Volume 19, Number 8
Equality, the benchmark of the United States, has not always been met when it comes to minority health, said Donna Shalala, Secretary of Health and Human Services (HHS). Shalala, speaking to more than 1,000 participants at the National Institutes of Health's (NIH) Office of Research on Minority Health (ORMH) conference, Challenges in Health Disparity In the New Millennium: A Call To Action, explained the Department's efforts to combat the disparities in health among racial and ethnic minorities (See UPDATE, April 17, 2000, Number 7). The conference, held April 17-19 to examine the many issues of health disparities, featured many officials from the HHS, the National Institutes of Health (NIH), and the health care field calling for more social science research.
HHS, said Shalala, has proposed spending $5 billion in FY 2001 on programs designed to improve minority health, including $20 million to establish a coordinating center for health disparities within ORMH that will integrate the various research resources of the NIH Institutes and Centers; and $60 million in funding by the National Cancer Institute to set up Special Population Networks for cancer control and research. (See UPDATE, March 20, 2000, Number 5) The NIH is currently seeking legislative authority to allow the new center to award grants for minority health research under exceptional circumstances, when Institutes and Centers are unable to fund research that has been identified as a priority.
If we really want to remove the disparities in health, stressed Shalala, we have to focus on three things: (1) prevention, (2) promotion of access, and (3) increasing cultural sensitivity in the health care profession. We also have to address economic structure, social customs and human behavior, she said.
The Secretary called for more research to examine health risk factors and determine how to modify unhealthy behaviors. We cannot wait until we have universal health care. She called for "culturally sensitive" care, and exclaimed that cannot wait until every person has health insurance. Quoting Martin Luther King, Jr., Shalala said, "I can walk to freedom only if I have a healthy body."
Director John Ruffin, head of ORMH since its inception, noted that his office serves as a catalyst. Health disparities, he said, is a complex problem resulting from a combination of forces: heredity, environmental insults, infectious diseases, personal habits, and inadequate social support. These factors, said Ruffin, also play a role in the lack of participation by racial and ethnic minorities in biomedical research.
Otis Brawley, Director of the National Cancer Institute Office of Special Populations, told the group that race, as defined by the Office of Management and Budget's Directive 15, is a sociopolitical construct. Anthropologists, however, reject it, said Brawley. The explanation of race as a biological causation factor is a misconception, he stated. This false idea dates back to infamous Tuskegee experiments, when researchers wanted to determine whether syphilis was a different disease in blacks versus whites, he continued.
He emphasized a need to move away from this construct. Migration studies show the effect of culture and environment, Brawley noted, citing evidence that reveals increased cancer rates among Chinese and Japanese immigrants to America, and whites who migrate from East to West. Diet, cultural habits, and poverty all play a role in the biological behaviors of genes, he told the group. Thus, there is a need to increase the attention to SES (socioeconomic status) and risk analysis of behavior and patterns of care.
The questions are, said Brawley, How do you get better care for all? How can we improve the quality of care? and What interventions can we do to improve the quality of care? Equal treatment would yield equal outcomes, race is not a factor in outcomes, he said.
Echoing many of the conference participants, Brawley called for research that examined how to influence healthful habits and how to convey accurate information in a culturally sensitive manner. We need to understand the role of social factors, he declared. Anthropologists, sociologists, and psychologists must be involved in the research.
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Director Allen Spiegel said that the ethical and social implications surrounding health disparities in diabetes must be examined. Spiegel said many individuals with diabetes are admonished to "just lose weight" or "just stop eating." If only it was that easy, he bemoaned. Instead, Spiegel called for culturally and linguistically appropriate messages. Further, he emphasized the need for research on how to prevent or delay diabetes and on lifestyle (i.e., behavioral and sociocultural factors). Spiegel said there is also a need for research on how to prevent or reverse obesity, a key risk factor for Type 2 diabetes which affects 90 to 95 percent of the 16 million Americans with diabetes.
HIV/AIDS is a social, cultural, and political problem as much as it is a scientific problem, Office of AIDS Research (OAR) Director Neal Nathanson told conference participants. AIDS is totally preventable and need not occur at all, said Nathanson. The OAR, he said, is supporting increased numbers of research projects on how to control AIDS. AIDS, he continued, is a major public health failure, citing the fact that there have been 40,000 new infections per year over the last 10 years.
