Training & Research of Services to the Asian American Elderly

 

Zhao Chen: Good morning everyone! I have the honor of introducing to you our next speaker, Prof. Marianne Fahs, the Director of Research, for the Brookdale Center on Aging, at Hunter College. The topic of her presentation is on “Healthy Aging among the Elderly Asian American: Can We Meet the Challenge?” Please welcome Prof. Marianne Fahs.

 

Marianne C. Fahs:

 

Thank you so much. It’s a pleasure to be here. I have a fair number of slides which I’m going to go over. We’ll be approaching this subject both from a research and policy perspective, because I think the two must inform each other to create better service. I’m hysteric with the scene we face in the U.S. as a whole. There’s been a huge increase in elderly that we’re at the brink of a demographic tsunami according to the latest statistics. From just last year, the group of over 65 is beyond 350,000 people. We’re now at 36.3 million, and set to take off over the next few years.

 

As we face the aging an explosion from our baby boomers as Commissioner Mendez-Santiago mentioned, by 2050 we’re going to have 87 million, more than double than the current population. To get a sense of how the Asian elderly fit into this national scene, you can see the Asian profile here, which is the light green, getting wider as we move into the 21^st Century. So the proportion of Asian elderly among our elderly is growing. This is the first time I actually saw this issue of immigration and aging being taken up by the press, so it’s just captured media attention, which isn’t that long ago as you see, only a few weeks ago there was a piece in the Washington Post. All of this means of course, that our aging population is going to be become increasingly diverse. Now Asian Americans, which you’ve heard constitute one-fourth of the nation’s total foreign born population, 8% are 65 years and older. We’re going to see a 213% increase over the next 50 years in the population of people who identify themselves as Asians. The proportion of the elderly who are Asians today will increase from 2.3%, all the way to 8% in 2050.

 

We’ve discussed Asians all morning, but what in the world does Asian really mean? When we say Asian, we’re also talking about Pacific Islanders. So, for us to talk about serving the Asian community I think the first thing we have to be aware of, and be very careful about is the vast diversity within the Asian community. Talking only about Asians as a general average can lead to an Asian fallacy, and I’ll give you an example of that, I think we get wrong statistics and wrong measures of indicators of risk. For instance, a large study we’re doing at Brookdale right now is on the effectiveness evaluation of smoking intervention. We’re working with a number of Asian American partners in Flushing and in Sunset Park, here in New York City. This was started in cooperation and collaboration with the New York City Department of Health and Mental Hygiene, began six years ago.

We were focusing on Chinese Americans in our particular study, the largest group as you know in New York City, over 400,000 counted by the Census, with some people saying that it is twice as many in reality. When we started the study, the only data we had on smoking rates among Asians, looked like this, which is put out by the Center for Disease Control (CDC). Asians on this chart look like they have a very low smoking rate, which is dangerous, because then people would say that we don’t really need services for Asian, but when we went into the Chinese community and actually did a household based survey, we found a 50% higher rate of smoking among Chinese American men than the general population. Chinese American women have a very low rate, so the average, even there, is misleading. So, what is needed is a trans-cultural gerontology, and we are just beginning to think about this in the level of depth and specificity that we need to think about it here in New York and in the US.

 

Our Commissioner gave us an inspiration talk on thinking about successful aging, as defined by Jack Rowe, who used to be the president at Mount Sinai Medical Center. Productive aging, as defined by Bob Butler, actually started in the National Institute of Aging which then developed into the first department of geriatrics at Mount Sinai Medical Center. There are many influences on being able to have this outcome of successful or productive aging. We have to take into account the larger context, including the larger environmental influences, all the way to social community influences living conditions and health care access. These are parts of what is influencing successful aging, and we need to develop better research, and better service models that encompass this broader understanding of what is contributing to successful aging.

 

We’ve heard a lot about the report on Asian American elders in New York City, and I commend if for it’s a wonderful finding, spearheaded by the founding Executive Director of the Brookdale Center and Aging, Rose Dobrof, in collaboration with various Asian partners. The report provided some groundwork for building a positive approach to increasing successful aging in our city. However, we really can’t ignore the overriding political context which is really looking at aging not as an opportunity, but as a crisis. We’re hearing that a lot in the media and that crisis really is coming through this background noise of ageism, stereotyping the elderly as non-productive, creating concerns that there could be financial collapse. The word crisis, invokes both a physical and political tone In terms of social security, we saw that issues being raised last year. This crisis mentality is a political connotation that really is just that, a political presentation. But what are the real facts? Is it a really a crisis, and what is the word crisis doing in terms of creating a political context?

