January 5, 2004

John Ruffin, PhD, Director
National Center for Minority Health and Health Disparities
National Institutes of Health
6707 Democracy Boulevard, Suite 800
MSC-5465
Bethesda, MD 20892

Dear Dr. Ruffin:
On behalf of the American Psychological Association (APA), I am pleased to respond to the call for comments on the NIH Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities. APA is the largest scientific and professional organization representing psychology in the United States and is the world's largest association of psychologists. APA's membership includes more than 150,000 researchers, educators, clinicians, consultants and students. Through its divisions in 53 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science, as a profession and as a means of promoting health, education and human welfare.
As you know, APA was an active participant in the legislative process that authorized the National Center for Minority Health and Health Disparities (NCMHD) and the current strategic plan. Our members also played a significant role in the development of former Surgeon General David Satcher's 2001 report on health disparities entitled, Mental Health: Culture, Race, and Ethnicity. Not only does psychological science have a great deal to contribute to the plans you have outlined, but APA's mission to promote health and improve human welfare embraces the goal of eliminating health disparities. For these reasons, APA and its members have a large stake in the success of NIH's effort to eliminate health disparities.

The National Cancer Institute's strategic plan eloquently expresses the need for NIH to engage in multiple approaches to combat health disparities:

"Disease always occurs within a context of human circumstances. In combination, risks related to genes, individual behaviors, and social and economic circumstances contribute to disease susceptibility. Moreover, social position, economic status, culture and environment are among the more critical determinants of who is born healthy, who grows up healthy, who sustains health throughout his or her life span, who survives disease, and who maintains a good quality of life after diagnosis and treatment."

NIH has invested in the training of scientists and the development of methodologies that make it possible for researchers to study behavioral and social phenomena such as patient-provider communications, racism, the multiple influences of socioeconomic status, allostatic load, and variable experiences of stress and its disparate impacts upon immune function. But NIH must follow up initial investments with strong, multi-institute partnerships in order to continue progress through the current "post-doubling" budget environment.

While we have a few suggestions to make, we do so in the context of a very positive appraisal. The strategic plan is an impressive document, reflecting the efforts of many scientists both within and outside of NIH. It is broadly conceived, and covers priorities for research on the prevalence of disorders, causes of disparities, intervention outcomes, and training issues. The plan also recognizes the particular need for further research along these dimensions for mental disorders. Many of the priorities listed by the various NIH institutes and centers call for behavioral research and outcome measures.

Because psychologists have particular expertise in the recruitment and retention of minority subjects in research, and the difficulties that are sometimes encountered, some APA scientists have communicated a concern about the seeming reliance on large-scale clinical trials delineated in the National Institute of Mental Health's plan and others. While there is a strong (and appropriate) emphasis on clinical trials, other outcome research strategies involving a whole range of quantitative and qualitative methods should be encouraged. We may find that the costs and complications associated with large-scale clinical trials of different ethnic minority populations are prohibitive. NIH should maintain contingency plans and fund a range of types of clinical research. Perhaps under the auspices of NCMHD and the NIH Office of Behavioral and Social Sciences Research (OBSSR), institutes and centers could plan how different levels of research on treatment outcomes (for example, efficacy and effectiveness studies with large and smaller samples of different ethnic groups) can fit together into a master plan to complement each other in determining best practices for ethnic minority clients. In this way, we are not putting all our outcomes research eggs into one basket. Also, research from different investigators using different methods can begin systematically to chip away at the issue of treatment effectiveness in a coordinated manner.

One of NIH's goals in releasing the plan and calling for comments is to demonstrate to the public and to policymakers the strength of its intent to tackle the multiple problems engendered by health disparities. This goal unifies the many NIH institutes and centers. The strategic plan could be made clearer by listing institute efforts by fiscal year in a single, unified plan. For example, presenting in one document the efforts that will continue or begin in 2004 would give the public an impressive and accurate vision of the scope of NIH's endeavors. As the plan is now communicated, one must read each institute's plan and then sort out what conferences have already been held and what efforts are beginning in 2004 and beyond.

One problem that NIH has encountered is that of adequately defining and categorizing current research efforts on health disparities, and the dollars allotted to those efforts. As you may know, the behavioral and social sciences have encountered similar problems. A good definition of the behavioral and social sciences was developed several years ago, but training for institute personnel to use the definition to generate accurate statistics has been challenging for OBSSR. It is ironic that a government institution like NIH so identified with science and good data could have difficulty categorizing its own sponsored research and training. The NCMHD has taken an important step in establishing a committee to sort out the definitional and data-gathering issues so that accurate information can be reported to the public. APA is willing and eager to be of assistance to the committee. Please contact me if APA can be of assistance, or can identify a psychologist with any particular skills sought by the committee.

Because of the importance of behavioral and social sciences research in reducing and ultimately eliminating health disparities, it seems reasonable for the National Center on Minority Health and Health Disparities to include a psychologist on its advisory council. It is fortunate that the Director of the OBSSR is an ex officio member of the council, but even that does not guarantee that the Center will have a psychologist adviser. APA will send a list of nominees for this council under separate cover, and we encourage you to appoint a psychologist knowledgeable about health disparities when a vacancy arises.

Many thanks for encouraging comments on the strategic plan. Please let me know if APA can be of assistance as the plans are carried forward.

Sincerely,

Norman B. Anderson, PhD
Chief Executive Officer
American Psychological Association

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