THE EPIDEMIOLOGICAL CONTRADICTION IN LATINAS' HEALTH OUTCOMES:
FACT OR FICTION?

May 2001

Written By
W. Azul La Luz
Sociology Department
Ph.D. Student
University of New Mexico
Albuquerque, NM

TABLE OF CONTENT

ABSTRACT

INTRODUCTION
                     Why Study Latinas?            Paucity Of Research            How the Paper is Organized

THEORETICAL PERSPECTIVE
                      Historical Perspective        Medicine In Latin America         Theoretical Grounding
                      Epidemiology and Social Epidemiology In the United States         Epidemiological Paradox
                      Bringing It Home To the United States        The Heart of the Matter        To Summarize

IDENTIFYING THE TARGET GROUP
                       Who Are These Latinas and Latinos?
                                Table One: Latina and Latino population in the USA, 2000
                                Table Two: National Distribution of Latinas and Latinos, 1999
                                Table Three: States with the Highest Concentrations of Latinas and Latinas, 1999
                       Latinas
                                Table Four: Latinas In the United States, 1995 TO 2000
                       Disaggregation
                       Whetting the Senses: Latinas in Prison

LATINAS' EPIDEMIOLOGICAL PARADOX
                      All Against Speak Now
                                 In Opposition: Stroke 
                                 In Opposition: Diabetes
                                 In Opposition: Cancer
                                 In Opposition: Physical Disability 
                                 In Opposition: Health Insurance and Access
                        All in Favor Speak Now
                                 In Favor: Heart Disease 
                                 In Favor: Mother and Child Outcomes
                                 In Favor: Mental Health 
                                 In Favor: Cancer
                                 In Favor: Culture Confianza
                        A Qualitative Example
                        In Summary

TOWARDS A METHODOLOGY
                        Future Direction

APPENDIX

BIBLIOGRAPHY
                        Web Citations

ABSTRACT

This paper explores the so called, "epidemiological paradox or contradiction" associated with Latina health outcomes in the United States. It explores the difference between medicine in the United States versus social medicine in Latin America. A historical materialist approach is explored through social medicine to explain the epidemiological paradox (EP) for Latinas in the United States. A new hypothesis is set forth which states that the EP is a mis-interpretation of Latinas historical reality, as an intersection of class, gender, race, and politics. In this new framework, the risk factors that supposedly make the EP a medical and social fact for Latinas the United States, are rendered irrelevant when used to analyze the Latina condition in the United States. Social Medicine methodologies are introduced. Specific future research is suggested that uses the social medicine methodologies to test the hypothesis.

INTRODUCTION

        Until recently, as a Human Geographer and Medical Sociologist indoctrinated in the dominant medical framework of the United States, I had viewed health and illness as separate states: Static, linear functions of an individual's or a society's location in relationship to time, place, and circumstance enveloped in social equilibrium and value balances. That is, as a function of individual determinates - pathogen ingestion and weak constitutions - and social control - hierarchical medical functionalism - imperatives with distinct latent and manifest ideological patterns whose ultimate aim was the beneficent elimination of disease and the altruistic betterment of life generally. I have come to see things a great deal differently over the course of my lately acquired formal education.
        This paper is about Latinas. It is also about health and illness. It looks at the current health controversy surrounding Latinas, namely the so called "epidemiological paradox," (Fuentes-Afflick, Hessol and Perez-Stable, 1999; Cervantes, 1996; Hayes-Bautista, Beazconde-Garbanati, Schink, and Hayes-Bautista, 1994). This paper frames the new hypothesis that predicts that when analyzed from a social medicine perspective, there is no epidemiological paradox (EP) for Latinas in the United States. Instead, what is in process in the EP is a confirmation of a particular social contradiction as predicted by Marx and Engels, as elucidated by others. Namely, health and illness outcomes must be viewed through historical context and analyzed through social science epidemiology methodologies. (Waitzkin, 2000; Breihl, 1995; Laurell, 1989).

Why Study Latinas?
        Latinas in the United States are a large and unique ethnic group (1) that bear critical research. Why should research about Latinas be done? I submit that there are, at very least, four important reasons.

Of the four reasons, one might think that the last one by itself would merit research about Latina.

Paucity Of Research
        Despite the population size of Latinas in the United States, their relatively large numbers have not engender adequate academic curiosity leading to substantial scholarly research. Research into Latina issues is a relatively new phenomenon in the United States. Serious and rigorous research on Latinas as a distinct sociological group, appears to have begun in the early 1980's (Sorensen and Siegle, 1992). Latinas have been virtually non-existent historically in the health literature in the United States before then.
        The paucity of rigorous (or even soft) research in all the social sciences with regards to all aspect of Latinas' lives is appalling. What small amount there is mostly surrounds birthing, and much of the research is contradictory (Cofer, 2000; Hogue, et al, 2000; Lambety and Coll, 1994). It is as if Latinas were only a human reproductive system.
        Them Latinas' situation in the United Sates cries out for new and varied research, particularly epidemiological research from a social medical perspective. This paper is an attempt to begin a narrative in that direction.
 

How the Paper is Organized
        In the next section, Theoretical Perspective, presents a theoretical framework grounded in social medicine. It includes a strictly abbreviated and interpretive, outline of the modern history of medicine in the United States and Latin America. It also includes a dialogue on epidemiology generally, and specifically relative to social medicine and Latinas.
        Some characteristics of Latinas are laid-out in the third section, Identifying the Target Group. There is no attempt to flesh-out who the Latinas are in the United States, their place of origins, or variations in culture. Nor is there any qualitative or quantitative accounting of risk factors. These are accepted as given for all the studies. The analyses of both these topics will be necessary in a more exhaustive treatment of the Latina issues, such as my dissertation.
        The fourth section, Latinas' EP, is divided into two subsections. The first subsection examines some postulated theories and research that has either attempted to disprove or prove that an EP exist with regards to Latinas. This section is not meant to be definitive. The section merely attempts to demonstrate some of the confusion and controversy surrounding the issue. The second subsection gives a qualitative example of one Latina's life which I believe epitomizes the Latinas EP in the United States.
        The last section discusses and concludes the paper with an eye towards a methodology that may be used to test the hypothesis presented: the EP is an irrelevant misinterpretation of political, social, and class factors.

