researcher first uncovered the phenomenon, sometimes called the Latino Health Paradox, 25 years ago. Nearly three decades later, the concept and its potential causes remain largely unknown to the general public and the subject of very limited research.
The Latino health paradox might hold some answers about health and effective health care for the entire population, but some public health advocates and researchers think that information has instead been obscured by immigration politics.
"As soon as you start talking about Latino birth outcomes and infant mortality then you have people start screaming about anchor babies," said David Hayes-Bautista, a professor of medicine and director of the Center for the Study of Latino Health and Culture at the UCLA School of Medicine. "There are all these knee-jerk reactions about Latinos that lead too many people to equate the whole group with the illegal and undocumented. Once that happens we miss out on what could be some very useful information."
Hayes-Bautista points to the debate over President Obama's health care reform package, much of which focused on the question of health insurance coverage for undocumented immigrants and the possibility that they might strain or drain the nation's health care resources. What ultimately passed was a law that created a waiting period for all immigrants and banned adult undocumented immigrants from reaping any of the reform's benefits. Yet almost no one was talking about the fact that Latinos, on average, use fewer health care services than other populations, Hayes-Bautista said, or that immigrants -- documented and some undocumented -- also pay income taxes.
"What health insurance pool doesn't need healthy people who won't require or seek a lot of services?" Hayes-Bautista said. "Everybody is wringing their hands about health care costs, and the [Latino health] paradox and some of its implications for cost savings, for efficiencies, aren't even considered."
Hayes-Bautista said Latinos' positive health profile is likely due to cultural, rather than genetic, factors. That means there may be things that other Americans could do to "Latinize," and have healthier babies or live longer lives, he said.
WHAT THE DATA SHOW
In October, the National Center for Health Statistics published its first report that included distinct average lifespan measures for white, black and Latino Americans. What it revealed was so surprising that it merited a story in the Wall Street Journal. Latinos -- despite reporting lower-than-average income and education -- had the nation's longest average lifespan. On average, Latinos outlive white Americans by 2.5 years and black Americans by nearly 8 years.
But the exact reasons why are unknown because Latino longevity hasn't been widely researched, said Hayes-Bautista.
Infant mortality has received a bit more attention than lifespan because the data has long been available, and because the United States' infant mortality rate ranking is 177th in the world, worse than the United Kingdom, Slovenia and Monaco.
Nationally, the white infant mortality rate was 5.6 per 1,000 births in 2007, the most recent year for which data are available. White Americans also have the nation's highest average income and education levels, markers usually associated with good health.
Average Latino education and income levels are closer to those of African Americans. But the difference between the infant mortality rate for most Latinos (Puerto Ricans are the exception) and the black rate is vast. There were 5.5 per 1,000 Latino infants born in 2007 who died before their first birthday. That same year, 13.3 per 1,000 black children died in their first year.
When the Doña Ana County clinic staff analyzed their highest-risk clients' files a few years ago, they found one of the few things they had in common was a high level of social isolation or a weak support network. Garcia said the clinic staff now try to recreate the kinds of bonds that are common in Latino families. The agency set up low-tech social networks -- the kind where people talk face-to-face about their life challenges, potential solutions and learn about various aspects of child, reproductive or women's health.
"I don't want to call it a support group, but it almost is," said Garcia. "Sometimes they bring the food and do like a pot luck. Sometimes we provide the food. But what we really do is try to facilitate those social connections in addition to providing access to medical care."
In 2007, 5 children per 1,000 born in Doña Ana County died before the age of one. Nationally, about 6 of all children per 1,000 born died before their first birthday.
But of the $326 million in infant mortality and low birth rate research funded by the National Institutes of Health in 2010, none of the study descriptions indicate that the causes of the Latino health paradox are being examined, nor are theories about its causes tested against other populations. NIH is the nation's largest public research funder.
Representatives of NIH's Office of Minority Health were not available to comment on the agency's funding priorities.
"In this country, we do set research agendas through a combination of public interest, political responsiveness and scientific interest," said Arthur Caplan, director of the University of Pennsylvania's Center for Bioethics. "It's a dance between all those things."
Caplan questions the existence of the Latino health paradox because of the difficulty defining who is and who is not Latino. But he does not question the idea that public sentiment may have limited the amount of research on Latino health that has followed since the idea was first put forward in the 1980s.
That lack of research could be a function of many things, Caplain said: There is no celebrity face or powerful interest group calling for research; there may not be any money-making opportunities that can come from what research may show; Latinos do not have a particularly large presence in the geographic areas where most medical research is conducted.
Caplan added the combination of public sentiment about immigrants and some lawmakers' assumptions about what share of the population consists of undocumented immigrants might also limit pressure to fund more research.
MORE RESEARCH NEEDED
Back in the early 1980s, Kyriakos Markides, a Cypress-born researcher and doctor was working in South Texas and noticed something interesting. There was a high number of Mexican Americans in the area -- particularly first-generation Mexican-American immigrants -- who lived long lives despite having some of the lowest incomes and education levels in the country. By 1986, Markides and his research partners had the data to support his observation. Markides called it the Hispanic Epidemiological Paradox.
"We went out on a limb," said Markides, who is now a professor of aging studies at the University of Texas Medical Branch in Galveston. "This was contrary to all the thinking about health at the time."
In the early years, questions about the veracity of the paradox were common, Markides said. Some centered around problems related to how often Latinos may be misclassified as white, black or some other ethnicity in health data.
Others suggested more fantastic explanations, such as the idea that Latino average life expectancy might be inflated by large numbers of ill Hispanic immigrants returning to their home countries to die. These deaths would then not be recorded in the United States. On the other end, there was also a theory that large numbers of Latino immigrant mothers gave birth in the United States then returned to their home countries with in the first month after birth -- the period at which children are at the greatest risk of death. Any resulting deaths were likewise simply not recorded in the United States.
Just last year, a new study was published questioning the existence of the paradox. It found that Latinos disproportionately suffer from certain diseases. But it did not examine infant mortality or life spans.
Markides did add a caveat to his notion of the paradox: "You always run the risk that people who do hear about what we found will walk away with too rosy a picture."
The nation's Latinos may be living long lives, but Latinos aren't keeping pace with the decline in disability during old age that is happening in the rest of the population, Markides said. Diabetes and late-in-life cognitive impairment are also more common among Latinos than the general population, he said.
And the positive aspects of Latino birth and death data decline and then disappear among Latinos whose families have lived in the United States for several generations. "This suggests, that there may be some aspect of culture," at workon health outcomes, said Markides.
Medical research into the Latino health paradox has remained limited. But some social scientists have taken an interest, Markides said.
A number of demographers who study birth death and other important life statistics have found that both the number of elderly immigrants returning to their home countries to die and the number of mothers who do the same with newborns are not large enough to sufficiently explain the Latino Health Paradox.
In a forthcoming study, Dan Powers, a University of Texas demographer, found that the mortality rate among infants born to Mexican-immigrant and Mexican-American women under age 25 -- who on average have both low incomes and limited education -- falls below that of infants born to white women in the same age range. But that Latino health advantage seems to disappear among Mexican-immigrant and Mexican-American mothers over age 30.
"What that suggests is that the lower overall infant mortality that we observe may be due to [the fact that] the bulk of the child bearing among Mexican Americans takes place primarily among younger, healthier women," said Powers.
That is big news in a country where nearly 15 percent of children are born to mothers over age 35. An important area for future research will be to understand why younger women of Mexican origin have such positive birth outcomes. That could provide important clues about how to reduce white and black infant mortality in the United States, Powers said.