There are 800,000 people living with AIDS in the United States. While AIDS cases in the Nation's white population have gone down, they have been steadily increasing in the black population. It is an "extraordinarily urgent problem," said Nathanson, and "behavioral and social science research is clearly required." Nathanson's comments came only days before the White House officially declared increasing world-wide AIDS' cases as an official threat to national security.
National Institute of Mental Health (NIMH) Director Steven Hyman told conference participants that "serious mental illness is an equal opportunity affliction." Yet, because there is a difference in understanding mental disorders, access to treatment, and treatment of mental disorders, there will be an additional folio to the first-ever Surgeon General's Report on Mental Health (See UPDATE, January 10, 2000, Number 1). The folio, titled "Culture, Race, and Ethnicity" to be released later this year, will increase awareness and access within minority communities, said Hyman.
NIMH, said Hyman, is very interested in cultural changes, SES, and the migration influence on the prevalence of depression. For example, Hyman noted that NIMH-supported research is examining what it means to go from being a majority in a majority population to a minority in a minority population.
Hyman also suggested that the increased sensitivity to disparities in health are causing a revolution in the way NIMH thinks about health services research, citing the Report of the National Advisory Mental Health Council's Behavioral Science Workgroup as an example of the Institute's efforts (See UPDATE, February 7, 2000, Number 3). NIMH, said Hyman, looks forward to funding its behavioral and translational centers. He emphasized that he hoped to focus the centers on disparities in the recognition of mental disorders.
Echoing Nathanson, Hyman said that there is an "extraordinary disparity in new incidents of HIV cases." As the nature of the epidemic has changed, said Hyman, so has NIMH's portfolio. Hyman indicated that NIMH has a $100 million HIV/AIDS-focused research portfolio.
Providing equal access to equal health care and forcing the research community to focus its efforts on areas of concern to minorities and the poor are keys to eliminating health disparities, says former Surgeon General Antonia Novello, now Commissioner of New York State's Department of Health. Health promotion has not narrowed the health disparities gap, she said. We need to look at the root causes of the problem including: poverty, inadequate housing, education, lack of social support, no jobs, racism, and political naivete, she said.
Novello called for access to comprehensive, family-based, available, and affordable health care. Social and economic costs alone do not account for health disparities, she said. The health care system, she continued, has to be sensitive to the language and culture of the community. To eliminate health disparities, Novello stressed that we must have a good education system, one that fits the needs of minorities. We cannot recruit professionals, if we do not invest in them. Minorities, she said, do not choose medical school because it is not accessible to them. There are no role models and no money, said Novello.
She also called for better data collection, noting that until 1989 Hispanics were characterized as "other." The lack of comprehensive data, she said, is the biggest barrier to assessing the true status of the need, she continued. She asked: "How can policy makers make good decisions without adequate data?"
David Burgess, a member of the ORMH's advisory committee noted that the past decade has seen unprecedented funding increases for NIH and health promotion. Despite this, "we have failed," said Burgess.
"Incrementalism has not worked, it is time for a new direction," he said. Supporters in Congress are leading the way, said Burgess, citing the introduction of legislation (H.R. 2391, the National Center for Research on Domestic Health Disparities Act) by Representative Jesse Jackson Jr (See UPDATE, July 12, 1999, Number 13). He further argued that we will not close the gap in racial and ethnic health disparities until we close the training gap. There is a tremendous amount of untapped potential. He hoped that the conference's recommendations will be radical, since what we have been doing has failed us and our children.
On the final day of the conference, participants expressed their desire for the NIH to support research that address the behavioral, social, and cultural influences on health, and the issue of minority training. Other recommendations included:
* The establishment of Centers of Research Excellence in behavioral science, nutrition science and metabolism, genome science, and biotechnology;
* Longitudinal studies focused on minorities, particularly the heterogeneity of African-Americans;
* The translation of research findings into tangible benefits for minority communities;
* Partnerships with minority communities based on trust and mutual respect; and
* The elevation of minority health as an academic discipline.
The ORMH will publish the proceedings of the conference later this year. For more information contact ORMH at: http://www1.od.nih.gov/ORMH/main.html.