THEORETICAL PERSPECTIVE

        Since the beginning of my formal education, I have had a certain uneasiness toward the underpinning ideologies presented as unifactorial, positivistic, dominant medical paradigms. Nonetheless, I had acquiesced to the prevailing "wisdom" that we individually contracted disease and were cared for through munificent institutionalized structures. That is, the "I" got sick, and the benevolent "they," the designated altruistic healers, "cured" us. Sometimes, whole groups of "I's" become ill because we contracted some morbidity agent which necessitated the healers to perform their magic through mass "scientific" cures (Waitzkin, 2000; Starr, 1949). My uneasiness has steadily grown until it has become full blown suspicion of hegemonic medical paradigms in the United States.
        I realize now that this uneasiness and suspicion stemmed from my personal primordial inculcation. My mother was a "curandera," a healer. From her monologues as we breast fed, to her advise to those that came through our doors at all hours, she taught us that illness and health are inseparable, that they are continually influx: we become ill or heal ourselves through and with others, in conjunction with our total environment.
        However, in my search for "scientific" truths, I forgot her teachings. I have only recently begun to re-examine the dominant medical position through lenses of historical collective health or social medicine (3) as proposed throughout Latin American countries such as Chile, Argentina, Brazil, and Ecuador, and others ( Waitzkin, Iriart, Estrada, and Lamadrid, 2001; Waitzkin 2000).
        At this juncture, it is important to examine briefly how the United States and Latin America have came to this point in history with relationship to illness and health ideologies.

Historical Perspective
        The illness sciences in the United States have followed, with minor deviations, the same linear capitalistic movement as the rest of the "manifest" market expansion through ideological legitimation. In the early to mid nineteenth century social medicine, chiropractic, and homeopathy, were all part of the nascent medical fabric in the United States. However, all these gave way to the capitalistic pressures of the market place and the ruling medical colleges, namely John Hopkins.
        As a direct consequence of the Flexner Report (1907) (which posited unproven universities) John Hopkins University, under the auspices and encouragement of the Rockerfella Foundation, consolidated the power of the unifactorial, disease model (Waitzkin, 2000).
        The American Medical Association (AMA) consolidated its powers with the help of the elite coming from Harvard and John Hopkins universities and established its hegemonic roll by the early 1900's. By 1920, the AMA had established national codification of board certification and state licensing through its state elite-dominated branches. Concurrently, market expansion encouraged exclusivity and congregating medical practices into large growing urban areas. Further, as a direct consequence of the facility afforded by cars and telephones, a"sovereign professional" class was created and firmly entrenched by the middle of the twentieth century (Starr, 1949).
        The medical establishment's entrenchment has dominated until today with medicalization of virtually every aspect of life. An excellent example of medicalization is human reproduction. Before medicalization of the birthing process, there was prestige for midwives, and curanderas who were almost entirely women - I helped my mother deliver several babies with very little or no problems. After medicalization, the entire reproduction process became the total domain of mostly male doctors. Every aspect of human reproduction has been medicalized from fertilization to feeding the new born (Freund and McGuire, 1999). Every aspect of a women's reproductive cycle, from menstruation to menopause have become the province of mostly male doctors. As a consequence, female processes are described in terms of illness while men's are described in terms of virility and robustness (Reagan and Willis, 2000).
        With the advent of the human "rights" movements of the 1950's an1960's - civil, prisoners's, sexual, women's, - there has been some concession to social factors, such as race and ethnicity (Fanion, 1963) and work stress and status (Jackal, 1977; Karasek and Theorell; Freund, 1982, 1990, 1998). However, the "medical industrial complex" still dominates. This is evident in the proliferation and exportation of health management organizations (Relman, 1980; Iriart, Merhy, Waitzkin, 2001).
        There is currently even a conservative movement to eliminate the little progress that has been made in the area of social determinates, civil and other rights: gains in human rights are viewed as invasion of the medical kingdom by the serfs (Satel, 2000).

Medicine In Latin America
        In Latin America the medical story developed much differently than in the United States. The mid Nineteenth Century to the early Twentieth Century saw the inception of hegemonic medicine in the United States, with a concomitant suppression of all other forms of medical thought. At the same time, in Latin America social medicine saw its inception and nourishment.
        The foundations of social medicine in Latin America came directly from pathologist such as Max Westenhofer who studied in Germany primarily under Rudolph Virchow. Some credit is also given also to Eugenio Espejo, a Spain Physician, who independently came with similar conclusion as Virchow. Nonetheless,Virchow, a Germany pathologist, whose multifactorial analysis of health and disease concatenating poverty and communicable diseases, such as typhus, is given much of the credit for being the father of social medicine in Latina America (Waitzkin, 2000).
        Virchow was intimately familiar with the pioneering work of Fredick Engels with regard to Engels' investigation of living quarter conditions and factory related disease causation, such as the relationship between tuberculosis and typhus and socioeconomic and environmental factors. Building on Engels' work, Virchow engendered the notion that pathology responds to constitutive change in society and thus, he birthed social medicine (Waitzkin, et al, 2001; Waitzkin, 2000).
        Virchow defined the new field as "social science," a term still used today in Latin America. He presented compelling statistical data and observation on pathology to buttress his arguments. These observations and significant investigations were extremely influential, to the point that his work, along with his political activism, were instrumental in the Germany reform movements that in 1848 brought about a revolution (Waitzkin, et al, 2001; Waitzkin, 2000).
        In Latin America, directly influenced by Virchow's, and later by Liberation Theology, Empowerment Education, and a number of other educational and grass roots initiatives, social medicine blossomed from the late Nineteenth Century to the present day. Admittedly there have been periods of intermittent repression by the state, particularly in the 1960's and 1970's, in many countries including Argentina, Brazil, and Chile. Despite these periodic setbacks, there have been many influential figures that have contributed to social medicine in Latin America. Such people as Luis Emillio Recabarren, Salvador Allende, Juan César Garcia, María Isabel Rodriguez in Chile; Juan B. Justo, in Argentina; Ernesto "Che" Guevara, in Cuba and elsewhere in Latin America; Pablo Arturo Suárez, and Ricardo Paredes in Ecuador; Camilo Torres in Colombia; and Frei Betto in Brazil.
        Currently, there are a number of progressive groups in Latin America based in Argentina, Brazil, Chile, Ecuador, and Mexico who continue to propagate and fight using social medicine as a tool for the progress of the labor class (Waitzkin, et al, 200).