 

I learned all of my economics these days from Paul Krugman, a columnist in the New York Times. The word crisis is essentially part of a larger political plan, really undermining the legacy of Franklin Roosevelt. The crisis within social security is really trying to move that program out of the public welfare system. The word crisis in that kind of political context comes from what I call “economic myths of aging”, and I think there are four large myths that continue to drive our policy, which then affects our ability to do funded research and service provision.

 

The first myth is that, preventive care is not cost effective, which is completely wrong. That was the belief up until 20 years ago, and some of the first studies I was lucky enough to be involved with showed that preventive medicine among 65 and older was very cost effective. Those findings continue only to become more and more clear as the elderly in general are undergoing what’s called compression of morbidity, where the civility rates really are decreasing among our nation’s elderly. Cost effectiveness is a policy approach that combines service and research towards political and advocacy, which actually affect legislation. There are many cost effective programs, which I will come back to later in my talk,

 

When we did a cervical cancer screening for the first time among elderly women, we found that not only was it cost effective but, cost saving when we looked at low income elderly women. This study got in to the Journal of American Medical Association, and received congressional attention. Another study we did on a national model, ended up influencing Congress to pass the first preventive benefit, funded by Medicare in this country. We started from a small program that was successful right here in New York City among low income women immigrants, and with a physician at Elmhurst Hospital, put together an effort that ended up influencing national policy.

Myth number two, is that the elderly are a drain on the health care system. What is the reality there? The health care system is one of the most productive systems in this country. In New York City, it is the third largest industry, and in fact, there was a very interesting study done by the Conservative Federal Reserve Bank that showed that the healthcare industry benefited from the recent recession. To the extent, yes, the elderly do use more health services, but in any other industry that would be considered a boom if we were buying for example more Healthcare, it’s a very important part of the economy, not only in New York, but many of our major cities including Boston, Houston and L.A. There’s a belief that we can’t continue to spend more and more on health care, which is absolutely untrue. There is some very good work coming out of Harvard now, David Cutler and others, that’s show we can continue to increase our spending on health care, without hurting spending on any other services for a great deal of time.

 

Myth number three is that the elderly are a drain on the economy. There’s absolutely nothing in economic theory that says that there has to be an economic decline associated with an aging population, and in fact, the data seems to show the total opposite. I predict that as the boomers move into this aging group, that there’s going to be a huge economic stimulus, due to the financial power these boomers bring with them.

Myth number four, increase longevity will cause an increase health costs. In reality, the cost per last year is holding constant. It’s actually a trivial increase in Medicare, and total nursing home cost when you look at it over time. The research again, out of Harvard, by David Bloom, another professor of Economics, states how for a long time that income does affect health, but now, it’s health that affects income. In developing countries we see an increase in 10 years gained in life expectancy, as a full million of percentage point to annual income growth. When you’re thinking 3 to 4% , that’s a huge percentage increase in annual income growth with longevity increases.

There’s no reason that developed countries can’t also follow those patterns. As we approach our aging boom, I think we’ve got a number of opportunities ahead of us to work as partners to develop research and services in New York to serve as models across the nation. To do it correctly, we need to think through a conceptual framework, and have a model that guides us. There’s currently no theory right now in the field of immigrant aging, successful aging, or urban aging. We’re just starting to think in terms of these contextual ways, developing multi-level models that include individual family and social support effects and create opportunities at the neighborhood level for productive and successful aging.

But what do we need to think through as we develop these models? We need to keep in mind a number of different issues including myths concerning immigrants such as the “healthy migrant effect”. These stereotypes affect Asian immigrants, trivializing all the social, health and mental health problems among the Asian population.

