The Science of Eliminating Health Disparities: Summary and Analysis of the NIH Summit Recommendations

Abstract

In December 2008, the National Institutes of Health (NIH) sponsored the first NIH Summit showcasing its investment and contribution to health disparities research and unveiling a framework for moving this important field forward.

The Summit, titled “The Science of Eliminating Health Disparities,” drew on extensive experience of experts leading health disparities research transformation in diverse fields. The Summit also provided a historic educational opportunity to contribute to health care reform. The theme, addressing disparities through integration of science, practice, and policy, introduced a paradigm for advancing research through transformational, translational, and transdisciplinary research.

Engaging active participation throughout the Summit generated recommendations bridging science, practice, and policy, including action on social determinants of health, community engagement, broad partnerships, capacity-building, and media outreach.

A REPORT ON THE ECONOMIC burden of health disparities in the United States, commissioned by the Joint Center for Economic and Political Studies, revealed that between the year 2003 and 2006, an estimated 30.6% of direct medical care expenditures for African Americans, Asian Americans, and Hispanics were excess costs caused by health inequalities.¹ The same study revealed that the combined costs of health inequalities and premature deaths in the United States in that same time period rose to 1.24 trillion dollars. Today, premature loss of life, increased burden of disease, and inadequate access to quality health care, endured by health disparity populations and working people in general, continues to pervade the health care system.² These same events will continue to spiral and take place tomorrow, and the next decade, if health disparities continue to persist.

This moral imperative of addressing health disparities has triggered an extraordinary national and global response from national governments, private philanthropies, faith and community organizations, and individuals. Federal agencies joined the battle in earnest on the basis of a compelling social justice argument when the Institute of Medicine's Report on Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care was released. Subsequently, growing commitments for health reform—with a focus on affordable, cost-effective, and quality care—provided renewed momentum to address health disparities. Along the same lines, the overwhelming research on the powerful influence of the social determinants of health provided a breakthrough for transdisciplinary research and innovation for science, practice, and policy.

The quest to tackle and eliminate health disparities has no historical model to guide national and global efforts. It requires a transformational change in the way we are currently addressing the issue. It also requires leadership and commitment at the federal level. The Minority Health and Health Disparities Research and Education Act of 2000,³ which established the National Center on Minority and Health Disparities (NCMHD) at the National Institutes of Health (NIH), provided a clear mandate of leading and coordinating biomedical research on minority health and health disparities. The Congressional Act charged the NCMHD with conducting and supporting research, training, and dissemination of information related to health disparities. The legislation also charged the NCMHD with leading the development of the NIH-wide Strategic Plan for eliminating health disparities. A primary goal was to ensure that the health disparities research activities of the NIH were being conducted as an integrated and comprehensive field of study. In collaboration with the other NIH institutes and centers, the NCMHD coordinates the NIH strategic plan to assess, track, and monitor results of the agency's efforts on minority health and health disparities research.⁴ The NCMHD also plays a lead role in the collaborative efforts with the other federal agencies to develop an integrated cross-disciplinary national research agenda on health disparities.⁵

Eliminating health disparities remains a monumental challenge. Creating and sustaining improved health outcomes for vulnerable populations demands community engagement, cross-disciplinary research, modern infrastructure, and visionary policies. The campaign to eliminate health disparities will require commitment to wage a battle well beyond the NIH. In light of the Institute of Medicine report, Examining the Health Disparities Research Plan of the National Institutes of Health: Unfinished Business,⁶ which called for increased oversight and coordination of health disparities research efforts, the NCMHD carried out its charge for organizing the summit with intensity, momentum, and a sense of mission.

The organizing principles were based on the concept that innovative research addressing health disparities needs to address the frequently distinct fields of science, practice, and policy. The Summit subsequently introduced the framework of Science, Policy, and Practice as an overarching, organizational construct to shape future research. The rationale for adopting this framework was as follows:

• Science. Science is a continuing effort of discovery, awareness, and application of findings. Applied health disparities science is essential for conveying new knowledge about determinants of health disparities, disease progression, and outcomes in different subgroups. It is also important for identifying and understanding risk factors for health disparity diseases and conditions.

