Statement of the Coalition for the Advancement of Health Through Behavioral and Social Sciences Research (CAHT-BSSR) on the FY 2004 Budget of the National Institutes of Health submitted for the record to the Subcommittee on Labor, Health and Human Services, Education and Related Agencies, Committee on Appropriations, U.S. House of Representatives
The Honorable Ralph Regula, Chair
May 14, 2003
Mr. Chairman and Members of the Subcommittee, the Coalition for the Advancement of Health Through Behavioral and Social Science Research (CAHT-BSSR) appreciates and welcomes the opportunity to comment on the Fiscal Year (FY) 2004 appropriations for the National Institutes of Health (NIH). CAHT-BSSR includes 17 professional associations, scientific societies, coalitions, and research institutions concerned with the promotion of and funding for research in the social and behavioral sciences. Collectively, we represent more than 120 professional associations, scientific societies, universities, and research institutions.
We commend you, Mr. Chairman, and the Subcommittee for sustaining the bipartisan commitment to doubling the federal investment in the NIH over the past five years. It is important that Congress, with the guidance of this Subcommittee, continue to invest in the promise of health-related research that transcends political and regional boundaries.
On behalf of the social and behavioral science community, CAHT-BSSR thanks the Subcommittee for its increasing support of social and behavioral science research at the NIH, especially that which falls under the rubric of Ahealth and behavior@ research. Mr. Chairman, we have embarked on an exciting new era of health-related progress, particularly in the social and behavioral sciences. Opportunities for creating sustainable interventions and prevention programs targeting the leading causes of death and disability in our society have never been greater. Additionally, despite the significant funding increases provided to the NIH, biomedical and behavioral research opportunities still outpace available funding. Accordingly, CAHT-BSSR strongly supports the recommendation of the Ad Hoc Group for Medical Research Funding’s request of $30 billion in funding, a ten (10) percent increase, for the NIH in FY 2004. Such a sum would allow the agency to sustain the momentum of discovery created by the doubling of its budget.
As this Subcommittee is aware, six of the ten leading causes of death in the United States are behaviorally based, including HIV/AIDS, smoking, violence, accidents, diet, and substance abuse. Other behavioral factors are also known to increase individuals= risk for disease, disability and early death: obesity, physical inactivity, inadequate social support, environmental contaminates, anxiety, and traits of anger, hostility or depression.
In addition, according to the Centers for Disease Control and Prevention (CDC), more than 90 million Americans live with chronic illnesses C heart disease, stroke, diabetes, cancer, among many others. Chronic diseases account for 70 percent of all deaths in the United States. The medical care costs of people with chronic diseases, according to CDC, account for more than 60 percent of the nation=s medical care costs. These diseases are among the most prevalent, costly and preventable of all health problems. Perhaps, more important is the fact that chronic diseases account for one third of the years of potential life lost before age 65. Fortunately, much of the chronic disease burden is preventable.
Social and behavioral science research is critical to America=s quest to promote health, prevent disease, and provide quality treatment. This research provides knowledge about the social, cultural, and economic environments that influence human health and behavior and the means by which these environments exert their influence. As you are undoubtedly aware, over the past decade significant advances have been made in uncovering the biological and genetic basis for specific diseases and condition. Yet, despite the impressive scientific gains, it is becoming increasingly apparent that knowledge about biological and genetic markers are important but limited in predicting
who gets sick, who seeks treatment for their health problems, and who recovers from illness. Social and behavioral science contributes to filling these gaps in our understanding of health.
The NIH=s Office of Behavioral and Social Sciences Research (OBSSR) has made significant progress in increasing the visibility and stature of social and behavioral science research at NIH. Created by Congress in recognition of the substantial influence of social and behavioral factors on health, OBSSR is congressionally-mandated to foster the development of cross-disciplinary communication and research collaboration among social and behavioral sciences and between social and behavioral sciences and biomedical sciences. We commend NIH Director Elias Zerhouni for his selection of OBSSR Director Raynard Kington as his Deputy Director.
At NIH, the OBSSR plays a leadership role in developing ideas for initiatives and in the gaining support for them within the NIH Institutes. While the Office does not have grant making authority, it has been active in organizing trans-NIH and trans-agency Requests for Applications (RFAs) and Program Announcements (PAs). Through the sponsorship and organization of conferences, workshops, lectures and planning groups, OBSSR works with NIH Institutes and Offices, as well as with outside organizations, to determine priorities for behavioral and social sciences research.
