|
|
Epidemiologic Research in Hispanic Populations
Opportunities, Barriers and Solutions
Working Group, July 31-August 1, 2003, Bethesda, MD
Summary and Recommendations
I. Objectives of the Work Group
The objectives of this work group were to identify research questions,
barriers to research, and methodological solutions to research
problems related to the study of cardiovascular, lung, blood and
sleep disorders in Hispanics. The Hispanic population in the United
States is increasing in size; is diverse in culture, backgrounds
and countries of origin; is experiencing unique influences from
social and behavioral acculturation to the U.S.; is reported nationally
to have lower rates of heart disease; is reported to have increased
prevalence of diabetes and asthma; and is generally poorer and
less educated. Consequently, Hispanic populations provide a unique
resource to study research questions not readily addressed by
other populations in the U.S. The work group identified critical
research questions in this growing segment of the U.S. population.
Barriers to research in Hispanics were identified and solutions
proposed.
II. Background on Hispanic Populations in the U.S.
The Hispanic population in the U.S. has grown considerably in
recent years, and in 2000, persons of Hispanic origin comprised
nearly 13% of the U.S. population. In 2003, the Hispanic population
became the largest minority population in the U.S. There have
been large increases in population from all of the primary countries
of origin. In Mexican Americans, the population sizes in 1990
and 2000 were, respectively 13 and 21 million. There is a marked
difference in the age distribution of those who were U.S. born
vs those born outside of the U.S., with native born showing a
much younger age distribution. Nearly 20% of the U.S. born Hispanics
were less than 10 years of age, while about 2% of foreign born
were in that group. Immigrants tend to be older and in the work
force. By 2050, the Hispanic population is expected to triple,
while the non-Hispanic white population is projected to increase
by 8%.
The economic status of the Hispanic population is lower than that
of non-Hispanic whites. For those age 65 or over, 21% of Hispanic
men are in poverty as compared to 6% of non-Hispanic white men.
For women age 65 or over, the percent in poverty is 26% for Hispanics
and 12% for non-Hispanic whites. Measures of wealth accumulation
show large average differences, with non-Hispanic white households
(male or couple-headed) of over $300,000 while those of Mexican
origin show less than $100,000. The percent of population (age
51-61) with no health insurance is less than 10% for non-Hispanic
whites, but slightly more than 40% for those of Mexican origin.
This large population growth and economic disadvantage will have
important implications for Hispanic health and for health care
services. While emigrants who leave their country tend to be healthier
than those who remain behind, it is critical to understand how
this healthier status can be maintained, how new immigrants can adopt
the healthy, rather than the unhealthy, behaviors of their new
country, and how they can successfully negotiate the health care
system and utilize the health care services available to them.
III. Hispanic Health in the U.S. and the Hispanic Paradox
National mortality rates imply that Hispanics have lower age-adjusted
mortality rates than non-Hispanic whites or non-Hispanic blacks.
Of the three major Hispanic groups, Puerto Ricans appear to have
the highest age-adjusted mortality rates and Cuban Americans the
lowest. The apparent Hispanic advantage in mortality holds for
both genders and for all Hispanic subgroups including those who
are age 65 years or more. Low mortality from cardiovascular diseases,
and major cancers such as lung, colon, breast, and prostate has
been reported. However, there are higher mortality rates from
cancers of the stomach, liver, gallbladder, and cervix. There
are also higher mortality rates from diabetes and liver diseases
in many of the Hispanic groups. The population studies of Mexican
Americans consistently find a high prevalence of type 2 diabetes.
The highest prevalence of self-reported physician diagnosed diabetes
is in the commonwealth of Puerto Rico when compared with the rest
of the nation. Other national studies confirm the high prevalence
of diabetes among Mexican Americans and Puerto Ricans living on
the mainland. In contrast to the national mortality results, the
San Antonio Heart Study did not find that Mexican Americans had
less overall mortality or mortality from heart disease than did
non-Hispanic whites.
Risk factors for heart disease, comparing Hispanics and non-Hispanics,
are best compared using national surveys, although regional surveys
often provide unique information. There are no major differences
in cholesterol and blood pressure, but Hispanics smoke fewer cigarettes
per day than non-Hispanic whites. However, there are more Hispanic
men currently smoking than observed in non-Hispanic white men.
Type 2 diabetes, as mentioned above, is significantly higher in
the Hispanic groups.
