Report

Americans born into minority racial and ethnic groups face disproportionately high infant mortality, low rates of childhood vaccination, late diagnosis of treatable neoplasia, high prevalence of cardiovascular disease and diabetes, and shorter life spans than does the population as a whole. Awareness of the difference in disease burden between the majority population and the minority and lower socioeconomic classes of Americans is growing. In addition, as a result of the demographic changes expected over the next 50 years, a majority of Americans will be members of groups that have historically been medically disadvantaged.

Health disparities are due to a number of factors, including access to social and economic resources, level of education, and occupation. Efforts to reduce these health disparities have typically targeted individual subpopulations, such as low-income persons, racial and ethnic minorities, women, and persons with disabilities. But as the proportion of medically underserved Americans continues to increase, along with the magnitude and cost of meeting these health disparities, this narrow approach appears increasingly inadequate.

Reducing the disparities will require multiple fresh approaches including (1) increased local, regional, and national literacy in science and health, so as to improve prenatal care, early childhood development, school readiness, and primary, secondary, and post-secondary education, and (2) increased inclusion of minorities in the health and medical research professions.

While it is clear that a researcher need not come from a minority or disadvantaged background to contribute to the understanding and remediation of health disparities, it is reasonable to expect that such individuals as a group would possess greater motivation, persistence, familiarity, sensitivity, and insight into this problem. Therefore, effective recruiting efforts should tap into this talent pool and focus on bringing under-represented groups into biomedical research.

NIH is well suited to undertake the second task--to plan, implement, and coordinate training programs with the potential to reduce health disparities by fostering inclusion of affected populations in the health and medical research professions. These programs--set amidst a wealth of scientific opportunities springing up today, and against the backdrop of growing public health demands in this country--must increase the depth and breadth of the nation's talent pool in health research, with particular emphasis on basic, translational, and clinical studies. There is an urgent national need for researchers who can advance health through scientific discovery, and for clinicians who can deliver the benefits of this research to an increasingly multicultural population.

Up to now, decades of efforts to attract pre-college, undergraduate, predoctoral and postdoctoral students to biomedical careers have yielded a paucity of minority investigators in research. For example, Hispanics, African Americans, Native Americans and Pacific Islanders represent almost 30 percent of the total population, but are underrepresented as students, researchers, and academicians in the physical, chemical, biological, and health sciences. During the last decade, representation of these minorities in the sciences has increased, but even today, they receive only six percent of the doctorates awarded annually in biology.

It is imperative that we draw widely on the intellectual capital required to reduce disease burden and enhance quality of life for more Americans, regardless of socioeconomic status. NIH-supported research and biomedical training programs are located in Bethesda, Maryland (Intramural Research Program) and in every state in the Union (extramural grants programs). Improved coordination between NIH programs and those of other federal and state agencies, academic health centers, health and research professional organizations, and the private sector will sustain a robust and more inclusive medical research community that is better prepared to reduce disease disparities.

After extensive study and analysis, the Committee offers five recommendations to increase the number of research scientists prepared to tackle the problems of disease disparities. These recommendations address both recruitment and retention and propose a sustained effort to educate and nurture a diverse scientific workforce without compromising its excellence and competitiveness. The recommendations do not require new funding mechanisms, but rather increased resources and a commitment to include individuals from many diverse backgrounds in the medical research enterprise. Success in implementing the recommendations will require the cooperation and counsel of partner organizations with NIH, including, but not limited to, the Association of American Medical Colleges (AAMC), the American Association of Dental Schools, the Howard Hughes Medical Institute, the Robert Wood Johnson Foundation, the National Medical and Dental Associations, the National Hispanic Medical and Dental Associations, the American Association for the Advancement of Science, and the Association of American Indian Physicians.

We recommend creating an NIH Academy to serve as a nexus for recruiting and training a diverse population of students to pursue careers in the health sciences. The Academy would operate initially as an intramural program on the NIH campus in Bethesda. After appropriate evaluation, the NIH Academy would expand to include academic health science institutions throughout the United States. The Academy requires a commitment across all NIH institutes and centers and from the leaders of both the Intramural and Extramural programs. Creating the Academy will include extramural program within academic health science institutions require increased funding and allocation of resources for research training.

Based on the available literature, suggestions from a large number of diverse groups, and the wisdom of many experts in this area, the committee sees four elements that will be critical for the success of the NIH Academy:

• Critical Element A: Mentoring
  
  Success within the intramural environment requires solid and sustained mentoring from NIH staff with consistent support and leadership from the NIH Director, Institute Directors, Scientific Directors, and Laboratory/Branch Chiefs. The dedication of NIH mentors as teachers and role models is fundamental to the intramural Academy's success. The extramural Academy will require the same dedication and leadership from faculty, staff, and administrators of academic health science centers.
  
  
• Critical Element B: Residential Program
  
  A residential program that supports students or fellows working and living together will reinforce the encouragement and counsel of mentors. A residential format fosters a sense of community and purpose and is essential for success.
  
