The Secret of L.A.’s Public Health

The Los Angeles County Department of Health Services recently released a spate of reports on the health of Angelenos, which, incidentally, tell us a lot about the future of the city. Yes, the reports are filled with jargon: death rates, years of life lost, age-adjusted this, gender-specific that. Yet, their bottom line is this: Diversity is one of the best things that ever happened to the health of the region. There’s a laugh line, too: The region’s vaunted medical-research institutions and its world-renowned health-delivery systems haven’t the foggiest clue about how to take advantage of this gift.

Although the medical field is enamored with the high-tech, magic-bullet approach to achieving health, medicine is much more about human issues. The humdrum of daily life, not medicine’s latest technological advances, is what really drives the patterns of how we live and die: what we eat, drink and ingest; how we move; with whom we associate; the depth of our emotional commitments; our spiritual quests.

Every region of the country has its own health risks associated with its living style. For example, New Orleans, where foods are outrageously fatty and are washed down by drinks available from sidewalk-window takeout bars, lives a perpetual health hangover: Its population is one of the most overweight in the country, and it has one of the highest death rates tied to heart attacks and alcohol-shot livers. In the wide-open spaces of rural Texas, New Mexico and Colorado, a drive of 100 miles one way, without seat belt fastened, to see a high-school football game or to meet a friend for coffee is routine, and motor-vehicle deaths in this area are far above the national norm.

Los Angeles’ health profile is conditioned by the region’s ethnic and racial diversity. The Department of Health Services reports waste no time in asserting that there is great variation among the ethnic groups that make this one of the most cosmopolitan societies on Earth. But the ethnic variation in health patterns is not always what one would expect.

One recurring pattern appears at first to make no sense. Measured in terms of deaths, Latinos, nearly half the county’s population, have far fewer heart attacks, cancers and strokes than either whites or African Americans. Measured in terms of years lived with pain and disability, Latinos and Asian-Pacific Islanders suffer far less from the lingering effects of surviving a heart attack than whites or blacks and are half as likely to have to live with the aftereffects of lung cancer, Alzheimer’s, osteoarthritis, drug overdose, stroke and diabetes. Measured in terms of birth outcome, Latinos have fewer low-birth-weight babies and lower infant mortality.

The paradox is that Latinos have great risk factors: lower income, lower education levels, lower availability of health services and less access to health insurance. Classically, these disadvantages add up to more sickness and early death. But year after year, in state after state, Latinos present a healthy profile. Only in diabetes and homicides is the Latino profile what one would expect, given their higher risk factors.

Even though the exact mechanisms are not completely known, it’s clear that culture plays a major role in these unexpected variations in health profiles. Just as the hedonistic culture of New Orleans leads to shorter life expectancy, Latino habits of the heart--food, family, prayer, fun--lead to good health outcomes and long life expectancy.

While Asian-Pacific Islanders are a single category in the Department of Health Services reports, a closer look reveals heterogenous health stories. The infant mortality rates among refugee Cambodians, Laotian and Hmong approach African American levels, while immigrant Korean, Chinese and Japanese infant mortality is lower, near Latinos’ levels. Culture plays an important role, but it can be overshadowed by lifestyle and history.

Understanding the role culture plays in health care is in its infancy. A Wall Street Journal reporter recently experienced some local “cultural competency” seminars provided to doctors and nurses. He came away feeling that not only did the seminars fail to provide much useful guidance, but they also came very close to stereotyping patients in racist ways.

At first glance, it appears that while Latinos and Asian-Pacific Islanders tend to be healthier on a number of measures, the health of African Americans is headed downhill: far higher rates of heart attacks, cancers, strokes, infant mortality, more years of disability, more years of life lost, earlier death and so on. Yet, these rates are not inevitably “hard-wired” into the African American population, by either genetics or poverty. A broader look, conducted by the United Kingdom’s National Health Service, shows how limited our understanding is of the relation between culture and health. In its first-ever analysis of “minority health” in the United Kingdom, the African-origin population, from West Africa and the Caribbean Commonwealth, was healthier than the indigenous English and Welsh populations: fewer heart attacks, fewer cancers and lower infant mortality. In a surprising twist, the Asian population, largely from India, Pakistan and Bangladesh, had poor health outcomes: higher death rates, more heart attacks and alarmingly high infant mortality.

The positive contributions of diversity to health have been missed by much of official Washington. A recent American College of Physicians report blithely states that “One in three Latinos is uninsured. Like the rest of the population without insurance, they tend to live sicker and die younger.” Yet, in Los Angeles, Latinos have one of the longest life expectancies and lowest disease burdens, in spite of their lack of health insurance.

Even the Department of Health Services reports stumbled over the cultural terrain. A classic question in health surveys asks respondents to state how healthy they feel, with four possible choices: “excellent,” “good,” “fair” or “poor.” In the L.A. surveys, as in many national surveys, Latinos and Asians are more than twice as likely as whites and African Americans to rate their health as fair or poor. Quite often, such responses are confused for a population’s actual health status: “Several studies have shown that self-assessed health is a valid and reliable indicator of a person’s overall health status,” one of the studies mistakenly states.

How is it, then, that the two healthiest segments of L.A.’s population, Latinos and Asians, report that their health is poor? Truth be told, the question is culturally incompetent: It simply should not be asked, for we learn nothing and, furthermore, trying to answer it may lead to false conclusions.

L.A.’s medical-research institutions have yet to realize they are sitting on a gold mine for 21st-century U.S. medicine. Los Angeles is the country’s living laboratory for understanding the linkage between culture and health. Houston is famous for its heart procedures and Boston for the New England Journal of Medicine. The Southland can be equally famed for revealing the relation between health and culture, with the region’s diversity as backdrop. *