• Practice. The goal of scientific knowledge pertinent to health disparities is practice improvement, e.g., the application of best evidence, and translation of scientific findings to close the disparity gap. To that end, it is essential to include practice considerations in disparities research. What is the evidence and what are the skills necessary to address disparities in public health interventions and health care delivery? Achieving in-depth background knowledge, diagnostic expertise, and effective critical appraisal skills is essential to ensure the best care for the appropriate patient, subgroup, or population. The lessons learned from science must be applied to improve public health practice and health care.

• Policy. The term policy as used here refers to the course of action, system of interventions (such as laws, measures, or funding priorities) adopted by entities, including governments, with regard to science or practice issues. Policy intervention needs to be a key component of the research aimed at eliminating health disparities. Science drives policy discussion, formulation, and implementation as it provides the needed evidence for the examination of legislation, regulations, and standards of practice that are equally integral and important in eliminating health disparities at the local, regional, national, and global levels.

In this article, we summarize the research recommendations and conclusions reached by participants at the Summit. The recommendations and conclusions are meant to stimulate further discussion, debate, and action on integrating health disparities science, practice, and policy.

Summit organizers encouraged researchers, scientists, practitioners, and policy experts to consider current scientific advances, gaps, and opportunities and provide recommendations that bridge science, practice, and policy. The 3 questions posed of speakers included the following:

• Bridging practice, policy, and science. Based on the analysis of recommendations from the summit, what areas of research should the NIH focus on to best advance health disparities research and to achieve domestic and global health equity?

• Research gaps within health disparity populations. What are the current gaps in health disparities research on health disparity populations and communities that the NIH could support and guide collaborations toward eliminating health disparities?

• Innovative opportunities for capacity-building and collaborations. What are the aspects of health disparities research that can benefit from partnerships and collaborations? What are the key strategies and innovative opportunities for research, training, and capacity-building?

SUMMIT STRUCTURE

The Summit was held in December 2008 at the Gaylord Resort and Convention Center in National Harbor, Maryland. It was attended by over 4400 people representing all 50 US states; US territories; Washington, DC; and more than 10 countries. Summit activities consisted of 3 multitopic plenary sessions within 4 breakout tracks totaling 100 speaker panels, 328 poster presentations, and numerous exhibitors.

Plenary Session Discussion Summary

The Summit began with introductory remarks from the NCMHD Director, John Ruffin, PhD, a health disparities retrospective from the NIH Acting Director Raynard Kington, MD, PhD, and inspirational remarks from Maya Angelou. Each of the 3 days featured well-respected keynote speakers including Governor Howard Dean, MD (Dem-VT), and Congressman Elijah Cummings (Dem-MD) from government, and industry leaders Evelyn Lewis, MD, MA, of Pfizer and Kenneth Moritsugu, MD, MPH, former Deputy Surgeon General, from Johnson & Johnson.

Plenary sessions were comprised of moderated panel discussions which highlighted the transdisciplinary requirements and organizational overlaps between research, policy, economics, culture, media, and industry that are required to effectively create sustainable partnerships and solutions.

The plenary discussions led to the following general conclusions: health disparities research should focus on social determinants of health, research needs to be collaborative and needs to promote community engagement, research should promote effective and sustainable partnership models, research should promote infrastructure and capacity-building for health disparities research, and media outreach and communication is an essential component of dissemination of research findings.

Health disparities research should focus on social determinants of health.

Biomedical research remains foundational to the understanding of disease conditions and biological responses in racial and ethnic minorities, low-income populations, and medically underserved communities. However, with the increasing wealth of evidence on the social determinants of health, health disparities research needs to include the social, cultural, economic, and political context that influence disease risk and health outcomes. Even when the social determinants are assessed, evaluation tends to be focused on 1 aspect (such as poverty, education, discrimination, stress, or health literacy) rather than on interacting complex processes. Therefore, research on the social determinants of health should strive to address the multiple determinants and social context of the individual, community, or population.

Research needs to be collaborative and promote community engagement.

Community members bring an essential understanding, expertise, and trust to the realm of research. The paradigm of community engagement needs to encourage bidirectional understanding and equal partnership. It should involve community members at all levels of research (from development to dissemination) and should provide access to resources, funding, and decision making in a manner that represents true partnership.

Research should promote effective and sustainable partnership models.

Effective partnership models are important for creating sustainable health disparities outreach and dissemination efforts. Partnerships that serve as critical models include those which involve complementary, cross-sectoral participation from government, nonprofit, research, corporate, faith-based, and community organizations. The causes and impacts of health disparities transcend health care and require coordinated efforts across federal, state, and local agencies.

