By: Yeeun Lee
Numerous studies have shown that lower-income and education status leads to poor health, which is why socioeconomic status is one of the major determinants of health. Studies have also shown that the Hispanic community often struggles with lower pay and educational attainment, yet their healthcare outcomes continue to surpass their higher socioeconomic counterparts, non-Hispanic whites. This contradicting phenomenon has been widely studied. In 1986, Kyriakos Markides, a sociologist at the University of Maine, coined the term “Hispanic (or Latino) paradox.” The term refers to how despite having less access to healthcare and generally being from lower socioeconomic status, Hispanics in the United States live longer than non-Hispanic whites.
In 2015, the Centers for Disease Control and Prevalence (CDC) published a report on the status of Hispanic health that supported Markides’ paradox. Hispanics had “a 24% lower risk of all-cause mortality and lower risks of nine of the leading 15 causes of death in the USA (notably, cancer and heart disease).” The report also showed the low insurance rates among the Hispanic population: over 40% reported being uninsured. There were variations in risk behavior and disease prevalence depending on where they were from as well as whether or not they were born in the United States.  While the scientific community has established that Hispanics have better health outcomes than their white counterparts, the reason we see this phenomenon is still widely debated.
There have been several theories as to why Hispanics in the United States have better health outcomes despite having fewer resources. For instance, Markides believed that Hispanic culture and its tight-knit communities offer not only social benefits but also protective health effects. Additionally, he suspected that Hispanic immigrants that recently moved to the United States had healthy behaviors such as smoking and drinking less than other populations.
However, other researchers have offered different explanations. A reason that was often cited before was the “salmon bias.” That is, the selective return of less-healthy individuals to their home countries, which could lead to underrepresentation in US death certificates. Another theory often discussed alongside the salmon bias, the “healthy-migrant hypothesis”, that states that the differences seen in immigrants is due to healthier individuals migrating to the United States. Over the years, both theories have been disproved in different studies.
A study in 1999 first disproved the salmon bias and the healthy migrant hypothesis for the case of the Hispanic Paradox. First, the study conducted analyses with and without Puerto Ricans and Cubans. For Puerto Ricans, neither hypotheses applies because deaths in Puerto Rico are included in US mortality statistics. For Cubans, the theories do not apply because “Cuba is not easily accessible, and the political conditions that prompted Cubans to migrate still exist, making return migration unappealing.” Still, Puerto Ricans and Cubans had lower mortality rates than their non-Latino white counterparts.
Then, the study looked at over 300,000 non-Latino Whites and Latino Whites and it separated them between foreign-born and US-born individuals to conduct an analysis. Both US and foreign-born Latinos had lower mortality rates than US and foreign-born non-Latino Whites. When looking at US-born vs. foreign-born individuals, both foreign-born Latinos and foreign-born non-Latino Whites had lower mortality rates than US-born whites. The study states, “the salmon bias hypothesis would be tenable for the results only if a proximity clause were added, stating that foreign-born Latinos engage in return migration because their homelands are closer to the United States than those of non-Latino White immigrants.” The healthy migrant hypothesis does not apply because foreign-born Latinos had lower mortality rates than foreign-born whites.
Another study conducted in 2010 looked at death certificates in the United States from 1979 to 1998 “to estimate the sensitivity, specificity, and net ascertainment of Hispanic ethnicity on death certificates compared with survey classifications.” The authors of the study concluded that the reporting of Hispanic origin on death certificates was reasonably good and that the Hispanic mortality paradox could not be due to misclassification of ethnicity in registration data systems. Thus, miscounting and misclassification are not factors that contribute to the Hispanic paradox.
Nonetheless, there are several factors that influence the health outcomes seen amongst Hispanics such as Hispanic subgroups, documentation and/or insurance status, and age of arrival and/or total time spent in the United States. Distinguishing between different ethnicities is important because death rates and smoking habits vary widely between Hispanic subgroups. Even the loss of protective factors based on changes in culture-driven behavior and social networks change between subgroups. Hence, belonging to one subgroup as opposed to another can drastically change one’s health outcomes.
Furthermore, documentation and insurance status also affects a person’s health. In the United States, Hispanics are more uninsured than any other racial and ethnic group. Within Hispanics, the undocumented and uninsured have less access to care, which worsens their health outcomes. The uninsured also “suffer disproportionately from substance abuse and mental health problems.”
In addition, the age at which a person arrives in the United States and the amount of time they have spent in the United States also influences a person’s health outcomes. The age at which a person arrives in the US is a significant factor as younger immigrants have better health outcomes in the long-run compared to middle-aged or elderly individuals. However, this does not apply to mental and drug conditions, as these affect adolescent populations in a disproportionately. Also, the protective effects of the paradox seem to erode the longer a person is exposed to the US culture, environment, and stressors.
As a whole, Hispanics do have better mortality outcomes than their other racial and ethnic counterparts in the United States. Nonetheless, the CDC report mentioned above also stated that Hispanics have higher rates of obesity and are much more likely to die from homicide, diabetes, hypertension, and renal disease than whites. The report does not mention mental health, which other studies have shown to be worse amongst Hispanics compared to other populations.
What’s more, Dr. Mikel Llanes, a professor at the University of Michigan Medical School, pointed out that measuring when people die is not equivalent to measuring their quality of life. Dr. Llanes said that the conditions in which Hispanics have the worst outcomes “represent sources of significant hardship and disparity faced by Latinos and also warrant greater attention.” For instance, Hispanics dying at higher rates due to homicide is suggestive of them living in more dangerous and unstable communities compared to the general US population.
Nevertheless, the CDC report is not the only source that fails to address quality of life. While there are several definitions of quality of life, the World Health Organization (WHO) defines it as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns.”
In 2018, The Washington Post published a report stating that “the number of legal immigrants from Latin America who access public health services and enroll in federally subsidized insurance plans” dropped because, given the changes in immigration laws in the United States, they feared their information was going to be used against them when deporting their relatives. The numerous barriers that Hispanics face today that affect their quality of life and thus their health are not taken into account when thinking of the “Hispanic paradox.”
Certainly, the Hispanic paradox is intriguing. But how long someone lives is not the same as how well that person has lived. When discussing the Hispanic paradox, taking into account that Hispanics are more likely to die from homicide, suffer from obesity, and experience mental health issues is crucial. Perhaps shifting the focus from why Hispanics live longer to how services can help improve and meet the needs of the Hispanic population is the better question to ask.
References The Lancet. (2015). The Hispanic paradox. The Lancet, 385(9981), 1918. Doi: 10.1016/s0140-6736(15)60945-x
 Abraído-Lanza, A. F., Dohrenwend, B. P., Ng-Mak, D. S., & Turner, J. B. (1999). The Latino mortality paradox: a test of the “salmon bias” and healthy migrant hypotheses. American journal of public health, 89(10), 1543–1548. https://doi.org/10.2105/ajph.89.10.1543
 Arias, E., Eschbach, K., Schauman, W. S., Backlund, E. L., & Sorlie, P. D. (2010). The Hispanic Mortality Advantage and Ethnic Misclassification on US Death Certificates. American Journal of Public Health, 100(S1). doi: 10.2105/ajph.2008.135863
 Teruya, S. A., & Bazargan-Hejazi, S. (2013). The Immigrant and Hispanic Paradoxes: A Systematic Review of Their Predictions and Effects. Hispanic journal of behavioral sciences, 35(4), 486–509. https://doi.org/10.1177/0739986313499004