Health And Health Care

Elderly ethnic minorities generally have greater health problems than their white counterparts. Moreover, minorities tend to have chronic disability at an earlier age than nonminorities (Hawkins & Kildee, 1990). Forty-one percent of elderly Latinos viewed themselves to be in poor or fair health, compared with 29.9% of all elderly (C. Lopez & Aguilera, 1991). Elderly Latinos also have disproportionately higher rates of disability than non-Latinos. Elderly minorities of color face serious problems in the arena of health care delivery. Many begin working at a very early age (often as young as 5 years of age) and are often employed in hard labor (factory work, farm work, or manufacturing) that leaves them with an assortment of work-related illnesses or disabilities. Access to the health care system (e.g., transportation, cost of care, communication) is another problem. Without adequate transportation, many Latino elderly have problems getting to their doctor's office, hospitals, or clinics. When they do arrive, they rarely discover bilingual staff to assist them.

Thirty-one percent of elderly Latinos had been bedridden for 1 to 30 days in the previous year, compared to 22% of elderly whites and 27% of elderly African Americans. In addition, elderly African Americans had an average of 43 ''restricted activity days'' during that same period, compared to 31 days for whites and 37 days for Latinos (C. Lopez & Aguilera, 1991). Latino elderly are less likely to visit a physician when having a health problem (8 visits annually, compared to 9.1 visits for white elderly and 9 for African Americans) (U.S. House Select Committee on Aging, 1989, pp. 9-10).

Even with Medicare, the elderly must put more than 15% of their income toward health care (Ehrenreich, 1990). Latinos are more underinsured for health care than any other racial or ethnic group and suffer disproportionately from disability or illness. Latino elderly are more likely to depend on Medicare to pay for health care; the general elderly population is more likely to have a private source of health insurance. Nevertheless, only 82% of Latino elderly were covered by Medicare, compared to 96% of all elderly (Andrews, 1989, p. 38). Eight percent of Latino elderly have no health insurance, compared to only 1% of all elderly (Andrews, 1989, pp. 37-39).

Data on personal care activities are not always consistent. For example, census data report that a higher proportion of Latino elderly have obstacles to personal care activities and tasks of household management than the overall elderly population (U.S. Bureau of the Census, 1990c, p. 4). A robust indicator of poor health is the need for assistance with activities of daily living (personal care, preparing meals, doing housework, getting around outside, basic finance keeping). However, in another study, it was discovered that nearly 23% of African American elderly need help with one or more of these activities, compared with 15% for whites and 19% for Latinos (C. Lopez & Aguilera, 1991).

In another study by the Commonwealth Fund, ethnic minorities were more likely to have problems with the most basic activities of daily living (eating, toileting, dressing, bathing, and transferring to bed or chair). Forty percent of Latino elderly had such problems, compared with 23% of all elderly. (Transferring was the most troublesome activity for Latinos.) Moreover, 54% of Latino elderly had problems with at least one instrumental activity (money management, telephone use, meal preparation, shopping, and light to heavy housework), compared with 27% of all elderly. Most burdensome for Latinos was heavy housework (Andrews, 1989, pp. 40-43).

Latino elderly rely on their families (typically a spouse or child) more than on other relatives and nonrelatives for assistance with the activities of daily living. Among Latino elderly living with others, more than 60% receive help from a child in the household with the most basic activities of daily living (Westat, 1989). Most Latino elderly do not pay for this family-based support. They live with others because they need such assistance and cannot pay for it (Westat, 1989, tables 2-30, 2-34). Following is an illustration of health and health care delivery problems for an elderly Latino. This story is based on fact. (The name has been changed to protect confidentiality.)

Case Study 1: Latinos

Eighty-three-year-old Samuele Perales, of Mexican descent, has fallen through the cracks of the American Dream. He is one of the countless people whom census takers cannot even find. Samuele is not very sick, but he feels weak and looks pale. He had tried to obtain medical treatment a couple of years ago by hitching a ride early one morning from outside the housing project where he stays with relatives who do not really want him. When he finally arrived at the outpatient clinic, he waited 14 hours without being seen by a physician or a nurse, then returned home. In the weeks that followed, Samuele did not return to the clinic.

Samuele did not, however, disappear completely. Most of the time, he could be seen in the basement cafeteria of an elderly day-care facility located near the center of the barrio and run by a religious agency. It is a nice place for the elderly poor to chat with friends, play cards, listen to music, watch television, eat a hot meal or two, and be safe for a while from the haunting visions of loneliness and the trauma of urban violence. Late one afternoon, volunteer workers at the center noticed that Samuele seemed listless and pale. After asking some questions of him, they communicated his symptoms to a member of the clinic's staff.

