Elias Zerhouni

Health disparities can be addressed only if policymakers collect sufficient evidence, if researchers find the root causes, and if affected communities help define the problems and develop solutions. These are some of the common themes that emerged from an April 14 HSPH symposium featuring the director of the National Institutes of Health (NIH) and the president of the Institute of Medicine (IOM), as well as speakers from other countries.

In the U.S., health disparities are among the top five research priorities, said NIH Director Elias Zerhouni, and are a component of a number of major NIH initiatives, including ones to address obesity and neuroscience.

"Research capacity is the limiting factor," Zerhouni said. "We need to make a specific investment."

From l to r, Lisa Berkman, Dean Bloom, and Christopher Murray

Researchers and policymakers should care about health disparities because they cut across all aspects of U.S. society and all countries, said discussant Harvey Fineberg, president of the IOM and former Harvard Provost and HSPH Dean.

He noted that health disparities research provides a lens for understanding influences on health, as well as for seeking how disparities affect other opportunities in life, such as financial prosperity. Probing the consequences of social inequalities in health will take collaborative, multidisciplinary research that considers entire groups of people and not just individuals, he said.

In one sense, health disparities are remarkably consistent, disproportionately afflicting the poor and disadvantaged in nearly every country for as long as researchers have measured it, observed moderator Lisa Berkman, Thomas D. Cabot Professor of Public Policy, Departments of Society, Human Development, and Health and Epidemiology. But major health problems can be as different as infectious disease in one country, cardiovascular disease in another, and cancer in another. The explanations and possible interventions are even more widespread, some ranging beyond science to social and civic realms.

	John Frank and Sujatha Rao

Five years ago, CIHR, an agency similar to the NIH, reorganized itself. Since then, CIHR’s budget has almost tripled as it seeks the root causes of disease and disability in hopes of translating that knowledge into policies, programs, and practices.

In the short term, Frank hopes to build up the public health infrastructure in Canada, develop and sustain new investigators, and strengthen links between academia and public health workers. Toward that end, his institute has funded seven interdisciplinary regional research centers that are co-governed with communities.

One major unsolved problem is understanding the relationship between income and health, Frank said. He cited a March study that found a correlation between income inequality and working-age mortality in the U.S. and United Kingdom, but not in Australia, Sweden, or Canada. Other studies have shown differences in the relationship between income and health in Canada and the U.S. "This is not a universal relationship," he said. "It’s contextualized by culture, policy, and history."

Sujatha Rao, member secretary of India’s National Commission on Macroeconomics and Health and HSPH alumna, identified lack of communication between researchers and policymakers as a major obstacle.

The diversity and size of India makes community sampling expensive and difficult, Rao said. The country of one billion people spans 14 national languages, 6,000 dialects, and "every possible religious denomination," she said. "It’s not just [having access to] drugs and doctors," she said. "It’s a whole lot of issues–social determinants and political, cultural, educational, and economic forces–that really drive health."

Harvey Fineberg

In the Americas, average life expectancy has increased from 1980 to 2000 as the average gross national product has increased, said Mirta Roses Periago, director of the Pan American Health Organization. But the fragile legacy of improved health is easily disrupted by financial crises and social upheaval. "Even with all of these efforts, the reality now is that we are looking at widening disparities and rising exclusion from the health system," she said. "[We need to] protect achievements in health. We have seen that going backwards is possible and quick."

The organization has found that it’s better for one’s health to live in an equitable country than to live in a rich, but inequitable, country, Periago said. The organization has identified five priority member countries in the hemisphere to target resources for reducing disparities, including Haiti and Honduras.

"We have evidence-based medical interventions, but scaling up is a major problem," she said. Researchers and public health workers need more tools to generate good data at the local level.

	Mirta Roses Periago

--CCM

Students Chat One-on-One with Health Officials

Passersby in the Kresge cafeteria on April 15 may have noticed a familiar face sitting among a group of inquisitive students. Former HSPH Dean Harvey Fineberg, now president of the Institute of Medicine, provided an insider’s view into the intersection between government and public health at an informal breakfast following a health disparities symposium held the previous day (see article above). He was joined by three fellow speakers from the symposium who shared international perspectives from Canada, India, and the Americas. Not able to attend was Elias Zerhouni, director of the National Institutes of Health, who had also spoken at the symposium.

The establishment of the National Center on Minority Health and Health Disparities in 2000 demonstrated U.S. commitment to addressing the yawning issue of health inequalities in the country. Now one major challenge is collecting data on the determinants of health disparities and then communicating their importance to the public and to policymakers. Referring to the need for rigorous research and not only case examples, Fineberg said, "The plural of anecdote is not evidence." Data must first be gathered, made compelling, and then personalized for the public, he said. Doing so may give them a deep sense of outrage at the inherent injustice of health disparities and motivate a desire for change.

Collecting more data may also strengthen a current weakness in the U.S. public health infrastructure–finding funding for projects other than those related to bioterrorism preparedness. Mirta Roses Periago, director of the Pan American Health Organization (PAHO), observed that the problem of underfunding is not unique to the U.S. To build resources, she said that public health professionals should involve other sectors in their work, noting that public health problems observe no boundaries. For example, road safety has improved in some PAHO member countries after car and pedestrian accidents were recast as public health problems, she said.

Periago also called for better routine monitoring and surveillance in PAHO member developing countries, where, for the past 30 years, the focus has been on conducting population surveys. Periago would like to see the establishment of more reporting systems, which incorporate health services systems that people use regularly.

Energetically slapping the table from time to time, John Frank, scientific director of the CIHR Institute of Population and Public Health in Canada, encouraged HSPH students to challenge conventional wisdom so that public health has a fairer representation in public discourse. For example, about 30 percent of U.S. adults are obese and more than half of adults are overweight. Why then, he asked, has there been so much focus recently on surgery and drug development for weight loss, when decreasing consumption of energy-dense food and increasing exercise could help the problem without any medical intervention? One factor may be the massive U.S. health care system, or, as Frank called it, the "vampire of social policy," sucking away funding from other programs.

The U.S. is not alone in its focus on biomedicine. The Indian government is attempting to provide a better balance between public health and medicine in its country by establishing two public health schools. Sujatha Rao, member secretary of the National Commission on Macroeconomics and Health in India, explained that decades ago public health had many successes in India, particularly in the control of diseases such as smallpox and malaria. Then, in the 1960s and 70s, medical care took the fore, with public health taking a backseat. The new schools should help return public health to a more prominent place in the country.

BREAKFAST WITH THE SPEAKERS

Friday, May 6

8:30-10 a.m., Kresge cafeteria

HSPH students and faculty are invited to share an informal breakfast with the international speakers from the next health disparities symposium (for more information about the symposium, see www.hsph.harvard.edu/now/apr29/index.html.

RSVP to hlthdisp@hsph.harvard.edu.