The health of latino children in the United States

The Health of Latino Children in the United States Fernando S. Mendoza

More than ever before, Latinos form a significant presence in the United States. Demographically, socially, and politically, Latinos and other minority groups are changing the face of American society. California is one example. In California, almost 26% of the population is now Latino. 1 Among children entering kindergarten with English as their second language, 100 different dialects are spoken. Three-quarters of these children are Spanish-speaking. 2 In the United States as a whole, the Latino population increased about 4% each year from 1980 to 1991. By 1991, Latinos were 9.3% of the U.S. population, up from 6.8% in 1980. 3 This rapid growth occurred as a result of both higher-than-average fertility and sustained flow of immigrants from Latin America. 3Clearly, Latinos are a significant part of America's future. What does this population trend mean for our society and its institutions? H o w should those who set public policy respond to these changes to ensure that we have a united and not a divided nation? To build upon one of the country's fundamental strengths, the diversity of its people, each individual must have the opportunity to succeed and believe that success is a possibility for him or her. One step toward achieving this match between opportunity and self-empowerment is to ensure that children remain healthy so Reprinted from The Future of Children, Critical Health Issues for Children and Youth, Volume 4, Number 3, Winter 1994, pages 43-72. We are grateful to the authors for allowing its republication here. Fernando S. Mendoza, MD, MPH, is associate professor of pediatrics and associate dean of student affairs at Stanford University School of Medicine. CURRPROBLPEDIATR1995;25:314-36. 53/1/69142

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that they can achieve their fullest potential. Not only do children need to learn behaviors that will keep them healthy, but also the social conditions in which they grow and mature must foster their health and well-being. This article will outline the important health issues for Latino children in the United States. The intent is not to delineate specific policies, but to identify critical factors to consider in policy development. First, current demographic trends are reviewed to provide a context for the discussion. A brief historical perspective on each of the major subgroups is given to highlight the underlying diversity of the Latino population. Next, significant health issues are discussed by developmental phase, including infancy, preschool age, school age, and adolescence. Then, issues that affect Latinos more globally, such as access to medical care and health insurance, are discussed. Finally, conclusions about policy implications are drawn.

A Word About Terminology "Hispanic" is the term used by the U.S. Department of Commerce, Bureau of the Census, for all individuals with ethnic origins from countries where Spanish is the primary language. Included are Mexico, Puerto Rico, Cuba, the Dominican Republic, Central and South America, and Spain. In the census materials, where detailed information is presented, data on persons of Mexican, Puerto Rican, and Cuban origin are provided, while those who are from Spain or are identified only as Hispanic are categorized in an "other Hispanic" group. The term "mainland Puerto Rican" is used to describe Puerto Ricans living in the continental United States. In numerous studies, the terms "Mexican-American" and "Cu-

Current Problems in Pediatrics / November/December 1995

TABLE 1. Number of births, fertility rates, and total fertility rates, by race and Hispanic origin, United States, 1990 Race/Ethnicity of Mother

Number of Births

Fertility Rate ~

Total Fertility Rateb

2,626,500 661,70t 3,457,417

62.8 89.0 67.1

1,850.5 2,547.5 1,979.5

Hispanic d Mexican American Puerto Rican ~' Cuban American Other f Total

385,640 58,807 11,311 139,315 595,073

118.9 82.9 52.6 102.7 107.7

3,214.0 2,301.0 1,459.5 2,877.0 2,959.5

Asian/Pacific Islander Chinese American Japanese American Hawaiian Filipino American Othera Total

22,737 8,674 6,099 25,770 78,355 141,635

49.9 40.8 115.1 63.5 91.8 69.6

1,357.5 1,111.8 3,223.3 1,881.0 2,675.0 2,002.5

39,051

76.2

2,184.5

4,158,212

70.9

2,081.0

Non-Hispanic White Black Totalc

American Indian/Alaskan Native Total All"

"Per 1,000women aged 15 to 44 years. bRates are sums of birthrates for five-year age groups multiplied by 5. qncludes races other than white and black. aPersons of Hispanic origin may be of any race. Rates are based on births and population in 48 states and the District of Columbia; New Hampshire and Oklahoma did not report Hispanic origin on the birth certificate. r persons of Puerto Rican origin residing in the 50 states and the District of Columbia. fIncludes Central and South American infants (83,008) and other and unknown Hispanic infants (56,307). ~Comprising primarily Southeast Asian and Asian Indian Americans. hlncludes persons for whom origin was not stated. Source: Centers for Disease Contro] and Prevention. Childbearing patterns among selected racial/ethnic minority groups--United States, 1990. Morbidityand Mortality WeeklyReport(May 28, 1993) 42,20:398-403. ban-American" are used to describe persons of Mexican or Cuban descent w h o reside in the United States but w h o s e citizenship is not explicitly defined. Persons of Hispanic origin are sometimes called Latinos, Spanish Americans or Hispanos. While most individuals identify themselves b y their c o u n t r y of origin, one of these generic terms usually is used to describe all subgroups. " H i s p a n i c " is the most general term, as it encompasses all Spanish-speaking origins. "Latino" usually is used to describe persons with ethnic origins f r o m a S p a n i s h - s p e a k i n g c o u n t r y in the Americas. Because this is the term that best describes the vast majority of people in the United States w h o originated from a Spanish-speaking country, here it will be u s e d interchangeably with "Hispanic."

Demographic Trends: A Complex and Heterogeneous Population The Latino p o p u l a t i o n in the United States is large and fast-growing. Within the Latino population, each

s u b p o p u l a t i o n historically has been c o n c e n t r a t e d in specific geographic areas, and each has a distinct social history. We will briefly examine these d e m o g r a p h i c and historical trends, for they are the driving force that will require policymakers at local, state, and national levels to consider the needs of the Latino population.

Composition, Size, and Growth Latinos c o m p r i s e a p p r o x i m a t e l y 9% of the total U.S. p o p u l a t i o n - - j u s t over 22 million people. 4 This figure represents significant g r o w t h over the past decade, which is the result of both high fertility rates and ongoing immigration. Between 1980 and 1990, the Latino p o p u l a t i o n in the United States increased b y 53%. By comparison, non-Latino whites increased b y 4.4% and black Americans, b y 13.2%. Asians s h o w e d the largest percentage increase at 107.8%, although the absolute n u m b e r of persons was smaller. Table 1 shows U.S. fertility rates for t990. For the United States as a whole, the fertility rate was 70.9 per 1,000 w o m e n of childbearing age. Latinos' fertility rate

Current Problems in Pediatrics / November/December 1995

315

Latino Population in the United States by Country of origin, 1992 Other "7oL

Cuban 5%

Puer

Rica 11'~ Central/Sour

American

4exican 63%

14%

FIGURE 1. Latino population in the United States by country of origin, 1992. (From U.S. Bureau of the Census. The Hispanic population in the United States: March 1992. Current Population Reports, Series P-20, No. 465RV. Washington, DC: U.S. Government Printing Office, 1993. (107.7) was about 71% higher than that for white nonLatinos (62.8). A m o n g Latino subgroups, Mexican Americans had the highest fertility rate (118.9). As n o t e d above, the Latino p o p u l a t i o n in the United States is diverse. Figure 1 depicts the composition of the Latino population by subgroup, based on country of originJ Data from the Latino National Political Survey s indicate that individuals of Latino heritage prefer to identify themselves by a national-originbased term rather than by a more pan-ethnic Latino or Hispanic label. Between 1980 and 1990, population growth varied by subgroup, with the largest increase in absolute numbers in the Mexican population, which increased by 4.8 million. The high level of growth in the Latino population is projected to continue into the next century. The Census Bureau indicates that Latinos may be 11% of the population in the year 2000, 13% in 2010, 17% in 2030, and 21% in 2050.1 (See Figure 2.)

Undocumented Immigrants The exact n u m b e r of Latinos w h o are undocumented immigrants ("illegal aliens") in the United States at any given time is not known. A number of estimates have been made; these are necessarily speculative and preliminary. Unofficial estimates from the U.S. Bureau of the Census put the total number of illegal immigrants at about 4 million persons as of April 1993. 6 According to the U.S. Immigration and Naturalization Service (INS), the number was about 3.2 million in October 1992. 7Net growth in the undocumented population is estimated at 250,000 to 300,000 per year. 6 The U.S. Bureau of the Census estimates that at least 50% of all undocumented immigrants in the United

316

States are of Hispanic origin--a total of about 2 million. Undocumented persons of Hispanic origin are primarily from Mexico, E1 Salvador, and Guatemala; 7 persons from Puerto Rico do not fall into this category. In 1992, the INS estimated that slightly more than 30%, or just over one million, of all illegal immigrants were from Mexico. Unofficial 1993 estimates by the U.S. Bureau of the Census showed that 52.1% of the undocumented population lived in California, 13% lived in Texas, and 9.3% lived in N e w York. 6 It is not known how many undocumented residents are children. A 1987 study 8reported that 70.5% of the counted undocumented population was aged 15 to 44. In the young adult ages, there was a marked excess of males, particularly of those born in Mexico; for ages 15 to 34, 57.5% of undocumented Mexicans were males. About 20% of those from Mexico were children under age 15, suggesting that many of those counted in the census are in families which have established residence in the United States. The Census Bureau is currently working in conjunction with the INS to update their estimates using data from the Immigration Reform and Control Act (IRCA) of 1986, which allowed persons who remain in the United States illegally and who arrived before January 1982 to register with impunity, and other indirect sources of information. It is estimated that, of the 3 million immigrants provided amnesty through the Immigration Reform and Control Act of 1986, nearly 1.6 million were in California. The demographic data on this group of immigrants as of 1990 show that 4.9% were less than 14 years, and another 5.5% were between 14 and 17 years. These are children belonging to families that were in the United States prior to 1982 or families that had worked in agriculture for at least 90 days in each of the three years prior to 1986. Therefore, it is likely that the proportion of new undocumented immigrants who are children is probably around 10%. It should be noted that research on health needs of Latinos generally has not differentiated between those who are U.S. citizens and those who are undocumented immigrants; thus, it is unknown how many undocumented residents are included in the studies. For example, the Hispanic Health and Nutrition Examination Survey (HHANES) did not ask whether or not participants were legal residents. It may be assumed that HHANES probably included many who.were undocumented. It is reasonable to assume that the needs of this population are similar to those of other Latinos living in poverty. Further, while the parents may be undocumented, some or all of the children may have been born in the United States and may, therefore, be U.S. citizens.

