Translating Epidemiologic
Findings into Action to
Eliminate Disparities
Research Seminar
College of Public Health and Human Sciences
Oregon State University
Corvallis, OR, May 24, 2013
Victor J. Schoenbach, Ph.D., go.unc.edu/vjs/
Department of Epidemiology and Minority Health Project
UNC 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 Gap
Is 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
 The movement to eliminate health
disparities
 Strategic plans and progress
 Translating epidemiologic knowledge
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 Budget
Fiscal 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
(Healthy People
2010 Final Review)
with data to measure disparities had no
change in health disparities.”
How Far Have We Come in
Reducing Health Disparities?:
Progress Since 2000
Recurring themes from an April 8, 2010 Institute of
Medicine workshop:
 Health disparities are not going away
 Economic hardship is an important contributor
 Institutional racism and racial discrimination persist
 Residential segregation, community environment
 Low levels of awareness among general public
 Policies of federal agencies besides those directly
related to health
 Community input/initiation is key
 The 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
Outline
 The movement to eliminate health
disparities
 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.
2.
3.
4.
5.
6.
7.
Attention, advocacy
Documentation, prioritization
Interventions identified, evaluated
Scalable, cost-effective
Delivery methods identified
Resources acquired and maintained
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 Bernier
JID 2004(May 1);189: S146-S152
Maintenance of parity in measles
vaccine
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 Bernier
JID 2004(May 1);189: S146-S152
Elimination of measles and
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 Bernier
JID 2004(May 1);189: S146-S152
Endgame: HIV/AIDS in African
Americans (PBS Frontline)
1983: The CDC begins tracking breakdown of HIV by race.
1985: First Black AIDS Organizations founded
1986: First Black AIDS Conference
1986: No one of color is invited to participate in the American
Public Health Association’s first session on AIDS in October
2004: HIV Becomes Leading Cause of Death for Young Black
Women
2010: Congress removes ban on federal funding for needleexchange programs
2011: Congress reinstates ban on federal funding for needleexchange programs
2012: Black AIDS Institute Report Highlights High HIV Rates
Blacks 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
Childhood
immunization 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
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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
 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
Competition
History is a record of
competition and
cooperation.
1st Century B.C.
.
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 over 100 billion
individual agents (neurons), in the
context of other types of cells and the
factors they secrete, as well as other
internal and environmental chemicophysical 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 and
responded to by 100 billion+ agents.
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
 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
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?
Research on fairness judgments
“We found that as children enter
adolescence, they increasingly view
inequalities reflecting differences in
individual achievements, but not luck, as
fair, whereas efficiency considerations
mainly play a role in late adolescence.“
Fairness and the development of inequality
acceptance. Ingvild Almas, Almås et al. Science
28 May 2010;328:1176-1178
The dinner that cost Bill Gates,
Warren Buffett and other
celebrities billions
Warren Buffett and Bill Gates. Photo: Getty
Some billionnaires donate to
good causes, others … - Why?
“This week … 40 billionaires – worth a
combined $230 billion (£145 billion) –
signed a "giving pledge" to donate at
least 50 per cent of their wealth to good
causes. It is a remarkable act of
noblesse oblige, even in a country
whose tradition of philanthropy is the
strongest in the industrialised world.”
www.telegraph.co.uk/news/worldnews/northamerica/usa
/7929657/The-dinner-that-cost-Bill-Gates-WarrenBuffett-and-other-celebrities-billions.html
“We have met the enemy and
(s)he is us” – or is (s)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-…
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.”
604
Long 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?