  
• Critical Element C: Continuity of Support
  
  Students of the NIH Academy must be nurtured through the continuum of training--from summer high school programs through college and graduate school, and post-residency and postdoctoral studies. Public and private support must be marshaled to support summer research, residential fellowships, scholarships, student loan repayment, and transitions from one career stage to another. Transition to the extramural environment after training should be given particular emphasis, such as through early career development grants such as the k22 program.
  
  
• Critical Element D: Community Involvement
  
  The experience and motivation of NIH Academy students and fellows will be enriched by opportunities to work on research problems in communities close to the various Academies.

A major national effort should be initiated to identify, recruit, and train highly talented individuals who have completed clinical and postdoctoral programs and possess a strong interest in reducing disease disparities. Particular emphasis should be placed on recruiting under-represented minority, disabled, and economically disadvantaged individuals.

This type of recruitment effort has two significant advantages: (1) It would begin to yield results in as little as five years because it is focused on individuals who have already completed clinical residency and postdoctoral programs, and (2) Expanding and raising the visibility of scientific opportunities associated with health disparities may attract additional talented individuals to the field, such as by creating a budgetary area of emphasis whose goal is to reduce health disparities).

These scholars should be drawn from the behavioral, environmental, and biological doctorate programs, and clinical residencies in the health sciences, including medicine, dentistry, pharmacy, nursing, laboratory animal medicine, and allied health professions. With the collaboration of organizations such as the AAMC, and the Robert Wood Johnson Foundation, the goal of this effort would be to identify and recruit the most promising clinical residents and postdoctoral fellows. The program would provide clinical research training and subsequent support, including bridge and start-up grants to enable recently trained individuals to become established within academic health science centers.

The goal of this effort is to provide patient- and disease-oriented training for a diverse cadre of individuals who will be going on to receive research grant support and enter academic positions. Existing NIH programs, such as the career development awards (K23 and K30), and the newly developed bridge grants provided by several Institutes could be used to implement this recommendation. Because such mechanisms are in place, only increased emphasis, coordination, evaluation, and commitment of funds are needed. Enhanced attention to nurturing and mentoring scientists during their early career development should also be incorporated in these programs.

The NIH has had a Minority and Disability Supplements program for many years. These grant supplements have been available to NIH-funded principal investigators who place disabled and underrepresented minority students and trainees into their research teams, thereby encouraging these individuals to pursue careers in biomedical science.

We recommend replacing these programs with a General Supplements program available to investigators, students, and fellows, but broadened in purpose to encourage all of our nation's talent in science, particularly disadvantaged individuals who traditionally might not have had such opportunities. This modified supplements program should track and evaluate participating students and mentors and should sharpen its focus on efforts to reduce health disparities among populations in the United States.

Because the minority and disability supplements have historically been under-utilized, we recommend national efforts to provide information and recruit students, investigators and faculty advisors to apply for such NIH-supported opportunities. This might include public service announcements, brochures distributed to high school and university faculty advisors, and active information programs by organizations like the AAMC, and other medical, dental, and scientific associations, in addition to publicity efforts already underway at NIH.

Many underrepresented minority students earn their undergraduate degrees at historically black colleges as well as at a comparatively small number of institutions in states with the largest populations of Hispanics, American Indians and Pacific Islanders. These institutions provide very good science instruction, yet often are unable to provide extensive medical research experiences on their campuses. We recommend increased NIH efforts to establish bridge grants, similar to those already in existence in several institutes, that fund collaborations between research-intensive universities and nearby institutions that serve predominantly minority populations. The goal of these efforts would be to offer a diverse group of students and faculty members the opportunity to collaborate, particularly on scientific questions pertaining to disease disparities.

There is no shortage of programs at the NIH, other government science agencies, and non-federal organizations intended to create a diverse science and technology workforce for the 21st century. There is, however, a lack of coordination and evaluation within and among these programs. For years, well-intentioned programs have continued without periodic evaluation and review of their success. We recommend that NIH identify leadership to survey its own Institutes in collaboration with other public and private agencies engaged in science and technology. The survey would have three goals:

A. Identify the various programs sponsored by public and private organizations.

B. Encourage public and private organizations to collaborate on national campaigns to inform a diverse population of students about careers in science and technology, and to direct them systematically to available programs.

C. Evaluate the programs in terms of their cost and effectiveness in recruiting and retaining individuals who traditionally might not have pursued career opportunities in science.

Implementing these five recommendations can advance the NIH mission, which is to improve the health of the country by sponsoring and conducting biomedical research and training. The changing demographics and patterns of disease in this country clearly require new approaches.

The committee has learned, through many interviews, discussions, and analyses of the literature, that the scarcity of minorities in health sciences and medical research is very real. There is much more work for public and private organizations and primary, secondary, and post-secondary educational institutions to do in improving the academic performance of all American students. We have come to appreciate that the image of a "pipeline" feeding the science workforce is misleading since it suggests a smooth, well-defined, and predictable passage from elementary school to college, graduate training, and into a science career. The route is more akin to a winding trail loaded with predictable and unpredictable obstacles which can cause the trail to be abandoned.

We believe the time is right to implement the five recommendations above. These measures should result in significant progress in reducing health disparities by broadly engaging the nation's diverse talent pool in the excitement and fulfillment of biomedical research careers today.