The "Hispanic paradox" states that based on the observation that
some risk factors are elevated and that there is social and economic
disadvantage, one would expect a higher mortality and morbidity
in Hispanic populations. However, national mortality data suggest
lower mortality for Hispanics, though some population-based studies
do not support this finding. If there is health advantage, it
is important to understand the source of the advantage, and to
develop preventive efforts so that the health advantage is maintained,
and not lost during the acculturation process. Conversely, if
the apparent health advantage is spurious, it is obviously important
to document this fact.
IV. Research Opportunities in Hispanic Populations
A. Acculturation and Immigration
One of the most unique features of Hispanic populations is the
wide range of immigration and acculturation experiences. Since
culture is a key determinant of health beliefs and behaviors,
social and psychological resources, and health care utilization,
the transition of Hispanic populations from one culture to another
provides a natural experiment in describing and understanding
the processes and consequences of cultural change. These consequences
can be both beneficial and harmful to varying degrees. By understanding
the components of cultural adaptation which influence health and
disease, modifiable factors can be identified, populations at
high risk can be targeted, and interventions can be tailored to
fit the specific components affecting risk. While there are the
more obvious components of acculturation such as changing diet
and psychological consequences of living in a society with different
norms, there are less evident components such as changing beliefs
about disease and the ability or inability to negotiate the medical
care system.
Current measurements of acculturation are generally non-specific
with a major component the assessment of language use. There are,
however, many other dimensions of acculturation that need to be
incorporated into measurements and defined clearly within the
specific cultural context. These include assessment of assimilation
into the structure of the society (cliques, clubs and institutions
or the functional integration into the broader society); the value
placed on preserving the culture of origin as compared to the
new culture; the attitude toward family structures, all of which
could influence health in different ways. Appropriate measurements
require knowledge of the culture of origin which is often lacking,
as well as the culture actually experienced by the immigrant.
Measurement techniques need to be developed to identify those
components of acculturation which influence health. Also, the
specific mediators between acculturation and health need to be
identified and quantitated.
B. Psychosocial and Behavioral
The "Hispanic paradox" described earlier has led to speculation
that there may be some protective behavioral or psychosocial component
which makes the Hispanic populations more resilient against coronary
heart disease. The psychological hypotheses have suggested that
spirituality, adaptive coping behaviors and adoption of healthy
behaviors may be protective, while "John Henryism" (the pressure
to succeed at all costs) may have detrimental effects. Social
hypotheses have proposed that family norms and strong social support
systems may be particularly protective. There are also negative
family forces and data show differences among Hispanic groups.
The prevalence of unmarried mothers is 60% among Puerto Ricans,
42% among Central and South Americans, 40% among Mexican Americans,
and 25% among Cuban Americans. Cultural hypotheses have postulated
that positive community norms and values, health beliefs, healthy
convictions, and traditionalism are beneficial to health. These
components, however, have not been fully examined within the context
of Hispanic health. The paradox itself needs to be examined since
there are conflicting results on whether it exists. Nevertheless,
the behavioral and psychological components listed above do provide
a unique opportunity to study these influences on disease.
Ethnicity involves a sense of "belongingness" with a group of people
that share a common historical origin. Both ethnic and minority
identity have the common motive of banding together, for promoting
a sense of connectedness to others for comfort and survival. Minority
cultures may be described as relational cultures, because many
members give significant attention to the nature and quality of
relationship with significant others. Relational factors present
unspoken and subtle, yet powerful messages that influence behavior.
A cultural variable such as ethnic pride, level of acculturation,
and traditionalism may operate as moderators or mediators of effect
between an environmental condition and a health outcome.
Within the Hispanic context, it is essential to integrate cultural
factors into classic health behavior models. How may the Latino
cultural concepts of familialism (the high significance placed
on the family unit), collectivism (the importance of friends and
extended family in helping to make decisions in health), simpatia
(the need for smooth interpersonal relationships in which criticism
and confrontation are discouraged), personalismo (the preference
for relationships with members of the in-group), and respeto (the
need to maintain one’s personal integrity and allow for
face-saving strategies) operate as additional components that
may add predictive strength to any of the classical health behavior
and motivation models established under mainstream American health
psychology? Beyond simple acculturation, there are opportunities
within Hispanic populations to study the relationship of cultural
orientation and healthy lifestyle to CHD risk and outcome. What
elements of traditional-agrarian lifestyle may protect against
CHD? Does a modernist-urbanized lifestyle only confer risk, or
does it offer protection? Does "John Henryism" as observed among
African-Americans also apply to Hispanics as a risk condition
for CHD and hypertension?
