David Hayes-Bautista, PhD, makes a point when spelling his name to emphasize the hyphen. "I put it in to keep the family tree straight," he says. "Actually, in Latin America you don't have to hyphenate. But here, people mess it up and they drop one or another of my names, or they reverse the order, and it mixes up the family tree. So, that hyphen is very important." Such distinctions are indeed very important to the nationally recognized medical sociologist, who, in spite of advice he received when he began his academic career to not study "this Chicano-health stuff ... it's not important ... nobody is interested," has spent 40 years examining the dynamics and processes of the health of the Latino population. His Center for the Study of Latino Health and Culture combines these research interests with teaching medical students, residents and practicing providers to best manage the care of Latino patients. In 2012, he received the Herbert W. Nickens Award from the Association of American Medical Colleges for "outstanding contributions to promoting justice in medical education and health equity in the United States." He spoke with U Magazine editor David Greenwald.
What have you learned that surprises you?
Dr. Hayes-Bautista: I was very surprised by what we now know as the Latino epidemiological paradox. When I was doing my graduate work at UC San Francisco, I was taught the minority-health-disparity model, which says that a population that has a lower income, less education, less access to care compared with the larger population is going to have worse health outcomes. According to that model, one would expect to see more heart attacks, more cancers, more stroke, more infant mortality, shorter life expectancy, more alcoholism, more smoking, etc. There weren't, however, any data specifically on the Latino population. Then in the 1980s we started to get some data based on recent census results. I was expecting to see that Latinos would have more heart attacks, more cancers, more strokes, shorter life expectancy, and all that. And I saw just the opposite. Initially I saw the data just for Los Angeles County, and Latinos had about 30 to 35 percent fewer heart attacks, 25 percent fewer strokes, 40 percent fewer cancers, lower infant mortality, longer life expectancy.
What did you think was going on?
Dr. Hayes-Bautista: My first thought was there's a problem with the data. The Hispanic indicator for the census was new; maybe people forgot to check it off, or something like that. But I also thought, if these data are good, it completely explodes every-thing I was taught. Since then, I've looked across the country. This is an accurate finding. There are 55-million Latinos in the United States. It doesn't matter whether they're in New York, Illinois, Florida, Texas, California, or if they are Cuban, Mexican, Puerto Rican, Salvadoran. They all vary around this paradoxical norm.
Why is understanding this paradox so important?
Dr. Hayes-Bautista: If we can more completely understand the mechanism that yields the Latino epidemiological paradox we can apply that knowledge to save close to 400,000 to 500,000 lives every year in the United States from heart disease, cancer and stroke. It seems that the researchers who are most interested in looking at the Latino epidemiological paradox tend to be Latinos. Your personal experience, your personal biography in many ways informs what you choose to research. By having greater diversity in the medical-research field, we will have more diversity in the questions that are being asked. If there had been more diversity in the past, perhaps we would know the answer by now.
What do you feel is behind the paradox?
Dr. Hayes-Bautista: Clearly it is not a random outcome. And it's not misclassification or an inaccurate observation. I've heard some crazy suggestions for why this finding can't possibly be true - that most sick Latinos go home to die so they don't show up in the data, things like that. It's nonsense. What we are looking at is a very large, stable population. There is nothing random here; there is something at work. Is it diet, frijoles and tortillas? Is it strong families? Is it spirituality? In answer to your question, I don't know.
You have been engaged in trying to bring more Latinos into medical research. What are some of the tactics to accomplish that?
Dr. Hayes-Bautista: This is something I've actually been working on since I was a student at UCSF and we formed a group called Chicanos in Health and Education. Then we helped to form a national group, the National Chicano Health Organization. At UCLA, which I came to in 1987, we created Chicanos/Latinos for Community Medicine, a Latino pre-health-professional group, and, after we documented a shortage in Latino physicians in 2000, we created a community-college pipeline program, Medicos Para el Pueblo/Medical Preparation and Education Pipeline (MEDPEP). We learned that 90 percent of Latinos start their post-secondary education in community college, so that is where we decided to focus our effort. The program currently links 10 or so community colleges to the UCLA medical school. MEDPEP identifies underrepresented minority students with an interest in graduate health-science education, offers conference and research participation, provides academic workshops, engages in leadership development, gives parent/family support, and makes available community-service and job-shadowing opportunities. Since its implementation, more than 200 students have transferred to four-year universities, many of whom are practicing in the healthcare field, attending health-professional schools, and receiving prestigious achievement awards and honors.
We have talked about encouraging underrepresented minority students to pursue careers in medical research. What is the need to bring more into clinical practice?
Dr. Hayes-Bautista: Most of the students who come through the MEDPEP pipeline actually are interested in clinical practice as family physicians or working in community medicine. So we need to reach out and encourage students from areas where there is a shortage of physicians, because it is those students who are most likely to return to those under-served communities to provide care. The truth is that most non-Latino students are not going to learn Spanish so they can work in underserved Latino communities where there is a need. When I speak to students in Bakersfield or Porterville or Visalia, I know they are more likely to return to practice in those areas. It's not 100 percent, sure, but students that come from those areas are more likely to go back. If I am speaking to a student from Long Beach or Manhattan Beach or Redondo, and I ask them how they would like to go practice in Visalia or Turlock, I don't generally get the same positive response. Again, this shows the importance of diversity. A more diverse population of physicians will service a more diverse population of patients.
When you look at Latino physicians, do you find a difference in the way they approach the practice of medicine relative to their colleagues from other backgrounds?
Dr. Hayes-Bautista: We've actually done a lot of work looking at that, going back to that period in 2000 when we identified the increasing shortage of Latino physicians. At that time, there were maybe 300 Latino physicians working in Southern California, and our idea was to write a book that would be helpful to non-Latino physicians who might work with a Latino-patient population. We looked at a large Latino independent practice association (IPA), and we identified the doctors within the IPA who were considered by their fellow physicians to be very good, the ones who were skilled doctors and who had really good relations with their patients. We wanted them to work on a chapter for our book. Most of the physicians, as it turned out, were International Medical Graduates - they had been trained in Latin American countries and then obtained their licenses to practice here. If I can summarize from the book what it is these Latino providers do that our current medical education in the U.S. does not really prepare its graduates for - and it sounds on the surface to be so simple, yet it can be really hard - is to treat each of their patients as unique individuals, each with unique issues in their lives beyond their medical conditions. One physician described for us two sisters, both of them diabetic. One was compliant, happy, outgoing. The other was noncompliant, morose, depressed. They came from the same family background. They ate the same kinds of foods. They had the same disease. But he would not have thought to treat them alike. He treated them as individuals.
That does sound like a very simple approach. Don't we teach that in medicine?
Dr. Hayes-Bautista: Not really. When dealing with minority patients there is a real tendency to say, "All Latinos are alike so tell me the three or four things I need to do with every Latino patient so I can say I'm culturally competent." The same would be true for patients from other ethnic back-grounds. Does a plastic surgeon in Beverly Hills approach his patients like that? No, each one is taken as an individual. As I said, on the surface it seems very simple - treat everybody like an individual. But it is far more difficult to do it in practice. There are classic narratives about race and ethnicity in this country. We saw that played out in the last presi-dential election. And those narratives are current in medicine just as they are in other areas of society. We have to get beyond the narratives.