Unequal Burdens and Unheard Voices: The Need for Minority Aging Research and Policy

Unequal Burdens and Unheard Voices:
The Need for Minority Aging Research and Policy

Carmen R. Green, MD, and Gilbert S. Omenn, MD, PhD
University of Michigan

"The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped."
Hubert H. Humphrey

Health disparities policymaking and health disparities research need a special focus on the elderly. The Annual Older Americans’ Month was celebrated for the first time in May 1963. At that time 17 million Americans had reached their 65th birthday; today, nearly 40 million Americans have reached their 65th birthday.(1) Despite numerous references to an aging America, there is less attention directed at who are aging. Currently, 16.1% of all Americans 65 years or older are minority elders, with the majority being African-American. Looking into the crystal ball to the year 2050 reveals a darker and older America with an 81% increase of white elders and a 217% increase in minority elders.(2) Estimates project increases of 128%, 301%, 322%, and 193% for African Americans, Asian Americans, Hispanic Americans, and American Indian and Alaska Native elders respectively.(2) Among the old-old, 85 years of age and older, the relative growth will be less due to lower survival.(3) Elderly women will continue to significantly outnumber elderly men, making aging a particularly important women's health issue.

Racial and ethnic minorities are disadvantaged when compared to whites on most major health indices.(4, 5) Increasing survival after cancers, strokes, and other catastrophic illnesses and injuries has been less among minority elders. The medical and technological advances that have yielded healthier aging for whites have not been applied as successfully for other populations, thus contributing to health and health care disparities. Overall, minorities have increased morbidity, shortened lives, and lower self-reported health even when their health insurance status is similar to whites.(4, 6) Furthermore, minority elders face significant barriers to quality health care because of more limited financial resources and diminished health care access and follow up.(7)

The National Institute on Aging has funded six National Resource Centers for Minority Aging Research.(8) These flagship programs have served an important mission through their commitment to 1) including minority elders in aging research designed to reduce and eliminate disparities, 2) developing the methodology and measures to accurately assess health and predict important outcomes in minority elders, and 3) developing investigators committed to careers in minority aging research. The literature suggests minority elders struggle with greater physical disability and functional limitations.(9) Interdisciplinary scholarship and social research focusing on subpopulations of the aging minority (e.g., in rural and inner city areas) and addressing economic, housing, and urban planning issues is critically important.(10) Local, state, and federal funding for minority aging research, including facilitation of public/private partnerships, is needed. Substantial, sustained efforts to improve the health and well-being of these understudied and vulnerable populations can help the nation’s health status and hopefully 3
our international standing. Both translation of what is known and research on open issues to gain useful new knowledge are needed for more effective policy initiatives in an age- and culturally-sensitive context.

Of course, the determinants of health in the elderly do not begin to act only after reaching age 65. Nevertheless, it is never too late to practice healthier behaviors, promote better health, and prevent chronic and acute diseases. Thirty years ago we showed that the reduction in relative risk from stopping smoking was just as great in people 65 and older participating in the Coronary Artery Surgery Study population (CASS) as among 55-64 and 35-54 year-olds. Moreover, due to the much higher rates of heart attacks and deaths, the absolute benefit in lives saved was far greater per 1000 persons among the elderly.(11) This result was so striking that it was highlighted in the President’s Budget presented to Congress for FY91.

A robust, innovative research agenda to promote successful aging for all should utilize a representative and diverse population across the life span with translational research from bench to bedside and clinic to community to policy--engaging laypersons, clinicians, researchers, and policymakers.(12, 13) Emerging issues that threaten quality of life and public health for millions of Americans such as pain and Alzheimer’s Disease, have received increased awareness and new legislation designed to address knowledge deficits and research funding (e.g., National Pain Care Policy Act of 2009 and the Comprehensive Alzheimer’s Breakthrough Act of 2009), but translation to broader communities is lacking.(13-15) Effective and highly respected participants from the community under study is also critical.(16) In addition, health policy research should work in concert with bench, bedside, and community researchers using4
community-based participatory research principles to address the most perplexing issues (e.g., aging in place, end of life and palliative care) in an interdisciplinary fashion.

