[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]


 
                   THE ROLE OF SOCIAL AND BEHAVIORAL
                       SCIENCES IN PUBLIC HEALTH

=======================================================================

                                HEARING

                               BEFORE THE

                      SUBCOMMITTEE ON RESEARCH AND
                           SCIENCE EDUCATION

                  COMMITTEE ON SCIENCE AND TECHNOLOGY
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 18, 2008

                               __________

                           Serial No. 110-123

                               __________

     Printed for the use of the Committee on Science and Technology


     Available via the World Wide Web: http://www.science.house.gov


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                                 ______

                  COMMITTEE ON SCIENCE AND TECHNOLOGY

                 HON. BART GORDON, Tennessee, Chairman
JERRY F. COSTELLO, Illinois          RALPH M. HALL, Texas
EDDIE BERNICE JOHNSON, Texas         F. JAMES SENSENBRENNER JR., 
LYNN C. WOOLSEY, California              Wisconsin
MARK UDALL, Colorado                 LAMAR S. SMITH, Texas
DAVID WU, Oregon                     DANA ROHRABACHER, California
BRIAN BAIRD, Washington              ROSCOE G. BARTLETT, Maryland
BRAD MILLER, North Carolina          VERNON J. EHLERS, Michigan
DANIEL LIPINSKI, Illinois            FRANK D. LUCAS, Oklahoma
NICK LAMPSON, Texas                  JUDY BIGGERT, Illinois
GABRIELLE GIFFORDS, Arizona          W. TODD AKIN, Missouri
JERRY MCNERNEY, California           TOM FEENEY, Florida
LAURA RICHARDSON, California         RANDY NEUGEBAUER, Texas
DONNA F. EDWARDS, Maryland           BOB INGLIS, South Carolina
STEVEN R. ROTHMAN, New Jersey        DAVID G. REICHERT, Washington
JIM MATHESON, Utah                   MICHAEL T. MCCAUL, Texas
MIKE ROSS, Arkansas                  MARIO DIAZ-BALART, Florida
BEN CHANDLER, Kentucky               PHIL GINGREY, Georgia
RUSS CARNAHAN, Missouri              BRIAN P. BILBRAY, California
CHARLIE MELANCON, Louisiana          ADRIAN SMITH, Nebraska
BARON P. HILL, Indiana               PAUL C. BROUN, Georgia
HARRY E. MITCHELL, Arizona           VACANCY
CHARLES A. WILSON, Ohio
ANDRE CARSON, Indiana
                                 ------                                

             Subcommittee on Research and Science Education

                 HON. BRIAN BAIRD, Washington, Chairman
EDDIE BERNICE JOHNSON, Texas         VERNON J. EHLERS, Michigan
DANIEL LIPINSKI, Illinois            ROSCOE G. BARTLETT, Maryland
JERRY MCNERNEY, California           RANDY NEUGEBAUER, Texas
RUSS CARNAHAN, Missouri              DAVID G. REICHERT, Washington
BARON P. HILL, Indiana               BRIAN P. BILBRAY, California
ANDRE CARSON, Indiana                RALPH M. HALL, Texas
BART GORDON, Tennessee
                 JIM WILSON Subcommittee Staff Director
          DAHLIA SOKOLOV Democratic Professional Staff Member
           MELE WILLIAMS Republican Professional Staff Member
                    BESS CAUGHRAN Research Assistant


                            C O N T E N T S

                           September 18, 2008

                                                                   Page
Witness List.....................................................     2

Hearing Charter..................................................     3

                           Opening Statements

Statement by Representative Brian Baird, Chairman, Subcommittee 
  on Research and Science Education, Committee on Science and 
  Technology, U.S. House of Representatives......................     6
    Written Statement............................................     7

Statement by Representative Vernon J. Ehlers, Ranking Minority 
  Member, Subcommittee on Research and Science Education, 
  Committee on Science and Technology, U.S. House of 
  Representatives................................................     7
    Written Statement............................................     8

                               Witnesses:

Dr. Lisa Feldman Barrett, Professor of Psychology; Director of 
  the Interdisciplinary Affective Science Laboratory, Boston 
  College; Appointments at Harvard Medical School and 
  Massachusetts General Hospital
    Oral Statement...............................................     9
    Written Statement............................................    11
    Biography....................................................    13

Dr. John B. Jemmott III, Kenneth B. Clark Professor of 
  Communication; Professor of Communication in Psychiatry; 
  Director, Center for Health Behavior and Communication 
  Research, University of Pennsylvania, School of Medicine and 
  Annenberg School for Communication
    Oral Statement...............................................    13
    Written Statement............................................    15
    Biography....................................................    29

Dr. Donald S. Kenkel, Professor of Policy Analysis and 
  Management, College of Human Ecology, Cornell University
    Oral Statement...............................................    30
    Written Statement............................................    32
    Biography....................................................    35

Dr. Harold G. Koenig, Professor of Psychiatry and Behavioral 
  Sciences; Associate Professor of Medicine; Director of the 
  Center for Theology, Spirituality, and Health, Duke University
    Oral Statement...............................................    36
    Written Statement............................................    38
    Biography....................................................    51

Discussion.......................................................    51

              Appendix: Additional Material for the Record

Statement of David B. Abrams, Executive Director, The Steven A. 
  Schroeder Institute for Tobacco Research and Policy Studies, 
  American Legacy Foundation....................................    72


      THE ROLE OF SOCIAL AND BEHAVIORAL SCIENCES IN PUBLIC HEALTH

                              ----------                              


                      THURSDAY, SEPTEMBER 18, 2008

                  House of Representatives,
    Subcommittee on Research and Science Education,
                       Committee on Science and Technology,
                                                    Washington, DC.

    The Subcommittee met, pursuant to call, at 10:02 a.m., in 
Room 2318 of the Rayburn House Office Building, Hon. Brian 
Baird [Chairman of the Subcommittee] presiding.


                            hearing charter

             SUBCOMMITTEE ON RESEARCH AND SCIENCE EDUCATION

                  COMMITTEE ON SCIENCE AND TECHNOLOGY

                     U.S. HOUSE OF REPRESENTATIVES

                   The Role of Social and Behavioral

                       Sciences in Public Health

                      thursday, september 18, 2008
                         10:00 a.m.-12:00 p.m.
                   2318 rayburn house office building

1. Purpose

    The purpose of the hearing is examine the role of the social, 
behavioral and economic sciences in improving our nation's health and 
well being and reducing the economic burden of health care.

2. Witnesses:

          Dr. Lisa Feldman Barrett is a Professor of Psychology 
        and Director of the Interdisciplinary Affective Science 
        Laboratory at Boston College, with appointments at Harvard 
        Medical School and Massachusetts General Hospital.

          Dr. John B. Jemmott III is the Kenneth B. Clark 
        Professor of Communication at Annenberg School of 
        Communication, and a Professor of Communication in Psychiatry 
        and Director of the Center for Health Behavior and 
        Communication Research in the Department of Psychiatry, School 
        of Medicine at the University of Pennsylvania.

          Dr. Donald S. Kenkel is a Professor of Policy 
        Analysis and Management in the College of Human Ecology at 
        Cornell University.

          Dr. Harold Koenig is a Professor of Psychiatry and 
        Behavioral Sciences, Associate Professor of Medicine, and 
        Director of the Center for Theology, Spirituality and Health at 
        Duke University.

3. Overarching Questions:

          How can the behavioral, social and economic sciences 
        contribute to the design and evaluation of more effective 
        public health policies? What lessons can be learned from the 
        decades-old national campaign to reduce smoking? To what extent 
        are public health policies in general being shaped by what has 
        been learned from the social, behavioral and economic sciences?

          What new and continuing areas of basic research in 
        the social, behavioral and economic sciences could 
        significantly improve our ability to design effective policies? 
        What new technologies and methodologies are enabling advances 
        in the research? Are there promising research opportunities 
        that are not being adequately addressed?

          What is the nature of interactions and collaborations 
        between behavioral and social scientists, biomedical scientists 
        and health (including mental health) practitioners? How might 
        these disparate research and practitioner communities be better 
        integrated to improve human health and well being? Is the 
        Federal Government playing an effective role in fostering such 
        collaboration?

4. Federal Spending on Social, Behavioral and Economic Sciences

    Basic and applied research in the social, behavioral and economic 
sciences is funded out of a number of federal agencies, led by the 
National Institutes of Health (NIH) and the National Science Foundation 
(NSF). According to research funding statistics compiled by NSF,\1\ a 
total of $1.215 billion was obligated to basic and applied research in 
all social sciences for fiscal year 2006 (FY06), including economics. 
Psychology was counted separately, and was funded at a total of $1.91 
billion in FY06, of which $1.76 billion was funded by Health and Human 
Services (primarily NIH). Federal support for academic research in 
particular was $711 million for social sciences and $629 million for 
psychology. There is also a significant amount of foundation support 
for public health related research.
---------------------------------------------------------------------------
    \1\ Data are based on self-reporting by agencies. In many cases, 
especially where there is interdisciplinary work, it is hard to tally 
exact dollars spent on one field or another, so these values are at 
best an estimate.
---------------------------------------------------------------------------
    The main support for basic research in the (non-medical) social and 
behavioral sciences comes from the Social, Behavioral and Economics 
Directorate (SBE) at NSF. Overall, NSF accounts for approximately 60 
percent of federal support for basic research in anthropology, social 
psychology and the social sciences at U.S. colleges and universities. 
In some fields, including archaeology, political science, linguistics, 
and non-medical aspects of anthropology, psychology, and sociology, NSF 
is the predominant or exclusive source of federal basic research 
support. The SBE budget for FY08 is approximately $220 million, making 
it the second smallest research directorate at NSF. Fifteen percent of 
SBE's budget is used not for basic research but to fund the collection 
and analysis of data on science and engineering research, education and 
workforce trends (including the data presented here), resulting in the 
biannual ``S&E Indicators.''
    NIH funds both very basic research, such as that of Dr. Barrett, 
and research-based interventions such as those designed by Dr. Jemmott. 
NIH also supports most health economics research, such as that carried 
out by Dr. Kenkel. NIH's Office of Behavioral and Social Sciences 
Research (OBSSR), created by Congress in 1993, serves as a coordinating 
and policy development office for research across NIH's many 
institutes, rather than funding research directly. OBSSR also serves as 
NIH's focal point for coordination of social and behavioral research 
agendas with other agencies, including NSF. Staff at both NSF and NIH 
report having a close and productive working relationship. Occasionally 
the agencies issue joint solicitations, such as a current solicitation 
in computational neuroscience.

5. Public Health Applications of Social and Behavioral Sciences

    NSF does not explicitly fund health research, but it does fund 
basic research on human behavior as it relates to biological and social 
phenomena. For example, NSF funds medical anthropologists who study the 
distribution of genes in a particular region as it relates to the 
prevalence of a certain disease, and cognitive neuroscientists who 
study aspects of brain function relevant to autism. NIH funds social 
and behavioral research with direct public health applications, such as 
reducing tobacco use, improving mental health, preventing obesity and 
slowing the HIV/AIDS epidemic.
    One of the biggest public health stories of the 20th century is the 
reduction in tobacco use and smoking-related diseases. Behavioral and 
social science research helped shape policies to stop kids from taking 
up smoking, and interventions to help those already addicted to quit. 
According to the Centers for Disease Control and Prevention, the 
portion of Americans who smoke dropped from 42.4 percent in 1965 to 
20.8 percent in 2007. However, cigarette smoking remains the leading 
preventable cause of death in the United States, accounting for 
approximately one of every five deaths (438,000 people) each year.\2\ 
The economic costs associated with smoking-related illnesses are 
estimated to be $165 billion in health care and disability.
---------------------------------------------------------------------------
    \2\ http://www.cdc.gov/tobacco/data-statistics/
fact-sheets/adult-data/
adult-cig-smoking.htm
---------------------------------------------------------------------------
    As biomedical and clinical researchers continue to develop 
understanding of disease mechanisms and develop effective 
pharmaceutical therapies, social and behavioral scientists continue to 
elucidate the role of social and behavioral factors in health and 
illness. The research community, however, has moved beyond genes or 
environment arguments about physical and mental health to studying how 
genes and environment interact in complex ways to produce behavioral 
and health outcomes. As such, there is an increasing need for these 
disparate research and practitioner communities to break down 
disciplinary and cultural barriers to advance public health and well 
being.

6. Questions for Witnesses

    Two of the witnesses in this hearing carry out the basic behavioral 
and economics research. One of the witnesses uses theories based on 
research to design interventions to stem the spread of HIV/AIDS among 
urban youth. A fourth witness studies the relationship between 
spirituality and health. All of the witnesses were asked to testify 
about the nature of their own research and its significance to public 
health policy. They were also asked about the increasing role of 
collaborations between behavioral scientists, biomedical scientists and 
public health practitioners to advance public health, and the role of 
the Federal Government in fostering such collaborations.
    Chairman Baird. Good morning. Thank you all being here for 
another of this committee's series of hearings on the role of 
social sciences and helping to meet some of the grand 
challenges facing our country today. This is the third in a 
series. We have previously had an operable hearing on social 
sciences as they impact energy policy and practices, then we 
had one on defense issues and its applications there.
    Today we look at one of the other great challenges facing 
our country, and that is health care. Our nation faces a triple 
challenge of access, cost, and outcome. We have 45 to 47 
million Americans with no health insurance. We spend more per 
capita than any other country on Earth on health care and yet 
our outcomes are not what they ought to be, and a great number 
of illnesses are fairly preventable, and a vast amount of our 
spending nationwide is related to behaviorally-influenced 
illnesses, either the behavior directly caused the illness or 
they can exacerbate the impact or behavioral factors can impede 
the treatment process. And this includes everything on the 
causal part, it includes everything from smoking to some degree 
of obesity.
    On the treatment side behavioral interventions have been 
immensely helpful in helping us address things like adherence 
to chemotherapy regimes or in the case of, for example, 
tuberculosis, drug adherence, medication adherence. These are 
absolutely critical.
    And so we believe as a former social scientist myself, that 
if we want to solve some of these health care problems, the 
social scientists have an absolutely essential role to play in 
that, and we have witnesses today who will share a diverse 
perspective on that.
    In a moment I am going to acknowledge my dear friend and 
colleague, Dr. Vern Ehlers, for opening remarks. We also have 
Dr. Roscoe Bartlett with us here today, and Eddie Bernice 
Johnson is here as well.
    Before we do, though, I want to acknowledge a Member of the 
Science Committee staff. Jim Wilson is retiring at the end of 
this year. I think this will be our last hearing before this 
committee, so hence, perhaps, Jim's last hearing. He is 
probably wiping away tears as I speak. Jim has been on the 
professional staff of the Committee since 1987. He invented the 
Internet, the Blackberry, and a host of other modern devices.
    Jim received his BS, MS, and Ph.D. degrees in aerospace 
engineering from West Virginia University, completed the Senior 
Manager's in Government Program at Harvard's Kennedy School of 
Government. He previously managed research programs in fluid 
dynamics at the Air Force Office of Scientific Research in 
Washington, DC, and served as an officer in the U.S. Air Force 
at the Flight Dynamics Laboratory at Wright Patterson Air Force 
Base in Ohio. Then he decided to do something with his life and 
came to work for us here at the staff.
    He has done an outstanding job. He is a good friend and has 
been a great public servant, and I just want to express my 
personal appreciation, and Jim, we have a small token of that. 
This is a flag which we took to Antarctica, and this has 
actually been to the South Pole and around the South Pole, so 
it has been in every time zone. That is an easy trip. You just 
walk around. But, Jim, please accept this with our gratitude 
for many years of service.
    [The prepared statement of Chairman Baird follows:]

               Prepared Statement of Chairman Brian Baird

    Good morning and welcome to this Research and Science Education 
Subcommittee hearing on the role that social, behavioral and economic 
sciences play in improving our nation's health and well being and 
reducing the economic burden of health care. This happens to be the 
very last scheduled hearing before the Science and Technology Committee 
this year. It seems fitting, as we are in the midst of a heated 
campaign season in which skyrocketing health care costs are a hot 
topic, that we highlight an aspect of health care that gets too little 
attention from the research and medical communities and government 
alike: prevention.
    We have a health care system that discourages doctors from spending 
time on preventative care. I don't think this committee is going to 
solve that problem. But we will look today at the choices that 
individuals make, and what researchers know about how and why we make 
those choices and how public policy might be shaped to help influence 
those choices to the benefit of both ourselves and society.
    Each of us decides whether to smoke, to exercise, to cook at home 
or stop at the nearest fast food joint. Most if not all of us in this 
room are pretty lucky. We are blessed with a good education, good 
health insurance and a well-paying job. We have all of the tools and 
resources we need to make the healthy choice every time, but we still 
engage in unhealthy behaviors. Access to information and resources is 
not the sum of what influences our decisions.
    Take smoking. After decades of an aggressive public anti-smoking 
campaign, the overall rate of smoking in the U.S. decreased by one-half 
to 21 percent. I imagine there are few teenagers in the U.S. who 
haven't had it drilled into them that smoking can kill. Yet, according 
to the CDC, each day approximately 4,000 kids between the ages of 12 
and 17 years initiate cigarette smoking. Social, behavioral and 
economics research did and continues to shape effective anti-smoking 
policies and to provide insight into why some efforts have fallen 
short. This is first and foremost about the health and well being of 
individual Americans. But it is also about the cost to our society. 
Smoking alone can be blamed for approximately $165 billion per year in 
health care and disability costs.
    Of course our health is not governed entirely by our behavior. Even 
those of us with the healthiest habits can be struck by a physical or 
mental illness that requires treatment. How do we respond to such 
challenges? Do we have the tools, and do our doctors have the tools to 
help us combat depression for example, whether it comes on out of the 
blue or in response to a major illness or trauma? They say a healthy 
body makes a healthy mind. The inverse is equally true. Yet it is only 
in the last decade or two that researchers are seriously exploring the 
mind-body connection. Another important and recent advance is that 
increasingly, clinicians, biologists and behavioral scientists are 
joining forces to answer the question: how do genes and environment 
interact, rather than making it an either/or proposition.
    The panel before us is engaged in some exciting work, ranging from 
very basic research on emotions to design of theory-based interventions 
to stop the spread of HIV/AIDS. I thank all of the witnesses for being 
here this morning and I look forward to your testimony.

    Chairman Baird. Vern, I recognize my dear friend, Dr. 
Ehlers.
    Mr. Ehlers. Thank you for yielding. I would just like to 
add my accolades. I have worked with Jim for a number of years. 
He has always been imminently fair, very thorough, and very 
capable. And we are certainly going to miss him. The only 
puzzle I have had constantly after all my great intelligent 
conversations with him is how he ended up being a Democrat. But 
that may be a partisan point of view. But, Jim, we really 
appreciate your work, and we are all going to miss you. Thank 
you.
    Chairman Baird. When you look at Jim's resume, those of us 
who are Members of Congress may not be rocket scientists, but 
some of our staff are. And that is very nice.
    Thank you for your remarks, Dr. Ehlers.
    With that I am pleased to recognize Dr. Ehlers for an 
opening statement.
    Mr. Ehlers. Thank you, Mr. Chairman. Today's hearing will 
delve into the public health implications of social science 
research and its application. Preventing disease and premature 
death is the underlying goal of the marriage between public 
health and the social sciences, and the impacts of this 
research are substantial.
    And I must confess, Mr. Chairman, I recognize we have had 
all these hearings because you are a social scientist, but you 
have done us a service because all the different hearings we 
have had this year have certainly opened my eyes to the power 
and usefulness and the social sciences in many different areas. 
So I thank you for holding all these hearings.
    The Social Behavior and Economics Directorate at the 
National Science Foundation provides support for the 
fundamental research that underpins many of today's public 
health interventions. In addition to studying the science of 
the brain NSF works to integrate the microscopic with the 
macroscopic actions of our day-to-day lives.
    In many ways the social sciences face similar challenges as 
the physical sciences do in bringing an innovative idea from 
the laboratory to the marketplace. Humans are such dynamic 
characters, particularly when it comes through their own 
health, that the scientists before us must juggle many 
different variables. Conducting gold-standard research projects 
with human subjects certainly poses unique challenges. 
Understanding the root causes of human behavior and emotion 
will assist lawmakers in crafting effective public health 
policy.
    I appreciate the work of the Chairman and staff on this 
series of hearings which have educated Members and the public 
about how social science research is impacting human behavior, 
energy, national security, and today perhaps the most important 
topic, how it affects our health. I look forward to hearing 
from our witnesses today about the research in these areas, and 
I thank you all for your attention.
    [The prepared statement of Mr. Ehlers follows:]
         Prepared Statement of Representative Vernon J. Ehlers
    Today's hearing will delve into the public health implications of 
social science research and its application. Preventing disease and 
premature death is the underlying goal of the marriage between public 
health and the social sciences, and the impacts of this research are 
substantial.
    The Social, Behavioral and Economics directorate at the National 
Science Foundation (NSF) provides support for the fundamental research 
that underpins many of today's public health interventions. In addition 
to studying the science of the brain, NSF works to integrate the 
microscopic with the macroscopic actions of our day-to-day lives. In 
many ways, the social sciences face similar challenges as the physical 
sciences do in bringing an innovative idea from the laboratory to the 
marketplace. Humans are such dynamic characters, particularly when it 
comes to their own health, that the scientists before us must juggle 
many different variables. Conducting ``gold standard'' research 
projects with human subjects certainly poses unique challenges. 
Understanding the root causes of human behavior and emotion will assist 
lawmakers in crafting effective public health policy.
    I appreciate the work of the Chairman and his staff on this series 
of hearings in the 110th Congress, which have educated Members and the 
public about how social science research is impacting human behavior as 
it relates to energy, national security, and, today, our health.
    I look forward to hearing from our witnesses today about their 
research in the social sciences. Thank you for your attendance.

    Chairman Baird. Thank you, Dr. Ehlers. If there are other 
Members who wish to submit additional opening statements, your 
statements will be added to the record at this point, and at 
this time I would like to introduce our distinguished 
witnesses.
    Dr. Lisa Feldman Barrett is a Professor of Psychology and 
Director of the Interdisciplinary Affective Science Laboratory 
at Boston College with Appointments at Harvard Medical School 
and Massachusetts General Hospital. Dr. John B. Jemmott, III, 
is Kenneth B. Clark Professor of Communication at the Annenberg 
School of Communication and a Professor of Communication in 
Psychiatry and Director of the Center for Health Behavior and 
Communication Research, and the Department of Psychiatry at the 
School of Medicine at the University of Pennsylvania.
    Dr. Donald S. Kenkel is Professor of Policy Analysis and 
Management in the College of Human Ecology at Cornell 
University, and Dr. Harold G. Koenig is a Professor of 
Psychiatry and Behavioral Sciences and Associate Professor of 
Medicine and Director of the Center for Theology, Spirituality, 
and Health at Duke University.
    As our witnesses know, we spoke briefly before, their 
spoken testimony is limited to five minutes each for your 
initial comments, and after that Members of the Committee will 
have five minutes each to ask questions. We are grateful for 
your years of research and contribution and that you would take 
the time from certainly busy schedules to join us today.
    With that we will, we have been joined, I should mention by 
Dr. Lipinski and thank you. And we will start with Dr. Barrett, 
please.

STATEMENT OF DR. LISA FELDMAN BARRETT, PROFESSOR OF PSYCHOLOGY; 
DIRECTOR OF THE INTERDISCIPLINARY AFFECTIVE SCIENCE LABORATORY, 
  BOSTON COLLEGE; APPOINTMENTS AT HARVARD MEDICAL SCHOOL AND 
                 MASSACHUSETTS GENERAL HOSPITAL

    Dr. Barrett. Congressman Baird, you and your colleagues 
deserve our deepest thanks for encouraging NIH to support basic 
research in the social and behavioral sciences. My colleagues 
and I are very grateful for your efforts, and I very much 
appreciate the opportunity to speak with you today.
    Seven years ago when the Twin Towers collapsed, people had 
many reactions. I would like to read two to you. One person 
said, ``My first reaction was terrible sadness but then came 
anger, because I couldn't do anything with the sadness.'' A 
second person said, ``I felt a bunch of things I couldn't put 
my finger on, maybe anger, confusion, fear. I just felt bad.''
    These examples demonstrate a phenomenon that I discovered 
almost 20 years ago. Some people feel the heat of anger, they 
feel the despair of sadness, they feel the dread of fear. Other 
people use the same words, but they feel, for lack of a better 
word, bad. Same words, different feelings.
    Over a 10-year period my lab found that people like the 
first speaker who have emotional expertise are more flexible in 
regulating their emotions. They are more centered, they are 
less buffeted by the slings and arrows of life than the second 
speaker.
    These basic research findings have now been translated into 
emotional literacy programs for children, teachers, and school 
administrators. By the end of next year 250 schools in the New 
York System alone will participate, and the results are already 
clear. Children who can identify, understand, and label their 
emotions effectively have fewer clinical symptoms, they are at 
lower risks for violent behavior, and for drug and alcohol 
abuse. They have better social skills, they have stronger 
leadership skills, and perhaps most surprisingly, they have 
higher scores, grades, in math, science, reading, and so on, 
meaning that emotional literacy must be a central piece of 
educational reforms like No Child Left Behind.
    These are welcome outcomes, especially given the recent 
UNICEF report showing that U.S. children have the second lowest 
well-being scores across 21 developed nations.
    Now, emotional literacy isn't just about happiness. 
Emotionally-intelligent children turn into the skilled and 
productive workforce of tomorrow, which translates into an 
increase in the gross domestic product. And emotional literacy 
has the potential to play a role in addressing some of the 
Nation's most pressing problems. For example, anecdotal 
evidence shows that regardless of people's plans, they often 
decide to retire on the spur of the moment after, let us say, a 
particularly bad day at the office.
    So instead of retiring at age 67, when they should, or at 
age 65, when they planned to, they retire on average at age 63. 
By teaching people emotional literacy when they are adults, we 
may be able to prevent that bad day at the office from causing 
them to retire early, allowing people more financial security 
and saving the government substantially in Social Security and 
health care benefits.
    From a purely scientific standpoint the discovery that not 
everybody feels anger or sadness or fear has ignited a literal 
paradigm shift in the study of emotion. We now know that 
emotions are not simple reflexes that are flipped on like a 
light switch in certain parts of the brain, which is why there 
is no single pill that cures depression, and there is no single 
gene that controls happiness.
    The exact nature of emotion is now the topic of heated 
debate and furious research, and the history of science teaches 
us that key scientific discoveries are made during such times. 
At the frontiers of science nothing speeds scientific progress 
like the clash of competing viewpoints. This may not be 
comfortable, and it is certainly not cheap, but it is 
absolutely necessary.
    Science is like a food chain, with basic research at the 
base, feeding translational research, which feeds applied 
research, and so on. Without this healthy base the entire 
ecosystem becomes weak and can't survive. Basic research in the 
social and behavioral sciences, you know, surprisingly, it may 
sound surprising to say this, is really being starved in 
America, and without the basic research today there will be no 
critical health solutions for tomorrow.
    It takes time for basic science to feed solutions, often 
decades. Scientific discovery is like slowly peeling an onion, 
while exploring one question, other, more nuanced questions, 
are revealed beneath. This means that you can't run science 
like you run on a business model where you set a tangible goal 
and try to meet it on a strict timeline of five years.
    Because the neuroscientist who discovered that canary 
brains grow new cells after birth wasn't trying to solve the 
puzzle of human mental illness. Social scientists who studied 
the evils of conformity after World War II weren't trying to 
keep people from using drugs and alcohol, and my own research 
on emotion wasn't originally targeted at helping children read 
better or helping retirees decide, you know, when is the 
financially right time to decide.
    Regardless of the goals that motivated my basic research or 
any basic research in the first place, it is simply a fact that 
this research is necessary to achieve the critical, and often 
surprising, results that help people live healthier and more 
productive lives.
    [The prepared statement of Dr. Feldman Barrett follows:]

               Prepared Statement of Lisa Feldman Barrett

Abstract

    People differ markedly in their emotional expertise. Many people, 
but not all, feel the heat of anger, the despair of sadness, the dread 
of fear. Some instead experience amorphous feelings that are either 
pleasant or unpleasant. This basic research finding has been translated 
into emotional literacy training programs with proven health, economic, 
and educational benefits. It also illustrates how basic research in the 
social and behavioral sciences allows people to live healthier and more 
productive lives.

