'UBLIG HEALTH LIBRARV 'NA110NAI. _ HISPANIC > HERITAGE i Hispanics and Health Research in the Public Health Service SEP141984 ("O ((0 ‘DOCUMENTS DEPARTMENT OCT 10 i934 UNIVHSIT$B¥RJALIFORNIA Public Health Building 31 C Research Issues Conference Room 10 National Institutes Se temberl3, 1983 of Health 9: O a.m.—4:OO p.m. Bethesda, Maryland ~ ' IthS ‘ Health Office of Equal Employment Opportunity a HISPANICS AND HEALTH RESEARCH IN THE PUBLIC HEALTH SERVICE conference her in commemoration of 1983 Nationa] Hispanic Heritage Week September 13, 1983 at the Nationa] Institutes of HeaTth Bethesda. MaryTand This: report was edited by ISL/i, Dru, under FDA Purchase Order No. 83F0555v’)70.’/IS. The views and recommendations included in the report, however, do not necessari 1;} represent the views of any agency of the United States Government. K AW: Tabie of Contents H S L/ N9 8 ‘9 PM i; ,5 Foreword ............................................................ i Pianning Committee .................................................. ii Introduction ........................................................ iii 1. WELCOMING REMARKS The Hispanic Heritage: A Ceiebration and a ChaTTenge, Faye G. Abdeiiah, R.N., Ed.D., Sc. D. .......................... I II. HISPANICS AND HEALTH RESEARCH: AN OVERVIEW Hispanics and Heaith Research, IsmaeI ATmodévar, Ph.D. .......... 5 Cuiturai and Individual Differences in ATcohoT, Drug Abuse and MentaT HeaTth Research, ManueI Ramirez, III, Ph.D. .... 16 Heaith Problems of Hispanic Americans, Fernando M. Trevino, Ph.D , M.P.H. .......................................... 29 III THE U.S. PUBLIC HEALTH SERVICE: RESEARCH AND TRAINING Hispanics and Heaith Research in the PubTic Heaith Service, Dennis Toisma .......................................... 39 Research Activities in the Food and Drug Administration. Leroy Gomez .................................................... 49 ADAMHA Support for Research Training, DeTores Parron, Ph D. ..... 54 NIH Extramurai Research Training Opportunities for Hispanics, Doris H. Merritt, M.D. .......................................... 58 Hispanics in Agency-Sponsored Training Programs: A Persona] View, Maritza CoTén-Puiiano ..................................... 63 Appendix: FuTi Program of the Conference ........................... 67 Foreword The yearly Hispanic Heritage Week celebrations have served for six years as a fruitful forum for Health Service workers to continue compiling data and knowledge about the health issues that affect the HiSpanic population. Once again we are providing another segment of the still incomplete panorama of the health needs of one of the rich cultural strands of the American people, the HiSpanic community. We are confident that wider knowledge about governmental research and community efforts in the health field will yield positive results for Hispanics in the future and, thus, research has been our emphasis this year. The organization of these conferences involves many people whose generous efforts constitute an additional reason for Hispanics to be proud of their heritage. To Hispanics and non-Hispanics alike who have shared their expertise or contributed to the success of the 1983 Hispanic Heritage Conference, we present this tangible proof of their efforts and our sincerest appreciation. David Diaz and Robert U. Hernandez Co-Chairs 1983 HiSpanic Heritage Week Planning Committee ii 1983 PLANNING COMMITTEE Chair Robert U. Hernandez, PHS—HEO, ADAMHA David Diaz, OASH OEEO Members Fernando Trevino, Ph.D.* OASH Pedro J. Morales, J.D. Ruth Sanchez-Dirks, Ph.D. Delores Parron, Ph.D.* ADAMHA Marta Sotomayor, Ph.D. Alexander Grant* FDA Rosamelia T. de la Rocha Marco Montoya, Ph.D. Roy G. Martinez Magdalena Miranda* HRSA Ray Lucero Henrietta Villaescusa Ernest J. Plata, Ph.D.* NIH Gene A. Spruill Doris Merrit, M.D. Dolores Lowery Denise White * Appointed Agency Representative Sponsors: Public Health Service Hispanic Employee Organizations and the Office of the Assistant Secretary tor Health, Office of Equal Employment Opportunity iii INTRODUCTION HiSpanic Americans active in research on health issues in the United States are relatively scare. Speakers at the 1983 conference on HiSpanics and Health Research in the Public Health Service, which was sponsored by the Public Health Service Hispanic Employee Organization, discussed research on Hispanics and emphasized the need to give impulse to existing programs and create new ones to encourage and support Hispanic involvement in biomedical research. Faye Abdellah, Deputy Surgeon General, U.S. Public Health Service opened the conference on this theme. Dr. Ismael Almodovar, president of the University of Puerto Rico, suggested careful appraisal of existing policies and new initiatives or programs aimed at minority populations in terms of the numbers and needs of the populations involved. "A Quality statistical information system and data base on Hispanic Americans, including Puerto Ricans must become a priority," he said. Dr. Almodovar described the evolution of health care in Puerto Rico through the efforts of the U.S. Public Health Service Center for Disease Control and the Commonwealth government. He also acknowledged the medical contributions of Puerto Ricans in Puerto Rico and HiSpanic Americans in the U.S. Dr. Manuel Ramirez of the Department of Psychology at the University of Texas summarized the major points made in an overview of research done with Hispanic groups in the U.S. He concluded by saying: "We must continue with our efforts to develop approaches to research, intervention, and primary prevention which are consonant with our individually unique ways of prceiving ourselves and our socio—cultural environments. The future success of alcohol, drug abuse, and mental health research with Hispanics, as well as Americans depends on our willingness as researchers and practitioners to accept the fact that cultural and individual differences are real and that they are important in the way people perceive and define health and illness, adjustment and maladjustment." iv The dearth of health statistics on HiSpanic Americans has, according to Dr. Fernando M. Trevino of the National Center for Health Statistics, limited the efforts of the health professionals trying to meet the health needs of the Hispanic population. He discussed the Hispanic Health and Nutrition Examination Survey to collect information on the health and nutritional status of Hispanics. By the time the study, which began in July 1982, ends in December 1984, 16,000 Hispanics will have participated. Epidemiologic and operational research and research training activities to identify preventable health problems and effective intervention nethods going on at the Center for Disease Control (CDC), were discussed by Dennis Tolsma, Acting Director of CDC's Center for Health Promotion and Education. Leroy Gomez, Denver District Director for the Food and Drug Administration (EDA) described that agency's research activities in food and drugs. Dr. Delores Parron, Associate Director of minority concerns, National Institutes of Health, Alcohol Drug Abuse and Mental Health Administration (ADAMHA) pointed out the shortage of minority research scientists trained for and concerned with investigating problems relevant to alcohol, drug abuse and mental health. Parron said most minority students select clinical careers because they want to become directly involved in service delivery in the community. She said ADAMHA has placed a high priority on promoting research careers among minority students as an equally meaningful alternative. She and other participants outlined minority develOpment programs within the National Institutes of Health and the FDA and increasing Hispanic involvement in these. THE HISPANIC HERITAGE: A CELEBRATION AND A CHALLENGE Faye 0. AbdeZZah, R.N., Ed. 0., Sc. 0. Deputy Surgeon General, U.S. Public .eaZth Service U.S. Department of'HeaZth and Human Services Through government this week we are recognizing and celebrating our Hispanic heritage. And I want to emphasize that word “our.” All of us—-regardless of what our surnames may be-—should be proud, as Americans, to have the heritage of Spanish culture, language. science, and art that belongs to this country. The United States today has the sixth largest Hispanic population in the world. One of every l6 Americans can claim a direct Hispanic heritage. As President Reagan said in his proclamation of National Hispanic Heritage Week, ”Hispanic Americans... are a part of all that makes America great.“ In that sense, then, every American is enriched by that heritage, directly or indirectly. So I am here today to observe and to celebrate ggr_Hispanic heritage. I have to admit that we have only begun to scratch the surface of knowledge regarding that heritage. And we can't do it justice by thinking about it for only one week in the year—-and then forgetting about it for the other 5l. Every American concerned about the internal strength of this country must make it our own personal business to know more about the contributions made by Hispanic peoples over the past three centuries to the life and culture of the United States. Recently we were recalling the involvement of the Public Health Service in the effort to improve the lives of individuals and families throughout this Hemisphere. Early in this century Dr. Bolivar J. Lloyd went to Peru and then to Ecuador to help prevent the spread of smallpox and plague. In fact, he stayed on in Ecuador and became that country's first Director of Health. Other physicians, nurses, sanitarians, and researchers from the Public Health Service have worked in Mexico and Peru, in Cuba, Guatemala, and Panama, in Chile, Argentina, and Venezuela. One of the great tragedies of our Hemisphere right now is the degree to which public health has become the victim of the struggles in Central America. It would be in the highest tradition of the U.S. Public Health Service if we pledged today that we would do whatever was possible to help restore the health of the men and women, and children, and the old people in Central America. Violence is one of the oldest and still one of the most virulent epidemics threaten- inq mankind. It paralyzes our homes and our communities. And it can destroy entire countries. Certainly, on a day such as this, when we come together to honor our Hispanic heritage, let us also honor our Hispanic brothers and sisters whose health and whose very lives are at risk today by acknow- ledging that we also have work to do closer to home. It is my impression-—and it is only an impression,for I have not made any detailed study--that this country is losing the potential contributions that Hispanic Americans can make in the field of bio- medical research. When you skim through the l982 annual report of National Institutes of Health (NIH) research grants. you may come upon a John Trujillo in New Mexico, a Garcia or a Villarejo in California, a Gomez or a Perez-Polo in Texas, or a Ramirez in New York. The best representation is obviously from Puerto Rico, which is a part of the United States political system and where the Spanish language and heritage prevail. But there is not much evidence elsewhere, particularly in those states with large Hispanic populations, that this particular group of Americans is getting its best chance to contribute to biomedical knowledge. And we have to ask, ”Why?” Are there too few Hispanic Americans entering the biomedical sciences? Do most Hispanic-American medical students overwhelmingly choose to practice and not choose research? That may be the case, but we don't know. It also may be that we have some barriers to entry still remaining, but which should be moved aside as quickly as possible. There are many competent Hispanic Americans in research, but they are not identified as the lead investigator on any NIH research or grants. We do have a problem of participation within biomedical research for Hispanic Americans, and sustained action must be taken to solve it and solve it quickly: 0 We need to pledge to ourselves that we will not forget the many hundreds of bright young Hispanic men and women who are building their careers within the fields of medicine and the related biological and physiological sciences. 0 We need to pledge our efforts to make sure that there are no barriers to their entry into this important field of research. 0 We need to pledge that those HiSpanic Americans who are in the field already actually do have the encouragement and the assistance to move ahead, to be given greater responsibilities and be encouraged to make more substantive contributions. 0 We need to identify Hispanics who are potential members of study sections and of the NIH Council. 0 And we need to pledge that, from here on, the health and welfare of the American people will be further assured by the active, vital participation of talented Hispanic Americans. It is my hope that, at next year's observance of Hispanic Heritage Week, and at every subsequent year's activities, we will be able to point to a growing community of researchers--Americans of Hispanic descent-—making outstanding contributions to the scientific heritage of every citizen of the United States. II. HISPANICS AND HEALTH RESEARCH: AN OVERVIEW HISPANICS AND HEALTH RESEARCH Ismael Almodavar , Ph.D. President, University of Puerto Rico I have been invited to speak on a very important topic focusing on Hispanics in health research. My presentation today will address the need for the important functions served by this federal agency and others in expanding support to higher education institutions with large numbers of Hispanic students and faculty. Ours, the University of Puerto Rico, is a state system with a total enrollment of 54,000 students and 4,200 faculty members. I shall provide data on the health needs of Puerto Ricans and how higher education serves this Hispanic community by providing human capital and research knowledge to serve their needs. In addition, I shall acknowl- edge the contributions of a group of distinguished Hispanics scientists to the nation's scientific scholarship and research. Programs for research in improving the status and delivery of health services in Puerto Rico play a vital part in addressing deficiencies in the well-being of our population. A brief overview about Puerto Rico and our health conditions and delivery system will give a clearer understanding of our continued need for research support in the areas of medical and health- related sciences. Puerto Rico has a proven and effective public health care system serv- ing approximately 67 percent of the island's population.l/ This area has improved dramatically since 1934 when Joseph w. Mountain of the U.S. Public Health Service initiated a study of the island's health conditions.2/ Since then the island has provided an excellent laboratory setting for nutritional studies and studies of tropical diseases. Founded in 1920, the Institute of Tropical Medicine became one of the best known research facilities in the world. In 1953, the Institute was replaced by the School of Medicine of the University of Puerto Rico. I should like to refer to the nutritional studies of Hispanics conducted by the National Center for Health Statistics. Many of the recommendations of these studies have lead to important progress, as evidenced by health status indicators in certain major areas. For example, in 1902, life expectancy in Puerto Rico was only 20 to 36 years; in 1940, it was 46 years by 1950 it had reached 60 years and in 1980, it was 73 years.§/ About 50 percent of Puerto Rico's 3.2 million inhabitants are 25 years of age or younger. The reduction of the infant mortality rate is an important indicator as it relates to the economic and social conditions which affect our society. Of 21,197 deaths which occurred in Puerto Rico, 1,325 were infants. This represents 6.3 percent of all deaths and a rate of 18.6 for every one thousand live births. Infant mortality has been reduced 83.7 percent since 1942 when 8,104 infant deaths were registered; that is, 103.4 deaths for every one thousand live births.4/ Among the factors that have figured prominently in the decrease of infant mortality and the improvement of age expectancy of the average citizen in Puerto Rico are the concerted efforts made by the Public Health Service's local Center for Disease Control and by the Commonwealth government officials to_achieve a higher quality of health care, their support of programs to train health professionals, the promotion of a diversity of community and self-help programs, and the encouragement of research concerning the causes and effects of illness affecting our population. Although Puerto Rico has shown great progress since the beginning of the century, increasing the effectiveness and capacity to analyze and create new options for the human resources and institutions in- volved in health delivery and education, much remains to be done. Only 61 percent of total hospital admissions in 1982 were to public hospitals, §f despite study findings conducted by the Puerto Rico Planning Board concerning poverty on the island which demonstrated that low—income groups have a higher incidence of acute and chronic conditions. Sixty-two percent of the Puerto Rican population is below the national poverty level. This indicates that the health needs of the poor are not being met, and leads me to mention more about the high incidence rates of chronic health problems which may be addressed through research, as well as financial resources for im- proved care and facilities.