Through the Kaleidoscope: Viewing the Contributions of the Behavioral and Social Sciences to Health -- The Barbara and Jerome Grossman Symposium (2002)

Lynda A. Anderson

Centers for Disease Control and Prevention

“As the Centers for Disease Control and Prevention (CDC) has expanded the scope of its prevention research,” Dr. Anderson began, “it has recognized the contributions of the behavioral and social sciences.” This important symposium, she thus noted, “will contribute to CDC’s continued commitment to prevention research.”

Her remarks today, Dr. Anderson said, would focus on two pertinent CDC activities: the Behavioral and Social Science Working Group (BSSWG) and the Prevention Research Centers (PRC) Program.

“Like this symposium,” she said, “the BSSWG facilitates communication, collaboration, and partnerships among CDC’s social and behavioral scientists.” Such agencies “tend to be organized around diseases rather than behavioral issues,” she noted, but “since I joined CDC 10 years ago, I have observed a substantial increase in its [more broadly based] behavioral and social research.”

BSSWG’s membership has grown to more than 200, Dr. Anderson observed, but it’s clear, “as indicated by several of [this symposium’s] featured speakers, that “a major challenge to behavioral and social scientists is acquiring an understanding of other disciplines’ vocabularies while keeping up-to-date in their own fields. This challenge is of particular importance to

population-based health research, which is influenced by a wide range of disciplines.”

The PRC Program, she said, provides one of several types of extramural prevention research funds available through CDC. It “is designed to connect science and public health practice and to improve health promotion and disease prevention efforts” in four ways by:

• focusing on high-priority public health issues;

• conducting rigorous, community-based prevention research with outcomes applicable to public health programs and policies;

• enhancing community partnerships; and

• bridging gaps between scientific knowledge and public health practices.

The PRC Program, Dr. Anderson noted, has grown since 1986, and presently supports 24*PRCs across the United States at schools of public health, medicine, or osteopathy that have accredited preventive medicine residencies. These PRCs, she said, “serve as a national resource for developing prevention strategies and applying those strategies at the community level.” For example, PRC investigators in South Carolina, having identified physical activity as a key issue, are “working collaboratively with a community coalition to include physical activity promotion in its strategic plan.” They are also helping the coalition expand and connect a number of walking/biking trials.

“One special feature of the PRC program is community participation” in community-based research, Dr. Anderson said, “although it has taken time for trusting relationships to develop between the PRCs and their community partners” across the nation. “Even regarding methodologies of doing research within communities, we need to understand the process of learning from the community as well as doing research with the community.”

Another priority for the PRC Program is to facilitate the application of research findings, she said. “Because insufficient transnational research has been done in the past, CDC is working with several PRCs to understand what contributes to the uptake of research results and to establish new

demonstration projects to examine what works in practice. Some of the concepts derive from CDC’s prior work on prevention strategies in HIV/ AIDS.”

Finally, Dr. Anderson noted, the PRC Program is actively seeking useful feedback. It is “creating an evaluation process, with help from a large independent consulting firm, [to] clarify how to judge the merit, worth, and significance” of the program. “We will use this information to improve our operations and to provide a basis for accountability. We want to define what we expect of the PRCs over the next five years and then set up evaluation strategies to ensure we are meeting these goals.”

J. Michael McGinnis

Robert Wood Johnson Foundation

“My dominant impression of today’s session,” Dr. McGinnis said, “is that its aggregate implications may be profound for the way we develop our strategies for improving health.” There is clearly the need for a “paradigm shift” in our understanding of the determinants of health and in the ways we act on them.

He then discussed four issues in particular that he thought were raised by the symposium’s discussions: a new vocabulary, the challenges it implies for the research endeavor, the challenges in the conduct of research, and the relevant charges to philanthropy in general and to the Robert Wood Johnson Foundation in particular.

New vocabulary. “What we have heard today are terms like social gradients, psychosocial variables, perceived stress, gene-environment interactions, collective efficacy, system cross-talk, allostasis, aggregate burden, resilience, positive health, and salubrious factors,” Dr. McGinnis pointed out. These terms have not heretofore been common to the biomedical sciences, but they are “most fundamental to the health of populations.”