Theoretical Grounding
        Unlike Unitedstatian medicine, a particular aspect of social medicine is its grounding in theory. Its research and methodologies are a direct result of its theoretical perspective, and in turn hone its theory by continuously reevaluating in light of application outcomes (Waitzkin, Iriart, Estrada, and Lamadrid, 2001; Waitzkin, 2000, Breilh, 1995; Laurell 1989).
        In the United States the dominant singular view is that germs and other pathogens cause disease, and as such disease is an individualistic causation and cure model. This view prevails even when dealing with the effect of epidemics on myriad individuals. This unifactorial view is in direct contrast to social medicine. Social medicine espouses the theoretical view that one of the most important cause of illness and health are the "material conditions of people's everyday lives... [and] ... an effective health-care system cannot limit itself to treating the pathophysiologic disturbances of individual patients." Effective development of health-care systems must encompass basal changes in economic, political, and social conditions (Waitzkin, 2000, 38).
        Also in sharp contrast to social medicine is the Unitedstatian (4) market driven, individualistic technocratic, therapies and the antithetical epidemiological approach, whether clinical or social. In contrast, social medicine epidemiology embraces a methodology that is life encompassing and historical (Breilh, 1995; Laurell, 1989). This is explained in more detail in the section to follow.

Epidemiology and Social Epidemiology In the United States
        In the United States, epidemiology is the art of projecting incidence and prevalence of illness events over a given period of time and for a specific population of individuals. Social epidemiology is the particular ideologies that form the Unitedstatian health sciences' underpinnings of human illness (Lupton, 2000; Armstrong, 2000), and which are used as one of the primary control methods of dominant medical thought (Breilh, 1977; Laurell, 1989). The sociological dimension of health and illness interact with United States hegemonic medicine, or circumvent it altogether, depending on one's theoretical outlook. Various elements become important in the dominant epidemiological discourse, such as aging (Estes and Linkins, 2000), culture (Trotter, 2000), gender (Lane and Cibula, 2000), geographic landscape (Catalano and Pickett, 2000), and socioeconomic status (Robert and House, 2000), but in all cases, it is an individualized perspective.
        That is, Unitedstatian social epidemiology attempts to explain health and illness trends in groups and/or populations from the dominant social context regardless of the group it is researching. Further, it treats social factors as superficial at best, or takes then for granted as common sense (Laurell, 1989). An excellent description of this may be found in research on hypertension by Schnall and Kern (1986) in which they explain the failure of hegemonic medicine to provide adequate genesis for hypertension, and they provide an excellent historical analysis relating it to the stress of modern society.
        As such, from the prevailing and currently dominant medical framework in the United States, epidemiology is an indispensable tool of Public Health because it allows public health providers to intervene in individualistic illness progression or in designing prevention programs and interventions from a medical and social perspective (Lupton, 2000; Armstrong, 2000; Fairbanks and Wiese, 1998). For example, childhood inoculations, needle exchange programs for IV drug users, anti-drinking and driving campaigns, or prostitution licencing to prevent spread of STD through illegal prostitution. Epidemiology also helps public health providers to propagate good health habits: well baby clinics, nutrition fairs, breast cancer screening, hand washing campaigns generally, and particularly in handling food, etc. In truth, much that passes for medical improvement outcomes, turns out to be historical antecedents to the improvement: tuberculosis decline with societal improvement with little regard to medical advances (Waitzkin, 2001).

Epidemiological Paradox
        If grounded in theory, another avenue of discourse epidemiology provides the entire field of health and illness is "food for thought," equivalent to the purpose philosophy discharges relative to the "hard" sciences generally. Both Unitedstatian and in Latin America epidemiology seem to lead the way in health science by identify unusual phenomena. One such thought-provoking, and unusual epidemiological phenomenon is any EP: an a priori expected health or illness outcome that does not occur, and actually has an unexpected and/or opposite (or lower or higher) outcome than is predictable from the observable facts or variables.
        There is an EP surrounding health and illness, and other social elements to do with Latinas in the United States. Latinas exhibit excellent health and illness outcomes relative to AA women and EA women. This, despite alarming discrimination, predominate lower class status employment, and exhibition of other high risk factors that should lead to poor health outcomes. This has been termed the "epidemiological contradiction" or "epidemiological paradox" (Cervantes, 1996, p3). This EP has also been found in Latina's incarceration patterns (La Luz, 1997).

Bringing It Home To the United States
        From another perspective, what is more important to the collective health/illness analysis is a dialectic formed from historical materialism and social medicine. As such, the intersection of class, culture, gender, race, and politics, overarched by the means of production, are the epidemiological direction of social medicine. Therefore any analysis undertaken must take into account every aspect of the entire group being analyzed (Breilh, 1995; Laurell, 1989).
        Social medicine or collective health... postulates the necessity to analyze the health and disease phenomena in the context of the economic, political, and ideological process of society and not just as biological phenomena that concerns individuals..." (Laurell, 1989, 1183)
        When examined through the lenses of social medicine, there may not exist an EP in Latinas in the United States. While the EP, as presented, is controversial and unproven, it has come to be accepted as hegemonic medical ideology. Though, in point of fact, it has neither been completely demonstrated as a reality, nor completely disproved. I discuss this in more detail in the next section, when I review of some of the literature.
        However, to press on with the theoretical, if we accept, for the sake of argument, that the EP exists, it has been explained as a function of the Latina and Latino experience. However, it may actually be a generalized theoretical construct caused through a mis-interpretation of the facts from a functional medical perspective. Other explanations of the EP using dominant ideological social epidemiological constructs that have been offered are:

         However, from a social medicine point of view, it may be none of these. What may be at the root of the issue is a misunderstanding of Latinas vis a vis a historical perspective as explained through social medical analysis. I submit that when analyzed in a historical theoretical framework, the "risk factors" will be rendered non-descriptive on any health and illness outcomes with regard to Latinas because the risk factors become irrelevant. Laurell better articulates the essence of the argument for me about Latinas in the United States:
        "... to theorize the external and internal articulations of the process of health and disease, emphasizing that it is not only socially determined
        but has social character in itself. That is, they do not limit themselves to enunciate that the social processes determine a pattern of risk
        factors but try to understand the dynamic interrelations between the social and the biological conceiving, however, that the social subsumes
        the biological... this interrelationship cannot be reduced to a particular pattern of "risk factors", but has to be thought of in terms of the social
        process that transform the biological process in a more complex manner than a mere change in the probability of exposure to one or another risk
        factor" (emphasis mine, Laurell, 1989, 1185).