§/ It is useful to consider the role of the University of Puerto Rico (UPR) in providing appropriate support to the Hispanic community in the prevention, control and treatment of health problems through participation in life sciences research and training of professional personnel. A good part of our contribution would not be possible without federal support. The most important federal sources of research funds for life sciences faculty have been, and continue to be, the U.S. Department of Health and Human Services and the National Science Foundation. Overall, the university has seen a very slight increase in Public Health Service support from $7,165 million in 1975 to $7,195 million in 1982.1] However, our own contributions to research must be recog- nized. Similar to mainland institutions, much of the vitality of ongoing research within our university system is based on an increase of university funds, invested especially during the last five years. We also face the same difficulties as universities everywhere: as research becomes increasingly sophisticated, the need arises to maintain state-of-the—art equipment and faculty salaries commensurate with other institutions. For a minority institution like ours, it becomes increasingly difficult to compete with mainland schools that have the most notable laboratories and scientists. Competition for federal grant dollars has been, and is becoming, extremely difficult. If one considers that Puerto Rico lies outside the mainstream of national developments, that at the federal level educational policies in many instances have excluded the island from important federal grant programs, and that in general the U.S. population is not aware that Puerto Ricans have the most deeply rooted Hispanic heritage among the U.S. citizens and that we are as well the poorest of all the seg— ments that comprise the Hispanic population, our efforts sh0uld be more appreciated. The role of the university in serving the need for qualified Hispanic Americans to participate equitably in private sector research opportunities should be mentioned. In Puerto Rico, pharmaceutical firms represent one of the largest components of growth in the island's manufacturing industries. Our public and private higher education institutions are cognizant that they must provide the technical ex- pertise to expand research and development opportunities in this area. Private industries which have taken advantage of full tax exemption over 20 years, like in many developing countries, lag in their efforts aimed at including research in addition to production and quality control programs. I have proposed to the government that one of the conditions to be included in long-term contracts should address the need for industry to develop sound research programs. Since plants for the manufacturing of instrumentation located throughout Puerto Rico provide the island's higher education institutions an added opportunity to undertake various types of cooperative education and research programs in various lo— calities, activities should be encouraged by all federal agencies to provide for the formulation of special initiatives, or serving as catalysts in developing industry/university partnerships. Increased focus in this area nationwide would be especially beneficial in tar- geting policy directives to universities with large numbers of Hispanic American faculty and students, and industrial or business areas with a large Hispanic labor force. More attention should be given to the impact Hispanic people are having on the economy of the United States and the potential of this growing entrepreneurial class. With this in mind, policies, new initiatives or programs aimed at minority populations must be carefully thought out in terms of the numbers and needs of the populations involved. The Hispanic popula— tion in the United States is currently estimated at about 18 million.§/ By the year 2000, Hispanic Americans may well be the largest ethnic group in our country, amounting to 25 percent of the United States population.§/ These demographic data suggest that policymakers and interest groups at all levels should be more aware of the special interests and needs of the Latin culture, as well as the obstacles inherent in language barriers and the distinct cultural differences between various Hispanic subgroups. Nationally based organizations with large numbers of Hispanic members that represent the interests of higher education, particu— larly science and engineering faculty, could perhaps do more to meet the special concerns of this minority group. Such organizations can be increasingly active in terms of addressing the educational disadvantages of minority group isolation and discrimination, and appraising federal laws and policies that deny access and mobility to their members. With respect to factors influencing the latter -- laws, policies and initiatives formulated at the national level to assist minorities -- the federal government must play a key role in assuring that new initiatives, both programmatic and regulatory, are developed with a full understanding of what they might mean in terms of creating barriers for the non-targeted population. I recently discussed this issue in testimony before the House of Representatives' Subcommittee on Postsecondary Education,lg/ and believe it plays an important part in providing for greater participation of Hispanic scientists in federal research programs. Another major policy concern is the actual level of participation of Hispanic scientists and technicians in federal research programs. We recently analyzed such participation within the Public Health Service's Financial Assistance programs, as well as other federal agencies. However informal our survey was, it showed that no detailed statistical information is available on the research needs of Hispanics, an appropriate federal role in response to this sector of society, or employment patterns of Hispanic scientists. ll/ Although the National Science Foundation (NSF) had published several reports and summaries to assess the status of science and engineering technology in our country, no consistent data base or comprehensive literature on Hispanic researchers seems to be avail- able. Some interesting data does emerge from the NSF studies I have cited regarding the U.S. scientific and engineering labor force. Over half of all Hispanic doctoral scientists and engineers tend to be em- ployed by educational institutions; most are "less likely than non— Hispanics to be employed in business and industry,“ and ”within edu- cational institutions, Hispanics are less likely to be tenured than non-Hispanics.” 12/ In the total United States workforce, Hispanic scientists and engineers compared favorably with Asians in their labor force particiaption rate, which was approximately 98 percent in 1970 for both groups, a‘figure that is higher than that for blacks (86 percent). Furthermore, during 1981, Hispanic recipients constituted 0.9 percent of all science/engineering doctorates awarded. In contrast, the number of doctorates awarded to Asian Americans was 5.7 percent, and to blacks, 1.8 percent. In the Life Sciences, Hispanics received 1.01 percent of the total doctorates awarded (26,635) during 1981. 18/ Although-these statistics are useful in assessing labor market conditions and access to educational opportunities for Hispanics, the level of participation for this minority in basic and applied research programs is not readily discernible in the long term. The literature appears almost devoid of extended studies or active, on— going examination of the health research and manpower development resources of Hispanics. Much of the available information identifies Hispanic participation by using the Spanish—surname procedure, which does not differentiate between subgroups or present a clear picture of existing differences in this area. During the last two academic years, the medical sciences faculty at the University of Puerto Rico has expanded its working partnership with National Institutes of Health officials. The strengthening of this relationship stemmed directly from meetings with NIH Task Force groups during 1981 and 1982. During the 1982—83 academic year, the Visiting Professor Program was instrumental in bringing NIH scientists engaged in intramural research to conduct conferences and meetings with faculty and students at our medical sciences campus. Another collaborative effort between NIH and the medical Sciences campus involves the provision of external training opportunities for our faculty at NIH intramural laboratories and clinics. Recently, two faculty members have been receiving training in radiology and immunology at the National Institute of Allergy and Infectious Diseases. 10 The NaTional lnsTiTuTes of HealTh have also provided major supporT for Three imporTanT research cenTers aT our universiTy: The PuerTo Rico Cancer CenTer, The Neurobiology LaboraTory, and The Caribbean PrimaTe Research CenTer. The Neurobiology LaboraTory, founded 16 years ago, is supporTed Joinle‘by local governmenT and NlH funds. This ouTsTanding faciliTy is under The direcTor of Dr. Jose del CasTillo, an inTernaTionally recog- nized research scienTisT renowned for his sTudies on The mechanism of neuromuscular Transmission. This inTerdisciplinary and inTerdeparT— menTal faciiiTy conTribuTes successfully To graduaTe biomedical edu-‘ caTion and research in PuerTo Rico. SixTeen scienTisTs and Ten sTudenTs (posTdocToral and graduaTe) have been involved in ongoing projecTs and special sTudies, incduding sTudies of The organizaTion of visual and audiTory sysTems. The laboraTory was also hosT To The Symposium on Neuromuscular Disease, co—sponsored by The Muscular DysTrophy Associ- aTion. An imporTanT course was also offered in conjuncTion wiTh The lnTernaTional Cell Research OrganizaTion on Cell ElecTrobiology. A research appraisal of The universiTy would noT be compleTe wiTh- ouT menTioning The Caribbean PrimaTe Research CenTer, Joinle funded by local and NIH funds since iTs free-ranging rhesus monkey colony was esTablished in 1940. A greaT number of behavioral research pro- jecTs have been underTaken in This colony, including The sTudy of a unique skeleTal collecTion which can yield imporTanT informaTion wiTh respecT To The geneTic inheriTance of anaTomical characTerisTics in These primaTes. One of The mosT compleTe daTa bases on diabeTes is also available in This collecTion of monkeys. The Biomedical EducaTion and Research Program (SUBE) has been successful in sTrengThening biomedical research faculTy and sTudenTs aT The UniversiTy of PuerTo Rico sysTem and oTher affiliaTed lnsTiTu- Tions. Funding for The program is provided by The Division of Research Resources of The NaTional lnsTiTuTes of HeaiTh. BoTh undergraduaTe and graduaTe sTudenTs are able To parTicipaTe in The specific biomed- ical research areas compaTible wiTh The sTudenT's inTeresT and exper- Ience. During The 1982-83 academic year, a ToTal of 22 projecTs were ini- TiaTed under The leadership of 25 invesTigaTors and 90 parTicipaTlng sTudenTs. The number of publicaTions ToTalled 92. In addiTion To The highly respecTed invesTigaTors aT The universiTy, already named, There are oTher individuals who are acTive in scienTific research and deserve menTion for Their conTribuTions: 11 Dr. Mario Rubén Garcia-Palmieri, Chairman of the Department of Medicine at the medical sciences campus, has conducted significant studies on coronary disease since 1967, providing valuable data regarding habits and socioeconomic factors; Dr. Manuel Martinez-Maldonado, Chief of the Department of Medicine at the Veterans Administration Hospital and a member of several NIH Study Sections, has distinguished himself in studies on nephronology, including a recently published Spanish language textbook; Dr. George V. Hillyer, Director of the Department of Biology at the Rio Piedras Campus, has received the Henry Baldwin Ward Medal, the top research award of the American Society of Parasitologists; Many other Puerto Rican scientists, active or retired, also deserve recognition. On the national level, Hispanic Americans have also vigorously addressed a broad array of scientific studies that have contributed to the advancement of new knowledge: 0 Dr. Pedro Barbosa, at the University of Maryland, directs Forest Entomology efforts and is considered a leading author- ity on the Gypsy Moth; Dr. Adolfo Figueroa—Vifias, a well-known Plasma Physicist, currently conducts research at the Goddard Space Life Center's Interplanetary Physics Division. Dr. Elba Mas—Hadden is active in Immunopharmacological studies at the College of Medicine, University of South Florida; Dr. Alex Cruz, of Colorado State University, is a member of the Advisory Committee to the Director of The National Science Foundation and receives substantial NSF research support; Dr. Eugene Cota-Robles, at the University of California in Santa Cruz, is a highly respected research scientist and a member of the NSF Science Board. These are only a few of the Hispanic scientists who are primary performers of basic research and educational leadership in our nation. 12 However long the actual liSt may be, federal agencies involved in research support can play a more active role_in promoting the basic principle of equality of opportunity to ensure that Hispanic Americans enjoy improved access to an equitable distribution of available pro- grams, thus addressing the health needs of the Hispanic population and providing maximum training and employment opportunities for them. Public speeches or haphazard promises by elected officials or poli- ticians are simply not enough. What are needed are various concrete measures free of political rhetoric or partisanship to expand and/or initiate new programs that invigorate a national commitment to the health status and education of the Hispanic population. In my view, funding for a variety of categorical programs serving the needs of minorities must be increased. The expansion of the Minority Biomedical Research Support (MBRS) Program to institutions other than historically black colleges and universities has strengthened the institutional research capability of higher education campuses with large student enrollments from other minority groups. It has also assisted in raising to 500 the number of Hispanics that pursue biomed- ical research careers under this program. 15/ MBRS support has been essential for the enhancement for investigator—initiated research in Puerto Rico. Since 1973, awards to the University of Puerto Rico, Catholic University, and Inter American University have totalled $8.5 million. 1§/ Within existing budget realities, MBRS has succeeded in creating a significant impact on colleges and universities located in most states with a large Hispanic population. Approximately 24 higher education institutions in California, Texas, New Mexico, and New York have re- search projects and facilities extending the benefits of this program to Spanish Americans. Although Florida and Illinois also have growing Hispanic populations, the MBRS-supported projects in these geographical areas serve primarily black and Native American minorities. Arizona, with a Hispanic population of 440, 701 had no current programs during Federal Fiscal year 1983. Recent consultations with PHS officials did not reveal the actual number of Hispanic MBRS project investigators or student participants nationwide. Such data is not collected on a regular basis and must be estimated using the surname procedure. On this basis one would miss a large number of Hispanics with surnames such as Hillyer, Stolberg.... Although a particular project may be located within a geographical area with Hispanic population, the grant may in fact be serving other minority students and faculty as well. lé/ Information submitted for the record contains supplemental material regarding the institutions with MBRS support that appear to serve a greater number of Hispanic students and faculty. 13 The Minority Access to Research Careers Program (MARC), adminis- tered by the National Institute of General Medical Sciences, is also worth noting. Since its initiation in 1972, this program has offered minority students the opportunity toimnsue meaningful graduate programs leading to the Ph.D. in biomedical sciences. Budget reductions in such program support can only enlarge the existing gap for those qualifiedanthin the minority community to acquire the skills needed for later educa— tional and occupational attainments in research careers. The Health Careers Opportunity Program likewise plays an important role in encouraging brightyoung people from disadvantaged backgrounds to pursue careers in health or allied health professions. Erosion of Federal funds for this program curtails the ability of grantees to gain access to an important health training opportunity. It is impossible to suggest an entire system of categorical, biomedical research, or health program grants that would provide hope to the college- educated Hispanic segment of the nation in overcoming ethnic fragmentation. Each segment of government that must make a decision on policy issues requires data on which to base programmatic intervention. The importance of a quality statistical information system and data.base on Hispanic-Amer- icans, including Puerto Rico's population, must become a priority. A consistent body of data should be made available annually on theselected characteristics of Hispanic life scientists and health professionals, in - cluding those engaged primarily in patient care, sudying the nature and effect of disease, or health service delivery research. Such data should also encompass occupational, economic, and other demographic variables. Federal agencies and the Congress can then develop guidelines for reserch methodology, personnel requirements, environment, budget, and time cons— traints, and fund projects aimed at providing solutions to the problems of Hispanics. Finally, I would like to suggest some specific problem areas which should be addressed: ° National comparison studies should be undertaken, on a regular basis, to assess Federal research and development Support to institutions with greater proportions of Hispanic students, fac- ulty and researchers. ° Increased public notice must be generated concerning the needs of Hispanic Americans in this important area through Federally sup- ported conferences which seek to forqean effective and productive partnership between the Federal Government and universities serving Hispanic faculty, students, and their communities. 14 Levels of participation must be improved for Hispanic researchers in Federally funded research centers of excellence, new and c0m- peting research grants, training programs, and National AdviSOry Councils and committees impacting on the development of science and technology. Direct and indirect cost reductions in biomedical science programs must be restored. Development of new health service researchers to work on signifi- cant issues affecting health service delivery to Hispanic popula- tions must encouraged. Efforts should be increased to expedite and disseminate new knowl- edge resulting from research project support to users and health personnel in areas with large Hispanic populations. Technical assistance and the provision of basic information must be expanded to minority scientists and administrators involved in the technical aspects of managing Federally funded programs. More community—based and continuing professional education programs should be developed in areas with sizable enclaves of Hispanic peo- ple to involve University faculty in improving scientific literacy at the local level. Joint initiatives should be promoted between Puerto Rican institu- tions of higher education and mainland universities in order to achieve coordination of research activities, pooling of logistical resources, and scientific consultations. Analyses could be made with reference to the proposed organizational changes at the National Institutes of Health, and what they would mean in terms of: health statistics, health services and occupational and biomedical research opportunities focused on the needs and possi- ble contribution of Hispanic populations. Increased emphasisnmst be given to support instrumentation and im - prove scientific laboratory facilities at higher education institu - tions serving large numbers of Hispanics. If there is genuine desire on the part of the Federal Government to monitor and analyze the status and participation of Spanish Americans in health programs and fundamental life sciences research, I am convincedthat some of the measures pr0posed and many ideas presented elsewhere will become a reality. It is hoped that plans will emerge that are long—rangeand devoid of political interference or of inappropriate decisions by Federal agencies and/or program officials. In closing, I urge that more importance be given to Hispanic initiatives as well as toestablishing a reliable source of technical information that can be organized in a scientifically sound, reasonably balanced, and cost- effective manner, and disseminated to the Government and the community so that our cause can be advanced effectively. IO. 11. 