HEALTH STATUS ASSESSMENT OF LATINOS IN THE MIDWEST BY Dr. Roberto E. Torres Michigan State University   Working Paper #5 July 1990   Abstract: This paper examines the current health status of the Latino population in the Midwest region based on the available data. There is a critical lack of data on health status and health-related issues of Latinos in the Midwest. Statistics indicate that heart disease and cancer are the two leading causes of death in this population. There are also indications that diabetes, cirrhosis, mental illnesses, hypertension, arthritis, substance abuse, AIDS, homicide and infectious diseases represent serious threats to the health of Latinos. Maternal and child health seems to be poor in many respects. Improvements on the Latino health status will require not just health programs tailored to their particular needs but, even more important, an active participation in the labor force within the Midwest economy.   About the Author: Dr. Roberto E. Torres is currently a PostDoctoral Fellow at the Julian Samora Research Institute at Michigan State University. Dr. Torres has a Ph.D. in SocioTechnological Planning with a specialization in health care planning.   INTRODUCTION According to the U.S. Bureau of the Census (1985), the Latino population will be the largest minority group in the United States by the end of the century. If the current rate of growth continues, these numbers will increase from 15.4 million (U.S. Bureau of the Census, 1980) to an estimated 39.4 million by the year 2000. The growing presence of Latino individuals in the economic, political, and social life of the U.S. makes their current health status an issue of major consideration to American society (De la Rosa, 1989). A considerable number of studies have been conducted on the health issues of the Mexican-American population in the southwest states. Markides and Coreil (1986) provide a comprehensive literature review on the health status of the southwestern Mexican-Americans. Other studies have addressed the health problems of Latinos in general in the U.S. De la Rosa (1989) provides a review of this literature, focusing on the most recent studies. However, very little is known on the health situation of Latinos in the Midwest. The need to have knowledge on the health problems of Latinos in the Midwest acquires importance if we just consider that in 1980 a million Latinos resided in five midwestern states: Illinois, Indiana, Michigan, Ohio, and Wisconsin (Santos, 1989). The purpose of this paper is twofold: 1) to assess the health status of Latinos in the Midwest, and 2) to make observations and recommendations to improve Latinos' health status and to indicate directions for future research. The health status assessment of the Latino population is based on published sources from the literature and reports and unpublished data supplied by several State Commissions on Spanish Speaking Affairs and State Health Departments in the Midwest. Latino statistics were usually compared to White non-Latino statistics, which were used as the standard. Whenever possible, findings on the health status of Latinos in the Midwest are compared to findings of Latinos nationally or regionally obtained from the literature. For the purpose of this paper, the Midwest definition included the following states: Illinois, Indiana, Michigan, Ohio, Wisconsin, Nebraska, Kansas, Minnesota, Missouri, Iowa and North and South Dakota. However, no data was available from the literature or from state authorities relative to Latinos in Minnesota, Missouri, Iowa and North and South Dakota. In many cases, state data on Latinos in non-existent. It is essential to mention that the term "Latino" is used in this paper to describe U.S. residents of Mexican, Puerto Rican, Cuban, Central or South American origin living in the mainland. Residents from Puerto Rico were not included in this analysis. The limited nature of the data to be presented in the following section does not allow drawing definitive conclusions about the Latino health status in the Midwest. Information is uneven and incomplete in many instances. However, this description should provide clues as to the magnitude and nature of the health problems suffered by Latinos in this region. Thus, rather than providing a definitive description of the health status of Latinos, this discussion should be seen as an inducement for further research. Data related to Latinos in Chicago will be presented more often than for Latinos elsewhere in the Midwest because of its availability in contrast to other cities/states which do not gather data related to Latinos. Though this is definitely a limitation, it should be remembered that in 1980 there were around 600,000 Latinos in Chicago, making it the biggest Latino population in the region. Latinos in Chicago comprise around 50% of the Latino population in the Great Lakes states. Thus, though Chicago statistics may not represent the whole Midwest region, they certainly represent a significant portion of the Latino Midwest population.   HEALTH STATUS ASSESSMENT General Mortality Data on Latino general mortality is almost nonexistent for the Midwest states. However, a few statistics related to Latinos in Chicago and Nebraska are presented. For example, the Chicago Department of Health (1988) reports that in 1986 the seven community areas with high concentrations of Latinos had a death rate of 6.9 per 1,000 population as opposed to 9.8 for Chicago. A study of Mexican-American communities in Chicago also reports a favorable death rate of 5.4 per 1,000 for two of the studied communities during the period 1979-81, while the rate for the city was 9.5 per 1,000 population (The Latino Institute, 1987). This seems to be explained at least partially by the youthfulness of the Latino population in Chicago. According to 1980 Census of Population data, over one-third of the Latino population in Chicago is below the age of 15. Shai and Rosenwaike (1987) in their study of mortality of first-generation Mexican-Americans and Puerto Ricans residing in the Chicago metropolitan area during 1979-81 calculated standardized mortality ratios (SMRs) by dividing