Research should promote infrastructure and capacity-building for health disparities research.

Focus on building infrastructure is needed, along with an optimal pipeline of researchers that promotes mentoring, promotes career development, and creates a diverse workforce. Cultural sensitivity and inclusion should continue to be of utmost importance across the spectrum of knowledge translation and dissemination into practice and policy efforts.

Media outreach and communication is an essential component of dissemination of research findings.

Timely, free-flowing communication across all disciplines is vital to providing current, accurate information. Mainstream media is a critical conduit of information that can shift critical perceptions impacting health care. This includes whether the science findings are accepted by the general public or the knowledge is put into action.

Summary and Analysis of Breakout Session Tracks

The breakout sessions provided a unique opportunity to discuss a variety of health disparity research topics. The 5 distinct tracks and session topics are provided in Table 1. In each session, participants were encouraged to examine conceptual challenges and current research methods. Each session topic challenged participants to broaden traditional concepts for understanding health disparities from distinct fields integrating a multilevel perspective at the intersections of science, practice, and policy.

TABLE 1.

Breakout Session Tracks: The Science of Eliminating Health Disparities Summit, National Harbor, MD: 2008

Track 1: Translating Science to Practice and Policy	Track 2: Health Disparity Diseases and Conditions	Track 3: Health Disparity Target Populations	Track 4: Building Capacitya	Track 5: Partnerships, Collaborations, and Opportunities
Clinical trials—diversity in community participation in research and clinical trials	Breast cancer	African Americans	City and county public health departments	Federal partnerships and collaborations
	Cardiovascular disease and stroke	American Indian and Alaska Natives	Community campus partnerships	Foundations
	Cancer	Asian Americans		Health organizations
				Medical associations
Community health centers	Cervical and ovarian cancer	Children and adolescent populations	Comprehensive centers
Community health workers	Colon cancer	Elderly populations
		Hispanic/Latino	Graduate education
Cultural competency	Diabetes and obesity	Immigrant populations	K-12 education
Discrimination, racism, and stress	Hepatitis
	HIV/AIDS	Lesbian, gay, bisexual, and transgendered populations	Practice-based research networks
Data collection methods—racial and ethnic, gender and SES categorization	Infant mortality
	Immunization and vaccination rates		State health departments
		Low SES populations	Undergraduate education
Faith-based initiatives	Mental health	Men
Gene–environment interactions	Oral health	Native Hawaiian and Pacific Islanders	Young investigators
Global health	Pregnancy outcomes
Health literacy	Prostate cancer	Persons with disabilities
Media and policy	Respiratory	Prison populations
Patient provider communication	Substance abuse	Rural populations
Quality improvement	Tobacco	US Pacific populations
Social determinants of health—WHO Commission knowledge networks		Women
Social marketing
Social networks

Note. SES = socioeconomic status; WHO = World Health Organization.

^aComprehensive centers, pipeline of researchers, and public health infrastructure.

Track 1: Translating science to policy and practice.

This track explored translational efforts that bridge science with practice and policy in areas such as cultural competency, health literacy, community-based participatory research, gene–environment interactions, and social determinants of health.

Track 2: Health disparity diseases and conditions.

Topics in this track focused on recent advances and research gaps identified within diseases and conditions such as infant mortality, heart disease, diabetes, cancer, HIV/AIDS, and mental health, with high burden among disparity populations. The challenges and opportunities in addressing determinants of the disparities in these conditions were discussed with the objective of identifying promising solutions or practices.

Track 3: Health disparity target populations.

This track explored the challenges and opportunities in eliminating health disparities within health disparity populations (i.e., racial and ethnic minorities, those of low socioeconomic status, and people living in rural areas).

Track 4: Building capacity.

To eliminate health disparities, we need to build capacity and invest in developing a cadre of researchers who can lead and train future generations of health disparities researchers. This track explored the challenges and opportunities in building research capacity including training and education.

Track 5: Partnerships, collaborations, and opportunities.

This track explored opportunities for partnerships and collaborations with public and private partners. It also provided a venue for representatives from many agencies and organizations to showcase their health disparities portfolio and share lessons learned.