12. 13. 14. 15. 16. 15 REFERENCES Puerto Rico Department of HeaIth, Office of MedicaI Assistance, Unpuinshed TabuIations from March, 1983. U.S. Department of HeaIth, Education, and WeIfare, Office of The Secretary, SOCIAL CONDITIONS AND HUMAN SERVICES PROGRAMS IN PUERTO RICO, 1979. Puerto Rico PIanning Board, COMPENDIUM OF SOCIAL STATISTICS, I980. Puerto Rico PIanning Board, ANNUAL REPORT ON VITAL STATISTICS, 1981. Cooperative System for HeaIth Statistics, Puerto Rico Department of HeaIth, STATISTICAL BULLETIN, 1982. Puerto Rico PIanning Board, THE PROBLEMS OF POVERTY IN PUERTO RICO, 1971. Office of PIanning and DeveIopment, Division of ExternaI Resources CentraI Administration, and Office of ExternaI Resources, MedicaI Sciences Campus, University of Puerto Rico, Unpuinshed TabuIations from August, 1983. U.S. Bureau of the Census, PopuIation Census: 1980. PopuIation Reference Bureau, Unpuinshed Predictions by Demographers, Washington, D.C.: I983. AImodovar, 1.: Statement Before the Subcommittee on Postsecondary Education, U.S. House of Representatives, San Juan, Puerto Rico: May 27, I983. NationaI Science Foundation, SCIENCE AND ENGINEERING, PERSONNEL: A NATIONAL OVERVIEW, NSF 822318: 1983. NationaI Science Foundation, WOMEN AND MINORITIES IN SCIENCE AND ENGINEERING: 1982. NationaI Science Foundation, SCIENCE AND ENGINEERING DOCTORATES: 1960- 81, NSF 83-309: 1983. Division of Research Resources, Puinc HeaIth Service, NationaI Institutes of HeaIth, Unpuinshed TabuIations from 1983. Office of PIanning and DeveIopment, Division of ExternaI Resources, and Office of ExternaI Resources, MedicaI Sciences Campus, University of Puerto Rico, op.cit. Division of Research Resources, Public HeaIth Service, NationaI Institutes of HeaIth, op.cit. w—l—IwA—,L, CULTURAL AND INDIVIDUAL DIFFERENCES IN ALCOHOL, DRUG ABUSE AND MENTAL HEALTH RESEARCH Manuel Ramirez III, Ph. D. Professor, Department of Psychology The University of Texas at Austin Introduction In l98l the Office of Special Populations of the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) selected a group of ethnic minority researchers to review and critique research on ethnic minorities which had been funded by the agency in the ten-year period between l972 and l98l. The group reviewed projects which had focused on American Indians (Native Americans), Asian Americans, Black Americans, and Hispanics. The reviewers were provided with extensive information on the research projects assigned to them, including copies of the proposals, IRG evaluations or ”pink sheets,“ progress reports, final reports and publications. Whenever possible, principal investi- gators were also contacted for additional information. The review for each project included a summary description of the project, demographic details on subjects studied, and information concerning theoretical approaches, methodology, research design, findings and implications of findings for policy and implementation. Upon completion of reviews of individual projects, an overview of the research for each of the four ethnic minority groups was prepared. The overview identified the major issues or themes around which the individual projects tended to cluster, focused on theoretical and applied implications of overall findings with recommendations for future research and suggested direction for the continuing role of ADAMHA in supporting research on ethnic minority groups. This paper (presentation) summarizes the major points made in the overview of research done with Hispanic groups in the United States. A total of 69 Hispanic projects were reviewed —- 52 percent fOCUsed exclusively on Mexican Americans, 43 percent on Puerto Ricans and 6 percent on Cuban Americans. The disciplines of the projects DTTHCIDEI investigators were varied: 35 percent were sociologists; 32 percent. psychologists; l8 percent, anthropologists; 8 percent, from various disciplines in education; 5 percent, psychiatrists; and 2 percent, physicians. Of the projects reviewed, 85 percent were funded by the National Institute of Mental Health (NIMH), l4 percent were funded by The National Institute on Drug Abuse (NIDA), and only one project was funded by The National Institute on Alcohol Abuse and Alcoholism (NIAAA). 17 In order to place the findings of this survey in proper perspec- tive, it is necessary to consider four major issues relating to health care in Hispanics: (l) Hispanics have historically been underserved by most mental health and mental health-related programs; (2) the mental health movement in the United States has traditionally ignored the role of cultural and individual differences in the develop- ment and implementation of alcohol, drug abuse and mental health intervention and primary prevention programs; (3) racism, poverty and minority group status have had and are continuing to have a significant impact on the psychological adjustment of Hispanics; and (4) the acculturation process is closely related to adequacy of psychological adjustment in general and to success in educational and economic endeavors in particular in most members of Hispanic groups. Biculturation and multiculturation figure most importantly in adjust- ment to the diverse environments in which most Hispanics live. I. Major Research Themes Identified The first theme identified concerned development and implementation of mental health services which were consonant with the cultures of the different Hispanic groups. The general assumption of these projects was that Hispanics underutilize mental health services because these~ services are usually not consonant with the Hispanic world view vis-a-vis illness and health. Although most of these projects were well under- way at the time of the review, definitive findings were generally not available from them. The following are some examples of this type of project: Salazar is developing a therapeutic program with a Mexican American culture orientation in a psychiatric ward of the Colorado State Hospital in Pueblo. Five hundred Chicano in-patients are participating in a therapy program which promotes ethnic identity, involves family members in the therapeutic program, and makes use of the Spanish language and of certain folk medicine techniques. The experimental group is being compared to 250 Chicanos receiving the traditional therapy program at the same hospital. Constantino is developing a therapeutic approach for use with Puerto Rican children and their mothers. The treatment methodology is based on Puerto Rican folk tales. Two types of folk tales are used 18 -- traditional stories and adapted folk tales which reflect life in the mainstream culture. The principal investigator's hypothesis is that this culturally specific therapeutic approach will provide models with which children can identify and will also mediate a more functional relationship with the mother. The cuento or folk tale therapy group is being compared to art/play therapy and non-treatment groups. Scopetta and Szapocznick, working at the Spanish Family Guidance Clinic of the University of Miami, are developing a family therapy approach for Cuban American families in which adolescent children are experiencing acculturation stress. Their Bicultural Effectiveness Training is aimed at teaching new bicultural skills to adolescents and their families. The experimental group is being compared to a group of families receiving structural family therapy. The second major theme to emerge from this review was the identifica— tion and utilization of supportive resources in Hispanic families and communities. The general assumption of these studies is that there are strengths in Hispanic families and communities which, if properly utilized, can provide cost-effective intervention and prevention. Although the findings of these types of projects are somewhat impres- sionistic, they have provided useful information which can be subjected to experimental tests in subsequent research. The following are examples of this type of project: Karno is studying Mexican-American and Anglo-American families in which one of the members has been given a schizophrenic diagnosis. Preliminary results indicate that Mexican-American families demonstrate more tolerant coping styles toward the "identified patient” than do Anglo-American families. Specifically, Mexican—American families: (l) accept schizophrenic disorders as a legitimate illness, thus removing personal responsibility from the individual patient, (2) show a greater willingness to tolerate deviant behavior in schizophrenic family members, and (3) represent strong social and emotional support networks that allow for sharing and effective buffering of problems. Keefe compared Anglos and Mexican Americans on the degree to which they rely on their families as well as on other informal sources of emotional support, such as friends and clergy. Her results indicated that the kinship structure of Mexican Americans and Anglo Americans is different. In addition, the most outstanding difference between the two groups was the tendency of Anglos to seek other sources of emotional support such as neighbors and friends,whereas Mexican Americans used the extended family as a primary source of support. 19 Still another promising study with respect to supportive resources in Hispanic families and communities is a project being directed by Rogler in New York. The project is examining lOO Puerto Rican inter- generationally linked parent and married-child families. The focus of this study is on how families of different generations cope with problems by turning to family members, friends, and neighbors as well as to unofficial help-giving organizations in the community. Finally, Vivian Garrison's work has focused on the role which black and Caribbean folk healers play in the mental health of urban residents in the New York City-New Jersey area. Her findings indicate that folk healers are doing effective work in secondary prevention and that some of the practices of these healers can be successfully integrated into traditional mental health programs and treatment/ diagnostic approaches. The third theme identified concerned the relationship of characteristics and dynamics of Hispanic communities to primary prevention and intervention in individuals and families in crisis. The Child Advocacy Project implemented in the Model Cities Area of Santa Fe, New Mexico,is one of the best examples of this third theme. The project developed culturally appropriate methods and techniques for dealing with adjustment problems of Hispanic elementary and junior high students. Over a period of five years the program trained indigenous care—givers to be case advocates and class advocates. Case Advocacy efforts involved activities such as: child advocacy, peer advocacy, family advocacy, institutional advocacy, peer pressure groups, alternative time use, big brother/big sister advocacy, refer- ral resource utilization and introspection. Class advocacy approaches involved collection and dissemination of information, resource alloca- tion, economic pressure development, legal intervention,and requested intervention by elected representatives. Moore has identified characteristics of Mexican-American gangs and religious organizations which play an important role in the adjust— ment of ex-prisoner/ex-drug addicts in an urban area of Southern California. The project was carried out by a coalition of former drug addicts and professional researchers. The results showed that Mexican—American convicts, whether in prison or in the streets, do not perceive existing institutional resources as helpful to them. It was also found that the convict's movement towards self-help and religious organizations are effective in rehabilitation because they reflect the culture of the Mexican—American community. 20 Fitzpatrick found that drug addiction for Puerto Rican youth in the Bronx has Characteristics distinct from that of drug ad- diction among blacks and Italians in New York and also from that of Puerto Ricans in Puerto Rico. His findings challenged the notion of ”drug culture,” indicating that Puerto Rican addicts are not alienated from their communities and families: the addict remains linked to his community, thus making it likely that he or she can return to healthy adult roles in the community. The fourth research theme focused on the relationship of migra- tion to psychological adjustment. Some of these projects also sought to identify economic and familial, as well as community factors which are related to migration. Dinerman identified socio-economic characteristics of Mexican families and communities which are related to migration to the United States. Napner and Pacheco focused on the effects of migration and return migration on individual adjustment of Puerto Rican adolescents. Their findings indicate that both family and peers, as well as perceptions of person- environment fit, play major roles in adjustment of the migrant or return migrant. Robles studied in—migrant, return—migrant, and non- migrant families in Puerto Rico. Her results demonstrated the importance of kinship and friendship networks in the adjustment of migrants and also indicated that children and adolescents of return-migrant families are having problems of incorporation into Puerto Rican society. The fifth theme centered on the relationship of education to psychological adjustment. As in the case of mental health services development and utilization, the principal assumption of these projects was that most of the problems experienced by Hispanics in educational settings result from the incompatibilities between Hispanic values and life styles and those which are reflected in most educational institutions. Leyba studied young adult male and female Mexican-American college students and school drop-outs. The results suggested that the schools can influence some of the major factors which lead to dropping out of school. Munoz and his colleagues identified variables which are related to the academic and psychological adjustment of Mexican-American and Anglo-American students in universities in the Southern California area. Their results indicated that there were many differences between the two cultural groups of students. There were also substantial sex differences in the Mexican-American sample. It was found that Mexican-Americans reported higher stress levels than did their Anglo-American counterparts. 21 The sixth and final theme focused on the psychodynamics and sociocultural factors of females who are heads of households. For example, Hernandez is studying Mexican-American women on the welfare rolls in San Antonio, Texas, who are heads of households with dependent children. Preliminary findings indicate that these women are actively seeking to become self-supporting by finding jobs and by taking advantage of educational programs in the community. Sanchez is focusing on the use of social-support networks by Mexican—American and Anglo—American female heads of households in a Northern California city; data collected are still under study in this project. Robles is comparing Puerto Rican women who were recently divorced to their friends who are still married. The investigator is studying the impact of families and friends on adjustment to the stresses of divorce. Findings from this study were not available at the time this report was prepared. Cooney studied Puerto Rican families who are headed by females; she focused on economic indicators and participation in the work force. Her findings show that the most economically disadvantaged households were female primary, rather than female-headed. Safa is examining the impact of long—term employment of Puerto Rican women in the garment industry on family structure and the forma- tion of female-headed households. The primary focus of the study is on questions such as the following: Will changes in the female role resulting from employment in a garment factory produce dissension in families or will they encourage a health restructuring of the male and female roles? The study is presently at an early stage of implementation. In summary, the results of my survey support three major con- clusions regarding alcohol, drug abuse, and mental health services for Hispanics: (l) To be maximally effective, primary prevention and interven- tion programs should reflect the culture and lifeStyle of the people they propose to serve. The crucial factor here is that service providers and patients share the same world view regarding health and illness. Fuller Torrey has very aptly referred to this process as the principle of Rumplestiltskin -- that is,the therapist knows the name of the illness or disorder because he or she shares some of the patient‘s world view. Most Hispanics hold a mestizo world view of illness and health which is quite different from the predominantly European world view reflected by psychiatry, medicine and the social sciences (Ramirez, 1983). 22 (2) There is need for development of new paradigms in alcohol, drug abuse, and mental health research. Rappaport (l977) has sug— gested that we need to challenge the traditional paradigms of American psychology and psychiatry which reflect an implicit faith that the single standard of white middle-class society is, on an absolute basis, superior to all others. The new paradigms, Rappaport suggests, must be based on certain assumptions: “They are respect for human diversity, the right to be different, and the belief that human problems are those of person-environment fit, rather than of incompetent (inferior) people or inferior psychological or cultural environments" (p. 22). (3) Closely connected to the need for new paradigms is the need to recognize that the United States is rapidly moving from an either- or to a multiple options society (Naisbitt, l982). This means that we must give greater emphasis to bicultural/multicultural processes in the lives of members of minority ethnic groups and place less emphasis on old notions of acculturation and assimilation. II. Future Research Needs and Areas The following areas for future research were suggested by this review: A. Coping with Rapid Change Migration, acculturation, changes from rural to urban, changes from the traditional to the modern -- these and many other changes and transitions are impacting the lives of Hispanics and are extracting a heavy toll in terms of energy, resources, and the ability to cope with life. The focus of future research should be on how families, communities, and individuals have been able to cope successfully with change. Additional focus should also be on those characteristics of culture and communities which provide support to individuals and families experiencing stress related to change. 