    Thank you for the opportunity to speak with you today. I run an 
interdisciplinary lab where we study the very basic nature of emotion, 
from both the standpoint of the psychologist (who measures behavior) 
and the neuroscientist (who measures the brain). Today, I'll wear my 
psychologist's hat and tell you the story of a single scientific 
discovery that is already improving the lives of Americans. It is also 
a promising lead to solving some of the country's most pressing public 
health issues, and illustrates the value of basic research in making a 
healthier and more productive nation.
    Seven years ago, when the twin towers collapsed, people had many 
reactions. Here are just two. One person said ``The first reaction was 
terrible sadness and tears . . .. But the second reaction is anger, 
because you can't do anything with the sadness.'' Another said ``I felt 
a bunch of things I couldn't put my finger on. Maybe anger, confusion, 
fear. I just felt bad on September 11th. Really bad.'' These examples 
demonstrate a phenomenon about emotion that I discovered fifteen years 
ago.
    When I was in graduate school, I noticed something curious in my 
psychotherapy patients. Some people used emotion words to refer to very 
precise and distinct experiences--they felt the heat of anger, the 
despair of sadness, the dread of fear. Others used the words ``anger,'' 
``sadness,'' and ``fear'' interchangeably, as if they did not 
experience these states as different from one another. They felt, for 
lack of a better word, ``bad.'' Outside the therapy room, I saw the 
same thing in friends and family and students. This observation was the 
basis for a decade-long research project (supported by both NSF and 
NIH) where my lab tracked the emotional experience of over 700 people 
during the course of everyday life using a then-novel scientific 
procedure called computerized experience-sampling (www.experience-
sampling.org). Using novel software and statistical procedures, we made 
an important discovery: people differ in their emotional expertise. 
Some people, as in the first example, are emotion experts and 
experience a wide variety of nuanced emotions, in much the same way 
that a wine expert can distinguish the type of wine as well as its 
vineyard and vintage. Other people, like the second example, experience 
emotion as an amorphous feeling that is either pleasant or unpleasant, 
just like wine novices who can't tell much more than whether a wine is 
red or white. Over a ten-year period, my lab discovered that 
differences in emotional expertise translate to important outcomes. 
Emotion connoisseurs are more flexible in regulating their emotions. 
They are more centered, and less buffeted by slings and arrows of life. 
Those with less emotional expertise, by contrast, live life as 
turbulent roller coaster with more ups and downs.
    These basic research findings are now being translated into 
emotional literacy training programs for children (ages four to 
fourteen), teachers, and school administrators (see www.ei-
schools.org). By the end of next year, 250 schools in the New York 
school system alone will participate, and already the results are 
promising. Children who can identify, understand, label, and regulate 
their emotions effectively have fewer clinical symptoms, and are at 
lower risk for violent behavior and drug and alcohol abuse. They have 
better social skills, and stronger leadership skills. Perhaps most 
surprisingly, hundreds of studies show that emotionally intelligent 
children have higher grades in math, science, and reading, meaning that 
emotional literacy must be included in educational reforms like No 
Child Left Behind. These are welcome outcomes, especially given the 
recent UNICEF report showing that U.S. children have the second-lowest 
rate of well-being across 21 developed nations.
    But emotional expertise isn't just about happiness--it translates 
into economic stability and productivity for our country. The 
emotionally intelligent children of today become the skilled and 
productive adults of tomorrow. In a recent forum on children's 
education, the noted economist and Nobel Laureate James Heckman argued 
that social and emotional expertise is necessary to improve the quality 
of the American workforce. A happier and socially skilled workforce 
translates into an increase in the Gross Domestic Product.
    Emotional expertise will even play a role in addressing some of the 
Nation's most pressing problems. For example, emotional literacy may 
help to prevent early retirement in adults, which costs the government 
significantly in social security and health care benefits. Anecdotal 
evidence shows that, regardless of their plans, people often decide to 
retire on the spur of the moment, say, after a particularly bad day in 
the office. So instead of retiring at age 67 (when they should), or age 
65 (when they plan to), they retire, on average, at age 63. By teaching 
emotional literacy to adults, we can prevent that bad day from causing 
them to retire early, allowing people more financial security and 
saving the government a lot of money in the process.
    From a purely scientific standpoint, the discovery that not 
everyone feels anger or sadness or fear has helped to ignite a paradigm 
shift in the study of emotion. Emotions used to be thought of as simple 
reflexes or light switches that turn on parts of your brain, and that 
could be turned off by a drug or changing the right gene. But we now 
know that's not the case, which is why there's no pill that cures 
depression, and no single gene that controls happiness. The exact 
nature of emotion is now the topic of heated debate and furious 
research, and the history of science teaches us that key scientific 
discoveries are made during such times. At the frontiers of science, 
nothing speeds scientific progress like the clash of competing 
viewpoints. This may not be comfortable, or cheap, but it is absolutely 
necessary.
    Science is like a food chain, with basic research at the base, 
feeding translational research, which feeds applied research, which can 
be used by service providers. Without a healthy base, however, the 
entire ecosystem becomes weak and cannot survive. Basic research in 
social and behavioral sciences is being starved in America. And without 
this basic research today, there will be no critical health solutions 
for tomorrow.
    It takes time for basic science to feed applied solutions. In 
genetics or pharmacology, the life cycle is of discovery is usually 
several decades. Scientific discovery is like slowly peeling an onion--
while exploring one question, other, more nuanced questions are 
revealed beneath (and sometimes, a lot of tears are shed along the 
way). But here in the social and behavioral sciences, a basic finding 
about emotion was translated after only 15 years--a relatively quick 
outcome for science, but one that serves both public health and the 
public treasury.
    Science is about exploration, risk, and discovery. This means that 
you cannot run scientific discovery like a business, where you set a 
tangible goal and try to meet it on a strict timeline. A seemingly 
trivial, everyday occurrence or a very abstract idea can, upon closer 
inspection, open up a new scientific vista. The neuroscientist who 
discovered that canary brains grow new cells after birth wasn't trying 
to solve the puzzle of human mental illness. The physicists who 
discovered quantum mechanics were not trying to build a better 
computer. Social scientists who studied the evils of conformity after 
World War II weren't trying to keep people from using drugs. And my own 
research on emotion wasn't originally targeted at helping children and 
retirees, but in the end, this is where it has led. Regardless of the 
goals that motivate basic research in the first place, it is simply a 
fact such research is necessary to achieve the critical, and often 
surprising, results that help people live healthier and more productive 
lives.
    Congressman Baird, you and your colleague Congressman Kennedy 
deserve a lot of credit for encouraging NIH to provide a better 
infrastructure to support basic research in the social and behavioral 
sciences. I know I speak for my colleagues when I say that we are all 
very grateful for your efforts. I myself am fortunate that my 
laboratory is well supported by federal funding agencies at the moment. 
In the context of today's hearing, however, this funding success is a 
bit misleading, because the majority of it pays for the neuro-imaging 
side of my research on emotion. Like many labs around the country, my 
lab is also struggling to move our social and behavioral research 
forward. For the social and behavioral sciences to realize their full 
potential in the service of this country's health and well-being, labs 
like my own need four things to succeed: a well-trained scientific 
workforce of sufficient expertise and diversity, more advanced 
technology that is suited to the scientific questions we want to ask 
(whether or not they have an applied value that is immediately 
obvious), an adequate level of research funds to see our best ideas 
(and perhaps riskiest) forward, and open minds that are not mired in 
the habits or agendas of the past.

                   Biography for Lisa Feldman Barrett

    Lisa Feldman Barrett, Ph.D., is currently Professor of Psychology 
and Director of the Interdisciplinary Affective Science Laboratory at 
Boston College, with appointments at Harvard Medical School and 
Massachusetts General Hospital. Dr. Barrett received her Ph.D. in 
clinical psychology in 1992, and has since received additional training 
in social and personality psychology, psychophysiology, cognitive 
science, neuroanatomy, and cognitive neuroscience. Her research focuses 
on very basic question of what emotions are, both from both the 
standpoint of the psychologist (who measures behavior) and the 
neuroscientist (who measures the brain). Her work also incorporates 
insights from philosophy, anthropology, and linguistics.
    Dr. Barrett is an elected Fellow of the Association for 
Psychological Science, the American Psychological Association, and the 
Society for Personality and Social Psychology. In 2007, she received an 
NIH Director's Pioneer Award for innovative research on emotion. She is 
also the recipient of an Independent Scientist Research Award from the 
National Institute of Mental Health, a Career Trajectory Award in 
Experimental Social Psychology, the James McKeen Cattell Award, and an 
American Philosophical Society Fellowship. Dr. Barrett has served as an 
elected member to the governing boards of the International Society of 
Research on Emotion and the Society for Experimental Social Psychology. 
For the past eight years, she has continually served on grant review 
panels for either the National Science Foundation or the National 
Institutes of Health. She is a founding Editor-in-Chief of the journal 
Emotion Review, and sits on the editorial boards of top tier journals 
in both psychology and neuroscience.
    Dr. Barrett's lab has been continually funded by the National 
Science Foundation since 1998. In addition to NSF funding, her lab 
currently receives support from the NIH Director's Pioneer Award 
program in the National Institute of General Medicine, the National 
Institute on Aging, and the Army Research Institute.
    Dr. Barrett has published over 90 papers and chapters, including a 
National Research Council white paper on the nature of emotion. She has 
edited three books on the science of emotion, including the current 
edition of the Handbook of Emotion. She also wrote the current entry on 
emotion for World Book Encyclopedia.

    Chairman Baird. Thank you, Dr. Barrett.
    Dr. Jemmott.

    STATEMENT OF DR. JOHN B. JEMMOTT III, KENNETH B. CLARK 
   PROFESSOR OF COMMUNICATION; PROFESSOR OF COMMUNICATION IN 
     PSYCHIATRY; DIRECTOR, CENTER FOR HEALTH BEHAVIOR AND 
 COMMUNICATION RESEARCH, UNIVERSITY OF PENNSYLVANIA, SCHOOL OF 
        MEDICINE AND ANNENBERG SCHOOL FOR COMMUNICATION

    Dr. Jemmott. I am very happy to be here today to share some 
of the work that I have been doing over the past 20 years or so 
in the era of HIV prevention, conducting a program of research 
that is designed to identify the social psychological factors 
that underlie HIV risk-associated behavior. Once you identify 
those factors, we develop interventions that are based on 
theory and that are tailored to the population to try to change 
their behavior. We then evaluate those intervention strategies 
using rigorous scientific methods, usually a randomized control 
trial, which is the best way to find out whether an 
intervention is effective.
    Along the way we try to address some practical questions 
about the best way to do HIV prevention. This might be 
questions about the race of the facilitator or the gender of 
the facilitator or the gender, composition of the group, or the 
age of the facilitator, all of these practical question about 
how to do intervention.
    Then if we find that an intervention is effective, we then 
try to disseminate it to people who can actually use to, go 
beyond publishing it in journals and get it to the end users. 
Then when the end users are using it, it leads to additional 
questions about whether it still works, and so we look at that 
as well.
    In our research we found that two of the key 
characteristics of effective interventions is one, that they 
are grounded in some behavior change theory, some systematic 
understanding of human behavior. And second, that they are 
tailored to the population, and this is usually based on 
qualitative research with that population so you can understand 
their beliefs and the context in which the behavior occurs.
    This slide shows one of the theories that we use called the 
theory of planned behavior. So it is a model of behavior. So 
the behavior might be abstinence or it could be condom use, and 
we basically begin at the behavior, and we work backwards in 
the model. We identify an intention, which is a plan to engage 
in the behavior. The best predictor of a person's behavior is a 
plan to do that behavior. And then we look at different types 
of beliefs that could influence those behaviors.
    And those beliefs did not come from the pages of academic 
journals. They come from our target population through 
qualitative research. We ask them what they believe. Then once 
we have their beliefs, we then try to develop interventions to 
target the beliefs, to change the beliefs in ways that are 
supportive of behavior.
    So through a mediational change by affecting building the 
intervention, affecting the beliefs, affects intentions and 
changes behavior, and you can extend the model further to a 
health outcome such as sexually-transmitted disease. So that is 
basically how our research is done.
    Our measures of success are the outcomes in terms of sexual 
behaviors related to HIV infection; abstinence, condom use, and 
limiting the numbers of partners. In some of our studies we are 
also, where appropriate, able to collect biological specimens 
that we can test for sexually-transmitted diseases such as 
chlamydia, gonorrhea, herpes simplex. And because we want to 
understand why the intervention works or why it didn't work, we 
also look at mediator variables, the beliefs and intentions 
that I mentioned earlier. Because if the intervention worked, 
we want to know which beliefs were actually responsible for the 
good outcome that we saw.
    But on the other hand, if it didn't work, then we want to 
know did we, in fact, change the beliefs that we intended to 
change and also if we did change them, were they actually 
related to the behavior. And then in this way we can design 
better interventions in the future.
    We also look at the participants and the facilitators' 
evaluations of the intervention because that is important in 
terms of whether it is practical and can be used in the real 
world.
    We have developed a number of successful interventions, the 
first five that you see listed there are being disseminated now 
by the Centers for Disease Control, and we have two others that 
are efficacious that we hope to have disseminated soon, one of 
which is in South Africa, where the HIV epidemic is having the 
largest impact.
    In terms of scaling up, there are a number of issues that 
come into play in terms of whether success interventions are 
adopted. Sometimes they are not. What are the variables that 
affect that? Interventions often have to be adapted, which 
means changing them, and so the question is if you change it, 
does it still work? So what kinds of adaptations are useful, 
and which ones are harmful?
    And then the third question is if it is efficacious in a 
randomized-controlled trial, is it still effective when it is 
used by teachers in schools or health professionals in clinics? 
And so researchers are required to look at effectiveness as 
well.
    We at the University of Pennsylvania and the Behavioral 
Sciences Cores, we cover a lot of different populations and 
research in a variety of different venues that I will not be 
able to go into, and we collaborate with people in other 
disciplines within the Center, in immunology, and clinical core 
in particular, so we see how the different areas of science 
work together with social science to address these health 
problems.
    And I will stop here.
    [The prepared statement of Dr. Jemmott follows:]

               Prepared Statement of John B. Jemmott III

1.  Please describe your work to prevent the spread of HIV/AIDS among 
urban youth and other populations. What social and behavioral theories 
underlie your research? How do you apply those theories to design and 
test interventions that may reduce risky behaviors in your target 
populations? What are your measures of success?

    My colleagues and I have been conducting a program of HIV/STD risk-
reduction research in urban populations. Our research program has 
several objectives. First, we seek to identify the social psychological 
factors that underlie HIV/STD risk behavior. Second, we seek to 
identify theory-based strategies that are culturally and 
developmentally appropriate. Third, we evaluate the efficacy of those 
strategies using scientifically sound methodology. This usually 
involves the use of a randomized controlled trial in which participants 
are randomly assigned to receive the intervention or to a control 
condition. A randomized controlled trial provides the most 
scientifically valid evidence for the efficacy of an intervention. 
Fourth, we address practical questions about the best way to implement 
HIV/STD risk-reduction interventions. For instance, we have examined 
whether the efficacy of an intervention varies depending on the race of 
the facilitator, the gender of the facilitator, whether the facilitator 
is a peer or an adult, and whether the intervention is implemented in 
single-gender or mixed gender groups. Finally, if an intervention is 
found to be efficacious, we seek to disseminate it so that it is 
available to providers who can employ it to curb the spread of HIV 
among their clients. This also leads additional research questions 
regarding the adaptation of evidence-based interventions to new 
settings and populations, factors affecting the adoption of 
interventions by service providers, and factors affecting the 
effectiveness of interventions when implemented by service providers 
and in new settings or populations.
    Our research as been funded since 1988 by the National Institute of 
Mental (NIMH), the National Institute of Child Health and Human 
Development (NICHD), the National Institute of Nursing Research (NINR), 
the Centers for Disease Control and Prevention (CDC), and the American 
Foundation for AIDS Research. We have conduced research with a 
diversity of populations, including inner-city African American 
adolescents, African American parents and their adolescent children, 
African American women clinic attendees, African American and Latino 
adolescent female clinic attendees, African American HIV serodiscordant 
couples where one partner has HIV and the other does not, African 
American men who have sex with men (MSM), middle class White college 
students, English-speaking and Spanish-speaking Latino adolescents, 
Xhosa-speaking South African adolescents, and Xhosa-speaking South 
African men. We have conducted our studies in a variety of settings, 
including schools, churches, universities, adolescent medicine clinics, 
women's health clinics, community-based organizations, low-income 
housing developments, and neighborhoods/communities.
    To address the problem of HIV/STD in any society requires an array 
of interventions that can be implemented in a variety of venues by 
different kinds of facilitators. Accordingly our research has developed 
many different types of interventions. A contentious debate in the area 
of HIV education and sex education for adolescents has revolved around 
the extent to which interventions should emphasize sexual abstinence as 
opposed to condom use. We have developed safer-sex interventions 
emphasizing condom use, abstinence-only interventions, and 
comprehensive interventions stressing both abstinence and condom use. 
Another issue has been whether peer educators are more effective than 
adult facilitators in changing adolescents' sexual behavior. We have 
developed both peer-led and adult-led interventions. Most of our 
interventions have involved small groups of participants led by a 
facilitator or a pair of co-facilitators. However, we have also 
developed one-on-one individual interventions for certain 
circumstances: for instance, nurses serving women in a hospital clinic 
or service providers to African American MSM who may conceal their 
involvement with men and consequently would be unwilling to attend a 
small group intervention. We have identified several efficacious 
interventions, including Be Proud! Be Responsible!, Making Proud 
Choices--a Safer Sex Intervention, Making a Difference--an Abstinence 
Based Approach, Cuidate, which is a Latino-tailored adaptation of Be 
Proud! Be Responsible!, Sister to Sister, which is an intervention for 
African American women in clinical settings, Sisters Saving Sisters, 
which is an intervention for African American and Latino adolescent 
girls, and Let Us Protect Our Future, which is an intervention for 
South African adolescents. Of these interventions, Be Proud! Be 
Responsible!, Making Proud Choices, Making a Difference, Cuidate, and 
Sister to Sister have been included in dissemination initiatives of the 
CDC.
    Our experiences in this area teaches that two key characteristics 
of effective HIV/STD risk-reduction interventions are (a) grounding in 
behavior change theory and (b) tailoring to the population or culture 
served. The social and behavior theories that we have employed include 
the social cognitive theory and the reasoned action approach, which 
includes the theory of reasoned action and its extension the theory of 
planned behavior. We use social cognitive theory to suggest 
intervention strategies to achieve behavior change, including skill 
building, modeling, reinforcement, and activities to build self-
efficacy. We use the reasoned action approach to help identify beliefs 
that should be targeted by the interventions to achieve behavior 
change. We selected the reasoned action approach because it can be 
tailored to a variety of populations and cultures, which facilitates 
the development of contextually appropriate interventions.
    Consider the theory of planned behavior. Briefly, according to the 
theory, the best predictor of a specific behavior is an intention or 
plan to engage in the behavior. Although it is understood that people 
do not always live up to their intentions, if a person does not plan to 
engage in a behavior, then it is highly unlike that he or she will 
engage in the behavior. Research has demonstrated a strong longitudinal 
relationship between intention and sexual behaviors, including condom 
use and abstinence. The theory also suggests that a behavioral 
intention is determined by attitude, subjective norm, and perceived 
behavioral control or self-efficacy regarding the behavior. Thus, 
people should intend to use condoms if they evaluate condom use 
positively, if they believe significant others think they should use 
condoms, and if they feel confident in their ability to use condoms.



    A valuable feature of the theory of planned behavior is that it 
directs attention to why people hold specific attitudes, subjective 
norms, and perceived behavioral control or self-efficacy. Behavioral 
beliefs about the consequences of engaging in the behavior determine 
attitude toward using them. For instance, adolescents may believe that 
sexual involvement may interfere with their ability to achieve their 
educational goals. With regard to condoms, people may believe that if 
they use a condom, their risk of sexually transmitted HIV infection or 
pregnancy will be reduced. On the other hand, they may believe that 
using a condom would interfere with sexual enjoyment. If I perceive 
that the consequences of a behavior are good, then I am more likely to 
engage in the behavior than if I perceive that the consequences are 
bad. Normative beliefs about important referents' approval or 
disapproval of the behavior determine subjective norm. These 
significant referents might include peers, parents, other relatives, 
church members, or sexual partners. Adolescents might be less likely to 
initiate sexual involvement if they understand that their parents would 
strongly disapprove of their having sexual intercourse. On the other 
hand, it may be difficult for adolescents to practice sexual abstinence 
it they believe that all of their friends approve of their having 
sexual intercourse. Control beliefs about factors that facilitate or 
inhibit condom use determine perceived behavioral control or self-
efficacy. This might include beliefs about the availability of condoms. 
If people are embarrassed to purchase or carry condoms they may not 
have them available when they need to use them. Impulse control beliefs 
concern people's confidence that they can control themselves enough to 
use condoms when sexually excited. Perhaps most emphasized in HIV 
prevention research are negotiation beliefs, which concern the people's 
confidence that they can persuade their sexual partners to practice 
sexual abstinence or to use condoms. Technical skill beliefs concern 
the people's ability to use condoms correctly and without ruining the 
mood.
    Several other factors may affect people's sexual risk behavior, 
including prior sexual experiences, race/ethnicity, gender, age, 
poverty, gender-role beliefs, parental monitoring and supervision, 
parent-child communication, religiosity, and alcohol and drugs use. 
According to the theory these are external variables. The effects on 
intention and behavior of variables external to the theory are seen as 
mediated by their effects on the attitudinal component, the normative 
component, the perceived control component, or all three. In other 
words, external variables, including an intervention, may affect 
variables that are a part of the theory and through a mediation chain, 
influence behavior. For instance, gender-role beliefs may influence a 
woman's confidence that she can negotiate condom use with her partner 
and may thereby affect condom-use intention and condom use. External 
variables may also moderate an intervention's efficacy. For instance, 
girls initiate sex at an older age than do boys, and girls have less 
power over the use of condoms than do boys. Accordingly, gender may 
both predict sexual debut and moderate the intervention's efficacy in 
increasing condom use.
    Given the way in which the theory explains the impact of external 
variables, the theory offers a clear prescription for the development 
of an intervention. We could design interventions to affect behavioral, 
normative, and control beliefs and through a mediation process 
influence intention and the targeted behavior. The theory also 
suggested a strategy for identifying the relevant beliefs: namely, 
target the salient behavioral, normative, and control beliefs in the 
specific population. Researchers can use qualitative research methods, 
including focus groups, key informant interviews, and elicitation 
studies, with the population to identify the salient beliefs. By 
targeting salient beliefs, an intervention may change attitude, 
subjective norm, and perceived self-efficacy, which would change 
intention, which, in turn, would change behavior. Identifying the 
population-specific salient beliefs serves to make the theory and the 
resulting intervention appropriate for the population. Perhaps most 
important, the theory suggested that the relative predictive power of 
the attitudinal, normative, and control components of the theory could 
vary from population to population. Thus, the prediction of a 
behavioral intention might be different in middle-class white college 
students as compared with low-income African American women as compared 
with African American MSM, but the theory might have predictive value 
in each of these populations.
    In developing our interventions we have conducted several phases of 
research. First, we conduct qualitative research with the population or 
culture, not only to identify the salient behavior, normative, and 
control beliefs regarding the behaviors we seek to change, but also to 
identify the contexts in which the behaviors occurs. An understanding 
of the context is essential to developing an intervention that is 
appropriate to the population. For example, knowing that adolescents 
are more likely to have sex when they are home can help researchers 
develop role-play scenarios regarding refusal to have sex that seem 
authentic to the participants. The second phase of research is to 
develop and employ a questionnaire to confirm that the salient beliefs 
identified are, in fact, related to the behaviors of interest. The 
third phase is to use the information from the first two phases to 
develop an intervention. In other words, the qualitative information 
about the culture or population and the quantitative information from 
the survey are integrated with the theoretical framework to create an 
intervention that is both grounded in the theory and tailored to the 
population or culture. The fourth phase is to pilot test the 
intervention, collect comments and criticisms from the participants and 
facilitators, and then design the final version of the intervention. 
The fifth phase is to test the efficacy of the intervention.
    Randomized controlled trials provide the most scientifically sound 
evidence for the efficacy of an intervention. We measure the success of 
our efforts to develop efficacious interventions by examining the 
quantitative and qualitative results of the randomized controlled 
trials. We typically have three specific aims in testing the efficacy 
of the intervention. First, we examine whether the intervention 
significantly improved sexual behavior outcomes, including abstinence, 
condom use, unprotected sexual intercourse, and multiple sexual 
partners. In some studies, we also examine whether the intervention 
influenced biological outcomes, that is, reduced the incidence of 
sexually transmitted infections. A focus on STI is important because it 
provides an outcome measure that is objective and less likely to be 
influenced by a socially desirable responding by research participants. 
In addition, it provides an actual health outcome for the intervention. 
Typically, our second aim concerns moderators of intervention efficacy: 
namely, whether the intervention is more effective with some 
participants as compared with others. For example, does the 
intervention have a better effect on adolescent boys as compared with 
girls, virgins as compared with sexually experienced adolescents, or 
single people as opposed to those in committed relationships? Or 
perhaps the intervention has a better effect when implemented in 
single-gender groups as compared with mixed gender groups or when the 
facilitator is the same gender as the participant. A third aim of our 
research is to test the mediation of the effects of the intervention on 
behavior: namely, if it changes behavior, why did it changed behavior, 
and if it did not change behavior, why it failed to change behavior. 
This is very important to future research to improve the intervention. 
This involves examining the theoretical mediators, that is, the beliefs 
the intervention targeted. Did the intervention actually have an impact 
on the beliefs it was designed to change? Were the beliefs related to 
the behavior we sought to change? By conducting this kind of mediation 
analysis a better understanding of why the intervention worked or did 
not work will emerge. Thus, we measure our success by examining whether 
the intervention changed behavior, whether it was more efficacious with 
some participants or under certain circumstances, and why it was or was 
not efficacious.
    Here are some examples of studies we have conducted. In each study, 
we followed the five phases mentioned earlier in developing and testing 
the interventions. One randomized controlled trial tested the efficacy 
of clinic based HIV/STD interventions. African American and Latina 
adolescent girls at the adolescent medicine clinic of a children's 
hospital were randomized to one of three interventions focused on HIV/
STD information, HIV/STD behavioral skill building, or general health 
promotion among, with 89 percent retained at 12-month follow-up 
(Jemmott, Jemmott, Braverman, and Fong, 2005). The skills building 
intervention participants reported less frequent unprotected 
intercourse and fewer sexual partners and were less likely to test 
positive for an STD at 12-month follow up, as compared with the health-
promotion control intervention. The efficacy of the intervention did 
not differ between the Latino as compared with the African American 
girls. We developed the ``Sister to Sister'' HIV/STD risk-reduction 
curriculum and evaluated it in a randomized controlled trial with Black 
adult women at a women's health clinic in Newark, NJ (Jemmott, Jemmott, 
& O'Leary, 2008). Among the 86.9 percent that returned for 12-month 
follow-up, those in the Sister-to-Sister intervention had reduced 
unprotected sexual intercourse and biologically confirmed STD rates as 
compared with those in the health control group.
    In another randomized controlled trial, Jemmott, Jemmott, and Fong 
(1998) assigned 659 African American adolescents to an abstinence 
intervention, a safer sex intervention, or a health-promotion control 
intervention. About 98 percent attended all sessions of the two-session 
interventions, and 93 percent returned for the 12-month follow-up. The 
safer sex intervention significantly increased condom use compared with 
the control group at three-, six-, and twelve-month follow-ups. The 
abstinence intervention significantly reduced self-reported intercourse 
at three-month follow-up compared with the control group. This was the 
first randomized controlled trial demonstrating that an abstinence 
intervention was efficacious in reducing sexual involvement. The 
interventions were equally efficacious when implemented by peer co-
facilitators as compared with adult facilitators.
    Finally, we recently completed a randomized controlled trial 
developing and testing the efficacy of an HIV/STD risk-reduction 
intervention for young South African adolescents, ``Let Us Protect Our 
Future'' (Jemmott, Jemmott, O'Leary, Ngwane et al., 2008). We randomly 
selected nine matched pairs of schools and randomly allocated schools 
to either a HIV/STD risk-reduction intervention or a health promotion 
control intervention. Grade 6 students completed baseline, post-
intervention, three-, six-, and twelve-month follow-up surveys written 
in Xhosa following translation and back-translation from English. We 
found that a significantly smaller percentage of students in the HIV/
STD risk-reduction intervention reported having vaginal intercourse, 
unprotected vaginal intercourse, and multiple sexual partners, as 
compared with their counterparts in the health-promotion control 
intervention. The intervention's efficacy did not differ significantly 
between girls and boys. Thus, our intervention approach, which 
integrates qualitative information about a population with behavior 
change theory, can be applied successfully not only to diverse 
populations in the United States, but also to populations in sub-
Saharan Africa where HIV is exacting its most devastating toll.