May 10, 2000 marks the 50th anniversary of President Harry Truman's signing the law that created the National Science Foundation (NSF). He did it on a train in Pocatello, Idaho. Harvard President James Bryant Conant was appointed the first chairman of the 24 member National Science Board. Alan Waterman was named the first NSF Director in March 1951. At an April 27 press conference, the NSF announced a number of activities to celebrate its half-century of accomplishments.
With assistance from Dow Chemical, Dartmouth College, and Science Service, the Foundation, under a program dubbed Scientists and Engineers in the Schools, will enlist accomplished researchers and educators to make presentations in the Nation's middle schools encouraging young Americans to study science and engineering and choose careers in those endeavors. NSF will also convene a conference this July at Dartmouth called S.E.E.ing (Science, Engineering, and Education) The Future Institute. The week-long conference will consider the impact of science, engineering, and technology on society in the coming years. According to NSF, these discussions will help build a framework for understanding and establishing priorities for the roles of government, industry, and academe.
In addition, the Foundation has released the Nifty Fifty discoveries that NSF-supported research has accomplished. Among the research achievements cited are The Panel Study on Income Dynamics (PSID) and the American Sign Language Dictionary. The PSID, a longitudinal panel survey, is credited with producing data that have been central in research and knowledge building in key areas such as: intergenerational relations; income, poverty, savings, and wealth; demographic events such as teen childbearing, marriage, and divorce, living arrangements and mortality; labor market behavior; and the effects of neighborhoods.
The American Sign Language Dictionary was compiled by William Stokoe of Williams College. He used linguistic techniques to discover that sign language was full of regularities and structure, very much like a spoken language. The dictionary attracted the attention and interest of other linguists and psycholinguists who embarked on additional studies that have revolutionized education of the deaf in the United States. These scientists discovered that deaf children who had an opportunity to learn and use sign language in the crucial early years of life did much better in developing the full, normal range of cognitive skills than kids who did not.
NSF has also produced a list of Nobel laureates who have received support from the Foundation. It includes 18 who have won the prize in Economics.
The entire Nifty Fifty and other activities related to the 50th anniversary can be found at http://www.nsfoutreach.org.
As it did in 1994, the National Research Council examined the U.S. Department of Agriculture's (USDA) National Research Initiative Competitive Grants program (NRI). The panel, under the direction of Thomas Urban, retired CEO of Pioneer Hi-Bred International, has proposed a number of changes for the program.
The major problem with the NRI has been, according to panel member Daryl Chubin, Senior Advisor to the National Science Board, that it is a "program long operated in the shadow of funding under-expectations." When launched in 1989, the NRI was supposed to change the culture of research at USDA in favor of competitive grants, and the program's proponents anticipated that the budget would grow to $500 million. In FY 2000, the NRI received $119.3 million from a Congress which still likes Formula and Special Grants.
The committee's report: National Research Initiative: A Vital Competitive Grants Program in Food, Fiber, and Natural Resources Research concluded that the NRI "did good work" and should by now be an $800 million program. However, the committee declared, it should not receive that amount of funding until it makes significant changes in the research accountability, priority setting, and organization of the program.
The panel commended the program for its mission supporting high-risk research with potential long-term payoffs, its emphasis on training and education, and its commitment to the peer review process. The panel recommended a more effective performance-tracking system and an internal information system that generates data on current NRI operations that would also be accessible on the NRI website.
Within USDA, the committee called for a new Extramural Competitive Research Service that would house the NRI and report directly to the Undersecretary for Research, Economics, and Education. At present, the NRI is part of the Cooperative State Research, Education, and Extension Service. Another recommendation seeks the establishment of a new NRI advisory board that represents stakeholders and has a non-USDA chair.
Under its current structure, the NRI consists of six components including Markets, Trade and Rural Development, which supports most of the social science research funded by the program. Addressing priority setting within each of these components, the panel proposed that six standing scientific-research review committees be assembled to identify critical issues.
The panel also suggested greater cooperation among the National Institutes of Health, the National Science Foundation, the Department of Energy, and the NRI in their efforts to support merit-based, peer-reviewed research in food, fiber, and natural resources. Finally, the committee urged an immediate increase in the size and duration of grant.