Current Problems in Pediatrics / November/December 1995

BOX 1. Caring for undocumented children: a personal perspective The use of public services for children of undocumented immigrants is currently a front-line political issue. Many have difficulty understanding w h y tax revenues should be used to provide health and educational services to children who do not belong in this country. A more humanitarian approach acknowledges that children do not have control over where they reside and therefore should not be punished by having services withheld because they are "illegal." Still others take the public health perspective that illnesses left untreated will likely become worse and may increase the risk for illness among others; therefore, provision of health services to children of undocumented adults is good public health policy. Yet in the current atmosphere of political debate involving health care reform, support for health care for undocumented children has not been prominent. Rather, the undocumented workers and their children have become political untouchables, viewed as the cause of unemployment, increased government spending, and increased crime. While none of these views can be well supported, immigrants often become scapegoats during economically troubled times. In reality, much of what is legal or illegal in terms of immigration is determined by the needs of the host country at the time policies are set. In this instance, especially in the Southwest and specifically in California, the need has been for cheap labor for agriculture. At the turn of the century, Mexicans immigrated to California to work in the fields. It was agriculture that made California a leading economic power in the United States and provided the basis for its subsequent technological development. Many of these Mexican field workers were undocumented, but when they were working in the fields doing back-breaking labor, many times with their children, no one asked for their papers. When they were paid less than the minimum wage but were charged excessive prices for food and shelter, no one asked whether they were detracting from the state's economy. And when their children attended segregated schools and rarely received basic health care, no one asked whether they were underutilizing the social services they were entitled to. Today, undocumented Mexican immigrants continue to provide the cheap labor needed to support the economy of California and other states. However, they are not only working in the fields, but also tending our gardens, cleaning our homes, making and serving our food, and taking care of our children. A recent report *by the Amnesty Education Unit of the Chancellor's Office of California Community Colleges shows that they are 5% of California's population but make up 12% of the work force. Even more remarkable findings were that 89% worked (compared with 53% of all Californians), and of those who worked most held more than one job (compared with 6% of all Californians). Yet, the average annual income for these immigrants was $11,400 compared with $24,921 for all Californians. Even with these hardships, immigrants from Mexico and other countries continued to come to the United States, documented and undocumented, because they believed that, by coming to this country, they could invest in the futures of their children and their children's children. Although society as a whole denied them, they believed in themselves and their families. Today, the children of Mexican immigrants are the teachers, doctors, lawyers, and business people who are on the verge of leading this country into the twenty-first century. Like many others of Mexican descent, I am thankful to my grandparents and parents for their sacrifices. So when I see the faces of children of the new immigrants, whether documented or undocumented, rich or poor, of color or not, I see the future and understand the importance of their success. --F.S.M. ~Source:Amnesty Education Unit. The new Californians: ten facts about immigration amnesty applicants. Sacramento, CA: Chancellor's Office,California Community Colleges,June 1, 1992.

Current Problems in Pediatrics / November/December 1995

317

Hispanic Population Growth, United States, 1970 to 2050

80.7 I r O

. w

Year

FIGURE 2. Hispanic population growth, United States, 1970 to 2050. From 1992 on the figures are based on middle series projections. Sources: U.S. Bureau of the Census. 1970 census of population: Persons of Spanish origin. PC(2)IC. Washington, DC: U.S. Government Printing Office, 1973; U.S. Bureau of'the Census. 1980 census of population: General social and economic characteristics. PC80-$1-7. Washington, DC: U.S. Government Printing Office, 1984; U.S. Bureau of the Census. U.S. Department of Commerce News. CB91-100. Washington, DC: U.S. Government Printing Office, 1991; U.S. Bureau of the Census. Population projections of the United States, by age, sex, race, and Hispanic origin: 1992 to 2050. Current Population Reports, Series P-25, No. 1092, Washington, DC: U.S. Government Printing Office, 1992.

Age Structure The Latino population is a relatively youthful one (see Figure 3). According to the U.S. Census Bureau, about 30% of Latinos are under age 15, compared with only 20% of the non-Hispanic white population. In 1992, the median age of Latinos was 26 years, compared with 34 years among non-Latino persons. 4 Among Latino subgroups, persons of Cuban origin were oldest, with a median age of 40 years, and persons of Mexican origin were the youngest, with a median age of 24 years. These distinctions suggest differing health-related needs among subgroups. While issues relating to children have particular urgency for Mexican and Puerto Rican families, Cuban Americans--like non-Latino whites--will soon require attention to their growing group of elderly. Latino families are more likely to have children present than are non-Latino families (Figure 4). According to the 1990 census, 63% of Latino families had children under 18 living with the family, compared with 47% of non-Latino families.

Geographic Distribution Although Latinos live in every state, almost 90% of all Latinos live in 10 states (Figure 5). In particular, California is home to one of every three Latinos, and Texas, to nearly one of every five Latinos. In the Northeast, much of the Latino population is located in Massachusetts, N e w Jersey, and N e w York. In the South, Florida is the state with the most sizable Latino population, as are Illinois in the Midwest and Arizona, Colorado, and N e w Mexico in the Southwest.

318

Of Latino subpopulations, those of Mexican origin are most likely to live in California and the southwestern states. A substantial proportion of the Puerto Rican population is located in the N e w York City metropolitan area, and many of Cuban origin are living in Florida. In addition, significant populations of these subgroups now live in other areas of the country (Figure 6). For example, more than 600,000 persons of Mexican origin live in Illinois, primarily in the Chicago metropolitan area. Many of Cuban descent live in California, N e w Jersey, and New York.

Income and Poverty Latinos of all ages are more apt to live in poverty than non-Latinos 1 (Figure 7). In 1991, more than one in four Latinos (28.8%) were living below the poverty level, compared with 12.9% of non-Latinos. As Figure 7 shows, 41% of all Latino children live in poverty, twice the proportion of non-Latino children living in poverty. In 1992, while Latino children represented 11.6% of all children in the United States, they were 21.5% of all children living in poverty. 4 And while Latinos are now about 9% of the total population, they are about 18% of all those living below poverty level in the United States. Table 2 shows how the Latino population compares with other ethnic groups in terms of the proportion living in poverty. Among the ethnic groups reported in the census, Latinos rank second (black Americans are first) in terms of the proportion in poverty. Latino families were also more likely than nonLatino families to live in poverty (Figure 8). Since 1989

Current Problems in Pediatrics / November/December 1995

Families with Own Children, United States, 1970 to 1990

Age of the Population, United States, 1990 0.4%[] 1.3%

85 + 80 to 84

0.6% r ~ 1.7%

75 to 79

1.0% r ]

70 to 74

1.3% r - ]

2.6%

2.0% ~ F - ]

65 to 69 60 to 64

70%

55%

4.3%

3.4% ~

50 to 54

50%

47%

4.7%

P 45 to 49 0=

4.3% ~ 5 . 7 %

~- 40 to 44

5 . 7 % ~ 7

35 to 39 9

30 to 34

. .

4 2

7.2%

%

~

%

~

8.7% 8.4%

25 to 29

1

0

.

5

%

~

20 to 24

1

0

.

3

%

~

I

8.1%

1970

9

7.4%

10 to 14

9

.

