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 Lenise Cummings-Vaughn
Dulce M. Cruz-Oliver
Editors

Ethnogeriatrics

Healthcare Needs of
Diverse Populations

123
Ethnogeriatrics
Lenise Cummings-Vaughn • Dulce M. Cruz-Oliver
Editors

Ethnogeriatrics
Healthcare Needs of Diverse Populations
Editors
Lenise Cummings-Vaughn Dulce M. Cruz-Oliver
Division of Geriatrics and Nutritional Division of Geriatrics Medicine
Science Department of Internal Medicine
Washington University in Saint Louis Saint Louis University
School of Medicine St. Louis, MO, USA
St. Louis, MO, USA

ISBN 978-3-319-16557-8 ISBN 978-3-319-16558-5 (eBook)

DOI 10.1007/978-3-319-16558-5

Library of Congress Control Number: 2016947093

© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG Switzerland
To Michael and Leighton for all your
advisement, loving support, and
understanding.
Acknowledgements

Thanks to the authors for their enthusiasm and contributions that made the vision of
this volume become a reality. It is a privilege to have all of you as colleagues and
share a passion for geriatrics. I also want to thank Nicole McAmis who tirelessly
worked on background research.

vii
Contents

Part I Ethnogeriatrics Foundations

1 Why Ethnogeriatrics Is Important ........................................................ 3
Jeannine S. Skinner, Lauren Duke, and Consuelo H. Wilkins
2 Historical and Conceptual Foundations of Ethnogeriatrics ............... 19
Gwen Yeo
3 Demographic Trends in Aging ............................................................... 35
Lenise Cummings-Vaughn
4 Impact of Immigration: Disease Exposure
and Health Maintenance ........................................................................ 51
Sandra Sanchez-Reilly and Dulce M. Cruz-Oliver

Part II Research Issues in Ethnogeriatrics

5 How to Study Ethnogeriatrics from the Global to the Local .............. 65
Miriam B. Rodin
6 Trial Participation and Inclusion .......................................................... 73
Goldie S. Byrd, Rosalyn Lang, Sharon W. Cook,
Christopher L. Edwards and Grace E. Byfield

Part III Clinical Care in Ethnogeriatrics

7 Health Disparities: Access and Utilization............................................ 89
Rosaly Correa-de-Araujo
8 Epidemiology of Aging: Racial/Ethnic Specific
Disease Prevalence .................................................................................. 115
John S. Mulvahill and Lenise Cummings-Vaughn
9 Caregiver: Roles in Health Management.............................................. 145
Sarah E. Harrington and Kimberly A. Curseen

ix
x Contents

10 Hospice/Palliative Care: Concepts of Disease and Dying .................... 159

Dulce M. Cruz-Oliver
11 Geriatric Psychiatry: Perceptions, Presentations,
and Treatments ........................................................................................ 179
William Maurice Redden

Part IV Education in Ethnogeriatrics

12 Incorporating Ethnogeriatrics into Training Competencies ............... 203
Natasha N. Harrison
13 Assessments for the Practicing Clinician: Practical Tools .................. 215
Nusha Askari

Part V Policy and Economics

14 Policy: Impact on Delivery and Access ................................................. 235
Milta Oyola Little
15 The Future of Ethnogeriatrics ............................................................... 247
Gwen Yeo, Christina L. Bell, Lauren Okamoto, and Kala Mehta

Index ................................................................................................................. 261

Contributors

Nusha Askari, Ph.D. Department of Neurology & Neurological Sciences, Stanford

University, Stanford Alzheimer’s Disease Research Center, MC 5979, Stanford
Neuroscience Health Center, Stanford, CA, USA
Christina L. Bell, M.D., Ph.D. Hawaii Permanente Medical Group, University of
Hawaii Department of Geriatric Medicine, USA
Grace E. Byfield, Ph.D. Department of Biology, North Carolina A&T State
University, Greensboro, NC USA
Goldie S. Byrd, Ph.D. Department of Biology, College of Arts and Sciences,
Center for Outreach in Alzheimer’s, Aging and Community Health (COAACH),
North Carolina A&T State University, Greensboro, NC, USA
Sharon W. Cook, Ph.D., M.S.W. Department of Sociology and Social Work,
North Carolina A&T State University, Greensboro, NC, USA
Rosaly Correa-de-Araujo, M.D., M.Sc., Ph.D. Division of Geriatrics and Clinical
Gerontology, National Institute on Aging, National Institutes of Health, U.S.
Department of Health and Human Services, Bethesda, MD, USA
Dulce M. Cruz-Oliver, M.D., C.M.D. Division of Geriatrics Medicine, Department
of Internal Medicine, Saint Louis University, St. Louis, MO, USA
Lenise Cummings-Vaughn, M.D. Division of Geriatrics and Nutritional Science,
Washington University in Saint Louis, School of Medicine, St. Louis, MO, USA
Kimberly A. Curseen, M.D. Department of Internal Medicine, Emory University/
Emory Healthcare, Emory Palliative Care Center in Wesley Woods Hospital,
Atlanta, GA, USA
Lauren Duke, M.A. Meharry-Vanderbilt Alliance, Vanderbilt University Medical
Center School of Medicine, Nashville, TN, USA

xi
xii Contributors

Christopher L. Edwards, Ph.D. Department of Psychiatry and Behavioral

Sciences, Department of Psychology & Neuroscience, and Department of Medicine,
Duke University School of Medicine, Durham, NC, USA
Sarah E. Harrington, M.D. Department of Internal Medicine, University of
Arkansas for Medical Sciences, Little Rock, AR, USA
Natasha N. Harrison, M.D. Department of Geriatrics and Extended Care, Greater
Los Angeles Veterans Healthcare System, Los Angeles, CA, USA
Rosalyn Lang, Ph.D. Department of Biology, North Carolina A&T State
University, Greenboro, NC, USA
Milta Oyola Little, D.O., C.M.D. Department of Internal Medicine—Geriatrics,
Saint Louis University, St. Louis, MO, USA
Kala Mehta, D.Sc. Department of Epidemiology and Biostatistics, University of
California, San Francisco, USA
John S. Mulvahill, M.D. Division of Geriatrics and Nutritional Science,
Washington University in Saint Louis, School of Medicine, St. Louis, MO, USA
Lauren Okamoto, M.D., University of Hawaii Department of Geriatric Medicine,
USA
William Maurice Redden, M.D. Department of Psychiatry and Behavioral
Neuroscience, St. Louis University School of Medicine, St. Louis, MO, USA
Miriam B. Rodin, M.D., Ph.D. Division of Geriatrics, Department of Medicine,
St. Louis University Hospital, St. Louis, MO, USA
Sandra Sanchez-Reilly, M.D., A.G.S.F., F.A.A.H.P.M. Division of Geriatrics,
Gerontology and Palliative Medicine, The University of Texas Health Science
Center at San Antonio, San Antonio, TX, USA
GEC and GRECC, South Texas Veterans Health Care System, San Antonio, TX,
USA
Jeannine S. Skinner, Ph.D. Meharry-Vanderbilt Alliance, Vanderbilt University
Medical Center School of Medicine, Nashville, TN, USA
Consuelo H. Wilkins, M.D., M.S.C.I. Meharry-Vanderbilt Alliance, Vanderbilt
University Medical Center School of Medicine, Nashville, TN, USA
Meharry Medical College, Nashville, TN, USA
Gwen Yeo, Ph.D., A.G.S.F. Stanford Geriatric Education Center, Stanford
University School of Medicine, Stanford, CA, USA
 Part I
Ethnogeriatrics Foundations
Chapter 1
Why Ethnogeriatrics Is Important

Jeannine S. Skinner, Lauren Duke, and Consuelo H. Wilkins

1.1 Ethnogeriatrics Foundations: Defining Key Terms

and Concepts

Ethnogerontology is the study of the causes, processes, and consequences of race,

national origin, culture, minority group, and ethnic group status on individual and
population aging in the three broad categories of biological, psychological, and
social aging [3]. Ethnogeriatrics refers to the influence of culture, race, and ethnic-
ity on health care for older persons from diverse ethnoracial populations.
The United States (U.S.) Census and Office of Management and Budget (OMB)
defines race as a sociocultural construct that is not biologically, anthropologically,
or genetically based [4]. Federal taxonomy mandates the minimum categorization
of five racial groups (Asian, American Indian or Alaskan Native, Native Hawaiian
or other Pacific Islander, Black or African American, and White). According to this
taxonomy, ethnicity, a separate construct, is categorized as Hispanic or Latino [5].
Table 1.1 provides detailed description of U.S. federal race/ethnicity classifications.
Conventional practices classify race based on phenotypic attributes such as facial
features and skin color [6]. Ethnicity focuses less on physical attributes and encom-
passes cultural, behavioral, and environmental factors, which may be a more rele-
vant construct for examining differences in health [7]. The Office of Minority
Health defines culture as the “thoughts, communications, actions, customs, beliefs,

J.S. Skinner, Ph.D. • L. Duke, M.A.

