There’s No Place Like Home … for Some

Abstract

Stroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. They should not exceed 1000 words (excluding references) and may be subject to editing or abridgment. Please submit letters in duplicate, typed double-spaced. Include a fax number for the corresponding author and a completed copyright transfer agreement form (published in the January and July issues). 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. 2-4 Differences in risk factor prevalence and management, 5,6 utilization of services, 7 and functional and motor impairments 8 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 States 9 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. 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. 3. 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. 4. Bonita R, Broad JB, Beaglehole R. Ethnic differences in stroke incidence and case fatality in Auckland, New Zealand. Stroke. 1997;28:758-761. 5. 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. 6. Horner R, Oddone E, Matchar D. Theories explaining racial differences in the utilization of diagnostic and therapeutic procedures for cerebro-vascular disease. Mibank Q. 1995;73:443-457. 7. Smaje C, Grand JL. Ethnicity, equity and the use of health services in the British NHS.