Compounding inequalities: racism, ageism, and health

Abstract

If the COVID-19 pandemic has showcased the best in medical advances, with manufacture of new vaccines within a year of the discovery of the virus, it has also highlighted the worst in global health-care provision, revealing systemic ageism and racism. These systemic failings have long been deep-rooted in health-care practice and policies. The chronic stress of racial minority groups experiencing marginalisation and microaggressions results in a deterioration of physical and mental health, known as “weathering”, illustrating the erosion of bodies. This phenomenon explains the higher mortality rates of Black men with prostate cancer and Black pregnant women in both the USA and the UK, and higher prevalence of mental health issues and lower life expectancy for Black people in both countries. Poor health outcomes are exacerbated by reduced access to health-care and compromised quality of care. In health-care systems in which access is contingent on securing insurance, such as in the USA, minority groups are placed at a disadvantage due to high insurance costs. However, even in public systems, such as the UK's National Health Service, treatment for minorities is shown to be inadequate, exemplified by consistent reports of lower satisfaction and poorer experience of care in British minority ethnic patients with cancer, compared with White patients, on the annual National Cancer Patient Experience Survey. Ageism, independent of race, has become entrenched in health-care systems. Although major consumers of services, older adults receive inadequate care due to stereotypes, prejudice, and discrimination. Studies have shown that older patients with lung cancer in the UK are referred less often for surgery, and that doctors are less likely to provide breast cancer screening for older women. Structural barriers exacerbate poor quality of care for older adults, including lack of transportation options compounding existing mobility restrictions, a shortage of geriatric specialists, and a recent shift to telehealth, in all countries for which data are reported. The combination of ageism and racism in health-care paints a concerning picture. A study published this month found that people with dementia experienced elevated risk of COVID-19 and poorer outcomes, and that this was especially the case for Black people with dementia, who were twice as likely to contract COVID-19 than were White people with dementia. By definition, the cumulative stress of racial discrimination will result in the most severe weathering in older adults; in fact, studies have shown that the chronicity of stress, rather than the severity, is linked to compromised health and premature mortality. Older adults from racial minority groups often exhibit poorer health-related quality of life, lower life expectancy, and greater multimorbidity. Moreover, their poor mental health has been largely overlooked and, given their experience of perpetual stress paired with the stigma of mental health difficulties, requires greater attention and support. The damaging effects of combined racism and ageism present a pressing public health challenge. In this issue, a study by Mahmud and colleagues showes that among older adults who received a flu vaccine, those from racial and ethnic minority groups were less likely to receive the more effective high-dose vaccine. These findings are important in refuting that health-care inequities stem exclusively from behaviours and attitudes of minority groups, often cited as justifications, such as greater mistrust in health-care or vaccine hesitancy, and force us to acknowledge structural barriers to vaccine uptake and access. Interventions are needed to address the unique needs and challenges facing older adults from minority groups. For example, as individuals from these groups report a preference for treatment from a physician from a similar minority group, interventions must focus on increasing representation of minority physicians, for example via increased support for medical trainees from minority groups to tackle lower completion rates, and rectifying lower compensation for doctors from a minority ethnic background. In the aftermath of the pandemic, when normality resumes, we must resist complacency and continue to hold policymakers and politicians accountable to implement changes within our health-care systems. Sweeping changes are needed within health-care practice, medical education, and research, with the aim of increasing awareness and understanding of the unique challenges of older adults from racial and ethnic minority groups. Only then can we begin to redress the generations of weathering. Effect of race and ethnicity on influenza vaccine uptake among older US Medicare beneficiaries: a record-linkage cohort studySubstantial racial and ethnic disparities in SIV uptake among Medicare beneficiaries aged 65 years or older are evident. New legislative, fiscal, and educational strategies are urgently needed to address these inequities. Full-Text PDF Open Access