the age-sex adjusted rates for each Latino sub-group by the age-sex adjusted death rate for the White non-Latino population. Rates were computed for persons 15-74 years old. The SMRs showed very low death rates for Mexican-American males and females when compared to non-Latino Whites. In contrast, Puerto Rican males and females showed much higher death rates when compared to the White non-Latino population. Looking to state-aggregate data, the Nebraska Department of Health reports that for 1987 the average age at time of death is 60 for the Latino population, while the average age for the White population is 74. Clearly, it is impossible to draw conclusions and generalizations about the general mortality of Latinos in the Midwest due to insufficient statistical data. As explained by the U.S. Department of Health and Human Services (1986), many states do not enter Latino identifiers on birth and death records. At best, we can only speculate about the health status of Latinos based on the statistics presented in this paper. The data from the Chicago Department of Health suggests that the Latino population in Chicago has a favorable general mortality situation in relation to the rest of the population due to its youthfulness. However, data from the Shai and Rosenwaike study and from The Latino Institute (1987) suggest that this may be true for the Mexican-Americans, but not for the Puerto Ricans who show a very unfavorable mortality rate. The authors explained, however that the low mortality rates for the Mexican-Americans could be a product of underdiagnosis, underreporting of illnesses or problems in the completion of death certificates due to cultural and language barriers. The favorable situation of Mexican-Americans is consistent with other studies of this population in the Southwest states which found a relatively favorable mortality situation considering their low socioeconomic status (Schoen and Nelson, 1981, Markides and Coreil, 1986). In any case, it is clear that the collection of complete and reliable data on the mortality situation of Latinos at the national, regional and local level is an urgent need.   Chronic Diseases This section presents data related to diabetes, cirrhosis, heart diseases, hypertension, cancer, arthritis and mental illnesses. Other diseases were not included because of lack of data.   Diabetes Shai and Rosenwaike (1987) found that the diabetes mortality rate for Mexican-American males was 14% higher than the rate for White non-Latino males in Chicago during 1979-81. Puerto Rican females' rate was 29% higher than the rate for the White female population. Garcia et al. (1985) and The Latino Institute (1987) also found diabetes to be a frequent chronic illness reported by Latino respondents in the two survey studies in Chicago. The same result was obtained in a three-county survey study in Wisconsin by Slesinger et al. (1977). In Michigan, Holmes (1988) reports that among persons screened by the Michigan blood pressure screening programs in 1981-82, Latinos were at unusually high risk for the occurrence of diabetes. Data from the Cristo Rey clinic, a primary health care center serving a significant proportion (60%) of Latino clients in Lansing, Michigan shows that in March, 1988 (a typical month) diabetes was the most frequent problem diagnosed (16.2% of all patient visits). Thus, although the data is limited, there are indications that diabetes is a serious health problem within Midwest Latino communities. This is consistent with the literature, which has extensively shown that diabetes is one of the most serious health problems experienced by Latino in the U.S. (Markides and Coreil, 1986; De la Rosa, 1985; U.S. Department of Health and Human Services, 1986).   Cirrhosis Cirrhosis is another ailment affecting the Latino community. Unfortunately, the data gathered for this paper only describes the city of Chicago. The Chicago Department of Health (1988) reports that in 1986 the death rate attributable to cirrhosis of the liver (frequently caused by larger consumption of alcohol) was higher in Logan Square (21.2 per 100,000), a community with high concentrations of Latinos, than in the city as a whole (19 per 100,000). In contrast, Shai and Rosenwaike (1987) found much lower mortality rates due to cirrhosis for the Mexican-American population than for the White non-Latino population in Chicago. However, the Puerto Ricans' rate for males was found to be more than twice the rate of their White counterparts, whereas for Puerto Rican females the rate was twice the rate of the White non-Latino females. National studies report a higher risk of death due to cirrhosis for Latinos than for the White non-Latino population (U.S. Department of Health and Human Services, 1986). This highlights the need to gather health data by Latino subgroups as well as for the total Latino population.   Cardiovascular/Cerebrovascular Diseases In regard to cardiovascular diseases, in 1984 heart disease was the leading cause of death in Latino communities in Chicago (The Latino Institute, 1987). However, data from the Chicago Department of Health (1988) indicates that in 1986 the incidence of deaths due to cardiovascular diseases was lower for Latino communities than for the city as a whole. Data from Shai and Rosenwwaike reveals very low death rates due to heart and cerebrovascular diseases for Mexican-Americans relative to the White non-Latino population in Chicago. For Puerto Ricans, the death rates for these causes were favorable for males, but unfavorable for females. One factor that may explain the relatively favorable situation of Latinos in terms of cardiovascular disease is the youthfulness of the populations. Although studies (Markides, 1986; U.S. Department of Health and Human Services, 1986) indicate that, in general, Latino individuals are less likely to die of cardiovascular or cerebrovascular diseases than the White population, the low socioeconomic status, eating habits and drinking and smoking habits of the Latino population will probably increase the rate of cardiovascular disease in the future. For example, the Nebraska Department of Health indicates that in 1987, Latinos had the highest rate of smoking (31%) followed by Whites (24%) and Blacks (18%). Another risk factor for cardiovascular disease is high blood pressure, also known as hypertension. The Michigan Department of Public Health (1988) reports that Latinos are at high risk for the occurrence of hypertension. In addition, Garcia et al. (1985) reports hypertension to be the second most frequently reported chronic disease (10%) by respondents surveyed in Chicago. Another study by The Latino Institute (1987) found similar results, since 9.4% of mostly Mexican-American respondents reported having this health problem. In Lansing, Michigan, the Cristo Rey clinic reports that for the month of March, 1988, hypertension was the second most frequent health problem of their clientele (15.6% of the total patient visits).   