Borrell and Markides 2024

Hispanic Paradox (origin)

First described by Markides and Coreil in the mid-1980s. Hispanic/Latino people (mostly Mexican Americans in the Southwest) had health outcomes more similar to non-Hispanic whites than to non-Hispanic Black people, despite sharing socioeconomic characteristics much closer to non-Hispanic Black people.

Health Outcomes Supporting the Hispanic Paradox

Better outcomes in: infant mortality, overall life expectancy, adult all-cause mortality, cardiovascular disease mortality, cancer mortality, and functional health. In 2019, Hispanics had lower age-adjusted death rates for all causes (523.8), heart disease (111.3), and cancer (105.6) than both non-Hispanic Black and White people.

Hispanic Life Expectancy vs. Other Groups (2019/2020)

Hispanic life expectancy: 81.9 years — higher than non-Hispanic White (78.8) and non-Hispanic Black (74.8). Even during COVID-19 in 2020, Hispanics (78.8 years) outlived non-Hispanic White (77.8) and Black (72.8) people, continuing to support the paradox.

Hispanic Infant Mortality vs. Other Groups

Rate of infant death for Hispanic women: 4.9/1000 live births — close to non-Hispanic White women (4.6) and much lower than non-Hispanic Black women (10.7). Within Hispanic subgroups: Cuban infants (3.9) lowest, Puerto Rican (5.6) highest.

Hispanic Population Size and Growth

As of 2022, Hispanics = ~63.7 million, or 19% of the US population. This represents 77% growth since 1980 (14.5 million). Fastest-growing subgroups (2010–2021): Venezuelan (169%), Dominican Republic (60%), Guatemalan (60%), Honduran (54%). Mexican-origin population had the smallest increase (13%).

Heterogeneity of the Hispanic Population

Hispanics self-identify as coming from at least 19 countries in Latin America and the Caribbean. They vary in: country of origin, nativity status, immigration patterns, language proficiency, educational attainment, and racial self-identification. This diversity challenges treating them as a monolithic group.

Racial Self-Identification Among Hispanics (2020 Census)

Most Hispanics identified as "Some Other Race" (42.2%), followed by White (20.3%), American Indian/Alaska Native (2.4%), and Black (1.9%). Racial self-identification varies by country of origin: Argentinians (32%) most likely to identify as White; Panamanians (17%) and Dominicans/Puerto Ricans (6%) most likely to identify as Black.

SES Profile of Hispanic Population

Hispanics are younger, have lower educational attainment, and are less likely to have health insurance than both non-Hispanic Black and White people. Median household income and poverty levels are worse than non-Hispanic Whites but better than non-Hispanic Black people. Within Hispanics, Mexican Americans have the lowest SES and insurance rates.

Explanations for the Hispanic Paradox

Multiple proposed explanations (may act independently or jointly): cultural practices, family support/familism, healthy or selective immigrant (healthy migrant) effect, healthy dietary habits, acculturation, genetic factors, ethnic enclaves, salmon bias, and death misclassification. No single explanation is conclusively supported.

Healthy Migrant Effect

Most Hispanic immigrants arrive in better health than the native population of their home country, because migration is demanding and selects for healthier individuals. However, early immigrant waves were mostly younger, health-selected men; recent waves include people across the lifespan with varying health statuses, potentially weakening this effect.

Salmon Bias (Hispanic Paradox context)

Some immigrants return to their country of origin when seriously ill or near death, artificially lowering measured mortality rates in the US for this group. This is a data artifact that may partly explain the apparent health advantage. Agreements with origin countries are needed to capture deaths occurring outside the US.

Acculturation and the Hispanic Paradox

Acculturation (adopting host country culture) can have both positive and negative health effects. Negatively, it may erode protective Hispanic traditions like familism and respect for elders, lead to adoption of unhealthy behaviors (e.g., increased obesity prevalence), and expose immigrants to the stresses of xenophobia and racial discrimination.

Familism

A core cultural value among Hispanic families emphasizing strong family support and ties. It serves as a pillar of social support and is associated with better health outcomes. Acculturation may erode familism, with negative implications for the health of infants and older adults.

Indigeneity and the Hispanic Paradox

As of 2010, ~45 million Indigenous people lived in Central and South America across 800+ groups. Indigeneity (culture, norms, language, traditional knowledge pre-colonization) may provide health-protective benefits contributing to the paradox. However, this is often lost when Hispanic Indigenous people are asked to identify only as "Hispanic" in surveys.

Acculturation's Health Paradox

Immigrants may arrive healthy but over time adopt unhealthy behaviors (e.g., poorer diet), leading to convergence with host country health patterns. Critics argue that acculturation frameworks ignore the stress of immigration itself, including xenophobia, discrimination, harsh socioeconomic conditions, and substandard medical care.

Shift from Immigration to Births as Hispanic Population Growth Driver

Before 2000, Hispanic population growth was driven primarily by immigration. After 2000, growth shifted to US-born newborns. This means the healthy migrant effect may disappear over time, potentially eroding the health advantages that have sustained the Hispanic paradox for 40 years.

Xenophobia, Anti-Immigrant Policies, and Health

States with structural xenophobia (anti-immigrant laws, e.g., Georgia and Alabama) create unwelcoming contexts that harm immigrant health. Evidence links anti-immigrant rhetoric and policies to: higher emergency department use, mental health problems and chronic pain in children, and lower satisfaction with health care among Hispanic adults.

Sanctuary Cities and Hispanic Health

Living in a sanctuary city may buffer Hispanic people against harmful immigration policies, regardless of legal status. Evidence suggests Hispanic adolescents and adults in sanctuary cities have better mental health than counterparts in non-sanctuary cities in California.

Ethnic Enclaves and Health

Neighborhoods with high proportions of Hispanic residents (ethnic enclaves) may mitigate stress from xenophobia and racial discrimination. Evidence suggests ethnic enclaves provide health advantages, particularly for older Hispanics, through social support, cultural familiarity, and shared resources.

Skin Color, Racial Discrimination, and Health Among Hispanics

Darker-skinned Hispanic people are more likely to self-identify as Black and to report discrimination (64% vs. 54% for lighter-skinned). They are also more likely to experience discrimination from other Hispanics (41% vs. 25%). This creates a "double jeopardy" — discrimination from non-Hispanic Black and White people AND from lighter-skinned Hispanics.

Data Challenges for the Hispanic Paradox

Key data limitations: (1) aggregate estimates may be driven by Mexican Americans (largest subgroup), masking within-group inequities; (2) salmon bias underestimates mortality; (3) race/ethnicity misclassification at death; (4) lack of disaggregated data by country of origin, nativity, and length of stay. Better data linkage and international agreements are needed.

Hispanic Representation in Genomics Research

Despite comprising 19% of the US population, Hispanics represent less than 0.5% of genomics research participants. This underrepresentation limits understanding of socio-epigenetics and gene-environment interactions related to discrimination. The All of Us Research Program offers an opportunity to address this gap.

Future of the Hispanic Paradox (Borrell & Markides 2024)

The health advantage is at risk of disappearing due to: shrinking and acculturating Mexican American population, changing immigrant demographics (older, less healthy newcomers), erosion of protective cultural practices, growing xenophobia, and a shift from immigration to US births as the growth driver. Granular, disaggregated data collection is urgently needed.

Policy Implication: Need for Disaggregated Hispanic Data

Treating Hispanics as a homogeneous group masks significant within-group health inequities. Researchers and policymakers must collect data disaggregated by country of origin, nativity status, length of US residence, racial self-identification, and language proficiency. A similar approach is needed for other groups treated as monolithic (e.g., Asian Americans).