Meharry-Vanderbilt Alliance, Vanderbilt University Medical Center School of Medicine,
1005 Dr. D.B. Todd Jr. Blvd, Biomedical Building, Nashville, TN 37208, USA
C.H. Wilkins, M.D., M.S.C.I. (*)
Meharry-Vanderbilt Alliance, Vanderbilt University Medical Center School of Medicine,
1005 Dr. D.B. Todd Jr. Blvd, Biomedical Building, Nashville, TN 37208, USA
Meharry Medical College, Nashville, TN, USA
e-mail: consuelo.h.wilkins@vanderbilt.edu

© Springer International Publishing Switzerland 2017 3

L. Cummings-Vaughn, D.M. Cruz-Oliver (eds.), Ethnogeriatrics,
DOI 10.1007/978-3-319-16558-5_1
4 J.S. Skinner et al.

Table 1.1 U.S. Federal Office of Management and Budget race and ethnicity categories
Race or ethnicity Definition
American Indian or A person having origins in any of the original peoples of North and
Alaska Native South America (including Central America) who maintains cultural
identification through tribal affiliation or community attachment
Asian A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian Subcontinent, including, for example,
Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam
Black or African A person having origins in any of the black racial groups of Africa
American
Native Hawaiian or A person having origins in any of the original peoples of Hawaii,
Other Pacific Islander Guam, Samoa, or other Pacific Islands
White A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa
Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin, regardless of race
Note: Data from U.S. Office of Management and Budget. Revision to the Standards for
Classification of Federal Data on Race and Ethnicity 1997

values, institutions of racial, ethnic, religious, or social groups” [8]. Culture also
informs lifestyle and health behaviors and thus plays an important role in ethnora-
cial differences in disease and chronic health conditions. Relatedly, cultural com-
petence refers to the knowledge and interpersonal skills that allow health providers
to understand, appreciate, and work with individuals from cultures other than their
own [9]. Improving cultural competence among health care providers may be a
critical step toward addressing health disparities [10]. Cultural humility describes
the process of self-reflection and self-critique in one’s limitations in intercultural
understanding and recognition of the power imbalance between patients and provid-
ers. Cultural humility helps to facilitate mutual respect and communication between
patients and providers [11].
The U.S. Department of Health and Human Services and the Center for Disease
Control defines health disparity as “a particular type of health difference that is
closely linked with social, economic, and/or environmental disadvantage” [12].
Dressler and colleagues [13] add to the definition by noting health disparities also
refer to differences in morbidity, mortality, and health care access by race and ethnic-
ity. Related terms include health inequality and health inequity. Health inequality
refers to systemic differences in the health of groups and communities occupying
unequal positions in society [14], whereas health inequity describes inequalities in
health that are the consequence of bias or injustice [15]. Despite differences among
these terms, they are often used interchangeably [16]. Social determinants of health
refer to the effect of social and economic factors that both directly and indirectly
affect health. Several conceptual models of social determinants of health have been
proposed [17–19]. While these models differ in complexity, most express health as
the byproduct of downstream and proximal factors such as health-related attitudes
1 Why Ethnogeriatrics Is Important 5

Table 1.2 Definitions of key definitions related to ethnogeriatrics

Term Definition
Acculturation The process of adopting the attitudes, values, and behaviors of a different
culture
Cultural The knowledge and skill to engage with people from different cultures
competence and backgrounds
Cultural humility The process of self-reflection in order to understand limitations in
intercultural understanding
Culture A society’s collective thoughts, actions, customs, beliefs, and values
Ethnicity A group based on shared beliefs, cultural, behavioral, and environmental
factors
Ethnogeriatrics The influence of culture, ethnicity, and race on health care in older adults
Ethnogerontology Study of the causes, processes, and consequences of race and ethnicity
on aging
Health disparity A health difference based on social, economic, and/or environmental
disadvantage
Health inequality Systemic health differences between groups based on differences in
societal position
Health inequity Health differences that are the product of bias or injustice
Race A social construct to define differences, usually physical attributes,
between groups that has no biological basis
Social determinants The direct or indirect effect of social and economic factors on health
of health
Socioeconomic A person’s or group’s position in society based on educational attainment,
status income, and occupational status

and behaviors, which are influenced by upstream and more distal factors such as
socioeconomic opportunities and resources (e.g., housing, income, and food supply)
[20]. Table 1.2 presents definitions of key terms related to ethnogeriatrics.

1.2 Between and With-In Group Heterogeneity in Health

Racial and ethnic health disparities exist across the lifespan and compound with age
[21, 22]. Generally, racial−ethnic minorities experience shorter life expectancies,
and higher rates of morbidity and disability than non-Hispanic Whites [23]. For
example, the average life expectancy at birth for African Americans is approxi-
mately 4 years shorter than that of non-Hispanic Whites [24]; however, Asian elders
have the longest life expectancy compared to all other groups [25]. Table 1.3 pro-
vides details on life expectancy by race/ethnic group. With regard to morbidity,
Hispanics/Latino, Mexican Americans in particular, have a higher prevalence of
cardiometabolic risk factors (abdominal obesity, high cholesterol, and high fasting
glucose levels) than non-Hispanic Whites and African Americans [26]. Heterogeneity
in health also exists within ethnoracial groups. For example, studies of risk factors
for diabetes vary considerably among Hispanic/Latino subgroups [27], and among
6 J.S. Skinner et al.

Table 1.3 Life expectancy by race/ethnic group

Race and ethnicity populations and life expectancies in the United States
Life expectancy % of Population over age Projected % of population
at birth 65 years in U.S. in 2012a over age 65 years in 2050a
Race
African American 74.5b 8.8 12.3
American Indian/ 71.1c 0.6 1.2
Alaskan Native
Asian 85.8d 3.8 7.1
Native Hawaiian/ 79.0e 0.1 0.3
Pacific Islander
White 78.8b 86.0 77.3
Ethnicity
Hispanic 81.2b 7.3 18.4
a
U.S. Census Bureau, 2012 Population Estimates and 2012 National Projections. http://www.census.gov
b
Center for Disease Control and Prevention. http://www.cdc.gov/nchs/
c
Indian Health Service. http://www.ihs.gov/newsroom/factsheets/disparities/
d
Center for Disease Control and Prevention. http://www.cdc.gov/minorityhealth/populations/
e
Arkansas Department of Health. http://www.healthy.arkansas.gov/programsservices/minorityhealth/

Asian-Americans, the prevalence of coronary artery disease is higher in Filipinos

and Asian Indians than Chinese, Japanese, Korean, or Vietnamese Americans [28].
Collectively, these studies highlight the need to further investigate patterns of dis-
ease between and within ethnoracial groups.

1.3 Explaining Racial and Ethnic Health Disparities

In this section, we provide a brief overview of the historical context of race in the
U.S. Next, we outline major psychosocial and individual level determinants of
health. We then discuss how culture intersects with health beliefs and behaviors.
Lastly, we review the role of social networks and environmental factors in health
disparities.

1.3.1 Historical Context

Historically, disparities in health status between racial groups were attributed to

innate biological differences between groups [29], individuals who were not
Anglo-Saxons were considered biologically inferior [30]. More recent, evidence-
based research has debunked this notion and confirmed racial taxonomy is not
discernible based on biological/genetic information [5] and as a result race is now
accepted as a sociocultural construct [29]. Because race is socially determined, it is
a fluid construct that can change over time and vary by location and culture. Yet it
1 Why Ethnogeriatrics Is Important 7

is common practice to assume race and ethnic classifications are static constructs
and infer group homogeneity. Studies of race, ethnicity, and gene variation demon-
strate greater genetic heterogeneity within than between racial/ethnic groups [6].
This does not negate the importance of race and ethnicity classifications, but these
classifications likely serve as surrogate indicators for more meaningful constructs
that explain disparities in health. These constructs include cultural experience and
beliefs, educational attainment, experiences with discrimination, and socioeco-
nomic positioning [31].
Race, particularly in the U.S., is associated with different life experiences that
affect health. For example, African American history is marked with gross social
injustices such as slavery, discrimination, and segregation [32]. Similarly, Native
Americans/Alaska Natives have experienced historical traumas including exploita-
tion, loss of land, and enculturation [33]. As a result, these groups often cite mistrust
of the health care system as a barrier to both health care and participation in clinical
research [34, 35]. Many ethnoracial groups continue to experience disadvantage and
a higher burden of psychosocial stress throughout life. These experiences may pro-
mote maladaptive coping strategies and increase vulnerability to disease and ulti-
mately exacerbate health disparities in late-life [33, 36].