Policy initiatives focusing on minority aging are sorely lacking. Often the special implications for minority elders are not even considered. The impact on and discussions including minority elders have attracted minimal attention, for example, during the recent economic meltdown, health care reform debates, and rhetoric about death panels. All in all, there seems to be a continuing failure to recognize that the overall well-being of America is intimately intertwined with the health status of those who are vulnerable, carry an unequal burden, and tend to be unseen and unheard. This situation continues despite increased awareness about increasing social and economic inequalities, clinician variability in decision-making based upon age, race, gender, and class, and many health professionals’ reports of feeling poorly equipped to address the needs of a diverse society in a culturally competent manner.(17, 18) These last points emphasize the importance of workforce preparation, on-the-job training, and diversity issues. For an aging and diverse society, there is a disconnect between such policy goals as the Healthy People 2010 metrics and the fragile academic pipeline, research funding, and service programs to help our country achieve Healthy People 2020 objectives, especially for older adults in reducing functional limitations.(19, 20)

As we turn our attention to implementing the 2010 healthcare reform legislation, we must commit to address health disparities at all ages from children to the elderly. Health promotion, disease prevention, improvements in the health care delivery system, and fundamental enhancements of the social and economic determinants of health all require a health disparities
lens. Nowhere is that lens needed more than in research, policy, and community engagement for minority elders.

REFERENCES
1. Projections of the Population by Age and Sex for the United States: 2010 to 2050 (NP2008-T12) [database on the Internet]2008. Available from: http://www.aoa.gov/AoARoot/Aging_Statistics/index.aspx
2. Projected Population by Single Year of Age, Sex, Race, and Hispanic Origin for the United States: July 1, 2000 to July 1, 2050 (NP2008_D1) [database on the Internet]2008 [cited June 10, 2010]. Available from: http://www.aoa.gov/AoARoot/Aging_Statistics/future_growth/future_growth.aspx#hispanic.
3. Interim State Projections of Population for Five-Year Age Groups and Selected Age Groups by Sex: July 1, 2004 to 2030 [database on the Internet]2005 [cited June 10, 2010]. Available from: http://www.aoa.gov/AoARoot/Aging_Statistics/future_growth/future_growth.aspx.
4. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, editors. Washington, DC: The National Academies Press; 2002.
5. Green CR, Anderson KO, Baker TA, Campbell LC, Decker S, Fillingim RB, et al. The Unequal Burden of Pain: Confronting Racial and Ethnic Disparities in Pain. Pain Medicine. 2003;4(3):277-94.
6. Satcher D. The Unequal Burden of Cancer. Cancer. 2001;91(S1):205-7.
7. Green CR, Ndao-Brumblay SK, West B, Washington T. Differences in Prescription Opioid Analgesic Availability: Comparing Minority and White Pharmacies across Michigan. The Journal of Pain. 2005;6(10):689-99.
8. Resource Centers for Minority Aging Research. [cited 2010 June 10, 2010]; Available from: http://www.rcmar.ucla.edu/centers.php.
9. Whitfield KE. Closing the gap: Improving the health of minority elders in the new millennium (p. ix). Washington D.C.: The Gerontological Society of America; 2004.
10. Committee on Facilitating Interdisciplinary Research, National Academy of Sciences, National Academy of Engineering, Institute of Medicine. Facilitating Interdisciplinary Research. Washington, D.C.: The National Academies Press; 2004.
11. Hermanson B, Omenn GS, Kronmal RA, Gersh BJ. Beneficial six-year outcome of smoking cessation in older men and women with coronary artery disease. Results from the CASS registry. New England Journal of Medicine. 1988;319(21):1365-9.
12. Curry L, Jackson J. The science of including older ethnic and racial group participants in health-related research. Gerontologist. 2003 Feb;43(1):15-7.
13. Green CR. The Healthcare Bubble through the Lens of Pain Research, Practice, and Policy: Advice to the New President and Congress. Editorial. The Journal of Pain 2008;9(12):1071-3.
14. Capps L. H.R. 756: National Pain Care Policy Act of 2009. 2009.6
15. Mikulski B. S. 1492: Alzheimer's Breakthrough Act of 2009 2009.
16. Omenn GS. Caring for the community: The role of partnerships. Academic Medicine: Journal of the Association of American Medical Colleges. 1999;74(7):782-9.
17. Weissman JS, Betancourt J, Campbell EG, Park ER, Kim M, Clarridge B, et al. Resident physicians' preparedness to provide cross-cultural care. Jama. 2005 Sep 7;294(9):1058-67.
18. Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, et al. The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization. The New England Journal of Medicine. 1999;340(8):618-26.
19. U.S. Department of Health and Human Services. Healthy People 2020, Objectives New to Healthy People 2020, OA HP2020–1: Reduce the proportion of older adults who have moderate to severe functional limitations Washington, D.C.2009.
20. U.S. Department of Health and Human Services. Healthy People 2020, Objectives New to Healthy People 2020, OA HP2020–8: Increase the proportion of older adults with reduced physical or cognitive function who engage in light, moderate, or vigorous leisure-time physical activities. Washington, D.C.2009.