Cancer Cancer is the second leading cause of death for Latinos in the city of Chicago (The Latino Institute, 1987). However, data on cancer from Illinois shows a relatively favorable situation for Latinos when compared to the White non-Latino population. Mallin and Anderson (1988) conducted a site-specific cancer mortality study where rates for first-generation Mexican-Americans and Puerto Ricans in Illinois were compared to that of Anglos for the 1979-84 period. Cancer mortality for all sites was lower in both immigrant groups than in Anglos. Significantly higher risks were found in Mexican-American females as compared to White non-Latino females only for cancer of the stomach, cervix and gall-bladder. The data also indicated significantly higher risks for stomach and cervix cancer in Puerto Rican females as compared to White non-Latino females. This relatively favorable situation is confirmed in Shai and Rosenwaike's study in Chicago, where they found very favorable cancer mortality rates for all sites for the Latino population in comparison with the White population. The Chicago Department of Health (1988) also reports that in 1986 the incidence of deaths due to cancer was lower in seven Latino communities than in the city. Once again, a factor that may explain this situation is the youthfulness of the Latino population. Since the risk of cancer is higher in older populations, the young age of Latinos seems to have favored them in comparison to the White non-Latino population which is older. These findings are consistent with sources reporting the cancer situation nationally, regionally or locally, which indicate that Latinos, in general, have a lower risk of cancer than the White non-Latino population. These sources also report, however, that Latinos have a higher risk for cervix, stomach, gallbladder, and pancreas cancer than the White population (U.S. Department of Health and Human Services, 1986; De la Rosa, 1985; Markides and Coreil, 1986).   Arthritis Arthritis is also a chronic condition affecting Latinos. For example, the Cristo Rey clinic in Lansing, Michigan reports osteoarthritis as the fourth leading problem diagnosed (6.8% of total visits) in March, 1988. The Latino Institute (1987) also found arthritis to be reported by 16.6% of the Latino sample surveyed, the most frequently reported health problem in this study. There are no reports in the literature of arthritis as a major health problem for Latinos in the U.S. However, orthopedic and musculoskeletal problems are very frequently reported by migrant workers (Slesinger, 1979). The health problems of this segment of the Latino population are discussed later in this paper.   Mental Illnesses Studies and statistics relative to Latino mental health are limited for the Midwest states. However, the available data consistently reveals a deteriorating mental health status for the Latino population. Slesinger et al. (1977), in their survey of Latino health needs in three counties in Wisconsin, found higher rates of mental health problems for Latinos than for the general population. This was consistently reflected in reported rates of nervousness, headaches, trouble sleeping, irritability, tension, and low spirits (i.e. depression). In Michigan, Saenz (1984) conducted a key informant survey of the mental health needs of the Latino population in the state. The most serious mental health problems reported by respondents were, in order of frequency, depression, alcoholism, anxiety, lack of identity, drug use and adjustment reactions (alcoholism and drug abuse are discussed later in this paper under the substance abuse section). This also leads to child/spouse abuse and neglect. The study found that these problems are triggered by a variety of social, cultural, and economic factors affecting Latinos such as alienation due to prejudice, cultural differences, family problems, language barriers, poor-self image, lack of education, academic underachievement, and unemployment and underemployment. In a formal evaluation of Latino mental health programs in Michigan, Bashshur et al. (1989) found "adjustment disorder", which refers to people who are going through some adjustment problem in their life, to be a frequent mental health problem in the city of Lansing. Affective disorders such as depression are very common and personality disorders such as schizophrenia and borderline delusions are also seen. Latino women often present dependent personality disorders. The evaluation report identified the causes of these problems to include the disruption of the extended family, poverty, lack of education, and language and cultural barriers. In southwest Detroit and in Genessee county, Latino women have been reported as suffering from chronic depression, anxiety, and somatic complains due to family conflicts. There is also considerable child and spouse abuse. Single mothers and children of single mothers are identified as being at particular risk for mental and emotional illness and need for support. Among children, "junior high" and teenagers are at high risk for emotional and mental health problems. This is due, in part, to stresses resulting form the teenagers conflicts between the traditional values taught by their parents on one hand, and the new social environment offered by the American society on the other hand. The