1.3.2 Psychosocial and Individual Level Factors

Psychosocial stress can be a deleterious or demanding condition that taxes or

exceeds behavioral resources [37]. Psychosocial life stressors related to race may
have negative effects on health outcomes [38, 39]. Compared to Whites, minorities
report greater exposure to stressful life events [40, 41]. Many researchers contend
this may be due, at least in part, to differences in socioeconomic position [42–44].
Individuals in low socioeconomic position may be more vulnerable to the effects of
maladaptive health behaviors such as smoking, physical inactivity, and alcohol con-
sumption. Smoking rates are highest among Native American/Alaska Natives [45]
and physical inactivity rates are higher among African Americans and Hispanics/
Latinos relative to Whites [46]. Alcohol consumption in the form of heavy drinking
is highest among Native Americans/Alaska Natives and lowest among Asian
Americans and African American women [47]. Psychosocial stressors such as per-
ceived discrimination are also more common in minorities than Whites and associ-
ated with poorer cardiovascular [48–50] and cognitive health [51]. Many maladaptive
behaviors decline with age, yet the effects of health behavior in early-life and mid-
life may have a cumulative effect on health and well-being in late-life. Moreover,
studies of stress physiology show chronic psychosocial stressors activate the hypo-
thalamic−pituitary−adrenal and sympathetic−adrenal−medullary systems, physio-
logical systems designed to adaptively respond to acute episodes of stress [52].
Chronic activation of these systems, which often occurs with chronic psychosocial
stress, is associated with metabolic dysfunction, increased susceptibility to diseases
and mortality [53].
8 J.S. Skinner et al.

1.3.3 Culture

It is widely accepted that cultural values and traditions influence health beliefs and
behaviors. Older minorities may differ in health behaviors related to self-care and
views on illness management. African American elders, a group with a high rate of
chronic disease, engage in a range of health behaviors that vary by illness type [54].
For example, a study examining racial differences in self-care behaviors for hyper-
tension showed African American women were more likely to consume recom-
mended amounts of fruits and vegetables but less likely to engage in physical activity
to manage hypertension than White women [55]. Furthermore, African American
elders are more likely to incorporate nontraditional self-care strategies such as home
remedies for chronic illness management than White elders. Similar findings have
been reported for Asian and Hispanic/Latino elders [56, 57]. Asian elders, Chinese
and Japanese elders in particular, have the longest life expectancy relative to all
other groups in the U.S. [25]. Longevity in this group has been attributed at least in
part to cultural value placed on health-promoting lifestyle behaviors [58]. A cultural
tradition that emphasizes self-discipline also may contribute to the adoption and
maintenance of health-promoting behaviors [54]. Hispanic/Latino elders with dia-
betes are less likely to self-monitor glucose levels than White elders [59].
Acculturation is the process by which one group adopts the cultural attitudes,
values, and behaviors of another [60]. Prior work on acculturation has mostly
focused on Hispanic/Latino populations of Mexican origin [61, 62]. In many stud-
ies, acculturation is determined by measures such as language proficiency and other
contextual factors such as immigration status, length of stay in the United States,
and number of generations residing within the United States [63]. Lower levels of
English proficiency have been associated with decreased utilization of preventative
health care access [64] and thus may increase one’s risk for disease and disability.
Language barriers may also impede communication in patient−provider interac-
tions and health-information seeking behavior. It is important to note English profi-
ciency is not a universal measure of acculturation and measures used vary by
immigrant status and racial/ethnic group [65].

1.3.4 Social Networks

Health and aging occur in a social context of family relationships and social ties.
Social connections can influence self-care behaviors and these dynamics may differ
by ethnoracial groups. A better understanding of how interpersonal relationships
impede and promote health in older minority adults may help inform the develop-
ment of effective and culturally appropriate strategies to leverage the potential ben-
efits of interpersonal relationships in maintaining and improving health in late-life.
African American elders are more likely to live with a child or grandchild than
White elders [66]. African Americans are also more likely to care for grandchil-
dren, and less likely to be institutionalized than Whites [67]. Gender differences in
1 Why Ethnogeriatrics Is Important 9

caregiving are well recognized, as women, particularly African American grand-

mothers, are disproportionately represented in this group. Studies show grandmoth-
ers with caregiving responsibilities are more likely to live in poverty and experience
functional limitations than their noncaregiving counterparts. Grandparents who are
caregivers are also more likely to live in overcrowded conditions [68]. As such,
coresidence with other family members may in part reflect socioeconomic position-
ing. Studies of social networks among African American elders show value is
placed on independence, resilience, and spirituality [57]. This may explain why,
despite strong familial social networks, African American elders may report receiv-
ing less care for their health [69]. Caregiving support for health management among
African American elders comes largely from informal networks, namely adult
daughters and other female family members [70].
Relative to White elders, Hispanics/Latinos are more likely to live in multigenera-
tional households [71] and assist with caregiving responsibilities [72]. Studies of
Hispanic/Latino elders show extended family is the primary support system [73].
Health management is perceived as a diffused responsibility among Latino elders
and their family members [58]. However, extended family members may lack suffi-
cient knowledge regarding disease management and this may pose a barrier to imple-
mentation of proper self-care activities [71, 74]. Similar to other minority elders,
Asian elders are more likely to live in multigenerational households than Whites
[54]. Generally, Asian elders are more likely to rely on informal networks of support
and may be reluctant to seek help from formal networks, such as health professionals
[75]. Family social support is also instrumental in encouraging health-promoting
behavior [58]. Less is known about the influence of social networks on health among
Native American/Alaska Native elders. However, studies of Native American/Alaska
Native communities show that respect of elders and support of family and extended
networks are core values. Moreover, health is often viewed holistically and good
mental health may be more valued than physical well-being [76].

1.3.5 Environment

Environmental conditions are largely influenced by socioeconomic position and can

have a profound effect on health and well-being, especially for older adults.
Socioeconomic status (SES) is an indicator of an individual’s access to resources
and opportunities as a product of social position and has been operationalized using
several indicators including educational attainment, income, and occupational sta-
tus [77]. Epidemiological studies show minorities are disproportionately repre-
sented at lower SES levels [78]. Individuals with higher incomes have access to
healthier and better quality options in dietary choices, housing environments, and
health care. Higher SES status individuals also may experience less psychosocial
stress [79, 80]. Some researchers contend that common indicators of SES may not
capture key factors such as aggregate data on household occupational status, social
relations, and historical context of individual and racial/ethnic group experiences [81].
10 J.S. Skinner et al.

Other researchers propose the use of occupational status as an index of SES may be
suboptimal in aged populations that are no longer working [82]. To address this, a
few studies have measured indicators of SES using cumulative wealth, such as
house values. These studies show wealth may be a more robust index of SES and
may better predict health outcomes than traditional SES indices in older adult popu-
lations [83, 84]. These studies have focused exclusively on Caucasian samples;
therefore, it has yet to be determined how wealth indicators relate to health in
diverse older adult populations.
Racial and ethnic minorities and individuals of lower socioeconomic status are
more likely to live in low SES neighborhoods than Whites [85]. Neighborhood
characteristics can affect health and well-being especially for older adults. Feelings
of safety, mobility, and health status have all been shown to be impacted by local
neighborhood characteristics. Perceived neighborhood safety was found to be a pre-
dictor of functional decline in a diverse sample of community-dwelling older adults
[86]. Older adults who perceive poor neighborhood safety are more likely to be
physically inactive [87], which is a predictor of disability and mortality [88].
Neighborhood conditions, such as excessive noise, trash, crime and other environ-
mental hazards, have been comprehensively described as neighborhood disorder
[89] and such communities often include resource inequities such as inadequate
access to quality food sources, recreation, and health care [90]. Neighborhood dis-
order is disproportionately experienced by marginalized communities including
seniors and ethnoracial minorities [89]. Older adults who reside in disordered
neighborhoods report poorer self-rated health [91] and worse neighborhood charac-
teristics have been associated with increased adiposity, hyperglycemia, and low
high-density lipoprotein levels [92]. Poor neighborhood conditions have also been
associated with an increased prevalence of metabolic syndrome among White and
Black elders [93]. Studies show higher perceived social cohesion, the degree of con-
nectedness between members of a community [94], is associated with improved
cardiovascular health outcomes in older adults. Researchers propose that
neighborhood social cohesion may function as an extended support system to
community-dwelling elders.

1.4 Challenges to Providing Health Care in an Aging

and Diverse Population

Substantial challenges exist to providing high-quality, equitable health care to older

adults. These challenges include a workforce that is not adequately prepared to care
for diverse older adults, a health care system that does not easily accommodate the
needs of diverse older adults, gaps in research on health among older adults, and
policies that do not consider the needs of older adults with diverse cultural beliefs
and preferences. In this section, we highlight a few of these challenges and thus
underscore the importance of the field of ethnogeriatrics.
1 Why Ethnogeriatrics Is Important 11

1.4.1 Inadequately Prepared Health Care Workforce

Currently, there are too few health professionals with expertise in geriatric care.
Because fewer U.S. medical residents are entering geriatric medicine, and overall
wages for geriatricians are significantly lower than that of other medical specialties
[95], this trend is likely to continue. Lack of diversity in the clinical care and leader-
ship workforce are associated with health care access and quality of care, especially
for minorities [96]. Recent statistics indicate that although African Americans,
Hispanics/Latinos, and Native Americans collectively make up approximately 25 %
of the U.S. population, they represent 13.5 % of U.S. physicians [97] and fewer than
2 % of individuals in senior health care management [98]. Minority physicians are
more likely to provide care to minority and underserved patient populations [99], and
racially concordant patient−provider interactions are associated with higher rates of
patient satisfaction and trust [100, 101].
Implicit and unconscious cognitive processes may influence a physicians’ per-
ception of the patients [102, 103] and social categorization based on physical attri-
butes such as race/ethnicity-related stereotypes among physicians [104, 105].
Providing ongoing training in cultural competence is essential to preparing provid-
ers to care for diverse groups of older adults.

