Closing the Gap

“Among American citizens there should be no forgotten men and no forgotten races.”

–Franklin D. Roosevelt

Despite the advent of a new, more conservative presidential administration, the federal government’s initiative to eliminate health disparities experienced by racial and ethnic minority populations is, by all accounts, alive and well in the new millennium. And the role of minority nurses in helping to achieve this initiative’s ambitious goals remains as pivotal as ever.

Launched in 1998 as part of former President Bill Clinton’s Initiative on Race, the U.S. Department of Health and Human Services (HHS)’s Initiative to Eliminate Racial and Ethnic Disparities in Health seeks to eradicate differences in health outcomes among minority populations in six critical areas by the year 2010:

• Infant mortality

• Cancer screening and management

• Cardiovascular disease

• Diabetes

• HIV/AIDS

• Immunizations.

This so-called “2010 initiative” is part of the Centers for Disease Control and Prevention (CDC)’s Reach 2010 Demonstrations and is expected to receive $38 million in funding for fiscal year (FY) 2002. HHS’ overall budget for activities that directly target improving the health of minorities, however, is a proposed $2.42 billion—an increase of $154 million over current spending. This proposed budget must still be approved by the House and Senate before it becomes effective for FY 2002, which begins October 1, 2001.

The Initiative to Eliminate Racial and Ethnic Disparities in Health parallels the focus of Healthy People 2010, the national prevention agenda designed to ensure good health and longevity for all Americans (for more information, see http://web.health.gov/healthypeople). A detailed overview of the health disparities initiative can be found online at http://raceandhealth.hhs.gov.

Of course, you can’t eliminate health disparities if you don’t have nurses to provide the necessary care and conduct the research needed to help identify and address the underlying causes of unequal health outcomes.

“The major issue for the profession of nursing as it relates to health disparities is the nursing shortage,” says Hilda Richards, RN, EdN, FAAN, president of the National Black Nurses Association (NBNA). “If this nation is going to improve the health care status of all Americans, we are going to need more nurses. Today nurses are older, fewer people are going to nursing school, the nursing faculty is retiring and there are fewer new nurses to replace them.”

Where the Money Will Go

“The issue of health disparities has received a lot of new money and attention,” notes Campbell Gardett, a spokesperson for the HHS’ Office of the Secretary. “It’s a matter of building on what has already been created.”

What has been created so far is a variety of programs, spread across several different federal health institutes. The increase in funding for FY 2002 will allow the HHS to develop more such programs and improve upon existing ones. Here’s a look at what the various organizations slated to receive increased funding are planning to do with the money.

The National Institutes of Health’s Strategic Research Plan on Health Disparities outlines a five-year goal (FY 2002-2006) focusing on research, research infrastructure, public information and community outreach (see www.nih.gov). The NIH, which is budgeted to receive an additional $203 million for a total of $1.8 billion in FY 2002, expects to expand its support of research and research training. The plan hopes to create:

• A better understanding of the causes of health disparities

• New and improved prevention strategies, diagnostics and treatments to reduce health disparities

• An expanded scientific work force committed to this goal

• Enhanced communication of research results to scientists, health professionals, affected communities and the public.

The proposed FY 2002 budget for the new National Center on Minority Health and Health Disparities (NCMHD), which was established last November, is $152 million—an additional $28 million over the previous year’s budget. The extra funds are earmarked to establish a Centers of Excellence program to conduct research on minority health issues, to support research training and to create two new loan repayment programs for extramural minority and health disparities researchers. (See “Center of Attention.”)

The proposed budget for the Office of Minority Health (OMH) is $43 million. The OMH is hoping to receive an extra $3 million in FY 2002 to support three of its programs:

• The Family and Community Violence Prevention Program, which supports a consortium of minority organizations working to reduce violence affecting minority youth and their families;

• The Minority Male Health Initiative, which will support community efforts to combat chronic diseases affecting minority men; and

• The Health Disparities Grant Program, which will provide 20 to 30 grants in FY 2002 to support pilot and small-scale projects initiated from private non-profit and public community-based organizations.

The OMH grant program is particularly relevant for minority nurses, says Georgia Buggs, RN, special assistant to the director at OMH. “Many minority nurses are working with faith-based organizations to create community outreach programs,” she says. “This kind of funding, which has not been available in the past, will enable them to be involved in pilot studies or collect data on a small scale.”

Another grant program—the Nursing Workforce Diversity Grants, sponsored by the Health Resources and Services Administration (HRSA)’s Division of Nursing—is budgeted for $6.2 million, an increase of $1.6 million from the previous year. These grants are designed to help schools of nursing, academic health centers, nursing centers, state and local governments and other public or private non-profit entities provide student stipends and pre-entry and retention activities for racial and ethnic minorities, who are seriously underrepresented within the nursing work force.