8

10.7% ~

%

~

7.0%

~

]

7.1%

9 Hispanic

[ ] Non-Hispanic

FIGURE 3. Age of the population, United States, 1990. Sources: U.S. Bureau of the Census, Data User Services Division. 1990 census of population and housing. Summary tape file 1C. Washington, DC, 1990; U.S. Bureau of the Census. The Hispanic population of the United States: March 1992. Current Population Reports, Series P-20, No. 465RV. Washington, DC: U.S. Government Printing Office, 1993. the proportion of Latino families living below the poverty level has been rising (from 23.4% in 1989 to 26.5% in 1991). Similar increases were not seen in the nonLatino population. Among Latino subgroups, poverty rates for families and children differ dramatically (Table 3). Puerto Rican families are most likely to be living in poverty (35.6%), and Cuban families are least likely (13.9%). A brief look at the immigration history of each ethnic subgroup will help to put some of these population trends into perspective. A Brief Historical O v e r v i e w o f

I 1980

1990

Year

15 to 19

Under 5

63%

2.5% ~ F - - ' ] 4.4% 2 . 9 % ~ FT-] 4.4%

55 to 59

5to 9

67%

3.4%

Latino

Subpopulations While Latinos share a common language and, to some degree, common cultural elements, there are differences among and within subgroups that pertain to social class, legal status, educational levels, and cul-

Hispanic

[]

Non-Hispanic

FIGURE 4. Families with own children, United States, 1970 to 1990. Sources: U.S. Bureau of the Census. 1970 census of population: Persons of Spanish origin. PC(2)IC. Washington, DC: U.S. Government Printing Office, 1973; U.S. Bureau of the Census. 1980 census of population: General social and economic characteristics. PC80-1-C1. Washington, DC: U.S. Government Printing Office, 1984; U.S. Bureau of the Census. 1990 census qfl population and housing. CP-I-1. U.S. Government Printing Office, 1992; U.S. Bureau of the Census9 Fertility of American women: June 1990. Current Population Reports, Series P-20, No. 454. Washington, DC: U.S. Government Printing Office, 1991. tural norms. This is particularly true for the first generation of immigrants, based upon the history of their immigration and experience as immigrants in this country. These differences have an important bearing on current health status and will be briefly described for each subpopulation. Mexican. There is great variability in the population of Mexican origin in the United States. Persons of Mexican descent have lived in the United States since the formation of the country and may be U.S. citizens, legal residents, or illegal immigrants. The recent history of Mexican immigration consists of two broad periods? The first is from the turn of the century through the mid-1960s. This period was characterized by extreme fluctuations in the number immigrating, depending on the labor demand in the United States. Most immigrants worked in agriculture, meat packing, brickyards and canneries, becoming the backbone of the work force in these industries. Since the mid-1960s, growing unemployment in Mexico and the prospect of employment has led to increased immigra-

Current Problems in Pediatrics / November/December 1995

319

Hispanic Population Growth for Selected States, 1990 (percentage distribution) All other states 13.0% Massachusetts Colorado New Mexico Arizona

3alifornia

34.4%

New Jersey

Illinois

New YOrK

Texas

9.9%

19.4%

FIGURE 5. Hispanic population growth for selected states, 1990 (percentage distribution). Source: U.S. Bureau of the Census. U.S. Department of Commerce News. CB91-100. Washington, DC: U.S. Government Printing Office, 1991. tion to the United States. Many of the immigrants are undocumented and are working in low-paying jobs. Puerto Rican. In contrast, Puerto Ricans have a very different history of immigration. Migration for this subpopulation reflects the dependent relationship of the island, first as a U.S. possession in 1898 and then as a commonwealth in 1952. It was after World War II that the most significant migration to the United States began. Most migrants m o v e d to the industrial centers of the eastern seaboard, especially N e w York, where they worked in the textile and garment industries; 50% of all mainland Puerto Ricans reside in the N e w York City area. In addition, all Puerto Ricans are U.S. citizens, which means that they are eligible for state and federal health care programs. This universal citizenship has resulted in a back-and-forth migration between Puerto Rico and the United States. Thus, Puerto Ricans are particularly linked to their country of origin even though they may reside in the continental United States. Cuban. Cuban immigration began after the 1959 Cuban Revolution, with political refugees. The early Cuban immigrants were well educated and better off economically than those who followed in later years. Moreover, they were eligible for government refugee resettlement assistance, which aided in the preservation of the Cuban professional and middle classes. Through political asylum, Cuban immigrants also qualified for citizenship quickly,

320

further increasing their access to governmental programs. The support for resettlement and the geographic concentration in Florida, where at present two-thirds of all Cuban Americans reside, provided Cuban Americans with an economic and political base to develop their community. Although many of the later immigrants from Cuba to the United States have been of lower socioeconomic status, the Cuban-American community has been able to maintain a better economic position than other Latino groups. Central~South American and Other. The most recent arrivals are Latinos from Central America who are fleeing political and economic turmoil, and those from the Dominican Republic who seek to improve their economic condition. Unlike Cubans, Central Americans have not been able to obtain ready political asylum. Thus, many are illegal residents who do not feel that they can return to their home countries, leaving them as persons without a country. Summary. Three factors emerge as critical in considering the health of Latino children in the United States: 9 the heterogeneity of the Latino population, including distinctive immigration histories for each subgroup, 9 the geographic concentration of specific Latino subgroups, and 9 the high rates of poverty among Latino families and children.

Current Problems in Pediatrics / November/December 1995

P e r c e n t a g e H i s p a n i c of Total P o p u l a t i o n , by S t a t e 1 9 9 0

MT j:

OR

/ NY

....

WY IA

NE

NM

PA

--NJ

- DE

UT CO KS

MO NC

OK

'.ajJ ~, HI

;'~

/-

\\\ ) FL

b~? AK

I

m

Lessthan 1%

[~

1% to 8%

I 9

9OjotolTOjo

\,

18% and over

FIGURE 6. Percentage Hispanic of total population, by state, 1990. Sources: U.S. Bureau of the Census. 1980 census of population: General social and economic characteristics. PC80-S1-7. Washington, DC: U.S. Governmen~ Printh~g Office, 1984; U.S. Burea~ of the Census. U.S. Department of Commerce News. CB91-100. Washington, DC: U.S. Government Printing Office, 1991.

All of these factors have a significant bearing on the health status of Latino children.

Critical Health Issues for Latino Children To analyze what is known about the health status of Latino children, we will examine topics from a developmental point of view. Significant issues arise in each developmental phase--infancy (0 to 24 months), preschool age (2 to 4 years), school age (5 to 11 years), and adolescence (12 to 18 years). However, an important concern for all age groups is access to health care. This will be discussed first because it is an issue that should be kept in mind when considering specific health problems of Latino children.

Access to Health Care

Latinos' access to health care is an issue that affects all age groups. Studies of health care utilization by Latinos have found that Latinos, particularly Mexican Americans, have lower utilization of physician services than other ethnic groups. For example, Trevino and Moss 1~ found that about one-third of Mexican Americans did not visit a physician at all during the course of a year. Only one-fourth of non-Latinos, Cuban Americans, and "other Hispanics" and one-fifth of Puerto Ricans had no physician visits during the course of a year. In 1986, Andersen and colleagues reported that Latinos found it more difficult than whites to get medical care in 1982, were more often refused medical care

Current Problems in Pediatrics / November/December 1995

321

Persons Below the Poverty Level by Age, United States, 1991 28.8%

Total population

65 years and over

20.7% ~% 22.7%

18 to 64 years

Under 18 years

•

40.7%

19.6%

Percentage of Total BB Hispanic

[ ] Non-Hispanic

FIGURE 7. Persons below the poverty level by age, United States, 1991. Source: U.S. Bureau of the Census. The Hispanic population in the United States. March 1992. Current Population Reports, Series P-20, No. 465RV. Washington, DC: U.S. Government Printing Office, 1993. for financial reasons, and had less insurance coverage than in previous years. 11More Latinos than whites said they put off medical care in 1982 because they had less insurance, needed medical care that year but did not get it, had a serious illness in the family that caused a financial problem, had medical emergencies, and were not satisfied with the medical care they received. In 1986, the National Access Survey 12 found that the proportion of Latinos w h o reported fair or poor health increased from 1982, although it decreased for whites and blacks. The s t u d y found that 21.7% of Latinos were uninsured, a 50% increase from 1982 and more than double the rate for blacks and whites. The percentage of Latinos without a regular source of health care was almost double that for non-Latino whites. In 1991, Trevino and colleagues 13 analyzed data from two separate surveys: the March 1989 Current Population Survey (CPS) and the Hispanic Health and Nutrition Examination Survey (HHANES). These data showed that, among all ethnic groups in the United States, Latinos were least likely to have insurance coverage against losses due to illness. More than one-third of the Mexican-American population, one-fifth of the Puerto Rican population, and one-fourth of the CubanAmerican population were uninsured for medical expenditures. These percentages compared with one-fifth of the black non-Hispanic population and one-tenth of the white non-Hispanic population. Among the unin-

322

sured, most Mexican Americans (53%) and Cuban Americans (60%), and 46% of Puerto Ricans were gainfully employed. Compared with Latinos with private health insurance, uninsured Latinos were less likely to have a regular source of health care, less likely to have visited a physician in the past year, less likely to have had a routine physical examination, and less likely to rate their health status as excellent or very good. Valdez and colleagues 14note that Latinos, particularly Mexican Americans, are uninsured because their primary employment is in the lower skilled and paid sectors of the economy, which are less likely to provide insurance coverage as a benefit. Further, a large percentage of Latinos live in states such as Texas and Florida, which severely restrict eligibility for Medicaid services and thereby increase the number of uninsured. Even those who are eligible for Medicaid have "access" difficulties because low reimbursement rates and payment delays limit the number of providers who are willing to take Medicaid patients. Valdez and colleagues found that, in 1989, 39% of Latinos under age 65, or 7.2 million persons, were uninsured for the entire year (Table 4). This rate was three times higher than that for Anglos (non-Latino whites) and almost twice the rate experienced by blacks. Among Latinos, there was substantial variability by subgroup. Mexican Americans and Central and South Americans experienced the highest rates. The proportion of uninsured also varied by state because of differences in Medicaid coverages and by geographic region (with highest rates in the South and Southwest, Table 5). Most individuals obtain their health insurance coverage through employment, either directly or through a parent or spouse. Latinos had a higher concentration than other ethnic groups in lowcoverage industries and smaller firms, reducing their likelihood of receiving health benefits.

Infant Health Among the most widely used measures of infant health in populations are infant mortality and birth weight. What do we know about these pregnancy outcome measures in Latino populations? /..

