9UNP0122SD Antonia Villaruel_WordPress

- Thank you. And it's a real privilege for me to be here. I wanted to tell you before I accepted the invitation to come to the University of Wisconsin, I had to reflect on what all my Badger connections were. And actually, I have quite a few. Two of my brothers have degrees from the University of Wisconsin here in Madison. And again, as I reflected on nurse leaders that have had a significant impact in my development, have also had connections to Wisconsin. Mary was my dissertation advisor, and she has a degree from here. And also Norma, a dean at the University of Pennsylvania had a profound effect on my career. It's also a privilege to be here at the Vivian Littlefield lectureship, because we did in fact have an opportunity to work together when she was president of the National Advisory Council for Nursing Education and Practice, which oversees most of the money for the division of nursing. 

I was absolutely young in my career. She was very welcoming, and certainly made an impact in the very areas that we're talking about. Because it was under her leadership, along with Marla Salmon that we commissioned a report, of which I was chair at, to take a look at diversity in the nursing workforce. That's still a publication, I think, badly in need of updating. But I think that was done in the '90s, sometime. We've all lost track of time. So at any rate, it's a wonderful privilege for me to be here. 

I do bring you greetings from Ann Arbor. 
(laughter)
 I have to tell you that usually I have a picture of our stadium, the Big House, but we're not feeling too big at the Big House these days. 

(laughter)
 So I thought this would be more appropriate. 

So this morning, what I'm going to talk about is health disparities. And again, some challenges and also some innovations. I want to start out by giving some definitions of health disparities, talk about some causes of disparities, talk about some of our challenges in addressing disparities, and again, show you some exemplars that I think give me hope in terms of us moving in the right directions. 

First of all, when we take a look at health disparities, there are several terminologies that get mixed up, from health inequities to health disparity, to health inequalities. There are some very subtle differences about these definitions that have reflections in terms of policy and who we target as having health disparities. Simply, a disparity is a difference. It's an inequality. It's when two quantities are not equal, as you can see here. 

A health disparity is defined as a chain of events signified by a difference in environment, access to, utilization of, and quality of care, and also health status. Or, a health outcome that deserves scrutiny. 

Currently, we have made policy decisions. And this definition or who was considered the health disparity population was defined by our government. Specifically, here, the National Institute of Health says that those that experience differences in health statuses in access are racial and ethnic minorities, rural populations, as well as socioeconomic status. Again, when we talk about efforts to reduce disparities, these currently are the three groups of populations that we're looking at targeting. 

Health and equality is based on observed differences and reflects differences in opportunity, treatment or status. For example, women live longer than men. Migrant workers die younger than stock brokers. Smokers are more likely to have lung cancer than non-smokers. 

Poor mothers are more likely to have lower-birthweight infants than non-poor women. And undocumented workers encounter more barriers to healthcare. These are facts. These are simple differences. This is the health inequality. 

When we're talking about health inequities, though, we're looking at differences in healthcare which are unnecessary and unavoidable, but more importantly, unfair and unjust. So given the example of health inequalities, we have to ask ourselves, again, based on ethical judgments about these differences, should migrant workers die younger than stock brokers? Is it acceptable that smokers have higher rates of lung cancer? Is it acceptable that poor mothers have lower birthweight infants? Should undocumented workers have access to healthcare. 

I'm not sure we've come to an agreement about all these. 

We do know that all inequities are inequalities. But are all inequalities inequities? That's the question that we need to answer. And these decisions are based on considering, are all health disparities unfair? Is it fair that someone is taller than you? And which health disparities are fair? Is there some level of disparity that we can work with, that we consider acceptable? 

When we make these ethical judgments, we have to go back to look at, what are actually been determinants of health disparities. There are biological determinants. 