2.  How might successful programs in behavioral interventions for AIDS 
prevention be scaled up, applied to other public health challenges, or 
otherwise used to better inform public policy?

    Considerable evidence from studies here in the United States and 
abroad documents that HIV/STD risk-reduction interventions can reduce 
sexual risk behaviors in a wide range of populations, including 
adolescents, women, men who have sex with men (MSM), substance users, 
patients in clinic settings, and other persons at risk. To have the 
most impact on the HIV/AIDS epidemic, these successful preventive 
interventions must be scaled up. We would argue that interventions 
would be easier to scale up if the intervention developers consider the 
likely end-users of the intervention during the process of development. 
In this way, they are more likely to develop an intervention that can 
be widely used than if practical questions are not considered from the 
very beginning. For example, if we are to develop an intervention for a 
broad range of African American MSM, we should consider not only 
whether it will be most efficacious when implemented by African 
American MSM facilitators, but also how realistic is it to scale up an 
intervention for African American MSM that must be implemented by 
African American MSM facilitators. If we know that women are the most 
common case managers for African American MSM, it might be more 
practical to examine whether women could successfully serve as 
facilitators of an intervention for the population. Clearly, an 
intervention that could be implemented by either women or African 
American MSM would be easier to scale up than one that must be 
implemented by African American MSM. This is just one example; the 
point is that efforts to scale up may be most successful if scaling up 
is considered from the beginning.
    Certainly, in the early years of HIV/STD risk-reduction research, 
the emphasis was appropriately on discovering interventions that could 
successfully change behavior. Now, that we know we can develop 
interventions to change behavior it is appropriate to shift the 
emphasis and focus on the development of interventions that can be 
scaled up. Several issues need to be considered when we focus on 
scaling up, among them are adaptation, adoption, and effectiveness of 
interventions.
    Research is needed on the how to adapt evidence-based interventions 
to meet the needs of different communities. This is important because 
to adapt is to change, and change may mean creating a new intervention 
that may or may not retain the efficacy of the evidence-based 
intervention. Research is needed to understand how to adapt 
interventions for new populations or settings while retaining the 
qualities that made the interventions efficacious. In this connection, 
a distinction is sometimes drawn between core elements of an 
intervention and key characteristics of an intervention. Core elements 
are aspects of an intervention that are considered essential to its 
efficacy and therefore should not be changed, whereas key 
characteristics are not essential to achieve efficacy and therefore can 
be modified. More research is needed to more fully understand which 
aspects of interventions are truly core elements and which are merely 
key characteristics.
    Research is needed on why evidenced-based interventions are or are 
not adopted. Although successful interventions are published in 
scientific, medical, and public health journals and therefore brought 
to the attention of researchers, academics, and professionals, the 
majority of service providers who work closely with populations at risk 
may remain unaware of the interventions. Thus, efforts must be made to 
disseminate successful interventions to likely end-users. The question 
then becomes whether these service providers decide to adopt the 
evidence-based intervention. The fact that service providers know that 
an intervention successfully changed behavior in a study does not 
necessarily mean that service providers will immediately adopt it. 
Other considerations figure in the decisions of service providers to 
use a given intervention. Research is needed into these decisions in 
order to devise effective strategies to encourage the adoption of 
evidence-based interventions. This may include research into ways to 
train service providers to implement the intervention, identifying and 
providing appropriate kinds of technical assistance, identifying 
barriers to adopting the intervention among all relevant 
constituencies. Examples of such barriers are funding, reasonable 
salaries for talented staff, high rates of turnover, organizational 
mission, and inadequate organizational capacity or infrastructure.
    A third type of research needed concerns the effectiveness of 
evidenced-based interventions when they are disseminated. Such studies 
are sometimes called Phase IV trials and distinguished from Phase III 
trials designed to test the efficacy of interventions. Although 
carefully controlled Phase III studies employing well trained and 
monitored facilitators who adhere to the intervention protocol strictly 
may demonstrate that an intervention is efficacious, it does not 
necessarily mean it will be effective when implemented under less 
controlled real world circumstances. Thus, Phase IV trials are needed 
to identify factors that affect the effectiveness of interventions when 
implemented by service providers with their client populations in their 
settings. These factors could then be taken into account both in the 
development of future interventions that can be more successfully 
scaled up and in the training of providers in the use of interventions. 
Examples of factors that might affect the effectiveness of an 
intervention are characteristics of the organization, including 
organizational mission, the type of training the service providers 
receive, technical assistance, supervision of staff, and staff 
turnover.
    Here is an example of a Phase IV effectiveness trial. After 
conducting several Phase III trials of the efficacy of the Be Proud! Be 
Responsible! intervention, we conducted a Phase IV trial of its 
effectiveness when implemented by service providers at community-based 
organizations (CBOs) serving African American adolescents 13 to 18 
years of age. We randomized 86 CBOs to implement ``Be Proud! Be 
Responsible!'' or a control health promotion intervention on diet and 
physical activity. In addition, we randomly assigned the CBOs to 
receive three different amounts of training. Each CBO implemented its 
assigned intervention with six groups of adolescents (N=3,448), and we 
randomly selected three of the six to complete three-, six-, and 
twelve-month follow-up surveys (N=1,707). We found that adolescents who 
received the HIV/STD intervention were more likely to report consistent 
condom use than were those who received the health-promotion control 
intervention. In addition, the effectiveness of the intervention did 
not improve significantly when the CBOs were given more expensive and 
labor-consuming training. This finding suggests that an HIV/STD risk-
reduction intervention whose efficacy has been established can be 
effective when implemented by CBOs, which play a critical role in the 
delivery of HIV/STD prevention services worldwide. Moreover, the 
training of the CBOs need not be especially expensive or labor-
intensive to achieve desirable outcomes.
    The findings from research on behavioral interventions to prevent 
HIV can be applied to other public health challenges. The leading 
causes of morbidity and mortality in the United States and in most 
parts of the world are health problems that are either caused by or 
affected by behavior and whose treatment or course are influenced by 
behavior. National health organizations throughout the world as well as 
international organizations all offer similar behavioral guidelines on 
how to reduce the risk of leading causes of premature death. These 
include guidelines regarding not only sexual behavior but also 
cigarette smoking, healthful diet, physical activity, alcohol 
consumption, and other use of other substances, screening behaviors, 
and treatment adherence. Given the focus on behavior, the same type of 
focus on behavior change theory and tailoring to the population is 
likely to be successful in efforts to address these other pressing 
public health issues.
    We can say this with confidence because although we are primarily 
HIV/STD risk-reduction researchers, in all of our studies we also 
include a control group that receives an intervention. A common control 
group intervention is a health promotion intervention that focuses on 
how chronic diseases can be preventing by engaging healthful behavior. 
This usually involves focusing on fruit and vegetable consumption and 
physical activity as a means to reduce the risk of hypertension, heart 
disease, obesity, and certain types of cancer. In developing these 
chronic disease prevention strategies we employ the same phases of 
research as in developing the HIV/STD interventions. Thus, we conduct 
qualitative research to identify salient behavioral, normative, and 
control beliefs and the context of the behaviors and then integrate the 
information with our theoretical framework to develop the intervention. 
An example of the success of this approach is the trial we recently 
completed in South Africa with grade 6 students. Our health promotion 
intervention was efficacious. Students who received the health 
promotion intervention reported more fruit and vegetable consumption 
and more physical activity over the twelve-month follow-up period than 
did those who received the HIV/STD risk-reduction intervention.

3.  Please provide an overview of the range of topics addressed by the 
Behavioral and Social Sciences division of the Penn Center for AIDS 
Research. What is the nature of the relationship between your division 
and the Center's other divisions in biological sciences and clinical 
research? How might social and behavioral research be used more 
effectively to guide or take advantage of biomedical research and vice 
versa? Given the potential for behavioral interventions to prevent the 
spread of HIV/AIDS and many other diseases, is the Federal Government 
investment in behavioral research reasonable relative to its total 
investment in research to prevent and treat these diseases?

    The Behavioral and Social Sciences (BSS) Core of the Penn Center 
for AIDS Research (CFAR) focuses on studies of risk behavior and 
outcome research as well as studies of epidemiologic, economic, and 
bioethical aspects of AIDS. Additional goals of this group are to 
develop strong linkages with the academic community of the University 
outside the Medical Center in order to establish a broad-based and 
comprehensive program in AIDS research. More specifically, the BSS Core 
services are guided by and designed to promote the following set of 
scientific priorities and principals: 1) Contextual circumstances 
(social, sexual, and drug using networks; community; geography) within 
which HIV transmission occurs and infection exists are crucial factors 
to understanding and responding to risk of infection, access and 
adherence to treatment; 2) Behavioral sciences have a critical role to 
play in the design and evaluation of clinical trials of both behavioral 
and biomedical interventions (microbicides, vaccines, and 
therapeutics); 3) Linkages between investigators (behavioral, clinical 
and basic), locally, domestically, and internationally is critical to 
the development of sustainable programs of innovative and meaningful 
AIDS research.
    Members of the BSS Core have an impressive history of productivity 
over the past 20 years and continue to be active in the behavioral and 
social science aspects of AIDS. The work of these faculty include the 
development of important and widely applied theory, the design and 
implementation of theoretically based prevention interventions, and 
leadership and participation in multi-site clinical trials of 
behavioral and biomedical interventions. The BSS Program has a rich 
portfolio of active AIDS research characterized by close collaborations 
among program members and between CFAR programs. The following provides 
a brief overview of the current work of the program with particular 
emphasis on those studies that the CFAR has been instrumental in 
facilitating.

International HIV Prevention Research

    BSS program members have been actively involved in an expanding 
international research agenda. In collaboration with Penn 
investigators, the University of Botswana was recently awarded a 
capacity building grant by NICHD. Botswana has the second highest rate 
of HIV/AIDS in the world. A limited capacity and infrastructure for 
rigorous HIV/STD prevention research has hampered efforts to curb the 
spread of sexually transmitted HIV infection among adolescents in 
Botswana. Accordingly, the broad long-term objective of the grant is to 
build capacity and infrastructure to develop, implement, and evaluate 
culturally competent, developmentally appropriate, sustainable 
interventions suitable for implementation in a variety of settings to 
dissuade Botswana adolescents from engaging in behaviors that increase 
their risk for sexually transmitted diseases (STDs), including HIV. 
This grant is a collaborative effort of a multi-disciplinary team of 
researchers at the University of Botswana and the University of 
Pennsylvania to build such capacity and infrastructure at the 
University of Botswana. It is directed by Bagele Chilisa at the 
University of Botswana and John Jemmott at the University of 
Pennsylvania. The capacity building is organized around three cores. 
Qualitative and Quantitative Methodology Core, Social and Behavioral 
Intervention Core, and the Administrative Core. In addition, three 
research projects that draw upon the cores to address adolescents in 
different settings were proposed: School-Based HIV/STD Prevention, 
Church-Based HIV/STD Prevention, and HIV/STD Prevention for Adolescents 
Living with HIV. The Principal Investigator of each core and research 
project is a University of Botswana faculty member and the Co-Principal 
Investigator is a University of Pennsylvania faculty member. Penn BSS 
Core faculty involved in the Botswana project include J. Jemmott, L. 
Jemmott, Metzger, Fishbein, Blank, Heeren, Teiltelman, Coleman, and 
Stevenson. In addition to the University of Botswana collaboration, 
Jemmott and Jemmott are implementing an NIMH funded school-based 
prevention program in South Africa and an NICHD-funded cluster-
randomized controlled to test the efficacy of a HIV/STD risk-reduction 
intervention among adult men in 48 randomly selected neighborhoods in 
Eastern Cape Province, South Africa.
    George Woody's work evaluating naltrexone treatment for high risk 
heroin injectors in St. Petersburg has led to currently funded studies 
of naltrexone implants in St. Petersburg and methadone treatment among 
HIV positive heroin users in Ukraine. Woody is conducting a NIDA 
supported randomized trial examining the efficacy of oral naltrexone 
(an opiate antagonist) with and without fluoxetine for relapse 
prevention to heroin addiction in St. Petersburg, Russia. This study is 
being done in collaboration with investigators from the Pavlov State 
Medical University and the Leningrad Regional Center for Addiction 
Treatment. An important component of this research is the measurement 
of HIV risk behavior since intravenous drug use is the primary route of 
HIV transmission in St. Petersburg. The findings thus far suggest 
significant reduction of heroin use and injection related risk 
behaviors among those receiving naltrexone. Adherence rates for 
naltrexone are also substantially higher than those found in prior 
studies of naltrexone. A supplement to the Penn CFAR has extended the 
St. Petersburg work to study co-morbidities between alcoholism, heroin 
addiction, TB, hepatitis and HIV. These projects have laid the 
groundwork for a CIPRA application to fund an HIV education, treatment, 
prevention and research center at Pavlov. Woody has an ongoing 
collaboration with researchers at the University of Rio Grande do Sul 
in Porto Alegre, Brazil. This group recently reported the results of a 
sero-incidence study modeled after the longitudinal work being 
conducted in Philadelphia, among cocaine users in Porto Alegre. The 
study estimates an HIV sero-incidence rate of 5.03/100 person years of 
follow-up. The findings of the work have formed the basis further 
prevention initiatives in Porto Alegre including the recent submission 
of a CIPRA application to establish a collaborative HIV research 
center.
    David Metzger is the protocol Chair for the HPTN 058, the first 
randomized trial of drug treatment (suboxone) using sero-incidence as 
an endpoint. He is also an investigator on a NIDA supplement (Richard 
Schottenfield PI; Yale University) to evaluate Behavioral and Drug Risk 
Counseling in methadone treatment in Wuhan, China. The work in Wuhan 
has evolved from and earlier collaboration with WenZhe Ho and 
investigators from the Chinese CDC, which examined changes in immune 
function during detoxification at a detoxification center in Wuhan. 
Metzger has also completed research on ACASI risk assessments with 
Brazilian collaborators during the funding period. Metzger has been 
collaborating on several projects designed to develop assessments of 
HIV risk behaviors in Brazil. In Porto Alegre, the Risk Assessment 
Battery was adapted and evaluated for validity and reliability and in 
Rio De Janeiro an ACASI risk assessment has been developed an evaluated 
for use with drug using populations entering treatment.
    Toorjo ``TJ'' Ghose, is a new investigator in the School of Social 
Policy and Practice, having joined the Penn faculty in 2007 after 
completing post-doctoral training at the Center for Interdisciplinary 
Research on AIDS (CIRA) at Yale University. He has recently been funded 
as part of the Penn CFAR Pilot study program to conduct a project 
entitled ``Implementing PATH India: Reducing HIV risk among the dually-
diagnosed in India,'' building on the work done domestically by Blank. 
This research examines HIV risk among treatment seekers at the All 
India Institute of Medical Sciences (AIIMS) in New Dehli who have been 
dually diagnosed with a mental health and substance use disorder. The 
pilot study comprises two phases, a first phase in which knowledge, 
attitudes, and risk behaviors are assessed for 200 persons, and a 
second phase in which PATH is translated and pilot tested for 20 
persons in a randomized pilot study. Collaborators at AIIMS have been 
working with Ghose, an Indian native, for several years and have been 
full partners in the development of the pilot study.
    Hans-Peter Kohler, a sociologist, Susan Watkins, a sociologist, and 
Jere Behrman, an economist, of the Population Studies Center, are 
leading an investigation of partnership patterns among couples in 
Malawi. This work, which received CFAR developmental funding initially 
and is now supported with NICHD funds, is built upon a longstanding 
social network research initiative Kenya. The goal of this project is 
to examine the role of networks in changing attitudes and behavior 
regarding family size, family planning, and HIV/AIDS in Malawi. The 
project focuses on two key empirical questions: the roles of social 
interactions in (1) the acceptance (or rejection) of modern 
contraceptive methods and of smaller ideal family size; and (2) the 
diffusion of knowledge of AIDS symptoms and transmission mechanisms and 
the evaluation of acceptable strategies of protection against AIDS (69-
72). Behrman also has grant support from NICHD to examine how economic 
transfers that provide support for dependent children and elderly are 
affected in a context in which HIV/AIDS and poor health has weakened 
traditional support networks. Tukufu Zuberi, a sociologist and 
demographer in Penn's Population Research Center, directs the African 
Census Analysis Project in collaboration with social scientists, 
demographers, and public health specialists in 14 African countries. 
This project provides CFAR investigators working in Africa with access 
to university resources including survey research resources and public 
health populations and HIV testing facilities. An important focus of 
the Census project is the demographic impact of the HIV epidemic in 
Africa. Mark Pauly, professor of economics at the Wharton School, is 
funded by a Fogarty award to collaborate with colleagues at the 
University of Natal in Durban, South Africa to assess the impact of 
poor health and HIV/AIDS on small businesses and the local economies 
where they are located in South Africa.

Health Services and Policy Research

    Although much of the work described above has important 
implications for HIV policy regarding prevention and care, a number of 
faculty have been involved in policy specific research. Policy related 
investigations by BSS program members have focused on access to care 
for HIV positive individuals and the structure of health care delivery. 
Dr. Barbara Turner's work has documented substantial deficiencies in 
the care of HIV+ persons nationally. Linda Aiken's research group has 
made important contributions to the development and evaluation of AIDS 
prognostic staging measures for use in controlling for severity of 
illness in the evaluation of treatment effects, in understanding the 
impact of organization of AIDS services on outcomes of care, and 
assessing racial disparities in AIDS health services and outcomes. 
Dennis Culhane of the School of Social Work, the Population Studies 
Center, and the Center for Mental Health Policy Research has examined 
the relationship between AIDS and homelessness in Philadelphia by 
integrating the City's administrative data bases for AIDS surveillance 
and public shelter utilization. Martin Fishbein has had a major 
influence on HIV prevention through the development and application of 
the Theory of Reasoned Action which he co-developed. He has been very 
active in research designed to test this theory in community trials 
including ``Project Respect'' which has greatly influenced HIV 
counseling strategies both domestically and internationally. He has 
continued to urge HIV behavioral research to recognize the important 
role theory in prevention and the need to integrate behavioral and 
biological measures in a rational manner. Currently he is leading a 
five year research effort designed to examine the link between exposure 
to sexual content in the media and sexual risk behaviors among 
adolescents.
    The BSS program includes several key faculty who have been 
important in the national and international response to the AIDS 
epidemic and who, although their work is not currently centered on AIDS 
research, are important resources to the program. Robert Boruch, a 
social statistician in the Graduate School of Education, chaired the 
National Research Council (NRC) Committee on AIDS Research and the 
Behavioral, Social, and Statistical Sciences's Panel on the Evaluation 
of AIDS Interventions. Boruch co-edited the NRC volume, Evaluating AIDS 
Prevention Programs. He is Director of the Campbell collaborative and a 
major voice in the public policy research, design and analyses. Robert 
Hornik, a noted social scientist in mass media communication and 
behavior change at Penn's Annenberg School of Communications, was a 
central participant in the AIDS Public Health Communications Program 
(AIDSCOM), and evaluated mass media interventions to prevent the spread 
of AIDS in Uganda, Zambia, Ghana, and Dominican Republic. Hornik has 
evaluated AIDS education and communication programs for WHO's Global 
Program on AIDS. Hornik and Fishbein, at Annenberg, have evaluated the 
impact of the mass media anti-drug campaign supported by the White 
House Office on Drug Control Policy.

Intervention Development and Testing with Adolescents

    John Jemmott's work has made significant contributions to HIV 
prevention theory and practice among high-risk African American 
adolescents in community-based settings. He is currently directing a 
very active program of prevention research. As the director of the 
Center for Behavior and Health Communications Research, Department of 
Psychiatry, School of Medicine, Jemmott and his group are leading a 
randomized controlled trial investigating the efficacy of abstinence 
and safer sex interventions with inner-city grade six and seven African 
American adolescents. One important result of that study was that a 
theory-based culturally tailored abstinence-only intervention reduced 
sexually intercourse during a 24-month follow-up period as compared 
with a health promotion control group. This is the first study to 
document an efficacious abstinence-only intervention over a two-year 
follow-up.
    Loretta Sweet Jemmott continues to conduct research focused on 
identifying modifiable psychological factors that underlie behaviors 
that lead to risk for sexually transmitted HIV infection among urban 
African Americans, and on designing and testing theory-based, 
culturally sensitive, developmentally appropriate interventions to 
reduce those risks. She has also conducted a number of theory-based 
descriptive studies that use theoretical frameworks to predict risky 
sexual behaviors among adolescents. She has been funded by the NINR to 
coordinate a partnership with the Hampton University School of Nursing 
designed to develop and evaluate strategies intended to narrow the gap 
in health disparities between American citizens of different ethnic and 
racial origins. Sweet Jemmott is leading a randomized trial of a theory 
based an abstinence-only intervention with parents and their adolescent 
children identified through black churches in Philadelphia.
    Subsequent to pilot funding through the Developmental Core, Anne 
Teitelman was successful in securing a K01. This Career Development 
Award will to establish a rigorous academic foundation for a research 
career devoted to developing and testing novel interventions for 
reducing HIV risk for adolescents. Thematically, the K01 will address 
the social context of HIV risk by integrating effective theory-based 
adolescent HIV prevention with promising partner abuse prevention 
strategies, emphasizing promotion of healthy relationships. It uses 
family planning clinics as a venue for providing a skill-based, 
culturally-tailored HIV and partner abuse prevention educational and 
advocacy program for African American girls living is economically 
disadvantaged circumstances. Partner abuse, which significantly 
increases risk for HIV, disproportionately affects low income African-
American adolescent girls, as does HIV. Critical to this project is the 
candidate's demonstrated ability to conduct HIV/STD research in 
partnership with minority communities, a long-term engagement in 
interdisciplinary scholarship aimed at improving health and a 20-year 
history as a primary care provider. The research plan is divided into 
two phases, both guided by social cognitive and gender theory. In phase 
1 she will conduct focus groups and individual interviews in order to 
develop and tailor the HIV/partner abuse intervention for adolescent 
girls and in phase 2 she will evaluate the initial acceptability and 
feasibility of this intervention in a limited RCT. Dr. Tetitelman's 
mentors on this project include BSS program members L. Jemmott and J. 
Jemmott.