8. Effects of Migration on Psychological Adjustment All indications are that the rate of migration of Hispanics to the United States will be increasing in the next decade or so. The problems of the Mexican economy and the political unrest in El Salvador, Nicaragua, Haiti, and Honduras will mean that an increasingly greater number of peoples from these countries will be coming to the United States in search of asylum and economic opportunity. Migration is 23 stressful not only to the migrants but to the peoples and communities in which the migrants settle. Evidence of this can already be seen in the Miami-Dade County, Florida, area where blacks and other ethnics as well as mainstream people and second and third generation Hispanics resent the new migrants and feel threatened by their presence. Research, then, must focus on effects of migration on both migrants and on permanent residents of communities into which migrants move. C. Identification and Reinforcement of Available Support Networks and Resources in Communities and Families As support for social programs decreases, it becomes increasingly important that Hispanics rely on existing resources in their families, communities, and cultures in order to cope with life stress. As was mentioned above, most of the projects reviewed here provided indica- tions that such supportive resources exist. However, there is need to acquire more knowledge about the exact nature of these resources and of the approaches for helping communities to make these more ef- fective and more available to a greater proportion of their residents. D. Encouraging Development of Bicultural/Multi- cultural Coping Skills in Youth Child and adolescent members of Hispanic groups experience bi— culturation stress as they attempt to achieve an identity with both their culture of origin and with the mainstream culture. These young people need to know how to cope effectively with institutions and agencies of the mainstream society as well as with family and friends in their community of origin. The politics of conflict and discrimina- tion in many communities is often so intense that it is often difficult for these young people to develop the bicultural identities they need to survive in the bicultural world in which they live. More research needs to be done into factors which either promote or interfere with the development of bicultural orientations to life and bicultural coping skills. Both intervention and primary prevention programs which can assist Hispanic youth in coping effectively with values and conflicts and in mediating between the world of their homes and that of the majority culture need to be developed. E. Drug and Alcohol Abuse Both drug and alcohol addiction are taking a heavy toll in Hispanic communities. Some of the research reviewed here has already 24 made preliminary contributions to understanding the nature of this complex problem, but more needs to be done. Specifically, there is need for development of primary prevention and intervention programs which are consonant with Hispanic cultures and world view vis-a-vis illness and health. F. Development of Mestizo World View-Based Theoretical Approaches, Instruments for Collection of Data, and Research Methodologies The projects reviewed here provide evidence that there is general acceptance of the fact that most of the tenets of traditional social science and psychiatry are not consonant with Hispanic cultures. Increasingly, we are beginning to recognize that individual and cultural diversity are real and that they demand the development of new paradigms. Rappaport (l977) has stated this effectively: “As we examine the dominant paradigms offered by psychology as a helping profession, we will discover that they are closely associated with a recognition of, but a disrespect for, individual and cultural differences. In this book the broad outline of a new paradigm will appear. They are respect for human diversity, the right to be different, and the belief that human problems are those of person- environment fit, rather than of incompetent (inferior) people or inferior psychological and cultural environments” (p. 22). Ensuring Productive and Fruitful Research This review identified certain orientations and actions which can be taken by ADAMHA staff, members of the IRGs, and by all health and mental health professionals and academicians to ensure that future ADM research with or on Hispanics is both productive and fruitful: A. Programmatic Orientation To ensure maximum benefits from future research and development efforts focus should be on areas of research and issues identified in previous sections of this paper. Specific focus on certain areas and issues should lead to increasing theoretical development and to the development of innovative techniques and procedures for data collection. B. Recognizing the Diversity of Hispanic Groups Care should be taken to ensure that funding for research and development projects does not get concentrated in one region of the country. There is great cultural diversity among Hispanic groups, and this demands that research and development be done on different groups living in various settings -— urban and rural, the Northwest, Midwest, Southeast, East and West coasts, as well as the United States-Mexico border region. Knowledge should also be sought on different generations of Hispanics -- on recent migrants as well as on those who have been in the United States for several generations. C. Involvement of Community Organizations in Research. Development, and Dissemination In many Hispanic communities grass roots and religious organiza— tions can help investigators to achieve local acceptance for research and development projects and can also assist in dissemination of findings. In many rural and urban Hispanic neighborhoods and com- munities, community action agencies, pre-school parent groups, bilingual program parent groups and lay religious groups are strong. active, and functional. Researchers should be encouraged to work closely with these groups to ensure greater relevance and success for their projects. D. Linking Resources of Academic Institutions with Those of Service Agencies More effective utilization of findings from research and develop- ment efforts can be ensured by encouraging coalitions between academic institutions and professionals with service institutions and organiza- tions. Not only can service organizations participate in and make immediate use of the research and development efforts, but they can also help to make training of researchers and health and mental health professionals more effective. E. Dissemination Components of Funded Projects Projects which are funded should be required to have detailed dissemination plans with the costs of such dissemination included in the budget. Prior to initiation of these research and development efforts, principal investigators should be required to make contact with agencies in organization6(in the communities in which they collected their data) which can assist in dissemination of information. F. The Role of ADAMHA The following actions can ensure that ADAMHA will play a more extensive and effective role in ensuring the fruitfulness and productivity of ADM research with Hispanics: 26 (l) Preparation and dissemination (both within ADAMHA and among practitioners and researchers on the ADAMHA mailing list) of brief annual ”state of the art" papers on ADM research and development efforts with Hispanic populations. These papers could encourage greater programmatic focus and would be an invaluable resource to people preparing proposals, to policy makers, graduate students, and to faculties of health and mental health training programs. (2) Continued appointment of minority scholars and practitioners to serve on the IRGs. The diversity of Hispanic groups should be kept in mind in making these appointments and care should be taken to keep from overrepresenting one region of the country or certain cliques of practitioners and researchers. It should also be recognized that IRG members can be very effective in disseminating information, and they should therefore be encouraged to participate in the recommended dissemination efforts. (3) Development of an ADAMHA associates program made up of key Hispanic researchers and practitioners from different regions of the country and representing various disciplines and areas of specialization. The role of this group would be to assist ADAMHA staff in disseminating information, in encouraging submission of first-rate proposals, and in disseminating vital information to graduate and professional students. ADAMHA associates could meet once a year with ADAMHA staff and IRGs to review the yearly "state of the art“ papers recommended above. (4) Creation of a developing Hispanic scholars and practi- tioners program made up of graduate and professional students in the health and mental health fields and in the social sciences. This program would orient developing minority scholars and practitioners as well as policy makers to resources and opportunities available through ADAMHA, thereby increasing ADAMHA's visibility in various training programs throughout the country. C. Conclusions The principal message which emerged from this survey is that we must continue with our efforts to develop approaches to research, intervention, and primary prevention which are consonant with our individually unique ways of perceiving ourselves and our socio- CUltural environments. The future success of alcohol, drug abuse, and mental health research with Hispanics, as well as Americans, depends on our willingness as researchers and practitioners to accept the fact that cultural and individual differences are real and that they are important in the way people perceive'and define health and illness, adjustment and maladjustment. 27 REFERENCES Atencio, T. COPAS Chi1d advocacy project (Project No. MH 23905). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1973. Cooney, R.S. Fema1e headed fami1ies: Puerto Ricans in the United States (Project No. MH 27224—02). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1976. Constantino, G. Temas I: FoTktaTes as therapy in Hispanic chi1dren (Project No. MH 2711-01). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1980. Dinerman, I.R. Househo1d composition, 1and tenure and propensity tg_migration (Project No. MH 35010). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1980. Fitzpatrick, J.P. Puerto Rican addicts and non-addicts: A comparison (Project No. DA 0031). Rockvi11e, Md.: Nationa1 Institute of Drug Abuse. 1974. Fu11er Torrey, E. The mind game: Nitchdoctors and psychiatrists. New York: Bantam Books. 1973. Garrison, V.E. Inner-city support systems project (Project No. MH 28467). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1979. Hernandez, D. Ro1e of patterning of Chicano househon heads on weTfare (Project No. MH 27326). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. Karno, M. The course of schizophrenia among Mexican Americans (Project No. MH 33502). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1980. Keefe, S. The Mexican American extended fami1y (Project No. MH 33425). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. Leyba, C.F. Mexican—American matricu1ation and retention rates (Project No. MH 22834). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1973. 28 Moore, J. The barrio impact of high incarceration rates (Project No. NH 33104). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1979. Munoz, 0.0. A study of Chicano drop—outs in higher education (Project No. MH 23597). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1974. Ramirez, M. Psycho1ogy of the Americas: Mestizo perspectives in persona1ity and menta1 hea1th. New York: Pergamon Press. In press. Rappaport, . Community psycho1ogy; Va1ues, research and action. New York: Ho1t, Rinehart and Winston. 1977. Rob1es, R.R. Returning migrants: The case of the neo—Ricans (Project No. MH 26245). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1976. Rog1er, L.H. He1p patterns in intergenerationa1 Puerto Rican fami1ies (Project No. MH 28314). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1976. Safa, H.I. Fema1e emp10yment and fami1y structure (Project No. MH 34131). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1980. Sa1azar, A.A. Research demonstration: Psychiatric treatment of Chicanos (Project No. MH 29106-01A2). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1980. Sanchez, A.T. The socia1 networks as an a1ternative resource (Project No. MH 32508). Rockvi11e, Md.,: Nationa1 Institute of Menta1 Hea1th. 1978. Szapocznik, 0., and Scopetta, M. Spanish fami1y guidance c1inic (Project No. MH 31236). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1980. Napner, S., and Pacheco, A. Menta1 hea1th of Puerto Rican migrant ado1escents (Project No. 32904). Rockvi11e, Md.: Nationa1 Institute of Menta1 Hea1th. 1980. 29 HEALTH PROBLEMS OF HISPANIC AMERICANS Fernando M. Trevino, Ph.D., M.P.H. Social Science Analyst National Center for Health Statistics The National Center for Health Statistics (NCHS) is the only agency in the entire federal government that is specifically mandated by Congress with monitoring the health status of the U.S. population and reporting its findings directly to the Congress. During the past 25 years, NCHS has accomplished this mission through numerous national surveys. NCHS has collected a multitude of data on almost every indicator of the nation's health. For example, NCHS can state how many people in this country are overweight, how many people went to the doctor last year, how many times they went, for what purpose, and how they paid for it. Data are available on how many people in this country suffer from hypertension or diabetes and whether they are under a doctor's care for the condition. NCHS data are available on the number of people needing eyeglasses who do not have them, as well as the number of people who have a par- ticular vitamin deficiency. And they can provide you with this information for a specific age group by sex and race. This informa- tion is used extensively by the Congress and numerous federal health agencies to identify health needs and groups with great health needs so that they can develop programs to meet those needs and evaluate the effectiveness of the programs. Yet, at present,NCHS can tell you absolutely nothing about the health of Mexican Americans. We do not even know how many Mexican Americans died in this country last year, let alone their health status, use of services, or unmet health care needs. 1/ This dearth of information regarding Hispanic health has seriously limited the efforts of the health professionals trying to meet these health needs. Health educators are having to develop their programs with minimal information regarding the health problems and health behaviors of Hispanics. Program managers serving Hispanics have to compete for funding for their programs without data to document the health needs of their target population,and medical, nursing and other health professional students are completing their training with almost no instructions whatsoever on how to best provide care for this population. 30 The U.S. already has the sixth largest Hispanic population in the world 1/ and our demographers tell us that, if it sustains its present rate of growth, the Hispanic population in this country will double every 25 years. 3/ With so little information available, our country's health care system is simply not prepared to serve effectively the ever increasing health needs of Hispanic Americans. One of the diffiCulties we face in trying to provide health care to Hispanics is the problem of language. Eighty percent of Hispanic Americans live in households where Spanish is spoken,with about a third of the population (over 3.7 million) usually speaking Spanish. 3/ The American Medical Association has recommended a physician—population ratio of one physician for every 650 persons. In the mid-1970's there was one Anglo physician for every 538 Anglos and one black physician for every 4,l00 blacks; yet there was only one Mexican American physician for every 20,000 Mexican Americans. Despite af- firmative action programs, the number of Mexican Americans gaining admission to the nation's medical schools remains small. Among those applying for a seat in a U.S. medical school for the first-year class of l98l-82 only l.4 percent were Mexican American. Of these, 28l were accepted,accounting for l.6 percent of all persons who were accepted by a U.S. medical school. 5] The problem, of course, is that few Hispanics survive the educational system long enough to earn a degree. In l976—77, Hispanics earned only 2 percent of all the bachelor's degrees which were awarded in this country. This is par- ticularly unfortunate,as two-thirds of Hispanic college students speak Spanish. §j Fortunately, there are non-Hispanic health profes- sionals who do speak Spanish,although in very short supply. The resulting language gap between the non-Spanish-speaking health professional and the non-English-speaking Hispanic patient is more likely to manifest itself in clinics providing care to Hispanic elders. The less educated, less acculturated, and less well-to-do these Hispanic patients are, the more likely they are to be monolingual in Spanish. The language gap also poses the greatest challenge to the mental health professional, the health educator and those seeking to secure patient compliance with a treatment regimen,as their efforts are almost totally dependent on good communications. Another barrier to effective health care for Hispanics is their low income. Hispanic families are generally larger and have lower incomes than non-Hispanic families and would, therefore, be expected to have less disposable income to pay out-of-pocket expenses for health 31 care. Yet Trevino and Moss have found that Hispanics are two and a half times more likely than non-Hispanics not to have health insurance.