The clinic serves a predominantly Latino community, but pamphlets about high blood pressure, smoking, and breast cancer now come in Kurdish, Vietnamese, and Cambodian as well as in Spanish and English. The faces of the outpatients reflect the cultural diversity of the area—and often the hesitation of people for whom the very idea of going to the physician remains foreign. (Once a small group of Kurdish women from Iraq refused to get off the bus at the clinic because they were not sick; they were pregnant but inexperienced with prenatal care.)

The physician ordered some blood tests for Samuele; results indicated anemia. Further tests revealed that Samuele cannot digest vitamin B-12. The nausea and illness the old man has been experiencing for untold years is a simple problem, with a simple solution— a B-12 injection once a month. All Samuele had to do was show up for his appointment. Today Samuele is keeping his end of the agreement.

The clinic is a community-oriented primary-care (COPC) system where patients do not just get rushed in and out. The physician also noticed that Samuele was short of breath and wanted to know why. Samuele admitted that he was not sleeping well. Why not? He said that he was not getting along with the relatives he has been staying with. Why not? Because he was old and forgetful. The physician continued to pry. But why did this adversely affect his sleep? Finally, Samuele revealed that his relatives had kicked him out of the tiny apartment. Then where was he staying? ''With friends at night.'' The physician knew that this signified that Samuele was very close to living on the street. Dignified, polite, and proud, the old man would not come out and say it.

While the physician prescribed a sedative to help with sleep, the clinic nurse took notes on Samuele's condition to pass on to a social worker who, hopefully, would be able to find Samuele a safe place to sleep at night. As they talked, the physician asked Samuele to remove his tattered straw cowboy hat. It was obvious why he always wore it. An oval growth—benign—bulged from the right side of his head. The physician measured the growth to discover whether it had enlarged. It had—a little—but perhaps that was a side effect of the B-12 injections. The physician told Samuele to return in two weeks, partly to continue monitoring his condition, and partly just to make sure that he was still around.

This case study illustrates possible subcultural responses to aging, the role of the elderly in Latino culture, and the need for and right to maximum support and care by others (the moral value of beneficence). Samuele's poverty and his poor health have clearly made him dependent on family and other caregivers. He has a right to have his personal welfare and physical well-being restored and maintained. His family and other caregivers are obligated to him in this regard. Moreover, members of Samuele's family are obliged to offer the highest standards of care of which they are capable in order to prevent any further adverse consequences for him (the moral value of nonmaleficence).

Samuele's professional caregivers are expected to offer preventive care in order to preserve his health and well-being (once again, the moral value of nonmaleficence). Samuele also has the right of continued assistance as long as he needs it (the moral value of fidelity). Since Samuele obviously needs help, his family is obligated to either offer help itself or recruit the services of others. They should not abandon him. In the case study, recall that the health care staff referred Samuele to a local social worker; the moral value of fidelity requires this.

At the macro level, this is an ethical issue of distributive justice. Society has a commitment to share material and/or human resources without regard to ethnicity, race, gender, social class, or subcultural differences. This discussion has offered moral principles—rules of moral conduct—that key on Samuele's health care needs and how he and his family and professional caregivers should respond in light of relevant ethical values and the subcultural context.

Latino elderly are among the most unprotected yet least conspicuous parts of the Latino community; they are unprotected from violent and property crime, health care risks in the environment, and financial liability. Since Latinos, in general, are a young population and among the most poverty-stricken segments of the U.S. population, the needs of Latino elderly tend to be ignored (C. Lopez & Aguilera, 1991). The rapid growth of the Latino elderly population has significant implications for the Latino community as well as for ethical issues of social responsibility and distributive justice, since this elderly population is among the neediest in the nation (Macionis, 1996).

Health care is unquestionably very expensive and therefore, for this reason alone, not equally accessible to all. The limits of biomedical technology are also being questioned (Beauchamp & Childress, 1994). The medical profession and some of those satisfied with the current health care delivery system work to avoid government intervention and regulation. Yet some of the most critical problems involving culturally diverse populations have not received adequate attention.

The following section addresses how subcultures construct their own ethical systems, with a focus on how these systems compare and contrast with the ethical system of the dominant culture. This involves discussion of how conflicts between the two systems are managed.

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