1.4.2 Organizational and Structural Health System Challenges

Structural factors related to the health care system also impact minority elders’ ability to
receive health care, navigate the health care system, and effectively communicate with
health care providers. Factors such as complex bureaucratic processes to determine
insurance eligibility, long waiting times to receive health care [106], and limited avail-
ability of culturally and linguistically appropriate services and resources (e.g., interpreter
services for elders with limited English proficiency and appropriate health education
materials) [107], all compromise the quality of health care minority elders receive.
The racial and ethnic classifications used in many health care settings present a
significant barrier to understanding the needs and preferences of diverse older
adults. The five racial categories and one ethnic category currently used in many
health care and research settings are not comprehensive and may not be linked to
culture, health-related attitudes and beliefs, and behaviors [29, 31]. More precise
and detailed classifications will advance our understanding of ethnogeriatrics and
help health providers better develop more patient-centered approaches, which will
ultimately improve geriatric care.

1.4.3 Gaps in Knowledge

Much of the existing literature on disparities among older adults focuses on differ-
ences between African American and White elders [108, 109]. This is largely due
to historically small sample sizes of other racial/ethnic groups in clinical research
12 J.S. Skinner et al.

and the broader US population. To provide health care to the changing demograph-
ics of the population, additional research related to health and aging in other racial/
ethnic groups is needed. For example, limited data shows Native Americans/
Alaska Natives have a shorter life expectancy than other groups and a high burden
of cardiovascular disease [110, 111]. Many Native Americans/Alaska Natives
reside in rural locations making access to health care challenging. Health care
delivered by the Indian Health Service, a federally funded program, is the primary
conduit of health care to many of members of these communities [112]. However,
these care centers are limited in number, inadequately funded, and limited in geri-
atric services. A second group for which there is even less health data is older
adults who are recent immigrants. There are many challenges associated with iden-
tifying and studying this segment of the population; therefore, it is unknown how
many immigrant individuals are older adults. Available data shows immigrant
experience unique barriers related to health care including limited knowledge
about the U.S. health care system and services and lack of adequate health insur-
ance [112]. As such, elders who are immigrants may be a particularly vulnerable
segment of the population.

1.5 Key Points

• The demographic profile of the U.S. older adult population is rapidly becoming
more racially and ethnically diverse. These groups demonstrate both within and
between group heterogeneity in their life experiences and cultural beliefs about
health and aging.
• Racial/ethnic group classifications do not in isolation explain disparities in
health. Examination of the independent and collective contributions of cultural,
environmental, and socioeconomic factors across the life course is necessary to
better understand to minority elder health and inform health care delivery for this
segment of the population.
• Challenges to providing quality ethnogeriatric care exist at the clinical, organiza-
tional, and structural levels of the current health care system. In order to address
these challenges, educators, researchers, heath care providers, and health policy
makers must
– Implement strategies to provide training and education to more health care
providers and increase the diversity of the work force
– Provide cultural competence training that addresses clinical, organizational,
and structural barriers to care for minority elders
– Increase access to health providers and systems that provide interpreter ser-
vices and accommodations for older adults with diverse health care needs and
preferences
– Routinely collect self-reported data on racial and ethnic group identification
and language preferences
1 Why Ethnogeriatrics Is Important 13

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Chapter 2
Historical and Conceptual Foundations
of Ethnogeriatrics

Gwen Yeo

2.1 Historical Development of Ethnogeriatrics

The concept of ethnogeriatrics was developed based on an identified need by educa-

tors and clinicians to have a discrete term to describe the unique issues in care of the
rapidly increasing number of elders from culturally diverse backgrounds. As indi-
cated in Fig. 2.1, it is conceptualized as the intersection of the fields of aging, health,
and ethnicity, and as such is inherently multidisciplinary and interprofessional.
Cultural influences on health and health care have been recognized for several
decades in the disciplines of medical anthropology, transcultural nursing, clinical
psychology, and social work. It was not until the late 1980s, however, that its appli-
cation to clinical geriatrics and geriatric training began to be explored in a system-
atic way. Likewise, the field of gerontology had included cultural diversity and
minority status in courses and textbooks on aging since some of the major pioneer-
ing work in the 1970s, but its application to the health care disciplines was not
clearly drawn until late in the decade of the 1980s. Dr. Jacqueline J. Jackson,
Professor of Sociology at Duke University, is usually credited with coining the term
“ethnogerontology” in the late 1970s to describe the arm of gerontology that
explores ethnic, racial, and minority issues. In 1987, Core Faculty members of the
Stanford Geriatric Education Center (SGEC) at Stanford University School of
Medicine adapted the term “ethnogeriatrics” from Dr. Jackson’s contribution to
describe health care for elders from diverse ethnic and cultural backgrounds [1].

G. Yeo, Ph.D., A.G.S.F. (*)

Stanford Geriatric Education Center, Stanford University School of Medicine,
1215 Welch Road Mod. B, Stanford, CA 94305, USA
e-mail: gwenyeo@stanford.edu

© Springer International Publishing Switzerland 2017 19

L. Cummings-Vaughn, D.M. Cruz-Oliver (eds.), Ethnogeriatrics,
DOI 10.1007/978-3-319-16558-5_2
20 G. Yeo

Fig. 2.1 The context of THE CONTEXT OF ETHNOGERIATRICS

ethnogeriatrics

Aging

Geriatrics Ethnogerontology
ETHNO-
GERIATRICS
Health Ethnicity
Transcultural
Health

2.1.1 Ethnogeriatric Education

To explore the degree to which health care training programs in various disciplines
had included ethnogeriatrics in their curricula, two small assessments were under-
taken in 1988; one looked at inclusion in textbooks, and the other in courses. SGEC
Core Faculty members reviewed 41 geriatric textbooks in their own disciplines, 17
of which had some reference to ethnic issues [2]. See Table 2.1.
A modest effort was also undertaken in 1988 by SGEC to assess the curricula in
ethnogeriatrics being taught in colleges and universities in the U.S. Listings of
courses in the National Directory of Educational Programs in Gerontology pub-
lished by the Association of Gerontology in Higher Education (AGHE) in 1987 [3]
were reviewed for content in “ethnic” or “minority” or “cross-cultural” issues. Of
the 404 colleges and universities listed, 41 had at least one reference to courses with
ethnogerontological content, 16 of which were associated with health care training
programs. A request for information was sent to the 16 programs, all of which were
on the East or West Coast, and responses were received from 8. In the process 4
other programs with similar courses were identified. Only one course combined the
three components of health, aging, and ethnicity; it was taught in a vocational nurs-
ing program in a community college in California. Another nursing program
reported that a cultural emphasis was included throughout their curriculum, some of
which applied to geriatric care. The most common pattern was a course offered in
ethnicity and aging in an anthropology or ethnic studies program that was open to
students in different fields, including health care disciplines [1].
Federal initiatives were a major impetus for the development of ethnogeriatric
education in the late 1980s in two significant ways: funding preferences for the mul-
tidisciplinary Geriatric Education Centers (GECs), and an important federally funded
conference in 1988 and its resulting book. Beginning in 1987, the Bureau of Health
2 Historical and Conceptual Foundations of Ethnogeriatrics 21

Table 2.1 Percent of geriatric textbooks with ethnogeriatric content, 1988

Number of geriatric Percent with some
Discipline textbooks reviewed ethnogeriatric content
Medicine 15 13
Nursing 15 47
Occupational therapy 1 0
Psychology 3 100
Social work 7 71
Source: Yeo (1991)