Despite operating with a very small staff and budget, the OBSSR has been very effective serving as a point of coordination for cross-cutting NIH initiatives. CAHT-BSSR believes that the Office has the potential to accomplish much more with the continued support of the Congress and the necessary resources. The OBSSR=s current budget is $25.93 million. CAHT-BSSR supports an appropriation of $28.5 million for OBSSR in FY 2002, an increase of 10 percent. A 10 percent increase would enhance the OBSSR=s ability to continue coordinating social and behavioral research across the NIH Institutes. Such an increase would allow the Office to implement the recommendations in the National Research Council=s (NRC) report, New Horizons in Health: An Integrative Approach. The report provides a research plan to guide NIH in supporting areas of high priority in the social and behavioral sciences. It Aidentifies a broad domain of questions at the interface of social, behavioral, and biomedical sciences, whose resolution could lead to major improvements in the health of the U.S. population.@ These priorities cut across Institute domains, underscoring the broad significance of social and behavioral science research for multiple disease outcomes as well as health promotion. Ten priority areas for research investment are recommended: pre-disease pathways, positive health, gene expression, personal ties, health, communities, inequality, population health, interventions, methodology, and infrastructure.
A ten percent increase in funding would also allow the OBSSR to develop and fund a number of planned initiatives, including: Evaluate internet interventions; Examine maintenance of long term behavior change; Support training for conducting behavioral randomized clinical trials; Expand the initiative on mind-body interactions and health; Support a workshop on Interdisciplinary training in behavioral, social and biomedical sciences; Explore barriers to and opportunities for research on the topic of allostatic load and the response to trauma and injury; Improve the information available to clinicians, communities and public health agencies on behavioral therapies; and Support a conference designed to examine the relationships between work and health and between family and health and between work, family and health.
Aging. The United States is on the threshold of a longevity revolution. Increased life span and the aging of the baby boom generation present unique challenges to health over the next several decades. As more of the United States population ages C the number of Americans ages 65 and older is expected to double by 2030 to nearly 68 million C it becomes increasingly vital to the health of our entire society that we age well. Many of the problems that can accompany aging, especially chronic diseases stem from behaviors and environments that place individuals at risk of negative health outcomes. National Institute on Aging (NIA)- supported research has shown that lifestyle and other environmental influences can profoundly impact outcomes of aging, and that remaining healthy and emotionally vital until advance ages is a realistic expectations. CAHT-BSSR strongly believes that there continues to be a need for social and behavioral science research to develop, maintain, and/or enhance the health and well-being, both physical and cognitive functions, of older individuals throughout the life span. Accordingly, CAHT-BSSR supports a 10 percent increase for NIA, commensurate with our support of an overall increase of 10 percent for the NIH.
AIDS. The HIV/AIDS epidemic in the United States continues to evolve. While the incidence of new AIDS cases had declined, HIV infection rates are continuing to climb in a number of population groups (e.g., women, racial and ethnic minorities, young homosexual men, people older than 50 years of age, and individuals with additive disorders). African Americans and Hispanics accounted for 45 percent and 20 percent, respectively, of newly diagnosed AIDS cases in 1998. Research has shown that behavioral change can successfully prevent or reduce the spread of HIV/AIDS. There is overwhelming evidence and numerous scientific studies that demonstrate that well-designed and well-delivered HIV prevention programs contributed to healthier behavior and have substantially reduced the number of new HIV infections. A better understanding, however, is needed of how to actually change behavior prior to HIV transmission, including how to maintain protective behaviors once they are adopted. We are far from realizing the full potential of prevention research on a global scale. A more refined understanding of social and cultural factors that contribute to HIV risk or protection is needed. CAHT-BSSR supports the National Organizations Responding to AIDS (NORA) request of $3 billion in funding for the NIH Office of AIDS Research (OAR).
Cancer. The pivotal role of lifestyle and other environmental exposures as causes of cancer is reflected in the substantial variation of cancer incidence around the world and in the changes in risk observed among groups the migrate and settle in a new country. Unfortunately, substantial barriers prevent major segments of the population from seeking and/or using cancer information. New information technologies must complement, not replace, older but effective strategies, such as the mass media, one-to-one counseling, and targeted print communications. Accordingly, for cancer communication to be effective it must be integrated in the cancer continuum from prevention through treatment to survivorship and to end-of-life issues. The National Cancer Institute (NCI) has long been a leader in health communications. Yet, despite the progress that has been made, major gaps remain in our understanding of how consumers use health information. There is a need to understand how individuals distinguish important from insignificant health risks, as well as deal with contradictory or inaccurate health messages so that they can make informed choices. There is additional need to narrow the gap between what is known about cancer communication and what is practiced. Research is needed to examine the best ways to inform physicians, nurses, and other health care providers of emerging best practices in patient care. CAHT-BSSR supports a 10 percent increase for NCI, commensurate with our support of an overall increase of 10 percent for the NIH.