Challenges for research. “If we think of our health determinants in terms of the primary domains of influence—genetic and biological predisposition, social circumstances, environmental exposures, behavioral choices, and access to medical care,” he said, “it is very clear that we have not only an obligation to understand to the fullest the within-domain influences that act in each of those areas but, more importantly, the cross-domain influences. That is where the action is.”

Conduct of research. Activities that are “born of essentially reduc-

tionist concepts,” Dr. McGinnis said, are “doomed to reductionist applications. We simply can’t be that narrow-minded in the way we structure our priorities and our activities.” Instead, “our designs have to begin with concepts that are fundamentally integrative in nature.” He then discussed six implications of this new reality for the conduct of research—for “the way we go about our business.” They are: how the research enterprise should be organized, the time horizons involved, the methodologies, the capacity to sponsor research, the review processes, and the translation of results.

Organization. We “need to organize at least a part of our research endeavor not around single laboratories but around multiple disciplines, . . . in a fashion that allows new insights with a broader view,” Dr. McGinnis said.

Time horizons. Similarly, he noted, we must avoid “the limited perspective of myopic lenses,” instead adopting time horizons that “extend as far into the future as we can responsibly, reliably, and validly structure.”

Methodologies. We need new analytic models to incorporate the multidisciplinary perspectives of researchers.

Capacity. “We clearly need to have a research community,” Dr. McGinnis said, “whose comfort level for dealing in a complex environment is higher than the comfort level of most of our research community to date.”

Review process. “We need, in effect, a new set of standards [that] is more generous to alien concepts and approaches.”

Translation. “Fundamentally, the public is programmed to focus on single diseases and to [employ] the same kind of reductionist model that orients our research community,” Dr. McGinnis said. Thus translating the importance of the broader perspectives of interdisciplinary research “has to be very high on our priority list as we look to the future.”

Implications for philanthropy. To complement the major funders— largely in the federal government—of research, the philanthropic community has three basic roles: “gap filling (that is, doing what others don’t); leveraging (making it easier for others to do what they want to do); and risk (stepping into arenas that are either politically sensitive or seemingly intractable, or for which the frontiers are ill defined),” Dr. McGinnis said.

He mentioned a few projects in this spirit—and “as testimony to the fact that we are committed to working with you in trying to [cultivate] this new ground”—that the Robert Wood Johnson Foundation currently has under way:

• To complement its risk factor orientation but not to abandon it (“we understand quite clearly the importance of some of the risk factors, whether it is tobacco or alcohol or illegal drugs, or certain others with clear and present impact”), the foundation has “added foci on community health—in particular, on the issues of social isolation and social connectedness—and on population health.”

• The foundation is developing a new program of Scholars in Health and Society, “which we hope will deepen the instincts and heighten the comfort level of people for interdisciplinary activity,” Dr. McGinnis said. It will parallel Robert Wood Johnson’s (RWJ’s) established clinical scholars program.

• “Taking a cue from our colleagues at the MacArthur Foundation, and hoping to partner with those colleagues, we will be forming a research network around the issues of social isolation and social connectedness” to focus on the basic mechanisms involved and on the translation of research insights into practical applications.

• “To jumpstart that activity, we will be developing a fairly significant community-oriented research program to try methods, in different ways [and] in different settings, for better engaging those who are most estranged in our society—both to improve their lives and, just as importantly, to learn what kinds of techniques might work.”

• “We are committed to expanding our investment in methodologies that can be used for drawing from these interdisciplinary activities.”

• “And we will be working again with partners on . . . marshaling the social support for a strong and sustained effort in these areas,” he said.

“There are clearly different roles for those of us who come at the funding responsibility from different perspectives,” Dr. McGinnis concluded. “But common is the obligation to challenge our assumptions about the way we do business. These six reports [of the NRC and IOM that inspired today’s session] will be tremendously helpful in that respect, and I give thanks to each of you who played a part in making that happen.”