C. Nutrition
One of the more obvious changes that can occur in the transition
of residence to a new culture is the change in diet. Though evidence
is limited, there is some information which suggests that Puerto
Rican diets become healthier as they acculturate to the mainland,
while Mexican American diets become less healthy in the U.S. as
compared to their diets in Mexico. There are significant differences
in the types of foods eaten by Puerto Ricans, Mexican Americans
and Cubans. From the Hispanic HANES (1982-1984) population over
age 64, tortillas are eaten by Mexican Americans but rarely consumed
by the other groups. Rice is more often eaten by Puerto Ricans
and Cubans but much less often by Mexican Americans. There are
also differences among these groups in the consumption of beef,
pork, beans, and eggs.
The changes in food consumption in the acculturation process can
be substantial, and provide a natural experiment to quantify the
change and to assess the impact on health and disease. While it
is difficult to obtain dietary information prior to immigration,
comparisons can be made among recent and long term immigrants,
those who have evidence of extensive acculturation as compared
to those who remain more traditional. The diets of the various
Hispanic groups can be quite different, and there is an opportunity
to quantify these differences and estimate the differential impact
on health in the different groups. In addition to the standard
hypotheses regarding dietary fat and atherosclerosis, and dietary
salt and hypertension, other dietary hypotheses can be addressed.
These include hypotheses regarding glycemic load and diabetes,
antioxidant vitamins/phytochemicals and heart disease, B vitamins
and heart disease, and the interaction between genes and physiologic
responses to diet.
The greatest challenge in addressing nutrient hypotheses is to
overcome the substantial difficulties in dietary assessment. The
usual problems in assessment are compounded by the added diversity
of Hispanic foods, and the variation among the Hispanic groups
and the varied manner in which food dishes are prepared and named.
While a 24-hour dietary recall can capture the specific foods
eaten during that period, multiple recalls are necessary for each
person to minimize the day-to-day variation in food intake. Food
frequency recalls are cost-efficient but it is essential that
they are constructed carefully to include the full range of foods,
preparation techniques, recipes and portion sizes. Utilization
of food frequency questions designed for U.S. populations are
inadequate for this purpose without extensive modification and
additions, and validation The assessment can be improved by a
combination of instruments, for example, to use at least 3 repeated
24-hour recalls along with a food frequency recall.
D. Obesity and Physical Activity
Obesity in Hispanic populations, as in all other ethnic groups
in the U.S., is increasing and worsening as a significant health
problem. In 2002, the age-adjusted prevalence of obesity among
adults age 20 or more in men was 26% for Mexican Americans and
24% for non-Hispanic whites. For women the comparable percentages
were 26% and 21%. In children from NHANES III, Mexican American
boys had a higher prevalence of obesity that either non-Hispanic
whites or non-Hispanic blacks. In girls, the prevalence of obesity
in Hispanics was higher than that in non-Hispanic whites, but
less than that in non-Hispanic blacks. The highest prevalence
rates in all these groups was among Hispanic boys, age 6-11 years
old, with 17.4% in the obese classification.
The controllable influences of obesity involve the balance in energy
from dietary intake and the expenditure from physical activity.
Measurement of energy expenditure in Hispanic populations is complicated
by the observation that levels of work activity, which are often
not measured, may be high relative to leisure time activity. Additionally,
leisure activity needs to be viewed in a different cultural context
(e.g., may be discouraged) when considering populations with high
levels of work activity. However, as levels of work activity change
in response to acculturation and improved education, the consequences
to obesity may be significant. The percent of the population which
does not partake in leisure-time activity is highest for Mexican
Americans as compared to non-Hispanic whites at all levels of
income. In Hispanics, the percent with no leisure activity is
highest for those at the lowest levels of income, decreases at
levels of middle income, but increases again for those of highest
income. Among Mexican Americans, the percent with no leisure-time
activity is highest among the least acculturated (Spanish speaking)
and lowest among the most acculturated (English speaking). Research
in Hispanic populations will need to carefully assess leisure
and work activity among adults, and evaluate the activity and
sedentary patterns of children.