Intervention Development and Testing with Couples

    J. Jemmott and his group are leading a major NIMH funded four-city 
multi-site cluster-randomized intervention trial on sexually active HIV 
serodiscordant African American couples. Couples in which one person 
has HIV and the other does not are randomly assigned to a sexual risk 
reduction intervention or a chronic disease prevention control 
intervention. Participants provide biological specimens for STD assays 
and compete ACASI at baseline, immediately post-intervention, and six 
and twelve months post-intervention. Thus far, the study has achieved 
very high retention rates in this high risk population, over 90 percent 
have completed the twelve-month follow-up assessment. The project 
involves BSS program members as co-investigators (Metzger, L. Jemmott, 
and Maslankowski) and receives services from the Clinical Core and the 
BSS Core in recruitment and assessment support. The data coordinating 
center for this multi-site trial is being directed by J. Richard Landis 
of the Biostatistics Core.

Intervention Development and Testing for Persons with Mental Illnesses

    Michael Blank examines mental health and substance abuse and 
relationships with HIV risk. His previous research with the SMI 
population has demonstrated high rates of both psychiatric and general 
medical comorbidity. Likewise, the HIV positive population has 
dramatically elevated rates of mental illness and other physical co-
morbidities. Blank's work has been substantially impacted by the Penn 
CFAR resulting in two R01 awards, and R13 to support three national 
scientific meetings of the SBSRN, and a U18 from the CDC in 
collaboration with investigators from the University of Maryland to 
examine implementation of HIV testing in community mental health 
settings. This work has evolved with investigators from the Center for 
Mental Health Policy Research and the Center for Health Outcomes and 
Policy Research at the School of Nursing (Aiken). These projects 
evolved from analyses of Medicaid claims data that found that the 
relative risk of HIV/AIDS is at least five times greater in persons 
with serious mental illness (SMI) relative to the general Medicaid 
population in Philadelphia and over seven times greater for those also 
treated for substance abuse. A cost study linked to these data showed 
that SMI with HIV had much higher health care costs than non-SMI 
persons with HIV and non-HIV persons with SMI. Based in part on these 
findings, and with co-investigators Aiken, Hines, Fishbein, Gross, 
Rothbard, and TenHave, Blank has been conducting an NINR funded 
investigation to study the effectiveness of integrating advanced 
practice nursing into ongoing Targeted Case Management (TCM) to enhance 
adherence to treatment regimens among persons with serious mental 
illness (SMI) who are also HIV positive. The work is built around a 
Public-Academic Liaison (PAL) model involving mental health services 
researchers from a number of specialized research centers at the 
University of Pennsylvania, with the public health and mental health 
programs in the City of Philadelphia.
    Blank has also has been conducting a randomized community trial of 
a preventive intervention delivered by mental health case managers in a 
one-on-one format for persons with SMI who also abuse substances. The 
intervention entitled, Preventing AIDS Through Health (PATH) is an 
evidence-based intervention that integrates features from the CDC 
project Respect to encourage safer sexual practices and promote condom 
use with aspect of the NIDA Community-based Outreach Model to reduce 
risk of blood-borne infections resulting from substance abuse. Co-
investigators for this work include Fishbein, Metzger, Hadley, Solomon, 
Rothbard, and Ten Have.
    Blank has also been directing a multi-site U18 project from CDC to 
increase HIV testing and improve linkage to care for HIV-infected in 
community mental health settings with large numbers of numbers of 
African Americans. Using a six-month longitudinal design, he will be 
enrolling participants who meet inclusion criteria for assessment, 
counseling, and Rapid HIV Testing at baseline. These participants will 
be interviewed again at six months post intervention. The study is 
designed to evaluate changes in HIV risk behaviors, linkages to HIV 
care, and subsequent use of mental health services. As the primary 
coordinating institution, the Penn research team will be collaborating 
with a mix of three types of facilities in Philadelphia and Baltimore, 
through our collaborators at the University of Maryland. Target 
facilities in both cities include university-based inpatient 
psychiatric units, Community Mental Health Centers (CMHCs), and 
Assertive Community Treatment (ACT) programs.

Intervention Development and Testing for Persons who Abuse Substances

    L. Jemmott is leading a randomized trial of a theory based sexual 
risk reduction intervention targeting African American women in drug 
detoxification. BSS program members who serve as co-investigators 
include J. Jemmott and Metzger. The intervention will be evaluated 
using STD incidence and self-reported sexual behavior as measured via 
ACASI.
    Philippe Bourgeois joined Pen and the CFAR BSS Program in 2007 as 
the fifth Penn Integrates Knowledge (PIK) Professor. PIK Professorships 
are awarded to exceptional scholars whose research and teaching 
exemplify the integration of knowledge across academic disciplines. Dr. 
Bourgois has earned international acclaim for his ethnographic research 
with drug abusers. He has devoted much of his recent research to the 
prevalence of violence and disease among homeless drug abusers in San 
Francisco. Bourgois's books include In Search of Respect: Selling Crack 
in El Barrio, which received the 1996 C. Wright Mills Prize from the 
Society for the Study of Social Problems of the American Sociological 
Association and the 1997 Margaret Mead Award from the American 
Anthropological Association and the Society for Applied Anthropology. 
Bourgois is currently funded to examine the HIV and HCV risk 
implications of the growing phenomenon in the United States of 
prematurely geriatric substance abusers by examining the aging process 
among both young and older injectors. He is contributing to a socio-
culturally contextualized understanding of variance in HIV and HCV 
infection rates among differentially vulnerable profiles of street 
based IDUs that is informed theoretically at the macro-structural 
level. A cross-generational and multi gender ethnographic team will 
collect qualitative data inside the shooting/sleeping encampments and 
income generating territory of two overlapping social networks of 
injectors (core N = 25-40 at any given time; peripheral N = 50-70). The 
project extends its ongoing collaboration with epidemiologists to 
clinical researchers and researchers and caregivers who work with 
comparable data sets of injectors in San Francisco in order to engage a 
multi-method dialogue. An immediate applied goal is to promote 
communication across the research/service interface. We will offer 
providers of health care, outreach and treatment an indigenous 
perspective on the effectiveness of their services among substance 
abusers by age cohort through our comparative study of: 1) injectors 
from the baby boom generation who are advancing from mid-life to old 
age with rapidly deteriorating health and ongoing HIV risk; and 2) 
homeless youth injectors (many of whom are the children of middle-aged 
substance abusers) who engage in risky injection and sexual practices.
    Charles Dackis, MD, an experienced researcher in substance abuse 
treatment has recently been supported by NIDA to conduct a trial to 
evaluate the efficacy of modafinil as a treatment for cocaine 
dependence in women, and as a means of reducing high-risk behavior 
(HRB) that increases the likelihood of HIV seroconversion. Modafinil, a 
wake-promoting medication that is approved for narcolepsy, has a low 
abuse potential despite its alerting effect. Modafinil also blocks 
cocaine-induced euphoria under controlled conditions [2, 3] and may 
reverse clinically significant cocaine-induced neuroadaptations. An 
effective pharmacological treatment for cocaine dependence should also 
reduce HIV seroconversion by diminishing unsafe sexual practices that 
often accompany cocaine procurement. Cocaine enhances sexual arousal 
and increases reckless sexual activity, including trading sex for 
cocaine with multiple partners. Cocaine-addicted women who engage in 
this dangerous practice are particularly vulnerable to HIV 
seroconversion and in need of effective treatment. Needle sharing by 
intravenous cocaine users is another avenue of HIV transmission that 
could be targeted by effective treatment.

Intervention Development and Testing using Media Communications

    Martin Fishbein is Harry C. Coles Jr. Distinguished Professor in 
Communication at the Annenberg School and is internationally recognized 
for his theoretical work in behavior change theory and relationships to 
risk behavior such as HIV. He is currently funded to examine media 
influences on risk behavior among adolescents. The media is a pervasive 
institutional structure in all modern societies. It has often been 
argued that the media industry encourages unsafe sex by irresponsibly 
portraying sexual behaviors. As a result, it is widely claimed that 
youth are negatively influenced by what they see, hear, and read in the 
media. There is, however, very little evidence to either support or 
refute this hypothesis. Historically, sexual portrayals in the media, 
like violence, have raised the ire of advocates, policy-makers, and 
parents dating back to the first mass media marketed to children. 
Today, the issue remains an important agenda item and has led to public 
health policy interventions such as V-chip ratings and technology 
legislation, movie ratings, and video game advisories. Yet few studies 
of the ``effects'' of mass media on specific behaviors are done due to 
theoretical, logistic, design, and cost considerations. One specific 
reason for this is that much ``media influence'' is designed to shape 
and perpetuate consumer preferences and is therefore not targeted to 
behaviorally-defined groups but rather to the mass consumer public. But 
other kinds of media effects predicated on the principles of social 
learning theory and other theories can be predicted for specific 
``audiences'' and specific behaviors. This application focuses on the 
media's role in presenting sexual content, implying sexual norms, 
modeling sexual decision-making (``self-efficacy''), and displaying the 
outcomes of sexual behaviors in relation to young adolescents, a group 
whose attitudes, norms, self-efficacy, and decision-making skills are 
all in flux and development. This five-year research project is the 
first to combine behavioral theory, communication theory, and a state 
of the art content analytic approach to investigate the relationship 
between exposure to sex in the media and early initiation of sexual 
intercourse and other sexual behaviors. Using this approach, the 
project will develop both objective (i.e., content analytic) and 
subjective, theory-based measures of (a) the quantity and content of 
adolescent's exposure to sexual media and (b) adolescents' sexual 
behavior and its underlying psychosocial determinants (i.e., beliefs, 
attitudes, norms, self-efficacy and intention). These measures will be 
tested for their reliability and validity, and they will take 
developmental, gender and ethnic differences into account. Based on 
this formative research, the project comprises a three-wave 
longitudinal proof of concept study to investigate the empirical link 
between exposure to sexual content in a broad variety of media (i.e., 
television, movies, music CDs, the Internet, video games, and 
magazines) and sexual behavior. In summary, this research uses a 
theoretically grounded, methodologically sound approach to more fully 
examine the relationships between media exposure and AIDS-related 
sexual behavior.

Intervention Development and Testing with MSM

    John Jemmott is currently conducting an NIMH funded study to 
develop, implement, and evaluate the efficacy of an HIV/STD risk 
reduction intervention for African American MSM. This is a 
collaborative effort by HIV/STI university-based researchers and Blacks 
Educating Blacks About Sexual Health Issues (BEBASHI), the oldest 
community-based organization (CBO) in the City of Philadelphia that has 
addressed HIV in the African American community, including MSM. The 
participants will be 594 African American MSM who will be randomized to 
a one-on-one sexual risk reduction intervention, ``Being Responsible 
for Ourselves (BRO)'' or a one-on-one health promotion intervention 
that will serve as the control condition. This study will provide an 
urgently needed intervention to reduce the risk of HIV and other STIs 
in one of the highest risk populations in the United States. 
Christopher Coleman, who holds a joint appointment with the School of 
Nursing and the Medical School, is a co-investigator on John Jemmott's 
MSM intervention study, has a longstanding research interest in HIV 
positive MSM.
    William Holmes' research has focused on modeling the relationship 
between childhood abuse and risk behaviors among MSM populations. More 
men with than men without childhood sexual abuse (CSA) histories report 
sexual behavior that has high risk for HIV transmission. His work has 
found that co-morbid post traumatic stress disorder (PTSD) and 
depression acts as both a mediator and a moderator of the association 
between CSA and sexual risk behavior. In his current NIMH funded study 
entitled, ``Interaction of abuse, PTSD, depression on men's sex risk,'' 
data from a cross sectional, random-digit-dial (HDD) survey of 1,200 
men from high AIDS prevalence areas of Philadelphia County will be used 
to test the model he has developed to explain the mediating/moderating 
pathway between CSA and lifetime sexual risk behavior in men. From this 
model, multidimensional HIV risk reduction interventions can be built.

Integrated Biomedical and Behavioral Trials

    David Metzger is the PI of the Penn Prevention Clinical Trials 
Unit, funded by NIAID and a research site for the HIV Vaccine Trials 
Network (HVTN), the Microbicide Trials Network (MTN) and the Prevention 
Trials Network (HPTN). This award in 2006 was built upon its successful 
involvement as a site for the HIV Network of Prevention Trials (HIVNET) 
and subsequently, the HIV Prevention Trials Network (HPTN). The Penn 
Prevention Clinical Trials Unit is one of 60 international and domestic 
trials units selected to develop and test behavioral and biomedical 
prevention interventions. The Penn Prevention CTU includes co-
investigators from the School of Nursing (Loretta Sweet Jemmott), the 
Infectious Diseases Division of the School of Medicine (Ian Frank), the 
Department of Immunology of the Children's Hospital of Philadelphia 
(Steven Douglas), and the Annenberg School of Communication (John 
Jemmott). The Penn Prevention CTU and its predecessor, the HPTU have 
made significant contributions to the research agenda of the HIV 
Clinical Trials Network and is currently involved in three active 
protocols: 1) the HVTN 502, the ``STEP'' study testing the ; 2) HVTN 
070, and 3) HPTN 035, a large international Phase IIb trial of Pro2000 
(entry inhibiting gel), and Buffer Gel (a buffering gel which 
inactivates virus). Penn's work in testing vaginal microbicides is led 
by Lisa Maslankowski. David Metzger, the PI of the Penn Prevention CTU 
also serves as the Chair of HPTN 058, a randomized trial of suboxone 
treatment for opiate addiction as HIV prevention taking place in 
Thailand and China.
    Courtney Schrieber received a developmental award to study 
pregnancy during clinical trials using a nested case-control method and 
a point-of-care questionnaire. This area of inquiry is unique and 
important because incident pregnancies are significant and a somewhat 
unexpected finding in NIH supported Phase II and III vaginal 
microbicide and vaccine trials that can serve a biomarker of risk 
behavior. Further, because the teratogenicty of investigatory vaccines 
and microbicides are unknown, thus pregnant women are dis-enrolled from 
these studies which may introduce bias in the studies as those at 
greater risk may be dis-enrolled more frequently. Reducing pregnancy 
rates during trial participation will help avoid the associated 
methodological complications and potential health risks. Schrieber 
seeks to explore the risk factors for pregnancy among trial 
participants in order to inform efforts to both identify 
characteristics of women who are likely to become pregnant during the 
study and to prevent pregnancy for trial enrollees.

Relation Between the Behavioral and Social Science (BSS) Core and Other 
                    CFAR Programs: Building Research Collaborations

    The BSS Program has encouraged collaborations among program members 
and between CFAR programs. This was evidenced in many of the projects 
already described that are led by members of the core. In addition, BSS 
Core members in conjunction with members of the immunology program 
(Douglas and Ho) are currently investigating the role of host factors 
on viral activity HIV and HCV infected individuals. This work, 
facilitated by the Penn CFAR, perhaps best exemplifies the program goal 
of cross discipline collaborations and have developed a productive 
program of research over the past five years. Dwight Evans' research 
involving HIV infected men prior to the advent of HAART, provided the 
first indication that stress was not only predictive of early HIV 
disease progression but was associated with alterations in immunity, 
suggesting that stress influences disease progression by altering key 
aspects of cellular immunity. His study of HIV infected women conducted 
in collaboration with Steven Douglas and David Metzger extended the 
understanding of these relationships and provided the first evidence 
that depression may alter the function of killer lymphocytes in HIV 
infected women. Evans' recently completed grant entitled ``HIV in 
Women: Depression and Immunity'' further explored these relationships 
and the ex-vivo impact of anti depressants among HIV infected women 
with depression. Metzger's research group had responsibility for 
screening, recruitment, and specimen collection and Douglas's lab 
conducted immunologic assays. This work demonstrated that resolution of 
depression is associated with restoration of NK cytotoxicity in HIV and 
found that ex-vivo treatment of lymphocytes with an SSRI enhances NK 
cytolytic activity. These findings were the basis of a recent NIMH 
award to Evans. This new study is designed to test whether depression 
is associated with non-cytolytic, chemokine and cytokine, functional 
alterations of killer lymphocytes, as well as chemokine receptor 
sensitivity of macrophages and T-cells that are relevant to HIV-
infectivity. The potential for impact of alcohol and opiates on HIV 
viral activity has also led to investigations of the mediating role of 
substance use on immune function among well characterized HIV infected 
individuals with Douglas and Ho. NIDA funded work on the relationships 
among opiates, substance P and HIV viral activity have found that 
methadone in vitro enhances infection of immune cells. With 
supplemental funds from NIDA this work was extended to examine factors 
associated with HCV activity. Using this model of collaborative 
research where behavioral scientist identify and assess well defined 
subject characteristics and deliver specimens for intensive and 
innovative analyses, Metzger's group is working with Douglas to examine 
the impact of alcohol abuse and dependence on viral activity and immune 
function.
    The collaborative capacity building project between the University 
of Botswana and the University of Pennsylvania is organized around 
three cores. Qualitative and Quantitative Methodology Core, Social and 
Behavioral Intervention Core, and the Administrative Core. The project 
draws upon members of the CFAR Biostatistics Core, including Dr. Susan 
Ellenberg and the CFAR Administrative Core, including Dr. James Hoxie. 
This partnership is committed to developing a creative, comprehensive 
and interdisciplinary HIV/STD prevention research program on 
adolescents that is fully integrated within the research and education 
mission of the University Botswana and dedicated to addressing the 
urgent need to stem the devastating impact of HIV on one of the highest 
risk adolescent populations in the world.

Effective Use of Social and Behavioral Research

    HIV/AIDS remains the most important public health problem facing 
our global community. Since the first cases of AIDS were reported in 
1981, infection with HIV has grown to pandemic proportions, with an 
estimated 65 million infections and 25 million deaths. To be sure, we 
now have effective treatment of HIV infection with highly active anti-
retroviral therapy (HAART) even in countries with limited resources. 
Still, these treatments do not reach all who need them, especially in 
low-resource countries and prevention is more cost effective than is 
treatment. Accordingly, there is a great need for effective behavioral 
strategies to reach and serve all persons who could benefit from 
treatment and prevention services.
    As with many health problems today, behaviors--for instance, 
practicing abstinence, limiting sexual partners, using condoms, using 
clean IDU equipment, and adhering to treatment regimens--are central to 
the spread of HIV and to the efficacy of treatment. Accordingly, an 
approach that integrates the lessons from behavioral and biomedical 
science is likely to be most effective in stemming the HIV pandemic. As 
biomedical advances are made, social and behavioral science 
contributions will be required to ensure the success of new biomedical 
prevention technologies and treatments, including microbicides and 
vaccines. For example, social and behavioral science research would 
contribute to an understanding of whether the technologies and 
treatments are acceptable to populations, whether new behaviors will be 
adopted, and the facilitators and barriers to optimal treatment 
adherence.

Adequacy of Federal Funding

    The Federal Government's investment in behavioral research on HIV 
has not been sufficient. Although the CDC has a number of dissemination 
initiatives, not enough funding has been allocated to result in the 
widespread use of interventions that we know are efficacious. If these 
interventions are effective when disseminated and if they were widely 
disseminated then we would not be witnessing the high rates of HIV that 
we are still seeing in the United States. Second, there are still 
important gaps in the portfolio of intervention strategies. African 
American MSM have the highest rates of HIV in the United States. 
Indeed, the rates of HIV among African American MSM rivals those seen 
in countries in sub-Saharan Africa, the region with the highest rate of 
HIV in the world. The CDC still does not have interventions for African 
American MSM with evidence of efficacy in reducing risk behavior and 
STD from randomized controlled trials to offer service providers who 
work with this population. Thus, additional funding is needed urgently 
for behavioral research on dissemination of efficacious interventions, 
including the adaptation, adoption, and effectiveness of those 
interventions. In addition, funding is also needed for interventions 
for populations, including African American MSM, where efficacious 
interventions are lacking.
    The present funding environment for behavioral research on HIV is 
tough. It is extremely difficult for investigators to receive funding 
for scientifically meritorious proposals when insufficient funds are 
available and strong proposals must be set aside unfunded. The is a 
problem for established researchers who may have to dismantle their 
research teams and lose their infrastructure because of a lack of 
funds. It is especially damaging for young scientists who are unable to 
secure the funding needed to launch their careers and may have to seek 
other careers because they are unable to produce the body of research 
required to earn tenure at leading universities.

                   Biography for John B. Jemmott III

    John B. Jemmott III received his Ph.D. in Psychology from the 
Department of Psychology and Social Relations at Harvard University. 
From 1981 to 1999, he served as Instructor, Assistant Professor, 
Associate Professor, and Professor of Psychology at Princeton 
University. He currently holds joint faculty appointments at the 
University of Pennsylvania as the Kenneth B. Clark Professor of 
Communication in the Annenberg School for Communication and as 
Professor of Communication in Psychiatry in the School of Medicine. He 
also directs the Center for Health Behavior and Communication Research 
in the School of Medicine at the University of Pennsylvania.
    Dr. Jemmott is a Fellow of the American Psychological Association 
and the Society for Behavioral Medicine. He has served as a regular 
member of several National Institutes of Health (NIH) panels, including 
the Behavioral Medicine Study Section, the AIDS and Immunology Research 
Review Committee, and the Office of AIDS Research Advisory Council. Dr. 
Jemmott has published numerous articles and has been the recipient of 
many grants from the National Institutes of Health to conduct research 
designed to develop and test theory-based, contextually appropriate 
HIV/STD risk reduction interventions for inner-city African American 
and Latino populations. He was identified in the 25 July 2008 issue of 
Science magazine as one of the 10 researchers whose work into HIV/STD 
risk reduction interventions received the most investigator-initiated 
(R01) grant funding from the NIH (fiscal year 2007).
    The Centers for Disease Control and Prevention have identified as 
effective and have disseminated three curricula based on his HIV 
prevention research with adolescents: ``Be Proud! Be Responsible! 
Empowering Adolescents to Reduce their Risk of HIV,'' ``Making a 
Difference! An Abstinence Approach to HIV/STD Risk Reduction,'' and 
``Making Proud Choices! A Safer Sex Approach to HIV/STD Risk 
Reduction.'' Dr. Jemmott is currently conducting research on HIV/STD 
prevention strategies for couples where one partner is living with HIV, 
African American men who have sex with men, and adolescents and adult 
men in sub-Saharan Africa, where the HIV pandemic is taking its 
heaviest human toll.

    Chairman Baird. Thank you.
    Dr. Kenkel.

STATEMENT OF DR. DONALD S. KENKEL, PROFESSOR OF POLICY ANALYSIS 
  AND MANAGEMENT, COLLEGE OF HUMAN ECOLOGY, CORNELL UNIVERSITY

    Dr. Kenkel. Thank you for the opportunity to testify. I am 
convinced that the social sciences in general and economics in 
particular have much to offer to improve our nation's health. 
Nobel Prize winning economist Gary Becker has argued that, 
``Economic theory is not a game played by clever academicians 
but is a powerful tool to analyze the real world.'' To inform 
public health policy, empirical health economists like myself 
combine economic theory with careful analysis of data to try to 
quantify the impact of various real world influences on 
individual health behaviors.
    In these comments I will try to overview some research on 
the economics of health behaviors and provide a few examples of 
their relevance for public policy and then make a few comments 
about the importance of NSF and NIH support for health 
economics.
    Some health economics research focuses on the health care 
sector. The research I will overview uses the tools of 
economics to better understand the determinance of these health 
behaviors outside the health care sector like smoking and 
obesity.
    The economic approach to human behavior emphasizes that 
people respond to incentives. Consequences for their health can 
provide people with very strong incentives to quit an unhealthy 
behavior like smoking or to start a healthy behavior like 
regular exercise. The history of smoking in the U.S. is a good 
example. Since the 1964, Surgeon General's Report on the health 
consequences of smoking, the prevalence of smoking among U.S. 
adults has dropped from over 40 percent to about 21 percent. 
Econometric studies suggest that improved consumer information 
about the risks of smoking helped lead to part of this drop. 
When people learned smoking was unhealthy, many people quit 
smoking, and others didn't start smoking in the first place.
    My colleagues and I recently completed an empirical study 
of the impact of pharmaceutical industry advertising on smoking 
cessation decisions, another important source of health 
information. Based on our results, we estimate that if the 
smoking cessation product industry increased its expenditures 
on magazine advertising by 10 percent, the result would be 
about 225,000 new attempts to quit smoking each year and 8,000 
successful quits each year.
    This is part of a growing body of evidence that direct-to-
consumer ads increased consumer demand for a variety of 
pharmaceutical products. Easing regulation on ads for smoking 
cessation products could exploit more fully the industry's 
profit incentives to promote public health.
    More generally, when crafting public policy, it is 
important to keep in mind the private incentives to improve 
public health. People want to live healthier, longer lives, and 
private sector firms can make profits helping them do so. 
Public policies should be structured to facilitate the public 
health gains enjoyed when firms pursue their private profits.
    The prices consumers pay for health-related goods also 
provides important incentives that influence health behaviors. 
Dozens of econometric studies estimate the price responsiveness 
of demand for alcoholic beverages and cigarettes. I have 
contributed to both lines of research. In research funded by 
the National Institute on Alcohol Abuse on Alcoholism, I found 
evidence that even heavy drinking falls when the prices of 
alcoholic beverages increase.
    Research funding from the National Cancer Institute helped 
my colleagues and I launch a series of studies on the effects 
of higher prices on youth smoking. The Guide Tax Policy, the 
NIAAA special reports to Congress on alcohol and health and the 
Surgeon General's reports on tobacco and health regularly 
review econometric studies of the price or tax responsiveness 
of alcohol and cigarette demand.
    Health economics research takes on hard research questions 
about the impact of public policies on health behavior. While I 
believe health economics research provides useful guidance for 
policy, it is important to keep in mind how hard the questions 
are. For example, over the past few decades the Federal 
Government and the states have launched massive and varied 
public policy campaigns to reduce smoking. As various policies 
have been enacted, it is clear that smoking rates have fallen 
and public anti-smoking sentiment has grown. Yet teasing out 
the direction of causality and the contribution of specific 
policies is extremely difficult.
    Social science research also contributes to public policy 
when it reminds us of the wisdom of the old comment, ``It ain't 
so much the things we know that get us into trouble, it is the 
things we do know that just ain't so.'' This in turn reminds me 
of the almost inevitable comment at the end of an academic 
paper, ``More research is needed.'' This comment is probably 
not what you want to hear, but it is not an admission of 
failure but reflects how science progresses. Answers to hard 
research questions are re-examined and probed, leading to new 
answers and better questions.
    Research on the economics of health behaviors requires data 
on health behaviors and on the factors that influence them. 
Federal and State governments' data collection efforts are a 
very valuable resource for this research. The NIH and the NSF 
Foundation, the NSF, also provide important resources for 
health economics research supporting investigator-initiated 
date collection.
    An applied field like health economics also relies on 
insights from economic theory and uses tools and methods 
developed in econometric theory. NSF support for even seemingly 
esoteric research topics in economic and econometric theory 
improves health economics research over time. The NIH, of 
course, provides support for many economics projects with more 
immediate significance for public health.
    I believe a source of missed research opportunities is the 
gap between economists and some of the other social and 
behavioral scientists including my colleagues here, who design, 
implement, and evaluate public health interventions. For 
example, some emerging research is exploring the use of 
monetary incentives to reduce smoking and illicit drug use. 
Increasingly, behavioral economists integrate insights from 
psychology into standard economic models of consumer behavior. 
Data from intervention research could provide a rich source to 
testing predictions from behavioral health economics.
    I will stop with my comments there. Thank you very much.
    [The prepared statement of Dr. Kenkel follows:]

