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5 The National Center on Minority Health and Health Disparities T he origins of the National Center on Minority Health and Health Dispari- ties (NCMHD) can be traced back to the 1990 creation of the Office of Research on Minority Health (ORMH) within the Office of the Director of the National Institutes of Health (NIH). This office emerged from the strong interest among Congress and the community in seeing NIH focus on research on minority health and health disparities. The office was expected to stimulate and coordinate research programs by NIH ICs. During the existence of ORMH, re- sources were allocated from the appropriation of NIH's Office of the Director. In November 2000, P.L. 106-525 established NCMHD. Dr. John Ruffin was named acting director, a position he held until 2001, at which time he was sworn in as the first director of NCMHD. NCMHD plays two key roles within the NIH minority health and health disparities program and Strategic Plan. First, as a newly created center, NCMHD oversees extensive funding programs directed at research infrastructure and ca- pacity, including institutional endowment awards, the Centers of Excellence Pro- gram, and the Loan Repayment Programs. Second, in an unusual role for an NIH center, NCMHD has the responsibility for coordinating minority health and health disparities research and the Strategic Plan across NIH. THE NCMHD AS A CENTER NCMHD administers three programs mandated by the legislation: the Cen- ters of Excellence (Project EXPORT) Program, the Research Endowment Pro- gram, and the Loan Repayment Program. 72

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THE NATIONAL CENTER ON MINORITY HEALTH AND HEALTH DISPARITIES 73 Centers of Excellence (Project EXPORT) NCMHD's Centers of Excellence Program supports the training of research- ers from minority and health disparity populations and the construction of facili- ties for conducting health disparities research at minority and majority academic institutions and organizations. Priority research focus areas include cancer, car- diovascular disease, stroke, diabetes, and the health of mothers and their infants. Eligibility to compete for the awards is determined by the size of an institution or consortium's student population from minority health disparities groups and evi- dence of its commitment to recruit, retain, and graduate minority students from its educational programs (NCMHD, 2005a). In Fiscal Year (FY) 2005, 74 Centers of Excellence were being supported in 29 states and the District of Columbia, Puerto Rico, and the U.S. Virgin Islands (see Appendix J). Research Endowment Program This program is designed to compensate for past educational and financial policies that had a disparate impact on the ability of schools serving racial and ethnic minority and low-income students by providing support for program de- velopment, making capital improvements, and access to emerging technology (NCMHD, 2005c). The endowments are awarded according to a formula based on the size of the school's corporate endowment and its status as a currently funded Section 736 institution. (Section 736 of the Public Health Service Act refers to health professions institutions and graduate programs with enrollments of underrepresented minorities that exceed the national average for such institu- tions.) The endowments can be broadly used to support infrastructure for both research and training. The distinction between the goals of the Research Endowment Program and those of the Centers of Excellence Program is not readily apparent. However, in its FY 2006 budget justification, NCMHD states that it "will continue to explore opportunities where this program can be linked to the Centers of Excellence" (Ruffin, 2005). In FY 2005, 11 institutions received Research Endowment fund- ing (see Appendix K). Loan Repayment Programs This important program seeks to alleviate the financial barriers that may discourage health professionals from minority and underserved communities from pursing a research career. NCMHD has established two distinct programs: the Health Disparities Research Loan Repayment Program and the Extramural Clini- cal Research Loan Repayment Program for Individuals from Disadvantaged Backgrounds. Both programs repay up to $35,000 per year for education loan

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74 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH debts in exchange for a commitment to conduct at least 2 years of basic, clinical, or behavioral research (NCMHD, 2005b). The goal of the Health Disparities Research Loan Repayment Program is to attract interest in research careers that focus on minority health disparities re- search or research related to the medically underserved. As a means of building the diversity of the biomedical workforce, and in keeping with P.L. 106-525, 50 percent of the awards are made to individuals from health disparity populations. The Extramural Clinical Research Loan Repayment Program for Individuals from Disadvantaged Backgrounds is designed to attract health professionals from low-income families into clinical research (including, but not limited to, health disparities research). In FY 2001, there were just 32 Loan Repayment Awards, but the number increased almost 10-fold to 304 awards in FY 2004 (Figure 5-1). The total num- ber of awards going to both underrepresented minorities and to nonminorities conducting health disparities research increased from 2001 to 2004. Since 2001, NCMHD has distributed 625 Loan Repayment Awards, or ap- proximately 75 percent of the total awarded. The distribution among other Insti- tutes and Centers (ICs) is seen in Figure 5-2. 350 $16.0 $13.6 mil 300 $14.0 $12.0 250 $12.2 mil $10.0 Awards 200 LR of $8.0 Awarded 150 millions) (in $6.0 Dollars Number 100 $4.0 $1.7 mil 50 $2.0 81% 77% 70% 75% 0 FY2001 FY2002 FY2003 FY2004 Nonminority Awardees Minority Awardees Current Dollars 2001 Constant Dollars FIGURE 5-1 Total NIH Loan Repayment Awards distributed for Fiscal Years 2001 2004 and total award amount for disparities research. SOURCE: Powe and Yeung, 2005.