E. Diabetes
Type 2 diabetes is consistently recognized as being highly prevalent
in Hispanic populations. There is regional and "country of origin"
variation, with some of the highest prevalence rates in the lower
Rio Grande Valley of Texas. Prevalence rates can reach up to 50%
of the population above age 45 years. The causes of these high
rates are not well understood, but genetic admixture with Native
American population groups is likely to play a role. In these
populations, there are incorrect assumptions that diabetics are
not compliant with medical advice and thus cannot lower their
blood glucose or Hb A1c. Experience has shown that with concerted
effort to communicate with the community to establish trust and
confidence, and to understand and use culturally appropriate methods,
diabetes control can be significantly improved. The lesson for
epidemiologic research is that successful entry into a community
requires extensive effort to learn and apply methods appropriate
to the cultural norms, and to extend effort and resources, in
advance of the study, to gain the community’s trust and
confidence.
The high prevalence of type 2 diabetes provides opportunities for
research. The higher prevalence means that required sample sizes
are more likely to be met. Known factors associated with diabetes
can be studied, again because of their higher prevalence (e.g.,
obesity). The differing genetic admixtures of the various Hispanic
groups can provide opportunities to investigate genetic influences
and gene by environment interactions. The variation in diet among
Hispanic groups and individuals can be used to assess dietary
influences in diabetics. Studies in Hispanic children can investigate
the increasing onset of type 2 diabetes in children and identify
factors related to childhood onset.
F. Asthma
Data on the prevalence of asthma in Hispanics is sparse, and often
dependent upon a medical history (which can be biased by availability
and use of medical care services) and by mortality (which only
accounts for the most severe fatal cases). A more carefully constructed
survey of asthma in North Brooklyn shows striking difference in
asthma prevalence between Puerto Ricans and Dominicans who live
in the same areas. The prevalence of asthma in Puerto Ricans was
13.2% but only 5.3% in Dominicans. These differences were not
explained by education, household size, household location, use
of home remedies, or country where education was completed. The
excess asthma in Puerto Ricans is also seen in mortality statistics
for asthma. The death rate from asthma for Puerto Ricans in the
Northeastern U.S. is double that for Cubans and other Hispanics
in the Northeast. The medical history data from NHANES suggests
that asthma in Hispanic groups other than Puerto Ricans is similar
to that in non-Hispanic whites. The hypothesized risk factors
for asthma include genetic susceptibility, gestational age, lower
respiratory tract illnesses, environmental factors, nutrition
factors, obesity and physical activity. There is a need to understand
the differing asthma rates among the Hispanic subgroups which
may lead to a further understanding of the role that risk factors
play in the development of this disease.
G. Genetics
While it is quite clear that single gene effects are very unlikely
to play a major role in the cause of heart, lung, blood, and sleep
disorders, it is equally clear that susceptibility to many of
these diseases, with responses to environmental factors, are genetically
mediated. There may be genetic contributions to disease susceptibility
that are specific to Hispanics and that require specific therapies.
There may also be genes that are important in all populations
but that are easier to detect in Hispanics. At the present time,
the answers to the above hypotheses are unknown but need investigation.
Much of the genetic research in Hispanics has concentrated on Mexican
Americans and on genetic influences on diabetes and obesity. In
the San Antonio Family Heart Study, diabetes is 2 to 3 times higher
in Mexican Americans than in non-Hispanic whites and 25-35% are
severely overweight. The family study approach is most efficient
with large pedigrees, and utilizing genome scans of known markers
(usually 400 or more), localization of potential “risk factor
genes” on the chromosomes can be done through linkage analysis.
Narrowing the chromosomal regions implicated by linkage studies
is daunting and recourse is often made to studying positional
candidate genes in the linked regions, identifying all common
single nucleotide polymorphisms (SNPs) in a candidate gene, and
analyzing all of the SNPs simultaneously to identify the SNP or
SNPs most likely to be influencing the trait. In addition, the
effects of genes are evaluated as to whether their effects are
influenced by other factors or by other genes.
Since family studies are most efficient with large pedigrees which
to some extent conflicts with the primary goals of population
epidemiology studies, it is most advisable to develop family studies
after the core epidemiology population has been identified. In
the primary epidemiology study, information about pedigrees should
be obtained, and DNA collected and stored. Because the various
Hispanic populations have varying admixtures from indigenous populations,
and because Hispanic populations have varying cultural, behavioral,
and environmental influences, opportunities exist to discover
susceptibility genes and identify environmental interactions.