There's health damaging behavior that's freely chosen, such as perhaps cigarette smoking. There's health damaging behavior, of which we engage in because there's limited choice. For example, one of my colleagues told me about an encounter she had with a poor woman around diabetes management. My colleague, who's a nurse practitioner, was saying, you know, you need to eat five a day. You need to eat more fruits and vegetables. And these are the types of foods you need. She was telling her all this and the woman said to her, "Honey, I'm going to give you the money that I have to spend on groceries, and you tell me how I'm supposed to do that." So again, the choices she made, maybe not freely chosen, but because of limited choice. There's also exposure to unhealthy conditions. And again, inadequate access to and essential services for other healthcare services. 

I'm going to look at some, or provide you an overview of some of these social determinants of health, again, that play a big impact in terms of health. We know from the big body of literature that social economic status, regardless of how measured, by education, by income, by wealth, predicts variations in health. We also know that the link between SES and race are linked, but they are distinct. Again, the best example of that is when we take a look at infant mortality, and we take a look at the differences in social economic status between low birthweight infants in white and black populations. At the poor level, the low SES status, disparities exist. Yet, when African American women, who have higher incomes, comparable to white women, their disparities or their rates of low birthweight are as bad as white women at the lower socioeconomic status. There's another dynamic that's going on. Linked, but distinct. 

Education and income have been linked with infant and adult mortality, acute and chronic infections and non-infectious diseases. And we know that health practices are patterned by SES. 

Again, persons with low SES are less likely to reduce high risk behavior or initiate new health-enhancing practices. Why is this? Perhaps again, it's limited choices that are available. 

We also know, again, trying to figure out how these environmental kinds of conditions really work to associate themselves with mental health disparities for example, or with cancer, or with some other diseases that we don't see a clear link. But again, as we're looking at different science approaches, we're seeing that again, chronic environmental stress that's brought on by these conditions may be an important pathway that we need to be taking a look at. 

There's another effect of socioeconomic status, and that's community socioeconomic context. Again, when we're talking about environmental hazards, we know lower SES communities often have worse pollution. Lower SES communities often have less healthy housing, work places, recreational areas, consumer outlets, and greater exposures to toxins such as lead paint, asbestos and infestation. 

I was at the University of Pennsylvania for a while, and I did work in the Latino community. I went to North Philadelphia, where there was a very high minority population, predominantly a Puerto Rican population. 

We did a lot of work in the schools. The conditions were horrid, but what really struck me was that we couldn't drink water. Forget about me, the kids couldn't drink water from the drinking fountains because of the lead pipes. 

Another issue, and my colleague, David Williams says this is the fundamental cause of racial disparities is racial and ethnic residential segregation. He said this is a fundamental cause of health disparities that leads to highly segregated schools, which impacts quality of education, severely restricts employment opportunities and income levels of communities, and isolates people from role models with stable employment and limits social network. 

Again, you can see by these graphs here, how segregated as a society we are. And there's not been that much difference between 1980 and 2000, between the segregation of blacks and whites. And again, blacks are pretty segregated from most of the other racial ethnic populations, as well. So again, it gets to be problematic, again, when we're looking at disparity issues. 

Another one is educational equality, and the fact that U.S. Schools are structured that students routinely receive dramatically unequal learning opportunities, based on the race and social status is simply not recognized. 

We were talking last night about the dropout rate. I think in some Milwaukee schools, it's abotu 50%. It's not just Milwaukee schools. It's Philadelphia schools. It's Detroit schools. It's inner city schools. Again, we know the critical links between education and health, and education and future opportunity. Again, this is an area that absolutely needs to be addressed and considered. 

So again, when we think about health disparities, and we think about what determinants are, and we think about the role of personal choice-- And this is said well by my colleague James Jackson at Michigan, that says that if you live under very stressful conditions, you have to work harder to maintain your mental health. Sometimes the strategies you use to cope become harmful in themselves. 

You have to use what's available to you. And the three resources that are most easily accessible to many residents in African American neighborhoods: liquor stores, fast food outlets and illegal subtances, are potentially harmful. So again, to try and intervene at an individual level, without considering context, becomes problematic. 