The Heart of the Matter
        It has been pre-supposed, a priori, by the dominate epidemiology, that Latinas evidence the same risk factors as the other females in the United States - EA and AA women. Even more important, it has been assumed that Latinas' health outcomes had the same relationship to these risk factors as do AA and EA. These risk factors defined by the Unitedstatian hegemonic medical/scientific establishment, are rendered meaningless with relationship to Latinas because the risk factors have been studied out of there respective collective historical dialectic: the intersection of production, reproduction, class and gender.
        For example, low paying, low status employment, is correlated with poor health outcomes in EA and AA (and even for acculturated Latinas). Employment of this type may be meaningless as a risk indicator of health outcomes for Latinas who are not acculturated to the Unitedstatian life styles. Employment that in the United States is considered low income and low status, may not be considered either by Latinas. Such "low status" employment, under different political, social, and class perspective may actually be prestigious and may provide a comparatively high standard of living, or quality of life wages not perceived as such by the dominant capitalistic culture.
        United States consumer status and reproduction mechanisms are closely tied to worker stratification and alienation. This may not be the case for first generation Latinas and Latinas living in enclave or colonias. In short, Latinas' health outcomes in the United States have been measured through a faulty hegemonic medical paradigm, instead of through their own collective self and group perception with its interrelation to all other ramifying factor of class, gender, race, and politics.
        A complete analysis and synthesis of these issues are far beyond the scope of this paper and will be fully constructed within my dissertation. However, an abbreviated directional overview of the main issues pro and con follows. This will be done with an eye towards the development of instruments that may be used in collective and individual interviews to gather the predictive data. Data that, I believe, will demonstrate that an EP only exist as it relates to the majority culture, but disappears when viewed from the Latina perspective.
        I do not fail to see the dangerousness of this argument. That is why, I hasten to add that even if my inferences are correct, it should not be used as a method of continuing to oppress and subjugate Latinas, particularly new arrivals to the United States. Instead we need to look at the salubrious side of the finding for replication and see how they eliminate social contradiction such as internalized racism, and reproduction.

To Summarize
        In short, social medicine's analytical tools have not been used much in the United States and are not well know. I posit that if we use the social science epidemiological approach to analyze the current controversy, the EP surrounding Latinas in the United States, the outcome of such an analysis would be, I believe, a totally new understanding of the Latinas' location in the United States stratification structure. The risk factors will cease to be such, transformed by the Latina's own world's view, into something far more insidious and dangerous.
 

IDENTIFYING THE TARGET GROUP

Who Are These Latinas and Latinos?
        Before exploring the risk factors and health and illness outcomes, it is necessary to write about who Latinas are in the United States. However, it was somewhat difficult to obtain accurate and exact numbers of Latinas as a distinct population subgroup. It is even more difficult to obtain disaggregate numbers of the Latina subgoups in the United States, namely, Mexican, Puerto Rican, Cuban, Dominicans, etc. I attempt to present a picture of Latinas and Latinos generally, then one about Latinas in particular as an extract from the numbers given.
        As may be seen in Table One below, according to the United States Census Bureau (2000), in 1999 Latinas and Latinos in the United States (USA)accounted for about 32.7 million people or about 11.7 percent of the entire population, excluding the United States colony of Puerto Rico. This 11.7 percent was made up of approximately 65.2% Mexican, 14.3% Central and South American, 9.6% Puerto Rican, 4.3% Cuban, and 6.6% other Latina and Latino peoples (US Census Bureau, 2000).

Table One: Latina and Latino population in the USA, 2000
 
Total and Disaggregate Total numbers Percentages
All Latinas and Latinos 35,305,818 11.70%
Mexican 23,019,393.34 65.20%
Central and South Americans 5,048,731.97 14.30%
Puerto Rican 3,389,358.53 9.60%
Cuban 1,518,150.17 4.30%
Other Latinas/Latinos Peoples 2,330,183.99 6.60%
Total 35,305,818.00 100.00%

(Original Table created from USA Census Bureau, April 2000)


Table Two: National Distribution of Latinas and Latinos, 1999
 
Region of the United States Latina and Latino Population Percentage
Totals 35,305,818 100.000%
Western States 15,340,503 43.450%
Southern States 11,586,696 32.818%
Northeast States 5,254,087 14.882%
Midwestern States 3,124,532 8.850%

(Original Table created from USA Census Bureau, April 2000)


        Table Two above shows the distribution of Latinas and Latinos by Geographic Region in the United States. Approximately 44% (13,983,000) of Latinas and Latinos lived in Western States, 33% (10,391,000) in the Southern States, 16% (4,909,000) in the Northwest States, and 8% (2,406,000)in the Midwest States.
        As may be seen in Table Three below, in 1999, which is the most recent Census Bureau offers in this regard, New Mexico was the state that had the highest concentration of Latinas and Latinos (where Hispanics constituted 40 percent of the total population). Following New Mexico were California with 31 percent, Texas with 29 percent, Arizona with 22 percent, figures that the USA Nevada with15 percent, and Colorado, Florida and New York with 14 percent (US Census Bureau, 1999).
        The majority of Latinas and Latinos live in rural or non-metropolitan areas. Of the numbers represented in Table One, Two and Three, some 52%, or about 16,484,000 million Latinas and Latinos in the United States live in rural or non-inner city areas. The other 48% (15,216,000) live in inner city areas of the USA (US Census Bureau, 2000, 1999).

Table Three: States with the Highest Concentrations of Latinas and Latinas, 1999
 
State Total Latina and Latino Population in State Percent of State Population
Arizona 1,056,011 22.10%
California 10,274,988 31.00%
Colorado 588,139 14.50%
Florida 2,266,687 15.00%
Nevada 287,671 15.90%
New Mexico 701,157 40.30%
New York 2,620,310 14.40%
Texas 5,953,110 29.70%

(Original Table created from USA Census Bureau, March 1999)
Latinas

As Table Four below shows, there are approximately 16.3 million Latinas in the United States. They are, as a population, relatively younger than EA women, and bear considerably morechildren within their fertility window (LatinMed.com, 2001). They are also a minority twice over: in the United States is here are less Latinas (16.3 million females) than there are Latinos (16.4 million males). All other peoples in the United States have more females than males. There has been no definitive answer for this fact. It is possible that this demographic fact is due to more Latinos than Latinas immigrating to the United States (La Luz, 1997), but that has not been definitively explained in any research.