                 Prepared Statement of Donald S. Kenkel

    Thank you for the opportunity to testify about ``The Role of Social 
Sciences in Public Health.'' I am convinced that the social sciences in 
general, and economics in particular, have much to offer to help 
improve our nation's health. Nobel Prize-winning economist Gary Becker 
has argued that: ``Economic theory is not a game played by clever 
academicians but is a powerful tool to analyze the real world.'' To 
inform public health policy, empirical health economists like myself 
combine economic theory with the careful analysis of data to try to 
quantify the impact of various influences on individual health 
behaviors.
    Health economics is a relatively young sub-field of economics, and 
in its early days was sometimes instead called ``medical economics'' or 
``health care economics.'' Today, many health economists continue to 
focus on the financing and delivery of health care. These economists 
explore important questions about physician behavior, the hospital 
industry, and private and public health insurance, to name just a few 
areas of health care sector research. However, many key health 
behaviors are outside the health care sector. Current estimates suggest 
that almost half of all deaths in the U.S. can be traced to cigarette 
smoking, sedentary lifestyles and obesity, and alcohol consumption.\1\ 
An exciting and productive line of research uses the tools of economics 
to better understand the determinants of these health behaviors. To 
give an idea of how productive: my colleague John Cawley and I recently 
co-edited a collection of the most important and interesting papers in 
the economics of health behaviors.\2\ The collection runs to three 
volumes and includes 85 academic studies written by health economists 
from the U.S. and across the world.
---------------------------------------------------------------------------
    \1\ Mokdad, A.H., Marks, J.S., Stroup, D.F., and Gerberding, J.L. 
(2004). Actual Causes of Death in the United States: 2000. JAMA 291 
(10): 1238-1245.
    \2\ Cawley, John and Donald Kenkel, co-editors (2008). The 
Economics of Health Behaviours, Volumes I-III. The International 
Library of Critical Writings in Economics, An Elgar Reference 
Collection. Edward Elgar Publishing: Northampton, MA.
---------------------------------------------------------------------------
    Another way to view the field of health economics is that health 
care sector economics is mainly about ``cure,'' while the economics of 
health behaviors is mainly about ``prevention.'' There is an old saying 
that an ounce of prevention is worth a pound of cure. Health economists 
have not been able to quantify the benefits of prevention quite so 
precisely. In fact, investing in prevention will not necessarily reduce 
aggregate health care spending. But our public policy goal is not 
simply to contain health care costs, but to spend our health care 
dollars well. Preventing deaths due to smoking, obesity, and other 
unhealthy behaviors can help the U.S. get the most value from the 
societal resources we invest in health.
    The economic approach to human behavior emphasizes that people 
respond to incentives. The consequences for their health can provide 
people with strong incentives to quit an unhealthy behavior like 
smoking or to start a healthy behavior like regular exercise. However, 
the health consequences only matter if people know about them. I've 
contributed to a line of health economics research that studies how 
health information shapes health behaviors. The history of smoking in 
the U.S. is a good example. Since the 1964 Surgeon General's Report on 
the health consequences of smoking, the prevalence of smoking among 
U.S. adults has fallen from over 40 percent to about 21 percent.\3\ 
Econometric studies suggest that improved consumer information about 
the risks of smoking led to part of this drop: when they learned 
smoking was unhealthy, many people quit smoking, and others didn't 
start in the first place. These studies exploit information 
``shocks''--discrete events like the publication of the 1964 Surgeon 
General's Report that provided people with more health information. 
International studies suggest that similar information shocks also 
reduced smoking in other countries.\4\ In a study I completed earlier 
in my career, I found that information appears to be an important 
incentive to adopt healthier behaviors related to smoking, drinking, 
and exercise.\5\
---------------------------------------------------------------------------
    \3\ Rock, V.J., A. Malarcher, J.W. Kahende, et al. (2007). 
``Cigarette Smoking Among Adults--United States, 2006.'' Morbidity and 
Mortality Weekly Report 56 (44): 1157-1161.
    \4\ Kenkel, Donald and Likwang Chen (2000). ``Consumer Information 
and Tobacco Use.'' In: Jha P and FJ Chaloupka, Editors. Tobacco Control 
in Developing Countries. Oxford University Press, pp. 177-214.
    \5\ Kenkel, Donald (1991). ``Health Behavior, Health Knowledge, and 
Schooling,'' Journal of Political Economy 99 (2): 287-305.
---------------------------------------------------------------------------
    My colleagues and I recently completed an empirical study of the 
impact of pharmaceutical industry advertising on smoking cessation 
decisions.\6\ Although many smokers quit `cold turkey' without 
assistance, medical research shows that smokers are more likely to 
successfully quit if they use a pharmaceutical smoking cessation 
product such as a nicotine replacement therapy. The cessation product 
industry's estimated retail sales are nearly $1 billion annually. In 
recent years the industry has spent between $100 to $200 million 
annually advertising these products. In other health-related markets, 
producer advertising has been shown to be an important source of health 
information that prompted people to consume more dietary fiber and less 
saturated fat.\7\ Similarly, we find that the more magazine 
advertisements smokers see for products like the nicotine patch, the 
more likely they are to try to quit smoking and to be successful. Based 
on our results, we estimate that if the smoking cessation product 
industry increases its average annual expenditures on magazine 
advertising by 10 percent, the result would be about 225,000 new 
attempts to quit and 80,000 successful quits each year.
---------------------------------------------------------------------------
    \6\ Avery, Rosemary, Donald Kenkel, Dean Lillard, and Alan Mathios 
(2007). ``Private Profits and Public Health: Does Advertising Smoking 
Cessation Products Encourage Smokers to Quit?'' Journal of Political 
Economy 115 (3): 447-481.
    \7\ Ippolito, Pauline M. and Alan Mathios (1990) ``Information, 
Advertising and Health Choices: A Study of the Cereal Market.'' RAND 
Journal of Economics 21 (3):459-480. Ippolito, P. and Mathios, A., 
(1995) ``Information and Advertising: The Case of Fat Consumption in 
the United States,'' American Economic Review: Papers and Proceedings, 
85 (2) May.
---------------------------------------------------------------------------
    The prices consumers have to pay for health-related goods also 
provide important incentives that influence health behaviors. Dozens of 
econometric studies estimate the price-responsiveness of demand for 
alcoholic beverages and cigarettes. I've contributed to both lines of 
research. In research funded by the National Institute on Alcohol Abuse 
on Alcoholism, I found evidence that even heavy drinking falls when 
alcoholic beverage prices increase, although there may be a subset of 
very heavy drinkers who are not responsive.\8\ This is consistent with 
other research that shows that higher prices reduce alcohol-related 
consequences including liver cirrhosis death rates and drunk driving. 
Research funding from the National Cancer Institute helped my 
colleagues and I launch a series of studies on the effects of higher 
cigarette prices on youth smoking.\9\ Higher cigarette prices 
potentially reduce smoking through three channels: by preventing youth 
from starting; by encouraging smokers to quit; and by encouraging 
smokers to cut down their daily consumption. Our research, and research 
in several other countries, call into question whether higher prices 
are really very effective in preventing youth from starting. Although 
the implications of our findings are still controversial, they tend to 
suggest that the main effect of higher prices is through encouraging 
smokers to either cut down or quit.
---------------------------------------------------------------------------
    \8\ Kenkel, Donald (1993). ``Drinking, Driving, and Deterrence: The 
Effectiveness and Social Costs of Alternative Policies,'' Journal of 
Law and Economics, pp. 877-913. Kenkel, Donald (1996). ``New Estimates 
of the Optimal Tax on Alcohol,'' Economic Inquiry 34: 296-319.
    \9\ DeCicca, Philip, Donald Kenkel, and Alan Mathios (2002). 
``Putting Out the Fires: Will Higher Taxes Reduce the Onset of Youth 
Smoking?'' Journal of Political Economy 110 (1): 144-169. DeCicca, 
Phillip, Donald Kenkel, Alan Mathios, Yoon-Jeong Shin, and Jae-Young 
Lim (2008). ``Youth Smoking, Cigarette Prices, and Anti-Smoking 
Sentiment.'' Health Economics 17 (6): 733-749. DeCicca, Philip, Donald 
Kenkel, and Alan Mathios (2008). ``Cigarette Taxes and the Transition 
from Youth to Adult Smoking: Smoking Initiation, Cessation, and 
Participation.'' Journal of Health Economics 27 (4): 904-917.
---------------------------------------------------------------------------
    By providing new insights about what influences health behaviors, 
health economics research helps shape public policies such as marketing 
restrictions or taxes that have broad effects on consumers and thus on 
public health. In contrast, other social and behavioral sciences study 
more targeted interventions, such as an individual-level intervention 
to help smokers quit, or a school-level intervention to prevent 
adolescents from abusing alcohol. Targeted interventions play an 
important role in public health and can yield highly visible success 
stories of individuals whose health was improved. Broad public policies 
can also yield important health improvements, but the success stories 
are found in data that might show that the population rate of smoking 
cessation increased over time, or that the population rate of drunk 
driving fell.
    Health economics research on the role of health information has 
important implications for broad public policies. In addition to 
directly providing information, other policies such as marketing 
regulations affect the flow of health information to consumers. Our 
study of smoking cessation product advertising is part of a growing 
body of evidence that direct-to-consumer ads increase consumer demand 
for a variety of pharmaceutical products. The U.S. and New Zealand are 
the only countries that allow DTC advertising of prescription 
pharmaceutical products. Even in these two countries, DTC ads are 
strictly regulated. In the U.S. this had led to an ironic situation: in 
some ways, ads for prescription pharmaceutical products for smoking 
cessation have been more heavily regulated than cigarette 
advertisements. Food and Drug Administration (FDA) regulations require 
prescription smoking cessation product ads in magazines to include at 
least an extra page of disclosures about side effects and 
contraindications; cigarette ads are only required to carry a short 
warning label. Easing regulations on ads for smoking cessation products 
could exploit more fully the profit incentives to promote public 
health. Ads for other pharmaceutical products, such as statins to treat 
high cholesterol, have similar potential. Because the potential gains 
and harms from advertising vary widely across products, it might make 
sense for the FDA to adopt a more flexible approach to regulate DTC 
advertising.
    More generally, when crafting public policy it is important to keep 
in mind the private incentives to improve public health. People want to 
live healthier and longer lives, and private sector firms can earn 
profits helping them do so. Public policies should be structured to 
facilitate rather than impede the public health gains enjoyed when 
firms pursue private profits.
    As mentioned above, many econometric studies estimate the price-
responsiveness of consumer demand for alcoholic beverages and 
cigarettes. Because prices can be manipulated by imposing excise taxes, 
these estimates also have implications for public health policy. The 
National Institute on Alcohol Abuse and Alcoholism's Special Reports to 
Congress on Alcohol and Health and the Surgeon General's Reports on 
Tobacco and Health regularly review econometric studies of the price- 
or tax-responsiveness of alcohol and cigarette demand.
    Health economics research takes on hard research questions about 
the impact of public policies on health behaviors. Typically we use 
observational data and try to identify natural quasi-experiments 
created, for example, by events or changes in policies. While I believe 
health economics research provides useful guidance for policy, it is 
important to keep these limitations in mind. For example, over the past 
few decades the Federal Government and the States have launched massive 
and varied public policy campaigns to reduce smoking. As various 
policies have been enacted, smoking rates have fallen and public anti-
smoking sentiment has grown. Yet teasing out the direction of causality 
and the contribution of specific policies is extremely difficult. An 
example is the controversy I mentioned earlier about the price-
responsiveness of youth smoking. Youth smoking rates remain higher in 
the tobacco-producing states, which until recent years have rarely 
increased cigarette taxes. Are youth smoking rates high in these states 
because cigarette taxes are low? Or are cigarette taxes low because 
smoking is part of the culture in these states?
    Social science research also contributes to public policy when it 
reminds us of the wisdom of the comment: ``It ain't so much the things 
we don't know that get us into trouble, it's the things we do know that 
just ain't so.'' \10\ This in turn reminds me of the almost inevitable 
comment at the end of academic papers: ``More research is needed.'' 
This academic comment is not an admission of failure, but reflects how 
science progresses. Answers to hard research questions are re-examined 
and probed, leading to new questions and better answers.
---------------------------------------------------------------------------
    \10\ Attributed to Artemus Ward, American humorist, 1834-1867.
---------------------------------------------------------------------------
    Because it is still a young field, it is not surprising that basic 
research questions on the economics of health behaviors remain 
unanswered. Recently, some of the questions receiving the most 
attention concern health disparities related to socioeconomic status. 
Again, smoking provides a stark example--it is increasingly true that 
smokers are more likely to have lower incomes and less schooling. For 
example, in 2006 about 35 percent of high school dropouts smoked, 
compared to only about 10 percent of college graduates and less than 
seven percent of those with graduate degrees. Why is this the case? One 
hypothesis is that people with more schooling are better able to gather 
and process information about the health risks of smoking. This 
explanation is supported by the fact that in the 1950s--before medical 
research firmly established the health risks of smoking--college 
graduates were about as likely to smoke as those with less schooling. 
But this explanation is hard to reconcile with the persistence of the 
schooling gap in smoking 50 years later, when virtually everyone 
understands that smoking kills. Health economists are exploring other 
explanations, such as the idea that there are other hard-to-observe 
differences between people with different levels of schooling.
    Understanding the schooling-smoking link might provide a case study 
for understanding the links between schooling and health more 
generally. If schooling helps people make healthier choices, 
investments in schooling could also pay off in the form of reductions 
in obesity or other health problems. If other hard-to-observe factors 
are the root causes of both low schooling attainment and unhealthy 
choices, investments in more schooling may not be enough.
    Research on the economics of health behaviors requires data on 
health behaviors and on the factors that influence them. Federal and 
State governments' data collection efforts are a very valuable resource 
for this research, including the National Health Interview Survey, the 
Behavioral Risk Factor Surveillance Surveys, the Youth Risk Behavior 
Surveillance System, and the Tobacco Use Supplements to the Current 
Population Survey. Federal support for ongoing longitudinal studies--
including the Panel Study of Income Dynamics, the Health and Retirement 
Survey, the National Longitudinal Surveys of Youth, and the National 
Longitudinal Study of Adolescent Health--provides especially useful 
data to follow individual health behaviors over time. Health economists 
often use data from ongoing collections to study health behaviors 
before and after a natural quasi-experiment in policy or circumstances. 
Innovations in data collection, such as the collecting biomarkers, 
present opportunities to move health economic research in exciting new 
directions.
    The National Institutes of Health and the National Science 
Foundation also provide important resources for health economics 
research through supporting investigator-initiated data collection. The 
National Institute of Health's data sharing policy ``expects and 
supports the timely release and sharing of final research data from 
NIH-supported studies for use by other researchers.'' Data sharing is 
essential for the scientific process. With data sharing, NIH and NSF 
support help not only the funded investigators, but can also prompt 
other researchers to replicate and extend the original data analysis, 
and to use the data in new ways to ask different questions.
    An applied field like health economics relies on insights from 
economic theory and uses tools and methods developed in econometric 
theory. NSF support for even seemingly esoteric research topics in 
economic and econometric theory improves health economics research over 
time. The NIH provides support for many economics projects with more 
immediate significance for public health. Unfortunately, sometimes 
important research falls in between the cracks. For example, developing 
new econometric methods for the analysis of data on health behaviors 
might seem ``too applied'' to NSF reviewers but at the same time seem 
``too theoretical'' to NIH reviewers. Educating NSF and NIH reviewers 
about each other's missions could help better integrate federal funding 
for health economics research.
    Another source of missed research opportunities is the gap between 
economists and the social and behavioral scientists who design, 
implement, and evaluate public health interventions. It is increasingly 
common for health economists to be involved near the end of these 
research projects, when they conduct cost-effectiveness analyses of the 
interventions. This is an encouraging trend, and the results of cost-
effectiveness analyses help to maximize the health benefits from 
limited budgets for interventions. As social scientists, however, 
economists could also be usefully involved earlier in the research 
design. For example, some emerging research is exploring the use of 
monetary incentives to reduce smoking and illicit drug use. Behavioral 
economists integrate insights from psychology into standard economic 
models of consumer behavior. Data from intervention research could 
provide a rich source to testing predictions from behavioral health 
economics.

                     Biography for Donald S. Kenkel

    Donald S. Kenkel is a Professor in the Department of Policy 
Analysis and Management at Cornell University, and a Research Associate 
of the National Bureau of Economic Research. His expertise is in areas 
of health economics and public sector economics. Broadly speaking, most 
of his research is on the economics of disease prevention and health 
promotion. He is the author of the chapter on ``Prevention'' in the 
Handbook of Health Economics. He has conducted a series of studies on 
the economics of public health policies, including: alcohol taxes and 
other policies to prevent alcohol problems (Journal of Applied 
Econometrics 2001, American Economic Review Papers & Proceedings 2005); 
cigarette taxes to prevent youth smoking (Journal of Political Economy 
2002); and advertising to promote smoking cessation (Journal of 
Regulatory Economics 2007 and Journal of Political Economy 2007). 
Another area of research and teaching interest is in cost-benefit 
analysis of public policies, especially policies that affect health. 
His research has been funded by the National Institute on Alcohol Abuse 
and Alcoholism, the National Cancer Institute, the National Institute 
on Child Health and Development, as well as private foundations.

    Chairman Baird. Thank you.
    Dr. Koenig.

STATEMENT OF DR. HAROLD G. KOENIG, PROFESSOR OF PSYCHIATRY AND 
BEHAVIORAL SCIENCES; ASSOCIATE PROFESSOR OF MEDICINE; DIRECTOR 
  OF THE CENTER FOR THEOLOGY, SPIRITUALITY, AND HEALTH, DUKE 
                           UNIVERSITY

    Dr. Koenig. Thank you, Mr. Baird.
    I am going to speak on religion, spirituality, and public 
health. In overviewing this topic I would like to say that the 
United States is a very religious and spiritual nation. Stress 
and depression are common and increasing in our country. Stress 
affects physical health and need for health services. Many turn 
to religion when stressed, facing sickness, or disability. 
Religion and spirituality may reduce stress, reduce depression, 
enhance quality of life, may be related to less alcohol and 
drug abuse, less crime, delinquency, related to better health 
behaviors, healthier lifestyles, better physical health, faster 
recovery, and less need for health services. May also enhance 
the community's resiliency after disaster or terrorism.
    Implications for public health and patient care, I will 
make some of those and make some recommendations as well. 
Ninety-three percent of Americans believe in God or a higher 
power. Eighty-nine percent report a religious affiliation. 
Eighty-three percent say it is--that religion is very, is 
fairly or very important to them. About two-thirds of Americans 
are members of a church or synagogue or mosque. Fifty-eight 
percent pray every day, and 75 percent pray at least weekly. 
Nearly half of the country attends church at least monthly, and 
42 percent weekly.
    We know that there is increased stress due to the recent 
economic downturn. We know that depression is increasing due to 
loss of jobs and homes. We know that debt is increasing, and 
people are not saving. We know that youth are facing many, many 
choices with very few absolute guides by which to guide their 
behavior and their choices. The population is aging, facing 
increasing health problems, fewer saving for retirement, and 
that is creating fear.
    We know that stress and depression affect physical health 
and use of health services, that diseases like heart attacks, 
hypertension, stroke, infection, wound healing, the aging 
process itself appears to be affected by stress and depression, 
and all of that increases hospital stays and need for health 
services.
    Many in the U.S. turn to religion to cope with stress and 
illness. After September 11, 90 percent of Americans turned to 
religion. That was reported in the New England Journal of 
Medicine. Ninety percent of hospitalized patients rely on 
religion to cope, and nearly half in some areas of the country 
say that it is the most important factor that keeps them going. 
Hundreds of quantitative and qualitative studies report similar 
findings.
    Research on religion, spirituality and health is increasing 
dramatically. Prior to the year 2000, if you did an online 
search, you would find that there were about 6,282 scientific 
articles on the topic. In the last seven to eight years that 
has increased to over 7,000 articles. Just in the last seven to 
eight years those are the number of articles. About 20 percent 
of those are original research studies. So to date there are 
nearly 3,000 studies looking at these relationships. More 
research has been conducted recently than in a long time 
previous to the year 2000.
    Now, religious involvement can buffer stress, reduce 
depression, enhance quality of life. Of 324 studies looking at 
depression, 204 find significantly less depression or faster 
recovery from depression in those who are more religious. Of 
359 studies looking at well-being, happiness, meaning, purpose, 
hope, 278 show significantly more positive emotions in the 
religious. With regard to increased quality of life, 20 of 29 
recent studies showing that.
    Here is just an example of some of the research showing 
that religious involvement affects the recovery rates for 
depression over time when you follow people.
    Religion is also related to less drug and alcohol use, 
especially among the young. Of 324 studies, 276 show 
significantly lower rates, less delinquency and crime found in 
40 of 52 studies. These are all peer review studies 
quantitative, original research published in science journals.
    Religion is related to less cigarette smoking, especially 
among the young. Fifty of 58 studies show that. Religious 
persons are also more likely to exercise. Unfortunately, it is 
not related to diet and weight. So whatever reason that is, but 
also religion is related to less extra-marital sex and safer 
sexual practices with regard to fewer partners. So 45 of 46 
studies show those relationships.
    Here is a slide I don't show in North Carolina, but I will 
show it here. Religious attendance and cigarette smoking. 
Clearly people attending services more aren't as likely to 
smoke. Religion is related to better physical health and 
recovery from illness. Here is a list of the different diseases 
which are less frequent among those who are more religious. 
This is just an example of survival after open heart surgery. 
This is out of Dartmouth. You can see that those with high 
religious support and high social support have much lower rates 
of death during the six months after surgery.
    This is a national sample of twenty thousand people looking 
at life expectancy. Among whites the length of survival is 
seven years longer among those attending services compared to 
those who aren't. Among African-Americans it extends to 14 
years longer. Religious persons need and use less health care 
services as well. Because there is greater marital stability, 
there is more social support, they are healthier, and that 
translates into shorter hospital stays, fewer hospital days, 
and less time spent in nursing homes because people are kept in 
the community longer.
    Here is an example just of the length of hospital stay at 
Duke Hospital based on religious affiliation alone. Here is 
looking at days spent in long-term care after hospital 
discharge. In African-Americans that means fifty days in the 
10-month period following discharge compared to five days.
    Religion enhances community resiliency to disaster and 
terrorism, helps people to cope with stress from an individual 
level, helps long-term adaptation. At the community level 
religious organizations are present in every community. Clergy 
are oftentimes the first responders. Religious communities are 
often present over the long-term after many other agencies 
leave, and many national religious organizations are active in 
disaster response.
    So what? So what? You can't convert everybody or make them 
religious, but there are numerous direct public health and 
patient care implications which have nothing to do with 
prescribing religion, endorsing religion, or overstepping the 
bounds of church-state separation guaranteed by the First 
Amendment.
    Here are some implications for public health. More research 
is needed, we don't understand the mechanisms. Even small 
health effects are likely to lead to big, public health impact, 
given that there are 200 million church members, 125 million 
weekly attenders.
    While not ethical or desirable to change a person's 
religion or spirituality, we need to know this information for 
planning health services. They also discover information that 
are useful for enhancing health interventions in non-religious 
people, using secular interventions. Congregations are one of 
the few places where persons of all ages and races, and 
economic levels meet regularly. You can do screening there, and 
health education. Ideal place to educate youth with regard to 
substance abuse; stress reduction and healthy lifestyle 
education for the middle-aged; and training for volunteering 
and mentorship for the elderly. Altruism is a basic value for 
churches, and here is potential volunteers to support programs 
in the community during disasters and non-disaster periods.
    Many implications for patient health. Religion may help 
patients to cope with illness, may affect their health 
outcomes. Many patients want their religion acknowledged, 
patients have spiritual needs, and patients are often isolated 
from sources of religious help. Religious beliefs influence 
medical decision-making and compliance with treatment. 
Religious communities support patients in the community. We 
want health care professionals to take a brief spiritual 
history, support the patient's beliefs and practices, identify 
their spiritual needs, and refer them to appropriate people.
    Chairman Baird. Dr. Koenig, I am going to ask you to 
conclude at this point, because we are about four minutes over. 
We will get to some of these issues in a second. If you one or 
two final comments but----
    Dr. Koenig. Okay. There are many recommendations as you can 
see for Congress here in terms of research, in terms of 
supporting congregational health programs, in terms of 
educating the public, and in terms of integrating faith-based 
organizations in disaster response.
    Thank you very much.
    [The prepared statement of Dr. Koenig follows:]
                 Prepared Statement of Harold G. Koenig

 Religion, Spirituality and Public Health: Research, Applications, and 
                            Recommendations

Summary

    This report reviews original research published in social, 
psychological, behavioral, nursing and medical journals since the 1800s 
that has examined relationships between religion/spirituality (R/S) and 
the health of individuals and populations. I describe (1) the 
prevalence of religious beliefs and practices in United States; (2) the 
increasing stress in America and negative effects on physical health; 
(3) the role R/S play in coping with stress and physical illness; (4) 
the relationships between religious involvement, stress, and 
depression; (5) the relationships between religion, substance abuse, 
and health behaviors; (6) the relationships between religion and 
physical health; (7) the impact on need for medical care and use of 
health services; and (8) the effects on community resiliency following 
natural disasters and acts of terrorism. This review suggests that as 
many as 3,000 quantitative studies have now examined relationships 
between R/S and health (mental and physical), the majority reporting 
positive findings. I examine the implications this research has for 
public health and patient care, and make recommendations that could 
lead to a better understanding of these relationships and to 
applications that may improve public health, promote community 
resiliency, enhance patient care, and lighten the ever-increasing 
economic burden of providing health care and protecting our population.