§/ Among persons residing in Standard Metropolitan Statistical Areas in the U.S., Mexican Americans were found to be the ethnic group with the high— est proportion of non-coverage for medical expenditures,with almost one-third of that ethnic group having neither private nor public health insurance. Among persons with annual family incomes of less than $7,000, almost one-half of the Mexican Americans are uninsured compared with one-third of the Cubans, one—fourth of white and black non-Hispanics, and one-fifth of the Puerto Ricans. Low-income Mexican Americans are considerably less likely than low-income blacks and Puerto Ricans to have Medicaid coverage (32 percent, 47 percent, and 63 percent respect— ively). An association was found between health insurance coverage and physician utilization. Uninsured Mexican Americans reported the fewest physician visits of all ethnic groups and had the greatest proportion of persons experiencing a long time interval since their last physician visit. Fully one—fourth of uninsured Mexican Americans had not seen a physician in the past two years. It thus appears that great numbers of Mexican Americans, particularly those with low incomes, cannot afford health care in this country and may be deferring needed medical treatment. Obviously, there are other characteristics of the Hispanic popula- tion that will have an influence on their health status. In addition to the language and income differences between Anglos and Mexican Americans, other differences exist, notably genetic admixture, educa- tional level, occupation, culture, lifestyle, and diet. Genetic admixture estimates for Mexican Americans range from l8—47 percent native American admixture. Relethford et al. have found an 18 percent native American admixture among upper-income Mexican Americans in San Antonio, Texas, and a 46 percent admixture among low—income Mexican Americans. 1/ In another study, Gottlieb and Kimberling have estimated 40 percent native American admixture in a sample of Mexican Americans in Colorado. §/ The native American admixture of Mexican Americans is currently being investigated by Stern et al as a possible etiological factor related to the greater prevalence rate of diabetes among Mexican Americans. 2/ Occupational health hazards faced by Hispanic workers is an area that has received little attention from the researchers in this country. Dicker and Dicker ranked occupational categories on the basis of oc- cupational injuries, illnesses, and fatalities and concluded that ”47 percent of all Hispanics work in the top five industrial categories ranked in terms of overall relative health risk." 19/ The largest proportion of Hispanics (28 percent) work in manufacturing,which ranks first in terms of occupational illnesses. 32 Migrant farm workers are an obvious example of a group of Hispanic workers who face great occupational and environmental health hazards. These workers often face pesticide exposure, ‘ experience orthopedic problems, and face health problems related to substandard housing and sanitary conditions at the worksite. _l/ The health consequences of the Hispanic diet have also been poorly documented. A greater prevalence of nutrition-related disease has been hypothesized among low—income Mexican Americans. lg/ Teller et al found that Mexican Americans experienced a mortality rate for amebic dysentery twice that of Anglos and a mortality rate for diabetes and undetermined causes three times that of Anglos. lg] These conditions have or are suspected of having a nutritional component. Of all deaths attributable to nutritional deficiencies among Mexican Americans in Texas, 77 percent occurred among children under five and persons over 74 years of age. 13/ Thus very young and elderly Mexican Americans would appear to constitute the group at highest risk for nutritional deficiencies. Given the high fertility of Mexican American women, proper nutrition is also of critical importance among pregnant Hispanic women so as to ensure optimal growth and development of their offspring. The Ten-State Nutrition Survey specifically found that Mexican Americans had more deficiencies in vitamin A and less in vitamin C than other low-income groups. l§/ The National Center for Health Statistics (NCHS) has produced estimates for the Hispanic population. However, currently published reports have not differentiated the Hispanic population by national origin (e.g. Mexican American). A study of births of Hispanic parentage in l978 revealed that Hispanic mothers were four times more likely than white non-Hispanic mothers to have received no pre- natal care whatsoever or to have initiated this care in the third trimester of pregnancy (l3.l% vs. 3.3). 19/ The figure for Hispanic mothers was 20 percent higher than for black non-Hispanic mothers (l3.l% vs. l0.9%). Hispanic women who received prenatal care had the lowest median number of visits for prenatal care of the three groups (9.3 for Hispanic women, ll.3 for white non-Hispanic, and 10.7 for black non-Hispanic women). Given that Hispanic women also have the highest fertility of the three groups, the provision of timely pre— natal care for Hispanic mothers is urgently needed. In l965, an investigation was conducted in Alameda County, California,by the Human Population Laboratory of the State of California to assess the relationship between personal health practices and health consequences. 12/ Their nine—year follow-up study revealed a strong inverse relationship between the total 33 number of good health practices reported and age-specific mortality rates. l8/ The seven good health practices identified in this study included (l) sleeping an average of 7-8 hours a night; (2) eating breakfast almost every day; (3) seldom, if ever, eating snacks; (4) controlling one's weight; (5) engaging in exercise; (6) moderate alcohol consumption; and (7) not smoking cigarettes. Persons who reported six or seven of these health practices were shown to have better health status and to live longer than persons who reported less than four of them. In l977, NCHS included a supplement in its National Health Inter- view Survey designed to obtain data on the prevalence of these seven preventive health practices among the noninstitutionalized U.S. population aged 20 years and over. The findings revealed that 68 percent of Anglo respondents reported sleeping 7-8 hours per night compared to about 6l percent of Hispanics and 56 percent of blacks. l2] About 60 percent of Anglos and 56 percent of Hispanics reported they ate breakfast every day but only 47 percent of blacks did so. Ethnic differences related to the frequency of eating snacks were negligible, with slightly more Hispanics reporting they never ate snacks. Both blacks and Hispanics reported a lower physical activity level than Anglos. Hispanics were found to drink less often than blacks or Anglos but to consume more drinks at one sitting. Hispanics were considerably more likely than blacks and Anglos to have never smoked cigarettes,and Hispanic smokers reported smoking fewer cigarettes than the other ethnic groups. Finally, 32 percent of Hispanics reported they were 20 percent or more above their desirable weight relative to their height compared with 38 percent of blacks and 24 percent of Anglos. Unfortunately, the sample for this survey did not include enough Hispanics to permit Hispanic estimates by national origin, age, and sex. Recognizing the urgent need for data on the health of Hispanics, NCHS began making plans in l979 for what will be the first large- scale survey of the Hispanic population ever conducted in this country. The survey is called the Hispanic Health and Nutrition Examination Survey (HHANES). In l980, I joined NCHS as their chief consultant for the design, development and implementation of this very important survey designed to collect information on the health and nutritional status of Hispanics comparable to that which has been obtained for the general U.S. population through previous NCHS surveys. The sample for the survey consists of the civilian, noninstitutionalized population aged six months to 74 years of: Mexican origin residing in Colorado, New Mexico, Arizona, Texas, and California; Puerto Rican origin in the New York City area; and Cuban origin in Dade County, Florida. The 34 HHANES will thus collect information for the three major Hispanic national origin groups and will do so through medical and dental examinations, dietary interviews, household interviews, anthropometric measurements, and numerous diagnostic and laboratory analyses. Every sample person is interviewed in his or her home regarding health practices, medical history, use of services, and socioeconomic and demographic characteristics. An appointment is then made for the person to come to our mobile examination center where we are able to conduct the examination in a standardized environment. At the center, the person receives a dental examination by a dentist, a medical history and a physical examination by a physician,as well as a dietary interview. Body measurements will be taken including height, weight, and skinfolds; and their blood and urine specimens will be taken so that these can then be subjected to numerous laboratory tests. Depending on the age of the participants, the rest of the three—hour examination will include the following: diagnostic ultrasound for detection of gallstones (20-74 years of age) glucose tolerance test for diabetes (20—74 years of age) electrocardiogram (20-74 years of age) hearing and vision tests (6-74 years of age) liver disease test (20-74 years of age) venereal disease test (l2—74 years of age) chest x-ray (20-74 years of age) mental healthinterview(zo'74 years Of age) alcohol consumption and drug abuse interview (l2-74 years of age). The survey began in July, l982 and will be completed in December, l984. When the survey is completed more than l6,000 Hispanics will have participated in this large data-collection effort which will yield approximately 5,000 data elements for each person who is interviewed and examined. Data from the HHANES will be released from l984 through 1987 in the form of NCHS reports and micro data tapes for use by interested researchers. These data will be 35 invaluable. For the first time we will be able to assess the health and nutritional status, estimate the prevalence of selected conditions, and determine the unmet needs for health care that exist among Hispanics in the United States. This is an exciting time for those interested in providing health services to the Hispanic community. During this decade, we will be collecting much of the information we have needed for so long —- data that can have a tremendous impact on the future health of Hispanics. Our efforts will by no means be concluded. Even after the HHANES is completed, we still will not know how many Hispanics die each year in our country or what the life expectancy of our children is. But we are off to a very good beginning. I hope that we can continue and expand these data collection activities in the future. Of equal import, we need to insure that these data are thoughtfully analyzed, that careful planning for services follow, and that the needed resources be committed so that we may pro- vide services that are found to be needed among Hispanics wherever they happen to live in our country. 36 REFERENCES Trevino, F.M. ”VitaT and HeaTth Statistics for the U.S. Hispanic PopuTation ” American JournaT of PubTic HeaTth. T982. 70: 979—982. Cruz, B.R. and Sheir, R. ”The T980 DecenniaT Census and Hispanics: Some PoTicy ImpTications.” In The State of Hispanic America. VoT. II. OakTand, CaTif.: The NationaT Hispanic Center for Advanced Studies and PoTicy AnaTysis. T982, p. 6. Waggoner, D. PTace of Birth and Language Characteristics of Persons of Hispanic Origin in the United States. Washington, D.C.: NationaT Center for Education Statistics. Spring T976. ”AppTicants to U.S. MedicaT SchooTs, T977-78 to T98T-82.” JournaT of MedicaT Education. T982. 57: 882-884. The Condition of Education for Hispanic Americans. Washington, D.C.: U.S. Department of Education, NationaT Center for Education Statistics. T980. Trevino, F.M. and Moss, A. ”HeaTth Insurance Coverage and Physician Visits Among Hispanics and Non-Hispanics." In HeaTth—United States, T983. Washington, D.C.: U.S. Department of HeaTth and Human Services, U.S. PubTic HeaTth Service, NationaT Center for HeaTth Statistics. (forthcoming). ReTethford, J.H., Stern, M.P., GaskiTT, S.P., and Hazuda, H.P. SociaT CTass, Admixture, and Skin CoTor Variation in Mexican Americans and AngTo Americans Living in San Antonio, Texas, with SpeciaT Reference to Diabetes PrevaTence. Submitted for pubTication. GottTieb, K., and KimberTing, W.J. ”Admixture Estimates for the Gene PooT of Mexican Americans in CoTorado.” American JournaT of EhysicaT AnthropoTogy. 50: 444 (abstract). Stern, M.P., GaskiTT, S.P., ATTen, Jr. C.R., Garza, V., GonzaTes, J.L. and WaTdrop, R.H. “CardiovascuTar Risk Factors in Mexican Americans in Laredo, Texas. I. PrevaTence of Overweight and Diabetes and Distributions of Serum Lipids.“ San Antonio: Department of Medicine, University of Texas HeaTth Science Center (mimeographed). 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 37 Dicker, L., and Dicker, M. ”Occupationa1 Hea1th Hazards Faced by Hispanic Workers: An Exp1oratory Discussion." The JournaT of Latin Community Hea1th. 1982. 1: 101—107. S1esinger, D.P. Hea1th Needs of Migrant Workers in Wisconsin. Madison, Wisconsin: Department of Rura1 SocioTogy, University of Wisconsin - Extension. 1979. The Hea1th of Mexican-Americans in South Texas. Austin: The Lyndon Baines Johnson Schoo1 of Pub1ic Affairs, The University of Texas. 1979. Te11er, C.H., Rodriguez, R., and C1yburn. “Physica1 Hea1th Status and Hea1th Care Uti1ization in Texas Border1ands.” Austin:- University of Texas. 1975 (mimeographed). ”Deaths Attributab1e to Avitaminosis and Other Nutritiona1 Deficiencies, 1970-1972.” Austin: Texas Department of Hea1th. Records and Statistics Division. 1975. Ten-State Nutritiona1 Survey 1968-1970. At1anta, Georgia: U.S. Department of Hea1th, Education, and We1fare. Center for Disease Contro1. 1972. DHEW Pub1ication Number (HSM) 72-8133. Ventura, S.J. and Heuser, R.L. Births of Hispanic Parentage, 1978. Month1y Vita1 Statistics Report. V01. 29, No. 12 Sup— p1ement, DHHS Pub1ication Number (PHS) 81-1120. Washington, D.C.: Nationa1 Center for Hea1th Statistics, Pub1ic Hea1th Service, U.S. Government Printing Office, 1981. Be11oc, N.B., and Bres1ow, L. ”Re1ationship of Physica1 Hea1th Status and Hea1th Practices.” Preventive Medicine. 1972. 1: 409-421. BresTow, L., and Enstrom, J.E. "Persistence of Hea1th Habits and Their Re1ationship to Morta1ity.” Preventive Medicine. 1980. 9: 469-483. Schoemborn, C.A., and Danchik, K.M. ”Hea1th Practices Among Adu1ts: United States, 1977." Advance Data. Washington, D.C.: U.S. Department of Hea1th and Human Services, Pub1ic Hea1th Service, Nationa1 Center for Hea1th Statistics, Number 64, 1980. III. THE U.S. PUBLIC HEALTH SERVICE: RESEARCH AND TRAINING 39 HISPANICS AND HEALTH RESEARCH IN THE PUBLIC HEALTH SERVICE Dennis Tonma Acting Director Center for Health Promotion and Education Center for Disease ControZ The Center for Disease Control (CDC) is committed to improving the health status of the Hispanic community as part of its ongoing efforts to prevent unnecessary morbidity and premature mortality and improve the quality of life. The efforts include a variety of epidemiologic and operational research and research training activities to identify preventable health problems and effective intervention methods, improve the application of prevention measures, evaluate new technologies, and provide training for professionals involved in preventive activities. A number of these projects include Hispanics as a group of primary concern. BIOMEDICAL/EPIDEMIOLOGICAL RESEARCH PROGRAMS Hispanic Health and Nutrition Survey CDC provides various types of support for the Hispanic Health and Nutrition Examination Survey (HHANES) conducted by the National Center for Health Statistics. The Clinical Chemistry Division, in the Center for Environmental Health, has served as the focus for laboratory support for HHANES since l980. From l980 to July l982, the Division's efforts included development and refinement of suitable analytic methods, specimen collection techniques, data processing procedures, and training and operations manuals. In July l982, the Division began to analyze the biological specimens col- lected in the mobile examination centers operated by the National Center for Health Statistics (NCHS) and will continue to provide these services through late l984. NCHS plans to collect specimens from more than l2,000 individuals of Hispanic background in 35 locations throughout the United States. The Clinical Chemistry Division will analyze the specimens for vitamin; A and E in serum, total iron and iron-binding capacity, erythrocyte proto— porphyrin, serum and whole blood folate, whole blood lead, plasma glucose, and trace metals of hair and serum. In addition, the Division collects and transmits CDC-generated laboratory data, including analytic data 40 from VD serologic testing, tetanus serology, and hematology to the HHANES coordinating center at NCHS. The division is also working with the HHANES Lipid Laboratory at Johns Hopkins University to assure standardization of measurements for cholesterol, triglyceride, and high density lipoprotein cholesterol. The Division of Bacterial Diseases at the Center for Infectious Diseases (CID) provides further support to the HHANES project by determin- ing antitetanus titers in sera supplied by NCHS. The data will be used to estimate the number of children who have received diphterial/pertussis/ tetanus (DPT) vaccine. The CID Division of Host Factors provides quality control for the HHANES hematology survey and all data on the white cell differential count. State‘Based Nutrition Surveillance CDC, through the Center for Health Promotion and Education, has been collaborating with state health departments to conduct surveillance of nutritional status. The surveillance data include information on the nutritional status of Hispanics, along with other ethnic groups who attend publicly supported health programs. The data on Hispanics have been the focus of particular attention because of the relatively high prevalence of growth stunting and high weight-for—height, reflecting obesity among Hispanic children. The results of the analysis of surveil- lance data among Hispanic children will be presented at the annual meeting of the American Public Health Association in Dallas, Texas, in November l983. CDC also has been engaged in field epidemiologic research designed to improve assessment and interpretation of data on nutritional status from Hispanic populations. The growth pattern of short stature and high weight-for-height, noted with greater frequency among Hispanic children relative to other ethnic groups in the United States, is also seen in other countries in the Americas. This growth pattern has been observed among children in Peru, and a research project has been initiated in poor, urban Peru to determine the best and simplest techniques for measuring body protein and energy stores in children. Knowledge gained in this research project will be applied to nutritional assessment in Hispanic- American populations. Diabetes Control Demonstration Project The Center for Prevention Services funds the San Bernardino Community Diabetes Control Program through a cooperative agreement with the California Diabetes Control Project. The goal of the program is to reduce morbidity and mortality due to diabetic complications such as 41 blindness, amputations, renal failure, diabetic ketoacidosis, and perinatal morbidity and mortality through coordination of resources and education of the public, patients, and providers. This program has specifically targeted the Hispanic population as one of its priority populations for intervention. The Hispanic population has a higher-than—average prevalence of diabetes, and in some San Bernardino County communities, Hispanics comprise nearly 50 percent of the population. Results are expected in l985. injury Prevention Demonstration Project The Center for Environmental Health (CEH) provides technical assistance to the Department of Public Health in Dade County, Florida, for a pilot injury prevention program in the Hispanic community known as Little Havana. The program is designed to reduce high injury rates associated with the home environment by modifying environmental conditions causing injuries. CEH assisted with the design, development and implementation of the pilot program; provides training and consultation; and monitors and evaluates this program on a continuing basis. The program involves comprehensive, community-wide outreach,includ- ing the dissemination of information, education and code-enforcement activities. Persons at high risk of injury are identified and intervention provided to make the environment safer. This includes installing smoke detectors, turning down water heater thermostats to prevent tap water scalds, and installing non—slip surfaces in bathtubs to prevent fall injuries, especially among the elderly. Tuberculosis Two studies conducted by the Division of Tuberculosis Control in the Center for Prevention Services have found Hispanics to be one of several subpopulations at increased risk of tuberculosis. A seven-year study monitored the incidence of drug resistance among newly diagnosed tuberculosis patients who had not been treated previously. The data showed higher rates of drug resistance in participating areas located near the U.S.