role-reversal of husband and wife within the nuclear family also affects Latino family relationships. Latino males are often unable to make the role transition when their wives have to work and they have to stay at home. This results in loss of self esteem in the husband and is associated with drinking and spouse abuse. Unemployment is a critical factor that exacerbates these problems. It is noteworthy that the report identifies the closing of two factories in the southwest Detroit areas as an important factor that may have accentuated the mental health problems of that Latino community due to increased unemployment. Early studies of the use of mental health facilities and early community surveys argued that the Mexican-Americans in the southwest states had a favorable mental health state as indicated by low service utilization rates. One plausible explanation is that the low utilization rates reflected economic, cultural and language barriers to the utilization of mental health services more than a low need for services. In fact, recent studies provide little evidence suggesting a mental health advantage for Mexican-Americans (Markides, 1986). Rogler et al. (1983) point out that, in the absence of well-designed community based epidemiological research assessing Latino mental health, the inferential evidence for comparatively higher rates of mental health distress among Latinos is substantially more than plausible.   Maternal and Child Health Data on maternal and child health of Latinos in the Midwest reflects a mixed situation of favorable and unfavorable conditions. Let us review the available data.   Maternal Mortality The Chicago Department of Health (1988) reports that from 1984-86, Humboldt Park, which is a primarily Puerto Rican community, had 3 maternal deaths and 5,270 births, while Chicago city had 26 maternal deaths and 162,020 births. Based on these figures, maternal mortality rates were computed. The rate for Humboldt Park is 5.69 per 10,000, while the rate for the city is 1.6 per 10,000 population. This reflects a very adverse maternal health situation for Puerto Ricans in Chicago.   Pregnancy/Delivery-Related Complications and Concurrent Illnesses In Wisconsin, the Department of Health and Social Services (1988b) reports that 15.2% of Latino mothers experienced pregnancy-related complications versus 13.7% of the White non-Latino mothers in 1988. Nine percent of Latino mothers experienced concurrent illnesses during their pregnancy compared with 5% of the White non-Latino mothers. However, the rates for complications during delivery are the same for Latinos as well as for the White non-Latino population.   Infant and Child Mortality The infant mortality rate is one of the most important statistics related to child health. In this respect, the Nebraska Department of Health reports a favorable infant mortality of 6.4 per 1,000 for Latinos compared to 8.1 for the White population in 1987. The Wisconsin Department of Health and Social Services reports (1988a) a Latino infant mortality rate only slightly higher than the rate for the White population for the period 1982-86 (9.4 vs. 8.6 respectively). Statistics from the Chicago Department of Health also indicate a favorable infant mortality situation for the Latino communities when compared to the city as a whole (The Latino Institute, 1987). In contrast, De la Rosa (1985) found an extremely high infant mortality rate of 38.9% per 1,000 for minorities in Lorain County, Ohio, where a considerable number of Latinos live. De la Rosa (1989) found Latinos in Ohio to be in a very critical socioeconomic situation, which is strongly related to infant mortality. In addition, the Chicago Department of Health (1988) indicates that in 1986 deaths due to diseases of early infancy appeared to be a serious problem in the Latino communities such as Humboldt Park (25.4 per 100,000 population), West Town (19.7 per 100,000) and Logan Square (21.2 per 100,000), all with a higher rate than for the city (16.1 per 100,000).   Prematurity Another statistic of interest within this context is the premature birth rate. The Wisconsin Department of Health and Social Services (1988b) indicates that for 1986 the percentage of births that were premature (less than 37 weeks gestation) was higher for Latinos (9.3%) than among Whites (6.0%).   Low Birth Weight Data about low birth weight was also gathered for this study. Low birth weight (less than 5.5 lbs.) has been found to be strongly related to infant mortality and, thus, represents a very important aspect of infant health that needs to be considered. In general, Latinos in Wisconsin and Chicago show a relatively favorable low birth weight rate considering the low socioeconomic status of the Latino population. For example, 1986 data from the Wisconsin Health and Social Services Department (1988a) shows only a slightly higher rate for Latinos (5.5%) than for the White non-Latino population (4.7%). In Chicago, the Latino and White populations had similar low birth weight rates in 1983 (6.3%). Indeed, the rate for Mexican-Americans was 4.5%, the lowest in the city, and the Cuban rate was 6.4%. Nevertheless, the rate for the Puerto Ricans was 9.3%, the highest among Latino subgroups (The Latino Institute, 1987).   Congenital Anomalies and Apgar Scores In Wisconsin, the rate of congenital anomalies for Latinos is similar to the rate for the White non-Latino population in 1988. In addition, the Apgar score, a test carried out by physicians to determine physical status of the newborn based on muscle tone, respiration, color, heartbeat and reflexes at one and five minutes after birth, was also similar for these two populations (Wisconsin Health and Social Services Department, 1988b).   