|III. Healthcare Outcomes: Inequities in Elderly Latinos'
excerpted Wrom: FDULHPQQWOYIYZUNNYCGPKYLEJGDGVCJVTLBXF
Equitable Health Systems: Cultural and Structural Issues for Latino
Elders, 29 American Journal of Law and Medicine 247-267 (2003) (159
The primary objective of health systems is to improve the health of
populations. While wealth and the social and physical environment are
important determinants of inequitable health outcomes, healthcare
systems also play an important role. Examining the equity of health
status is therefore a key indicator of equity in healthcare systems.
Equity in health outcomes can be determined by making a number of
comparisons between Latino and non-Latino white elderly in terms of
mortality rates, morbidity rates, functional status and self-assessed
Studies focusing on mortality find that Latino older persons have
lower mortality rates than non-Latino whites for certain disease
conditions. Cross- sectional data from the National Center for Health
Statistics show that Latinos age 65 and older are less likely than older
non-Latino whites to die from heart disease, cancer or stroke. The
National Longitudinal Mortality study offers further evidence of the
Latino mortality advantage: both genders and all Latino subgroups have
lower death rates among middle-aged (45-64) and elderly Latinos as
compared to non-Latino whites.
Among the Latino subgroups, Cubans have the most pronounced advantage
and Puerto Ricans the least. Puerto Ricans have higher all-cause, age-
adjusted mortality rates than Cubans (406.1 versus 299.5 per 100,000) or
Mexican Americans (348.4 per 100,000). This pattern among Latino ethnic
groups seems logical since the socioeconomic status of the Cuban
population is higher than that of Puerto Ricans and Mexican Americans.
The Latino advantage for mortality relative to non-Latino whites is
surprising, however, given the disproportionately high poverty levels,
low education and greater risk profile for disease found among the
Latino population. Some have referred to this pattern of high risk and
low mortality as an epidemiological paradox.
The mortality advantage enjoyed by Latinos for cancer and heart
disease, however, does not extend to all other disease conditions.
Latinos of both genders, for example, have a higher mortality at all
ages from diabetes. The mortality rate for diabetes among middleaged and
older Latinos is twice that of the general population. In addition,
Latinos have higher mortality from chronic liver disease, homicide and
HIV as compared to the general population.
The Latino mortality pattern results in Latinos having a higher life
expectancy relative to other racial and ethnic groups. In 2000, the
average life expectancy at birth for the total U.S. population was 73.9
years for males and 79.4 years for females, whereas the life expectancy
for Latino males and females was 75.2 and 82.8, respectively. Latino
life expectancy at age 65 (males 19.1 additional years, and females 22.4
additional years) exhibits an advantage as well when compared to the
total population (males 15.9 additional years, and females 19.5
additional years). Yet while Latinos live longer than other populations,
evidence suggests that they do so in relatively poor health.
Some of the advantages that Latinos experience in the areas of
mortality and life expectancy do not extend to morbidity. Data on the
incidence and prevalence of disease among the population find that
Latinos have higher rates of a number of diseases that significantly
impair individuals' functioning and quality of life. It is estimated
that nearly 85% of elderly Latinos have at least one chronic condition.
Latino elderly experience major medical problems including high
prevalence rates for arthritis, cognitive impairment, diabetes,
cardiovascular disease, depression, hypertension and cerebrovascular
problems. Mexican Americans are more likely than non-Latino whites to
report having high blood pressure, and Latinos overall have a higher
prevalence of influenza, pneumonia, gallbladder disease, and infectious
and parasitic diseases. Studies focusing on cancer indicate that Latinos
are more likely to have cancer of the cervix, stomach, liver, esophagus,
pancreas and gall bladder. Additionally, elderly Latinos are at a
greater risk for developing liver cancer, pancreatic cancer, stomach
cancer and cervical cancer, as well as hypertension and lipid disorders.
They also have higher rates of undiagnosed hypertension compared to
One of the most significant and consistent findings is the excessive
prevalence of diabetes found in the Latino population, particularly
among Mexican Americans. This is particularly significant since diabetes
is considered an "ambulatory sensitive condition," meaning
that adequate outpatient medical care can reduce the severity of the
condition and lower hospitalization and complication rates. Rates of
non-insulin dependent diabetes are two to five times greater for Latinos
than among the general U.S. population in both sexes and at every age.
Latinos also have a higher mortality from diabetes than blacks or
non-Latino whites, regardless of gender or age. They also have earlier
onset and more severe forms of the disease. Among elderly Latinos, Type
II diabetes is associated with muscle loss and functional impairment.
These Latinos also experience higher rates of diabetes-related
complications, which include conditions such as kidney failure, loss of
limbs and blindness. Secondary conditions associated with diabetes can
often be prevented or delayed with adequate medical care, indicating
that the higher complication rates for Latinos maybe an indicator of
inequitable medical care.
C. Functional Status and Self-rated Health
Many of the disease conditions noted above have consequences for
physical and social functioning. As Table 1 infra demonstrates, older
Latinos are more likely than non-Latino whites to report needing
assistance in Activities of Daily Living (ADLs) that involve personal
care functions as well as Instrumental Activities of Daily Living (IADLs)
that involve household care functions. Within each ethnic group, the
disability rates rise as income declines. Older Latinos who live in
poverty are more likely to have ADL needs but are less likely to have
IADL needs as compared to similar non-Latino whites (Table 1).
Latino elderly, on average, experience earlier and more functional
declines than the rest of the older population. Mexican American elderly
are more likely than non-Latino whites to report difficulty eating,
toileting, dressing, preparing meals, shopping, using the telephone and
doing light housework. Disability is not necessarily a static
phenomenon, however, and some functionally disabled persons regain their
independence, such as after post-stroke rehabilitation. Latinos age 60
and older not only have a greater prevalence of ADL and IADL difficulty,
but also are less likely to recover from these difficulties when
compared to non-Latino whites. For Latinos, living longer, therefore,
may not necessarily mean more years with a desirable quality of life.
One study estimated that the total life expectancy of Latinos at age 15
is two years longer than that of non-Latino whites (64 versus 62
additional years), but the disability- free life expectancy is two years
shorter (49 additional years for Latinos versus 51 for whites).
Accordingly, researchers argue that among Latinos, physiological aging
tends to precede chronological aging so that Latinos in their late
forties have health profiles similar to non-Latino whites who are age
A global indicator of health status is how individuals self-assess
their own health. Health status research commonly asks individuals if,
overall, they would say their health is excellent, very good, good, fair
or poor. This question correlates highly with later mortality rates as
well as current morbidity rates and is considered a good global health
measure. As seen in Table 1, about 20% more older Latinos than older
non-Latino whites rate their health fair or poor, a gap that remains
when only considering those living in poverty.
In summary, despite longer Latino life expectancies, significant
inequities exist for older Latinos in a number of health outcomes
including some chronic diseases, disability and self assessed health.
The additional years of life, therefore, do not result in adding
"more life" to their years.