The release of this important compendium of research reviews signals the coming of age of the field of minority aging in the United States. At least two important leadership decisions can be credited for this significant accomplishment: one is the emphasis in statements and rules by the National Institutes of Health on the necessity for including minorities in federally funded research (Chapter 6); the second is support from the Gerontological Society of America for the creation of the Task Force on Minority Issues in Gerontology (c. 1987), the membership of which called for a “comprehensive volume devoted to emergent issues surrounding the aging process of diverse race and ethnic groups” (p. xvii). In the absence of such high-level leadership and the significantly larger population of the United States, Canada lags far behind in the generation of quality research on our immigrant and minority populations.
The impetus to better understand the experiences of racialized older adults is predominantly demographic (Chapter 24). The increasing proportion of people aged 65 and older in the U.S. population overall is matched in significance by the fact that in some parts of the country, the proportion of ethnic groups referred to as “minorities” will exceed that of their “non-Hispanic white” (NHW) counterparts, and their aging experiences are distinct. For example, while more seniors are living longer, healthier, active lives, evidence shows that African-American baby boomers are no better off than their grandparents (Chapter 3). This presents challenges for formal services that must adapt to meet the needs of “minority” seniors who could soon comprise the bulk of their clients. There is evidence that increasing use of nursing homes by minorities is offsetting the migration of many NHWs to assisted living facilities (Chapters 13 and 18). What’s more, this trend may accelerate with the implementation of the Affordable Health Care Act (Chapter 14). Health and social care providers thus need to grapple with the complexities of providing “culturally competent” care (Chapter 12). Some maintain that the workforce is insufficiently prepared for this challenge as only five per cent of social workers undergo gerontological training, and sustained effort is needed to build capacity in this area (Chapter 15).
Minority family caregivers have typically compensated for the insensitivity of formal services to the needs of their elders by providing care in the home (Chapter 3). The caregiving role is often culturally mandated, particularly for women, and minority caregivers often face “poverty, poor health, barriers to service utilization and discrimination” (p. 259). Often, this results in worse physical and mental health outcomes than their NHW counterparts (Chapter 19). Researchers are nonetheless questioning the ability and willingness of younger generations to assume the bulk of responsibility for elder care in light of their exposure to a globalized economy and the cumulative disadvantage experienced by minority populations (Chapter 27).
The populations on which this book focuses the majority of its attention are the African Americans and Hispanics whose numbers are large enough to ensure their representative inclusion in most study designs, even those requiring randomization. Less commonly included in the reviews of extant literature are the Asian/Pacific Islander and Native American populations. That these and other new immigrant groups are relatively understudied is recognized as a methodological shortcoming of the U.S. minority literature in several chapters. This is internally problematic because existing research points to very different patterns in these populations, some of them cultural (e.g., religious affiliation, discussed in Chapter 4), some associated with the process of immigration (e.g., relocation stress, a sudden drop to minority status; see Chapter 5), and others that reflect structural barriers and the paucity of quality care alternatives suitable for minority groups (Chapter 18).
Health outcomes, such as morbidity and mortality, vary considerably across minority and immigrant groups (Chapter 9). For example, whereas levels of disability are higher among Native Americans and U.S.-born African Americans, in concert with cumulative disadvantage theory (as discussed in Chapter 29), new immigrants from Africa and Latin America exhibit a disability advantage due to immigrant selection (Chapter 8). This advantage nonetheless diminishes with time, and older immigrants, in particular, are worse off than their native-born counterparts.
Also problematic is the tendency to use pan-ethnic labels such as Asian-American or Hispanic within which considerable variation is buried (Chapter 4). The call for studies that better reflect the heterogeneity found within ethnic groups is echoed throughout the book. Contributors argue that the poorly defined and inconsistent use of social constructions such as race, culture, and ethnicity obscure their complexity and results in essentialist explanations of health and social outcomes among minority older adults (Chapters 15 and 28). Within-group differences are thus overlooked, cultural dynamism is ignored, and attention is deflected from the structural inequities that underlie apparent cultural/racial differences. This trend is also problematic for Canadians seeking data comparable with our own minority populations, which are predominantly immigrants from Asia.
The sensitivity of contributors to important methodological concerns shared by Canadian ethno-gerontological researchers nonetheless offsets the book’s focus on minority populations and a health system incongruent with those found in Canada (Chapter 33). The majority of authors draw attention to the complexity of variables that intersect and compound the inequities experienced by minority older adults. The intersectionality paradigm, clearly explicated in Chapter 28, is evident, if not explicit, throughout the book’s four sections that draw on the disciplines of psychology, public health/biology, social work, and sociology. For example, research on aging immigrants and racialized minorities with developmental disabilities must avoid conflation of the effects of culture, socioeconomic disadvantage, and discrimination based on colour and disability. Understanding how disadvantage is intensified as each social determinant of health affects the other over time is more important than the influence of any of them in isolation (Chapter 20).
Paying more attention to these intersections within groups represents an important departure from studies that have used ethnocentrically derived constructions, such as IQ, to compare minorities with NHWs. Such comparisons have led to inaccurate and damaging appraisals of the relative “lower intelligence” among or “higher provision of services” to minorities that threaten to skew policy assessments of their abilities and needs (Chapters 3 and 6). Theoretical constructs as well as assessment tools and interventions that are not formulated with reference to NHW experiences alone are desperately needed (Chapter 15).
Less political but similarly inclusive ecological and biopsychosocial approaches are also evident throughout the book. Studies of genetically influenced diseases known to cluster within particular ethnoracial groups (e.g., hypertension, sickle cell anemia, diabetes, obesity) must also take into consideration the influence of income and poverty (Chapter 31), education (Chapter 9), stress associated with minority status (Chapter 5), social capital (Chapter 26), and neighbourhood characteristics and service access (Chapters 17 and 30) which, in turn, affect diet and exercise behaviours (Chapters 11 and 12). The salience of these social determinants for health and social outcomes underscores the importance of targeted health promotion, prevention interventions, and policy changes to minimize risks (Chapter 29).
Also evident in many of the chapters is the importance of adopting a life course perspective so as to be able to understand how experiences (e.g., relocation, exposure to discrimination, etc.) that differ by identity markers (e.g., ethnicity, gender, socio-economic status) culminate over a lifetime to produce late-life health and social outcomes that are distinct from the majority population. As a result, many authors speak to the need for longitudinal data initiated in the early phases of life among diverse minorities. Critical race theory (discussed in Chapter 16) extends the notion of cumulative disadvantage beyond the individual life course to include historical experiences of discrimination. It is important to our understanding that a mistrust of health systems prevents some racialized minorities from engaging with valuable health information and interventions (e.g., end-of-life care; see Chapter 16).
Traditionally dominated by large-scale, comparative (quantitative) approaches, the field of minority aging must now embrace more qualitative and mixed-methods studies capable of adding texture to the broad brushstrokes that currently define this burgeoning area of research (Chapters 25 and 26). It is time to move beyond description to a deeper understanding of the mechanisms underlying the inequities experienced by minority older adults (Chapter 23). This volume does a superb job of showing us the way.