Prenatal Care It is widely recognized that early and frequent prenatal care reduces the risk of infant mortality and pregnancy complication. Certainly, one contributing factor that may explain some of the maternal and child health problems indicated by these statistics is the low utilization of prenatal care that Latino women exhibit. In Chicago in 1986, Latino women were less likely to seek prenatal care during the first trimester than non-Latino women (Chicago Department of Health, 1988). In Nebraska, 9% of Latino mothers versus 3% of White non-Latino mothers had no prenatal care started in the third trimester of pregnancy in 1987. In Wisconsin, the Department of Health and Social Services (1988b) reports that 66% of Latino mothers compared to 86% of non-Latino mothers began prenatal care in the first trimester in 1988. On the other hand, 60.8% of Latino mothers had ten or more prenatal care visits during their pregnancy compared with 81.7% of non-Latino White women.   Teenage Pregnancy Teenage pregnancy constitutes another area of problems for the Latino communities. In Chicago, Humboldt Park, a primarily Puerto Rican community, has the highest incidence of teen births among Latino communities, that is, 26% compared to 18.5% for the city of Chicago as a whole (Chicago Department of Health, 1988). In Wisconsin, the percentage of births for mothers under age 20 was 19.6% for Latino women versus 7.2% for the White non-Latino population in 1988 (Wisconsin Department of Health and Social Services, 1988b). This problem has been reported in a Latino needs assessment conducted in the state of Kansas as well (The Greater Kansas City Community Foundation, 1988). Teenage pregnancy involves higher risks of complications for the mother during delivery as well as for the newborn and it involves emotional and socioeconomic adjustments that can result in individual and/or family crisis. Thus, in summary, the data presented in this section on maternal and child health is uneven and incomplete, but provides important clues as to the health status of Latino mothers and infants in some of the Midwest communities. As expected, the data reflects the variations of the states within the region. However, a number of observations emerging from this discussion should be highlighted. Infant and child mortality statistics indicate striking variations, from a favorable status in Nebraska and Wisconsin to an unfavorable condition in Ohio. Statistics for Chicago show a favorable situation in terms of infant mortality, but a negative situation when considering deaths due to diseases of early infancy. It is interesting to note that a forthcoming research report by Santiago (1990) reveals that Wisconsin was the only Midwest state to report absolute gains in the number of manufacturing jobs between 1970 and 1988, while the greatest losses occurred in Ohio and Illinois. One possible explanation, then, is that the aggravated infant and child health conditions in Ohio and Chicago are a result of the economic deterioration in those states. In any case, the main concern emerging from this discussion is that there are Latino communities suffering critical infant and child mortality problems that need urgent attention from public authorities. In general, low birth weight seems favorable for Latinos, especially for the Mexican-American population. In contrast, low birth weight was unfavorable for the Puerto Rican population. In terms of prenatal care, a consistent finding was that Latino women delay prenatal care and receive significantly less prenatal care visits than the White population, both crucial factors that certainly should be affecting Latino pregnancy outcomes and infant health. It is interesting to note that the higher rate of pregnancy-related complications and concurrent illnesses exhibited by Latino mothers in Wisconsin may be, at least, partially explained by the low utilization of prenatal care. A crucial finding that deserves special attention is that, among the Latino subgroups, Puerto Ricans exhibit the worst health status as shown by indicators such as maternal mortality rate, low birth weight rate, and teenage pregnancies. The Latino pattern of low birth weight, teenage pregnancy, and delayed prenatal care herein described is consistent with findings from other reports or studies of the Latino population in the U.S. (U.S. Department of Health and Human Services, 1986; De la Rosa, 1989). In regard to infant mortality, researchers argue that the situation of Mexican-Americans is favorable (Markides and Coreil, 1986), while other reports state that studies on Mexican-Americans have found a high neonatal mortality (U.S. Department of Health and Human Services, 1986). These conflicting findings draw attention to the great need for establishing systematic, uniform and reliable data collection procedures at the federal and state government level.   SUBSTANCE ABUSE Alcoholism As described previously, data shows a higher rate of cirrhosis diseases for Latinos than for the White non-Latino population in Chicago. This disease is caused mainly by excessive alcohol consumption. Thus, the expectation is that alcoholism is a serious health problem for Latinos. Due to lack of data, De la Rosa (1985) reports unofficial estimates made by individuals working with Latinos experiencing alcohol problems in Ohio. The assessment of these individuals is that alcohol problems for Latinos in Ohio put the rate of alcoholism at two or three times the state average. In the study conducted by Saenz (1985), alcoholism was found to be the most serious problem for Latino males according to key informants. The Latino Institute (1987) also reports that 49% of the Latino sample surveyed in their study consumes alcoholic beverages. Of those that drink, 51% usually have 1-2 drinks, 21% have 3-4 drinks, 11% have 5-6 drinks, and 15% have more than 6 drinks per drinking episode. In contrast, Slesinger (1977) found a relatively low incidence of alcohol-related problems in the Latino population of three Wisconsin counties. Thus, there is not enough data to make definitive conclusions on the frequency and severity of this problem in the Midwest region. However, the available data, in general, indicates that alcoholism is a serious problem at least in several Midwest Latino communities. This is supported by studies that have found alcoholism to be a severe health problem among Latinos in the U.S. (Alcover, 1983; Department of Health and Human Services, 1986).   