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TESTIMONY ON "HEALTH DISPARITES: BRIDGING THE GAP"
BY RUTH L. KIRSCHSTEIN, M.D., ACTING DIRECTOR
NATIONAL INSTITUTES OF HEALTH
U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
BEFORE THE SENATE SUBCOMMITTEE ON PUBLIC HEALTH
COMMITTEE ON HEALTH, EDUCATION, LABOR AND PENSIONS
JULY 26, 2000
Good morning, Chairman Frist, Senator Kennedy and other Members of the
Subcommittee. I am Dr. Ruth Kirschstein, the Acting Director of the National
Institutes of Health (NIH). I have with me today Dr. John Ruffin, Director,
Office of Research on Minority Health, and Dr. Vivian Pinn, Director, Office
of Research on Women=s Health,
NIH. Thank you for the opportunity to appear before you today to discuss
health disparities, which I believe to be a significant public health problem.
The causes of health disparities are multiple. They include poverty, level
of education, inadequate access to health care, lack of health insurance
and societal discrimination, and lack of complete knowledge about the causes,
treatment, and prevention of serious diseases disproportionately affecting
differing populations. The causes are not genetic, except in rare cases
such as sickle cell disease. All of us, regardless of race, have basically
the same genetic construction.
The evidence of health disparities in this country is striking and beyond
dispute. Just two weeks ago, the Federal Interagency Forum on Child and
Family Statistics, 2000 released a comprehensive report measuring national
indicators of well-being in America=s
children. The report found that gauges of children=s
well-being, such as mortality, teenage pregnancy and juvenile violence,
are at their lowest rates in two decades. The Washington Post reported
the news under the banner headline: AReport
Paints Brighter Picture of Children=s
Although it is true that indicators of children=s
health contain good news, the report contained additional conclusions that
have become all too familiar. While the picture was brighter for white children,
the picture was dimmer for many minorities. For example, infant mortality
nationwide among African Americans and Native Americans is more than twice
as high as among whites and Hispanics.
This latest news is only one of a series of troubling findings that have
been reported in recent years. The maternal mortality rate in the United
States is four times higher among African-American mothers than among white
mothers. Although the prevalence of asthma is only slightly higher in African-American
children than in white children, African Americans experience greater disability
and more frequent hospitalizations from complications of the illness. Mortality
from coronary heart disease is 40 percent higher in African Americans than
whites. The mortality rate from stroke in African Americans is nearly 80
percent higher than the rate among Caucasians. These disparities exist with
virtually every major disease, including cancer, AIDS, end-stage renal disease,
liver disease, tuberculosis, and osteoarthritis.
The Federal Government is engaged in multi-faceted initiatives designed
to address health disparities in Americans. One America in the 21st
Century: The President=s Initiative
on Race, seeks to overcome racial division in our society. One goal
of this effort is the reduction of health disparities among minorities by
improving the health-care infrastructure and removing obstacles to the delivery
of and access to health care among minority populations.
A second initiative is Healthy People 2010, a national program to
promote wellness and disease prevention, which has the elimination of health
disparities as one of its primary goals.
A third effort is the Department of Health and Human Services=
Initiative to Eliminate Racial and Ethnic Disparities in Health,
which has targeted six health disparities for elimination. The six are disparities
in infant mortality, cancer screening and management, cardiovascular disease,
diabetes, HIV/AIDS, and immunization.
The elimination of health disparities will require a cross-cutting effort,
involving not only various components of the Federal Government, but the
private sector as well. At NIH, we are committed to fulfilling our own role
in the battle against health disparities. We have the responsibility to
place special emphasis on those diseases and conditions that are major contributors
to health disparities, with the goal of making measurable progress against
these problems. We have the responsibility to ensure that the new knowledge
we generate in our laboratories and our clinics benefits all our citizens
and all our communities. We also have the responsibility to attract and
train the next generation of scientists and health care professionals to
ensure that we will have the culturally and ethnically diverse work force
in research and medicine that is essential to eliminating health disparities.
NIH has a history of addressing health disparities through its Institutes
and Centers through a number of targeted programs and research projects.
