DATA POINTS TO AN EMERGING PROBLEM
- Mexican-Americans born in the United States have higher rates of depression and phobias than those born in Mexico.
- Hispanics represent nearly 25% of the population without health insurance.
- By the year 2025 Arizona will gain 1.2 million persons of Hispanic origin.
The U.S. behavioral healthcare system, with its maze of insurance and eligibility requirements, specialist referrals, consent forms, deductibles and other seemingly endless red tape, can be difficult for anybody to navigate; for Latino immigrants, whose health literacy may be fairly low to begin with, it can be almost impossible.
"They don't understand what people are trying to do for them," according to William Vega, Ph.D., "and if it will cost them money, they're unlikely to do it." That's also true for people who are already in behavioral health care, he added. "It's difficult to keep people in care, and to keep them compliant and adherent."
Vega's remarks came during his presentation, Trends in the Behavioral Health Status Among Latinos in the United States, delivered at the ABHP Summer Institute in Sedona in July 2005. As Director of Research at the Behavioral Research and Training Institute, University of Medicine and Dentistry of New Jersey, and Emeritus Professor of Public Health at the University of California, Berkeley, Vega has been studying those trends for more than a decade, and the trends are down, notwithstanding the present protection afforded by the so-called Latino Paradox.
LATINO PARADOX EXPLAINED
The Latino Paradox holds that Latinos are currently healthier than they should be, according to most conventional yardsticks. Despite a host of risk factors - lower incomes, lower educational levels, higher rates of obesity, higher-density living arrangements - which should make them less healthy than the average American, the exact opposite is true. In all indicators - physical health, mental health, and substance abuse - Latinos, especially immigrants, enjoy substantially better health than the overall U.S. population.
For starters, Latinos as a group enjoy lower mortality from any cause: 35% less for heart disease, 43% less for cancer, 25% less for stroke. And that's despite the aforementioned concerns about diet and obesity. Less well known is that Latinos enjoy similar comparative advantages in mental and behavioral health, Vega said.
Of course, that's not saying much. The U.S. has some of the highest rates in the world of behavioral health problems. Vega listed a variety of countries - among them Italy, Spain, France, Germany, and various nations in South America and Africa - which all enjoy far lower prevalence of psychiatric disorders and substance abuse than the U.S. Furthermore, he added, if anyone does have a psychiatric disorder problem, it's usually far more serious in the United States, perhaps seven or eight times more likely to be disabling from a standpoint of social functioning.
"It's a danger to your health and mental health to come to this country," Vega warned, not entirely tongue-in-cheek.
CULTURE TRUMPS GENETICS
The experience of first-generation Latino women with dual diagnosis illustrates the dynamics of the Latino Paradox. In the U.S., it's accepted as a "given" that 70-80% of people with schizophrenia or bipolar disorder will also abuse alcohol or drugs. "We assume that's a natural state of being with these disorders," Vega explained. By way of contrast, in Mexico there are almost zero rates of alcohol or drug dependence among women, 0.1% and 0.4%, respectively. "Culture is pre-empting the development of dual diagnosis in Latin American societies, "Vega observed.
Vega, W. (2005). "Trends in the behavioral health status among Latinos in the U.S.- A call for action," 2005 Summer Institute, Sedona, Arizona.
Culture can trump genetics. Behavioral health problems and addiction are not triggered by any one factor, such as a gene disorder, but rather involve complex metabolism, as well as interaction with the environment. Inheritability rarely rises to 50%, and never rises above 50% for any substance abuse problem. "Ultimately, it's the controlling norms of culture that can pre-empt a genetic predisposition to vulnerability," Vega explained.
The cultural protection consists chiefly of what Vega described as "social capital," which can include personal resources, the ability to form relationships, religious networks, other social and emotional support, and family cohesiveness. Latinos place a tremendously high value on family cohesiveness and solidarity, he explained. "They feel good about their families and proud of them, which provides an added measure of protection against potential behavioral health and addiction problems." Other factors that can work in their favor include employment, mobility, and realistic expectations.
Use of the native language, in this case Spanish, can be viewed as a barometer of acculturation or assimilation, and thus can indicate the extent to which the cultural protections are still in effect. "It's obvious that language is a proxy for something," Vega mused. "It could possibly even be one single thing, such as social interaction. It's not magic or voodoo, but it attests to the emotional and material support available in those networks."
LOSING THE PROTECTION
The problem is that the protection doesn't last. As immigrants become assimilated into the mainstream U.S. culture and lifestyle, their incidence of mental illness and substance abuse increases "fantastically," Vega said. In the case of the aforementioned Latino women with non-existent substance abuse and behavioral health problems, when they immigrate to the U.S., these problems escalate enormously over time and generations.
Vega, W. (2005). "Trends in the behavioral health status among Latinos in the U.S.- A call for action," 2005 Summer Institute, Sedona, Arizona.
"It's eight to 15 times higher, and that's just in the first generation," Vega pointed out. "Obviously, you can conclude that those individuals who develop problems have some pre-disposition. The bottom line, though, is that in Mexico, that potentiality was not unleashed, and here it is."
As acculturation takes its toll on their well-being, Latinos as a group will have to contend not only with the added burdens of a language barrier, lower incomes, and lower educational levels, but with a variety of new, unfamiliar challenges such as family instability, Vega continued. After two generations in the U.S., the percentage of Latino children who have both parents residing at home drops from 80%, which is also the norm for families of European origin, to 60%, the norm for disadvantaged families. Family disruptions and conflicts such as divorces impact Latino immigrants more severely than native-born U.S. citizens.
"It looks like the re-fortification of the underclass," Vega warned. "That's why it's imperative to build social policies that really work, and at the same time, to recognize emerging opportunities to make changes."
The stakes are high for helping Latinos to navigate the behavioral health system. By the year 2050, they will total about 108 million people, comprising 25% of the total U.S. population. Trends and changes in their health status will hold profound implications, not just for Latinos themselves, but for the entire U.S. behavioral healthcare system and society as a whole.
Therein lies an additional consideration for policy makers, leaders and service providers who seek to enhance services to this growing population, Vega added. Noting that 40% of all Latinos are younger than 21 years of age, while Caucasians are collectively growing older, he observed, "It's obvious who's going to be paying the bill for Social Security, and it's important that they have the education and economic mobility to pay for it."
In closing, Vega pointed to what he termed a "whole range of cultural issues," such as the behavioral health care system's need for more widespread delivery of bilingual services and intervention. "That's why we need cultural competence," he concluded.