Participants in a discussion of the report at the National Academy of Sciences on April 27 agreed that the proposed changes would make the program more effective. However, doubts were raised as to the acceptance by NRI's congressional appropriators that these changes would lead to significantly more funding. The culture of support for agricultural research on Capitol Hill is still mired in the world of production agriculture and despite panel chairman Urban's plea that we need to look beyond the farm part of the food, fiber and natural resources process, Congress still seems reluctant to do so.
The gun debate that has languished on Capitol Hill is an example of false choices, according to a noted criminologist. Lawrence Sherman, the Albert Greenfield Professor of Human Relations at University of Pennsylvania, was the featured speaker at the National Institute of Justice's (NIJ) April 5 Perspectives on Crime and Justice lecture series.
Sherman examined the current gun control policies and the research available to determine their merit in reducing gun violence. Upon reviewing the research and considering the epidemiology (or causes) of gun violence, Sherman concluded that there were only two policies that effectively focused on the high risks of gun violence: uniformed police patrol of gun crime hot spots and background checks before gun sales. Other policies were either labeled "promising" or "doesn't work."
The "more laws vs. more enforcement" positions of the opposing sides in the current dispute are not mutually exclusive, he said. In fact, research suggests that a combination of the two policies "could work wonders" in reducing gun violence. He argued that neither side readily employs research into the discussion, and when it is brought into the debate it "has appeared in the usually suspect pattern of selective invocation of the mantel of science to support one argument or another." Sherman stressed that "far too often, there has been simply no research to cite on the major policy issues."
The current interest and focus on safe gun technologies — external trigger locks, internal trigger locks, increased trigger pull-back pressure — may be misplaced, said Sherman. Safe gun technology, he noted, seems to be aimed at the middle-class gun owner "who would use a trigger lock as conscientiously as they use their automobile safety belts." He said that from an epidemiological perspective, the premise of these "‘safe gun' technologies is the corollary of ‘safe people,' or the ones who can be trusted to use the gun lawfully and safely." Therefore, the efficacy of safe gun technologies depends a great deal on how we define "safe people." Current epidemiological data indicate, said Sherman, that the "current legal boundaries between people declared ‘safe' and ‘unsafe' for gun ownership fall very wide of the mark." The Brady Bill and the current background check debate define safe people as those with no felony convictions. "Yet by that definition, the majority of crimes with guns are committed by people who are legally ‘safe,' law-abiding citizens for purposes of present gun ownership policy." He noted that samples of people arrested for using guns in the commission of crimes "consistently find that the majority have no prior felony conviction."
Sherman pointed out that gun patrols and background checks work. These two strategies, he said, are focused on "high risks of gun violence." In defense of gun patrols, Sherman pointed to two NIJ-funded studies (Kansas City and Indianapolis) indicating that uniformed patrols against guns reduce ensuing gun violence. Both studies showed a reduction of gun violence resulted after police increased gun patrols and gun seizures.
He similarly explained that research supports the use of background checks as a means to prevent or reduce gun violence. Sherman pointed to two impact evaluations (in California and in Florida). The California study concluded that convicted felons prevented from buying guns were "18 percent less likely to be charged with a gun offense over the next three years than the gun buyers who had felony arrests but no convictions." The Florida study found that after the state had adopted a mandatory waiting period and background check for gun purchases, homicide rates dropped relative to [control groups]."
Putting background checks on the "what works" list has a definitive policy impact, Sherman noted. It calls for closing the so-called gun show loophole, and also requiring third-party gun transfers to be subject to background checks.
Gun buyback programs, in which the police pay individuals for returned guns, do not reduce or prevent gun violence. These programs, he said, do not direct resources to any of the root causes of gun violence. Supporters of this type of "prevention" program claim that every gun bought back is a potential life saved. However, Sherman pointed out that not all guns are at equal risk of being involved in a crime, which he said depends on "geographical area, type of gun, recency of manufacture, and prior criminal records of the gun owners."
To support his criticism of these programs, Sherman pointed to three "moderately strong scientific evaluations" of gun buyback programs (two in St. Louis and one in Seattle) that showed no reductions in gun homicides or assaults. Gun buybacks may have an impact on reducing gun violence, he said, if these programs were "limited to residents of the small percentage of all public housing projects nationwide that suffer gun violence problems. But based on the city-wide program results, that seems unlikely."
