Translating Epidemiologic Findings into Action to Eliminate Disparities American College of...

Translating Epidemiologic Findings into Action to Eliminate Disparities

American College of EpidemiologyMinority Affairs Committee WorkshopChicago, IL, September 8, 2012

Victor J. Schoenbach, Ph.D., go.unc.edu/vjs/Department of Epidemiology and Minority Health ProjectUNC Gillings School of Global Public Health

Marion E. Schoenbach (Enabler)

Outline

The movement to eliminate health disparities

Strategic plans and progress Translating epidemiologic knowledge

into public health action on disparities Propositions about human behavior Challenges for epidemiology

Secretary’s Task Force on Black & Minority Health, 1985

Useful landmark Heckler Report Minorities experience

60,000 excess deaths Eight main

recommendations calling for outreach, cultural awareness, coordination, health care access, data, research

Report of the Secretary’s Task Force

"Despite the unprecedented explosion in scientific knowledge and the phenomenal capacity of medicine to diagnose, treat, and cure disease, Blacks, Hispanics, Native Americans, and those of Asian/Pacific Islander heritage have not benefited fully or equitably from the fruits of science or from those systems responsible for translating and using health sciences technology.“ (Introduction and Overview)

ACE 10th Annual Scientific Meeting, 1991 in Atlanta, GA

Morbidity/Mortality GapIs it Race or Racism?”

A consciousness-raising experience

Healthy People 2010

Overarching goals: Goal 1: Increase Quality and Years of Healthy Life

Goal 2: Eliminate Health Disparities

Healthy People 2020: overarching goals

1. Attain high quality, longer lives free of preventable disease, disability, injury, and premature death.

2. Achieve health equity and eliminate disparities.

3. Create social and physical environments that promote good health for all.

4. Promote quality of life, healthy development, and healthy behaviors across all life stages.

Outline



into public health action on disparities Propositions about collective behavior Challenges for epidemiology

NIH Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities

“Over the last two decades the overall health of the Nation has improved significantly. Yet there continue to be striking disparities in the burden of illness and death experienced by African Americans, Hispanics, Native Americans, Alaska Natives, Asians, and Pacific Islanders. …. These disparities are believed to be the result of the complex interaction among biological factors, the environment, and specific health behaviors. Inequalities in income and education also appear to underlie many health disparities in the United States.”

NIH Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities (con’t)

“In fiscal year 2001, the NIH spent over $2 billion on research, research infrastructure, and public information and community outreach efforts to reduce health disparities. This provided a strong basis for further investments over the longer term – investments that promise substantial progress in reducing the incidence, prevalence, severity, and social and economic burdens of diseases and disabilities that affect racial and ethnic minorities and other health disparity populations.”

NIH Health Disparities Strategic Plan, Fiscal Years 2004-2008

“Medical and scientific advances have introduced new opportunities for the continued improvement of health for all Americans. However, in spite of notable improvements gained as a result of the advancement of knowledge through basic and applied research, diagnostics, and treatment, there continues to be an alarming disproportionate burden of illness among minority and medically underserved populations.”

NIH Health Disparities Strategic Plan, Fiscal Years 2004-2008 (con’t)

“In fiscal year 2003, the NIH spent over $2 billion on research, research infrastructure, and public information and community outreach efforts to reduce health disparities. This provided a strong basis for further investments over the longer term—investments that promise substantial progress in reducing the incidence, prevalence, severity, and social and economic burdens of diseases and disabilities that affect racial and ethnic minorities and other health disparity populations.”

NIH Health Disparities Strategic Plan and BudgetFiscal Years 2009-2013

”As long as even one of our fellow Americans encounters barriers to optimal care – whatever the reason – our work is unfinished.”

Healthy People 2010 Final Review: Changes in health disparities

“most of the population-based objectives with data to measure disparities had no change in health disparities.”

How Far Have We Come in Reducing Health Disparities?: Progress Since 2000Recurring themes from an April 8, 2010 Institute of Medicine workshop:Health disparities are not going awayEconomic hardship is an important contributorInstitutional racism and racial discrimination persistResidential segregation, community environmentLow levels of awareness among general publicPolicies of federal agencies besides those directly related to healthCommunity input/initiation is keyThe Affordable Care Act should help

Department of Health and Human Services Summits“The 2012 Science of Eliminating Health Disparities Summit is an HHS-wide endeavor involving a broad spectrum of the federal government that seeks to advance activities to eliminate health disparities. The agenda will build on the momentum of the 2008 Summit and the increased interest of federal agencies to demonstrate their commitment towards improving the health of all Americans. The 2012 Health Disparities Summit represents an ongoing focus on emerging science and its intersection with practice and policy, while maintaining momentum on current national and international trends in addressing the social determinants of health.” http://www.nimhd.nih.gov/summit_site/about.html

But there has been progress! (Personal recollections of Gladys Reynolds)

When I first came to CDC in 1960 as an EIS officer, there were almost no minorities and probably no African Americans (at CDC in Atlanta). In 1965 there was an African American EIS officer and they couldn't find a place for him to rent near CDC. There were very few women in professional positions especially at higher levels. I think I was the second woman to be a GS15. Believe me there was major resistance. I could tell many stories but I won't. But, I was lucky. Almost every boss I had was great and supportive of our efforts. (Only one exception.)

Outline


Strategic plans and progress Translating epidemiologic

knowledge into public health action on disparities

Propositions about collective behavior Challenges for epidemiology

Eliminating a disparity through public health action: steps

1. Attention, advocacy2. Documentation, prioritization3. Interventions identified, evaluated4. Scalable, cost-effective5. Delivery methods identified6. Resources acquired and maintained7. Feedback and affirmation

A Tale of Two Disparities

Childhood immunization / measles elimination

HIV/AIDS

Childhood immunization / measles elimination

Dual strategy: universal interventions + targeted interventions

Gap in measles vaccine coverage narrowed from 15% (1985) to 6% (1992) to 2%.