Children. Our Nation’s most precious resource is our children. The congressionally-mandated National Children’s Study (NCS), a prospective, longitudinal study of pre-and post-natal growth and development is seeking to uncover the contributions of the conditions and the milieu in which a child grows and develops. It is the first study of its kind and the first longitudinal study of this scope on children. Led by the National Institute of Child Health and Human Development, NCS has incredible potential, but will require a substantial commitment on the part of the many partners. Further, child development involves some of the most complex and important questions facing behavioral and social science researchers. Through the years, research has repeatedly shown us that many diseases and problems of adulthood are rooted in childhood behaviors. Additional research is needed to address child health behaviors such as diet, exercise, and stress management and the connections such behaviors have to adult outcomes. CAHT-BSSR joins the Friends of NICHD in urging Congress and the American people to increase their commitment to NICHD so that our Nation can capitalize on emerging discoveries and address urgent public health needs. Accordingly, CAHT-BSSR supports the Friends of NICHD recommendation for an appropriation of $1.33 billion for the Institute, an increase of 10 percent.
Diabetes. Over the last 30 years, the prevalence of type 2 diabetes has tripled. At the same time, children and adolescents are increasingly susceptible to type 2 diabetes. This trend is particularly evident in racial and ethnic minority groups, especially African Americans and American Indians. Findings, however, from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) -supported Diabetes Prevention Program (DPP), a major clinical trial comparing diet and exercise to treatment with a drug in 3,234 people with impaired glucose tolerance, a condition that often precedes diabetes, found that lifestyle changes in diet and exercise and losing a little weight can prevent or delay the disease. The study makes clear that behavioral and social factors play a major role in the management of diabetes and its accompanying complications. Additional social and behavioral research is needed to develop behavioral interventions for the various segments of society that can produce sustained changes in lifestyle behaviors, thus providing a cost-effective way of preventing obesity and type 2 diabetes. CAHT-BSSR supports a 10 percent increase for NIDDK, commensurate with our support of an overall increase of 10 percent for the NIH.
Health Disparities. Among minority populations in the United States, health disparities have remained persistent and have, in some cases, increased. Expected demographic changes magnify the importance of addressing disparities in health status. Beyond the need to monitor changes in the health status of different racial and ethnic groups, there is a need to understand the causal factors underlying these differences which include: genetic factors, socioeconomic position, health risk behaviors, and psychosocial factors (e.g., stress access to health care, and environmental and occupational risk factors). Research has revealed a well-documented relationship between socioeconomic status, health, and longevity. People with higher incomes and greater wealth tend to be healthier and live longer. The causes of this relationship, however, are unknown. To aid in understanding causal links between health and wealth, additional social and behavioral research is needed, including the support of more economic measures in future clinical trials to allow scientists to assess the impact of economic status on health, and vice versa. CAHT-BSSR commends the OBSSR and the National Center for Minority Health and Health Disparities for their sponsorship of research to expand the understanding of the economic implications of racial and ethnic health disparities in the U.S. CAHT-BSSR supports a 10 percent increase for NCMHD, commensurate with our support of an overall increase of 10 percent for the NIH.
Mental Health and Depression. According to the World Health Organization=s AGlobal Burden of Disease@ study, mental disorders represent four of the ten leading causes of disability for individuals age five and older. In the United States as well as other Adeveloped@ nations, major depression is the leading cause of disability. As noted by the National Institute of Mental Health (NIMH), mental disorders are Atragic contributors to mortality, with suicide perennially representing one of the leading preventable causes of death in the United States and worldwide.@ Mental disorders, which often strike early in life, during childhood, adolescence or early adulthood, are profoundly destructive to individuals and the well being of families. They cause immeasurable suffering. The current social and economic burden of mental illness in America is enormous. Additionally, depression has been related to health outcomes in a variety of diseases. It is associated with increased morbidity and mortality, decreased productivity, increased suffering by family and friends, impaired personal relationships, greater utilization of medical resources, and increased risk for violence towards partners/spouses and for incarceration due to violent acts. Depression is the fourth leading medical condition with the greatest burden worldwide, measured in Disability-Adjusted Life Years (DALYs). Major depression has been found to be more prevalent in patients with chronic medical disorders than in patients without these disorders. The mechanisms by depression affects these diseases, however, is unclear.