-Mexico border,as well as among the Asian and Hispanic subpopulations. The rates for these two race/ethnic groups were significantly higher compared to the rates for whites, blacks and American Indians. A new study has been started to monitor drug resistance rates among previously treated patients as well as among never—treated patients. Data will also be gathered regarding country of origin. Another study 42 was conducted to determine whether tuberculosis patients with organisms resistant to antituberculosis drugs are more infectious than patients with organisms susceptible to these drugs. Patients with resistant organisms were matched by race/ethnicity, sex, age (1 5 years) and geographic location to patients with susceptible organisms. Data from the study showed family and other close contacts of Hispanic, black, and Asian patients were more likely to become infected than contacts of white cases regardless of resistance status. The risk of infection ap- peared almost twice as high for contacts of Hispanic patients compared to white patients. CDC has awarded cooperative agreements to states and large cities to reduce high rates of tuberculosis by providing outreach services and assure compliance with treatment regimens. Personal Violence CDC's Center for Health Promotion and Education has analyzed data on homicide and suicide in the Hispanic population. Homicide. An analysis of homicides occurring between 1970 and 1978 in the U.S. indicates that homicide mortality took its greatest toll among minorities, males, and the young. Among Mexican-Americans in the five South- western States (1975-1980), homicide rates for Hispanic males and females are considerably higher than the rates for Anglo males and females. A detailed analysis of the numbers and characteristics of homicide victims will be published in l984 in a national surveillance report entitled ”Comparison of Homicide among Anglos and Hispanics in Five Southwestern States.” Suicide. Explanations for suicidal behavior have intrigued behavioral scientists for hundreds of years. Despite the attention this phenomena has received, efforts at intervention and prevention appear to have had little impact on death rates attributable to suicide over the last three decades. CDC is currently working on the development of a clearer understand- ing of the etiology of suicide, the evaluation of the most prominent attempt at suicide prevention (i.e., suicide prevention centers), and a more detailed examination of the age, sex, and ethnic categories for which suicide poses the greatest risk. Two suicide research projects, completed in l982, reveal that Hispanics have suicide rates somewhat lower than those for white non-Hispanics for all age and sex groups. The results of the analysis of data from 1975-80 were published in a report entitled “Comparison of Suicides among Anglos and Hispanics in Five Southwestern States.” 43 Hispanic Health Risk Appraisal Survey ”El Camino a La Salud," a health risk appraisal study begun in l980 and supported by the Center for Health Promotion and Education, set out to investigate the strength of the association betweenchanges in health behavior and educational intervention following a health risk appraisal of a Mexican-American population. This cohort study was conducted to see which educational intervention method accounted for the greatest change in health behavior of Mexican—Americans between the ages of 30 and 55. The first phase of the project focused on translating the CDC Health Risk Appraisal into Spanish, pretesting it for comprehension and effective- ness, and then making revisions. The second phase focused on administering the appraisal, giving feedback information and conducting an educational intervention program. U.S.—Mexico Border Survey At the annual meeting of the U.S.-Mexico Border Health Association in April 1978, federal, state and local health officials expressed several concerns related to the provision of family planning services along the U S.- Mexico border. In response to these concerns, the public health officials at the meeting resolved to support household probability surveys on both sides of the border to assess the need for and use of family planning and maternal and child health services. The U.S. Department of Health and Human Services assigned the lead responsibility for conducting the survey on the U.S. side of the border to CDC. In l979, CDC conducted a sample survey of women of reproductive age living on the U.S. side of the U.S.-Mexico border area. Several articles describing family planning practices and contraceptive use and comparing differences between Anglos and Mexican-Americans in planning for births and using contraceptive sterilization were published as a result of findings from the survey. Other articles based on findings from the survey explore the need for family planning services among Anglo and Hispanic women in border counties and tell about the lung cancer mortality and smoking habits of Mexican-American women. Health Hazard Evaluations Over the past three years, CDC's National Institute for Occupational Safety and Health (NIOSH) has conducted several health hazard evaluations involving workers in Puerto Rico and Hispanic workers in California. In l982, NIOSH completed a health hazard evaluation at Caribbean Gulf Refin- ing Operations in Bayamon, Puerto Rico. This evaluation found health hazards resulting from exposure to benzene and to hydrogen sulfide at this oil refinery. In l982, NIOSH also conducted a health hazard evaluation 44 at West Foods, a mushroom cultivation facility in Ventura, California. This investigation found dermatitis from exposure to pesticides and acute organo- phosphate pesticide poisoning for the Hispanic workers at this facility. Currently, NIOSH has two active health hazard evaluations in Puerto Rico, one involving exposure to polynuclear aromaticsat a graphite electrode manufacturing facility. The second investigation involves potential exposure to benzene and other chemicals at a petrochemical plant. The Institute also has four active health hazard evaluations in California involving pesticide exposure for Hispanic farm workers. In addition, NIOSH is col— laborating with the California Rural Health Federation on a prospective reproductive health study of female farm workers exposed to pesticides. Puerto Rico Fertility and Family Planning»Assessment The Puerto Rico Fertility and Family Planning Assessment, carried out by the Center for Health Promotion and Education, is a multi-purpose study serving both programmatic and research interests. The study is of programmatic interest because Puerto Rico, as a Commonwealth of the United States, is allocated financial support for family planning and maternal-child health programs from the same funding sources as states in the continental U.$. Relevant baseline data are needed for assessing the acceptability of and the need for famiiy planning and maternal-child health services in Puerto Rico. From a research perspective, Puerto Rico is unique for two reasons: 1) the high use of female sterilization -- over one-third of the women of reproductive age are sterilized —- and 2) interesting migration patterns back and forth to the U.S. mainland. How these factors and others have affected the demographic patterns in Puerto Rico, especially fertility, has long been the concern of demo- graphers. A special feature of the Puerto Rico study is the collection of life history data such as contraceptive use, pregnancies, education, migration, marriage, and employment which will enhance the study of the demographic processes in Puerto Rico and their determinants. A preliminary report on fertility and family planning in Puerto Rico will be prepared for distribution to the Department of Health in Puerto Rico in late 1983 or early 1984. This report will be based on data from the pregnancy history, family planning, sterilization, and future birth intentions sections of the assessment instrument. In addition, several publications on fertility and family planning are expected to result from the assessment. Premature Thelarche in Puerto Rico CDC has been collaborating with the Puerto Rico Commission on Premature Thelarche and the Puerto Rico Department of Health investigating the cause of a recent outbreak of premature thelarche. Premature thelarche 45 refers to breast enlargement in girls less than 8 years old. A significant number of cases have been reported by pediatric endocrinologists from Puerto Rico with reports coming from virtually all municipalities on the island. Most of the girls with this condition are less than 2 years old. A case-control study of premature thelarche revealed that a significant number of mothers of girls with the condition have a history of ovarian cysts; approximately half of the girls with premature thelarche have ovarian cysts diagnosed by ultrasonography. A survey of the homes of girls with premature thelarche did not reveal the presence of drugs or other chemical known to contain estrogens or have estrogenic activity. Samples of other potential sources of estrogen were collected, and tests for the presence of estrogen are in progress. A large study is under way to determine the possible cause of premature thelarche. A follow-up study is also in progress to determine the natural history of premature thelarche. Dengue The Center for Infectious Diseases has a field facility in San Juan, Puerto Rico, serving as the headquarters for epidemic services for dengue. Dengue is an infectious tropical disease transmitted by mosquitoes and characterized by fever, rash, and severe pains in the joints. In l98l the first dengueepidemic in this hemisphere occurred, causing l0,000 cases and l50 deaths in Cuba. The program in San Juan is attempting to: l) characterize the molecular epidemiology of dengue viruses and define dengue virus strain variation; 2) define qeoqraphic variation in the ability of the transmitting mosquito and use information gained for predicting epidemic spread and developing new control strategies; 3) develop rapid and improved diagnostic methods for dengue viruses; 4) develop more ef- fective methods for mosquito control; and, 5) develop virologic surveillance allowing monitoring of dengue serotypes and severity of illness. Guatemalavfiield_Activities CDC undertakes a variety of field investigations and surveillance and control activities on diseases endemic to Central America through its association with the Ministry of Health and a major university in Guatemala. These efforts have provided significant information on the northward extension of diseases such as yellow fever, dengue, and Venezuelan encephalitis and their potential impact on the health of U.S. border populations. In addition, studies are conducted on the epidemiology control, and therapy 0* diseases such as malaria, onchocerciasis, and leishmaniasis which conSLitute a threat to local populations and U.S. visitors to the region. Surveillance of a drug resistant form of malaria in areas of Central America is a continuing effort and provides a source of accurate medical advice on malaria prevention to travelers in the region. 46 TRAINING PROGRAMS As stated previously, the efforts of the Center for Disease Control to improve the health status of Hispanics in the United States include a variety of research and research training activities. The following Summary focuses on specific training activities that are benefiting Hispanic groups directly. Occupational Safety and Health Training Since August l979, NIOSH has supported a training project grant at the School of Public Health, University of Puerto Rico,in San Juan. Under the direction of Carlos Villafane, M.D., the program trains nurses, physicians, industrial hygienists, and safety professionals in various aspects of occupational and environmental health. NIOSH is also working with the Department of Vocational Instruction of Dade County, Florida, to develop and test a course for supervisors and instructors on Safety and Health for Industrial/Vocational Education. The course was developed jointly by NIOSH and the Occupational Safety and Health Administration (OSHA). Special assistance was provided by the OSHA Area Office in Fort Lauderdale. Many of the schools in the Miami/ Dade County areas are predominantly Spanish-speaking. . . NIOSH staff from the San Francisco regional office have also par- tiCipated in several training programs on occupational health hazards f0r Hispanic farm workers. Epidemiology Training Program CDC officials and personnel from the Ministry of Health in Mexico recently opened discussions on the possible development of an epidemiology training program in Mexico. The prospect for developing such a program was enthusiastically received, and the program is scheduled to begin in early l984. CDC is planning to send approximately five epidemiologists to Mexico to support the program. Childhood Immunization Programs in Latin America The International Health Program Office (IHPO) provides technical assistance to Latin American countries on the development and evaluation of childhood immunization programs. IHPO is collaborating with the Pan American Health Organization, the governments of several Latin American countries, and the National Aeronautics and Space Administration in the development of solar_powered refrigerators to support immunization activities. 47 Leptospirosis The Division of Bacterial Diseases, in the Center for Infectious Diseases, serves as a collaborating center with the Food and Agricultural Organization and the World Health Organization for the epidemiology of leptospirosis. Leptospirosis is a group of diseases with many manifesta- tions, including fever, headache, chills, severe malaise, vomiting, muscular aches and conjunctivitis. Fatality is low but increases with advancing age and may reach 20% or more in patients with cases of leptospirosis resulting in jaundice and kidney damage. The collaborating center provides training and reference microbiologic services for Middle and South American countries. Through these activities, the collaborat- ing center has had a major impact on the provision of diagnostic services for leptospirosis throughout Latin America. This summary of CDC activities involving Hispanics demonstrates the commitment CDC has to improving the health status of the Hispanic community as a part of our ongoing efforts to prevent unnecessary morbidity and premature mortality and improve the quality of life. 48 PUBLICATIONS Holck, Susan E.; Warren, Charles W.; Morris, Leo; and Rochat, Roger W. “Need for Family Planning Services Among Anglo and Hispanic Women in U.S. Counties Bordering Mexico,” Family Planninggferspectives, Vol. l4, No. 3, (May/June l982) l55-l59. Holck, Susan E.; Warren, Charles W.; Rochat, Roger W.; and Smith, Jack C. “Lung Cancer Mortality and Smoking Habits: Mexican-American Women,” American Journal of Public Health, Vol. 72, No. l (January l982): 38-42. Rochat, Roger W.; Warren, Charles W.; Smith, Jack C.; Holck, Susan E.; and Friedman, Jay S. ”Family Planning Practices Among Anglo and Hispanic Women in U.S. Counties Bordering Mexico,” Family Planning Perspectives,” Vol. l3, No. 4. July/August l98l): l76-l80. U.S. Department of Health and Human Services, Public Health Service. Centers for Disease Control, Center for Health Promotion and Educa- tion. Comparison of Suicides Among Anglos and Hispanics in Five Soutmmstern States. U.S. Department of Health and Human Services, Public Health Service Centers for Disease Control, National Institute for Occupational Safety and Health. Health Hazard Evaluation Report: HETA 8l-327-ll6l; Caribbean Gulf Refining Corporation, Bayamon, Puerto Rico. U.S. Department of Health and Human Resources, Public Health Service Centers for Disease Control, National Institute for Occupational Safety and Health. Health Hazard Evaluation Report: HETA 8l-366-l248; West Foods, Ventura, California. Warren, Charles W.; Smith, Jack C.; Garcia—Nunez, Jose; Rochat, Roger W.; Martinez—Manaut, Jorge “Contraceptive Use and Family Planning Services Along the U.S.—Mexico Border," International Family Planning Perspectives, Vol. 7, N0. 2 (June l98l): 52-59. Warren, Charles W.; Smith, Jack C.; and Rochat, Roger W. ”Differentials in the Planning Status of Most Recent Live Births to Mexican-Americans and Anglos.“ Public Health Reports, Vol. 98, No. 2 (March-April l983): l52-l60. Warren, Charles W.; Smith, Jack C.; Rochat, Roger W.; and Holck, Susan E. ”Contraceptive Sterilization: A Comparison of Mexican-Americans and Anglos Living in U.S. Counties Bordering Mexico,“ Social Biology, 28 (Fall, Winter l98l): 265-280. 