Ethnicity and Equity: Missing the Point
To the Editor:
We read with interest the recent editorial by Fustinoni and Biller on ethnicity and stroke.1 We feel that ethnicity is a critical aspect of understanding stroke outcomes, particularly within the Pacific rim, and are concerned by what appears a dismissive and cursory approach to the subject.
Despite the variation in definitions of “ethnicity” and “stroke,” ethnicity has consistently been shown to be a significant variable for stroke. Ethnic differences in stroke incidence and stroke related mortality have been well documented in the United States, Europe, and New Zealand.2 3 4 Differences in risk factor prevalence and management,5 6 utilization of services,7 and functional and motor impairments8 have also been described to a lesser extent.
We agree with the suggestion of Fustinoni and Biller that lower socioeconomic status and associated risk factors may explain some of the stroke burden carried by ethnic minority populations. However, within each social class, premature stroke mortality still remains substantially greater for black men than white men in the United States9 and for Maori than non-Maori in New Zealand.10
Despite the increased stroke incidence rates, increased stroke severity and poor functional outcomes, mortality rates, and discharge destinations are the same for both black and white populations in Europe,3 and our recent work found that such outcomes are better for non-Europeans than Europeans in New Zealand. This challenges the fallacy that ethnic minorities are an unhealthy burden and that “whites” are the “gold standard.” We propose that the family unit plays a pivotal part in this important stroke outcome and that more attention should be directed toward supporting their role in stroke care.
Finally, we believe that as an editorial on ethnicity and stroke, the article by Fustinoni and Biller missed the main point. Although genetic research may explain some of the differences reported, current literature suggests that equity of stroke care does not exist for ethnic minorities. Accessibility, quality of service, and equity cannot be separated when delivering effective stroke care. There is little information about access to and the quality of stroke care services for any ethnic minority group. Perhaps rather than attempting to locate a responsible gene(s), such a refocus of research demands more attention in order to guide practical action. Some may find ethnicity and stroke research repetitious, but it is a fundamental tool for assessing need and monitoring the impact of health policy.
A sense of control over one’s health and a sense of hope are important determinants of health status.11 We believe that these are best achieved when there is partnership between researchers, health providers from ethnic minority groups, and the communities themselves on ethnic-specific research. In doing so we aim to encourage participation of all ethnic groups in stroke research and identify barriers to stroke care. Obtaining this information is just one step in the development of a framework to improve stroke outcomes. The humanitarian and economic rewards for reducing ethnic disparities are great,12 but further quality research is needed for these rewards to materialize.
- Copyright © 2000 by American Heart Association
Fustinoni O, Biller J. Ethnicity and stroke: beware of the fallacies. Stroke. 2000;31:1013–1015.
Sacco RL, Boden-Albala B, Gan R, Chen X, Kargman DE, Shea S, Paik MC, Hauser WA. Stroke incidence among white, black, and Hispanic residents of an urban community: the Northern Manhattan Stroke Study. Am J Epidemiol. 1998;147:259–268.
Stewart JA, Dundas R, Howard RS, Rudd AG, Wolfe CD. Ethnic differences in incidence of stroke: prospective study with stroke register. BMJ. 1999;318:967–971.
Bonita R, Broad JB, Beaglehole R. Ethnic differences in stroke incidence and case fatality in Auckland, New Zealand. Stroke. 1997;28:758–761.
Sacco RL, Kargman DE, Zamanillo MC. Race-ethnic differences in stroke risk factors among hospitalized patients with cerebral infarction: the Northern Manhattan Stroke Study. Neurology. 1995;45:659–663.
Horner R, Oddone E, Matchar D. Theories explaining racial differences in the utilization of diagnostic and therapeutic procedures for cerebrovascular disease. Mibank Q. 1995;73:443–457.
Smaje C, Grand JL. Ethnicity, equity and the use of health services in the British NHS. Soc Sci Med. 1997;45:485–496.
Horner R. Racial variations in ischaemic stroke. Stroke. 1991;22:1497–1501.
Casper ML, Barnett EB, Armstrong DL, Giles WH, Blanton CJ. Social class and race disparities in premature stroke mortality among men in North Carolina. Ann Epidemiol. 1997;7:146–153.
Pearce N, Pomare E, Marshall S, Borman B. Mortality and social class in Maori and nonMaori New Zealand men: changes between 1975–7 and 1985–7. N Z Med J. 1993;106:193–196.
Ring IT, Firman D. Reducing indigenous mortality in Australia: lessons from other countries [see comments]. Med J Aust. 1998;169:528–529.
Gaines K, Burke G. Ethnic differences in stroke: black-white differences in the United States population. SECORDS Investigators. Southeastern Consortium on Racial Differences in Stroke. Neuroepidemiology. 1995;14:209–239.
We thank Drs Harwood, McNaughton, McPherson, and Weatherall for their interest in our editorial.R1 We agree that there may well be patterns of disease that distinguish different ethnic groups. We do not agree that these differences may be determined “despite the variation in definitions of ethnicity.” If groups that are to be matched are not properly defined on the basis of comparable features, results will be flawed. If various but incorrect criteria are applied repeatedly, results may appear “consistent” but in fact only reflect a marred methodology. All the more so with a variable that is defined socially rather than scientifically. For instance, one of the studies cited by Harwood compares stroke incidence between white, black (defined by skin color) and Hispanic (defined by language) residents of an urban community in Manhattan.R2 Another reports stroke incidence among Maori, Pacific Islands people (defined by place of birth), and “Europeans” in Auckland.R3 Not surprisingly, Europeans is not defined as a group, it is just included. Of course, how does one classify a European? By birth, descent, language, or merely “appearance”? One strongly suspects that “Europeans” in Auckland would probably be “whites” in the United States. Moreover, “persons of Indian or Chinese origin were included with Europeans because there were too few.”R3 Can results obtained in this way be consistent? Harwood and colleagues point out that even if purportedly “ethnic” differences may be explained by socioeconomic factors, within each social class premature stroke mortality remains greater for blacks and Maoris than for whites and non-Maoris. This could perhaps reflect a real ethnic difference. It could also be the result of a different social and therapeutic attitude in the management of stroke toward blacks and Maoris. It is curious that in many published reports, ethnic minorities have usually fared worse, notwithstanding the fact that in some instances mortality, discharge destinations, and outcome have been similar or even better in minorities. In any case, results will continue to be controversial if ethnic groups are not properly defined and other possible variables not looked at.
We fully agree that accessibility, quality of service, and equity cannot be separated when delivering stroke care and that information in this respect is scarce regarding minorities. Nevertheless, as we showed, genetic research has provided some breakthroughs that have not entirely been expected, in some cases disproving false “ethnic” assumptions. This was the main point of our editorial.
Fustinoni O, Biller J. Ethnicity and stroke: beware of the fallacies. Stroke.. 2000;31:1013–1015.
Sacco RL, Boden-Albala B, Gan R, Chen X, Kargman DE, Shea S, Paik MC, Hauser WA. Stroke incidence among white, black and Hispanic residents of an urban community: the Northern Manhattan Stroke Study. Am J Epidemiol.. 1998;147:259–268.
Bonita R, Broad JB, Beaglehole R. Ethnic differences in stroke incidence and case fatality in Auckland, New Zealand. Stroke.. 1997;28:758–761.