CAHT-BSSR also supports the NIMH’s decision to increase its focus surrounding vulnerability and resilience. Why do some people collapse under life stresses while others seem untouched by traumatic circumstances such as extreme poverty, terrorism, war, or natural disasters? Research to date suggests that resilience or vulnerability is the result of many interacting factors including: genetic predispositions, social skills and self-esteem, and environmental influences. CAHT-BSSR supports a 10 percent increase for NIMH, commensurate with our support of an overall increase of 10 percent for the NIH.
Obesity. It is now estimated that more than half of the adult U.S. population are obese. Over the past decade, statistics show that there has been an astounding increase in the prevalence of obesity among adults, both genders, in all ethnic and racial populations, and in all age groups. Accordingly, these individuals are at greater than average risk of mortality and morbidity due to such diseases as diabetes, cardiovascular disease, stroke, and certain types of cancer, among others. While genetic factors are believed to contribute substantially to the predisposition towards obesity, environmental factors play important role. Prevention of obesity is frequently attempted through educational approaches aimed at improving knowledge and motivation. Such approaches, however, have been largely ineffective at preventing weight gain. In contrast, environmental and policy approaches attempt to modify the environment in which such choices are made, rather than relying on individual will. Changes in the environment that reinforce factors supporting health lifestyles and reduce the barriers to such a lifestyle may also serve to diminish health disparities, as these barriers may be more prevalent in disadvantage and ethnic minority communities. CAHT-BSSR urges the Subcommittee’s support for additional research to investigate the lifestyle barriers that are contributing to the fattening of America.
Substance Abuse. The latest estimate of the economic burden for illegal drug use exceeds $110 billion. These costs are incurred through virtually every sector of American society. The National Institute on Drug Abuse (NIDA) supports a comprehensive portfolio of research into all aspects of drug abuse and addition. Despite NIDA=s efforts, additional funding for new research is need to ensure that our current drug prevention efforts are responsive to all populations and to differences in the needs and responses of audiences that often vary in gender, ethnicity, and age. Mr. Chairman, prevention research is vitally important, given that the greatest risk for initiating drug use occurs during adolescence. CAHT-BSSR supports a 10 percent increase for NIDA, commensurate with our support of an overall increase of 10 percent for the NIH.
With regard alcohol, it now estimated that alcohol use and abuse costs the nation $185 billion annually. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), about 14 million adult Americans have an alcohol-use disorder. Unfortunately, children also suffer from these disorders C 23 percent of 14- to 18-year-olds interviewed in a state survey reported having had at lease one clinically diagnosable symptom of alcohol abuse or dependence during their lifetime. Even worse, among college-age youth, alcohol abuse is epidemic. How to reduce drinking among young people is a complex and urgent issue, one that needs to be addressed by social and behavioral science research. The problem spans a range of issues, from policymaking to mental and physical health. NIAAA has identified gaps in the available data on college drinking and is planning to expand its research in this area. Such an expansion would better inform the design of interventions. The Institute has assembled college and university presidents with scientists to assess the problem of college drinking and to develop and disseminate strategies for preventing it. Social and behavioral science research shows that individuals who begin drinking early in life have a dramatically higher risk of later becoming alcoholic than those who being later. Other research show personality characteristics, evident as early as age three. Attention to developing effective methods to identify high-risk youth and preventing them from drinking is needed. There is also a need in alcohol research to examine the cultural and socioeconomic context in which health disparities occur. CAHT-BSSR supports a 10 percent increase for NIAAA, commensurate with our support of an overall increase of 10 percent for the NIH.
In closing, Mr. Chairman, CAHT-BSSR would like to emphasize that we are in an era when Americans= health is increasingly damaged by preventable chronic diseases. Fortunately, we are also in a period of exceptional promise in the social and behavioral sciences. Modifying behaviors and our social environments hold the key to major health benefits. Social and psychological factors C how we think, feel and behave, as well as the environment in which we live C have profound influences on health. Increasingly, our knowledge of the significance of social and behavioral factors is critical to improving the health of all Americans, as well as maintaining our economic growth. Your continued support for the social and behavioral science research programs at the NIH is vital to maintaining America=s status as the world premier biomedical, social, and behavioral research leader. We thank the Subcommittee for the opportunity to present our views.