V. Recommendations
Population Identification and Selection for Study
- Because of the diversity of culture, countries of origin,
genetics and acculturation, research should be conducted on Mexican
Americans, Puerto Ricans, Cuban Americans, and Central/South Americans
in sufficient sample sizes for each group.
- Because of regional and local influences on behavior, social
and economic factors, changing population composition, and external
exposures, multicenter studies should be done, with populations
selected in diverse regions of the country, including rural and
urban settings, border and non-border settings, and communities
of varying population densities of Hispanic origin.
- Because of significant influences of immigration and acculturation,
populations should include those with varying lengths of residence
in the U.S. The impact of movement within the U.S. and return
to country of origin needs to be studied.
- Because little is known about the health outcomes, risk factors,
and behaviors in the countries of origin, studies should be done
within these countries.
Population Recruitment
- Strong community support and input is required for high participant
recruitment.
- Prior to study implementation, adequate time and commitment must
be given to develop knowledge of the community, to establish liaisons
with the community, and to gain a relationship of trust with the
community.
- Participant recruitment varies by community, neighborhood, and
social and economic status. Resources and labor will vary and
commitment is needed to support an effective level of effort.
- Participants residing in barrios generally need additional recruitment
effort and may be influenced by safety, poorer health of individuals,
and difficulty in finding time to participate. Repeated attempts
and incentives are needed.
Resources, Materials and Methodology for Hispanic Research
- Data collection procedures and questionnaires are only minimally
developed for use in Hispanic populations. In addition to language,
the appropriate cultural and community context needs to be considered
in development of these instruments. Resources need to be expended
to develop new methods and to expand use of existing methods appropriate
to the various Hispanic population groups.
- A repository of available culturally appropriate research instruments
and protocols applicable to Hispanic populations should be developed
and maintained.
- Research on questionnaire development relevant to Hispanic populations
is needed in the following areas:
- Physical activity.
- Health and cultural beliefs with particular attention to incorrect
stereotypes and misconceptions.
- Acculturation and traditional beliefs with attention to development
and validation of measures not solely dependent upon language.
- Diet
- Personnel resources should include professionals involved in
intervention research so that the study design and content can
provide relevant data for future intervention studies.
- To better understand Hispanic health and risk in the nation,
maximal use of national surveys and data needs to be implemented.
Comparative analysis of U.S. surveys (NHANES) should be conducted
in conjunction with national surveys in other countries (e.g.,
Mexico). Morbidity and mortality follow-up of Hispanic HANES and
NHANES III should be funded and conducted to provide national
estimates of disease and death rates among Hispanic populations.
Inaccurate classification of Hispanic status on death certificates
leads to downward bias in death rates, and improving this ascertainment
and classification process is a priority.
- Research in Hispanic populations should include the training
of professionals of Hispanic origin. Both Hispanic and non-Hispanic
researchers need to be trained in cultural issues and norms relevant
to the populations being studied.
Community Support
- Community support is critical for any successful recruitment
and retention.
- Studies in Hispanic populations must provide a contribution back
to the community. The contribution can include study results,
community newsletters, a presence at community functions, and
information about how the research can benefit their health as
well as that of their children. Both the study and community can
benefit from using community workers in the conduct of the study.
- Studies will need to address, in advance, how to communicate
study information back to participants, and how to handle health
problems discovered in participants who do not have access to
health care services.
Needed Research (in priority order)
- The "Hispanic Paradox" needs to be evaluated in all
Hispanic groups. Though the data are not consistent, evidence
from national studies describe lower mortality from many causes,
including CHD, in Hispanics compared to non-Hispanics even though
Hispanics have increased prevalence of type 2 diabetes, poorer
economic profiles, and less access to health care. These existing
estimates may be biased due to methodological problems. In particular,
there is evidence that Hispanic deaths are undercounted, in part
due to ethnic misclassification, in national mortality statistics,
including the National Death Index. A high priority should be
attached to efforts to correct these deficiencies. Valid estimates
of incident morbidity and mortality rates are urgently needed
for the Hispanic population groups to confirm or reject the "Hispanic
paradox" and whether difference exist among subgroups. Longitudinal
cohort studies of sufficient sample size among Hispanics are needed
to definitively answer this question. Clearly, health policy with
respect to Hispanics is unlikely to be optimal if it is widely
believed that their mortality, both all-cause and cause-specific,
is lower than in the general population when, in fact, it is higher!