Introduction

    Until recently, scientists have largely avoided studying the 
relationship between religion and health. A young faculty member 
wishing to examine these relationships was often told that conducting 
such research amounted to an ``anti-tenure'' factor. Furthermore, there 
was little if any funding from NSF/NIH to support such research. 
Religious beliefs and behaviors were largely thought of as too 
subjective, not quantifiable, unscientific, and based in fantasy and 
infantile projections or illusion (Freud). As a result, health 
professionals today ignore their patients' religious or spiritual 
needs, and have little appreciation for their relationship to health.
    Times are changing. There has been a tremendous surge in research 
examining relationships between religion, spirituality, and health (95 
percent conducted without funding). Research on this subject carried 
out prior to the year 2000 has been systematically reviewed in the 
Handbook of Religion and Health (Oxford University Press, 2001). That 
review uncovered over 1200 studies published in a wide array for 
psychological, behavioral, medical, nursing, sociological, and public 
health journals. During the time since publication of this book, the 
amount of research on the subject has increased dramatically. An online 
search using the keywords ``spirituality'' and ``religion'' between 
2000 and 2008 in PsychInfo (the American Psychological Association's 
online database of research in the psychological, social, and 
behavioral sciences) recently uncovered 7,145 scientific articles 
(about 20 percent reporting original research). Repeating the same 
search but restricting the years to 1806 to 1999, uncovered 6,282 
articles. Thus, more research on religion, spirituality and health has 
been published in the past seven to eight years than was published in 
the nearly 200 years before that. Covering this massive research base, 
then, is a daunting task.
    The present report reviews original research conducted in the 
social, psychological, behavioral, and medical sciences that has 
examined relationships between religion/spirituality (R/S), and health. 
Where individual studies are cited, these represent some of the best 
work on the topic in terms of research design. They often utilize large 
representative population-based or clinical samples, control for 
relevant confounders, and employ distinctive, uncontaminated measures 
of religion/spirituality (R/S). Most studies are observational in 
research design, although a small number of clinical trials are 
included. Some aspects of this review are systematic (for example, 
studies on depression, positive emotions, substance abuse, delinquency, 
health behaviors), while others are not. For example, studies reported 
on physical health outcomes have been chosen to illustrate the kinds of 
studies published, but the review is not systematic. A complete 
systematic review of this area is now underway (Handbook of Religion 
and Health, 2nd edition, Oxford University Press, 2011).
    Below I examine (1) the prevalence of religious beliefs and 
practices in the United States; (2) the increasing stress in our 
population and the negative effects of stress/depression on physical 
health; (3) the role that R/S plays in coping with stress and physical 
illness; (4) the relationships between religious involvement, stress, 
and depression; (5) the relationships between religion, substance 
abuse, and health behaviors; (6) the relationships between religious 
involvement and physical health; (7) the impact on need for medical 
care and use of health services; and (8) the effects that religious 
involvement has on community resiliency following natural disasters and 
acts of terrorism. Next, I examine the implications of this research 
for public health and clinical practice. Finally, I make a series of 
recommendations for Members of Congress to consider.

Facts to Ponder

  The United States is a very religious nation:

Fact #1: 93 percent of Americans believe in God or a higher power, 
according to a Gallup Poll conducted in May 2008, (see website: http://
www.gallup.com/poll/109108/Belief-God-Far-Lower-Western-US.aspx).

Fact #2: 89 percent of Americans report affiliation with a religious 
organization (82 percent Christian, i.e., Protestant or Catholic), 
according to a representative national survey conducted by Baylor 
Institute for Studies of Religion in September 2006 (see website: 
http://www.baylor.edu/content/services/document.php/33304.pdf). Same 
figures reported by Gallup Poll in December 2007 (see website: http://
www.gallup.com/poll/103459/Questions-Answers-About-Americans-
Religion.aspx)

Fact #3: 83 percent of Americans say religion is fairly or very 
important to them, according to a September 2006 Gallup Poll (latest 
data available) (see website: http://www.gallup.com/poll/25585/
Religion-Most-Important-Blacks-Women-Older-Americans.aspx)

Fact #4: 62 percent of Americans say that they are members of a church 
or synagogue, according to a December 2007 Gallup Poll (latest data 
available) (see website: http://www.gallup.com/poll/103459/Questions-
Answers-About-Americans-Religion.aspx)

Fact #5: 58 percent of Americans pray every day (and 75 percent at 
least weekly), according to a 2008 U.S. Religious Landscape Survey (see 
website: http://religions.pewforum.org/)

Fact #6: 42 percent of Americans attend religious services weekly or 
almost weekly (and 55 percent attend at least monthly), according to 
aggregate Gallup Pools in 2007 (see website: http://www.gallup.com/
poll/105544/Easter-Season-Finds-Religious-Largely-Christian-
Nation.aspx).

  Stress and depression are common in American society, 
especially due to the recent economic downturn. Both stress and 
depression worsen when people develop medical illness and health 
problems.

Fact #1: Stress levels, and likely stress-related disorders, are 
increasing in the United States, based on Associated Press-AOL poll 
(see website: http://www.aolhealth.com/healthy-living/debt-stress; also 
see: http://www.usatoday.com/news/health/2007-10-23-
stress-N.htm)

Fact #2: Rates of significant depression in the community are about 
five to ten percent, and place a substantial burden on the economy due 
to cost of treating depression and time lost from work due to 
depression-related disability (Journal of the American Medical 
Association 2002, 287:203-209; Journal of Clinical Psychiatry 2003m 
64:1465-1475; PharmacoEconomics 2007, 25:7-24)

Fact #3: Nearly 50 percent of hospitalized medical patients develop 
depressive disorder, usually due to the prolonged stress and life 
changes caused by medical problems (American Journal of Psychiatry 
1997; 154:1376-1383)

  Stress and depression have effects on physical health and 
need for health services

Fact #1: Psychological stress and depression adversely affect health. 
This applies to a wide range of medical outcomes (hypertension, 
myocardial infarction, stroke, speed of wound healing, etc.), and may 
even affect the aging process itself (based on changes at the DNA 
level) (Lancet 1996, 346:1194-1196 (wound healing); New England Journal 
of Medicine 1998, 338:171-179 (general review); Lancet 2003, 362:604-
609 (prognosis after myocardial infarction); Proceedings of the 
National Academy of Sciences 2004,101:17312-5 (cellular aging) )

Fact #2: Depression increases length of hospital stay and cost of 
medical services, in addition to adversely affecting the quality of 
life of the patient and their family (American Journal of Psychiatry 
1998, 55:871-877; Social Psychiatry and Psychiatric Epidemiology 2004, 
39:293-298; for more recent information, see the following NIH report: 
http://www.nih.gov/news/pr/jan2007/nimh-19.htm)

  Many in the United States turn to religion for comfort when 
stressed or sick.

Fact #1: Religion is often used to cope with stress. Following the 
terrorist attacks on September 11, 2001, research shows that nine out 
of ten Americans turned to religion to cope (New England Journal of 
Medicine 2001, 345:1507-1512)

Fact #2: Religion is often used to cope with mental/physical health 
problems. Research shows that in some areas of the United States, nine 
out of ten hospitalized patients say they use religion to cope with 
illness, and over 40 percent say that it is the most important factor 
that keeps them going. (Handbook of Religion and Health, 2001; Oxford 
University Press). Since the year 2000, over 130 separate quantitative 
studies have documented high rates of religious coping in a range of 
health conditions, especially in minority groups and in women. This 
number does not include hundreds of peer-reviewed published qualitative 
studies (in the words of patients) that support these findings.

  Religious involvement may help to reduce stress, minimize 
depression, and enhance quality of life.

Fact #1: Because of its effectiveness as a coping behavior, religious 
involvement may reduce psychological stress, buffer against depression, 
and speed recovery from emotional disorders (American Journal of 
Psychiatry 1992, 149:1693-1700; American Journal of Psychiatry 1998, 
155:536-542; Journal of Nervous and Mental Disease 2007, 195:389-395).
    Of studies examining religion and depression prior to the year 
2000, 64 of 101 studies (64 percent) reported less depression or faster 
recovery from depression among the more religious (Handbook of Religion 
and Health, ibid). Since the year 2000 (past seven to eight years), 140 
of 223 studies (63 percent) reported less depression or faster recovery 
from depression in the more religious (unpublished review).

Fact #2: Religious involvement is associated with positive emotions 
(greater well-being, happiness, optimism, hope, meaning and purpose in 
life) and higher quality of life.
    Well-being: Of research conducted prior to the year 2000, 106 of 
131 studies (81 percent) reported that religious persons experienced 
more positive emotions (Handbook of Religion and Health, ibid). Since 
the year 2000 (past seven to eight years), 172 of 228 studies (75 
percent) have reported this same finding (unpublished review). Quality 
of Life: Since the year 2000, 20 of 29 studies on R/S and quality of 
life reported that they were positively associated.

  Religious involvement is related to lower rates of alcohol 
and drug abuse, less crime and delinquency, and better grades in 
school.

Fact #1: Religious involvement predicts lower rates of alcohol and drug 
use, particularly in high school students, college students, and young 
adults (Prevention Science 2001, 2(1):29-43; Social Science Research 
2003, 32:633-658; Psychology of Addictive Behaviors 2003, 17:24-31; 
Social Science & Medicine 2003, 57:2049-2054; Journal of Adolescent 
Health 2006, 39:374-380; Journal of Adolescent Health 2007, 40:448-455; 
Alcoholism: Clinical and Experimental Research 2008, 32:723-737).
    Concerning research published prior to the year 2000, 124 of 138 
studies (90 percent) reported less alcohol and drug use/abuse in those 
who were more religious (Handbook of Religion and Health, ibid). Since 
the year 2000 (past seven to eight years), an incomplete review 
indicates that 152 of 186 studies (82 percent) reported this same 
finding (unpublished review). Thus, 276 of 324 studies report 
significant inverse relationships between religious involvement and 
substance abuse.

Fact #2: Delinquency rates and crime are less frequent in those who are 
more religious (Journal of Adolescent Research 1989; 4:125-139; 
Sociology of Religion 1996; 57:163-173; Social Forces 2004; 82:1553-
1572; Journal of Family Issues 2008; 29:780-805).
    Prior to the year 2000, 28 of 36 studies (78 percent) reported that 
delinquency or crime rates were lower among the more religious 
(Handbook of Religion and Health, ibid). Since the year 2000 (past 
eight years), an incomplete review indicates that 12 of 16 studies (75 
percent) report similar findings.

  Religious involvement is related to healthier lifestyles and 
fewer risky behaviors that could adversely affect health

Fact #1: Religious involvement is associated with better health 
behaviors, including less cigarette smoking and more exercise 
(Cigarette smoking: Journal of Gerontology, Medical Sciences 1998, 
53:M426-434; Prevention Science 2001, 2:29-43; Social Science & 
Medicine 2003, 57:2049-2054; Families in Society 2004, 85:495-510; 
Nicotine & Tobacco Research 2006, 8:123-133; Journal of Adolescent 
Health 2007, 40:506-513; Exercise: American Journal of Public Health 
1997, 87:957-961; Activities, Adaptation & Aging 2002, 26:17-26; Family 
& Community Health 2006, 29:103-117)
    Smoking: Prior to the year 2000, 22 of 25 studies (88 percent) 
indicated that religious persons are less likely to smoke cigarettes 
(Handbook of Religion and Health, ibid). Since the year 2000, an 
incomplete review indicates that 28 of 33 studies (85 percent) reported 
this finding. Exercise: Four of six studies have reported that 
religious persons are more likely to exercise. Weight, however, is 
another issue; only one of eight studies show that religious persons 
weigh less than those who are less religious (probably because of those 
potluck suppers!).

Fact #2: Religious involvement is related to less extra-marital sex and 
safer sexual practices (fewer partners) (Social Psychology Quarterly 
1985; 48:381-387; American Journal of Public Health 1992; 82:1388-1394; 
Journal of the American Medical Association 1997, 278:823-832; Social 
Science & Medicine 2003, 57:2049-2054; American Journal of Community 
Psychology 2004, 33(3-4):151-161; Pediatrics 2006, 118:189-200).
    Prior to the year 2000, 37 of 38 studies reported this finding. 
Since 2000, an incomplete review indicates that eight of eight studies 
(100 percent) report this.

Fact #3: Religious involvement is related to a lower risk, healthier 
lifestyle, particularly among youth. This includes greater likelihood 
of wearing seat belts, better sleep quality, regular vitamin use, 
regular physical and dental visits, etc. (Psychological Reports 1991; 
68:819-826; Health Education and Behavior 1998; 25:721-741; European 
Journal of Pediatrics 2005; 164:371-376; Preventive Medicine 2006; 
42:309-312; Journal of the National Medical Association 2006, 98:1335-
1341).

  Religion is related to better physical health and faster 
recovery

Fact #1: Religious involvement is associated with less cardiovascular 
disease, improved outcomes following cardiac surgery, lower rates of 
stroke, less cardiovascular reactivity and lower blood pressure, better 
immune/endocrine functioning, improved outcomes for patients with HIV/
AIDS, lower risk of developing or better outcomes from cancer, and less 
susceptibility to infection:
    Coronary artery disease: International Journal of Cardiology 1986, 
10:33-41; Cardiology 1993, 82:100-121; American Journal of Cardiology 
1996, 77:867-870; Journal of Clinical Epidemiology 1997, 50:203-209.
    Cardiac surgery: Psychosomatic Medicine 1995, 57:5-15; Health 
Psychology 2004, 23:227-238.
    Cardiovascular reactivity: International Journal of Neuroscience 
1997, 89:15-28; Annals of Behavioral Medicine 2004, 28:171-178; Journal 
of Health Psychology 2005; 10:753-766.
    Blood pressure: Hypertension 1988; 12:457-461; Hypertension 1995; 
26:820-829; International Journal of Psychiatry in Medicine 1998, 
28:189-213; Behavioral Medicine 1998, 24:122-130; Psychosomatic 
Medicine 2001, 63:523-530; Journal of Gerontology 2002, 57B: S96-S107; 
Journal of Biosocial Science 2003, 35:463-472; Psychosomatic Medicine 
2006, 68:382-385.
    Stroke: American Journal of Epidemiology 1992, 136:884-894; Stroke 
2000, 31:568-573.
    Metabolic problems: Diabetes Care 2002, 25(7):1172-1176; Archives 
of Internal Medicine 2006, 166:1218-1224; Psychosomatic Medicine 2007, 
69:464-472.
    Immune/endocrine: Psychology and Health 1988, 2:31-52; 
International Journal of Psychiatry in Medicine 1997, 27:233-250; 
Journal of Psychosomatic Research 1999, 46:165-176; Breast Journal 
2001, 7:345-353; Annals of Behavioral Medicine 2002; 24:34-48; Journal 
of Biological Regulators & Homeostatic Agents 2003, 17:322-326; Health 
Psychology 2004, 23:465-475; International Journal of Psychiatry in 
Medicine 2004, 34:61-77; Journal of General Internal Medicine 2006, 
21:S62-68; Journal of Psychosomatic Research 2006, 61:51-58.
    Cancer: Journal of the National Cancer Institute 1989, 31:1807-1814 
(misc. cancers); Journal of the Royal Society of Medicine 1993, 86:645-
647 (colorectal); Social Indicators Research 1996, 38:193-211 (misc. 
cancers); International Journal of Psychiatry in Medicine 2002, 32:69-
89 (gastrointestinal); International Journal of Psychiatry in Medicine 
2003, 33:357-376 (breast); American Journal of Epidemiology 2003; 
158:1097-1107 (colon); Oral Oncology 2006, 42:893-906 (oral).
    Infection susceptibility: British Medical Journal 2006, 
332(7539):445-450.
    For reviews of the research before 2000, see Handbook of Religion 
and Health, ibid. For a more recent review, see Medicine, Religion and 
Health (2008, Templeton Press). For a critique of this research, see 
Lancet 1999, 353(9153):664-667, and Blind Faith (2006, St. Martin's 
Press).

Fact #2: Religious involvement predicts greater longevity and lower 
mortality, with religious attendance being the strongest predictor (and 
associated with seven to fourteen years of additional life) (American 
Journal of Public Health 1996, 86:341-346; American Journal of Public 
Health 1997, 87:957-961; Demography 1999; 36:273-285; Journal of 
Gerontology, Medical Sciences 1999, 54:M370-M37; Journal of 
Gerontology, Medical Sciences 2000, 55:M400-405; Archives of Internal 
Medicine 2001, 161:1881-1885; Annals of Behavioral Medicine 2001, 
23:68-74; Research on Aging 2002; 22:630-667; American Journal of 
Epidemiology 2002, 155:700-709; Journal of Health and Social Behavior 
2004, 45:198-213; Annals of Epidemiology 2005, 15:804-810; 
International Journal of Epidemiology 2005, 34:443-451; Journal of 
Clinical Epidemiology 2005, 58:83-91; Journal of Gerontology 2005, 
60:S102-S109; Journals of Gerontology 2006, 61:S140-S146).

Fact #3: Religious activity predicts slower progression of cognitive 
impairment with aging, and may be associated with a slower progression 
of Alzheimer's disease (Journal of Gerontology 2003, 58B:S21-S29; 
Journal of Gerontology 2006, 61:P3-P9; Neurology 2007, 68:1509-1514 
(Alzheimer's); Journal of Gerontology, Medical Sciences 2008, 63:480-
486)

Fact #4: Religious involvement predicts less functional disability with 
increasing age, and faster functional recovery following surgery 
(American Journal of Psychiatry 1990, 147:758-759; Journal of 
Gerontology 1997, 52B:S306-S316; Journal of Aging and Health 2004, 
16:355-374; Research on Aging 2008, 30:279-298).

  All things being equal, religious people need and use fewer 
health care services; this is because they are healthier, more likely 
to have intact families to care for them, and have greater social 
support

Fact #1: Religious involvement is related to greater marital stability 
and social support, particularly in minority communities. This affects 
the kind of support and monitoring a person with chronic illness will 
have in the community (which may keep them out of the hospital or out 
of a nursing home). Marital stability: Journal of Health and Social 
Behavior 1989, 30:92-104; Behavior Genetics 1992, 22:43-62; Journal for 
the Scientific Study of Religion 1997, 36:382-392; Addiction 2007, 
102:786-794. Enhanced family relationships: Sociological Quarterly 
2006; 47:175-194. Social support: Research on Aging 1991, 13:144-170; 
Journal of Gerontology 1997, 52B:300-305; American Journal of Geriatric 
Psychiatry 1997, 5:131-143; Health Care for Women International 2001, 
22:207-227; Journal of Palliative Medicine 2006, 9:646-657; Journal of 
Health Psychology 2007, 12:580-596). Prior to the year 2000, 19 of 20 
studies found that religious persons had significantly more social 
support.

Fact #2: Religious involvement is associated with lower rates of health 
services use (medical), both acute hospitalization and long-term care 
(Social Science & Medicine 1988, 27:1369-1379; Southern Medical Journal 
1998, 91:925-932; International Journal of Psychiatry in Medicine 2002, 
32:179-199; Archives of Internal Medicine 2004, 164:1579-1585).

  Communities with high percentage of religious involvement 
recover more quickly from natural disasters and acts of terrorism

Fact #1: After the police, firefighters, and emergency medical 
technicians, religious communities are often the first responders and 
often the most enduring responders following disasters. The extensive 
literature (both research studies and popular articles) documenting 
this fact is described in two books, In the Wake of Disaster: Religious 
Responses to Terrorism and Catastrophe (Templeton Press, 2006), and 
Tend My Flock: Emergency Planning for Faith Communities (forthcoming, 
2009).

Fact #2: Religious involvement is related to better mental health, 
greater community resilience, and higher social capital following 
disasters (Journal of Community Psychology 2000, 28:169-186; Annals of 
the New York Academy of Sciences 2006, 1094:303-307; Journal of Health 
Care for the Poor & Underserved 2007, 18:341-354; Social Science & 
Medicine 2008, 66:994-1007).

Implications for Public Health and Patient Care

    So what? Should we try to make people more religious? There are 
numerous direct public health and clinical applications for all of the 
above that have nothing to do with prescribing religion, endorsing 
religion, or over-stepping the bounds of church-state separation that 
the 1st Amendment guarantees. I divide the implications of this 
research into two categories: implications for public health and 
implications for clinical care.

Implications for Public Health

    (1) More research is needed. Although there is every reason based 
on existing research to suggest that religious involvement is related 
to better health, we don't really understand why this is the case. 
Religion can certainly have negative health effects as well, but 
certain aspects of religion (cognitive, behavioral, or social) appear 
have positive effects on health and well-being. Is this not relevant to 
the health of our population and resiliency of our communities? The 
problem is that we don't know what aspects of religion are particularly 
healthy, or how these health benefits occur in terms of behavioral and 
physiological mechanisms. We also don't fully know how religion impacts 
the health of communities, or their resiliency to crime, poverty, 
teenage pregnancy, school performance, venereal disease transmission, 
natural disasters, etc. Given the widespread prevalence of religious 
beliefs and activities (with nearly 200 million church members, and 
over 125 million weekly church attendees), even small effects on either 
individual or community health could have enormous public health 
impact.
    (2) Although it is not ethical or desirable to change or increase 
religious involvement for health reasons, it is important for social 
and behavioral scientists to learn how R/S is affecting health and then 
inform the public about this. People, then, will need to make their own 
choices in this regard, free from coercion or manipulation. 
Furthermore, doesn't the majority of the U.S. population for whom 
religion is important deserve to know what effect their religious 
beliefs and practices are having on their health? This is particularly 
true since certain religious practices in some settings may actually 
worsen health (about five to ten percent of studies find negative 
correlations between religion and health). For religious beliefs, 
practices, and rituals that are shown to improve health, knowing this 
may help to boost the health effects that these beliefs/practices have 
for religious people (since it may encourage them to continue these 
practices, or may help them to utilize their beliefs to help them 
change unhealthy lifestyles). Thus, education of the public and 
dissemination of research findings about factors that may affect health 
is an important role for both health professionals, as well as for 
government agencies interested in maintaining and enhancing the health 
of the population.
    (3) There are many human characteristics that we study in the 
social and behavioral sciences that we cannot change, but need to 
understand what impact they are having on health for planning purposes 
(i.e., anticipating health care needs of the population). These include 
age, gender, race, ethnic background, sexual preference, political 
belief, etc. There are also characteristics that we may be difficult to 
change, and yet we need to know how these factors affect health and use 
of health services. These include the effects of poverty, personality, 
level of social involvement, health habits, obesity, and so forth. This 
doesn't prevent us from conducting research to better understand how 
these factors affect health. For some reason, however, religion seems 
to be placed in a different and separate category. Currently, there is 
widespread bias in the mainstream scientific community against research 
on the health effects of traditional religious beliefs and practices 
[just take a look at the portfolio of NSF/NIH grants and see how many 
grants in the psychological, social, and behavioral sciences are 
focused this area of research].
    (4) What about one-third of the U.S. population who are not 
religious? It may be that they too will benefit from research on 
religion, spirituality and health. By learning about how R/S affects 
health, we can apply this knowledge to non-religious settings and to 
non-religious people using secular techniques. For example, how does 
religious involvement convey meaning and purpose, hope, self-esteem, 
protection from depression, and buffer against stress (and perhaps 
consequently reduce blood pressure, heart attacks, and stroke, or slow 
the development of cognitive impairment and disability with age)? If we 
know the mechanisms, we could use them to enhance the way secular 
beliefs and behaviors provide these healthy effects. This would benefit 
everyone.
    (5) There is even some research that suggests that communities 
where high proportions of the population are members of religious 
groups have better health in general, even the non-religious people who 
live in those communities (see Annals of Epidemiology 2005, 15(10):804-
810; American Journal of Sociology 2005, 111:797-823). Shouldn't public 
health experts be interested in why and how this occurs? Would such 
research not provide clues on how to enhance the health of entire 
populations?
    (6) There are few places where people of all ages (young, middle-
aged, and elderly), all socioeconomic levels, and all ethnic 
backgrounds congregate on a regular basis as happens in religious 
communities. This makes religious organizations an ideal route by which 
to provide health screening, health education, and other disease 
detection and prevention services. A few studies have shown that health 
education programs in churches can affect diet, weight, exercise, and 
other health behaviors, and this is particularly true for minority 
communities who often do not have easy access to such information or to 
preventative health care services. Religious communities may also be an 
ideal place to provide alcohol and drug education, as well as inculcate 
moral values and character that could affect future decisions that 
impact health, pro-social behaviors, and even affect the ability to 
afford health insurance during adulthood. More research is needed and 
effective programs developed. Again, such efforts could have a direct 
impact on public and community health.
    (7) Religious communities often have altruism as one of their basic 
values. Thus, members of churches, synagogues and mosques represent an 
army of potential volunteers to assist with social programs, mentoring, 
and direct service provision. This is perhaps most evident with regard 
to disaster preparation and response. Why are we not supporting and 
nourishing this role that many faith communities are already engaged 
in? Instead, faith groups often meet resistance from formal emergency 
management services when they try to help, since they are not 
integrated into these efforts. Without the volunteer help that faith 
communities provide, it is not hard to imagine what the additional cost 
to FEMA might be. The health of our communities, particularly when 
affected by natural disasters or acts of terrorism, may depend on 
whether religious communities are fully prepared and involved in 
response efforts.

Implications for Patient Care

    (1) If future research confirms that religious involvement 
significantly affects mental and physical health, then health 
professionals need to be educated about this and need to consider this 
in their treatment of patients. In fact, one could argue that there is 
already sufficient research evidence to begin to do this. Furthermore, 
there are other reasons why health professionals should be integrating 
spirituality into patient care. Here are a few (see Spirituality in 
Patient Care, 2007, for a complete description):

          Many patients are religious or spiritual, and would 
        like it addressed in their health care. Because religious 
        beliefs are used to cope with illness (either mental or 
        physical), religious patients would like their spiritual needs 
        to be acknowledged and addressed by their physicians (and by 
        nurses who provide more direct and personal care)

          Patients, particularly when hospitalized or 
        imprisoned by chronic illness, are often isolated from their 
        religious communities. Our country has recognized that when 
        people are prevented from practicing their religious faith 
        because of circumstances imposed on them, we have provided the 
        resources necessary for them to practice their faith (based on 
        the principle of religious freedom). This is why we have 
        chaplains in the army, and in federal and state prisons and 
        psychiatric facilities. Hospitalized patients with medical 
        problems or the chronically ill are no different. Many people 
        are hospitalized far away from their religious communities of 
        support (this is especially true for nursing homes, where 
        contact is minimal even when religious communities are nearby).