Finally, the National Institute for Nursing Research (NINR)’s budget will be $117 million, representing an additional $12 million in FY 2002. Approximately 20% of the NINR budget targets health disparities, notes Daniel O’Neal, RN, MA, CS, chief officer of science policy and public liaison.

But Is It Enough?

Many minority nursing leaders, such as Mary Lou de Leon Siantz, RN, PhD, FAAN, president of the National Association of Hispanic Nurses (NAHN), are pleased with the proposed additional funding and hopeful that this is an indication that the Bush administration is supportive of these initiatives.

“It was one of the first things President Bush mentioned in his State of the Union speech,” Siantz says. “It seems Bush is solidly behind the initiatives, since each NIH institute has its own strategic plan with the goal of eliminating ethnic and racial disparities in health.”

In particular, she believes the NCMHD’s Centers of Excellence program is the perfect vehicle to help spread minority heath care initiatives across the country. “Local researchers and experts need to be able to participate in the process [of reducing minority health disparities] in their regions,” Siantz asserts.

Lillian Tom-Orme, RN, PhD, MPH, FAAN, president-elect of the National Alaska Native/American Indian Nurses Association (NANAINA), is equally optimistic. When she was in Washington, D.C., this past spring, Tom-Orme noted that “all indications are to continue. My understanding is that the Bush administration is supportive of the initiatives. The new HHS Secretary [former Wisconsin governor Tommy Thompson] is supportive.” However, she stresses, “the initiatives must continue with the same vigor as has been previously shown.”

“It’s a good beginning for the year,” agrees the NBNA’s Richards. “But in reality, it will take a while to really narrow the gap between disparities.”

Testifying on the FY 2002 Department of Labor-HHS Appropriations Budget earlier this year, Richards outlined the NBNA’s funding recommendations, all of which falls shy of the proposed budget:

• $140 million for the Division of Nursing

• $145 million for the NINR

• $200 million for the NCMHD

• $65 million for the OMH.

The NBNA is also calling for Congress to provide legislative assistance for additional funding to increase the number of registered nurses, nursing faculty and nurses prepared at the baccalaureate degree level. In addition, the association recommends increased funding for research studies to determine safe nursing care in acute and community settings, and more initiatives to prepare young people to enter nursing and other science-based professions.

Likewise, Kem Louie, RN, PhD, president of the Asian American/Pacific Islander Nurses Association (AAPINA), does not believe the proposed 2002 funding is sufficient.

“Additional funds are needed to research the complex factors behind these disparities and to begin designing interventions,” she says. “But these health disparities are longstanding and affect generations of families. This amount of money is not enough if the federal government plans to [fund the programs] for only one or two years.” Louie feels strongly that “there should be a long-term commitment and strategic planning for at least 10 years of funding until these disparities are truly eliminated.”

Minority Health Research Needs Minority Researchers

Initiatives that target increasing the number of racial and ethnic minority nurses and nurse researchers, along with increased participation of minority patients in research studies, are crucial to the fight against health disparities.

“The push is to not only get more minorities participating in clinical trials but also to get minority nurses involved in solid research,” Richards explains. “We know that many of the clinical trials that modern medicine was built on did not include people of color. We have a mission to assure that this inequity gets turned around.”

To reach that goal, the NBNA supports additional funding to increase the number of minority researchers studying minority health issues. The association also supports the collaborative arrangement between the NCMHD and NINR to ensure that more nurses are part of the clinical trials team.

Betty Smith Williams, RN, DrPH, FAAN, president of the National Coalition of Ethnic Minority Nurse Associations (NCEMNA), agrees. “More minorities need to receive funding for [minority health] research,” she emphasizes. “Typically, the institutions that are considered research centers, especially in nursing, receive the lion’s share of the funds, but researchers at these institutions tend to lack the community input and participation necessary to do research on minority populations.

“There needs to be more money put into education and training to create a larger pool of ethnic minority nurses who have research skills and knowledge,” she adds.

NCEMNA, which represents the NBNA, NAHN, AAPINA, NANAINA and the Philippine Nurses Association of America, is working with the NINR and NCMHD to further the development of nurse investigators in minority health research. One such project partners approximately 30 research-intensive majority educational institutions with smaller nursing schools that have large ethnic minority student populations.

The three organizations are currently finalizing a project summary, and this summer the NINR is expected to start awarding funds to help colleges and universities develop such partnerships. According to O’Neal, “We expect to provide a fairly large amount of money to extend these partnerships, make them work more effectively and then promote the model to the rest of the nursing community.”

Siantz is encouraged by the additional funding to develop more minority researchers, pointing out that such programs have previously been unavailable at many universities. The NAHN president stresses the importance of offering research training for minority nurses at all levels.