And our world continues to be divided no longer by the formal, political and military walks, but by a tragic faultline between those who can benefit from those opportunities and those that seem cutoff from them. Again, we're talking about disparities worldwide, but our country is a microcosm of what that fault and what that faultline is. 

One of the things that I'll bring to your attention is that there is a PBS special that's coming out that's called, "Unnatural Causes." And in there, a number of noted scientists are going to be looking at, again, social determinants in health, and racial ethnic disparities, and talking about issues like infant mortality, cardiovascular disease, and a number of different issues to take a look at this context. Again, one of the areas that people are looking at is that maybe we need to start reframing our advice from, "Don't smoke. If you can, stop. If you can't cut down. 

Eat a balanced meal, the five a day." But rather to, "Don't be poor." And if you can, stop. If you can't, try not to be poor for too long, because it's detrimental to your health. Live near a good supermarket and affordable fresh produce stores. 

In the city of Detroit and neighborhoods where I work, there are no major grocery stores. There are, again, fast food outlets, mom and pop stores. So we know that it's easier to buy a bag of chips than it is to buy a banana. 

Again, another example. Make sure you stay physically active and exercise at least three times a week. 

And be safe on the roads. Maybe that's not an issue here in Madison, where you're full of parks. But again, it's problematic, because people don't live in safe neighborhoods, where there's good sidewalks, and again, where the environments are safe. Again, relying on public transportation, which in most major cities, is not adequate. 

I'm going to swith now to again talking about the emphasis on racial and ethnic disparities, which we've indicated is a high priority in our country, and certainly in policy areas. I'll talk a little bit about those. The main reason it's such an issue is because racial and ethnic disparities are still persistant. Most minority populations, African Americans, Latinos, and some Asian populations have higher mortality in general, and in age-specific conditions, as well as certain disease conditions. And over the 50 years, these are unchanged, and in many instances, getting worse. 

For example, we have not made a dent in the whole issue of infant mortality among African American women. 

The whole issue related to HIV/AIDS is absolutely skyrocketing in African American and Latino populations. Again, I think there are many incidences, both in cancer and mental health, that have similar stories. So we're not making a dent in that. We can talk about it from it's a human rights, it's a humanity piece. But again, these are important people who contribute widely to our work force. 

I was driving in to the airport yesterday, and listening to the whole debate of the Jena 6. There was an African American caller who was talking about the situation. And what he said was that over 70% of the prison population is African American. And what he said was you can't tell me that African American men are any more violent, are predisposed to crime more than white men. So there is an issue, again, in terms of what is equality, again, what is justice and moving that forward. 

So again, it brings light that there are many conditions that play into these disparities. 

We've had a number of policy initiatives. The secretary's task force on black and minority health was in 1985. And again, that has been the spring board for a lot of action, for more data, for more research. It's a priority in terms of Healthy People 2000 and 2010, which says we're working to eliminate these disparities in healthcare. The National Institute for Health, since the 1985 report, has made efforts to include racial and ethnic groups in research. Not only include them, but mandate that they be included. The Department of Health and Human Services Office of Minority Health, again, a number of different initiatives. And the Institute of Medicine, with their landmark study on unequal treatment that documented over and over, again, the bias in healthcare against racial and ethnic populations. 

So again, we have a lot of policy initiatives, or let's say we have a lot of nice policies written in paper. 

There has been a shift in this administration in terms of really, what the focus is and how we might be able to go about that. So we have nice paper. We have enough framework. But we don't have a lot of action going in there, or at least not enough action that has been able to make a measurable difference. This is the quote from Healthy People 2010, again, which calls for an elimination of health disparities among segments of that population, again, by gender, race or ethnicity, education or income, disability, geographic location or sexual orientation. 

So do you feel challenged enough with trying to figure out how we're going to address this particular issue? I'm going to bring a couple more. 