Sherman noted that there were several policy ideas that held promise, largely because they address known risk factors for gun violence. These include: a ban on handgun sales and possession for all convicted misdeamants, a ban on high caliber handguns, elements of the Smith & Wesson agreement (stronger trigger-pull pressure, serial number system, etc.), ammunition control for all or some sized bullets, ammunition waiting periods, and national one-gun-a-month laws. These policy alternatives, he emphasized, would have to be subject to rigorous evaluations of their effectiveness in reducing gun violence. This list, he said, is far from exhaustive, but in order to find out if they work they need to be tested.
In what might seem like a marriage of strange bedfellows, both the Brookings Institution and the Heritage Foundation are concerned enough with the deterioration of the presidential appointment process to launch, with the support of the Pew Charitable Trust, an initiative that seeks to improve the situation.
The Presidential Appointee Initiative (PAI), under the direction of Paul Light, Director of Governmental Studies at Brookings and Virginia Thomas, Director of Governmental Studies at Heritage, was launched at a press conference in Washington on April 28. The chairs of the Advisory Panel, former Republican Senator Nancy Kassebaum Baker and former Clinton OMB Director Franklin Raines, as well as Rebecca Rimel, President of Pew, also participated in the event.
The participants used words like: "a hazing process," "failing," "voyeuristic," "an accepted culture of scrutiny," "lots of bitterness," to describe the current process of selecting and confirming people for government jobs. With the end of the Clinton administration, the PAI views the current time as a "window of opportunity" to fix some of the more egregious problems including time delays, too many forms with too many insidious questions, Senate non-responsiveness, and the narrowing of the recruiting pool because too many good people do not want to go through the process.
The initiative has released the results of a survey of former Reagan, Bush, and Clinton appointees that shows "the presidential appointments process leaves nominees exhausted, embarrassed, and confused." It hopes to publish A Survivors Guide for Presidential Nominees, and will sponsor a series of forums and seminars on the nomination and confirmation process and related issues. In March 2001, to celebrate the 200th anniversary of Thomas Jefferson's inauguration, PAI will release a reform agenda that "will lead to a faster, more supportive, and more efficient appointments process."
For more information about the PAI see http://www.appointee.brookings.org or http://www.heritage.org.
Julie Samuels has been named the Acting Director of the National Institute of Justice, the Department of Justice's (DOJ) lead research and development agency. Replacing long-time NIJ head Jeremy Travis, who departed for the Urban Institute, Samuels has a long history with the Department of Justice. After graduating from the University of California at Berkeley's Graduate School of Public Policy, she joined the Office of Policy and Management Analysis (OPMA), within DOJ's Criminal Division, as a Presidential Management Intern in 1979. Samuels became Director of OPMA in 1986, and — with a couple of intervening details and special projects — served in that position until being named NIJ's Acting Director.
Eve Blither, Executive Director of the National Education Research Policy and Priorities Board (NERPPB), has resigned from her post, effective June 1. The NERPPB is charged by Congress to advise the United States on the federal educational research and development effort, and works with the Assistant Secretary of Education for the Office of Educational Research and Improvement (OERI) to forge a national consensus with respect to a long-term agenda for educational research, development, and dissemination. Blither oversaw the Board's development and publication of peer review standards to govern research conducted and supported by OERI. The Board is currently seeking a replacement for Blither. All interested persons should contact NERPPB Chair Kenji Hakuta in writing at 80 F Street, NW, Washington, DC 20208.
Gerald Fischbach, head of the National Institute of Neurological Disorders and Stroke, will likely not be nominated by the Clinton Administration to head the National Insitutes of Health (NIH). The administration and officials of the Department of Health and Human Services have apparently decided that the Senate would not be able to confirm him quickly enought to allow for a meaningful tenure. NIH deputy director Ruth Kirschstein will continue as acting director.
COSSA provides this information as a service and encourages readers to contanct the agency for further information, guidelines, and application materials.
The OERI is currently accepting applications for its Comprehensive School Reform Grant competition. For more information about the grant competition, contact Cheryl Kane, U.S. Department of Education, 555 New Jersey Ave., NW., Room 604B, Washington, DC 20202-5530; 202/208-2991 (Telephone); cheryl_kane@ed.gov(Email); http://www.ed.gov/offices/OERI (OERI web address).