ANALYSIS OF BREAKOUT SESSION RECOMMENDATIONS

Recommendations from 83 breakout sessions were analyzed via a mixed-method qualitative and quantitative approach. Recommendations were reviewed and coded into themes (categories) and subcategories. During the process of coding, categories and subcategories that emerged were added and revised to accurately reflect material in the recommendations. An iterative coding process was utilized to reflect revisions in categories and subcategories. After the qualitative coding of the first 2 major themes listed earlier was completed, categories and subcategories were quantified via counts and percentages (recommendations were not duplicated in the first 2 themes). The third theme contained recommendations previously listed in the first 2 themes, and, as such, it was deemed inappropriate to compare through quantification of counts and percentages.

Each session submitted multiple suggestions, and every suggestion was analyzed independently. The overarching paradigm of science, practice, and policy guided the analysis of the recommendations. It served as a logical cross-cutting framework across the health disparities field, and it also helped to organize the priorities and recommendations.

The qualitative methodology included choosing a categorical theme a priori as well as allowing themes to emerge without preconceived limitations. The categorical theme of intersections between science, practice, and policy was chosen prior to the analysis and based on the Summit framework. A major theme which emerged from the analysis was partnerships and collaborations; another dominant theme pertained to research capacity-building/infrastructure development.

It should be noted that in this analysis, as with qualitative research, coding and classification are subject to interpretation. As much as possible, efforts were made to accurately reflect the purpose of the Summit and the intent of the participant recommendations.

RESULTS

Summit breakout session recommendations addressed a variety of subject matter. The numbers and percentages of breakout sessions that submitted recommendations from each track are provided in Table 2. Many of the recommendations proposed a course of action that bridged the fields of science, practice, and policy. Others provided suggestions within 1 of these 3 fields. Some proposals pertained to broad perspectives and others focused on details of research agendas and methods. Still, others offered a range of suggestions for improving health care practice that will reduce health disparities. Many seemed primed for immediate implementation, whereas others may require further discussion and planning to develop an appropriate action plan. Collectively, the proposed summit conclusions provided various strategies based on the experience, creativity, and hard work of speakers and moderators who participated in the Summit breakout sessions.

TABLE 2.

Number of Sessions That Provided Recommendations in Each Category: The Science of Eliminating Health Disparities Summit, National Harbor, MD; 2008

Track	No. of Sessions	%
Track 1: Translating Science to Policy and Practice	23	28
Track 2: Health Disparity Diseases and Conditions	26	31
Track 3: Health Disparity Target Populations	22	27
Track 4: Building Capacity	9	11
Track 5: Partnerships, Collaborations, and Opportunities	3	4
Total	83	100

Theme I: Intersections Between Science, Policy, and Practice

More than three quarters (78%) of breakout sessions that submitted recommendations for analysis offered suggestions that bridged the fields of science, policy, and practice (n = 65 sessions). Subcategories within this theme included suggestions that bridged science and practice, science and policy, or policy and practice.

Recommendations that bridge science and practice.

Recommendations that bridged science and practice (n = 27 sessions) encompassed many concerns. Major concerns focused on improved data collection and measurement models for health disparities research. Proposed suggestions placed in this category included translational and interventional research linking biological and nonbiological determinants of health. Some discussions offered suggestions to explore the complex factors of environment, lifestyle, genetics, socioeconomic status, economics, and culture. Overall, participants called for an increased understanding and awareness of the social determinants of health to influence health care and public health practice. One session specifically proposed mapping the social determinants of health, stating “in the same way as the genome has been mapped, we need a mapping of the fundamental social determinants of health called ‘the socio-nome.’ ” The target topic sessions in track 1 concluded that health disparities research needed to explore overlaps with culture, values-based health systems, and patient-centered care within diverse populations. In addition, the need to obtain clarity on the determinants of health literacy was proposed. Specifically, participants suggested research to analyze variations in how health literacy is defined and measured, develop consensus on these measures, and assess the impact that environmental context has on health literacy fluctuations. Specific recommendations focused on educating physicians and providers about the importance of clinical trials, integrating clinical trials with patient care, understanding the sociocultural predictors of disparities, and conducting research on the various types of interventions delivered by community health workers.

Recommendations that bridge science and policy.