“You don’t have to be a highly trained, PhD-level nurse to be able to participate in the research process,” she says. “At the bachelor’s level, minority nurses can learn how to recruit minority subjects into clinical studies. At the bachelor’s and master’s level, they can learn how to manage research projects.”

Understanding Behavioral Differences

As researching and eliminating minority health disparities becomes an increasingly high priority on the national agenda, minority nursing leaders hope this will signal the end of the longstanding practice of rarely including persons of color in clinical trials.

“In order to have valid data, you need to collect information about all populations,” says Williams. “Up until the early 1990s, most studies didn’t even include women, let alone minorities.” But in recent years, she notes, there has been an increase in research grants for studies that address diverse patient populations.

“Health disparities are based on health behaviors,” Williams continues. “Therefore, [researchers] must have better knowledge and understanding of the behaviors of the racial and ethnic groups they are researching, which must then be clarified and verified by the people in those communities.”

Once the “unhealthy” behaviors are identified and understood, then people can be taught to modify these behaviors to improve their overall health. For example, African Americans, Hispanics and Native Americans are more likely to suffer from diabetes than Caucasians, a disparity that Richard believes is related to differences in diet and lifestyle.

“We need to help people modify that kind of unhealthy behavior, which takes cultural sensitivity,” she says. “And whatever we do in that area must be based on good, solid research.”

More NIH Programs Target Minority Health

Two other notable National Institutes of Health (NIH) programs that address ethnic and racial minority health disparities are budgeted to receive an infusion of funding in fiscal year 2002.

The Agency for Healthcare Research and Quality is budgeted to receive $1 million to launch a National Disparities Report. Starting in fiscal year 2003, AHRQ will send Congress an annual report on prevailing disparities in health care delivery. The report will compare accessibility, use and quality of health care services as they relate to racial/ethnic and socioeconomic factors in priority populations.

The HIV/AIDS in Communities of Color initiative, for which funding has more than doubled since it was developed under the auspices of the Congressional Black Caucus, is earmarked to receive $358 million. This includes $50 million targeted for infrastructure development, technical assistance, prevention and treatment linkages, and education in racial and ethnic minority communities.

Center of Attention

by Anne Baye Ericksen

As the federal Healthy People 2010 initiative seeks to uncover more answers to questions about how Americans can prevent disease and live longer, healthier lives, more questions continue to surface—particularly in the area of health risks that disproportionately affect racial and ethnic minority populations, compared with the white majority.

Indeed, there are striking, even alarming, contrasts between Caucasians and people of color when it comes to the prevalence of serious health risks like infant mortality, asthma, Type 2 diabetes and HIV/AIDS, to name just a few. While these disparities aren’t exactly “new” discoveries, recent revelations of just how large and deep these gaps actually are has captured national attention—including that of the National Institutes of Health (NIH).

To put sharper teeth into the fight against minority health disparities, last November the NIH created the National Center on Minority Health and Health Disparities (NCMHD). In January, NIH Acting Director Ruth L. Kirschstein, MD, named John Ruffin, PhD, an African-American biomedical researcher, as the NCMHD’s first director. The new center officially replaces the Office of Research on Minority Health (ORMH), which had limited capacities.

Moving Forward

While still in its early stages, NCMHD has established three main goals, each pertaining to research. First, it aims to assist in the development of a multidisciplinary national research agenda that reflects the current health needs of racial and ethnic minority populations. The second goal is to support basic clinical and population research designed to identify potential risk factors for disparate health outcomes.

Lastly, NCMHD plans to extend research efforts into medically underserved minority communities. This will include educating young people of color about health care career opportunities in practice and research. Additionally, NCMHD picks up where the ORMH left off in coordinating minority health research conducted by other organizations under the NIH umbrella.

Dr. Ruffin brings to NCMHD extensive experience in the area of minority health research. In 1990, he was appointed as the first associate director for research on minority health at the NIH. In this position, Ruffin spearheaded several groundbreaking programs. One of his first directives established a fact-finding team of approximately 1,000 health care professionals from minority communities. Their mission was to identify health concerns in those communities and to train practitioners in providing culturally competent care to their minority patients.

This program eventually became the basis for the federal Minority Health Initiative. In 1992, Congress approved a budget of $45 million for the initiative; eight years later, its budget has grown to more than $86 million.

Through NCMHD, Ruffin hopes to extend the initiative’s reach, both via direct research and by funding independent projects that support the center’s goals—something the ORMH could not do because it was not an independent center within the NIH. These combined efforts will be instrumental in helping to reduce the number of questions and increase the number of answers regarding minority health disparities, while arming health care providers with more knowledge to make their patients’ lives a little better.

Anne Baye Ericksen is a free-lance writer based in Southern California who specializes in health and career issues.