49 RESEARCH ACTIVITIES IN THE FOOD AND DRUG ADMINISTRATION / Leroy Gomez Denver District Director Food and Drug Administration The research at the Food and Drug Administration (FDA) is somewhat genera] in nature, in that it is not specificaTTy geared toward the Hispanic community. The amount of resources utiTized are modest when compared to other divisions of the Department of HeaTth and Human Services (DHHS). For instance, our totaI research budget for FY 1983 was $77 miITion; the FY 1984 budget is $82 miTTion. A11 of this is appTied re— search and most of it is conducted in-house. Our extramuraT research has been decreasing in recent years. For instance, in the drug area, budgets have gone from $3 miTTion in FY 1981 to about $1.8 miiiion in FY 1983. The FDA mission is somewhat different from the missions of other parts of the department. We must ensure food safety and whoTesomeness, as weIi as the safety and effectiveness of drugs, bioTogicaT products, and medicai devices. The safety of cosmetics and ensuring that the use of radioiog- icaT products does not resuIt in unnecessary exposure to radiation are aiso priorities. Most agency activities are geared toward reguIatory decisions. We must ensure that the science used in FDA reguIatory decisions gains credi- biTity and merits the support of the pubTic and scientific community. This depends on the extent to which the reguIatory decisions of FDA re- fTect the best avaiTabTe scientific knowiedge. The agency has learned, from its experience with saccharin, that unTess we get the support of the scientific community in generaT, there wiTT be a probIem with credibiiity among the consuming pubTic. Over the years, the FDA has Ted in the deveIopment of methods to detect and measure substances that may aduTterate foods and/or drugs. We conduct research on the underiying mechanisms of diseases resuIting from human exposure to toxic substances or radiation as weTT as on the carcinogenic, mutagenic, or teratogenic risks of chemicais. 50 The FDA's responsibilities span a number of areas, today I will discuss two major areas, foods and drugs. We need to protect the public from unsafe foods, and in such a way so as to encourage inno- vation and abundance in our food supply. The foods we regulate include all categories of nutrient and non—nutrient components of food, such as raw agricultural products and substances intentionally or unintention- ally added to the food supply, such as preservatives, pesticides or packaging materials. We also concern ourselves with substances of nat- ural, microbial, or industrial origin that can contaminate food, i.e. . aflatonin, botulinum and polychlorinated biphenols (PCB's); and subs- ‘ tances produced by reactions between substances in the first three groups that take place in food storage or preparation. It is a critical public health matter that components of foods in all four of the above categor- ies be studied to find whether they represent any type of health risk. Research is being carried out to resolve the uncertainties asso- ciated with the disciplines of toxicology and nutrition. This research requires an expanded investment in several scientific areas. These are biochemistry, pharmacokinetics, endocrinologys'molecular biology, immun— ology, neurotoxicology, pharmacology, behavioral toxicology, and epidem— iology. Studies of the whole animal and, at subcellular, cellular, tissue and organ levels will be required. Previously used indices are inade- quate because they no longer reflect the FDA's responsibilities with respect to the allergic, immunotoxic, behavioral and other subtle debil— itating effects possibly produced by food and cosmetic constituents. The agency uses different approaches in data collection and analysis to establish the relationships between dietary practice and health status. Researchers want to estimate human exposure to the hazardous components of food and cosmetics. The population's nutritional needs must be determined and the agency must develop strategies to lmproVe the nutritional status of those peoole who are at risk not receivinn enough n nutrition. For example, the nutritional dietary habits of the Americ public have changed so that 50 percent of all calories consumed are now estimated to come from processed foods. The FDA's Market Basket Survey should be expanded. Up to the present, it was primarily geared to determine levels of pesticides and heavy metals present in our food supply. We need to isolate, purify and identify potentially hazardous food constituents and adulterants. These come in various categories: 1. environmental contaminants, such as PCB's, dioxins and other contaminants 2. animal drugs 51 3. metabolites of microbial origin Several attempts are being made to improve biological tests for various forms of human toxicity, including: 1. chronic toxicity 2. fetal and neonatal toxicity 3. behavioral and immune toxicity 4. dermal and ocular toxicity We apply the toxicity tests that are used and all epidemiological studies to determine the adverse effects (hazards) of food constituents. We have recently been faced with the problems of sulfites in foods and the fact that individuals in our own population are susceptible to those particular substances. The agency has to develop practical control technologies necessary to detect or prevent hazards resulting from the storage or processing of foods. One major problem area is the issue of aflatonin in foods. We need to study how they are formed and, specifically,what risks are associated with ingesting aflatoxin in foods. Approaches in the drug area are somewhat similar to those in foods, in that we need to track the drug experience and develop trends. One example of these techniques is selecting hospital ward units to parti— cipate in intensive drug surveillance programs. Studies include: drug exposure, adverse reactions and important clinical events in pediatric patients. This involves the prescription, use and accidental ingestion of acetaminophen and aspitirin among children. We are also engaged in a risk assessment of sedative premedications in children undergoing CAT scans and the study of birth defects related to the use of Bendectin during pregnancy. Other studies involve acute and long-term clinical toxicity of drugs. At present, we are conducting epidemiological studies involving over 300,000 people of all ages in Seattle, Wash., using both case control and cohort types of analysis to quantify the incidence of acute and long-term toxicity of drugs commonly used in clinical medicine and sur- gery. Recent studies have focused on: acute cholecystltis and thiazides vaginal spermicides and congenital disorders first trimester of drug use and congenital disorders hospitalization rates in vasectomized men. .5me 52 Methodology and bioavailability testing continues on Quinidine, Amino— phylline and Theophylline, all drugs which affect the cardiovascular system. One of the agency's major responsibilities is in Drug Availability Assurance. We have a product problem reporting for drugs and radiophar— maceuticals. Its purpose is to obtain and process information or problems with drug products at the point of patient distribution and usage. Drug advertising is one of the issues the agency is facing. Before embarking on any project, we must decide whether the legally mandated information on prescription drug promotional activities is presented in a manner which serves physicians and their patients. In—house research is for the most part conducted at four FDA fac- ilities; three in Washington, D.C. and the National Center for Drug Analysis in St. Louis, M0. The Division of Drug Biology is conducting research in pharmacology and toxicoioqy in laboratory animals in areas like neuropharmacology, cardiovascular toxicity; the age-related effects of drugs in prenatal, newborn and aged animals; and the biology and toxicology of animal endocrine systems. Research is being carried out on the antidotes to some common poisons. The research and development of methods and materials used in radioimmunoassay for the evaluation of biopharmaceutical problem drugs continues. The Division of Drug Chemistry analyzes drug products for the Drug Quality Assurance program and develops methods of analysis where no method exists or where existing methods are inadequate. We have a responsibility to ensure that drugs that are obtained by the Veterans Administration, the Department of Defense and various state organizations do in fact meet the standards prescribed for those drugs. At our National Center for Drug Analysis in St. Louis, scientists are connecting research on the application of instrumental techniques to the analysis of large numbers of drug samples. They are also studying the use of computers and microprocessors to acquire and mani- pulate data from mechanized systems and to control such systems. One of our new programs, the Orphan Drug Program,is designed to ensure that new and beneficial therapies are developed to help victims whose illnesses fall outside the more common, spotlighted diseases which command wide public interest and concern. These are drugs useful in treating rare diseases that lack commercial sponsors. They are often unavailable to patients because of limited commercial interestsince pharmaceutical manufacturers are not able to recover research costs. The FDA seeks to support work in areas where there is already some clinical evidence that the drug or device is likely to be useful. 53 In order to coordinate health community efforts and reduce potential duplication in the department's programs on orphan products, the Depart- ment of Health and Human Services established the Orphan Products Board in March 1982. The board consists of FDA, NIH, CDC, ADAMHA, HCFA, VA and DOD members. In the past year, the FDA has assisted in locating sponsors for al- most two dozen products useful in treating rare diseases and several new uses for drugs already on the market. The first grants are now available for orphan drug research. Between 15 and 30 awards ranging from $20,000 to $70,000 each, will be made. The first year's effort is quite modest, only $ .5 million, with the possibility of $1 million becoming available in FY 84. There is a possibility that work on those drugs not approved under the orphan drug program will be supplemented by funds available to the Secretary of Health and Human Services. This could amount to as much as $4 million. 54 ADAMHA SUPPORT FOR RESEARCH TRAINING Delores Parron, Ph. D. Associate Director for Minority Concerns _ National Institute of Mental Health Alcohol, Drug Abuse, and Mental Health Administration The shortage of minority research scientists trained for and concerned with investigating problems relevant to alcohol, drug abuse, and mental health is well documented and long standing. The nature of research training itself and the extended training period for a research career present special problems of access and funding for individual minority students and for institutions with substantial minority enrollment. Within the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) there are eleven investigator training and development awards. Four of these programs are aimed at predoctoral level, five are post— doctoral awards and two -— the Minority Access to Research Careers (MARC) and the Minority Biomedical Research Support (MBRS)-- are pre- baccalaureate programscomparable to those of the National Institutes of Health. This support is for training in an array of biomedical and behavior science disciplines that are central to the research enterprise related to understanding alcohol, drug abuse, and mental health topics. Although all eleven research training programs are open to all qualified applicants on a competitive basis, three of the programs are targeted toward promoting access to research careers and increasing the number of minority investigators. These programs are: ADAMHA—MARC Program ( or Alcohol, Drug Abuse and Mental Health Administration Minority Access to Research Careers program) assists institutions with substantial minority enrollment in training greater numbers of scientists and teachers in fields relating to alcohol, mental health and drug abuse. The objec- tives of this program are two—fold: l) The MARC Honors Under- graduate initiative is aimed at increasing the number of well— prepared students who can compete successfully for entry into doctoral degree programs in disciplines related to the alcohol, drug abuse and mental health field, and 2) the MARC Faculty Fellowships allow persons who are faculty at institutions whose 55 student enrollments are drawn substantially from ethnic minority groups to pursue advanced research training in areas related to alcoholism, drug abuse, or mental health. Following such training, it is intended that recipients of these fellowships will return to their home institution to teach, conduct research, and assist and inspire students in preparation for research careers in these areas. Minority Biomedical Research Support (MBRS) is aimed at strengthen- ing biomedical science capability of institutions with a tradi- tionally high minority student enrollment. Projects supported are those with emphasis on alcohol, drug abuse, or mental health-related research. Minority Fellowships Program is supported by the National Institute of Mental Health and administered by the national professional organizations of the core mental health disciplines: American Sociological Association, American Psychological Association, Council on Social Work Education, American Psychiatric Association, American Nurses' Association. Minority students apply directly to these organizations for support of training in an institution of their own choice to which they have been accepted foradmission. In this program alone, 194 Hispanic men and women have participated in the last five years. The National Institute of Mental Health (NIMH) funds two research and development centers that focus on the study of mental health of Hispanics. Dr. Lloyd Rogler heads the Hispanic Research Center of Fordham University in the Bronx, New York, and the Spanish-Speaking Mental Health Research Center of the University of California at Los Angeles, is headed by Dr. Amado Padilla. Both have provided guidance and inspiration to innumerable Hispanic investigators and others interested in studying topics relevant to Hispanic Americans. Some other examples of the broad range of opportunities for research training supported by ADAMHA are programs of the NIMH Center for Studies of Antisocial and Violent Behavior, which have given priority attention to recruiting Hispanic trainees. Two of these grants provided clinical training (although the emphasis was given to training evaluation researchers of service programs), and the other (just recently funded) provides research training. Together, these programs have supported 14 Hispanic; -- 6 men and 8 women. The programs in which these Hispanic trainess have received stipends and tuition are the following: 56 l) “Training Criminal Justice Planners and Evaluators at the Master's Level,“ University of Texas at El Paso, Texas. The goals of this program, headed by Dr. John Hedderson, was to develop researchers who would be familiar with a wide range of research techniques and who could function as full- time researchers in local criminal justice agencies,as well as crime and delinquency specialists in larger research organizations. The special objective was to train 24 students at the master's level in evaluation and policy research. The training itself included seminars in research methods, statistics, formal organizations, deviancy, and criminology. The trainees engaged in a research practicum in a community service agency and attended special seminars conducted by experienced evaluators. The trainees were expected to complete a thesis and be awarded an M.A. degree in Sociology with an emphasis on evaluation research. A principal intent was to attract a substantial proportion of qualified Hispanic students from the University of Texas at El Paso, where nearly half of the undergraduate population was Hispanic. Four Hispanic men and two Hispanic women received full support in this program. 2) “Applied Research in Deviant Behavior," University of New Mexico, Albuquerque, New Mexico. The purpose of this training program headed by Dr. Philip May was to make academic training in deviance more oriented and relevant to local populations in the Southwest and to criminal justice agency needs; to develop and implement courses and learning materials relevant to the understanding of deviances for the local Hispanic and American Indian populations; and to provide educational opportunities at the master's level for Hispanics and American Indians. New Mexico, the site of the training program, has the highest proportion of Hispanics (372 in l980) of any state in the U.S. A total of l4 students received support in this program. Five of these trainees were Hispanic -- four women and one man. 3) Dr. Philip May also provides leadership for a doctoral program in applied research on deviant behavior. 57 This research training program builds upon the aforementioned program by focusing on a broader range of issues associated with deviant behavior and its regulation and control by official agencies and public action. The three principal objectives are: to provide quality research training to five predoctoral students for three years, with special attention given to minority persons from Hispanic and American Indian back- grounds; to further improve departmental and institutional capacity to develop staff and program capabilities relative to instruction with allied researchers in ”the epidemiology of deviant and antisocial behavior” and ”the deterrence of deviant and antisocial behavior (and violence)”; and to improve state and public agency capability to cope with deviant conduct (especially involving minority populations) by providing a pool of well—trained and qualified minority researchers. Three of the four predoctoral trainees appointed for the forthcoming academic year are Hispanic -- two women and one man. The choice of a career in research rather than the clinical area is one that confronts most minority students. Because of their strong interest in helping their communities through active involvement in service delivery, the majority of ethnic minority students have chosen careers in the clinical area. Promoting research careers among promising young minority students as an alternative that is just as meaningful to the long-range well-being of minority communities as clinical practice is an activity that has very high priority within ADAMHA. 