Mortality. Only recently have infant mortality data on Latinos in the United States been published. Before 1991, infant mortality risks among Latinos had not been evaluated at the national level. In 1991, Becerra and colleagues is analyzed the 1983 and 1984 Linked Birth and Infant Death data sets, providing the first national assessment of Latino infant mortality. As Table 6 shows, Latino neonatal (less than 27 days) and infant (28 to 364 days) mortality rates overall are much lower than those of black Americans and approximate the rates of the non-Hispanic white popu-

Current Problems in Pediatrics / November/December 1995

F a m i l i e s B e l o w t h e P o v e r t y L e v e l , U n i t e d S t a t e s , 1981 to 1991

30 u)

(9

. m

27.2%

E

~

26.5o/,

LL 20 0 (9 (9

10 11.4% 9.2%

r(9 0"i

I

I

I

I

I

I

I

10.2% I

1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 Year

-~-- Hispanic

~

Non-Hispanic

FIGURE 8. Families below the poverty level, United States, 1981 to 1991. Source: U.S. Bureau of the Census. Poverty in the United States: 1991. Current Population Reports, Series P-60. No. 181. Washington, DC: U.S. Government Printing Office, 1992. lation. These rates are lower than might be expected given the high rates of poverty among Latinos, since morbidity and mortality are often associated with poverty. When Latino subgroups are examined, rates for Latinos of Mexican and Cuban origin are the same as or even lower than those for non-Hispanic whites. However, Puerto Ricans have rates that are significantly higher (7.9 and 11.6 for neonatal and infant mortality, respectively) than those of non-Hispanic whites. Except for Puerto Ricans, Latinos in all subgroups who were born outside the continental United States had slightly lower mortality rates than those born in the continental United States. In a 1993 study of final natality statistics for 1991, Ventura and Martin ~6 found that rates of low birth weight (LBW)--that is, less than 2,500 grams--were 6.1% among all Hispanic infants, 5.7% among non-Hispanic white infants, and 13.6% among non-Hispanic black infants. Rates of low birth weight, like neonatal and infant mortality rates, varied within the Hispanic population. Among infants born in the continental United States, the low birth weight rate was highest among infants of Puerto Rican descent (7.9%) and lowest among those of Cuban origin (4.8%). The low birth weight rate among single-delivery infants born in Puerto Rico was 8.3%. Mendoza and colleagues 17examined data from the 1987 National Vital Statistics System and the Hispanic H e a l t h a n d N u t r i t i o n E x a m i n a t i o n S u r v e y (1982 through 1984), comparing incidence of low birth weight among Mexican, Puerto Rican, and Cuban infants by Low Birth Weight and Preterm Birth.

TABLE 2. Persons below poverty level, 1991 Persons Total

Percentage below poverty level 14.2

Hispanic 28.7 Non-Hispanic white 9.4 Asian and Pacific Islander 13.8 Black 32.7 Source: u.s. Bureau of the Census. Poverty in the United States: 1991. Current Population Reports, Series P-60, No. 181. Washington,DC: U.S. GovernmentPrintingOffice,1992. nativity status of the mother and by the trimester when prenatal care was begun. Overall, the low birth weight rate for Latinos (7.0%) was higher than that for nonHispanic white infants (5.6%) but lower than that for non-Hispanic black infants (12.9%). However, rates among Latino subgroups again showed differences. Rates were lowest for infants of Mexican and Cuban origin (5.7% and 5.9%, respectively) and highest for Puerto Rican infants (9.3%). Overall, Latinos had a higher rate of preterm births (less than 37 weeks gestation) than non-Latino whites for women over 20 years of age (10.5% and 7.9%, respectively). However, w h e n comparisons between Latino subgroups were made, differences emerged. Women of Cuban descent had a preterm birth rate of 8.7%, while those of Mexican descent had a rate of 10.5%, and those of Puerto Rican origin, a rate of 12.1%. Black women had a rate of 17.3%. Among all groups, the incidence of preterm birth was found to be associated with the timing of prenatal care.

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TABLE 3. Poverty rates for Latino families and children, 1991 Ethnicity

Families below poverty level

Female-headed families below poverty level

Children below poverty level

Percentage Latino 26.5 49.7 40.4 Mexican 27.4 47.7 39.7 Puerto Rican 35.6 66.3 57.9 Cuban 13.9 -33.3 Central/South American 23.9 42.9 33.4 Non-Latino white 7.1 24.6 13.1 Source: U.S.Bureau of the Census. The Hispanic population in the United States:March 1992. Current Population Reports,SeriesP-20,No. 465RV. Washington, DC: U.S. Government Printing Office,1993,pp. 16-17,20-21. Mendoza and colleagues observed that prenatal care seemed to have the least effect on the prevalence of low birth weight for mothers of Mexican origin. Even with no prenatal care or care begun in the third trimester, only 7.2% of mothers had low birth weight infants. This compares with 9.5% for non-Latino whites with the same care pattern. This finding is important because w o m e n of Mexican descent are least likely to utilize prenatal care; approximately 40% do not start prenatal care in the first trimester, and 13% receive late or no prenatal care. TM Reasons for the lower-than-expected rate of low birth weight among w o m e n of Mexican origin are unknown. Health behaviors during pregnancy have been suggested as a possible explanation, but further research is needed to identify specific behaviors or other factors that may contribute to this finding. For example, while Mexican-American w o m e n have a lower rate of cigarette smoking, Shiono and colleagues 19 found that this fact is not responsible for their low rate of low birth weight. It has been suggested that, although low birth weight has been a principal means for assessing pregnancy outcome, it may not adequately indicate infant health status for some populations. 2~ Other Parameters. Information available on other parameters of infant health among Latinos is limited. The Hispanic Health and Nutrition Examination Survey (HHANES), conducted by the National Center for Health Statistics in 1982-1984, was the first comprehensive health survey of Mexican Americans in the Southwest, Puerto Ricans living in N e w York City, and Cuban Americans residing in Miami. Before HHANES, data on Latino children were limited to results of small clinical studies and regional epidemiologic studies. 21 Congenital Anomalies. A m o n g Latinos, congenital anomalies do not appear to occur at a greater rate than for non-Latino whites. Approximately 2% of newborn infants are born with a major malformation, and another 3% have anomalies found later in childhood. 22

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Data from HHANES showed that, among MexicanAmerican, Cuban-American, and Puerto Rican children living in the continental United States, 0.5% or less had a known or physically visible congenital anomaly, a~ Chavez and colleagues analyzed data from the Birth Defect Monitoring Program of the Centers for Disease Control and Prevention and found that, overall, Latinos had fewer congenital anomalies (14.4 per 1,000) than did non-Latino whites (18.9 per 1,000) or blacks (17.9 per 1,000). 23 For Mexican-American children, only 1 per 1,000 live births had Down's syndrome, a rate slightly lower than that for the non-Latino white population (1 per 600 to 800 live births). 23 Because data on congenital anomalies causing fetal or neonatal death are not currently available, conclusions about risks for congenital anomalies among Latinos must be guarded. In 1989, the U.S. Standard Certificate of Live Births was modified by the National Center for Health Statistics both to increase the data base concerning live births and to improve the data on Latinos and other minorities, a4 Beginning with the 1989 data year, the information should be available on almost all births in the United States each year. More complete data and, thus, more accurate conclusions about the prevalence of congenital anomalies and other conditions should result. The growth patterns of Latino infants (0 to 24 months) are difficult to assess because of the lack of longitudinal data. Cross-sectional data from HHANES are available for 12-, 24-, and 36-monthold children. These data suggest that, through infancy and early childhood, Latino children--specifically Mexican-American and Puerto Rican children living in the continental United States--have growth patterns similar to those for non-Latino whites. 25 Yet clinical studies report high rates of failure to thrive among poor Latino children, a6 Most of these studies drew their samples from public facilities that may be treating a poor population of children, those who are new immigrants with limited access to health and nutritional Growth and Nutrition.

Current Problems in Pediatrics / November/December 1995

TABLE 4. Proportion of uninsured nonelderly (<65-year-old) residents in the United States by Year and Ethnicitya Ethnicityb

1979 Number (x 1000)

1989 Percentage

Number (x 1000)

Percentage

Number (x 1000)

Change Percentage

All United States 28,703 14.8 37,739 17.5 9,036 315.5 Latino 2,860 25.7 7,177 39.0 4,317 150.9 Mexican 2,119 27.8 5,301 41.6 3,182 150.2 Puerto Rican 291 16.5 463 22.6 172 59.1 Cuban 165 22.1 192 22.1 27 16.4 Other c 285 28.9 1,221 44.3 936 328.4 Anglo 19,716 12.7 22,281 13.8 2,256 13.0 Black 5,236 22.7 6,584 24.0 1,348 25.7 Asian and other 891 22.1 1,695 21.8 804 90.2 ~'Sourcesof data were March 1980and 1990Current Population Surveys. bLatinoindicates Hispanics of any race from the Western hemisphere; Anglo, the non-Hispanicwhite population and Hispanics of European country of origin; black, the non-Hispanicblack population or AfricanAmericans; and Asian and other, the remainder of the non-Hispanic population, which is composedprimarily of peoples of Asian heritage. tOther Latinosinclude Central and South Americans. Source: Valdez RB, Morgenstern H, Brown ER, et al. Insuring Latinos against the costs of illness. Journal of the American MedicalAssociation (February 1993)269,7:891. programs, and those whose families may be in a tenuous socioeconomic situation. Nutritional data from the HHANES show that the prevalence of iron deficiency anemia is less than 2% among Mexican-American, mainland Puerto Rican, and Cuban-American irtfants 0 to 2 years. 27An evaluation of the dietary intake of infants found that Mexican-American infants i to 2 years were most deficient in intakes of fruits and vegetables and least deficient in milk intake. 28 Last, of note in the Mexican-American sample from HHANES, 49% of eligible children less than 2 years of age had received nutritional supplements from the Women, Infants, and Children (WIC) program. 29 Overall, although some growth and nutritional findings indicate that Latino infants are doing fairly well, others still suggest that the quality of diets available to these infants and their access to nutritional supplement programs may be lacking. Moreover, the demographics of this population of children imply that their economic resources are not sufficient to meet adequate housing and food needs. This alone should be sufficient, reason to give high priority to nutritional programs for Latino infants. Developmental Issues. Developmental problems during infancy are always of concern because they may be the antecedents of significant functional impairment for preschool and school-age children. At present, there is v e r y little d o c u m e n t e d e p i d e m i o l o g i c data on the p r e v a l e n c e of significant d e v e l o p m e n t a l p r o b l e m s among Latino infants. Parental reports in the H H A N E S indicated that approximately 0.2% of Mexican-American and mainland Puerto Rican children, ages 6 months to 4 years, had mental retardation. 25,3~It is not possible to determine if the mental retardation of these children is mild,