 

There’s obviously tremendous complexity of factors that affect health in the community. Here in New York, we find very large variations in life expectancy by neighborhoods. Disparities as our Commissioner said are extremely important issues to address in New York, and that really should be our goal in the next 20 years, to reduce these disparities in life expectancy. How do we do that? There’s a very good article recently published in the Journal of Urban Health by the editor of the American Journal of Public Health, Mary Northridge, an Assistant Professor at Columbia University. Her method on how to start thinking through community based, models to improve healthy aging, is to not only an emphasis on the individual, on including the family but on a larger policy and social context of improving neighborhoods and political atmospheres and environmental atmospheres that will allow and support productive and successful aging.

Dr. Northridge also mentions something called proximate influences. Here we have the more traditional things that we think about when we do gerontology research, such as health behavior, social integration, social support, stressors, and buffers. Again, that can be part of the cultural, political, or contextual setting of the city. What we’re aiming for, well-being and positive health outcomes, that’s just whipping through a very complex way of thinking about how research really should address and take into account and model all these factors that influence healthy aging.

Obviously, Asian aging research development has to be multidisciplinary, and in fact, what we’re developing here at CUNY under the leadership of distinguished professor Nick Freudenberg, Distinguished professor of Urban Public Health at Hunter, who has a grant from National Institutes of Health to develop trans-disciplinary curriculum in Urban Public Health. We at Brookdale, are growing from that base to develop a model of healthy urban aging which really doesn’t exist yet in the literature. There’s beginning to be some work done, by people at Harvard, looking at neighborhood effects on health, but this is where the field is going and obviously needs stronger partnerships with community based organizations and social workers. We bring into the mix a lot of different skills, such as epidemiology, economics, in addition to gerontology and the other social sciences that perform gerontology.

A few things that Brookdale has been up to, includes looking at the healthy migrant hypothesis. We also looked at Geographic Information System, a neighborhood based analysis of hospitalization rates to the proportion of foreign born within those neighborhoods. An issue in American culture and politics right now is this myth that immigrants are costing society. This is very controversial, and the work out of the Urban Institute clearly shows that economic benefits will exceed economic costs. What we’re finding out here very quickly in New York City in area such as Jackson Heights, almost 75% are foreign born and the lowest hospitalization rate. Foreign born actually had the same rates as U.S. born. The fact is, we’re saving about half a million among foreign born elderly every year in terms of lower hospital costs than U.S. born. Now, is that a good or a bad thing? Does that reflect a healthy migrant hypothesis, which is that you’ve got to be very healthy to leave your home country, is it lack of access? That’s where we are in our research, Whether needs aren’t known and understood, or if it’s lack of access, which I suspect. Immigrants are not costing more than the native born population in hospital cost. How can we reverse this process and have the native born learn healthier behaviors that immigrants bring with them? One of the best things that happened in New York City in the past 20 years is that Korean markets, Chinese restaurants, and Indian restaurants, have really improved the health in New York City; Work done yb the National Center of Health Statistics shows over a 15 year period, relevant risk factors smoking, obesity and hypertension, doubles within among immigrants.

 

In terms of occupational risks, it’s well known that immigrants and people of color in the U.S. have much lower rates of filing with worker’s comp to address occupational related injuries. It’s a terrible consequence here in New York City. We did a small study funded by the Rabowitz / Johnson Foundation that again, looked at the garment industry and used standardized health status measures that Carol Peng was talking about, the SF-36. We used a short form of the SF-12 so that we could actually document everything. This is the first document action ever, of the actual pain and suffering that these women, mostly Chinese and Latino women, are experiencing Carpal Tunnel syndrome working in the garment industry and they suffered severe financial hardship and lost of insurance. We need to do much better effort in here in New York City, and their rights and responsibilities for safety in the workplace. Since this is an aging issue, it happens during your working years, but it progresses into pain and disability as an older person. So we’ve got this dual challenge, I think there will be a lot of opportunities for jobs, but also non-market productivity. There’s a lot of talk in the conferences that I go to, and retirement is no longer the end of productive activity. It is merely a transition in which you can then start something else, maybe non-market, more social volunteer work, I think there can be a lot of productive contributions in the years to come and so this myth of everyone retiring and then flying off to retirement is really a myth, I think New York is going to be a wonderful place to age and we’re going to see a lot of new programs and productivity coming out of our aging seniors. That’s one positive way to think about it. We also need to help family caregivers. Asian Americans have the highest rates of caring for their family, older family members of all the ethnicities compared in this study.