          Religious beliefs affect medical decisions, and may 
        conflict with medical treatments. This is a very practical 
        reason why health professionals need to communicate with 
        patients about religious or spiritual beliefs. Studies find 
        that 45 percent to 73 percent of seriously ill patients 
        indicate that their religious affect their medical decisions 
        (Archives of Internal Medicine 1999, 159:1803-1806; Journal of 
        Clinical Oncology 2003, 21:1379-1382; Family Medicine 2006, 
        38:83-84). Yet 90 percent of physicians do not take a spiritual 
        history or discuss these matters with patients, and 45 percent 
        of physicians say that it is not appropriate to do so (Medical 
        Care 2006, 44:446-453). How can physicians practice competent 
        medicine if they don't have knowledge about factors that will 
        affect compliance with the treatments they prescribe?

          Religious struggles or spiritual conflicts over 
        medical issues have been shown to predict increased mortality 
        and worse medical outcomes (see Archives of Internal Medicine 
        2001, 161: 1881-1885). If left undetected and not addressed, 
        these struggles may adversely affect disease course despite the 
        best of medical treatments.

          Religion influences health care in the community. 
        Because of the rising costs of health care, most health care is 
        now shifting out of the hospital and into the community. 
        Hospital stays are becoming shorter and shorter (since 
        hospitalization is the most expensive form of medical care), 
        and people are being discharged sicker and sicker into the 
        community. If patients are involved in a religious community, 
        they will have a ready support system that can provide 
        emotional support, monitor compliance, and provide practical 
        services (meals, home-maker services, respite care, rides to 
        physician office). If they are not, then they are dependent on 
        family members for support, and if no family is available, then 
        they are forced to rely on the government. This will become a 
        real issue as our population ages and the medical needs 
        escalate (Faith in the Future: Healthcare, Aging, and the Role 
        of Religion--see Further Readings).

    (2) What are some sensible ways that clinicians can integrate 
spirituality into patient care, without prescribing religion or 
coercing patients to believe or practice? First of all, most of their 
patients are already religious to at least some degree (recall that up 
to 90 percent of seriously ill patients in some parts of the U.S. use 
religion to cope), so clinicians don't have to promote religion. It's 
already there. What they do need to do, however, is to recognize it, 
support it, and consider it when making medical decisions and 
developing treatment plans. Here are some ways to do that:

          For patients admitted to the hospital or those with 
        serious or chronic medical illness, physicians should take a 
        brief, screening spiritual history that identifies if spiritual 
        beliefs are (1) important to the patient, (2) helping the 
        patient to cope (or, alternatively, are causing spiritual 
        struggles), (3) influence medical decisions or conflict with 
        treatments prescribed, (4) membership in a supportive spiritual 
        community, and (5) whether there are any spiritual needs that 
        someone should address (see Journal of the American Medical 
        Association 2002, 288:487-493). This takes about two minutes to 
        conduct.

          Support (verbally and non-verbally) the religious or 
        spiritual beliefs of patients if those beliefs are helping the 
        patient to cope.

          If spiritual needs or conflicts are identified, refer 
        patients to professional chaplains or trained pastoral 
        counselors to address these needs.

          If patients are not religious, then the spiritual 
        history should focus on what gives patients lives meaning and 
        purpose in the setting of illness (grandchildren, hobbies, 
        etc.), and then those activities supported. Religion should 
        never be prescribed, forced, or even encouraged in patients who 
        are not already religious, so as not to add guilt to the 
        already heavy burden of illness. Inquiry and support in this 
        area must always be patient-centered and patient-directed.

    (3) Health professionals in hospital and outpatient settings should 
be willing to accommodate the religious or spiritual beliefs and 
traditions of patients. Examples: For the American Indian, this may 
involve altering the environment (or providing alternative 
environments) so that traditional spiritual ceremonies concerning 
sickness and death may be performed (if requested by the patient or 
family). For the Muslim patient, the environment should be altered so 
that the patient can perform his or her daily prayers, and care 
arranged so that only gender-matched health professionals give personal 
care. Religious and cultural sensitivity will help both the patient and 
the family to cope better with illness, will improve patient and family 
satisfaction with care, and thereby will likely enhance medical 
outcomes.

    (4) Efforts should be made to ensure that there are adequate 
numbers of chaplains available so that patients' spiritual needs can be 
adequately addressed. A recent study conducted by Harvard investigators 
documented that three-quarters (72 percent) of patients dying of cancer 
said that their spiritual needs were minimally or not at all met by the 
medical system (i.e., doctors, nurses, or chaplains) (Journal of 
Clinical Oncology 2007, 25:555-560). Currently, there are only enough 
chaplains in U.S. hospitals to see about 20 percent of patients (one in 
five) (International Journal of Psychiatry in Medicine 2005, 35:319-
23). There are typically no chaplains in outpatient settings and no 
chaplains in nursing homes. Who meets these patients' spiritual needs?

Recommendations

    Recommendations for Members of Congress emphasize their providing 
support for research on R/S and health (support for both research 
training and research projects); public education of the role of 
religion in health and wellness; health professional education on why 
and how to integrate spirituality into patient care; and motivating 
health care systems to allow health professionals the time necessary to 
address the spiritual needs of patients. Finally, recommendations are 
provided for supporting and integrating efforts by religious 
organizations in disaster preparation and response.

I. Support Research

(1). Because research on the effects of religious/spiritual beliefs and 
behaviors is a substantial need, current barriers at NSF/NIH to funding 
research on the effects of traditional religious beliefs/behaviors need 
to be overcome. This could be done by (1) assigning a specific branch 
at NSF/NIH to review such grants, (2) ear-marking funds to support such 
research, (3) establishing review sections at NSF/NIH with the specific 
expertise and sensitivity to this topic so as to give such grants a 
fair chance of being awarded.

(2). Provide NSF/NIH training grants to support the development of 
young researchers on university faculty to conduct research in this 
area, or to help senior investigators to transition their research into 
this area. There are currently models at NSF/NIH of junior and senior 
investigator awards, but none focus on supporting the training of 
researchers to study the health effects of R/S.

(3). Urge NSF/NIH to develop a ``request for proposals'' (RFP) in the 
area of the effects of traditional religious beliefs and behaviors on 
mental, physical, and social/community health. The John Templeton 
Foundation may be willing to partner with the NSF/NIH to provide 
support for such a competitive grants program.

(4). Establish an intramural research program at the NSF/NIH to examine 
the impact of religious beliefs and practices on public health, the 
cost-savings that this might produce, and the effectiveness and 
acceptability of disease detection and prevention programs within (or 
in cooperation with) religious organizations, especially in minority 
congregations.

II. Support Congregational Health Programs

(1). Consider partial government support for parish nurse programs 
within religious congregations that provide disease screening, health 
education, lifestyle change, and volunteer recruitment and training for 
service delivery. If that latter keeps members of religious communities 
in their homes and out of hospitals or nursing homes, then this could 
represent a substantial cost savings for Medicare and Medicaid.

(2). Along these same lines, encourage the development of health care 
system-religious congregation partnerships. This would involve closer 
working relationships between local hospitals or medical systems and 
religious communities for the purposes of providing early disease 
detection and referral for treatment, volunteer recruitment and 
training, and the teaching of health promotion activities that 
encourage self-care, keep people healthy, and reduce the need for 
expensive medical services (Florida Hospital is a good model to 
follow). Such efforts could also be expanded outside of congregations 
to persons in the general community who need services, but have fallen 
through the cracks of the current health care system.

III. Educate the Public

(1). Develop a public education campaign to help disseminate research 
findings (both past research and new research) on the role that R/S 
plays in maintaining health and well-being. There is already great 
public interest in this topic as exemplified by multiple cover stories 
on spirituality and health in popular magazines such as Reader's 
Digest, Newsweek, Time, Prevention, and others.

(2). Support/encourage adult education classes at State and federally 
funded universities to teach the public about relationships between R/S 
and health, and how people can take advantage of these relationships to 
prevent disease, overcome addiction, and enhance their health and well-
being. These classes should also emphasize the seeking of timely 
medical care, and the important role that allopathic medicine plays in 
health and wellness. Religion and medicine should complement each 
other, not compete or conflict.

(3). The public should be taught how to talk with their doctors about 
R/S. If religion is important to a patient, should this be a 
consideration in their selection of a physician? What are some ways 
that patients can communicate with their physicians about the important 
role that religion plays in their lives and how it could influence 
their medical decisions? A recent article by Elizabeth Cohen on CNN.com 
illustrates such an approach (see website: http://www.cnn.com/2008/
HEALTH/09/11/ep.faith.medicine/index.html?iref=newssearch).

(4). The public should also be taught how to talk with their clergy 
about initiating a health programs within their local religious 
congregation. If the 500,000 religious congregations in America all had 
such programs, then two-thirds of the U.S. population would be exposed 
to disease detection, disease prevention, and health promotion efforts. 
Since persons of all ages participate regularly in religious 
congregations, this means that health education efforts would occur at 
all ages, from the young (focused on substance abuse prevention and 
character development) to the middle aged (focused on healthy eating, 
exercise, stress-reduction, etc.) to the elderly (focused on 
volunteering, mentoring and generative types of activities).

IV. Include Faith Communities in Disaster Preparation and Response
    Part of maintaining public health involves protecting communities 
who may be in constantly threat of natural disasters and even terrorist 
attacks, and helping them to recover if those events occur. Religious 
organizations already play a big role in this regard, both at the 
individual level in helping persons cope with the stress of the event 
and on the community level in helping communities minimize their losses 
in the short-term and recover over the long-term. What can the 
government do to support faith-based efforts? Here are some 
recommendations (see In the Wake of Disaster for more details):

(1). Research and Education. Research is needed to determine the 
prevalence of spiritual needs and the extent to which they are met (and 
by whom) during each phase of a disaster. Further research on the 
relationship between addressing spiritual needs and long-term mental 
health outcomes following disasters is critically needed. Systematic 
data are needed on the activities of clergy and non-clergy volunteers 
from the faith community following disasters. Although more research is 
clearly needed, much is already known that justifies a major 
educational initiative. Education is needed for Emergency Management 
Services (EMS) agencies/personnel, mental health authorities, and 
faith-based groups to help dispel myths and misconceptions about each 
other, to define the unique roles that each group serves, and to 
emphasize the consequences of not valuing and not including each other 
in the disaster response.

(2). Leadership. Government supported EMS agencies should take the lead 
in inviting Faith-Based Organizations (FBOs) to participate in disaster 
planning and response. Government agencies should encourage interested 
FBO's to identify the types of resources they wish to contribute to the 
disaster response effort. This may involve efforts to coordinate 
disaster response; mobilize and train clergy and congregational 
volunteers to provide psychological, social and spiritual support; 
raise funds or material necessities to assist victims during their 
recovery; or many other potential activities.

(3). Organize and coordinate. Government supported EMS agencies need to 
take the initiative to establish a body to coordinate FBO efforts. Once 
established, it could organize itself into national and local networks.

(4). Include in Planning Phase. On the local level, EMS agencies should 
include deployment of FBO resources as part of their response protocol. 
As noted above, this would require that the leaders of local FBOs are 
included in disaster response planning.

(5). Encourage teamwork, partnership and collaboration. Partnerships 
should be encouraged between mental health workers and local faith-
based groups. Local mental health workers should be encouraged to visit 
or participate on local ministerial associations or church councils. In 
this way, the two groups could develop working relationships and 
establish referral patterns before a disaster strikes. Mental health 
counseling services could offer a spiritual component by developing a 
referral network with local pastoral counselors or clergy. Faith-based 
groups, in turn, could refer members who need specialized mental health 
care to mental health professionals. Furthermore, mental health 
professionals could provide education to faith-based communities on how 
to identify mental disorders, which kinds of interventions might be 
helpful, and when to refer.

(6). Consider making trained clergy ``first responders.'' Besides 
offering necessary spiritual support, local clergy are ideally 
positioned to serve as first responders in meeting the psychological 
needs of disaster survivors and triaging those with more complex needs 
to mental health professionals--enhancing the efficiency with which 
scarce specialized mental health services can be delivered. In many 
communities, clergy serve this function anyway following disasters (by 
default). However, making this part of the formal EMS response would 
help to systematize and coordinate the effort.

(7). Credential. There needs to be a way of screening clergy before 
sending them out into the field to ensure that they are adequately 
trained. Basic national standards should be established for 
credentialing clergy, as well as methods of identifying clergy 
credentialed in disaster response prior to a disaster. This needs to be 
done as part of pre-disaster planning to ensure that it is part of a 
coordinated response.

(8). Fund. First, provide greater flexibility in support mechanisms by 
offering more grant options than SAMHSA currently offers. The options 
should address the pastoral care needs of disaster victims during long-
term recovery extending beyond the first few months after the event. It 
is during recovery, as people begin to put their lives back together, 
that issues of meaning and purpose in life begin to surface and 
pastoral care services are most needed. Second, make it easier for FBO 
groups to apply for available funding to help support their preparation 
and response.

V. Educate Health Professionals

(1). Physicians, nurses, social workers, counselors, and hospital 
administrators need to be informed of the existing research on R/S and 
health, and the rationale for integrating spirituality into patient 
care. Most health professionals did not receive training on how to do 
this, and many are nervous about doing so and feel unprepared. They 
don't know how to take a spiritual history or what to do with the 
information they learn from it. They don't know what a chaplain does, 
the type of training a professional chaplain receives, or how the 
chaplain can be useful to them or their patients. They don't know what 
benefits might result from their addressing the spiritual needs of 
patients and ensuring that those needs are appropriately addressed. 
Many medical schools are now developing courses on religion, 
spirituality and medicine for medical students. In fact, nearly 100 of 
the 141 medical schools in the U.S. and Canada now have such courses 
(70 percent of which are a required part of the curriculum).

(2). These medical courses, however, are a relatively new development. 
In 1992, only three medical schools had such courses. As a result, most 
physicians in practice today have no training in this regard. The same 
is true for nurses and other health professionals. This means that CE 
(continuing education) programs are needed to train current health 
professionals about how to sensitively and sensibly address spiritual 
issues with patients. These CE programs could be held at regional 
medical centers or in local hospitals, with several institutions linked 
by video-conferencing or Internet-based methods.

VI. Initiate Health Care System Changes

(1). Even with adequate education and training, health professionals 
need time to address the spiritual needs of patients. Administering a 
screening spiritual history, supporting patients' beliefs, and referral 
to pastoral care all take time, precious time that most health 
professionals don't have in the busy clinic or hospital setting. While 
freeing up such time will be modestly expensive in the short-term, 
there is every reason to think that it will be cost-effective in the 
long-term. If patients have their spiritual needs addressed, this will 
likely influence their health over the long-term and reduce their need 
for future health services (as well as enhance satisfaction and help 
them move more smoothly through the health system). In the only 
clinical trial that has examined this possibility, researchers found 
that physicians taking a spiritual history (which added 2.1 minutes to 
the visit) resulted within three weeks in oncology patients 
experiencing less depression, greater functional well-being, and a 
strengthening of the doctor-patient relationship (see International 
Journal of Psychiatry in Medicine 2005, 35:329-347).

(2). Government-funded health programs should emphasize the importance 
of health professionals addressing the spiritual needs of patients and 
need to free them up from other responsibilities to do so (this is true 
for physicians, but perhaps even more true for nurses). This may 
require providing monetary or some other types of incentive for 
hospitals to free up time for physicians, nurses, social workers, and 
chaplains to address these issues. Perhaps tying this to Medicare/
Medicaid reimbursement based on post-hospitalization patient 
satisfaction surveys might be one route to go. This would require that 
all hospitals include post-hospitalization surveys that assess patient 
satisfaction with spiritual care, which few such survey currently do.

Suggested Readings

Medicine, Religion and Health. Templeton Press (September, 2008)
    The latest review and discussion of research on religion, 
spirituality and health (including both mental and physical health), 
written in a reader-friendly, non-researcher format (updates the 
Handbook of Religion and Health, 2001). Length: 235 pages. To order, go 
to website: http://www.templetonpress.org/
book.asp?book-id=124

Spirituality in Patient Care, 2nd Edition. Templeton Press (2007)
    This book is for health professionals interested in identifying and 
addressing the spiritual needs of patients. It addresses the whys, 
hows, whens, and whats of patient-centered integration of spirituality 
into patient care, including details on the health-related sacred 
traditions for each major religious group. This book provides health 
care professionals with the training necessary to screen patients 
sensitively and competently for spiritual needs, begin to communicate 
with patients about these issues, and learn when to refer patients to 
trained spiritual-care professionals who can competently address 
spiritual needs. Sections specifically address mental-health 
professionals, nurses, chaplains and pastoral counselors, social 
workers, and occupational and physical therapists. A ten-session model 
course curriculum on spirituality and health care for medical students 
is provided, with suggestions on how to adapt it for the training of 
nurses, social workers, and other health professionals. Length: 264 
pages. To order, go to website: http://www.templetonpress.org/
book.asp?book-id=105

Handbook of Religion and Health. Oxford University Press (2001)
    This is a comprehensive review of history, research, and discussion 
of religion and health. Its 35 book chapters span mental and physical 
health, from well being to depression to immune function, cancer, heart 
disease, stroke, chronic pain, disability, and others. Appendix lists 
1200 separate scientific studies on religion and health that are 
reviewed and rated on 0-10 scale, and followed by 2000 references and 
extensive index for rapid topic identification. This is the most cited 
of all references (books, book chapters, and peer review articles) on 
religion and health. Length: 714 pages.

The Link Between Religion and Health: Psychoneuroimmunology and the 
Faith Factor. Oxford University Press (2002)
    Edited volume (15 chapters) examines the role of 
psychoneuroimmunology as an explanation for the link found between 
religion and physical health. Leaders in psychoneuroimmunology discuss 
their respective areas of research and how this research can help 
elucidate the relationship between religion and health. This volume 
reviews research on religious involvement, neuroendocrine and immune 
function, and explores further research needed to better understand 
these relationships. Length: 304 pages

Faith in the Future: Healthcare, Aging and the Role of Religion. 
Templeton Press (2004)
    This book presents a compelling look at one of the most serious 
issues in today's society: health care in America. How will we provide 
quality health care to older adults who will need it during the next 
30-50 years? Who will provide this care? How will it be funded? How can 
we establish effective, comprehensive, and cost-effective systems of 
care as demographic and health-related economic pressures mount? 
Innovative programs created and maintained by volunteers and religious 
congregations are emerging as pivotal factors in meeting health care 
needs. Summarizing decades of scientific research and providing 
numerous inspirational examples and role models, the authors present 
practical steps that individuals and institutions may emulate for 
putting faith into action. Length: 200 pages. To order: http://
www.templetonpress.org/book.asp?book-id=63

In the Wake of Disaster: Religious Responses to Terrorism & 
Catastrophe. Templeton Press (2006)
    Based on White Paper produced for the Center for Mental health 
Services (CMHS) of the U.S. Department of health and Human Services 
(DHHS). Examines psychological responses to natural disasters and acts 
of terrorism, outlines the emergency response system in the United 
States, and describes that role that individual religious faith plays 
in coping with disaster. However, the main focus of the book is 
describing the role that faith-based organizations play in responding 
to disasters, and discusses the many ways that they are involved at all 
stages whenever a disaster strikes. See pp. 109-119 for recommendations 
to public policy-makers. Length: 162 pages. To order: http://
www.templetonpress.org/book.asp?book-id=84

Faith and Mental Health: Religious Resources for Healing (Templeton 
Press, 2005)
    This book is also based on White Paper produced for the Center for 
Mental health Services (CMHS) of the U.S. Department of health and 
Human Services (DHHS). It provides an updated review of the history, 
research, and interventions related to religion and mental health. The 
focus is on examining faith-based delivery of mental health services. 
Five faith-based organizations are discussed: clergy and local 
religious congregations, networking and advocacy groups for the 
chronically mentally ill, national religious organizations that deliver 
mental health services, and groups that deliver faith-based mental 
health services but do not belong to a national religious group 
(religious counselors, chaplains, pastoral counselors). See pp. 255-275 
for recommendations to public policy-makers. Length: 342 pages. To 
order: http://www.templetonpress.org/book.asp?book-id=80

Handbook of Religion and Mental Health. Academic Press (1998)
    Due to our religiously diverse society, The Handbook of Religion 
and Mental Health is a useful resource for mental health professionals, 
religious professionals, and counselors. The book describes how 
religious beliefs and practices relate to mental health and influence 
mental health care. It presents research on the association between 
religion and personality, coping behavior, anxiety, depression, 
psychoses, and successes in psychotherapy, and discusses specific 
religions and their perspectives on mental health. Chapters address 
clinical considerations when treating Protestants, Catholics, Mormons, 
Unitarians, Jews, Buddhists, Hindus, and Muslims. Length: 408 pages.

                     Biography for Harold G. Koenig

    Dr. Koenig completed his undergraduate education at Stanford 
University, his medical school training at the University of California 
at San Francisco, and his geriatric medicine, psychiatry, and 
biostatistics training at Duke University Medical Center. He is board 
certified in general psychiatry, geriatric psychiatry and geriatric 
medicine, and is on the faculty at Duke as Professor of Psychiatry and 
Behavioral Sciences, and Associate Professor of Medicine. He is also a 
registered nurse (RN).
    Dr. Koenig is founder and former Director of Duke University's 
Center for the Study of Religion, Spirituality and Health, and is 
founding Co-Director of the current Center for Spirituality, Theology 
and Health at Duke University Medical Center. He has published 
extensively in the fields of mental health, geriatrics, and religion, 
with over 300 scientific peer-reviewed articles and book chapters and 
nearly 40 books in print or in preparation. He is the former Editor-in-
Chief of the International Journal of Psychiatry in Medicine and of 
Science and Theology News. His research on religion, health and ethical 
issues in medicine has been featured on over 50 national and 
international TV news programs (including The Today Show, ABC's World 
News Tonight, and several times on Good Morning America), over 80 
national or international radio programs (including multiple NPR and 
BBC interviews), and hundreds of national and international newspapers 
or magazines (including cover stories for Reader's Digest, Parade 
Magazine, and Newsweek). Dr. Koenig has given testimony before the U.S. 
Senate (September 1998) and the U.S. House of Representatives 
(September 2008) concerning the effects of religious involvement on 
public health. He has been interviewed by James Dobson on Focus on the 
Family and by Robert Schuller in the Crystal Cathedral on the Hour of 
Power. Dr. Koenig has been nominated twice for the Templeton Prize for 
Progress in Religion.
    His books include The Healing Power of Faith (Simon & Schuster, 
2001); The Handbook of Religion and Health (Oxford University Press, 
2001); and his autobiography, The Healing Connection (2004); Faith and 
Mental Health (2005); In the Wake of Disaster (Templeton Press); 
Kindness and Joy (2006); Spirituality in Patient Care, 2nd edition 
(2007); and Spirituality and Medicine (2008) published by Templeton 
Foundation Press. Dr. Koenig travels widely to give workshops and 
seminar presentations (see
http://www.dukespiritualityandhealth.org/about/
speaking-engagements.html).