Drug Abuse De la Rosa (1985) found that individuals working with Latino drug abusers in Ohio estimate the rate of drug abuse among Latinos to be higher than that of the general population. In Michigan, the Department of Public Health (1988) reports the Latino's admission rate to treatment programs to be 233.16 per 100,000 compared to 180.6 per 100,000 for the White non-Latino population. Literature on this problem suggests that drug abuse rates for Latinos in the U.S. are higher than rates for the White population (U.S. Department of Health and Human Services, 1986).   Acquired Immunodeficiency Syndrome (AIDS) The risk of AIDS is higher in U.S. Latinos than in White non-Latinos. In Michigan, the Department of Public Health (1990) reports that the cumulative incidence, which is the number of cases per 100,000 U.S. population of the respective ethnic/racial group, is 20.3 for Latinos versus 9.9 for the White population. Selik et al. (1989) conducted a study on the risk of AIDS among Latinos by region in the U.S. According to their data, between 1981-88 the Midwest region exhibited a cumulative incidence of 26.7 for Latinos versus 8.9 for non-Latino Whites. The relative risk, that is, the ratio of the cumulative incidence of a group to the cumulative incidence in non-Latino Whites is 3.0, which indicates that Latinos had three times the risk of Whites to suffer from AIDS. Puerto Rican-born and Cuban-born people showed the highest cumulative incidence among Latino sub-groups (87.3 and 72.7 respectively). The relative risk for Puerto Rican-born was 9.9 and 8.2 for Cuban-born. When looking to homosexual non-intravenous drug abusers in the Midwest, Latinos had a cumulative incidence rate of 14.6% versus 6.9% for Whites with a relative risk of 2.1. Heterosexual intravenous drug abuser rates show that Latinos exhibited a 7.2 cumulative incidence rate, while Whites had a .3 rate, yielding a 22.4 relative risk. It is critical to note that Puerto Rican heterosexual intravenous drug abusers had a cumulative incidence of 45.6, which yields a relative risk several times greater (141.5) than the risk for other Latino populations.   Other Health Problems There are other health problems suffered by the Latino population in the Midwest states that also deserve special attention. Shai and Rosenwaike (1987) report that during the 1979-81 period in Chicago, the homicide mortality rate for Mexican-born was four times that of Whites, whereas the rate for females was two times the rate of Whites. For Puerto Rican-born males, the homicide rate was eight times the rate of the White population, while the rate for females was three times the rate of Whites. Usually, this problem is tightly related to drug abuse and alcoholism. When looking to suicide rates in Chicago, Puerto Rican males showed a higher rate than White non-Latino males (41%), while Puerto Rican females and non-Latino White females had a similar rate. Rates for Mexican-Americans were very favorable when compared to the White non-Latino rates. On the other hand, rates related to death due to accidents were similar for Latinos and for Whites. Other diseases such as pharyngitis, bronchitis, problems of the digestive system, diseases of the nervous system and sense organs and skin problems have been reported to be a frequent problem in areas of high concentration of Latinos in Cleveland, Ohio (De la Rosa, 1985). Shai and Rosenwaike (1987) report that Mexican-American females in Chicago had a death rate due to pneumonia and influenza 80% higher than the White non-Latino female rate, while Puerto Rican males and females showed rates 61% and 38% higher than their White non-Latino counterparts respectively. These are diseases associated with poverty and poor sanitary conditions. In Chicago, the Chicago Department of Health (1988) reports for 1986 that the incidence of certain reportable illnesses such as gonorrhea, bacillary dysentery, chicken pox, and lead poisoning appeared as health problems in community areas with 33% or more Latinos. On the other hand, the Michigan Department of Public Health (1988) reports that in 1986 Latinos had a tuberculosis incidence rate of 9.8 per 100,000 compared to 3.3 per 100,000 for non-Latino Whites.   Migrant Agricultural Worker's Health The migrant worker is one segment of the Latino population that has always been among the lowest in health status, earnings, job security, educational attainment and political power. In addition, their high mobility makes it very hard for them to have a regular or continuous source of care. Therefore, the health problems of this population deserve to be discussed separately in this section. Studies (Slesinger, 1979; 1981; 1988) show that in Wisconsin the migrant worker as well as their children have very poor health conditions. This is especially important as the majority of migrant workers (about 90%) in Wisconsin, for example, are Mexican-Americans (Slesinger, 1988). Numerous health problems prevail for the adult population in Wisconsin, including headaches, eye and dental problems, backaches and orthopedic/musculoskeletal-related problems (caused by long hours of bending or standing) and chronic conditions such as high blood pressure, diabetes, and arthritis. Migrant women report histories of unusually high fetal loss and infant and child mortality. Symptoms of mental health distress such as nervousness, irritability, trouble sleeping and low spirits are also reported to be more frequent in this population. In addition, Slesinger et al. (1986), in a study of health and mortality of migrant farm children in Wisconsin, found that the incidence of chronic conditions is several times greater in migrant farm children than in the U.S. children population. Childhood mortality appears to be 1.6 times higher than in the U.S. population. A dental health survey of a group of migrants in northwest Michigan found that migrant children generally showed higher number of decayed teeth and lower numbers of restored teeth than U.S. school children. Migrant children also have less caries-free teeth (Woolfolk et al., 1984). De la Rosa (1985) also reports that migrant workers in Ohio have commonly recognized health problems including respiratory ailments, diseases of the digestive system, skin problems and disorders of the nervous system. In Michigan, migrants are still faced with diseases like tuberculosis, diarrhea, hepatitis, and gastro intestinal disorders and lag several decades behind the general population in their prevention. They have an average life expectancy of under 50 years (Rochin et al., 1989).   