 

Mental Health is a leading issue just beginning to be addressed. We’re developing research now with Bellevue Hospital to look at therapeutic intervention for Asian elders and their families who are depressed is three times higher suicide ratesxa among elderly Chinese immigrants and these findings and some of the earlier discussion just underscore the urgency for more research on mental health of elderly Chinese immigrants and how can we better build programs that will take into account the complex factors affecting this.

 

Obviously, these cultural issues, many Chinese do not recognize depression, there’s somatisized, there’s neurasthinia, official diagnosis in China and there are many other contextual factors we need to count for that we may be mixing up with depression too in our depression scales such as grief experience associated with immigration. The joined stress of immigration and aging which is kind of a double whammy, the stigmatization for mental illness that can sort of compound depression and again the depressive symptoms that expresses somatic complexities be aware.

 

So what are the implications then of all of these research threads that I’ve been talking about? For training a new health work force, I certainly agree with our Commissioner regarding what he said. In a new report just out yesterday from the National Taskforce on the Health Care Workforce on Predicting Workforce Needs In the Future Associated with Our Aging Population, one of the first things, we need is a lot more social workers, as well as geriatricians, nurses, and home care workers. To develop new workers to help those already in the field to develop new skills in cultural competence is a huge amount of training. Brookdale has a very strong active training program; we’re very eager and involved in this effort.

Another area is evidence based practice and outcome assessment. Social work, now, is talking about this all the time, but isn’t doing it. We need to get to the next step where we’re actually doing it. Dr. Carmen Mirano, who is our new Senior Research fellow at the Brookdale Center, is leading an effort to develop training programs in education and in outcome based, evidence based practice in social work. Again, these kinds of trainings require multi-disciplinary teams and can build partnerships with researchers and put together as I pointed out earlier, cost-effectiveness analysis that can change policy. But, we have to have outcomes first to demonstrate that our small programs are making a difference in the quality of life among the elderly and family members. All these things have economic benefits to society, and can actually be measured and used in policy modeling to present cost-effectiveness analysis that can then affect actual legislation and program allocations.

 

We’re going to face a huge doctor shortage, this was in the New York Times just a couple of years ago. We have only 9,000 currently certified in geriatric medicine right now, and we need 20,000. That need is only going to continue to grow. I found a book that was recently published on social work practices and the Asian American elderly. So, what’s the importance of the Ivory Tower, as we call it? Theory is important. It helps provide a framework from which you can then build these analyses that can be politically effective, but you need to ask different research questions, and generate new ideas. I’m a health economist, so I have a bias towards health economics, cost effectiveness analysis. There is no single best framework to develop research but I would say that, building in the social work perspective, with the economist’s perspective, is a very exciting direction to proceed in, as well as bringing in behavioral sciences in epidemiology. The example of tobacco control which I’ve been involved for the Chinese community in Flushing and in Sunset Park is an example where behavioral science and economists have come together, along with political activists, and created a totally new atmosphere in this country about tobacco. We need to do the same thing in many other areas including areas affecting aging and risk factors.

We should incorporate a variety of methods. I do quantitative work, but I partner with qualitative researchers. Ethnography is extremely important, and in some ways probably the most important as we need to understand cultural context better.

Evaluation should be done on every single program that you put in place because then it becomes replicable, people can learn from it. It can become a model for the city, or the nation. Evaluation should be rigorous, participatory, and include the community based participants. There should be multiple methods of evaluation, qualitative and quantitative, as well as be multi-leveled, we should be looking at the family, the individual, and the community. It should be on going, and not just stop. Once we have our first outcome, only then will we actually be able to change prevention priorities in this country.

It’s not just though research and service partnerships to build better models in this field that will help inform Congress to develop, perhaps, better programs funded by Medicare that actually include community-based long term care. We need a social strategy, and work together with the activists. There also has to be political will to listen to evidence based medicine.

That’s not where we’re at the moment, but hopefully within the next few years, the U.S. will have an administration that actually listens to evidence. I believe very strongly that sustainability, through policy change and research can contribute to that. Thank you very much for your kind attention, and I think we can all gain and benefit so much from the active involvement of ourselves with our seniors, and as we become seniors, our continued active engagement in the community.