moderate, or severe. Among the general population of children, 3% have some degree of mental retardation, and approximately 0.15% have severe retardation. 22 Speech p r o b l e m s w ere r e p o r t e d by p a r e n t s in HHANES for 2.3% of Mexican-American and 1.3% of mainland Puerto Rican children 6 months to 4 years. 3~ One could speculate that the parental reports in the HHANES may underestimate the developmental problems among Latino children because such a high proportion of persons are uninsured and, therefore, may not have had access to a physician for diagnosis. Future studies are needed to both estimate and validate the preval ence of d e v e l o p m e n t a l p r o b l e m s a m o n g Latino children. Infectious Diseases. Infectious diseases are of particular concern in Latino infants because of adverse environmental conditions associated with poverty, lack of i m m u n i z a t i o n s , and limited access to health care. Latinos appear to be at higher risk of common childhood illnesses preventable by immunization than members of other ethnic groups. 31 For example, in Los Angeles County, California, in 1988 Latinos' risk of measles was 3.6 times greater than for black children and 12.6 times greater than for non-Latino white children. An overrepresentation of Latinos was documented in periodic measles outbreaks in the United States during the 1980s. As a result of a lack of rubella immunizations among susceptible w om en in their childbearing years, increased rates of rubella and congenital rubella syndrome were reported in New York City in 1986. 31 In 1990, low rates of immunization among Latino children were documented by the Children and Youth Policy Project. Among Latino infants, only 34.6% had adequate immunizations by 2 years of age, and only 11.8% of immigrant Latino infants were i m mu n iz e d

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TABLE 5. Health insurance coverage in the nine states with the largest Latino nonelderly populations in 1989a State

Total (•

All United States

18,422

Proportion of nonelderly Latino population, percentage Uninsured Medicaid Other insuredb 39.0

11.8

49.2

California 6,944 43.7 11.0 45.3 Texas 3,980 47.6 7.8 44.6 New York 1,727 31.0 26.2 42.8 Florida 1,331 36.5 6.7 56.8 Illinois 828 22.9 12.0 65.2 New Jersey 533 28.1 10.5 61.5 Connecticut 123 13.5 11.5 75.0 Washington 106 23.3 20.3 56.4 Michigan 100 12.5 25.5 62.1 aSourceof data was March 1990Current PopulationSurvey. bOther insured categoryincludesgroup and individualcoverage,as well as someMedicarecoverage. Source: Valdez RB, MorgensternH, BrownER, et al. Insuring Latinosagainst the costs of Illness. Journalof the American MedicalAssociation (February 1993) 269,7:892. fully by 2 years of age. Non-Latino whites were immunized at a rate of 47.3%, and blacks at a rate of 20.0%. An increase in HIV infection and AIDS among Latina women has resulted in an increased incidence of AIDS among their infants. Latina women account for 20.8% of the reported AIDS cases a m o n g U.S. women but comprise only 8.6% of the U.S. female population. 32 Twenty-four percent of childhood AIDS cases are Latino children, although Latino children comprise only 13% of U.S. children. Puerto Ricans seem to be disproportionately affected compared with other Latino subgroups. The greatest number of Latino pediatric AIDS cases are in New York City, followed by Puerto Rico. Perinatal transmission accounts for 88% of pediatric AIDS cases among Latino infants. 32 These figures make clear the need for aggressive and effective health education for Latinos, particularly for women of childbearing age. Latino women and men, especially youth and young adults, need education on how their behavior might affect themselves and others, including those who are unborn.

Chronic Illness and Unintentional Injury. Mortality from chronic illnesses and unintentional injury is difficult to estimate for Latino infants because of the lack of ethnic-specific mortality data. Recently, the National Center for Health Statistics (NCHS) and the Centers for Disease Control and Prevention (CDC) have begun to obtain ethnic-specific mortality data. s3 This information will greatly improve our knowledge in this area. At present, the rates of chronic medical conditions among Latino infants do not appear to be higher than those for non-Latino white infants. 34 Summary. It is premature to describe with any certainty the health and developmental status of Latino

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infants. Clearly, we need to improve our knowledge about health issues in this population. In the meantime, because infancy is the most critical time with respect to the rapidity of physical and developmental growth, programs such as WIC and immunization programs seem appropriate and needed, as is general access to health care.

Preschool-Age Children The preschool-age period, from two to five years of age, is a unique and critical time in a child's life. Although the rate of physical growth of children slows somewhat, their rate of cognitive, psychological, and social development continues at a rapid pace. Preschool children are more interactive with their environment than infants, and this activity can have both positive and negative consequences. For example, problems resulting from exposure to environmental toxins such as lead become critical at this age. Unintentional injuries also become more common. Although the environment holds risks to children's health, the environment also provides the stimulation so necessary for cognitive development. It is during this period that children begin to experience organized learning with other children, in either formal or informal settings. The preschool period is when children begin to develop independence from their parents and b e g i n to d e v e l o p their o w n s e l f - a w a r e n e s s a n d identity. Health and developmental problems that manifest themselves during infancy and receive little or no treatment m a y continue into the preschool years. Such chronic problems may affect a young child's health and development during these years. Moreover, children living in impoverished environments--first as infants, then as preschoolers--may require even more health

Current Problems in Pediatrics / November/December 1995

services than the family and local health agencies are able to provide. Forty-two percent of Latino children in this age group are living in povertyY Twenty-nine percent live in single-parent families, and 30% are without health insurance. 3s These figures demonstrate the limited resources available to Latino preschool children and their families. Growth and Nutrition. The growth of children traditionally has been a measure of children's overall wellbeing. Although Latino children demonstrate average weight gains during the preschool years, their linear growth, or height, is somewhat stunted. It is linear growth that best measures overall growth of children and that is best for comparing one population with another. While linear growth, or stature, of individual children can be affected by genetic factors, for most populations of children, poor nutrition and recurrent illness are the major factors causing poor linear growth and leading to populations of shorter children. ~" In contrast, a child's weight can be affected by similar factors but is more likely to show catch-up growth. Indeed, for Mexican-American children in particular, weights seem to be less affected by poverty than their heights. Martorell and colleagues 37 found that, for Mexican-American children two to five years old in the HHANES, poverty or socioeconomic status was a major determinant of children's stature. Children of Mexican origin were about 2 centimeters shorter on the average than the U.S. norm. Their findings indicate that, if these children were not living in poverty, their heights and overall growth would be similar to that of the average U.S. child. One reason for slower growth may be poor nutritional intake. One s t u d y of the Central Valley in California found that one in eight children was going hungry; most of these children were poor and Latino. Nutritional supplement programs such as WIC usually are not available to children older than two or three years of age because of the limited resources of this program. Food stamp distribution to families is also dependent upon legal residency status and, therefore, may not be meeting the needs of all Latino children. Latino children three to five years old were found in one study to have poor intakes of fruits and vegetables, and high intakes of fat and s u g a r y According to the HHANES, iron deficiency anemia was present in only 0.5% of Mexican-American and 1.3% of m a i n l a n d Puerto Rican preschoolers assessed. These rates compare with the national rate of 5%. 3~ Chronic Medical Conditions. Unlike growth and nutrition, chronic medical conditions among preschoolers do not appear to vary with poverty levels. According

TABLE 6. U.S. neonatal and infant mortality risks a by ethnicity, 1983-84 Ethnicity

Neonatal Mortality

Infant Mortality

Non-Hispanic white 5.2 8.3 Black 10.9 17.2 Hispanic 5.6 8.7 Mexican 5.2 8.3 Puerto Rican 7.9 11.6 Cuban 5.0 7.0 Other b 5.5 8.4 aRiskscalculatedper 1,000 livebirths. bIncludes Central American, South American, and other Spanish ethnic origin. Source: BecerraJE, Hogue CJR,AtrashJK, and Perez N. Infantmortality among Hispanics: A portrait of heterogeneity. Journal of the American MedicalAssociation (January1991)265,2:217.