Fewer sessions (n = 15) submitted recommendations that bridged science and policy compared with the recommendations submitted for the other 2 subcategories in this theme. This may reflect a need expressed in a suggestion from one session: “Scientists need to be better educated in policymaking.” Suggestions for policy-related research included an examination of the social and political processes that shape social determinants of health in order to inform and guide development of effective interventions. An example offered was to conduct geospatial analysis, identifying differential distribution resources in neighborhoods that can be used for policy-based activities to ameliorate the problem (e.g., liquor stores in minority communities). Other discussions included establishing policies to ensure that equity is incorporated as an aspect of quality in quality-of-care research. Some others suggested linking health financing to science-based interventions.

Participants proposed implementing new policy-related requirements regarding the NIH research review process, the design and conduct of research, and the dissemination of results. One recommendation was for the NIH review process to move the discussion of inclusion plans from human subjects' protection (which is not scored) to the science design-review (which is scored). Other suggested requirements were that investigators should be accountable for research plans pertaining to recruitment in clinical trials and publications, grants should require that research results be made publicly available, and scientific reports should be written in plain language.

Recommendations that bridge policy and practice.

There were 23 sessions that submitted recommendations for bridging policy and practice. Some suggestions included broad practice perspectives, whereas others focused more on policy recommendations.

Recommendations with broad practice and policy perspectives included an integration of mental health and primary health care. Suggestions for clinical practice, some of which also addressed access to care, included developing guidelines for clinical practitioners to avoid clinical uncertainty, increasing the number of health professionals from underrepresented ethnic minority populations in health professions, requiring patient-centered communication and cross-cultural skills training in health professions education and in the licensure and certification process, and improving coverage for interpreters and care management services. Specific suggestions placed in this category focused on the need to address colorectal cancer disparities from multiple levels (individual, provider, system, community, and policy). Participants proposed studies to examine tailored patient navigation approaches, system-delivery transformation, and the application of new colorectal cancer screening and diagnostic technology, recognizing that disparities in survival rates and mortality cannot be eliminated simply by providing health insurance. Regarding rural health disparities, participants asked that state and federal attention be given to factors pertaining to rural communities and health facilities and to examining the influence of these factors on the quality of health care of individuals in rural America.

Theme II: Partnerships and Collaborations

Partnerships and collaborations emerged as a prominent focus during the analysis. A total of 61 of the 83 (73%) sessions that submitted recommendations included suggestions pertaining to this theme (track 5 focused on partnerships and collaborations). The importance of partnerships was apparent in the welcome message by J. R., who stated, “Our success in eliminating health disparities will depend on our continued ability to foster and maintain robust partnerships.”

Cross-disciplinary collaborations and partnerships.

This subcategory contains recommendations from 23 sessions about various types of collaborations, such as global collaborations, interdisciplinary partnerships, and collaborations between federal agencies, state government agencies, and several types of research entities.

Suggestions for reducing or eliminating global health disparities included capacity-building for foreign partners, establishing creative partnerships with nongovernmental organizations, providing telemedicine and other online services such as databases of best-practices and other knowledge transfer systems, assembling a database of key professionals in all health care fields, and assisting developing nations with networking.

Recommendations that proposed an interdisciplinary approach advocated seeking new methodologies and interactions between disciplines, building linkages to other fields such as economics and education, using principles from existing successful models of interdisciplinary research, and providing interdisciplinary training opportunities. Some specific suggestions that pertained to federal agencies proposed using coordinated federal interagency collaborative approaches to disseminate, educate, and answer broad lifespan question that spanned the research continuum (e.g., from research to practice). Several recommendations suggested fostering NIH and nonfederal research collaborations that encourage innovative interventions and involvoning nontraditional partners.

Community partners.

Over one third of the sessions with recommendations (29 of 83) submitted suggestions that involved engagement of community partners. Several sessions promoted community-based participatory research, community-owned and managed research, and a community outreach program in which community hospitals engage in research. Overall, suggestions reflected partnerships and structures in place to accelerate translation of research to practice and policy that are tailored to improve health in communities and neighborhoods.

Other suggestions included promoting the public health policy agenda by supporting and establishing centers for health equity, focusing on the broader social determinants of health, (i.e., undertaking a broader socioecological analysis of the causes of health inequities), promoting a community-centered local public policy agenda, and advocating for equal distribution of resources in communities.