Professions (BHPr) in the Health Resources and Services Administration (HRSA)

which funds multidisciplinary GECs included a funding preference for “institutions
that demonstrate a commitment to increased minority participation—or efforts to
recruit minority faculty” [4]. In 1989, the preference was expanded to include link-
ages with predominantly minority educational institutions or health facilities and
“developing curricula or expanding teaching concerning minority elderly” and “pro-
viding trainees with experience in caring for minority elderly” [5]. Similar prefer-
ences were continued through the 1990s, providing an incentive for the applicants for
GEC funding throughout the U.S. to implement or expand their training programs in
the developing field of ethnogeriatrics in the multiple disciplines they train.
In order to provide curriculum resources and to encourage health care training
programs to expand their offerings in minority aging, BHPr and the Health, Alcohol,
Drug Abuse, and Mental Health Administration (ADAMHA) of the National
Institute of Mental Health sponsored a 2-day invitational conference in February,
1988, Minority Aging: Essential Curriculum Content for Selected Health and Allied
Health Professionals. Approximately 100 experts attended and shared background
papers, which were published in 1990 in a volume by the same name as the confer-
ence, edited by Dr. Mary Harper of ADAMHA, who was a major advocate for the
development of the field of ethnogeriatrics [6].
The early 1990s found educational programs in ethnogeriatrics blossoming on
many fronts. Some of the important contributions include the following:
• A symposium on the ethnogeriatric contributions of GECs at the 1990 American
Society on Aging meetings documented the development of 24 modules or teach-
ing units by 12 GECs, 13 monographs, 7 videotapes, 36 conferences sponsored by
20 GECs, 13 clinical training sites, and 3 computerized bibliographic databases [7].
• In 1991, the Association for Anthropology and Gerontology (AAGE) compiled
a collection of 30 course outlines and resources from various universities in
Teaching About Aging: Interdisciplinary and Cross-Cultural Perspectives [8].
• In 1991, Virginia Commonwealth GEC sponsored a teleconference seen by an
audience of several thousand, Ethnic Diversity: Barrier or Benefit in Health
Care for the Elderly.
• In 1992, a 2-day conference, Ethnogeriatric Curriculum: What Should We Teach
and How Should We Teach it? sponsored by Stanford GEC, Meharry GEC, and
Palo Alto Veterans Administration Geriatric Research, Education, and Clinical
Center (GRECC) was attended by 94 faculty from 11 disciplines and 16 states.
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nor to be blamed. We do not wish to speak disrespectfully of the
army; it is very useful in war and very ornamental in peace.
The morning’s sport was not good, and therefore the worthy
baronet was sulky and ill-humoured, and kicked his dogs; and he
made use of such language as is very unfashionable to print.
Colonel Crop re-echoed the unprintable exclamations of the great
unpaid, but Lord Spoonbill did not seem to heed the sport, or more
properly speaking the want of sport. It is very provoking to be in a
passion with anything that thwarts our humour, and it is still more
provoking to find another, who ought to be in a passion with the
same object, regard the matter with total indifference and unconcern.
Thus provoked was the worthy and exemplary magistrate Sir George
Aimwell. His red face grew redder, and his magisterial looks became
more majestic; at length, with a due degree of deference to one of
noble rank, he began to utter something like reproach or
expostulation to Lord Spoonbill.
“Upon my word, Spoonbill, this may be very good sport for you,
but it is not so for me. I never saw the birds so shy or the dogs so
stupid. But you seem to be very easy about the matter.” Then turning
to the colonel, he continued: “I suppose his lordship is thinking of old
Greendale’s pretty niece.”—At this speech the baronet laughed, and
so did the colonel. Who could help laughing at it?
Lord Spoonbill smiled, and only replied in an affected drawl, “By all
that is good, Sir George, you must think me a great simpleton to be
caught by a pretty face. The fact is, I am not much of a sportsman,
you know. I could enjoy a battue very well, but this hunting about for
a few stray birds is poor work.”
“A battue, forsooth!” exclaimed the amiable baronet:—“I believe
those villains the poachers have scarcely left a single bird in the
Cop-wood.”
The worthy magistrate was going on, but his indignation at the
shocking violation of those most excellent laws which the wisdom of
our ancestors has formed, and the folly of their descendants has
tolerated, so entirely overcame his feelings, that in the violence of his
anger he incurred the penalty of five shillings; but his companions
did not inform against him. In a word, he swore most bitterly and
tremendously. Our readers must not blame him too hastily for this
transgression. Let them consider that he was a magistrate, and of
course very zealous for the due observance of the laws. Swearing is
certainly wrong; but that is a mere trifle compared to poaching: the
uttering of a single profane oath being, in the eye of our most
excellent laws, precisely one-twentieth part of the crime of an
unqualified person having in his possession a dead partridge.
When the baronet had relieved his bursting heart, and vented his
swelling indignation in the mode above named, and when Colonel
Crop had sympathetically joined him in the execration of the
transgressors of our most excellent and equal laws which regard the
arrangement of game, then did Sir George proceed:
“Could you believe it, Spoonbill?—You know the pains I have
taken with that wood—I say, could you believe it, after all the
expense I have been at about it—after having six men sitting up
night after night to watch it, that in one afternoon, and that in broad
daylight, it should be almost cleared by those infernal villains?”
Here the baronet became angry again, and no wonder; it was
beyond all endurance. Not only did he as a magistrate feel grieved at
the violation of the laws, but as a gentleman and a man he was
pained at the loss of those birds which he seemed born to shoot.
The birds were gone and the poachers were gone; the first he could
not shoot, and the last he could not commit. And what is the use of
living in the country, if there are no birds to be shot and no poachers
to be sent to gaol?
Pitying the sorrows of the magistrate, Colonel Crop replied, “Too
bad, ’pon my honor.”
But Lord Spoonbill having recently quitted the university, in which
he had been taught to investigate and seek out the connection of
cause and effect, enquired:—
“But how could the rascals do all this without being detected, if you
had men to keep the wood by night and day?”
 “I will tell you,” said the baronet, whose violence seemed a little
abated by the kind sympathy of his friends: “it was entirely owing to a
rascally gamekeeper of mine, who, no longer ago than last Sunday
week, instead of attending to his duty, must needs go sneaking to
church. I saw the fellow there myself. He absolutely had the
impudence to come into church when he knew I was there. I
dismissed him however at a short notice. I was determined to have
no church-going gamekeepers.”
“That going to church was abominable,” said the colonel.
“But I thought you had always guns in your plantations, Sir
George?” said Lord Spoonbill.
“So I have,” replied the magistrate; “but unfortunately the guns had
been discharged in the morning on some boys and girls who had
gone to look for nuts; and as one of the boys was nearly killed, the
under keeper took it into his fool’s head that he would not charge the
guns again; so I gave him his discharge.”
“You have been very unfortunate in your servants, Sir George.” So
spake the colonel, who was more than usually eloquent and voluble;
and Sir George was especially delighted with him, for he seemed to
enter so fully into all the magistrate’s feelings upon the subject of
game and poaching.
It is astonishing that, notwithstanding all the pains which the
legislature has taken upon the subject of the game laws, which are
so essential to national prosperity and the Protestant succession, still
there is a possibility that gentlemen may be deprived of their sport by
the intervention of a poacher. The laws are too lenient by half; and till
it is made felony without benefit of clergy to be suspected of
poaching, we shall never be free from this dreadful calamity. Our
legislators have done a great deal, certainly; but they ought to take
up the subject with as much zeal as if the cause were their own.
Now while Colonel Crop was sympathising with Sir George
Aimwell on his great and serious calamity, Lord Spoonbill was
gradually withdrawing himself from his companions, and moving
towards the side of the field which lay nearest to the road, and
looking with great earnestness in the direction of the village of
Neverden. It was not long before his eye caught the object for which
he had been looking. There came clumsily cantering towards him a
quadruped, the appearance of which would have puzzled Buffon,
and on its back there sat a biped as unclassable as the beast on
which he rode. The two were usually called Nick Muggins and his
pony. Lord Spoonbill took great pains to see Nick by accident.
“Have you any letters for the castle, Muggins?” said the heir of
Smatterton.
“Isser,” replied Muggins, and forthwith he produced two letters,
one of which was addressed to the Right Honorable the Earl of
Smatterton, and the other to the Right Honorable Lord Spoonbill.
“I will take charge of them,” said his lordship.
To which proposal Nick Muggins made no objection. His lordship
then, just by way of condescendingly noticing the humble post-boy,
said—
“There now, I have saved you the trouble of riding any farther,
unless you have any letters for the parsonage?”
“Here is one, sir, for the young lady as lives at Parson Grindle’s.”
Muggins looked rather significantly at Lord Spoonbill when he thus
spoke, and his lordship replied—
“You may give that to me, and I will take care of it.”
What arguments were used to induce this breach of trust in the
guardian of the Smatterton post-bag, is not stated, nor known, but
conjectured. Muggins, when he had given the letter to his lordship,
looked rather hesitatingly, and as if he wished to speak; his lordship
interpreted his looks, and said, “Well, what are you waiting for?”
To this interrogation Muggins replied with a cunning simper, “Why,
please, sir, my lord, on case of any questions being axed, perhaps
your lordship, sir, will just-like get a poor boy off, you know, my lord.”
“Bah!” replied his lordship, “leave that to me.” And thereupon those
arguments were used which had been of such great and decided
efficacy in previous cases of the same nature. The undescribable
rider of the undescribable beast then turned about and went