More recently, health disparities has been an area of increased research
emphasis and a budget priority at NIH. Ten years ago, the Office of Research
on Minority Health was established. With the support of the Congress, we
have devoted significant resources to health disparities research. We have
substantially increased the numbers of minorities participating in NIH-sponsored
clinical trials. We are training minority scientists. NIH is funding partnerships
between Historically Black Colleges and Universities and Institutions that
have a longer history of NIH support.
However, as long as health disparities exist, and in some cases continue
to widen, more could be done. Today, I want to emphasize what we are doing
now, and what we will do in the future.
Scientific research is all about trying new approaches when current ideas
do not achieve expected results. This philosophy applies to health disparities.
We have made strides in some areas, but we will not rest until health disparities
no longer exist - - period. It is clear that we need a different approach.
The Administration has proposed to create a coordinating center in the
FY 2001 Budget and legislative authority for the Office of Research on Minority
Health to award grants in certain circumstances. We would also support the
creation of a national center for research on minority health and health
disparities as proposed in S.1880 and H.R. 3250.
While we envision authority for the Center to award grants to fill- in
research gaps and build capacity at research institutions, its major role
would be to coordinate the efforts of all Institutes and Centers at the
NIH. I believe the primary research on diseases that result in health disparities
must remain at the Institutes and Centers with expertise in disease-specific
research. Research on cardiovascular disease that has a disproportionate
impact on minorities, should continue to be led by the National Heart, Lung
and Blood Institute. Research on HIV/AIDS that afflicts minorities more
than nonminorities should be led by the National Institute of Allergy and
Infectious Diseases and the Office of AIDS Research. Research on cancer,
another illness resulting in health disparities, should be led by the National
Cancer Institute. But NIH must do a better job of coordinating such research
among the various Institutes and Centers, and we believe our initiative
will do just that.
For the past six months, NIH has been developing a comprehensive Strategic
Plan to Reduce and Ultimately Eliminate Health Disparities. The Plan,
which for the first time will coordinate the research resources of the NIH
Institutes and Centers, is currently in draft form and is being reviewed
by the outside advisory committee of the NIH Office of Research on Minority
Health. The goal is for the Strategic Plan to be ready for submission as
part of the NIH Fiscal Year 2002 budget, as an outline of the NIH=s
priorities and commitment to research on health disparities. The Plan sets
forth the NIH objectives for reducing and eliminating health disparities
over the next five years. The plan focuses on three major areas: 1) research;
2) research infrastructure; and 3) public information, outreach and education.
Any discussion of health disparities would be incomplete without including
women=s health. Our efforts to
include more women in NIH-funded studies were invigorated by passage of
the 1993 NIH Revitalization Act, which required that researchers look for
sex-based differences in clinical studies of drugs and other interventions.
Under the leadership of the Office of Research on Women=s
Health, NIH developed and issued new guidelines to the scientific community.
Full implementation of these guidelines was accomplished by the end of 1995.
The impact of the guidelines is not yet fully known because clinical trials
are not yet available for analysis. We intend to monitor closely the results
of these trials as they are completed to ensure compliance with the guidelines.
Two months ago, the General Accounting Office issued a report entitled:
NIH Has Increased Its Efforts to Include Women in Research. I am
pleased with the report=s overall
conclusion that NIH has made great strides in women=s
health research. The report did contain one criticism, that NIH had not
ensured that research be designed to allow sex-based analysis of results.
Unfortunately, GAO reviewed unpublished reports based on research that occurred
before the new requirements were enacted. Let me assure you that the requirements,
which were mandated in the 1993 NIH Revitalization Act, are being met. Both
Dr. Pinn and I are committed to ensuring this throughout our entire portfolio
Meanwhile, data from 1998, the most recent available, show that nearly
67 percent of all participants in NIH-supported research were women. We
are confident that women are being
included in clinical trials in large and increasing numbers. We are currently
enhancing a new NIH-wide system for tracking clinical trial data to ensure
that women are accurately counted.
As we proceed, we intend to work with this Subcommittee and other congressional
panels to ensure that our approaches to health disparity research, including
women=s research, have public
input, and receive priority.
Thank you for the opportunity to testify. I will be pleased to answer any
questions that you may have.
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