Theme III: Research Capacity-Building and Infrastructure Development

Research capacity building and infrastructure development is a broad theme with many facets. Because this theme contains recommendations that were previously listed in the first 2 themes, comparison through quantification of counts and percentages would not be appropriate.

Participants offered a range of ideas to build capacity and develop infrastructure for health disparities research. Most suggestions pertained to capacity-building utilizing a participatory approach and advocating for community involvement in planning and conducting research. In general, the recommendations emphasized translating research findings into practice. Discussions on capacity-building in communities also included establishing practice-based research and comprehensive centers.

Suggestions for strengthening workforce infrastructure included accelerating the pipeline of researchers from the career development phase to independence, offering research protected-time for junior faculty, providing opportunities for moving post doctorate researchers into junior faculty positions, and expanding mentoring opportunities. Participants also offered proposals for addressing kindergarten through 12th grade and higher education. They included integrating health disparities content into educational curricula, introducing a social justice approach to health, providing tutoring, career development and mentoring, supporting parent and community involvement, and promoting global health internships or health management programs. The need for support of evaluation and tracking outcomes was also addressed.

CONCLUSION

As the NCMHD continues to further its mission to coordinate and support innovative health disparities research, it will build on the recommendations provided at this Summit to foster and expand partnerships that transcend and intersect the fields of science, practice, and policy. We identified several key issues including the need to promote a solid framework to unravel the complex interplay of determinants. These determinants will not only include health care access, but the interaction of biological, behavioral, social, environmental, economic, cultural, and political factors. We also were persuaded that the health disparities gap will also require improved data collection, inclusivity, careful analysis and interpretation of research, and the dissemination of results into practice and effective policy that influence positive health and lifestyle choices.

Our analysis has produced the beginning of an agenda to pursue cross-disciplinary interventions integrating science, practice, and policy for health disparities research. The solution will not be to select or prioritize any of these recommendations as primary, but rather to develop effective mechanisms to restructure our efforts. Key considerations are: (1) causes and impacts of health disparities transcend health care, (2) partnerships and collaborations are critical, (3) there is a critical need to build health disparity research capacity and expand training opportunities for new researchers, and (4) the electronic and print media need to be partners for disseminating information about health disparities and related research findings.

Causes and Impacts of Health Disparities Transcend Health Care

The costs and impacts of health disparities place complex economic burdens on the nation. Future research needs to guide broader policy decisions regarding education, housing, environment, employment, and income that directly impact an individual's perspective on health and health care. We need to promote aggressive and effective intervention to alleviate the inequities that affect health and the rising costs that have overwhelmed and continue to overwhelm our resource-strained nation.

Partnerships and Collaborations Are Critical

Effectively addressing health disparities requires the cultivation of partnerships which can provide a nexus for developing research, strategies, interventions, measures, tools, policies, and institutional shifts that will directly change health care outcomes among vulnerable populations. Existing models for collaborations must continue to be strengthened. We must also support new federal initiatives on achieving health equity. The role of the NIH and others in the biomedical research community is to ensure science plays a role in guiding health policies that benefit health reform and achieve health equity. Even though many federal agencies and departments currently include in their mission initiatives the need to mitigate health disparities, knowledge gaps remain, especially among health disparity populations and in the context of their environment and living conditions. Gaining enhanced insight into the biological and nonbiological pathways of health disparities and the implications for predicting and preempting negative health outcomes, or participatory involvement in personalizing care, will significantly contribute to moving these new initiatives that become a part of health reform.

Build Health Disparity Research Capacity and Expand Training Opportunities

Success in alleviating health disparities requires opportunities for transdisciplinary studies, expanded training opportunities, and development of capacity—from grassroots community workers to researchers, providers, and government and industry leaders.

Partner With Media to Disseminate Health Disparities Information and Research

Efficient dissemination of targeted research and information plays a critical role in influencing health decisions. Media not only provide health news and information, but also promote products and lifestyles that directly or indirectly impact health, practices, and behaviors. Currently in the United States, commercial interests play a dominant role in media messaging. Media outlets need to restore the “public trust” and promote health based on scientific evidence and public health benefits.

The recommendations presented in this manuscript are the product of the historic NIH Summit. It is the hope that aspects of this report and recommendations will prove useful to those concerned with the increased burden of health and inequality among vulnerable populations. It is also our hope that this report will stimulate discussion and contribute to a robust and enduring role for the nation in advancing the health disparities research agenda.