homewards, and the heir of Smatterton soon rejoined his sporting
companions.
Lord Spoonbill was now in possession of two letters more than did
of right belong to him; and though he had taken great pains to
become possessed of at least one of them, and though he was glad
that he could prevent the information which they contained from
reaching the destined point, still he was not altogether comfortable.
Once or twice he determined that the letter designed for the
parsonage of Smatterton should reach its destination, and then he
as often changed his mind again. It may seem strange, and perhaps
be thought not true, that an hereditary legislator should descend to
such meanness as to intercept a letter. It is indeed strange, and but
for its strangeness it would not be here recorded. But Lord Spoonbill
was one of those decided characters that do not let trifles deter them
from pursuing their schemes. He was rather proud of the dexterity
and address with which he pursued any object on which he had fixed
his mind, and he mistook, as many other prigs do, obstinacy for
firmness. He had fully made up his mind to a certain end, and he
was not choice as to the means. Yet he was a man of honor, a man
of the nicest honor, a man of the most sensitive and susceptible
honor. If any one had been capable of calling him mean, if any one
so bold as to have expressed the slightest idea that his lordship was
a contemptible fellow, with what indignation would he have heard
and repelled the suspicion. His notions of honor must have been
very curious and quite unique. We wish it were in our power to
present to our readers an analysis of those views which Lord
Spoonbill took of the principles of honor. We are not equal to a task
so truly philosophical: we can only say that his lordship did descend
to the meanness of intercepting a letter, and did call and think
himself a man of honor. If any of our readers think that this is very
paradoxical and altogether improbable, we congratulate them on
their ignorance.
We cannot help at this part of our narrative shifting the scene for a
little moment, just enough to shew our readers the effect produced in
another quarter by the conduct of the above-named man of honor.
From the sportsmen at Neverden we turn to the rectory of
Smatterton and its inhabitants. Dr Greendale was in his study as
usual, not kept away by any weariness of the preceding evening.
Mrs Greendale felt more acutely the trouble of company departed
than of company coming, and Mrs Greendale was not selfish in her
sorrows, but communicated them to all about her. Penelope
Primrose felt the full weight of her aunt’s troubles; and as the good
lady of the rectory had been rather disappointed the preceding
evening she was not in one of her best humours. Patiently as
possible did Penelope bear with those ill humours, for her mind was
buoyed up with hopes of pleasing intelligence from abroad. The hour
arrived which usually brought the postman, but no postman arrived.
It was possible the clocks at Smatterton were too fast. The hour was
gone by, a full hour was past. It was not probable that the Smatterton
clocks were an hour too fast. There was a little hope that Mr Darnley
might be at Smatterton in the course of the morning; but the morning
passed away and Mr Darnley did not come. But a messenger came
from the rectory of Neverden with enquiries after Dr and Mrs
Greendale. Penelope asked very particularly after the rector of
Neverden and Mrs Darnley, and hoped that they arrived safely
home, and that they had taken no cold, and—and—just as a matter
of curiosity, had they heard from their son lately? The answer was,
that a letter from Mr Robert Darnley had arrived the very hour before
the messenger set out. Penelope turned pale, and then blushed
most intemperately, because she felt how pale she looked; and then
she thought—“Now I know he has forgotten me.” Immediately after
however she thought again, and then it occurred to her that, as
Robert Darnley was remarkable for his great filial affection, it was
possible that he might have had no time to write by that conveyance
more than one letter. But she still could not help thinking that he
might have sent her one small letter: if it had been but short, it might
have been a memorial of his thoughts still dwelling upon her. She felt
hurt, but would not be angry; and hoped, very earnestly hoped, that
she was not cherishing a foolish and fond passion for one who had
relinquished all fondness for her. It was very strange and altogether
unaccountable. It was so very much unlike the usual frankness and
openness of mind for which Robert Darnley was so remarkable.
These were painful thoughts, and the more painful because so very
perplexing. It is somewhat wearying to exert the mind very diligently
and perseveringly, even in solving problems and guessing riddles
which are mere abstractions; but when, in addition to the perplexity,
there is personal and deep interest and moral feeling, then the
agitation and weariness of the mind is at the highest.
Penelope found her accustomed resource in trouble, and her
consolation under life’s perplexities, in the kind and paternal
attention of her uncle. She spent the greatest part of the afternoon of
that day in Dr Greendale’s study, and listened with great pleasure to
the fatherly exhortations of that most excellent man; and, as she was
afterwards heard to observe, she thought that he spoke more like an
angel than a man. She treasured up in her heart the hope that the
morrow would bring tidings from the beloved one.
 CHAPTER V.
Sir George Aimwell and his companions found but little sport in the
field, and it was not unpleasant to Colonel Crop to hear that it was
now high time to leave the birds and to adjourn to dinner. This was a
relief also to the baronet himself; for though he was a keen
sportsman he never suffered the amusements of the field to interfere
with the duties of the dinner table. Colonel Crop was aware of this
laudable peculiarity in the manners of Sir George of Neverden, and
therefore enjoyed a day’s sport with him far more than he would
have done with another.
Those of our readers who know the worthy baronet need not be
informed of the superior style of his culinary arrangements. It was
very well for him that his table had this attraction, for it is very certain
it had no other. His own conversation was by no means the most
brilliant. Lady Aimwell might indeed be capable of conversing, but
the guests of Sir George never heard her voice, excepting so far as it
was absolutely necessary that some words must be uttered by the
lady who presides at the head of a table.
Speaking of the intellectual accomplishments of the magistrate of
Neverden, we may not be considered as making a needless
digression if we narrate an anecdote, or rather expression, a critical
expression, of the worthy baronet. Mr Peter Kipperson, the wise and
knowing agriculturist of Smatterton, one day dined at the table of Sir
George of Neverden hall. Now Peter was a very literary man, who
thought there was nothing worth living for but science and literature;
and having somewhere read that it was impossible to take shelter in
a shower of rain with such a man as Burke, without discovering him
to be a man of genius, Peter was desirous of continually showing off,
and was instant in season and out of season. Therefore when sitting
at the table of the worthy baronet, he assailed the magistrate with
various scientific subjects, but all to no purpose; there was no
response from his worthy host. Endeavouring to adapt himself to the
moderate talents and circumscribed reading of the baronet, he next
started the subject of novels and novel reading, taking care to
insinuate that, though Sir George might not read the trash of
circulating libraries, he might be acquainted with some of our best
novels. To this at last the baronet replied—
“Oh, yes; I remember many years ago reading a novel called Tom
Jones, written by a Bow-street officer. I recollect something about it
—it was very low stuff—I forget the particulars, but it was written in
the manner of servants.”
Hereupon Mr Peter Kipperson set it down as an indisputable fact
that baronets and magistrates were the most ignorant creatures on
the face of the earth, and he congratulated himself that neither he
nor Sir Isaac Newton were baronets.
Our readers may therefore very well imagine that if we pass over
in silence the dinner at Neverden hall, where sat Sir George and
Lady Aimwell, and Colonel Crop, and my Lord Spoonbill, we are not
transgressing the truth of history. Soon after the cloth was removed,
Lady Aimwell made herself invisible, and Sir George made himself
what he called comfortable.
“Now, my good friends,” said he, “you know my way. Pray take
care of yourselves. Pass the bottle. There—now—well—you know—I
—sometimes—it is very rude—you—I know you will—excuse”—
Saying, or muttering as above, the guardian of laws and game
sank to sleep in his easy chair, and left Lord Spoonbill and Colonel
Crop to amuse each other. They were however very bad company,
for one had no good in his head, and the other had nothing at all
there.
Lord Spoonbill smiled at the baronet in his easy chair, and Colonel
Crop smiled also. Colonel Crop looked at his lordship most
imploringly, as if to beg that he would say something to which yes or
no might be replied; but the heir of Smatterton was more deeply
engaged in his own thoughts. Colonel Crop filled his glass and
emptied it, and cracked nuts, and picked his teeth, and took snuff,
and yawned, and looked at the pictures, and looked at his own
fingers, and put them into the finger glass, and took them out and
wiped them. Lord Spoonbill filled his glass, and did not empty it, and
did not look at the pictures, and he took out his watch and put it into
his pocket without looking at it. Of many events it is said, that they
are no sooner said than done. But all these movements took up a
much longer time in doing than they have in the reporting. It was a
great relief to the colonel that Lord Spoonbill looked at his watch, for
that enabled the man-of-war to say, “What time is it?”
Lord Spoonbill answered by guess, and the colonel was not very
particular. When about half an hour more had elapsed, the heir of
Smatterton rang to order his horse, and he said to the colonel, “Crop,
I shall leave you to play at backgammon with Sir George. Make my
apologies. I have some matters to attend to at the castle.”
Lord Spoonbill then took his departure from Neverden hall. It was
a fine moonlight night, and the road from Neverden to Smatterton
was peculiarly well calculated for the enjoyment of a moonlight ride.
The domain of Neverden was for the most part on low and level
ground; and the road from the hall towards Smatterton lay partly by
the side of the park, over the low fence of which a person on
horseback might have a most beautiful view of plantation scenery,
and a distant glimpse of lofty and swelling hills, dark with abundant
foliage, but softened by indistinctness and remoteness. The ground