If we're going to be looking at elimination of disparities, we need to be looking at fundamental causes. And one of those would be the elimination of discrimination. From Dorothy Height, who was a civil rights maven says that, "Covert discrimination is the problem. 

It's more difficult than overt. Unless we acknowledge that racism exists, we will never eliminate it. If people define racism only as certain attitudes, then the solutions they will seek are ways of changing these attitudes. If racism is seen as pervasive, fundamental and systemic, then the solutions sought will be different and deeper in character." So maybe as a result of some of the policy initiatives, maybe as a result of unequal treatment, at least we have an awareness that racism plays. Again, we can look at our attitudes and think about how we might have encounters with patients at different levels, and how we think about our care. 

But what we're saying is this is not enough. Many of the fundamental causes of racism are institutional. They've been in place for so many years that we don't even recognize why they came and what kind of issues we're dealing with. 

My favorite example that I like to use is the GRE exams. 

How many of you love to take GRE exams? And what we know, what the science is behind the GRE exams is that even the testers will acknowledge that they discriminate against women and against minorities. Those groups of folks are going to have lower GRE scores. But yet, nursing schools hang onto to that as if it's a fundamental predictor of success. Yet, we have not done the work, either, to determine that in itself will lead to success in graduate schools. Some people are taking a look at that and some people have eliminated that, or put that into consideration. But again, that is a fundamental piece. The whole issue of ACT and ACT scores came up, when? After Brown v. The Board of Education. 

And it was a way to keep black people out of colleges of higher institutions. That's fundamental. No one questions that. 

A big issue, again, in trying to deal with this is, again, do we really have a shared vision of what's unfair and where it is that we need to go. Again, part of that happens because our perceptions of racial and ethnic inequities differ. There are two huge news stories that, again, I think are raising conversations about some of these inequities. One of them is O.J. How many think O.J. did it this time? 
(laughter)
 But more importantly, what's going on with the Jena 6? And again, the whole discussion about did these six African American students, was justice served in that particular area. 

It's causing a lot of debate. I'm going to share with you, again, some different perspectives that we have. 

This one has to do with Katrina. This was a survey done that asked, "What would've been the government's response if most of the victims had been white?" The majority of blacks said that it absolutely would've been faster. What whites said is that it would've been the same. Perspectives on Katrina. What were personal reactions to the disaster. And again, you can see that Katrina has had more of an impact on African Americans who felt depressed, felt angry and had a close friend or relative that was impacted. Again, not as signficant in terms of perceptions of white persons. 

Part of this comes from a person's own experiences with racism and discrimination. Again, a survey, have you ever had experience with racism in healthcare, 35% of the African Americans, 36% of Latinos said absolutely. And whites, 15%. Never had an experience. 

And I would ask you. How many of you have ever had an experience where you felt you've been treated unfairly? There's not a whole lot of hands that have gone up. That's great for you. But what this is saying is that realities are different. This may not be your reality, but you have to acknowledge that this certainly is other people's reality. 

Perception is reality. 

Another survey. Do you feel that racial minorities have equal job opportunities as whites? Again, what you see is that most whites think absolutely, whereas African Americans and Hispanics think less likely. This was a big debate, as we had our proposal too, which eliminated minority or affirmative action preferences in the state of Michigan, a huge debate. Again, should students be admitted by merit, or should race and ethnicity be considered. Again, what we see is that whites think it should be merit only, where again, blacks, primarily and high among Latinos think that it should be a consideration. Do you favor or oppose affirmative programs for racial minorities? Again, African Americans and Latinos favor that, as opposed to the majority of the white population. And again, part of it is determined when people say have we made links, or have we made progress in eliminating disparities or in moving these things forward. 

Many people say we don't need it anymore, and that we needed it at a particular time, but we don't need it anymore. Again, different perceptions. 