Table Four: Latinas In the United States, 1995 TO 2000
 
HISPANIC ORIGIN (of any race) 2000 1999 1998 1997 1996 1995
Population 32,734 31,337 30,252 29,182 28,099 27,107
(Percent of total) 11.90% 11.50% 11.20% 10.90% 10.60% 10.30%
Male population 16,442 15,761 15,233 14,716 14,193 13,713
Female population 16,293 15,576 15,018 14,466 13,906 13,328
Female % of all Hispanics 49.774% 49.705% 49.643% 49.572% 49.489% 49.168%
Female % of all Females 11.558% 11.172% 10.865% 10.559% 10.246% 9.909%
Female % of entire population 5.907% 5.712% 5.557% 5.402% 5.243% 5.071%

(Original Table created from USA Census Bureau, February 2000)
Disaggregation
        Disaggreation in Sociology is defined as the separation of once distinct population grouping into separate groups. If there is controversy over the EP concerning Latinas, there is even more controversy over whether Latinas and Latinos constitute a distinct ethnic group that should be treated as a single group or as a disaggregate population (Aponte, 1995, 1991). This is a particularly important issue to some because of the political ramification of disaggregation. If one accepts the premise that Latinas and Latinos are not a distinct population, the power of a Machiavellian singularity appears: Divide and conquer.
        This paper is not the place to conduct an exhaustive argument on this very important issue. It is an argument that must be addressed before either controversy is solved. However, Martin Marger (1994) espoused the conventional sociological view that ethnic groups can be identified if they share five basic characteristics: Unique cultural traits, sense of community, ethnocentrism ascribed membership, and territoriality. It has been demonstrated that Mexican, Puerto Rican, Cubans, Dominicans, etc., in the United States share these five traits in common enough that they constitute a distinct ethnic group (La Luz, 1997). As such, I treat them as an discreet and distinct ethnic group in this paper.
 
Whetting the Senses: Latinas in Prison
        A curious fact directed the current research to this medical sociological avenue of looking at the EP in Latinas: Latinas were far less represented in prison populations from 1990 to 1994, in all geographical regions of the United States, and in all federal prisons, in comparison to the two other major ethnic groups in the United States- AA and EA women (La Luz, 1997). The risk factors that correlate highest with the incarceration of any ethnic group of either gender, is economic marginality; alternately called low socioeconomic status (Merlo and Pollock, 1995; Sohoni, 1994; Crites, 1976). The most dominant characteristics of economic marginality are: high poverty levels, high unemployment, high single-headed households, high non-marital pregnancy, low wages, and low educational attainment (Steffensmeier and Streifel, 1992; Applebome, 1989; Cole, 1989; Klein, 1979; Bresler and Leonard, 1978; Glick and Neto, 1977; Heffernan, 1972 ).
        Economic marginality is as high for Latinas, and in many cases higher, than either AA or EA populations in the same geographic areas. However, Latinas remain under-represented in the United States prison population. While this is a positive phenomenon, it is an EP since the cause of this beneficial outcome is not explainable by the risk factors that explain prison rates for the other large population, namely AA and EA women (La Luz, 1997). In an attempt to explain this incarceration anomaly, I researched other fields for my master's thesis.
        The literature concerning health outcomes for Latinas, vis a vis high risk factors, appears to imply that Latinas also exhibit the same EP with regards to health and illness outcomes (Cervantes, 1996; Hayes-Bautista, et al, 1994). That is, Latinas generally exhibit better health than other minority groups or approximately the same health outcomes as EA women. This, despite the fact that Latinas experience higher rates of poverty, lower educational attainment, and inadequate access to health insurance and health services. This paradox ostensibly seems to be explainable through cultural factors (La Luz,1997; Cervantes,1996; and Hayes-Bautista, Beazconde-Garnbanati, Schink, and Hayes-Bautista,1994).
        Other researches make similar contentions. A few of these will be explored below, but no attempt has been made to comprehensively review the entire literature on this topic. Neither has an attempt been made at an exhaustive methodological or statistical analysis here. That would be far beyond the scope of this particular paper. However, the articles presented are, I believe, representative of the controversy. Further, at this juncture, no attempt has been made to re-interpret the articles presented here through a social medical perspective.


 

LATINAS' EPIDEMIOLOGICAL PARADOX
        When I was doing the master's in Sociology, the seminal article that began my search in the direction of the EP was by Arturo Cervantes (1996) who is a physician and medical researcher affiliated with the Harvard School of Public Health. In this article, he expounds at length about the topic and list research findings in several areas spanning the years1985 to 1995, which to him evidence the Latina epidemiological phenomena. A sample of these are:
        "Compared to non-Hispanic populations, Latinos have: 1) a lower overall mortality rate, including lower mortality rates from cancer, cardiovascular disease, suicide, and chronic obstructive pulmonary disease (Sorlie et al, 1993); 2) low rates of low birth weight, neonatal mortality, postneonatal mortality and infant mortality (Becerra et al, 1991); 3) low levels of smoking among women, and for smokers, lower consumption (Marcus and Crane, 1985); 4) low risk of eating a poor diet, a higher average intake of protein, vitamins A and C, folic acid, and calcium (Guendelman and Abrams, 1995); 5) lower rates of crack cocaine smoking (Wagner-Echeagaray et al, 1994); 6) low levels of alcohol consumption (Black and Markides,1993); and 7) fewer sexual partners among women (Marin et al, 1993).
        Given that some of the material may be considered dated now, within the last year, I reviewed more than 200 journal abstracts specifically geared towards Latinas health and illness issues, from the various medical and sociological sources in the medical library on the UNM campus. This search yielded many related articles, but only four new articles specifically used the terms "epidemiological, contradiction or paradox" (Abraido-Lanza, Dohrenwend, NgMak, and Turner, 1999; Fuentes, et al, 1999; Flack, Amaro, Jenkins, Levy and Mixon, 1995; and Magana, 1995).
        Abraido-Lanza, et al (1999), tests the salmon hypotheses which basically says that Latinos have low rates of mortality, compared to other groups in the United States, because Latinos, like salmons, go home to die. "Home" being various countries of origin other than the United States. Abraido-Lanza, et al (1999) conclude that something else must be at work because the salmon explanation does not wash statistically. Fuentes-Afflick, et al (1999) conclude that "[t]he EP of LBW [low birth weight] in Latinos (sic) is valid." Flack, et al (1995) simply review some of the literature with respect to establishing an epidemiological benchmark for minorities to be used for future investigation. Magana (1995) subsumes the existence of the paradox, and attempts to explain it through the realm of religiosity, and states that the lack of research on Latina subgroups may lead to explanations of Latina's health status that are too simplistic and faulty.
        Beyond these four articles, most of the abstracts examined speak to the levels of incidence or prevalence of particular illness or health states in Latinas, but do not specifically speak to the issue of the EP. Therefore, with the exception of the articles that specifically use the terms "epidemiological paradox," the major thrust of this subsection will be implicit. Some of the articles that are germane by implication are explored.
        Additionally, the majority of articles detailing the EP concerned reproduction, child birth and birthing related outcomes. This is a curious fact: It is as if the sexual reproduction of Latinas were the most important facet of their being. Accordingly, many of the articles reviewed here have to do with birthing. However, every attempt has been made to included other sources of speculation.
        Lastly, confounding the entire issue is that most of the research articles are about Latina subgroups - Mexican, Puerto Rican, Cuban, etc. - without comparison with each other or to EA or AA groups. Additionally, there is a second dominant subculture with regard to Latinas: This dominant subgroup, although not dominant in numbers in the United States, is dominant in demeanor and expression over Latinas. It is Latinos. This is changing, slowly and gradually, but more through acculturation and the feminist movement than through maturation. Comparison with both Latinos and other Unitedstatian groups would be appropriate. Unfortunately, if the literature is limited with regard to Latinas in general, it is even more scarce with regards to prevalence of comparisons between Latinas and Latinos (Nakamura, 2000).
 