to the HHANES, 2.3% of Mexican-American, 7.4% of mainland Puerto Rican, and less than 1% of CubanAmerican preschoolers had chronic medical conditions. 34 Except for the Mexican-American sample, in which younger children had a lower prevalence than older children, the rates of chronic medical conditions for preschool, school age, and adolescence were not significantly different. The conditions found included both physical and developmental health problems. Both the overall rate of chronic medical conditions and the types of conditions were similar to those of non-Latino whites, except for a higher prevalence among the mainland Puerto Rican children. Among mainland Puerto Rican children sampled in the HHANES who had a chronic medical condition, 62% had asthma. A similar high rate of asthma has been noted in Puerto Rico. 39 If the cases of asthma were eliminated from the Puerto Rican sample, the prevalence of chronic medical conditions among Puerto Rican children would be similar to or lower than that of the non-Latino white population (5%). Parental Perceptions of Children's Health. Another way of measuring overall health is to obtain the assessment of a parent. When a parent categorizes a child's health as excellent, very good, good, fair, or poor, important insight is obtained about the parent's perspective of health. While this perspective may be influenced by a variety of factors, such as socioeconomic status, cultural perspective, or prior experiences with the health care system, it still may provide the best global assessment of the child's functional health status, answering the question, "Is the child doing well or not?" In the 1984 National Health Interview Survey conducted on a national probability sample by the National Center for Health Statiistics,ao 3% of non-Latino white mothers stated that their children were in fair to poor

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327

TABLE 7. Percentage of children and adolescents rated in poor health Mexican-American Mainland Puerto Rican Cuban-American Intergroup difference a Mothers of children 6 months to 11 years 14.1 19.9 6.7c p<.01 Mothers of adolescents 12 to 18 years 16.9 20.1b 8.4c NS Children 6 to 11 years 11.4 15.2b 16.5c NS Adolescents 12 to 18 years 18.7 17.0 7.5c NS aBychi-square adjustedfor sample weightsand complexsample design. bPopulationestimatedoes not meet usual reliabilitystandards and can be used onlyfor an approximationof true population estimates. cPopulationestimateis unreliableand, therefore,estimateonly reflectsattributes of examinedsubjects. Source: MendozaFS, Martorell R, and CastilloRO. Interim report--Health and nutritional status of Mexican-American children. Grant No. MCJ060518. Rockville,MD: Maternal and Child Health ResearchProgram, Bureau of Maternal and Child Health and Resources Development, 1989, p. 110. health. About 5% of black mothers reported their children to be in fair or poor health. Among preschool child r e n s a m p l e d in H H A N E S , 11.3% of MexicanAmerican mothers, 15.7% of mainland Puerto Rican mothers, and 2.4% of Cuban-American mothers reported their children in poor health. These rates doubled for children who lived in poverty and for children whose home language was Spanish. Interestingly, the children who came from bilingual homes had a rate that was intermediate to the rates of children who spoke English at home (lowest rate) and those who spoke Spanish at home (highest rate). This suggests that a cultural influence, in addition to the socioeconomic, may be affecting mothers' perception of children's health status. Latina mothers who perceived their own health as poor were more likely to perceive their children's health as poor. Most important, if Latina mothers perceive their children to have poor health, then their children appear to have increased utilization of health care services. 41 However, questions remain. Does increased maternal concern about a child's health support or detract from the child's health and developmental status? Does increased health care utilization improve the child's health or label him or her as a vulnerable child? We need to u n d e r s t a n d the d e t e r m i n a n t s of this perception among the mothers. Because policies and interventions involving preschoolers must involve parents, a better understanding of the parental perspective of risk for children is needed. Exposure to Environmental Toxins. Exposure to environmental toxins can have direct effects on the health and development of Latino preschoolers. Most commonly, lead is the toxin of concern because of its ubiquity and its now well-documented effects on the developing child, even at low levels of exposure. In 1990, Carter-Pokras and colleagues reported blood lead levels among 4- to 11-year-old Mexican-American, Puerto Rican, and

328

Cuban-American children in HHANES. 42 Preschoolers were most at risk, with 4.9% of Mexican-American and 10.6% of Puerto Rican preschoolers having levels greater than 25 micrograms per deciliter (~g/dl). Fifteen percent of Mexican-American and 20.1% of Puerto Rican children had lead levels greater than 15 ~g/dl. (The current standard for an elevated lead level is 15 mg/dl.) It might be expected that Puerto Rican children would have higher-than-normal lead levels because they were principally sampled in the HHANES from the New York City area. Yet Mexican-Americans who were sampled in the southwestern United States also showed significant levels. It is clear from their data that the physical environment of poverty can have a direct health and developmental effect on Latino children. Exposure to pesticides has also been a source of concern. Unfortunately, data on this type of exposure are seriously lacking. It is surmised that, because many of the farmworkers in the United States are Latino, particularly in the midwestern and western states, their children are at risk for exposure to pesticides. The risk may be compounded by substandard housing, often located in close proximity to the fields. Children may be sprayed inadvertently while they play outdoors in the vicinity of fields.43 Children may also be at risk while working in the fields. Wilk 43 estimates that 25% of farm labor is performed by children, and young children frequently are in the fields with their parents because of a lack of child care. Pollack 44 s u r v e y e d 50 c h i l d r e n of m i g r a n t farmworkers in the state of New York and found that 36% had been sprayed in the fields, and 35% had been sprayed while in their farm dwelling. Moses 45has raised concerns about the short- and long-term exposure to pesticides of the children of farmworkers and the possible links to health and developmental problems, particularly cancers. This area of research is vitally important for Latino children who live in rural areas.

Current Problems in Pediatrics / November/December 1995

TABLE 8. Projected percentage reduction in the uninsured rates under different strategies for covering the uninsured by ethnicity Strategy Percentage uninsured in 1989

Total United States 17.5

Latino

Anglo

Black

39.0 13.8 24.0 Projected Percentage Reduction 37 23 42 36 33 37 21 19 16 39 34 32 23 23 20 44 41 38 54 40 56

Asian and Other 21.8

25 Poor (<1.0 PI) 29 33 All children (<18 years) 34 17 Full-time workers 18 Full-time workers and minor dependents 34 30 20 Full-time/part-time workers 22 Full-time/part-time workers and dependents 41 38 40 Full-time workers and poor 46 Source of data was March 1990Current Population Survey. PI indicates PovertyIndex. Source:ValdezRB, MorgensternH, and BrownER, et al. Insuring Latinosagainst the costs of illness.Journalof theAmericanMedicalAssociation (February 1993)269,7:894.

Summary. Latino preschoolers are at particular risk of exposure to environmental toxins and suffer from lack of access to medical care. Some health problems are more likely to occur within certain subgroups. For example, Puerto Rican children in this age group have a higher rate of asthma.

with 14% of non-Latino white school children. Thus, while the prevalence of chronic conditions for Latino school-age children is probably no greater than for nonLatino whites, the lack of health care is likely to have a particularly significant impact on those who do have chronic health problems.

School-Age Children The health issues of school-age Latino children, ages 5 to 11 years, are, to some degree, a continuation of those previously seen in the infancy and preschool periods.

Perceptions of Health Status. As noted above, how a person perceives his or her health can be taken as an assessment of overall functional health. The HHANES queried half of all school-age children surveyed about their perception of their own health. At the same time, the survey's physicians were asked to make a global assessment of each child's health. Although the physicians assessed less than 1% of school-age children's health as fair to poor, 11.4% of Mexican-American and 15.2% of Puerto Rican schoolage children rated themselves in fair to poor health (Table 7). 34 The p r o p o r t i o n s w ere even h i g h e r for Spanish-speaking schoolage children, 25% for Mexican Americans and 27% for mainland Puerto Ricans. 3~It is evi dent from these findings that school-age Latino children have significant concerns about their health. Furthermore, mothers' ratings of school-age children also showed high percentages concerned about their c h i l d r e n ' s health. S e v e n t e e n p e r c e n t of MexicanAmerican and 23.3% of Puerto Rican mothers believed that their children were in poor health. Differences between physicians' assessments and mothers' and children's assessments of health status are difficult to evaluate. Perhaps Latino children have unmet health care needs. These could be health problems that w oul d respond to medical treatment (for example, recurrent infections), or they could be health concerns that are less amenable to medical therapy (for example, stress-related disorders). Health problems in the latter group may have cultural underpinnings and

Chronic Medical Conditions. The rate of chronic medical conditions such as asthma does not change significantly during this period compared with the preschool years. However, the increased demand on children to undertake normal activities and become active learners requires that any morbidity or dysfunction arising from a chronic medical condition be minimized to have the least effect on the child's development. For example, asthma can be effectively controlled to minimize its effect on children. However, lack of access to health care and insufficient funds to purchase needed medication and equipment can result in even mild asthma causing significant morbidity and mortality. 46 The H H A N E S data s h o w e d differences a m o n g Latino subgroups in medical treatment obtained for chronic medical conditions. Of Mexican-American children with chronic conditions, 58% reported visiting a physician in the past year, while 79% of Puerto Rican children with chronic conditions visited a physician in the previous year. 34 This difference reflects the fact that 36% of Mexican-American children are uninsured, while only 13% of mainland Puerto Rican children are without health insurance. 3s Of all school-age Latino children, one-third are uninsured. This compares

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may be affected by the family's cultural perspective of health. This is not to say that the conditions initiating these health concerns are not real. Rather, initiators for these disorders may be the same as for other, nonLatino patients (such as poverty, family disruption, or anxiety with a life situation), but the symptoms may be expressed differently by Latino patients. If health care providers are unable to respond to these patient issues, then the patients' health care needs will not be met. To accomplish this task requires that health care providers, and health care systems, be culturally sensitive. In the final analysis, it is this psychosocial connection of health care providers to their patients that is required to meet the health care needs of patients. At the program level, improving the situation for Latinos can be accomplished by educating health care providers about Latino culture(s) and increasing the number of persons from Latino backgrounds w h o enter the health care professions.