Here we take a look at issues between immgrants and non-immigrants. And again, huge debates. And again, some ugly things going in this whole immigration sentiment, in terms of how it is that we treat people, documented or undocumented from other countries. Again, an immigrant strengthens the U.S. because of hard work, immingrants are more hard working than others. Again, higher percentage of immigrants say yes, they are, as opposed to those who are non-immigrant. Whereas, non-immigrant folk are concerned that immigrants are taking jobs away, that the government isn't tough on immigration, and that the government should spend more to prevent illegal immigration. So again, these are important challenges, the perceptions is an important piece. 

Other challenges, if you haven't had enough, include the lack of diversity in the healthcare work force, the lack of data and research, and the limited science in health disparities. 

Our profession, whether we're looking at nursing, medicine or dentistry, do not reflect the composition of the population. In nursing, I always say it's 2% Latinos. It's been that way for 15 or 20 years. And I don't think in my lifetime it's going to increase to be more than that. It is more than just Latinos or African Americans not wanting to be nurses. There are other issues, again, that we need to take a look at. Certainly, the diversity work force report that we did many years ago highlights some of the issues, both in terms of admission, in terms of recruitment, in terms of faculty being prepared in cultural competence, in terms of the diversity of the faculty, are all important systemic barriers that need to be addressed. I think some of our nursing colleagues think that well, gee, we're doing really better than some of our professions. But it's, you know, bad is bad. And nothing to be proud of here. 

Another issue that I think bears attention is the whole issue of what is our research base for addressing health disparities. I'm a researcher, so our course, it's an area that I'm concerned about. Again, concerned about in terms of how we look about that in terms of our links to practice. A few years ago, two or three years ago, I edited a volume of the Annual Review of Nursing Research. And contributors were racial ethnic minority scientists. And Sandra had a very important chapter there on cancer. 

Crosscuttingly, again, taking a look at all the chapters that were done in cancer prevention and treatment, in terms of health discrimination in our practice settings, nurses, and looking at care of the elderly, and looking at care of children with disabilities, this is what we found. There were important subtantive areas that had not been extensively studied. I think the one area, and several things that came out in Sandra's chapter, and I hope you're not going to be talking about that, I don't want to steal your thunder. But important areas that had not been studied was end of life care in racial and ethnic populations. 

I think the whole issue of prostate cancer in terms of treatment was another area that had not been addressed. Lung cancer, although it's the leading cancer killer, there are very few studies to be able to do that. When I did one on children maybe about ten years ago, I was astounded that there was maybe two studies on sickle cell anemia, one of the most common conditions faced by African American children. So how is it that we're going to build practice when we have no research base. It's not an issue only of having-- 

In this body of research, we found that there were important areas that have not been extensively studied. For example, nobody looked at the issue of discrimination. Nobody looked at structural barriers to healthcare. Given the study done by the Institute of Medicine on equal treatment, there were very few nursing studies that took a look at the issue of discrimination or treatment by nurses in healthcare settings. Most of the research that had been done had been done in England. 

So why are we not taking a look at that issue. Do we believe that nurses who are all-loving, all-caring, don't discriminate. No one has asked the question. But there's no way that we can think, given all the stuff that's been around us, that that's not going to affect interactions we have with patients. Given that you're in a setting where there is not diversity in your classroom, and maybe not in your clinical experience. There isn't any reason to think that you could have a shared perspective of what's going on with that particular plan. 

We found that there was limited research on all racial and ethnic minority populations. The majority of work had been done with African American. There was less related to Latinos, and even less related to certain Asian groups, and again, not in all areas. For example, even the work done with Latinos, the majority of the work was done with Mexican Americans, and not with Puerto Ricans, who again, when you take a look at the gradient and differences between populations, Puerto Ricans experience worse health disparties than any other Latino subgroup. 

There's certainly a need for intervention studies and a need for more expansive contacts. Again, given all the determinants of disparities, we're limited, maybe by our practice, maybe other reasons, but we're limited by taking-- We have a very limited view of environments, a very limited view of persons. 