Judy Vaitukaitis

National Institutes of Health

Dr. Vaitukaitis, who is director of the National Center for Research Resources (NCRR), explained that its job is to work with the 26 other components of National Institutes of Health (NIH) to provide “infrastruc-

ture” such as technology, shared resources, and biorepositories. “Our responsibility,” she said, “is to catalyze research by defining ‘rate-limiting reactions’—steps in the disciplinary research process that limit progress.” And although her center serves the entire mission of the National Institutes of Health, Dr. Vaitukaitis’s remarks at the symposium concentrated on behavioral research.

Program research support is provided competitively through four NCRR divisions: clinical research, biomedical technology, comparative medicine, and research infrastructure. The Division of Clinical Research is the primary source for behavioral studies and accounts for about two-thirds of NCRR’s support in this area: in FY 2001, the division provided approximately $58 million to host behavioral research and that level is estimated to grow to $66 million for the next fiscal year, she said.

The major programs through which NCRR supports behavioral research are the general clinical research centers, approximately 65 biomedical research technology centers, regional primate research centers, and a program for shared instrumentation.

A national network of 80 general clinical research centers (which conduct both inpatient and outpatient research) provides biostatistical support to investigators. The Division of Comparative Medicine supplies animal models of human disease for research. Through the Division of Research Infrastructure, NCRR provides competing grant awards, ranging from $500,000 to $3 million, for the following purposes: building or renovating research laboratories; enhancing the biomedical-research capacity of minority institutions that award Ph.D.s in the health-related disciplines; and supporting eligible institutions in states that receive less than 5 to 7 percent of NIH’s grant awards per year.

Examples of clinical research studies “include those on nutrition, exercise, sleep, lifestyle changes, compliance with treatment regimens, and behavioral aspects of unintended pregnancies and transmission of sexually transmitted diseases,” Dr. Vaitukaitis said. “We provide the research nurses, the biostatisticians, the specialized laboratories, at no cost to the investigator or to the research subject.” (She reminded the audience that NCRR’s support is limited to infrastructural resources; “the other parts of NIH— the categoric, or disease-of-the-week institutes—provide the primary research funding to the investigators.”)

Clinical research studies “can be carried out longitudinally for long periods of time,” Dr. Vaitukaitis observed. “We have many centers that have been in place for more than 30 years, so we match up with the need

for longitudinal studies and can probably cut your costs where you use some of these resources.”

NCRR also provides access to imaging technologies—“bio-informatics”—and it is in the process of setting up bioinformatics regional centers. “Hearing comments today, it sounds as if you would be good candidates,” she said. A consensus derived from the six NRC and IOM reports “would be very helpful to us in moving forward with those bioinformatics resources and being responsive to your needs as well.”

Also with respect to imaging research, NCRR is in the process of building a pilot test bed, known as the Biomedical Informatics Network (BIRN), she said, in collaboration with the National Science Foundation, the San Diego Supercomputer Center, and several universities. The BIRN will initially concentrate on neuroscience studies that generate large data objects and host very large databases; this is expected to challenge the network and help drive the development of tools to facilitate sharing of data and its analysis.

“That approach will facilitate the kind of research that some of you have talked about—putting data into a national database so that investigators can access it to do their own research,” Dr. Vaitukaitis said. “After getting the bugs out of the system and some sense of what it is going to cost, we will distribute it to the entire country so that any behavioral, biomedical, or basic-science investigators supported by other federal agencies or the private sector would be able to have access.”

With regard to animal models, “mouse models for a variety of diseases and genetic modifications are available” from NCRR, she said. “We support Jackson Labs and have recently started a national network of Jackson Labs, if you will, for this purpose.”

She also noted that NCRR is in the process of working with NIH’s Genome Institute to develop the rhesus monkey as a model for polygenic disorders. “The technology to be developed over the next couple of years is intended to examine risk factors, such as drugs or environmental exposures, that modulate gene function. The nonhuman primate can also be used for studying neurodegenerative and other diseases.”

The resources described above are just a sample of NCRR’s repertoire, selected to address some of the research needs relevant to this symposium, Dr. Vaitukaitis said. They are merely the tip of the iceberg.

“The president’s budget request for NCRR is just under a billion dollars. NCRR’s role is to be a catalyst for discovery—to find out what researchers’ needs are and then to set priorities with the collective community to address the most pressing needs first.”