Health Equity–Getting beyond Hope

Health is a top priority for Americans, as is often shown in polls commissioned by Research!America and others. In the latter 20th century the Congress invested in that priority, and that investment paid off. Stunning advances made a reality of many Americans’ hopes for longer, better life and a more productive life for ourselves and future generations. From 1950 to 2000, nearly one million early deaths related to coronary disease have been averted, bringing an economic return of $3.6 trillion. To achieve that, the investment in NIH by each American taxpayer has been around $3.70 per year for 30 years. Seat belt laws and public education campaigns about putting babies to sleep on their backs have saved hundreds of thousands of American lives from car accidents and SIDS.

But while this is cause for celebration, we cannot take this pace of progress for granted, and we have much to do to achieve the hope of better health for all Americans.

In Advocacy in Health Care, former Congressman Paul G. Rogers (1921-2008), Research!America’s former chair emeritus, wrote, “We do not hear much in Washington these days about protecting the vulnerable.” It is a sad commentary that his statement is as true today as when he wrote it in 1986.

According to United Health Foundation’s 2009 America’s Health Rankings™ report, the average mortality rate for African-Americans far exceeds that for Caucasians or Hispanics. The CDC found similar disparities in cancer rates. Americans see this as unacceptable: In a 2010 poll commissioned by Research!America, 83% said it is important to conduct research to understand and eliminate these differences and achieve health equity.

Paul Rogers was renowned for saying, “Without research, there is no hope.” Research brings hope for solutions to diseases that currently have none. It tells us which treatments work for which patients. Yet for hope to make an impact, it must inspire action and commitment to a purpose. Health disparities cannot be eliminated without a sustained, significant investment in research.

The hope for health equity is consistent with Americans’ fundamental view that all are created equal. It is long overdue that we make that hope a reality, but without research, there is no hope. We must fund our health research agencies—NIH, CDC, AHRQ, NSF and FDA—at a strong sustained level, to better understand disparities and find new solutions through personalized medicine and prevention. We must fully engage the public as partners in their own health and agenda-setting for research; all health is local, and the public has an invaluable role to play in identifying factors in their communities that contribute to disparities. Lastly, if you are reading this, you likely already have an interest in and knowledge of health disparities. Seek out like-minded organizations or individuals as partners in the fight to end disparities. You may find partners in unexpected places. Educate yourself about ways to tell your elected officials that health equity is important to you and to most Americans. Visit www.researchamerica.org/speaking_out for resources to help.

Seminar 2 begins now...

Readers and cinbtributors are directed to The Planned Segments item beneath the BACKGROUND ON THE BLOG SECTION of our front page. Then scroll down to "The Second Seminar: Health Care in the American Grain which provides the stage set for our blog for the next week thru the 20th of June.