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THE NATIONAL CENTER ON MINORITY HEALTH AND HEALTH DISPARITIES 75 208 200 Awards 150 Repayment 100 Loan of 50 Number 19 16 13 8 7 6 6 6 5 5 3 1 1 0 NCI NEI NIA FIC NIMH NICHDNHLBI NIDA NIDDK NCRR NIAID NIDCD NIGMS NCMHD FIGURE 5-2 Loan Repayment Awards for minority health research in Fiscal Year 2004. Acronyms: see Appendix I. SOURCE: Powe and Yeung, 2005. Research Capacity Building The goal of this program is to develop a cadre of researchers who will contribute to reducing and eliminating health disparities. Two specific programs are in place to meet this objective: the Research Infrastructure in Minority Insti- tutions (RIMI) Program and the Minority Health and Health Disparities Interna- tional Research Training (MHIRT) Program. The NCMHD RIMI Program originally developed as a partnership between the NIH National Center for Research Resources and ORMH. RIMI's primary goal is to strengthen the integration of teaching and research at predominantly minority-serving academic institutions, through support of faculty training, espe- cially as it relates to research in areas that address the elimination of health disparities, student training, educational experiences that will encourage students and faculty to conduct health disparities research, and academic infrastructure. The MHIRT Program, formerly the Minority International Research Train- ing Program, provides opportunities for approximately 300 U.S. minority under- graduate, graduate, and medical students to gain 10 to 12 weeks of research experience abroad each year. The program is managed by NCMHD, but the NIH's Fogarty International Center provides co-funding and program staff sup- port for the international aspects of the supported programs. Research efforts

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76 EXAMINING THE HEALTH DISPARITIES RESEARCH PLAN OF THE NIH include cancer epidemiology, reproductive biology, parasitology, malaria, ethno- pharmacology, and neurobiology. Community-Based Research and Outreach NCMHD recently established an Office of Community-Based Participatory Research and Outreach, which launched a new program that will support collabo- rative partnerships between academic institutions and community-based organi- zations. These partnerships will support several activities, including: (a) research studies examining the interface of physical and psychological environments and their health impacts on communities of color and the medically underserved, (b) methodological research looking at effective methods of measuring racism and community-level outcomes, (c) the evaluation of outcomes, and (d) research impact. This program is intended to build on NCMHD's existing community- based research and outreach initiatives through its Project EXPORT program (Ruffin, 2005). Collaborations with Other ICs In addition to the core programs described above, NCMHD co-funds a num- ber of collaborations with NIH's other ICs. NCMHD reports that over the last 3 years, it has provided roughly $180 million to support more than 500 collabora- tive projects, thus representing an average NCMHD contribution of $360,000 per project (Ruffin, 2005). RESPONSIBILITIES FOR THE MINORITY HEALTH AND HEALTH DISPARITIES RESEARCH PROGRAM AND THE STRATEGIC PLAN NCMHD has responsibilities for the NIH-wide minority health and health disparities research program and the Strategic Plan. The extent and definition of the responsibilities, and the nature of the authority that manages the responsibili- ties, are important organizational questions and issues (see Chapter 6). NCMHD currently functions in a de facto manner, with the responsibilities treated as mandates. Resources and Capacity of the NCMHD Given its dual missions as a grant-making center and as an apparent coordi- nator and manager of the trans-NIH minority health and health disparities pro- gram and the Strategic Plan, NCMHD considers its financial base and staffing resources to be inadequate. Although NCMHD's budget and staffing have in- creased since its creation, its leadership and Advisory Council still regard these

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THE NATIONAL CENTER ON MINORITY HEALTH AND HEALTH DISPARITIES 77 resources as inadequate for managing the dual responsibilities with which NCMHD has been tasked (Kane, 2004; Ruffin, 2004; Sullivan, 2004). Science Leadership and Presence Within the NCMHD A critical need for the coordination and management of the minority health and health disparities research program and the Strategic Plan involves the pres- ence of distinguished science leadership and expertise in minority health and health disparities within, and available to, NCMHD for the trans-NIH research program and the Strategic Plan. Such leadership and presence is important for advice about and assistance with the planning, coordination, monitoring, assess- ment, and meaningful articulation of health disparities research issues with the ICs, as well as with other agencies and the nation's relevant science community. This broad and challenging need can be satisfied by the presence of eminent science leadership within NCMHD, and, importantly, by assembling and having access to expertise from across NIH and from the scientific, provider, and other relevant communities. This may be accomplished by including these individuals in committees and panels, either standing or ad hoc, to contribute to the science base, presence, and resources of NCMHD, the ICs, and other agencies. Findings: The dual roles of NCMHD as a granting center and as a coordinator of major trans-NIH efforts are unique. The leadership of NCMHD and its Advisory Council call attention to the need for increased administrative staffing for NCMHD. There is a need for increased science leadership and presence in NCMHD, particularly for proper management of the trans-NIH initiative. Recommendation 9: The NIH director should review and assess the administrative staff- ing of NCMHD to ensure that it is sufficient to attend to the Center's responsibilities. Increasing the science leadership and presence within NCMHD should be pursued by the NIH and NCMHD directors. This entails the appointment of additional eminent scientists, recognized in the areas of minority health and health disparities, and the establish- ment by NCMHD of committees and panels with relevant exper- tise from within and outside NIH.