SUMMARY: OBSERVATIONS AND RECOMMENDATIONS Several observations emerge from the previous discussion. There is a critical lack of data on the health status of Latinos in the Midwest. Vital statistics are non-existent for Latinos, though some states such as the state of Michigan have already taken the necessary steps to correct this situation. It is essential to collect vital statistical data in order to produce mortality statistics. Morbidity data, that is, information on the disease patterns of Latinos, is also fundamental for formulating and targeting public health policies and programs for this population. It is important to stress that this should be done on a periodic, systematic basis to monitor health status changes over time. Based on this type of data, it will then be possible to determine what health policies and programs are required to meet the health needs of Latinos. The data presented on health status aspects of the Latino population in this paper is very limited. Nevertheless, it offers clues as to what the Latino health problems are in the Midwest. Heart disease and cancer appear as the two leading causes of death among Latinos. There are also indications that diabetes, cirrhosis, mental illnesses, hypertension, arthritis, substance abuse, AIDS, homicide and infectious diseases represent serious threats to the health of Latinos. A big concern is the high infant mortality in some communities, the higher rates of pregnancy-related complications and concurrent illnesses, the high teenage pregnancy rate and the low and delayed utilization of prenatal care by Latino women. When comparing the Latino and the White non-Latino populations, statistics show a relatively favorable situation for Latinos relative to cancer diseases in general. The exceptions are gallbladder, cervix and stomach cancer, where Latinos show higher mortality rates. The situation for cardiovascular diseases seems to be favorable for Latinos also, though risk factors such as smoking and hypertension, among others, may increase their incidence in the future. On the other hand, many indicators show a relative disadvantage for Latinos in general or for Latinos subpopulations when compared to non-Latino Whites regarding diabetes, cirrhosis, AIDS, homicide, maternal and child health and infectious diseases in some communities. Therefore, in summary the available data suggests that Latinos in the Midwest experience a combination of health problems characteristic of underdeveloped countries (e.g. infant mortality, early infancy diseases, infectious diseases) as well as health problems characteristic of developed countries (e.g. cancer, heart disease). Contrary to populations in developed countries which have made the transition from infectious diseases to chronic diseases, the Latino population seems to be yet at the midpoint of such a transition. An important finding from this paper that should be highlighted is that, within the Latino population, Puerto Ricans consistently show the worst health status as reflected by indicators such as general mortality, maternal mortality, cirrhosis, AIDS, homicide, low birth weight, heart disease and suicide. In fact, this does not seem to be a coincidence since the socioeconomic status of Puerto Ricans in the Midwest is the worst among Latino populations as shown by data form a forthcoming study by Santiago (1990). This also indicates that Latinos should not be treated as a homogeneous group, since significant differences exist in the type of health problems experienced by Latino subgroups. Given our knowledge on the health status of Latinos in the Midwest, what can we expect in the future for the Latino population? Will the health conditions of Latinos improve during the next decade or will the health status deteriorate? In attempting to address this question, it is necessary to consider the effect of the changing economy of the Midwest on the Latino communities. The deindustrialization of the Midwest economy has impacted negatively on Latinos due to their overrepresentation in manufacturing occupations. Worker displacement has resulted in increased Latino unemployment and reemployment in the service sector, where fringe benefits such as health insurance coverage are not offered. Consequently, the number of uninsured and underinsured is likely to increase. The only result that can be expected from such changes is an increased deterioration of the Latino health status. Many of the Latino health problems identified in this paper (e.g. mental health ailments, substance abuse, hypertension, infant mortality, homicide) are associated with low socioeconomic status and poverty. Improvements on the health status of Latinos will require not just health programs tailored to their particular needs (e.g. health education, prenatal/postnatal care, hypertension screening programs) but, even more important, an active and well remunerated participation in the labor force within the Midwest economy. As Santos (1989) states, many of the jobs emerging from a revitalized industrial America will require advanced skills and training. For Latino workers, the new industrial jobs may be beyond their reach. Latinos are not making improvements in education; in 1981 and 1970, Latinos averaged only ten years of schooling. Public policies should be geared toward the capacitation of Latino workers by means of education and training in order to facilitate their participation in the new economic structure. This will consequently lead toward an improvement of the health status of the Latino population in the long-run. Finally, a policy-oriented research agenda directed toward a better understanding of Latino health problems should be, at least, broadly defined. Empirical research on the health needs of the Latino population in the Midwest states is critical in order to know what type of health and other social interventions are needed. It is very important to develop research studies which identify not only the needs of the Latino population in general, but also the needs of the specific Latino subgroups (e.g. Mexican-Americans, Puerto Ricans, etc.). In addition, it is necessary to carry out research that identifies the needs of Latinos living in different communities within the Midwest region. This would allow the formulation of tailor-made policies directed toward the different problems experiences by Latinos. Secondly, the Latino health consequences resulting from the Midwest's deindustrialization process needs to be investigated to understand how Latino well-being has been affected by economic change and what intervention measures are necessary.   