Obesity.

Perhaps most problematic to school-age Latino children, for long-term health, is the issue of obesity. Mexican-American and Puerto Rican children are significantly more obese than non-Latino white children. 3y,47Both of these Latino subgroups show increased fat deposition in the trunk, which has been linked with higher cardiovascular disease risk in adults. 4y,4s Interestingly, despite this deposition of fat in the trunk area, Mexican Americans may have less heart disease than members of other ethnic groups. 4s The higher prevalence of obesity among MexicanAmerican and Puerto Rican children seems to start as early as six to seven years of age and is seen throughout adolescence and adulthood. 47,4s The high rate of obesity is of concern not only because of the potential risk for cardiovascular disease, but because of its link to Type II diabetes. Latinos, especially Mexican Americans, are at high risk of Type II diabetes, which is associated with obesity. The prevalence of Type II diabetes among Latinos is two to three times greater than that found among non-Hispanic whites. 49 At present, more than twice as many Latino as non-Latino adults are above the 95th percentile for weight, that is, are considered obese. S~ To avoid the morbidity associated with obesity in adulthood, aggressive nutritional and physical exercise programs which are culturally appropriate are needed for school-age Latino children. That programs be culturally appropriate is essential because of the importance of helping Latino children maintain a positive selfimage. This is particularly true with respect to diet manipulation, where cultural norms need to be taken into account.

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Summary. A m o n g s c h o o l - a g e c h i l d r e n , o b e s i t y emerges as a problem of particular significance for long-term health, which is added to those previously described for the younger age groups. Adolescents Adolescence is the transition from childhood into adulthood (ages 12 to 18 years). For Latino adolescents, several issues emerge as critical: problems with growth and nutrition, perceived poor health status, high rates of infectious disease, and high-risk behaviors that can have serious consequences for health and well-being.

Growth and Nutrition. In adolescence, it appears that Mexican Americans and mainland P u e r t o Ricans undergo less of a growth spurt than do non-Latino white adolescents. ByThe overall result is that Latino adolescents are significantly shorter than non-Latino adolescents. Mexican Americans also are somewhat delayed in their sexual maturation, while mainland Puerto Ricans are similar to other U.S. adolescents. 4a This stunting of linear growth for Mexican Americans and Puerto Ricans and possible delay in sexual maturation for Mexican Americans may be the result of poor nutrition. For example, Mexican-American adolescents report very poor nutrient intake, with only 55% taking in the recommended daily food group requirements. In addition, Mexican-American and mainland Puerto Rican female adolescents have been found to have the highest rates of iron deficiency anemia when compared with other age and sex groups of Latinos. 2z These data suggest that the quality of the diets of Latino adolescents with respect to specific nutrients such as iron may not be adequate. Like their younger cohort, Latino adolescents have high intakes of fats and sugar, and these intakes most likely are the underlying cause of the obesity noted among Latino adolescents. 47~~The high sugar content of Latino adolescents' diets may also be one reason that Latino adolescents, especially Mexican Americans, appear to have a higher prevalence of dental caries and gingivitis, or gum inflammation, than the general population and a greater need for dental care. 51 Nutritional programs providing education and supplements are fairly limited for adolescents in general and for Latino adolescents in particular. This is because the limited resources available for nutritional programs have been directed at younger age groups. But with the high rates of poverty and the possible nutrition-related health problems that are evident among Latino adolescents, specific policies are needed to improve the nutritional status of this population. Beyond the growth and dietary deficiencies noted above, inadequate diets and hunger among Latino ado-

Current Problems in Pediatrics / November/December 1995

lescents may be compromising their ability to learn in school. Nutritional programs could be one of the keys to improving school performance, thus easing the transition of this group into the adult world.

Infectious Diseases and High-Risk Behaviors. The period of adolescence is a time when high-risk health behaviors-including early sexual activity, other behaviors increasing the risk of HIV infection, substance abuse, and violence--can result in lifelong consequences. In particular, sexual activity of adolescents can put them at risk of early pregnancy, as well as of infection with sexually transmitted diseases (STDs). The most serious of these is infection with HIV and the development of AIDS. Although Latinos comprise only 12% of 13- to 19-year-olds, they account for 18% of the cases of AIDS reported for this age group, se Throughout the 1980s, rates of gonorrhea decreased for all ethnic groups, including Latinos, although the decline was slower among teenagers than among other age groups. In 1991, Latinos were found to be twice as likely to be infected with gonorrhea as whites. However, Latinos experienced the largest decrease in gonorrhea rates w h e n compared with either blacks or whites. The gonorrhea rate for Latinos decreased by 60%, from 311.0 per 100,000 population in 1985 to 124.4 per 100,000 in 1990. Among whites, the decrease was 64% (129.0 per 100,000 in 1985 and 45.8 in 1991). Among blacks, the rate decreased by only 9~ (from 1,972.6 in 1985 to 1,792.1 in 1991). Latinos and blacks also suffer from higher rates of primary and secondary syphilis than whites. Syphilis rates are six times as high among Latinos as whites (12.6 per 100,000 population versus 2.0 per 100,000 in 1991). ~2 In 1991, syphilis rates for both whites and Latinos decreased, but for blacks they increased alarmingly, by 141%. In the past two to three decades, adolescent sexual activity has been rising, with age at first intercourse decreasing and the number of sexual partners increasing over time. s2 Yet high levels of sexual activity have not been accompanied by consistent use of condoms, which is one w a y to reduce the risks for HIV and STDs. A 1992 study analyzing condom use among 1,198 teenage males ages 15 to 19 in 1988 found that Latinos were less likely to use condoms than either white or black teenagers, s2 While Latinos had the fewest sexual partners, they had intercourse more often each month than blacks, but less often than white teenagers. Clearly, health awareness and prevention programs oriented to Latino adolescents are desperately needed. Substance Abuse. Like other adolescents in the United States, Latino adolescents are experiencing the prob-

lem of substance abuse. Both legal substances (such as alcohol and tobacco) and illegal drugs (such as marijuana and cocaine) have resulted in serious health problems for all adolescents, including Latinos. Results of a national survey reported in 1991 showed that alcohol intake among Latino adolescents was slightly higher than for non-Latino adolescents. 53 Almost 23% of Latinos reported drinking in the past month compared with approximately 20% of non-Latino white adolescents, although Latinos reported less heavy drinking than the non-Latinos. According to the survey, about 10% of both Latino and non-Latino white adolescents had used marijuana in the past year. Latino adolescents reported less cigarette smoking (16.7% smoked during the past year) than non-Latino white adolescents, among w h o m 23.2% smoked in the past year. The data available appear to indicate that, while drug usage among Latinos may be lower than that among non-Latino whites during adolescence, it may be higher during y o u n g adulthood. 54 Chavez and Swain 55 suggest that the problem of drug use among Latino adolescents m a y be underestimated because school-based surveys fail to take dropouts into account. It is clear that prevention and early intervention programs are needed and that these must be sensitive to the cultural milieu of the adolescents.

Violence. Violence as a source of injury and death has become a major public health problem, particularly for adolescents, in the United States. While all adolescent males are at risk for violence, poor, urban young men of color (particularly Latino and African-American) are at highest risk. 56 Only recently have national statistics on homicide for Latinos been published. During the period from 1979 to 1987, Latino adult males were more than 3.5 times as likely to die from homicide as nonLatino whites; Latino females were twice as likely to be murdered as non-Latino whites. Data published by the National Center for Health Statistics 57 from 26 states in 1991 showed that Latino adolescents and young adults have a rate of death from homicide that is more than three times the rate for nonLatino whites (28 per 100,000 population compared with 8 per 100,000 population). These data showed that unintentional injuries were the leading cause of death for Latino adolescents. Other data available also suggest the magnitude of the problem for this segment of the population. For example, in Los Angeles, California, from 1970 to 1979 the homicide rate of Latino males increased nearly 300%, from 9.1 to 32.6 per 100,000 population. The homicide rate most likely varies according to the specific subpopulation and community circumstances, s6 Some of the violence is due to gang activity. According to

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Prothrow-Stith, gangs "speak loudly and clearly to the d e v e l o p m e n t a l issues of adolescents," particularly when those needs are not being met by their environment. s6 Gangs provide a sense of community and of belonging. To be successful, violence prevention strategies must be culturally specific and age-appropriate; and they must include the target population in the decision-making process. Perceived Health Status. Perceived health status during adolescence is even worse than it was during the s c h o o l - a g e y e a r s (see Table 7). A l m o s t 19% of Mexican-American adolescents report that their health is poor. ~ This is almost matched by the proportion of mainland Puerto Rican adolescents (17%) who report poor health. Only 7.5% of Cuban Americans perceive their health to be poor; this proportion is similar to the percentage of non-Latino white adolescents (almost 3%) who report that their health is poor. s7 An interesting finding is that almost 33% of Spanish-speaking adolescents believe that their health is poor. These high rates of poor health perception among Latino adolescents can be compared with results of physician surveys of the same population. Physicians reported that less than 1% of the adolescents had fair to poor health. We can only speculate on the meaning of this discrepancy. Perhaps the combined stresses of adolescence, poverty, and school result in a sense of poor health. Further investigation of this topic is needed to understand why Latino adolescents have this perception. Access to Care. It is estimated that about 34% of Latino adolescents do not have health insurance, compared with only 13% of non-Latino white adolescents24 Among Latino adolescents, there is significant variability by subgroup. Thirty-seven percent of those of Mexican descent lack health insurance, while 11% of Puerto Rican adolescents lack health insurance. Data from the HHANES indicate that cost is the most common barrier to health care for Latino adolescents, and having a regular source of health care is the best predictor of gaining access to care2 s Summary. Latino adolescents are particularly at risk of morbidity and mortality due to high-risk behaviors and other social causes such as violence. These adolescents experience a disproportionately high rate of AIDS and have a much greater chance of dying from homicide than do non-Latino white adolescents.