All Against Speak Now
        It is customary to begin with the opposition's point of view. Therefore, listed first are explanations of some of the illness and health issues that seem to indicate that the EP does not exit, or at best is a function of other sociological phenomenon such as SES.
 
In Opposition: Stroke
        Stroke is the third leading cause of death in adults in the United States. In New Mexico,
        death due to strokes in Latinas is greater than in EA women (Kattapong and Becker, 1996). Ignorance about factors leading to strokes, such as high blood pressure, lack of exercise, and poor eating habits, are just as high in Latinas as in EA in the United States (Kattapong, Longstrech, Kukull, Howard, Bowes, Wilson, Bigney and Becker, 1997). This latter article, which is a follow-up on the former, does not specify how the change in prevalence between Latinas and EA women has come about, nor does either article delineate if higher mortality is a function of higher numbers generally, or an issue of speedy access to care.

In Opposition: Diabetes
    Diabetes in Mexican-Americans is two to five times more prevalent than among other minorities in the U.S. Of the 30 million Latinas and Latinos in the United States in1998, some 1.2 million were diagnosed with diabetes, and it was estimated that as many as 675,000 went undiagnosed. Being overweight is a major risk factor for diabetes and Latinas and Latinos are more at risk for being overweight than EA in the United States (Flagg,1999; Hazuda, Haffner, Stem, and Eifler, 1988; Samet, Coultas, Howard, Skipper, and Hanis, 1988).

In Opposition: Cancer
        Latinas' five-year breast cancer survival rate (70%) is far worse than for EA women (84%). This is due in part to late diagnosis. Latinas tend to not seek medical attention until they present with severe symptoms (Flagg,1999). Additionally, comparison of records in New York City between 1969 to 1971 and 1979 to 1981 showed that Latinas born in the United States had higher rates of stomach and cervical cancer than EA women (Rosenwaike and Shai, 1986).
        In several other studies, Latinas of various ethnic subgroups - Columbian, Ecuadorian, Dominican, Mexican American, and Puerto Rican - were as likely as EA to develop breast cancer, were more likely to die of it, and were less likely to seek early diagnosis and treatment (Nazario, Figueroa-Vallés, Rosario, 2000; O'Malley, Kerner, Johnson and Mandelblatt, 1999; Laws and Mayo,1998).

In Opposition: Physical Disability
        The prevalence of functional limitation and disability were higher for Puerto Ricans and Dominicans in comparison to EA women in the same geographic area of Massachusetts in 1998. Women demonstrated more physical limitations than men, and that Puerto Rican and Dominican women demonstrated more limitations than EA women. Additionally, it was also noted in this study that Puerto Rican men demonstrated more disability than EA men ( Tucker, Falcon, Bianchi, Cacho, and Bermudez, 2000).
 
In Opposition: Health Insurance and Access
        Risk for chronic disease and injury among minorities vary both intra- and interstate. Contributing to this risk is low rates of health insurance and poor health care accessability. For example, Latinas and Latinos were more likely than EAs to report poor access to health care, such as no health-care coverage and cost as a barrier to obtaining health care. They were also more likely to report fair or poor health status - obesity, diabetes, and no leisure-time physical activity - than EA women(Bolen, Rhodes, Powell-Griner, Bland, and Holtzman, 2000).
        Approximately 93% of all people with diabetes have health insurance coverage of some kind - private (73%), medicare (58%), medicaid (15%), veterans (5%). Approximately 54% had multiple coverage. However, a much greater proportion of AA and EA had coverage than did Latinas and Latinos. This trend held true for all insurance coverage (Harris, 1999). In Arizona, Latinas and Latinos (26.2%) are twice as likely as EA (11.0%), to not have health insurance (Bolen, Rhodes, Powell-Griner , Bland, and Holtzman, 2000).

All in Favor Speak Now
        As mentioned above, a review of the literature revealed only a limited number of articles that spoke directly to the EP. Below are those that speak in favor of the issue, or which vacillate on the issue, through various types of illness and health topics.

In Favor: Heart Disease
        Where coronary and ischemic heart disease is concerned, Latina/o are substantially less at risk than either EAs or AAs:
        "While coronary heart disease is for Latinos, as other Americans the leading cause of death, the mortalities rates are much lower than Non-Hispanic whites. Comparative mortality rates per 100,000 for CHD, taken from the Analysis of Health Indicators for California's Minority Population exemplify variation among Latinos. Several studies verify lower cardiac mortality rates compared to non-Hispanic whites. Although risk profiles ( Type A personality, obesity, Diabetes, hyperlipidemia, hypertension, lack of exercise) are similar or unfavorable compared to non-Hispanic whites, Mexican-American men generally are less likely to have electrocardiographic evidence of myocardial infarction and exhibit ischemic mortality rates 20-25% lower than whites (LatinoMed.com, 2000).
        The CHD rates, normalized by 100,000, and for age, according to LatinoMed.com (2000) are as follow for: Mexican-American 88, Puerto Rican 94, Cuban American 92, EA 121, and AA 188. The difference is dramatic. It is posited that Latinas/os may have an unidentified protective factor which may be genetic (Diehl, 1989; Friis, 1981; Stern, M.P. 1985).