 

Zhao Chen: Now I would like to introduce David Chen, Executive Director of the Chinese American Planning Council.

David Chen:

Thank you! Prof. Fahs touched upon many of the issues I was going to discuss about today.

I agree with what she said. The way you survive in the field, is by improvising on current theories. I was hoping that my fellow panelist Peter Kwong would be here today to support me on this fact. About 25 years ago, Peter and I used to run a youth program in Chinatown, and Peter used to write a lot about gang problems in Chinatown. He would come to talk to me about the deficit model and about how the youth services are in the city. I am surprised those 25 years, later when we put on our reading glasses. We’re now talking about the elderly. Pete and I also talked about research for the future. A lot of things have changed while a lot of things still haven’t changed. We still live in the mission of deficit model, where we have enough data.

 

For the longest time we have always focused on the world we live in now. We always focus on needs. But as Professor Fahs said, need are not the only thing now. You got to talk about outcome measures. What is their impact? How do we measure impact? If you don’t have the question at the beginning, you won’t be able to measure it at all. Research and planning has become very important that. I’m not a researcher, but I believe a researcher and advocate both have something in common, which is that they keep on asking questions. I don’t know how to solve the problems because I’m not a practitioner, but I do want to keep on asking questions that I want changes too, because I think that’s the part that I can contribute to from a providers, perspective. We ask the same questions, but how come things aren’t being done yet? Tell me a reason why it can’t be done. I think this is where the practice of theory comes together.

 

Implementation deficit is similar to what Professor Fahs mentioned in terms of access. How are we providers in the field utilizing data to enhance ability to do things, And to write proposals that address evidence based or knowledge based funding. Now a day, if you don’t do evidence or knowledge based funding, you can’t a get grant.

We keep on talking about effectiveness, when we come across it, unit cost is held more expensive than others. When we talk about seniors, our paradigm has to change, social services in general. In the investment model, their thinking is, why are senior citizens 55 and over, less able than before. Senior citizens are definitely able people. They may not be physically competent in many ways, but they are mentally smarter than many young people, are more reliable, and dependable. Why don’t we emphasize on that as an investment model to build other models. Remember, the trend is always building new models.

 

We are the paradigm to provide and always look for the deficient model. Somehow we didn’t address the resilient factor. We’re so good at talking about risk factors, but somehow we forgot about identifying the resilient factor. Why are we so resilient among the Asian community? To overcome a situation that could have been worse if we didn’t face this adversity, you have to identify adversity. Yet, the answer to the solution such as positive aging, can lead to an attractive way to reduce cost. We can then incorporate that into the research model, not just risk factors but also resilient factors. We can then share with the rest of the population how to, prevent this kind of thing from happening. A word about cultural competence, I was involved with a cultural framework development agency in the late 80s. You always talked about framework development, but they really didn’t know what the details were. How many have you not heard of the term cultural competence? Everybody has, right? I was asked last summer by the development agency to form a focus group and to figure out what was cultural competence? 15 years ago the had no clue, and now, they still don’t. Certain proposals are rated on their inclusion of cultural competence, and today we’re still asking what it is. The good news is that they are obviously working on it. But then it really changes the fact they need to look at certain specifics, to help measure. It’s important for us to understand what cultural competent means and look upon it from a practitioner’s angle. How do you develop and deliver and cultural competent services? Cultural competence is not just ethnic culture, but also of sub-culture. Cultural competence really starts with the researchers. If you don’t ask the right questions, or don’t bring up the issues, especially the grounds of understanding those differences, the tools you have developed will be harder to use. I think you go back to planning research, evaluation, and assessment, it goes into a cycle. It happens all the time in evaluation, somehow we still talk about cost efficiency and effectiveness. How do we translate our research in a cultural competent way, but also from an Asian American perspective, use a deficit model and turn it into a mindset, into an investment model, so we can get some funds for research. I always say that it’s conferences like this that brings people together to talk about an issue, but regret there isn’t enough resources to get it done. After 25 years, I’m still talking. Like I said, it’s the same issue we dealt with then with young people. It’s the same issue we deal with today with older people. It takes a village to raise a child. Now I say it when I put on my reading glasses, it takes a village to raise an elderly also. Thank you very much.