Conclusions and Policy Implications To fully evaluate the health risks faced by Latino children and youth, more research is needed. The es-

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tablishment of data bases, such as the new birth certificates, will provide standardized information that will help policymakers and planners determine priorities at national, state, and local levels. A federal-level initiative should be developed for obtaining data on highrisk groups of children and adolescents; and this effort should be coordinated with state and local governments. Health care reform will require local health care systems to adjust to the needs of their patient populations to m a x i m i z e efficiency. Clearly, collecting adequate information will be crucial to this process. We know that adult Latinos have good life expectancy, low mortality, and restricted intake of alcohol, tobacco, and drugs among women, especially those who are not acculturated to U.S. norms. Particular vulnerability exists in the area of communicable diseases. Some of these infectious diseases can be prevented easily and inexpensively through immunizations or other measures. Others, such as HIV infection and AIDS, are much more difficult to address. Latino families also are subject to a variety of environmental risks associated with occupational hazards or poverty. We have enough information to know that in some areas, such as pregnancy outcome, we are faced with what has been called an epidemiological paradox: Despite the presence of risk factors (late or no prenatal care, and low-income and education levels), Latinos have relatively low rates of infant mortality and low birth weight. These and other health indicators have suggested to some researchers that, despite high levels of poverty and low levels of educational attainment, the Latino population does not conform to the "urban underclass" model that has formed the basis of social policies addressing the needs of poor and minority populations, s9 Assumed characteristics of the underclass include the following: 9 High rates of persistent poverty 9 High rates of unemployment and low labor force participation 9 Accelerated family disintegration, with males largely absent from the economic and psychological life of the family 9 High rates of welfare dependence 9 Multiple health problems, including low birth weight babies, high infant mortality rates, and increased mortality of adolescents from drugs and gang warfare 9 Educational failure 9 Alienation from major social institutions Hayes-Bautista and colleagues 59argue that Latinos do not fit this model because they exhibit 9 High labor force participation and low labor force desertion 9 High rates of family formation

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9 Low welfare dependency 9 Strong health indicators 9 Strong educational improvement 9 Strong sense of citizenship Because of these discrepancies, they conclude that the underclass model is inappropriate for developing social policy relating to Latinos. Further research is needed to articulate "protective mechanisms" that may cushion against the effects of low-income and education levels, and lack of access to care. Policies should be d e v e l o p e d that m a i n t a i n and b u i l d u p o n the strengths that Latinos bring to U.S. society--in particular, the high cultural value placed on health, family, and work. In addition, what needs to be addressed is lack of opportunity. One such opportunity is access to medical care. In particular, the lack of health insurance coverage has reached crisis proportions. Although Latinos have high rates of employment, they suffer from a number of problems that have a direct impact on their access to health insurance. First, they tend to work for small firms or in other industries that typically do not offer their employees health insurance. In addition, Latinos, especially Mexican Americans, have a greater number of dependents per worker than do Anglos or blacks, because of high birth rates. Valdez and colleagues 14 considered the effects of different strategies for health care reform on Latino populations and concluded that, no matter which strategy is employed, Latinos may still face major health care access difficulties (Table 8). Strategies mandating that employers provide health insurance coverage to employees might actually threaten jobs available to the Latino community. If employers face increased costs of labor, some may be forced to lay off workers, keep wages low, or go out of business. This is especially of concern because of the relatively high concentration of Latinos working for or operating small businesses. In addition, mandates could leave out large segments of the Latino population, especially children. At greatest risk are children whose families are undocumented. These children are most likely to suffer health problems, have little access to health care, and live in poverty. Although their parents may be supporting local and regional economies by working for low wages, the economic infrastructure of these regions is not always willing to include these children in their future health care plans. This is a challenge that must be met by health policymakers and politicians. Mandates for universal health care coverage could have another deleterious effect: Low-wage jobs could show further declines in real wages to pay for the mandated benefits. If Medicaid were available for all of the poor instead of for only categorical groups, many more

Latinos w o u l d be insured. H o w e v e r , this solution would not necessarily improve the problem of access because of provider dissatisfactions with the program and reluctance to participate. As a result of these considerations, ensuring access to medical care in the Latino community will require attention to both the financing mechanisms and the structure of the medical care system. One suggestion is to further pursue consumer-sponsored comprehensive prepaid health plans, which can be created on a large scale and at the local neighborhood level. 14Other alternatives could include the use of school-based clinics or the development of other community-based models. The focus should be on primary care and prevention rather than on acute care. Given the positive health attributes of the Latino population, even with minimal access to care, the goal of health policies for Latino children and families should be to increase levels of wellness and preserve good health behaviors by increasing the accessibility of health care. 6~Preventive measures should be given priority, especially for communicable diseases that can fairly easily be controlled. Health promotion and disease prevention programs are critical for school-age children and adolescents. In particular, education for HIV prevention, drug use prevention, and conflict resolution should be started during the school-age years to be effective. They must also include parents and the local community. Latinos need to be involved, not only as health care providers and educators, but also as consumers with an influential voice. The number of Latino health care providers should be increased. A health practitioner need not be Latino to practice in a Latino community; but the needs of the specific populations being served should guide the development of local health policies and programs. Specific local or regional needs may dictate clear local priorities. For example, Mexican-American farmworkers and their families may be at very high occupational and environmental risk and have extremely limited access to health care. 41 Those on the United States--Mexico border in Texas may live in settlements that lack septic tanks, sewers, and running water or that expose residents to the d u m p i n g of hazardous w a s t e s .61 Perhaps the most difficult group to make policy recommendations for are the undocumented Latino children. While they are most likely to suffer from poverty and its ensuing health problems, they are also least likely to receive health care. These children need to have three categorical issues addressed: funds for health care, comprehensive health education, and improved continuity of care. The first of these recommendations is the most prob-

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lematic b e c a u s e of the c u r r e n t political situation. N o n e theless, if the e c o n o m y of the U n i t e d States i n v o l v e s h e m i s p h e r i c m a r k e t s w i t h Mexico a n d C a n a d a , p e r h a p s in the f u t u r e w i t h the rest of Latin America, p a r t of the e c o n o m i c basis of these m a r k e t s s h o u l d g o t o w a r d m a i n taining the h e a l t h of the p e o p l e in these countries, particularly the h e a l t h of the children. The initiation of the N o r t h A m e r i c a n Free T r a d e A g r e e m e n t s h o u l d p r o v i d e the o p p o r t u n i t y to e x a m i n e this possibility. The t w o o t h e r issues, c o m p r e h e n s i v e h e a l t h e d u cation a n d i m p r o v e d c o n t i n u i t y of care, are m o r e a m e n able to q u i c k e r action. First, the m e d i c a l a c a d e m i e s of the U n i t e d States a n d M e x i c o n e e d to find better w a y s to s h a r e i n f o r m a t i o n o n the h e a l t h care status of their children. It is r a r e t h a t s t u d i e s f o c u s i n g o n M e x i c a n c h i l d r e n w h o live o n the M e x i c a n side of the b o r d e r are p u b l i s h e d in the A m e r i c a n literature, a n d as a result ( a n d n o t e d above), little is k n o w n a b o u t the h e a l t h care n e e d s of i m m i g r a n t children. L e a r n i n g m o r e a b o u t the h e a l t h of the c h i l d r e n living o n b o t h sides of the b o r d e r w o u l d be the first step t o w a r d i m p r o v i n g h e a l t h care for i m m i g r a n t children. I n a d d i t i o n , efforts s h o u l d be m a d e to e d u c a t e L a t i n o c h i l d r e n a n d families a b o u t h e a l t h a n d illness. Second, a n d n o less i m p o r t a n t , w o u l d be to d e v e l o p a h e a l t h care s y s t e m for these c h i l d r e n a n d their families that is international, that is u s a b l e o n b o t h sides of the b o r d e r , a n d t h a t is c o m p r e h e n s i v e . W h i l e this m a y s e e m a n e x p e n s i v e e n d e a v o r , it is n o m o r e costly t h a n the m o n e y s p e n t o n a d v a n c e d illnesses b e c a u s e of m i s s e d d i a g n o s e s , u n n e c e s s a r y tests, or inc r e a s e d n u m b e r of illnesses r e s u l t i n g f r o m d i s c o n t i n u o u s care. I n s u m m a r y , p o l i c y m a k e r s will n e e d to anticipate the g r o w t h in the L a t i n o p o p u l a t i o n n a t i o n w i d e a n d to r e c o g n i z e its h e t e r o g e n e i t y . P o l i c i e s t h a t i m p r o v e c h i l d r e n ' s h e a l t h i n c l u d e t h o s e a i m e d at r e d u c i n g p o v e r t y a n d its associated risks in L a t i n o families. Successful p o l i c y m a k i n g will r e q u i r e a p a r a d i g m shift, f r o m c o n s i d e r i n g L a t i n o s as a social p o l i c y p r o b l e m to v i e w i n g t h e m as an i n v e s t m e n t o p p o r t u n i t y a n d m a x i m i z ing their e n g a g e m e n t in society. The author would like to thank Nora Krantzler for her assistance in editing this article.

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