In Favor: Mother and Child Outcomes
        The greatest number of studies demonstrating some facet of the EP are studies to do with mother's good health, low use of illegal or harmful substances, and beneficial nutritional habits before and after birth, the low incidence of preterm births, and high birth weight (Fuentes-Afflick, et al, 1999). In most of these studies Latinas quit smoking, stop drinking alcohol, and stopped taking drugs during gestation (Schaffer, Velie, Shaw, Todoroff, 1998). Additionally, Latinas also had excellent health outcomes despite having inadequate, or no, conventional prenatal care (Higgins and Burton, 1996).
        High number of births, low birth weight and high infant mortality, are usually correlated with the mothers poor health or associated risk factors. Latinas have one of the highest birth rates among all women in the United States. Their birth rate, per 1,000 of women of reproductive age, is an average of 107; with about 116 for Mexican American, 90 Puerto Rican, 50 Cuban, and 107 for other South American women. This compares to about 64 for the general Unitedstatian population (Becerra, J.E,. 1991).
        Child bearing, then, appears to demonstrate the EP concerning Latinas. There appears to be an inverse correlation between low and moderate birth weight babies delivered to Latinas and the mother's prenatal care, as well as at-risk factor for poor birth outcomes - high unemployment, high single head of household status, high incidence of not having prenatal care, etc. (Hajat, Lucas, and Kingston, 2000; Fuentes-Attlick, et al, 1999; Higgins and Burton, 1996).
        Acculturation has been used as a measure of inverse proportion for the EP; the more acculturated the Latina, the worse the health outcomes (Balcazar and Krull, 1999). In an examination of 4,404 births to Mexican-born and United States-born Mexican Women it was found that foreign-born Latinas who spoke English at home appeared to exhibit better birth outcomes than United States born Latinas who spoke Spanish at home. This would seem to go against the usually held belief that the Latina's culture was the primary factor in the EP (English, Kharrazi, and Guendelman,1997).
        It was found that foreign-born Latinas who spoke English at home usually came from higher SES in their native country and they tended to adhere more closely to their root culture. United States-born Latinas who spoke Spanish at home tended to be from lower socioeconomic, rural areas in marginalized communities that had adopted poverty-driven risk behaviors such as subrosa barrio cultures (English, et al, 1997).

In Favor: Mental Health
        The National Institutes of Mental Health (NIMH) says prevalence of mental illness is estimated at about 20 percent of the U.S. population. That means millions are affected. This is an estimate from two epidemiologic sources: the Epidemiologic Catchment Area (ECA) study of the early 1980s and the National Co-morbidity Survey (NCS) of the early 1990s. The National Institute of Health (NIH) states, regarding epidemiological research for all ethnicities in the United States, and referring specifically to depressive states in Latinas subgroups, that "Prevalence information for other racial and ethnic groups is not definitive...." However, NIH also says that depression is less for EAs and Latinas/os than for Afro-American. NIH does NOT give incidence or prevalence. (National Institute of Health, 2000).
        In the United States, then, there are fewer Latinas exhibiting or reporting depression than other ethnicities - such as EA or AA women in the United States. Latinas report fewer incidences of depression, and/or seek out less assistance for depression from traditional medical service areas such as doctors, hospitals, mental health centers, or health clinics(Nakamura, 1999). If the prevalence level of depression in Latinas has an inverse proportion to risk factors for depression, as found Nakamura (1999), then the EP exists for depression also.
        By way of comparison with EA women, studies seem to support the EP: Latinas seem to evidence the same or less mental illness and depression than EA women. This may be due to cultural inculcation in Latinas and/or modes of release and expression through family and community. In Latinas, these modes of expression generally permit more and open communication than in the EA culture (Nakamura, 1999).
        As such, it would appear that an argument can be made for depression similar to the argument that is made in child bearing matters for Latinas: Latinas' culture may have a preventive or even curative component on these illnesses or medical situations.

In Favor: Cancer
        In direct opposition to the material presented concerning Latinas experiencing more cancers, the Cancer Foundation chart of cancer incidence from 1990 to 1997 (Appendix B) show that Latinas have lower rates of cancer (240.9 for all cancers)when standardized by 100,000 population, than either EA (352.4) or AA (337.4). The only higher instances were cancer of the cervix, where Latinas exhibit higher rates than both EA and AA: is in(15.4, 8.4, 11.7 respectively). Interestingly, Latinos also have a cancer rate which is much lower than either EA men or AA men.

In Favor: Culture Confianza
        For example, La Luz (1997) found that the outstanding preventive difference keeping Latinas out of prison was one of culture and community structure. Echoed over and over again throughout the literature, relative to the Latina and Latino community, was the solidarity engendered by the family-centered sense of community felt within the various Latina and Latino enclaves across the United States: confianza (La Luz, 1997). The sense of protectiveness and belonging led to a tightly knit network community structure. The confianza structure was reinforced by a very real sense of being, at best, marginal outside the barrios (Heyck; 1994, Castillo, 1995; Cervantes 1996; Gonsalez, 1996; Kanellos, 1997, 1994).
        The utter sense of trust and faith (confianza) in the family and by extension, along with confianza in the immediate community at large (reinforced by marginality) acted as a kind of insulation against the outside world. This confianza was built on unconditional family-centeredness, on the principal that children come first. That the family, children, and women (in that order) had to be protected at all costs from any and all threats and dangers, whether internal or external (Kanellos, 1997, 1994; Heyck, 1994; Cervantes, 1996; Hayes-Bautista, et al, 1994).
        Whether or not it is phenomenological cultural construct, or some other determinates that account for the EP, at least in prison rates and birth outcomes, remains to be conclusively determined. However, it is important that some definitive answers are found to address the needs of such a large population, a population that makes up more than five percent of the entire population of the United States.
        Others have said, that there is need to design research that will test the theory that it is socioeconomic status rather than race or gender that is really at work (Nakamura, 1999; Holzer, Swanson, Shea, 1999; Knight, Virdin, Ocampo, and Roosa, 1994; Weissman, Bruce, Leaf, Florio, and Holzer, 1991).

A Qualitative Example
        The issue has been examined pro and con, though admittedly not exhaustively, through published research articles. It is fruitful now to introduce a qualitative example of the EP.
        Marcia,  a descended of Senegalese slaves, Caribe Indians, Spanish invaders, and several other ethnicities, was a typical Puertorriquena. In essence, a Latina. She lived in poverty most of her life. She worked at home, in New York City, taking care and raising seven children, and several grand children in the Latina/o tradition.
        Marcia was very proud of the fact that as a young women in Puerto Rico, she worked as a maid in the Caribe Hilton in San Juan. She also worked rolling cigars, and cutting sugar cane, but the job she always bragged about was the maid's job at the Caribe Hilton. She believed that it was an honor to have been permitted in to such an opulent place to work. It was prestigious and lucrative employment to her.
        Outside of the usual and customary mild diseases - flues, colds and childhood diseases - she was not seriously ill until her late sixties. From all I have read, Marcia's experience with the health system in the United States, is typical of what Latinas have suffered here (Cofer, 2000; Hogue, Hargrave, and Collins, 2000; Bayne-Smith, 1996; Lambety and Coll, 1994). She suffered a great deal of discrimination. Three examples will suffice to illustrate the point:

        It would appear that Latinas suffer racism in every aspect of their being. Specifically with regard to health and illness issues, Latinas have inadequate access to health insurance, health screening and health care generally. When they do get health care it is ersatz (Cofer, 2000; Hogue, et al, 2000; Lambety and Coll, 1994), as my mother's experiences illustrates.
        Perhaps more importantly, when viewed through a social medical prism, Marcia's life exemplifies a type of synthesis of the social contradiction created by class and gender in the Unitedstatian dominant culture. Employment that would be considered menial, low status, and to some in the UNited States, embarrassing, Marcia found rewarding, validating, and lucrative. Much of her life reflects this non-Unitedstatian synthesis. I submit that if research is conducted within this framework, most unaculturated Latinas will fit this or a very similar portrait.