One of the areas, my area of research is HIV prevention. In my area, we know that there's an increasing incidence of HIV among Latino youth. But again, a few studies and a few intervention studies that have been conducted with this group, there were no effective interventions tested or developed with the population, despite 25 years of the HIV/AIDS epidemic. No evidence-based practice. No way to address cultural issues related to Latinos. 

There is now. It's my curriculum. I'm happy to talk to you about that. 

But again, we need more than one. One is not enough. We need to have one for youth. But there are still no interventions for women. Again, incidences are increasing among that population, so we need people. We need researchers. We need people to take on that particular issue. Again, these are certain populations that, again, need to have interventions. In talking, Sandra and I were having this discussion before. You all have great challenges ahead of you in terms of the research. 

We've addressed a lot of the easy questions. I'm not going to say they were easy, because they were very hard when we were doing them, as well. But you have a base, then, of which you can ask questions, that certainly are a lot more difficult, and a lot more challenging, and require a different perspective. We need for you to move it up a notch, to move the science up a notch, to start looking at these populations that are hard to reach. As a reviewer, I get tired of hearing that we're going to do this on a white population first, and once it's successful, then we'll be able to apply it to different populations. But it doesn't work that way. Different context. Different reasons. Again, when you look at who is in need, it's again, our monies are a little bit displaced, I believe. 

Our challenges are in bridging the great divide, both in terms of practice and also in terms of research. 

There's an historical mistrust in communities, in racial ethnic communities, between researchers, and also between institutions. I remember when I was at one institution interviewing for a position. I said I wanted to be able to talk to some community members, because my research is community-based. My colleague said, not a problem, we're a very prestigious university. We give a lot, the community loves us. All we have to do is tell them we're from XYZ university and the doors will be open to you. So I met with some community leaders. I said, you know, I'm interested in HIV prevention. Is this something that you're interested in, something that you support? They said to me, yes, you know, we're invested in you. 

We want you to be successful. It's an important area. We want you to work with us. They said, only one thing. I said, okay. They said don't tell anybody you're from XYZ university, or the doors will be closed to you. 
(laughter)
 So differences in perception. 

There's an incongruence of the methods of our research in terms of how we work with communities. We need to study things. 

We can't come up with an answer because we don't know enough yet. When I started working on HIV, or actually it was pregnancy prevention in the Michigan area, I would start doing work, and they asked what they could do. I said I don't know enough yet, you know, I'll let you know in seven to ten years. They had no use for me. And I could see that it's like I need to start moving and shifting to look at joint intervention research. While it may not be the total answer, and while it may be a way to find the answer, again, it's progress in that particular area. At least you're trying to do something. Communities are facing these issues right now. Much of our research happens in hospital settings. We need to be adept at working at more community settings and working in partnerships with communities. 

We love to control things. I do experimental studies. I like to have lots of control over different things, but that's not always possible in clinical settings or community settings. Again, we're trying to understand, it's important not only for science, but it's also important for the diffusion that we design interventions that communities are able to take over. 

I was at a CDC meeting, and we had a meeting with researchers in communities looking at CDC's agenda on their sexual reproductive programs. And a community member said, you know, I wish researchers would talk to us before they develop these interventions. He said he wanted to use evidence-based interventions. But the only evidence-based intervention that you have for homeless is a 17-week session intervention, that's over an hour long that requires a health professional to be able to do that. He said that's not going to work, and he could tell from the onset it wasn't going to work. So again, if what we're creating isn't going to have utility to the end users, we're missing great opportunities. 

Finally, there are a limited number researchers, black, white, Latino, or others, who are willing to conduct research with racial and ethnic minority populations. So we have work to do to be able to work with you to help us to address some of the issues. I'm not that old, but I am worried about the next generation that's going to come after me. And I want people to be engaged in that type of research. I know many of you as students, as faculty, are interested in that. We would welcome you, I'm sure, to many of our programs of research. We need people to take the baton. 