then gradually rose, and on the left hand might be seen at no great
distance a broad and gracefully undulating river, far indeed from the
sea, but bearing on its bosom the sails of commerce and the barks
of pleasure. And there ran rippling by the side of the road a little
prattling infant streamlet, bounding along its bright pebbly channel as
in haste to reach the calmer and more majestic expanse of waters.
On the right hand a dense and dark plantation of firs skirted an
abruptly rising ground, at the end of which the road brought the
traveller by a sudden turn to an immediate and full view of the
massive and whitened towers of Smatterton castle. The castle rose,
as some writers would say, but stood, we think, is the most proper,
majestically towering above all surrounding objects, and enjoying
from its lofty turrets a view of four counties; what these counties
were we will not say,—we dislike personalities.
 Now as Lord Spoonbill rode along under the bright light of the
moon, undisturbed by any earthly sound but the tinkling of the
sheep-bell, or the barking of some cottage curs, he did seem to
himself to enjoy the beauty of the scenery and the pleasant balm of
the autumnal air. And as a feeling of scenic beauty penetrated his
soul, there entered also with that a thought of moral beauty, and he
felt that his mind did not harmonize with the repose and beauty
which surrounded him. The feeling was not strong enough to be
called remorse, it was not serious enough to border upon
repentance. He felt conscious that he had acted with meanness, that
he had been guilty of a piece of cruelty. He had used a most
contemptible and debasing artifice to produce alienation between too
worthy and excellent young persons, loving and beloved, confiding
and hoping amidst their doubts and difficulties. These feelings were
unpleasant, and he endeavoured to soothe himself by sophistry.
After all, what injury had he done to Robert Darnley? It would be a
pity that so fine a woman as Penelope Primrose should be sacrificed
to such a dull, plodding, common-place man as the younger Darnley.
Common-place men are not worthy of the notice of men of fashion,
nor deserving of the ordinary privileges of humanity. His lordship had
some recollection of Mr Darnley as being a very poor creature, and
he thought that it was not probable that he should have gained any
great degree of improvement by commercial pursuits and habits of
business; for, as everybody knows, these things tend very much to
degrade and to cramp the mind; while on the other hand those
pursuits in which his lordship had been engaged had quite the
contrary effect. It must be very ennobling to the mind to be engaged
in gambling, horse-racing, lounging, bird-shooting, fox-hunting, and
seduction; and any woman of sense and spirit must infinitely prefer a
protector of this description, to a common-place man who knows
nothing of the world. As to Penelope then, his lordship very naturally
concluded that he was designing her an essential service. Poor,
simple, artless creature, she knew nothing of society, all her days
had been passed in a sequestered village; and as Robert Darnley
was almost the only person she was acquainted with, at all likely to
make her an offer, she fancied that she must of necessity be in love
with him. Lord Spoonbill had not according to his own account been
much of a reader, but he had read the Sorrows of Werter, and he
had read many other compositions of that nature; and he invariably
found that the lovers of the betrothed and the married were men of
genius, fine feeling, elegant manners, and every species of
sentimentality; and he observed that they were induced to the very
laudable practice of seducing the affections of young women from
their husbands or lovers, by a mere principle of compassion. It was a
pity that so much sense and sensibility should be so ill met, and then
how kind and considerate for some high-minded young gentleman,
like my Lord Spoonbill, to save them from the stupidity of a common-
place husband, and consign them to infamy and a broken heart.
Nothing of course can be a greater manifestation and proof of
sensibility and fine feeling, than seducing engaged affections, and, if
Lord Spoonbill had written his own history, we should have heard of
as much sympathy being expressed for him as there has been for
Werter and such like coxcombs; but as we do not suffer his lordship
to speak for himself, our readers must be content to contemplate his
character in all the baldness of truth.
While thoughts as above described were occupying the mind of
his lordship, he drew nearer to the domain of Smatterton, and as the
view of the castle and village opened upon him, he saw more lights
in the cottages than usual at that time in the evening, and he heard
at a little distance sounds of more than ordinary movements. And
presently there came galloping towards him a servant from the
castle. Thinking that it was a messenger sent for himself, he stopped
the man to ask what was the matter. The man drew up his horse just
for a moment, and in hurried accents replied that Dr Greendale had
been taken seriously ill, and that the Earl had given orders to ride
over to M—— to fetch his lordship’s own physician. Waiting for no
further interrogations the messenger rode off as fast as before.
Will it be believed that at this moment one of the first and
promptest thoughts that occurred to Lord Spoonbill was the idea,
that should this illness terminate fatally, the event might facilitate his
designs upon Penelope? Yet so it was. This was his first and
strongest feeling. He had forgotten all the fatherly kindness of that
good man. He was insensible to any impression from the
numberless acts and words of friendship received from the pious and
holy rector. Dr Greendale had been for many years an intimate friend
of the family at the castle. The Earl, though a haughty man and of
very strong aristocratic feelings, had never regarded the worthy
rector with any other feeling than friendship and respect; and the
Countess, though not insensible to the charms and fascinations of
fashionable life, yet delighted in the moral repose and the sober
beauties of the pastor’s character. The Earl and Countess did not
condescend to visit at the rectory, but the doors of the castle were
most cheerfully open for the doctor, and there was sincerity in their
language, when the noble inhabitants of the mansion declared that a
more welcome guest never crossed their threshold. There must have
been something good and pre-eminently good in the character of a
man who could thus as it were command the moral homage of minds
in the highest walks of society. The doctor was not a man of fortune
or of family. His respectability was altogether personal and individual.
This good man had taken very especial notice of the heir of
Smatterton, and had endeavoured, according to the best of his
ability, to impress upon the mind of the young lord those principles
which, in after-life, might become a blessing to him; and when he
could not but observe with all his natural disposition to candor and
charity, that there were bad principles at work within, he
endeavoured to hope for the best, and in his pastoral admonitions to
the youth he did not assume the sternness of the censor, but
adopted the gentle insinuating language of a friend to a friend. He
was grieved, indeed, when he saw that Lord Spoonbill was likely to
become a frivolous character, but he was spared the bitter
mortification of knowing that he was decidedly profligate.
Miserably degraded must have been the mind of Lord Spoonbill
when intelligence of the good man’s illness reached him, that he
could think only, or chiefly, of the vicious benefit likely to accrue from
the fatal termination of that illness. There was indeed another
thought in his lordship’s mind. He could not but notice the hurry in
which the messenger seemed to be, and he was also struck with the
obvious sensation which the illness of the rector had created in the
village. And this thought was more powerfully impressed as he rode
past a few cottages near the park-gate. He there heard the
comments and commendations of the humblest of the humble, and
the poorest of the poor. He heard the aged tremulously uttering their
lamentations; these lamentations were perhaps rather selfish, but
still they were such as did honour to him for whom they were
expressed, if not to those by whom they were used. Then his
lordship thought within himself of the power and efficacy of moral
worth; and he himself began to be almost sorry; but his more
degrading and vicious thoughts had the ascendancy; and he was
fully resolved not to be moved or melted by the sorrows of ignorant
rustics.
He rode up to the castle, and having dismounted he proceeded
immediately to the magnificent saloon, in which the Earl was so fond
of sitting even when alone. As Lord Spoonbill entered the apartment,
the Earl raised his eyes from a book which he was reading, and said,
“You are soon returned, Spoonbill; did you find Sir George’s
company not very inviting? Or, have you left Crop to enjoy the sole
benefit of the worthy baronet’s wit and humour?”
“I left the baronet taking his nap after dinner, and desired Crop to
stay and amuse him with his backgammon when he should wake.
My visits at Neverden, you know, are never long.”
The Earl was about to resume his book, when Lord Spoonbill
added, “But pray, sir, what is this account I hear from one of your
people about Dr Greendale? I hope the old gentleman is not
seriously ill.”
By this interrogation the Earl seemed to be roused to a recollection
of what might otherwise have passed away from his mind. Laying
down his book, he said:
“Oh!—ay—right: I am very sorry to tell you that the poor man is
very ill. That is, so I understand—I sent immediately for my
physician, and I also said that, if it were necessary, I myself would go
down to the rectory and see the good man. He will be a very great
loss to the village. The poor people are very much attached to him,
and I believe he is very conscientiously attentive to his duties. We
must do all we can for him.”
 “Certainly, we must. I am sure I should be extremely sorry to lose
him. What is the nature of his complaint? I was at the rectory last
night, and he seemed perfectly well.”
“They tell me,” replied the Earl, “that it is a fit of apoplexy, and that
the poor man is in a state of total insensibility. I would certainly go
down and see him, late as it is, if I thought it would do him any good.
I shall hear what my physician says.”
“If you will give me leave, sir, I will walk down to the rectory, and
bring you word how the doctor is. That will save you the necessity of
going out so late.”
“Very good, very good, do so, I am anxious to hear some more
particular account.”
Lord Spoonbill then departed for the rectory. And, when having
heard what was the nature of the rector’s illness, he had reason to
apprehend that the hand of death was upon him, the young lord was