In Summary
        An attempt has been made to illustrate qualitatively the so called EP. Also research was presented on both side of the argument. As such, according to the literature present against the EP, Latinas have a higher incidence and prevalence of cancer, diabetes, obesity, stroke, high blood pressure, and physical disability, than do EA women (Nazario, et al, 2000; Tucker, et al, 2000; Flagg, 1999;O'Malley, et al, 1999; Law, et al, 1998; Kattapong, et al, 1996; Kattapong, et al, 1997; Hazuda, et al, 1988; Samet, et al, 1988). Latinas also have poor access to health services and insurance coverage which contributes to the former (Bolen, et al, 2000). These conclusions would certainly seem to put the lie to the EP. Or do they?
        On the other side of the argument, Cervantes' (1996) findings directly conflict with others for such processes as cancer, diabetes, obesity, stroke, high blood pressure, and abusing drug related behaviors. His finding also buttress the other findings about Latinas appearing to exhibit excellent birth outcomes despite high risk factors and adverse environmental conditions, and they present less mental health problems and depression in particular, than EA women (Hajat, et al, 2000; Namamura, 2000; National Institutes of Health, 2000; Balcazar, et al, 1999; Fuentes-Afflick, et al, 1999; Schaffer, et al, 1998;English, et al, 1997; La Luz, 1997; Higgins, et al, 1996; Guendelman and Abrams, 1995; Wagner-Echeagaray et al, 1994; Marin et al, 1993; Markides,1993; Sorlie et al, 1993; Becerra et al, 1991; Marcus and Crane, 1985). The Cancer Foundation also weighs in on the side of the EP by showing in their charts that over a 9 year period (1990 to 1997, inclusively) that Latinas had with only one exception, lower rates of cancer than either EA or AA women.
        The findings in favor of the EP seem to contradict those that are against it. A new hypothesis based on qualitative analysis, quantitative research, and a social medical framework, will demonstrate the fallacy of the epidemiological arguments pro and con.

TOWARDS A METHODOLOGY

        The purpose of this paper has been to explore the possibility that, when view from a social medicine perspective, the so called epidemiological paradox in Latinas in the United States, is a fallacy created through the use of risk factors that are meaningless in the interpretation of Latinas health and illness. The presented research pro and con about the EP controversy, though not exhaustive, demonstrates just how contradictory the research on Latinas is. The controversy continues unabated. In study after study presented here there appears to be no clear cut answer to the question: is there some element of culture that is clearly acting to protect Latinas from poor health outcomes in spite of their extremely high risk factors for poor health outcomes? The answer is a resounding: no one really knows yet, and no one has actually disproved or proved the issue. How can research on the very same topic engender such confusion?
        I posit that if one accepts the premise that illness and health, as well as other quality of life determinates, are a phenomenological construct, then it may be that these very social constructs - class, gender, race and politics - define more than individual realities. They locate reality within the group and the environment to create illness and health. Conversely, these very factors may prevent or mitigate illness, and improve health outcomes, at least temporarily through internalized racism production, and particularly, reproduction factors.
        From a theoretical perspective, view through a historical medical framework, I submit that it is necessary to re-evaluate the entire controversy. A new hypothesis: Namely that whether there is an EP or not is irrelevant. That what is at work has to do with the means of production, and particularly reproduction at the intersection of class, gender, race and politics.
        Latinas make up over 5% of the United States population, a significant enough portion of the population that they merit far more research consideration than they seem to be receiving, particularly in light of the claim of an EP and the confusion and controversy it engenders .
        In the epidemiological methodology of social medicine there may be a new answers to this conundrum. What is needed is to use social medicine's collective approach. To do qualitative and quantitative analysis of historical patterns of production and reproduction in Latina/o enclaves in the United States and Canada. Besides the historical analyses, it would be important to conduct both individual and stratified group "collective interviews" as presented in the works of Laurell (1978, 1989).
        Of particular importance is to follow a similar methodology as used to analyze the alienation from the means of production in two Mexican villages (Laurell, Gil, Machetto, Palomo, Rulfo, Cháves Yrbina, and Veláquez, 1977), in which collective and individual surveying techniques, and qualitative analysis are used to determine the needs of to separate segment of a continuous society. Or the participatory research model used to assist mine workers in assessing their specific needs for improving the employment situation and life in general, through collective and individual questionnaires (Laurell, Noriega, Martinez and Villegas. 1992).

Future Direction
        One of the processes that must be undertaken is to dissect each and every study on the issue of the EP for confounding variables, for poor design, and for rigor. In this manner, some clear literature direction my be found that can be used to buttress the hypothesis presented here, from a social medical framework.
        Equally, as important, or possibly more so, is to conduct social science epidemiological research in several enclaves in the United States and Canada, using the epidemiological methodologies of social medicine describe above. I would propose choosing X amount of enclaves, and administering the surveys - individually and group - and conducting individual and group meetings to confirm and readjust the questionnaire findings. It would be an extensive project, but one well worth the effort.

 

APPENDIX
A
CANCER FOUNDATION CANCER PREVALENCE CHART 1990 - 1997

1. There is some controversy of the uniqueness of this group, see the section on "disaggregation."

2. I use the term "exploited" and "exploiter" nations, instead of the commonly used terms, "developing nations" or "third world nations," as I believe the terms are more descriptive of the dynamics in the world today, and they are more in keeping with the ideological represented in this paper.

3. Throughout this paper "social medicine" is used, with the understanding that it encompasses both the terms "social and collective medicine."

4. Instead of the misleading term "American" which predominates in the medical literature of the United States when speaking of the United States of America, the literal translation of "Unitedstatian" from the Spanish word "Estadounidense" is used throughout this paper.