So before you get all depressed, let me just tell you that there are some innovations and I think some strategies that that I think are useful, and I think some things to consider. First of all, it's important to realize, if you didn't get this, that there are no quick fixes. These issues have been rampant. 

We're not going to be able to fix them with one research study, with one program of research. There are no quick fixes. This is going to take a concentrated effort of a number of persons to be able to work on these. 

I think we need to be taking a look at population initiatives versus behavior change only. And it means, I believe, that we have to take a look at what it is that we're doing in our research, and think about the policy implications, so it can have a greater impact. We know for example that seatbelts, water fluoridation and teenage driving, have probably done a lot more to reduce car mortality and dental caries than any "let me show you how to brush your teeth" type of intervention. 

We also need to be looking at interconnections among conditions versus single diseases and populations. Again, one area that I think about is that whole issue of pregnancy prevention, HIV prevention, and cervical cancer prevention, specifically among youth. When you think about it, they pregnant, they get HIV, and they get cervical cancer the same way, sexual behavior. But people talk about these things in silos, not recognizing that gee, maybe if I talk to, you know, maybe the HPV vaccine is an opportunity for me to talk to my child about sex and about HIV prevention and pregnancy prevention. 

But these groups of folks aren't talking across. So what you get would be so much more powerful, for example, to lobby for comprehensive sex education versus what it is that we currently have. So again, being able to work across. I mean, these are diseases that are related. Cardiovascular disease and diabetes, for example, are also related. And again, interventions are the same, but people aren't talking and are looking at replicating. So there has to be a better synergy. 

Finally, I also think we need to be taking a look at levels of intervention. And I think this is what we're talking about, how it's getting to be complex. We have some interventions, and I'll say mine for example, HIV prevention with Latinos, that gets at the general population of HIV among Latinos. 

But then there are other subpopulations that need more extenstive type interventions, because that alone is not going to catch them. So we have to, again, that's I think going up the next level and targeting those populations that need additional resources. 

I believe the best health policy is good social policy approaches. And that means education, that means housing and neighborhoods, and that also means employment. It means, I believe, for you all here and for you as faculty that we have to move out of the classroom and that we have to move out of the health settings and go into communities. We need to see where our patients are coming from. We need to understand what those realities are. That's only going to improve our practice. 

As I said before, we need to look at the practice and policy implications of our research. If what we're doing is not going to improve policy, if it doesn't have real implications for what's going on in practice setting, then I think we really need to question why it is we're doing what it is that we're doing. 

It's a great paper, but that's about all it is. 

I think promising approaches, and again, we're getting a lot support from the NIH, is looking at transdisciplinary work, looking at developing sustainable partnerships, and looking at the development of infrastructures. Many of the problems that we discussed today, and that contribute to health disparities, again, don't reside only with the nursing and nursing science. We need sociologists. We need demographers. We need educators, again, to be able to work together, to be able to address these situations. 

I think again, in schools, in areas that we're working with, we need to look at building sustainable partnerships between communities and between populations. There's no reason that each individual faculty member has to find a population. We do it among our schools, too. We're a school of public health, and a school of social work, and a school of education. 

It's the same community, and nobody knows that anybody is there. They're working with the same groups. Again, how much richer our educational experience would be, how much richer the fruits of our efforts would be if we were able to coalesce. Again, the development of infrastructures, again, making sure that faculty are rewarded, that students are rewarded for doing the type of hard work that needs to be done. 

Just to mention, I was on a transdisciplinary initiative looking at the issues of infant mortality. It was a very interesting exercise in how it is that we might be able to work together. It was difficult, a lot of different times, because we certainly have different perspectives and again, ways that we should go about approaching particular efforts. We tried to do this in combination or conjunction with communities, but we even had a different perspective on who "community" was. The physician who was PI of the group thought community meant community providers. So when I talked about getting input from community, that was his community. 