References Alcocer, A.M. (1983). "Use and Abuse of Alcohol Among Hispanic Americans." Grassroots (11/83), 39-48. Bashshur, R., A. Donabedian, H. Neighbors, R. Price, S. Selig and G. Shannon (1989). Ethnic Minority Mental Health Programs in Michigan: A Formal Evaluation, Michigan State Department of Mental Health. Chicago Department of Health (1988). "Fact Sheet on Hispanic Health: Chicago Resident 1986." Chicago: Office of Management Information Systems/Data Processing, May, 1988. De la Rosa,M. (1989). "Health Care Needs of Hispanic Americans and the Responsivenessof the Health Care System."Health and Social Work, 14, 104-113. Garcia, R., I. Saucedo-Gonzalez and A.L. Giachello (1985). Access to Health Care and Other Social Indicators for Latinos in Chicago. Chicago: The Latino Institute. Holmes, R.E. et al. (1983) Increased Prevalence of Diabetes Mellitus in Hypertensive Minority Group Females: A Special Risk Group. Presented at the National Conference on High Blood Pressure Control, April 20-22, 1983. In Minority Health in Michigan: Closing the Gap,p.38, (see Michigan Department of Public Health, 1988). Mallin, K. and K. Anderson (1988). "Cancer Mortality in Illinois Mexican and Puerto Rican Immigrants, 1979-1984." International Journal of Cancer,41,670-676. Markides, K.S. and J. Coreil (1986). "The Health of Hispanics in the Southwestern States: an Epidemiological Paradox." Public Health Reports,101,253-265. Michigan Department of Public Health (1988). Minority Health in Michigan: Closing the Gap.Michigan: Michigan Department of Public Health. Michigan Department of Public Health (1990). Michigan HIV/AIDS Report, Vol. 5, Number 3. Rochin, R.I., A.M. Santiago and K.S. Dickey (1989). Migrant and Seasonal Workers in Michigan's Agriculture: A Study of Their Contributions, Characteristics, Needs, and Services. Institute Research Report #1, Julian Samora Research Institute, Michigan State University. Rogler, L.H., R.S. Cooney, G. Constantino, B.F. Earley, B. Grossman, D.T. Gurak, R. Magady and D. Rodriguez (1983). A Conceptual Framework for Mental Health Research on Hispanic Populations, Monograph #10, Hispanic Research Center, Fordham University. Saenz,S. (1984). An Assessment of the Mental Health Needs of Hispanics in Michigan,Report to the Michigan Department of Mental Health. Santiago, A.M. (1990). Life in the Industrial Heartland: A Profile of Latinos in the Midwest.Institute Research Report #2, Julian Samora Research Institute, Michigan State University (Forthcoming). Santos, R. (1989). Hispanic Workers in the Midwest: A Decade of Economic Contrast 1970-1980. Working Paper #2, Julian Samora Research Institute, Michigan State University. Schoen, R. and V. Nelson (1981) "Mortality by Cause Among Spanish Surnamed Californians, 1969-71." Social Science Quarterly,62,259-274. Selik, R., K.G. Castro, M. Pappaioanou and J.W. Buehler (1989). "Birthplace and the Risk of AIDS among Hispanics in the United States." American Journal of Public Health,79,836-839. Shai, D. and I. Rosenwaike (1987). "Mortality Among Hispanics in Metropolitan Chicago: An Examination Based on Vital Statistics Data." Journal of Chronic Disease,40,445-451. Slesinger, D.P. (1979). Health Needs of Migrant Workers in Wisconsin. Madison, Wisconsin:Department of Rural Sociology, University of Wisconsin-Extension Center. ______________ (1988). "Health Status of Wisconsin's Migrant Agricultural Workers." As You Sow, No. 19. Slesinger, D.P. and E. Cautley (1981). "Medical Utilization Patterns of Hispanic Migrant Farmworkers in Wisconsin." Public Health Reports,96,255-263. Slesinger, D.P., B.A. Christenson and E. Cautley (1986). "Health and Mortality of Migrant Farm Children." Social Science and Medicine,23,65-74. Slesinger, D.P., D. Johnson and P.Oyarbide (1977). Health Care Needs of a Hispanic Population in Dane, Dodge, and Jefferson Counties.Madison,Wisconsin: Department of Rural Sociology, University of Wisconsin-Extension Center. The Greater Kansas City Community Foundation (1988). Hispanic Needs Assessment (Executive Summary). Kansas City:The Greater Kansas City Community Foundation. The Latino Institute (1987). Tocar el Corazon: Needs Assessment for Project Alivio. Chicago: The Latino Institute. U.S. Department of Health and Human Services (1986). Report of the Secretary's Task Force on Black and Minority Health. Washington,D.C.: U.S. Government Printing Office. U.S. Bureau of the Census (1980). Persons of Spanish Origin by State: 1980 Census of Population, Supplementary Report (PC-8-0-s1-7). Washington,D.C.: U.S. Government Printing Office. In "Health Care Needs of Hispanic Americans and the Responsiveness of the Health Care System.", p.104(see De la Rosa,1989). ___________ (1985). Persons of Spanish Origin in the United States. Current Population Reports (Series P-20,No.403). Washington,D.C.: U.S. Government Printing Office. In "Health Care Needs of Hispanic Americans and the Responsiveness of the Health Care System.", p.104 (see De la Rosa,1989). Wisconsin Department of Health and Social Services (1988a). Minority Groups in Wisconsin: Measures of Health. Wisconsin: Division of Health. ___________ (1988b). Wisconsin Maternal and Child Health Statistics 1988. Wisconsin: Division of Health. Woolfolk, M., M. Hamard and R.A. Bagramian (1984). "Oral Health of Children of Migrant Farm Workers in Northwest Michigan." Journal of Public Health Dentistry,44, 101-105.