more deeply moved. He really did make anxious haste to the
parsonage. It is a great pity that he did not pay more attention to
these frequent admonitions which he received as it were from his
better genius, and by which he was reminded that good principles
were not altogether foreign to his nature; but he resisted them—he
felt “a dread of shame among the spirits beneath.”
 CHAPTER VI.
When his lordship arrived at the rectory, he found the door
standing open, and the lower apartments of the house deserted.
While he was hesitating whether he should seek his way to the
doctor’s apartment, one of the domestics made her appearance, and
his lordship very earnestly inquired after the afflicted pastor. With
deep and unaffected feeling she replied, that her dear master was
very, very ill, and with increased emotion continued—
“Oh, my lord, if you will see him, perhaps he may know you—he
may try to speak.”
“Certainly I will see him. How long is it since he was taken?”
“Only two hours, my lord. He was quite well this afternoon at five
o’clock, and then he went into his study, where he always goes
about that time, and we heard nothing of him till about two hours
since; his bell rang, and I went, your lordship, to see what my master
wanted, and there I saw him sitting in his great chair quite
speechless.”
The poor woman was overcome with her own emotion, and Lord
Spoonbill hastened to the room into which the patient had been
removed. When he entered the apartment, he saw by the light of one
dim candle, and a recently kindled fire, the figure of Dr Greendale
sitting in an easy chair, in a state of apparent insensibility, and on
one side of him sat Mrs Greendale, grasping his hand with
convulsive eagerness, and looking anxiously on his still and frozen
features: how like and how unlike what he was! On the other side
Penelope was kneeling, holding him also by the hand, and hiding her
face, that its expression of deep feeling might not needlessly distress
her aunt. Gentle sobbings were heard, and the hard breathings of
the death-stricken man. His lordship stood for a few seconds as if
rivetted to the spot where his eye first caught the sight of the
melancholy group. Mrs Greendale first noticed the presence of a
stranger, and recognised his lordship, who then advanced with slow
and gentle step towards the sick man, and silently took the hand of
Mrs Greendale, whose tears then flowed afresh, as with louder
sobbings she exclaimed—
“Oh, my lord, what a sight is here! Those dear eyes have been
fixed as they are now for hours. He was a good man, my lord; such a
heart! such tenderness! Oh, he cannot, he cannot continue long! Oh,
that I should live to see this!”
As Mrs Greendale spoke, Penelope rose from her kneeling
posture, and turning round, then first saw that Lord Spoonbill was in
the room. His lordship intreated Mrs Greendale to compose herself,
and then turning again towards the sick man’s chair, he held out his
hand to Penelope, who resigned to his lordship the hand the dying
man, which she had been holding. Lord Spoonbill took the offered
hand, and kneeling on one knee pressed the hand to his lips, and
looked with searching earnestness to the face of the patient, as if
endeavouring to rouse him into consciousness and recollection. The
eyes were fixed and motionless, and their brightness was passing
away. After a few moments there appeared a convulsive movement
of the lips, and there seemed to be a gleam of consciousness in the
eye, and the hand which Lord Spoonbill had been holding was lifted
up and placed on his lordship’s head, from whence it fell in a
moment, and the breathing, after one long sigh, died away and was
heard no more. At the instant of the change, Mrs Greendale uttered
a piercing shriek, and fell senseless to the floor. Penelope, as if
unconscious of the distress of her aunt and the presence of Lord
Spoonbill, knelt gently down, and lifting up her hands and her eyes,
murmured a prayer, which relieved for a moment her bursting heart;
for tears came copiously to her aid, and her presence of mind was
soon restored, and she assisted the domestics in removing Mrs
Greendale into another apartment.
Lord Spoonbill then took his leave, and as he quitted the house of
mourning he felt as he had never felt before. He had seen life in
many of its varieties, but death had been to his eye and thoughts a
stranger. He had now witnessed such a scene as he never had
before. His mind was deeply and powerfully moved. But yesterday,
and he had seen Dr Greendale in the fullness of strength and the
vigour of health, and life was bright about him, and he was in its
enjoyments and sympathies. One day, one little day, produced an
awful change. The music of the tongue was mute, the benevolence
of the look had fled, the animation of the intellect had vanished, and
the beatings of the kind heart had ceased. Then did the young lord
call to mind many kind expressions which the good man had used
towards him. He thought of the day when he went at the desire of the
Earl his father, rather than by any prompting of his own inclination, to
call at the rectory and take leave of the doctor, previously to setting
out on his journey to Cambridge, when he first entered the
University. He recollected that on that occasion he had been
received in the doctor’s study, and the good man carefully laid aside
his books, and drew his chair round and conversed with him most
cheerfully and most wisely; and he remembered how very tenderly
he hinted at the possibility of juvenile follies, and how like a friend
and companion he endeavoured to guard his mind against the
fascinations of vice. He remembered also the fervent prayer which
the good man uttered at parting, and the words seemed to live again,
and he heard afresh the pious rector pray, “May God bless you, my
dear young friend, and keep you from the evil that is in the world,
and make you an ornament to that station which you are destined to
fill.” Then came to his mind the sad neglect of all the kind precepts
which the holy man had given him, and he felt that as yet the
pastor’s prayer had not been answered by the event. Now, had
these feelings been followed by that sobriety and steadiness of
thought which should be the natural fruit of such emotions, it had
been well for him; but unfortunately he had so much satisfaction in
these emotions, and looked upon them as being virtue, and not
merely the means of virtue, so that they failed to produce any lasting
effect upon his mind, or to cause any change in his conduct. He was
proud of his remorse and pleased with his regrets, and so the virtue
which had its birth in a tear, evaporated when that tear was dry.
Before Lord Spoonbill had left the rectory many minutes, he met
the medical gentleman on his way to the house. He stopped the
physician and told him that all was over.
 With due solemnity, and professional solemnity is very solemn
indeed, the medical attendant of the Earl of Smatterton shook his
head and replied—
“Indeed! Aye, I thought I should find it so, from the account which
the messenger gave me. However, my lord, as I am thus far, I may
as well just look in. There is a possibility, perhaps, that even yet the
use of the lancet may not be too late.”
Lord Spoonbill did not oppose the physician’s wish, though he had
no expectation of any benefit to be derived from it. He therefore
returned and waited the report. The man of medicine soon rejoined
his lordship, and pronounced the patient beyond the reach of
professional skill.
“The spirit, my lord, has left the body,” continued he, “according to
the vulgar expression.”
No man could more heartily enjoy the reprobation of vulgar
phraseology than could Lord Spoonbill, generally speaking; but at
this moment he was not disposed to be critical, and he answered the
medical man rather pettishly. He was not for his own part able so
quickly to make the transition from the grave to the gay as persons
more accustomed to such scenes. It is also not very uncommon for
the imperfectly virtuous to be exceedingly morose when under the
impression of serious or religious feelings. The physician was very
much surprised at the manner in which his lordship received the
above-quoted speech; for it is a great absurdity in these enlightened
days to imagine that there is any such thing as a soul. If there had
been any such thing, the medical gentlemen, who have very
minutely dissected the human body, certainly must have found it. But
as they have not seen it, clearly it has no existence, and that which
we take for the soul is only a sort of a kind of a something that is not
a soul, but is only a word of four letters. Many of the Newmarket
students indeed had discovered this fact before the dissectors had
revealed it.
When the medical philosopher observed that Lord Spoonbill did
not express any approbation of the phraseology whereby a doubt of
the existence of a soul was intimated, he did not consider that the
disapprobation might be more from feeling than from opinion, and
therefore he proceeded to the discussion of the subject in a regular
and systematic method. His lordship was, however, not at all
disposed to listen to his arguments, and the two walked side by side
in silence to the castle.
When the Earl saw his medical oracle, he directed his inquiries
first to him—
“Doctor, you will be seated,” having been uttered with its usual
majesty of condescension, the Earl then proceeded to ask—
“And now, doctor, what report do you bring of our worthy rector?”
“Dr Greendale, my lord, is no more. Life was extinct before I could
reach him; and I am of opinion that nothing could have saved him.”
“Indeed! you don’t say so! It is a sad loss. The doctor was a most
excellent man. I had a very high opinion of him. I gave him the living
purely for his moral worth. He had nothing else to recommend him. I
always make it an invariable rule to distribute the church preferment
which is in my power, purely on the ground of merit. I am never
influenced by any political feeling.”
“Your lordship,” replied the physician, who understood his
lordship’s mind as well as his body, and perhaps better; “your
lordship is remarkable for the good judgment which you always
exercise in these matters, and indeed in everything else where the
public good is concerned. It would be well for the country if the
distribution of public and responsible offices were in such good
hands. We should not hear so much the language of dissatisfaction.”
“Doctor, you are disposed to compliment. But it is not very easy to
prevent the language of dissatisfaction. It is too common and too
indiscriminate. It is not proper that the common people should
acquire a habit of carping at all the acts of the government. The
multitude cannot understand these things. Now I have studied the
science of government with great and close attention, and I think I do
know something which even the ministers themselves do not rightly
understand. They are engaged in the dry details of office, and they
have been brought up in the trammels of prejudice. For my part I