A Latino oral health paradox? Using ethnography to specify the biocultural factors behind epidemiological models.

Angelica, a 28-year old immigrant from a small town in rural Jalisco, Mexico, remembers that she began brushing her teeth at the age of eight to keep them “shiny” and “white.” Because toothpaste was not available in her ranchito of barely 200 houses—and would have been too expensive if it were--Angelica used to heat a tortilla until it grew hard and dry and then ground it into a fine polish. She had learned this trick from her mother, who herself had polished her teeth with charcoal. Yet despite her lack of preventive dental care, Angelica suffered no dental problems until several years after arriving in the U.S., in California’s Central Valley. Partly because of her own childhood free of dental pain, Angelica was unprepared for the dental problems of Oscar, her son born in the U.S. When he was barely two and a half, she remembers, his teeth became “black.” “His teeth were falling out in pieces. And the woman at WIC [the federal Women, Infants, and Children program] told me that it wasn’t normal,” she said. Her son continued to have more cavities; by the time he was nine, he had already had five fillings and two extractions. Although epidemiologists may understand the different oral health profiles of Angelica and her son as evidence for a “Latino health paradox,” for Angelica, her son’s Early Childhood Caries (ECC) came as something of a shock. “Here I am, 28, and I’ve only had one tooth that hurt me. But just look at my poor son,” she lamented. The contrast between Angelica’s and Oscar’s experiences would appear to support the epidemiological model of the “Latino health paradox,” often used to describe a trend of worsening health among Latino immigrants as they acculturate to life in the U.S. Studies of mental health, drug use, cardiovascular disease, and child birthweight have been used to lend support to this much-noted “paradox” (Acevedo-Garcia et al. 2007; Escobar et al. 2000; Sundquist and Winkleby 1999). Yet studies on this “paradox” often lump together Latinos from a variety of cultural origins, and exactly what factors mediate the transition to poorer health status among second- and third-generation Latinos are not well understood. Specific environmental, social, behavioral, and cultural factors contribute to the different oral health profiles of Angelica and her son, and yet the “paradox” model neglects attention to the distinct bio-cultural environment that shaped Angelica’s relatively caries-free childhood. A second epidemiological model may be used to explain Angelica’s childhood free of oral disease—that of the “epidemiological transition.” This model posits a contrast and evolutionary transition between the disease profiles of developing and developed countries, as infectious diseases are believed to give way to chronic “lifestyle diseases.” According to this model, Angelica’s lack of cavities as a child may be due to oral disease being a disease specific to developed countries—that is, a “disease of civilization” caused by a modern diet. Yet the high rates of decay among children in some parts of Mexico (Cook et al. 2008) belie this facile contrast. Indeed, recent scholarship has debunked “the epidemiological transition” model as too simplistic, noting that it relies upon an essentialized opposition between “tradition” and “modernity” that ill-describes the health realities of the stalled modernity (Garcia-Canclini 1995) experienced by developing countries such as Mexico (Martinez and Leal 2003). Moreover, this model has rarely been put into productive dialogue with the model of the “Latino health paradox;” it has little to say about the causes of the pronounced degree of oral disease experienced by Angelica’s son. In this article, we will examine the severe oral disease of children such as Oscar against the backdrop of his mother’s own experiences with oral disease, using ethnography to illuminate important gaps in both epidemiological models. We suggest that a careful ethnographic analysis of the causes of the high rate of oral disease among children of Latino immigrants—maintaining a binational framework--can help redress the limitations of each epidemiological model. Based on in-depth interviews with 29 Mexican immigrant caregivers in rural California and participant observation of family life, we reconstruct the diverse “epidemiological worlds” inhabited by parents in rural and urban Mexico to unravel the specific factors that help mediate this paradox. What explains the contrast in oral health profiles between U.S-born children like Oscar and Mexican immigrant mothers like Angelica? What are the causes of the high rates of oral disease of the U.S.-born children of Mexican immigrants? In examining these questions, we argue that the health problems of children of immigrants must be understood within a bi-national context, and show that epidemiological models relying upon static oppositions between “traditional” and “modern” health practices and disease profiles must give way to more sophisticated processual analyses.