Follow-up of HHANES and NHANES III, as recommended above, could
contribute substantially to clarifying the true mortality experience
of Hispanics.
- Studies in Hispanic children should be undertaken to identify
risk factors for diabetes, asthma and obesity, to identify trends
over time in these diseases, and to identify prevention efforts.
Preliminary evidence suggests that diabetes, asthma, and obesity
are significant health problems for Hispanic children. Inclusion
of children can enhance recruitment and retention.
- Research should be undertaken to determine the genetic, environmental
and other factors, including fetal exposure, that may contribute
to differences in asthma among Hispanic groups. Data show that
asthma is significantly higher among Puerto Ricans as compared
to other Hispanic groups.
- Research needs to be undertaken to better define and measure
obesity in Hispanics (fat mass vs. muscle mass), to seek genes
and identify gene-environmental interactions of particular importance
for obesity in Hispanic populations, and to better understand
the interrelationship of obesity, diabetes (which is so highly
prevalent in the Hispanic populations), and other CVD risk factors,
including sleep disorders.
- Research is needed to identify the mechanisms that link acculturation
- to physical health, including obesity, diabetes, asthma, cardiovascular
disease/risk factors and sleep disorders;
- to mental health, particularly depression;
- to social behaviors (including social interaction within families
and the larger society),
- to health behaviors (such as those relating to utilization of
health care resources, nutrition and smoking); and
- to communication of disease risk.
Hispanic populations encompass a full range of immigrant populations,
from very recent immigrants to persons whose families have
lived in the U.S. for generations. Consequently, Hispanic
populations provide unique research opportunities to study
the links between acculturation and health outcomes. Acculturation
processes need to be identified and mechanisms for the role
that acculturation plays in both improving and harming health
need to be studied.
- Research is needed on the impact that community and neighborhood
have on individual health among Hispanics, including factors such
as density and proximity to the U.S. border, which may be supportive
and/or harmful for healthy behaviors. Communities provide unique
environments for immigrant populations, providing familiar language,
markets, religious activities, and social support. What are the
resources for integration into the larger society with respect
to health care access, education, and employment? Are there unique
stress factors for immigrant populations related to the type of
community or neighborhood in which they live?
- Epidemiology studies in Hispanics should capture information
and materials relevant to genetic research including full family
pedigree information and histories, and DNA. Genetic research
involving recruitment and examination of large pedigrees, though
needed, are not essential for initial efforts in developing epidemiology
studies. Since the Hispanic populations are from many different
countries, there are differences in genetic admixture with the
indigenous populations which will be relevant to genetic research.
When identified by other studies, analyses of candidate genes
and gene-environmental interactions will provide an important
contribution.
VI. Members of the Working Group
Co-chairs of the working group
Amelie Ramirez, Dr. P.H., Baylor College of Medicine, Houston,
TX
Michael Stern, M.D., University of Texas Health Science Center,
San Antonio, TX
Members
Ronald J. Angel, Ph.D., University of Texas at Austin, TX
Sharon Brown, RN, Ph.D., University of Texas at Austin, TX
Felipe Gonzalez Castro, Ph.D., Arizona State University, Tucson,
AZ
David B. Coultas, M.D., University of Florida, Jacksonville,
FL
Carlos Crespo, Dr. P.H., State University of New York, Buffalo,
NY
Helen Hazuda, Ph.D.,University of Texas Health Science Center,
San Antonio, TX
Jean MacCluer, Ph.D., Southwest Foundation for Biomedical
Research, San Antonio, TX
Kyriakos Markides, Ph.D., University of Texas Medical Branch,
Galveston, TX
Lucina Suarez, Ph.D., Texas Department of Health, Austin,
TX
Greg Talavera, M.D., MPH, San Diego State University, San
Diego, CA
Katherine Tucker, Ph.D., Tufts University, Boston, MA
VII. NHLBI Planning Group
Division of Epidemiology and Clinical Applications
Paul Sorlie, Cay Loria, Cheryl Jennings, Ana Gonzalez, Paula
Einhorn
Division of Heart and Vascular Diseases
Winnie Barouch
Division of Lung Diseases
Hector Ortega, Sri Ram
Division of Blood Diseases and Resources
Duane Bonds
Office of Prevention, Education and Control
Matilde Alvarado
Last Updated June 2011
|
|