Risk ratio for disease among nonwhite children (vs. white) declined from 4-7 to 4 to elimination of endemic disease

Elimination of Measles and of Disparities in Measles Childhood Vaccine Coverage among Racial and Ethnic Minority Populations in the United States Sonja S. Hutchins, Ruth Jiles, Roger Bernier. JID 2004;189:S146-S152

Increase in vaccine coverage and reduction of disparity

Elimination of Measles and of Disparities in Measles Childhood Vaccine Coverage among Racial and Ethnic Minority Populations in the United States Sonja S. Hutchins, Ruth Jiles, and Roger BernierJID 2004(May 1);189: S146-S152

Maintenance of parity in measles vaccine


Elimination of measles and disparity


Endgame: HIV/AIDS in African Americans (PBS Frontline)1983: The CDC begins tracking breakdown of HIV by race.1985: First Black AIDS Organizations founded1986: First Black AIDS Conference1986: No one of color is invited to participate in the American Public Health Association’s first session on AIDS in October2004: HIV Becomes Leading Cause of Death for Young Black Women2010: Congress removes ban on federal funding for needle-exchange programs2011: Congress reinstates ban on federal funding for needle-exchange programs2012: Black AIDS Institute Report Highlights High HIV RatesBlacks have a higher rate of undiagnosed HIV infections compared to other groups, according to a February. Although they make up less than 14 percent of the U.S. population, blacks make up 44 percent of all new infections.

A Tale of Two Disparities

Childhoodimmunization HIV

Magnitude of problem + +++Embedded in socio-economic + ++Availability of interventions ++ +Cost, cost-effectiveness ++ +Use existing health care infrastructure ++ +Neutral or favorable to commercial,

religious, political interests ++ -Near-term, visible, marketable impact ++ ?

Secretary’s Task Force, 1985

“The Task Force acknowledged that the factors responsible for the health disparity are complex and defy simplistic solutions. Health status is influenced by the interaction of physiological, cultural, psychological, and societal factors that are poorly understood for the general population and even less so for minorities.”

Outline



into public health action on disparities Propositions about human

behavior Challenges for epidemiology

Competition

History is a record of competition and cooperation.

1st Century B.C.

.

Propositions on human behavior: looking under the hood

1. Living systems are made up of fundamental building blocks (e.g., quarks, electrons, protons, atoms, molecules) organized into organelles, cells, organs, etc.

Propositions

2. Living systems replicate, diversify, compete, cooperate, invade one another, incorporate one another, combine, and evolve into systems of increasing complexity.

Propositions

3. Complex living systems have nervous systems that can create the experiences of consciousness, memory, imagination, deductive logic, extrapolation, anticipation, prediction, and other mental functions.

Propositions

4. These mental functions are generated by the interactions of large numbers of individual agents (neurons), in the context of other types of cells and the factors they secrete, as well as other internal and environmental chemico-physical influences.

Propositions

5. The resulting thoughts and actions, which are also influenced by perceptions and expectations of others’ thoughts and actions, are generally aimed at advancing the organism’s interests, as these are perceived by the organism.

Propositions

6. Collaborations, organizations, governments, strategic plans, policies, legislation, enforcement actions, and everything else reflect these myriad, competing influences. Ultimately, better outcomes require that thoughts and actions reflect more accurate, efficient, coherent and integrated brain functioning.

Propositions

7. Epidemiology should assign greater importance to understanding nutritional, microbiological, hormonal, environmental, behavioral, social, and institutional influences on the functioning of the nervous system and behavioral implications.

Outline



into public health action on disparities Propositions about human behavior Challenges for epidemiology

Challenges for Epidemiology

Epidemiology has been called “the basic science of public health”. Can epidemiology really study basic processes and fundamental determinants?

Fundamental determinants

Fundamental determinants of health are biological, behavioral, environmental, and health services. But health services reflect human behavior, and increasingly the environment does as well. Is human behavior – heavily influenced by biology – the fundamental determinant?

“We have met the enemy and he is us” – or is he?

“For a long time, it was generally assumed that many of the mental processes that make goal pursuit possible require consciousness. But in the past decade or so, the scientific study of goal pursuit has discovered that these processes can also operate without conscious awareness, and hence, human behavior may originate in a kind of unconscious will.Ruud Custers and Henk Aarts. The unconscious will: how the pursuit of goals operates outside of conscious awareness. Science 2010 (July 2);329(5987):47-…

Research on increasing fairness and generosity

Examples: Fairness and the development of

inequality acceptance. Ingvild Almas, Almås et al. Science 28 May 2010;328:1176-1178

Indirect punishment and generosity toward strangers. Aljaz Ule et al. Science 18 Dec 2009;326:1703-

Jonathan Cole interview with Academe

Are we losing our smarts?

“The results of this study show that long working hours may be one of the risk factors that have a negative effect on cognitive performance in middle age.” 604Long working hours and cognitive function: The Whitehall II Study. Marianna Virtanen et al. Am J Epidemiol 2009;169:596-605

Can consciousness be improved?

Transcendental Meditation is attracting increasing interest.(www.davidlynchfoundation.org)

“Quiet time” programs have shown great promise in urban schools with typical problems.

Can epidemiologists evaluate a wholistic intervention with long-term impact?

Can consciousness be improved?

Translating Epidemiologic Findings into Action to Eliminate Disparities American College of...

Documents

Transcript of Translating Epidemiologic Findings into Action to Eliminate Disparities American College of...