58 NIH EXTRAMURAL RESEARCH TRAINING OPPORTUNITIES FOR HISPANICS DJris H. Merritt, M.D. Research Training and Research Resource Officer National Instituten of Healt The National Institutes of Health (NIH) conduct a large extramural research training program. In the l950's and during the following decade, the purpose of the program was as much to enrich the departmental research environment as it was to support students. Reaching a peak in the l960's, support for the training program dwindled as its critics deplored the use of federal funds for training and especially for the training of physicians, who were perceived to abuse it for purposes of specialty practice rather than for preparation of research careers. As a result of congressional activity, all Public Health Service (PHS) research training was brought under one authority, the National Research Service Award (NRSA) Act of l974. By statute and by regulation, the institu- tional research training grant, once a source of major scientific enhance- ment for institutions, has been severely curtailed in numbers and dol- lars. Although approximately l0,000 individuals are supported under the NRSA each year, the funds are now primarily for trainee support, and institutions may actually lose money and deplete other programs in order to compete for these funds. Unfortunately this new era of curtailment came at a time when the need to provide an enriched research training environment in minority schools and for minority persons was publicly recognized. The neces- sity for action was so stark and the mechanisms for providing institu— tional support so rigid that, in l972, the Division of Research Resources devised a new program known then as the Minority Biomedical Support Grant and now as the Minority Biomedical Research Support Grant (M85). The MBS program was the first of the NIH minority programs to be activated. At that time 38 institutions received grants totaling 52 million. Since its inception, the M85 program has expanded to include several traditional majority institutions with large minority student enrollments and two-year colleges with more than a 50 percent minority student body population. The focus of activity is on support of highly meritorious scientific research projects. In l982, the program funded 77 awards,of which l7 were made to predominantly Hispanic institutions. This amounted to $4,425,554 or l7.9 percent of the available MBS funds. 59 As the Division of Research Resources was beginning to strengthen institutional support for minority sch00ls and minority students, the National Institute of General Medical Sciences (NIGMS), the institute responsible for two—thirds of NIH predoctoral training, was also seeking ways to enrich and improve the research environment of minority institutions. In l975, the minority access to research careers program was established with the MARC Faculty Fellowship and the MARC Visiting Scientist Award. The primary goal of the MARC program was, and remains, to assist minority institutions in the training of greater numbers of minority scientists in the biomedical disciplines and to help strengthen the research and teaching capabilities of these institutions. The faculty fellowship program provides opportunities for advanced research training for selected faculty members of four- year colleges, universities and health professional schools in which student enrollments are drawn substantially from ethnic minority groups. These institutions may nominate faculty members to apply for MARC fellowship support for a period of advanced study and research training in graduate departments and laboratories, either as candidates for the PhD degree, or as investigators obtaining postdoctoral research training in the biomedical sciences. 0f the l76 individuals competing in the Faculty Fellowship program, 90 percent have returned to minority institutions. The MARC Visiting Scientist Award allows outstanding scientist teachers to serve as visiting scientists at four-year colleges, universities and health professional schools which meet the same eligibility criteria as the above. This program is now administered through the Federation of American Societies for Experimental Biology FASEB). The third arm of the MARC program, the Honors Undergraduate Research Training Program, was established in l977 when NIGMS successfully received a waiver from the NRSA guidelines,allowing it to define predoctoral students as students seeking the baccalaureate in minority schools. The program began with 29 awards and in l98l supported 426 students in 89 programs. In l982, $l,4l3,000 out of $5,637,000 or 25 percent of the MARC support went to six institutions with significant numbers of Hispanic students. The newest of the programs to join the MARC series (l98l) is the one offering individual predoctoral fellowships to outstanding graduates of the MARC Honors Undergraduate Program for advanced training toward the terminal degree in biomedical science. Awards are made initially for a period of 2 years and are renewable for at least 2 years. 60 The MARC Honors Undergraduate Program is considered extremely successful. In the last review of the 46 students graduated in FY l979, 48 percent had entered graduate schools and 30 percent professional schools. In l983, it is estimated that ll2 Hispanics are being sup- ported by MARC programs and six students by individual fellowships. Chronologically, the next program designed for minority students was the Minority Hypertension Research Development Summer Program, developed by the National Heart, Lung, and Blood Institute. This program was designed to encourage the recruitment and development of minority investigators in specialized activities related to hyper— tension and to stimulate hypertension research, prevention, control and education by offering minority faculty members and graduate students the opportunity to enhance their research capabilities in these areas. Its special characteristics are: 0 Training is offered at hypertension training centers of excellence,and training takes place usually within a hundred miles from the participating minority schools; 0 Participating faculty or graduate students are nominated by the affiliated minority school and accepted by the training center; and o The funding includes stipends. In fiscal years l982 and l983, ten predominantly Hispanic institu- tions participated in the program. The most recent program for support of minority students at all institutions stems from a presidential initiative to provide a sum- mer apprenticeship experience for minority high school students. At its inception in the summer of l980, the program supported 200 high school students in 4l institutions. In fiscal year l98l, 300 institutions received support; 92, or l4 percent, of the 658 students supported were of Hispanic origin. It should be emphasized that this is the only extramural program that the NIH supports for high school students. There are some special research training programs at the NIH, two of which, while not designed for minorities, do attract minority students: 0 The medical student elective program is the oldest of these, conducted for students who wish to fill their elective requirements at the NIH. No financial support is available. 61 However, for those with relatives in or around the District of Columbia or who have independent means, it can be an extremely exciting experience. The applicants may apply up until March l for appointments beginning in September, January and March of the following year. Medical school transcripts, letters of approval and a recommendation from the Office of the Dean and one instructor must accompany the letter. There are ten clinical areas available: anesthesiology, endocrinology- metabolism, genetics, psychopharmacology, surgical oncology or the use of computers in clinical medicine,to mention a few. During I982 approximately l50 students took advantage of this program. In the summer of l982, the NIH launched a special summer research program. Each medical school was invited to nominate two students for a summer experience at NIH normally after their first or second years. Students receive approximately $2,000 for approximately three months. Of the 60 students supported this year, approximately 20 percent are from minority groups. A very successful program for minority college students has been the one conducted by the National Institute of Allergy and Infectious Diseases (NIAID). Fifty students come to the Institute for a two and a half day program on NIAID's biomedical research activities. Of those 50 students, 20 are invited to return to the NIAID laboratories in Bethesda or Hamilton, Montana, for the summer months. The students are paid at a rate of a GS 3-5 depending on their educational level,and are invited to return for successive years. Since the inception of the program in l979, approximately 20 percent of the students have been of Hispanic heritage. The Extramural Associates Program is designed for research adminis— trators at minority institutions so that they can learn, not only about the National Institutes of Health Extramural Programs, but also become familiar with other agencies in the Washington area Wthh support research activities. This program is funded under the Intergovernmental Personnel Act,which requires that the institutions sending the participants provide 50 percent of their support. It is a five-month experience for up to eight individuals, and two sessions are conducted per year. Graduates of the program return to their institutions with a complete set of reference materials on the NIH and other Federal agencies and gain sufficient understanding of how the NIH operates so that they can serve as an invaluable local resource. Approximatelv 11 of the 63 62 individuals completing the program were nominated by institu- tions serving Hispanic populations. Finaiiy, it is worth noting that the NIH Pubiic Advisory Groups make finai decisions on the support appiications. 0f the 2,249 members in these study sections and counciis, 83 (or 3.7 percent) are of Hispanic origin. 63 HISPANICS IN AGENCY-SPONSORED TRAINING PROGRAMS: A PERSONAL VIEW Maritza CoZdn—Pullano Chemist, Denver District Food and Drug Administration Friends know me as and call me Maritza Colon—PvZZano, but at the Food and Drug Administration headquarters I am known as Maritza the Mid—Level one or,simpZy, as the Mid-LeveZ person. I even get introduced that way. The reason for it is that I am the first Hispanic accepted into the Food and Drug Administration’s Mid—Level Career Development Pr That’s one of the reasons why I was invited to participa: on this panel. J ... 1m». :2 s4 ( Q) The Mid—LeveT Training Program is a 12-month program designed for empioyees at the 63—11, 12 and T3 TeveTs. It offers two options, Management and Scientific, both of which combine interagency work assignments with externaT training opportunities. The management option is designed to deveTop a continuing source of manageriaT taTent within the Food and Drug Administration. The Scientific option is designed for empToyees who wish to sharpen their scientific or technicaT skiiis for persona] deveTopment and to enhance the agency‘s scientific and technicaT capabiiities. This program is of great importance to the agency. It ensures that many of its present employees are prepared to assume new assignments as required by the FDA's human resources needs, or to perform more efficientTy in their present position. The Mid-LeveT program does not guarantee promotion nor new permanent assignments upon compTetion. There have been three Mid-LeveT classes. The first one, in 1974, had fourteen graduates. At that time, the management option was the onTy one avaiTabTe. The agency then became aware of the need to strengthen its scientific resources, to have their scientists understand and participate in the new technoTogicaT revoTution. They saw the need for a science-based reguTatory approach, and the second Mid-LeveT Career DeveTopment Program in 1980 provided both management and scientific options. This cTass consisted of eight students, five of them chose the scientific option. This year there are seven associates,with five in the scientific option I Chose the scientific option. As part of my training, I am doing research at the AnimaT Drug Research Center in Denver, 64 Colorado, as well as learning different immuno assay techniques at the University of Colorado Medical Center. Another training program is the one known as the Long—Term Training Program. This program allows an employee to attend an educational institution as a full—time student for one year. The program is sponsored as a means for employees to acquire knowledge and skills needed to perform their current duties or the anticipated duties of their post training assignment. The data on hand shows that during the past six years a total of 47 employees participated in the Long-Term Training Program. Three of them were Hispanic: Jose Roybal is a research chemist at the Animal Drug Research Center in Denver, Colorado; Ana Maria Placencia is a research microbiologist at the Sterility Research Center in Minneapolis, Minnesota; and Luis Ledesma is a Long-Term Training Program Associate. He is a Consumer Safety Officer in the Dallas District and his courses in Biomedical Engineering will be completed in May l984. Another special training program was the Stride Program, now known as COTA, or the Career Opportunities Training Agreement. A formal program designed to provide GS-l to 9 employees with op- portunities for career advancement, Stride was a competitive program which identified a target position in the professional series and allowed the selected individual to obtain the training and experience needed to qualify for the position. The interns attended a college or university for up to twenty hours each week and then received on- the-job training for the remainder of the week. The main difference between the Career Opportunities Training Agreement and Stride is that employees from GS—i to 15 are now eligible for COTA. The training is composed of on—the.job assignments and, whenever appropriate, formal educational experience. STRIDE data for thepast l3 years shows that 4l interns were selected for the program, with no Hispanics among them. Working in the field, although not in the Stride program, there is one Hispanic who started as a laboratory aide, and is now a research microbiologist at the Animal Drug Research Center in Denver, Colorado. There are within FDA seven field research centers, each located within a district regulatory laboratory and near a University. These centers are: 0 Elemental Analysis Research Center in Cincinnati, Ohio, which develops new methods for detecting metals in foods, animal feed, tissue products and pharmaceutical preparations; 65 0 Total Diet Research Center in Kansas City, Missouri, which develops methodology that will facilitate and Support the analysis of the new “total diet” market basket surveys for chemical contamination; 0 Animal Drugs Research Center in Denver, Colorado, which is responsible for the development of analytical procedures to isolate, identify and quantify parent compounds and metabolitES in animal tissues and feeds; 0 Mycotoxin and Natural Poison Research Center in New Orleans, which is responsible for the development of methodology for the isola— tion and characterization of new natural toxicants, with prime emphasis on naturally occurring poisons. o Pesticide and Industrial Chemical Research Center in Detroit, Michigan, which develops both quantitative and qualitative methodology for new pesticides and industrial chemicals in human and animal foods; 0 Sterility Research Center in Minneapolis, Minnesota, which develops new and improved methods for the analysis of sterile drugs and medical devices; and 0 Seafood Product Research Center in Seattle, Washington, which develops analytical methods designed to detect environmental and natural toxic materials and determines the quality of both fresh and salt water seafood products. Each research center has four staff scientists,and there are four Hispanic scientists among them—-two in Denver, one in Seattle and one in Minneapolis. The data from FDA final districts show that of the 53 employees doing in—house research, five are Hispanic. Of 265 employees in scientific-oriented training programs (details, courses, etc.) 25 were Hispanics. There are also a few scientific—oriented extramural training programs, among them. the Co-op Program, the Summer Aid Program, the Junior Fellowship Program, and post doctoral fellowships. The data show that out of 50 students, 10 have been Hispanics. As a result of meetings between key agency officials and the leadership of organizations such as the Society for the Advancement of Chicanos and Native Americans in Science (SACNAS), the FDA has 66 begun a coordinated effort to identify and place Hispanic scientists in the Agency'sfellowship programs, an effort that will undoubtedly result in a greater level of participation by His anics in the important work that is performed by the Food and rug Administration in safeguarding the health of all Americans. 67 APPENDIX PROGRAM Tuesday, September I3, I983 9:00 am. OPENING CEREMONY Mistress of Ceremonies: Ruth Sanchez-Dirks, PhD. Associate Deputy Director OEEO, PHS 9:05 am: INTRODUCTION OF AGENCY OFFICIALS Wilford J. Forbush Deputy Assistant Secretary for Health Operations and Director, Office of Management, PHS 9: IO am. INTRODUCTORY REMARKS Robert U. Hernandez President, Public Health Service Hispanic Employee Organization and, Chief, Personnel Operations, ADAMHA 9:I5 a.m. WELCOMING REMARKS Faye Abdellah, RN, Ed,D:, Sc.D, Deputy Surgeon General US. Public Health Service Introduced by: Marco Montoya, PhD. Health Scientist Officer National Center for Drugs and Biologics, FDA 9:30 am: "HISPANICS AND HEALTH RESEARCH" Keynote Speaker: Ismael Almodovar, PhD. President, University of Puerto Rico Introduced by: Magdalena Miranda Chief, International Medical Education Programs Branch, Bureau of Health Professions, HRSA 10:00 am. BREAK lO:I5 a.m. “THE HISPANIC HEALTH AND NUTRITION EXAMINATION SURVEY” Speaker: Fernando Trevino, PhD. Social Science Analyst National Center for Health Statistics, OASH Introduced by: Marta Sotomayor, PhD: Executive Secretary, Office of Extramural Protect Review National Institutes of Mental Health, ADAMHA I 1:30 am. LUNCH 68 12:30 pm "STATUS OF BIOMEDICAL/EHDEMIOLOGICAL AND RELATED RESEARCH" Panelists: Victor J. Ferrans, M.D., PhD. CHAIRPERSON Chief, Ultrastructure Section Pathology Branch Heart, Lung and Blood Institute, NIH Leroy Gomez District Director, Denver District FDA Vince Hutchins, MD. Director, Division of Maternal and Child Health HRSA John Marshall, Ph.D. Director, National Center for Health Services Research OASH Manuel Ramirez, PhD. Professor, Department of Psychology University at Texas Austin, Texas Dennis Tolsma Acting Director Center for Health Promotion and Education, CDC 2:00 p.m. BREAK 2zl5 p.m_ “HISPANICS IN BIOMEDICAL, EPIDEMIOLOGICAL AND RELATED RESEARCH TRAINING PROGRAMS” Panelists: Doris H. Merritt, M.Di Research Training and Research Resource Officer National Institutes of Health Delores Parron, PhD. Associate Director for Minority Concerns National Institute for Mental Health, ADAMHA Maritza Pullano Chemist, Denver District FDA Dennis Tolsma Act. Diri, Ctr, for Health Promotion & Education, CDC 3:30 pm. AWARDS PRESENTATION Presenter: Robert U. Hernandez 3:45 pm. 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