When I said it needs to be pregnant women, he said, well, they really can't help us define what our research studies should be. And that was just contrary. But the discussions were hot, and they were heated. And I think that we were able to at least develop some good science proposals. I think the most innovative one that we had was between one of our researchers and also our social worker, who was looking at food deprivation and food access, and how that related to pre-term labor. So we got some very creative things that went on. I do believe that at the end of the day, we had some things to teach our colleagues about approaches, about whatever. 

We had these discussions about people who say, well, the major cause of disparities is racial segregation in neighborhoods. And I'd say, well, I understand that, but I can't do anything about that. I can move, but that's about the only thing that I can do. 

So, you know, I understand that a client encounter isn't going to solve the whole disparities issue. But it's an opportunity for me. It's an opportunity for nurses. It's an opportunity for physicians. So let's figure out what we can do in that encounter to be able to move forward. But again, not easy questions. 

I'm going to give you some examplars. Again, of how we've been able to at least move on this particular journey. And the one that I have had the opportunity to work in, and have certainly learned a great deal from, is our Detroit URC Initiative, Urban Research Center. It was established in 1995, so we've been together for a long time. 

Initially brought together by CDC funding. Once the funding ran out, we've been very successful in getting NIH money, in getting other CDC monies, and getting university monies, and getting private foundations monies to support the work of again, these diverse schools in their university, as well as two communities in Detroit, one predominantly African American and one primarily Latino. This is a community-based participatory action research group that again, works well with communities. 

We have a set of guiding principles. We say that our research is conducted with mutual respect, recognizing the expertise that each other brings to the table, and having open communication. I will tell you, we have open and loud communication. 

Our principles, as we look at ways in which we can enhance the capacity of everybody, not just the community-based participants, but researchers as well, in the process. We do, again, a lot of team building. Our principle is that the community is involved as appropriate in all phases of the research. It's enlightening to, when I was talking about an intervention study, and I was talking about a control group, I happen to have an equal control group, and one of the community members raised an issue about the control group. 

I thought he was going to say, gee, how can you have a control group when you know that this intervention is effective. He was concerned that that control intervention that I had was going to be too effective, and would diminish the results of the effectiveness of the intervention. So I though, oh, my gosh, how very wonderful. 

Again, we work at at striking collaborations among our schools and among communities. And again, Detroit is very segregated. So this process has allowed very different partnerships, again, between these two communities in Detroit. Again, we've looked at producing and disseminating findings that again, reside not only in journals, but again, through community forums. 

Our successes, very important. Most importantly, me as a researcher, would say that we have good science. That we have an infrastructure to reduce health disparities. 

We have an infrastructure that supports education and research. We have students involved in all aspects of our projects. We certainly have had new partnerships among our members. And the approaches have been interdisciplinary. 

But the last exemplar I'm going to mention to you is one that I've been involved in for the past ten years. And that is the National Coalition of Ethnic Minority Nursing Associations. This is a group of all these ethnic minority associations, the Black Nurses, Hispanic Nurses, Asian Pacific Islander Nurses, Philipine Nurses Association, and also the Native American Association, came together and as we looked at our history and what it is that we're doing, we said we can do a lot more with each other than we can do in our separate silos. So we formed a coalition. We've been in existence for ten years. We're celebrating our anniversary on Capitol Hill. 

One of the tangible fruits of our labor is a $2.5 million grant that we received from the National Institute for General Medical Sciences to help prepare the pipeline of minority nurse researchers. I would invite all the minority nurses that are here, who are thinking about research as a career, to visit our Web site, to talk to myself or Sandra, who's been an important advisory member in this grant, to think about coming to a conference that will be subsidized. We will pay for your way to go. Next year it's going to be in San Diego. The year after that in New Mexico. But it's an incredible opportunity to see other ethnic nurse scientists that are working, and who are absolutely willing to support you on your journey. 

So in closing, I'll just leave you with some nuggets of wisdom from the Motor City. Coming together is a beginning. Keeping together is progress. Working together is success. 

I'll look forward to successful working relationships with you all. Thank you very much.