                               Discussion

    Chairman Baird. Thank you, Doctor, and thanks to all our 
witnesses for outstanding comments and observations and most 
informative.
    We will proceed now in the questioning. I will yield 
myself, recognize myself for five minutes, and then we will 
follow with my colleagues.
    First of all, I want to thank you all. As a social 
scientist, some of the friends here from the social science 
community will recognize that I have been one of the most 
passionate advocates and harshest critics of my own 
disciplines, and the reason is I believe we have so much to 
offer, and we so often don't offer it as well as we can. And 
the exception to that is illustrated by the testimony today. 
And I congratulate you.
    What I find most impressive is that we are talking about 
rigorous empirical designs, followed by applications in the 
real world, followed by testing those applications with real 
world impacts. And all of this stemming in many cases from 
basic research that then gets moved up as science is supposed 
to. And with real world impacts.
    What I would like to do is follow up on each of the 
examples, and we will probably have a second round of questions 
as well.
    Let me start, we will just follow in order. Dr. Barrett, 
when you talk about the example of teaching emotional, I am 
blanking on the word. Literacy. Thank you. So I may, give us an 
example of how you would do that with a person and with what 
impact that might have. How would it change things?
    Dr. Barrett. Sure. Well, I mean, first of all, I should 
point out that I don't personally do work on emotional 
literacy. That work is actually being done by other people. I 
did the basic research, and my lab pretty much continues to do 
basic research on emotions.
    Chairman Baird. Well, let me jump to the basic research 
then.
    Dr. Barrett. But I can answer that question----
    Chairman Baird.
    Dr. Barrett.--for you. So basically, I mean, my husband 
tells a joke. Right. The joke he tells is that when he first 
met me, he knew three emotion words; happy, sad, and hungry. 
And----
    Chairman Baird. My kind of guy.
    Dr. Barrett.--that usually gets laughs but, you know, but 
the point being that what you do, what emotional literacy 
programs do is they turn people into emotional experts who have 
a large emotion vocabulary, so they have a lot of different 
words for emotion, and they understand the distinctions between 
those words. So they understand the difference not just between 
anger and sad but between irritation and anger and rage. And 
they use those words to help them to better see emotion, you 
know, more precisely see emotion in other people, to more 
precisely label their own responses, and to better know how to 
act.
    So if I just feel bad, that doesn't tell me very much about 
what to do next. However, if I understand that I am feeling 
irritated as opposed to enraged, then I can plan something 
more, my response a little bit more precisely.
    So it basically has to do with using words to shape the 
experience of emotion and the perception of emotion, to be able 
to see emotions in others. And this sort of sounds like just 
word play until you realize that actually words have, are a 
constitutive rule in emotion, that is, emotions, you know, 
there was just an article in Newsweek this week about emotion, 
that, you know, fear can be found in this part of the brain, 
and anger can be found in that part of the brain, and you know, 
that is, it is an unfortunate article, because there isn't a 
tremendous amount of science to back up those claims.
    And so if you take a model like that, then it seems like 
this is just wordplay. But if you believe that the words that 
people use and the language that they speak actually has some 
real informing emotions and in grounding emotion perception, 
then it becomes a completely common-sensical thing to do.
    Chairman Baird. And your research and that of our 
colleagues in the field has been able to empirically identify 
that people differ in how they process their own emotional 
experience and communicate their own emotional experience, and 
that that difference then relates to a host of other variables.
    Dr. Barrett. Yes.
    Chairman Baird. And by educating people about these issues, 
you can then influence other variables.
    Dr. Barrett. Yes. Exactly. So in our lab we spent almost a 
decade doing research that was funded both by the, mainly 
actually by NSF with some support from NIH but mostly it came 
from NSF, where we did something called, we call it experience 
sampling, but basically people almost, over 700 people took 
little palm pilots out into the world with them, and we 
measured a number of things about their emotional experiences 
and then brought them back into the lab and did very controlled 
measurements there of their body, of their faces, and so on. We 
actually also did some brain imaging with these people, and 
what we found really clearly was there is no question that 
people vary in, not just in the words that they know for 
emotion but actually in the precision of their experiences and 
that these have effects in peoples' ability to perceive emotion 
in others and to regulate their own responses and so on.
    Chairman Baird. Great. Thank you.
    I am going to go over my time just a little bit, because I 
want to follow up with Dr. Jemmott. I want to compliment you 
for your courage. In this institution over the last few years 
anything dealing with sexuality has been a target for reverse 
earmarking. By that I mean Members of Congress during an 
appropriations debate target studies based solely on their 
title. Dr. Ehlers and I both have been enraged by this in the 
past, knowing nothing about the study. They just say, oh, this 
deals with sex. We don't think we should spend any money on 
sex, therefore, we are going to cut the budget.
    What you have done is stepped forward and said, look. We 
can make a research-based effort to identify how to intervene 
in a deadly behavior and disease system and apparently with 
good results.
    Could you give it some sense of outcome? Just, you talked 
about the various metrics against which you measure. Just give 
us a sense of, you know, you got these various intervention 
programs. What are the outcome? What have we seen in terms of 
outcome for these things?
    Dr. Jemmott. Well, one study that we, we have done two----
    Chairman Baird. Make sure, please make sure your mic is on 
up there. Maybe. That is hard. You might want to lower the mic 
a little bit to yourself. Okay.
    Dr. Jemmott. Okay. We did two studies that were done in 
clinics, and when you are working in a clinic, it is possible 
to have actual sexual outcomes in terms of sexually-transmitted 
diseases. One study was with African-American women in Newark, 
New Jersey, and the educators in that study were nurses. We 
developed a very, very brief intervention that is appropriate 
in that setting, 20 minutes, and it dealt with the skills 
necessary to use condoms and to reduce your number of partners, 
et cetera. And----
    Chairman Baird. It is not just how to put a condom on. It 
is how to convince your partner that a condom is the way you 
are going to go.
    Dr. Jemmott. Absolutely. And it is using it correctly as 
well. And we followed the women who received the intervention 
for a year, and we found that those who received the 
intervention had a lower rate of chlamydia, gonorrhea, and 
trichomoniasis compared to a control group of women who also 
received an intervention from nurses that dealt with chronic 
disease prevention.
    We did a similar study in Philadelphia with African-
American and Latino adolescent girls who were 15, about, 
approximately 15 years of age. They were all sexually 
experienced. They were in the adolescent medicine clinic. They 
received a skill-building intervention. Some of them received 
an intervention that dealt with chronic disease prevention, and 
we followed them for a year. We found significant reductions in 
their number of partners, increased use of condoms, and a lower 
rate of chlamydia, gonorrhea, and trich, trichomoniasis in that 
study as well.
    So we have been able to have outcomes in terms of sexual 
behavior as well as sexually-transmitted disease. Obviously 
when you work with younger populations it is not really 
feasible to look at sexually-transmitted disease as an outcome, 
so in those populations you want to look at self-recorded 
behaviors, especially abstinence.
    We have a study that we just completed in South Africa that 
is currently under review where they were grade six students in 
South Africa, hardly any of them were sexually active at the 
beginning of the study. Their average age was about 12, and 
only three percent were sexually active. We followed them for a 
year after the intervention, and fewer of them reported sexual 
intercourse over that period, unprotected sex, and reported 
fewer partners, you know, again, compared to a control group 
that received the chronic disease prevention, intervention.
    So we have had some positive outcomes, you know, not just 
here in the United States, with a variety of populations but 
also overseas.
    Chairman Baird. And especially given that you are speaking 
today on the HIV capital of the United States of America.
    Dr. Ehlers.
    Mr. Ehlers. Thank you, Mr. Chairman. Just a quick follow 
up. Did I understand you correctly to say that your abstinence 
program actually worked?
    Dr. Jemmott. Yes.
    Mr. Ehlers. Because we have a lot of debate about that here 
in the Congress.
    Dr. Jemmott. Yes. We have an abstinence program that works. 
It worked in a study that we did here. We have had two of them. 
One worked briefly for three months, but then in a second 
study, which is also under review right now, we followed the 
adolescents for two years and found a significant effect of our 
abstinence intervention in reducing initiation of sexual 
involvement.
    And the participants were grades six and seven African-
American adolescents in Philadelphia, and again, it was 
compared to a control group of adolescents who learned about 
chronic disease prevention.
    Mr. Ehlers. Thank you. And Dr. Kenkel, you mentioned some 
studies on how increasing costs led to reduction of use. I 
assume that applies only for non, the beginning of use of non-
addictive substances, or would that also apply to someone who 
is smoking or someone who is using hard drugs? Did the cost 
increase result in less use, or is it beyond help simply 
because it is an addictive behavior?
    Dr. Kenkel. No. Actually the research suggests that a 
number of addictive behaviors, addicts do seem to respond to 
higher prices. There is a controversially-named theory at least 
developed by Gary Becker and Kevin Murphy at the University of 
Chicago called model of rational addiction. Now, I know to a 
lot of people that almost sounds like an oxymoron, but the 
basic idea is simply that addicts still respond to the same 
kind of incentives that non-addicts do, and it may be 
difficult, and it certainly is more difficult to change 
behavior, but, again, there is evidence that shows that when 
the price of cigarettes go up, people are more likely to quit 
smoking. My research found pretty heavy drinking responded. 
Maybe not the heaviest drinking but some very heavy drinking 
seemed to respond to higher prices. And there has been some 
research that looked into the same kind of price responsiveness 
of illicit drugs, including heroin. And all of those find some 
evidence that higher prices can reduce consumption of these 
goods, even by the addicts.
    Mr. Ehlers. And even for hard drugs then?
    Dr. Kenkel. The hard drug, there has been some studies. I 
mean, that is a very, very difficult----
    Mr. Ehlers. Yeah.
    Dr. Kenkel.--thing to study. I mean, basically on the data 
we don't know that much about the use, nor do we know exactly 
about what prices people are paying. So trying to figure out 
how much prices affect use, it is a doubly difficult challenge. 
But there have been some studies that indicate that, yes, even 
the heroin----
    Mr. Ehlers. And Dr. Koenig, I really enjoyed your 
presentation, perhaps because I am a religious person, but I 
suspect most everyone just drives themselves that way in some 
fashion.
    But what, are there any implication you can draw? You can't 
somehow instill religion in a person to try to improve their 
health.
    Dr. Koenig. Yes.
    Mr. Ehlers. And another question is is it perhaps the 
health outcomes are related to the fact that a number of 
religious behaviors are related to health? For example, for 
years some denominations have strongly discouraged smoking, 
long before the Surgeon General's report. Others discouraged 
drinking very strongly.
    Is it related to that, or is it, in fact, intrinsic to the 
belief of the person, him or herself?
    Dr. Koenig. It is related to as you described, better 
health behaviors, less cigarette smoking, more exercise, et 
cetera, et cetera. The religious, you know, beliefs that say 
you shouldn't over drink, et cetera, et cetera, so that is a 
major factor.
    Also, there is the social factor, the fact that people have 
more support in religious congregations, and then also there is 
the cognitive, the beliefs themselves. They oftentimes are 
positive or optimistic about coping with stress, about deriving 
meaning to the negative experiences which help people to cope 
better.
    In terms of the applications, there are practical 
applications. Because it is so common, so frequent that people 
have religious beliefs and behaviors, how are those affecting 
health? And how as people become more secular in this country, 
how will that affect the increase in health problems? And so 
those are just some of the issues. Clinically there is the 
issue of people have spiritual needs, and doctors aren't 
addressing them. Ninety percent of doctors never even talk to a 
patient about their religious beliefs, and yet those are 
affecting their compliance, their coping with illness, et 
cetera.
    So those are the issues.
    Mr. Ehlers. Okay. Thank you. I was just reading the Old 
Testament recently and the early part of it, and it is just 
striking reading through all the rules and restrictions that 
Moses put in place, how many of them are really health related. 
So this goes back a long way.
    Chairman Baird. Dr. Lipinski.
    Mr. Lipinski. I would like to thank the Chairman for 
holding this hearing and the hearings that we have held and 
probably most importantly right now is last year in the fight 
where there was a threat to NSF funding for social sciences, 
and Dr. Baird really stepped up there, and I gave a little bit 
of help there, but we made sure that that wasn't, we made sure 
we took care of that in the America COMPETES Act.
    And Chairman Baird is the only one who I allow to call me 
Dr. Lipinski, and this is the only place he is allowed to do 
it, here in this Subcommittee. I do have my Ph.D. from Duke in 
political science, so I have fond memories of Duke, a great 
university. I spent maybe too many years in school. One of the 
classes that I remember more from than any other perhaps, when 
I was at Stanford I took a, got a degree in engineering 
economic systems. Decision analysis was something that was, I 
was very interested in. I took a class from Amos Diversky, and 
you know, decision theory, and really the fact that the risk 
aversion that people have and how people make choices not 
really necessarily based on what economically would seem to be 
the clearer choice.
    So I really think that so much of that could be used, 
utilized in making public policy, and Dr. Kenkel, I know you 
were, you know, you were talking about incentivising. We do a 
lot of that in public policy, although sometimes we don't like 
to admit that. But I think a lot of the research that you were 
doing you are talking about in terms of smoking, some of that 
is obviously economic when you are talking about whether or not 
the economics actually impacts people who are addicted to 
drugs. And I think that is very important work, but also 
looking at, beyond the economics of what psychology tells us 
about choices that people make.
    What you, I just want to ask you, Dr. Kenkel, what else, 
what do you think we should be doing more of here in terms of 
helping to, you know, put the question aside of what policy 
should we be doing to incentivise what behavior we want to see 
more of or less of here in this country, but what should we be 
doing in terms of funding? How could we better fund, you know, 
the type of research that would be helpful to us in making 
public policy?
    Dr. Kenkel. That is a tough question obviously. In the kind 
of social science research that health economists use relies 
very heavily on secondary data sets, and so as I said, 
mentioned before, you know, the continued support and expanded 
support for the ongoing data collection efforts of both the 
Federal Government and also, you know, investigator-initiated 
data collections. You know, I am thinking about these ongoing, 
longitudinal data sets like the Michigan Panel Survey of Income 
Dynamics or the Fireman Health Surveys, provide incredibly rich 
resource for health economists and other social scientists to 
both explore the questions that, you know, the data sets were 
designed to answer but also a lot of times to exploit them to 
answer some new questions. So I think a lot of times the, a lot 
of the economics research actually wasn't planned necessarily 
to be used in these data sets, but we suddenly realized we 
could exploit the natural experiment that was created in the 
data, using ongoing data collection.
    With that, I think providing a support for some of the new 
developments in data collection, biomarkers, for example, are 
an exciting idea to connect some of the traditional social 
science kind of variables about schooling and income and 
socioeconomic status with data actually on a much more health-
related, even genetic-related information, something they are 
beginning to use.
    The same types of innovations would really also be 
possible, I think, and should be encouraged in kind of trying 
to provide those links between economics and the other social 
science. New sub-field of economics known as behavioral 
economics, which exactly tries to do what you suggest, that is, 
import the insights from psychology and improve the economic 
models to explore when is it going to be the case where the 
economic model isn't really capturing fully what is going on. 
And can we get to an improved understanding and therefore, also 
maybe improve public policies by kind of combining our forces 
with psychological data.
    And, again, I guess it just shows, you know, the kind of 
research I do, I keep on coming back to sort of facilitating 
data collections and facilitating cooperations between social 
scientists of different disciplines. Some of the most important 
ways I think you could support the type of research where I 
think it needs to go.
    Mr. Lipinski. Thank you. I thank all of you for the work 
that you are doing in multi-disciplinary research. I found when 
I was a political scientist that there wasn't nearly enough of 
them. It seems like there is more of a push in recent years to 
do that, so I think that is very helpful.
    Chairman Baird. Thank you, Dr. Lipinski.
    Mr. Lipinski. I yield.
    Chairman Baird. And that, actually that issue of 
interdisciplinary work is part of what was included in the 
America COMPETES Act, of course, and I would note on the issue 
of behavioral economics that cognitive economic work really of 
Canaman and Diversky and that group, in my judgment certainly 
could help us understand the collapse that this country is 
experiencing right now.
    If you look at the cognitive biases and decision-making 
confirmation bias, for example, is one area. Maybe we have a 
hearing, which would be, hindsight is 20/20, but if you look at 
the role of confirmation bias, that simple cognitive error is 
so profound in getting people to believe that this market 
couldn't do what it has done, we might be able to somehow 
prevent prophylactic measures, cognitive prophylactics in the 
financial markets would be an interesting topic for somebody's 
dissertation at some point.
    We will have another round, so if you have other comments, 
I see Dr. Barrett has something, but I want to make sure we get 
to Dr. Bartlett, and then we will come back around.
    Mr. Bartlett. Thank you very much. Dr. Barrett, thank you 
for your concern about the amount of money that goes into basic 
research. We are starving almost everywhere. I regret that we 
require you to indicate in your grant application for basic 
research where it might have a societal payoff. We ought to be 
pursuing knowledge. There will be societal payoff. There is no 
way of knowing ahead of time where that societal payoff will 
be. But the average American doesn't understand that, and we 
have a truly representative Congress.
    Dr. Jemmott, your comments were very interesting. HIV AIDS 
is a very unique disease. It is essentially universally fatal. 
We can slow the process down. It is the only disease I know in 
a very long time which would totally disappear in one 
generation with appropriate behavioral change. Isn't that true?
    Dr. Jemmott. Yes. Ultimately it would.
    Mr. Bartlett. So your research is enormously invaluable. 
Let us get there. It is very unique. Kills everybody who gets 
it, but it would disappear totally in a generation with 
appropriate behavioral changes. So thank you very much for your 
contributions.
    Several years ago I was driving and over the radio there 
were three reports. Two people had died in New York City from 
something that might have been citicosis, and if it was 
citicosis, it might have come from dried pigeon manure, so 
there was a fairly serious suggestion we might ought to kill 
all the pigeons in New York City because two people died.
    That same radio report said that there was a report of the 
deaths that occurred in cigarette smoking. The last in which I 
saw a date was 472,000. By the way, it took cigarettes less 
than three days to kill as many people as the terrorists killed 
on 9/11. And in that same report there was a report of flying 
saucers over Oklahoma.
    Well, I thought, gee. If I was coming here from somewhere 
else, and I saw a society where two people died in New York 
City that might have had citicosis, and if it was citicosis, it 
might have come from dried pigeon manure, therefore, we are 
going to kill all the pigeons in New York City. And 472,000 
people died from cigarette smoking, and they were still 
advertising cigarettes. I think I would want to fly around a 
bit, too, before I landed.
    This is just insane, isn't it? You know, I can't yell fire, 
fire in a crowded theater because somebody might get hurt 
leaving. And yet they can advertise cigarettes to my grandkids 
and my great-grandkids when it kills 472,000. Is there any 
logic in that?
    I just can't see the--see, I don't, if you want to smoke, 
you go ahead and smoke, but I want no cigarette advertising. If 
I can't yell fire in a crowded theater, you can't have 
cigarette advertising. Buy it if you wish, but it is dispensed 
from under the counter in a brown paper wrapper with skull and 
cross bones on it. A rational society I think would do that.
    Dr. Koenig, you mentioned the increase in lifestyle from 
those who are religious. I am a Seventh Day Adventist, and we 
and Mormons live seven years longer than the average. I don't 
know that other people are less religious than we. Don't you 
think lifestyle has a whole lot to do with that? Because we 
have a very different lifestyle.
    Dr. Koenig. Yes. Absolutely. Lifestyle, behaviors, and it 
starts from childhood on, the way kids are taught and the 
decisions that they make with regard to their sexual practices, 
their drinking, their smoking, everything. Studies show that 
religious youth are more likely to sleep better, more likely to 
take vitamins, more likely to get regular health care, regular 
dental care. Religion impacts in so many ways in terms of their 
health, their healthy lifestyles, their health behaviors, their 
decisions.
    Mr. Bartlett. Then why are we so hesitant politically to 
talk about religion when it has so many positive benefits? Why 
are you kind of relegated to the, well, not lunatic fringe, but 
some fringe, and if you talk about religion and you are in 
politics.
    Dr. Koenig. It's the same way in health care. You talk 
about religion, you are immediately marginalized.
    Mr. Bartlett. Yeah. Why is that?
    Dr. Koenig. I don't know.
    Mr. Bartlett. Any of the rest of you have any observations 
why you are marginalized wherever your discipline is when you 
talk about religion?
    Dr. Barrett.
    Dr. Barrett. Well, you know, a couple of years ago a major 
social, the major research conference in social psychology, 
people asked this question exactly. They asked the question of 
you could count, why is it that you can count on one hand the 
number of social science, social psychologists who study 
religion when it is, you know, a foundational aspect of many, 
in fact, now we hear most people's lives certainly in the 
United States. And, you know, I think that the answer that 
people came up with at this meeting was multi-faceted.
    First of all, it is often, you know, science often 
overlooks the most obvious things. I mean, overlooks the things 
that are right in front of you and that seem most obvious. 
Right? Nobody, very few people actually do research on the 
psychological impact of touch, yet we touch each other all the 
time. We shake hands, we pat people on the back, we hug our 
children. You know, there is not a lot of research on this 
topic even though it is a very, very basic thing.
    But also for some reason it, you know, there is a certain 
stigma to, there has been a certain stigma, the same kind of, 
to religious, to public discourse about religion in the same 
way that there is stigma for lots of things that seem natural 
and obvious. I mean, paradoxically like sex. And so the reason 
why there is stigma I don't think anybody really understands, 
although people are interested in this topic and are starting 
to study it. But there is, you know, sociologists and social 
psychologists have a lot of understanding about stigma and how 
it influences behavior.
    The irony, of course, is that the federal funding agencies 
are not funding that. They don't fund research on stigmas so 
much anymore, and if they do, it is in very limited pockets. 
But it is a topic that has been around in social psychology 
both from a social standpoint and from sociology for, really 
for 100 years.
    Mr. Bartlett. Thank you, Mr. Chairman. We might look to 
Hollywood for a little of the problem.
    Chairman Baird. And for the problem with smoking, Dr. 
Bartlett. It is amazing the implicit message about smoking that 
has come through Hollywood in recent years. You can't advertise 
cigarettes on television, but you can sure show every actor 
that the kids look up to smoking a cigarette in almost every 
scene anymore.
    Dr. Kenkel, I particularly appreciated your comment, I will 
recognize myself for five minutes. We will do a second round 
and then--about it is not what you know that is so much 
trouble, it is what you know that ain't so. One of the great 
values of the social science research is the counter-intuitive 
finding. I remember some years back there was the program 
called Scared Straight. This was the idea that we were going to 
take kids and put them in, kids, juvenile offenders, we were 
going to take them to the really hardcore, I think they did 
this in Rahway, New Jersey. They were going to take them and 
scare them to death, and this was, got a national TV show about 
it and there were programs initiated in State Legislatures 
across the country. And then, thank goodness, some social 
scientist actually did some follow-up research, and if my 
recollection serves correctly, the kids who had gone through 
the Scared Straight Program had a higher recidivism rate than 
the kids who hadn't.
    And the counter-intuitive was a lot of people thought, 
well, we will take those kids there, and we will scare them to 
death. The kids apparently thought, gee, I want to be a bad, 
tough guy like those guys in prison, and the case is true in 
some of our interventions. There is some fascinating research 
about on the economic, behavioral economic realm recently about 
if people have paid a certain amount, does that provide a 
disincentive or a justification.
    And so I commend you for raising this issue, because 
sometimes it is not confirming what we think it would be but 
disconfirming the so-called common sense assumption.
    Tell us a little more about this advertising of smoking 
cessation products. Flush that out a little bit for us. It is 
apparently illegal to advertise these things, but if we did, we 
could save a lot of lives. Again, back to Dr. Bartlett's 
paradox, I am sure that was a negotiated deal with the 
cigarette companies probably but----
    Dr. Kenkel. Well, it is no longer illegal. Actually, the 
irony of the advertising situation was one of the first things 
that attracted us to the topic. We are looking at magazine 
advertisements for these products back in the 1990s when most 
of these products were by prescription only. And because they 
were by prescription only, when, a company could advertise say 
the nicotine patch, but then they would have to have a full 
page of fine print disclosure of all the contraindications 
about how bad nicotine was for you.
    At the same time in the same magazine, the next page, you 
could have an advertisement for Marlboro's, anther nicotine 
delivery system, and they only had to have that tiny little, 
you know, Surgeon General's box. And so we looked at this 
thing, you know, why is it that we seem to be regulating the 
ads for the products that will help us quit smoking and making 
it more difficult to advertise them than we are advertising for 
the actual products we are trying to get rid of, you know, in 
the public health approach.
    So we actually looked at sort of two aspects of our 
research on the smoking cessation advertising. One that I 
mentioned in the testimony earlier was that when people see 
more of these ads on, in magazines at first, and we are 
extending the research to look at television ads, it really 
does seem to be, help stimulate them to think about quitting.
    And interestingly enough a lot of the times when they think 
about quitting after they use, they see the ads, they don't 
necessarily even use the product, which in economic jargon is 
sort of a positive externality, the idea that some of the 
social gains from the advertisements, the firms are not 
managing to gather as higher profits, but they are doing, 
improving public health.
    Now, the earlier part of our research also looked at the 
effect of the regulations on the firms' decisions to advertise 
themselves, and we found that when products went from 
prescription to over the counter, this changed the way the 
advertisements are regulated and made it a lot easier to 
advertise, and therefore, the firms advertised a lot more. So 
when you start putting those two things together, you realize 
that the way we were regulating prescription products for 
smoking cessation actually probably worked to discourage 
smoking cessation.
    Chairman Baird. But you now can see, so that is no longer 
an issue.
    Dr. Kenkel. Yes. So now most of the products are over the 
counter----
    Chairman Baird. Okay.
    Dr. Kenkel.--and that is why they are all, but you see the 
same thing going on now, you know, another possibility, we 
haven't done this research yet, would be on things like the 
statins for cholesterol reduction. A lot of the statin drugs 
are going to still be by prescription only, and therefore, they 
are relatively difficult to advertise. And it is not clear that 
perhaps the public health goals might be better served if we 
made it easier to advertise things like statins as easy as it 
is to advertise the Big Macs that give us the cholesterol in 
the first place.
    Chairman Baird. Dr. Koenig, I appreciate your testimony 
very much, and I think there has been attention in the social 
sciences, pro and con. I mean, it is also true that some of the 
criticism of studies, for example, in the realm of Dr. 
Barrett's research and literacy, emotional literacy, can also 
be opposed on the religious side. In other words, there are 
some religious institutions that pass out to their parishioners 
lists of key terms that say if your child is going to school 
and they use the word, emotional literacy, well, that is 
covert, secular humanism, and I mean, these things, a little 
less so today, but some real counter attacks and issues of Dr. 
Jemmott's type of research. Using a condom is implied to 
instill, to promote sexual behavior, so, therefore, it is 
abstinence only. The debate is not about whether, the real 
debate, the substantive debate is not about whether abstinence 
can prevent sexually-transmitted disease. By definition it can. 
The question is does abstinence only have superior outcomes to 
abstinence with education about responsible decision-making, 
appropriate use of prophylactics, et cetera.
    Can you comment on the dual nature of that tension and how 
we can be sort of more respectful of the positive contributions 
on both sides.
    Dr. Koenig. Yes. There are plenty of negative effects that 
religion can potentially have, and those are really 
understudied as well as the positive effects. There has been 
such a resistance, though, within the field of science to study 
anything about religion at all because of this conflict between 
religion and science. And to try to better understand part of 
it in the mental health field, as you may know, you know, our 
profession has, if anything, been negative towards religion. It 
has excluded it. Freud said it was a neurotic obsession, and it 
was unhealthy, and you did, you got psycho-analyzed so that you 
would get rid of it, and you would be healthier.
    Chairman Baird. Well, Williams James didn't.
    Dr. Koenig. Williams James. No. He was in favor of or he 
described the phenomena in positive ways. And that created this 
whole negative view towards religion, and even within medicine 
today the only time it comes up is when there is a conflict, 
when there is an issue of abortion or a Jehovah Witness refuses 
blood products, and then it comes up in the discussions in the 
teaching centers. But otherwise these positive effects that we 
have been talking about are ignored largely because there is 
fear to talk about it, to get involved in it.
    And so we need education. Education is critical for health 
professionals, for researchers to help them study this area 
that is so common and has an impact one way or the other on 
public health.
    Chairman Baird. I really appreciate your presence and 
compliment Dr. Ehlers for identifying this aspect of the 
hearing today.
    And would recognize Dr. Ehlers for five minutes.
    Mr. Ehlers. Thank you, Mr. Chairman, and just continuing on 
that topic, it has always been a real puzzle to me since I came 
to Washington, if you read the documents on which this nation 
is founded, it is very striking, and not just the documents 
founded on but the writings of Jefferson, Adams, and so forth. 
Very explicit references to the religious faith constantly.
    And today it is the opposite attitude, and I don't know 
whether to blame Freud or someone else. But it is, you know, 
the founders were so eager to defend religion they had the 
First Amendment guaranteeing freedom of religion. Today is 
seems to be trying to have freedom from religion. And I don't 
understand the phenomenon myself.
    I have to comment on Dr. Bartlett's comments, my good 
friend, who, when he talks about religious stigma and then 
Hollywood, reminds me of a friend of mine who is a movie, in 
the movie industry in Hollywood and frequently is asked to come 
to cocktail parties generally on a Saturday night, and one of 
his favorite things to do is to go around the room and talk to 
the actors and directors and all those and ask them a simple 
question. What percentage of the people in America do you think 
will be in church tomorrow morning? And then a number of years 
of doing this the highest percentage that was ever given him 
was 10 percent. The average was two percent. As you said it is 
over 50 percent.
    There is an incredible disconnect between the Hollywood and 
reality. But it is not just Hollywood. It is a lot of people 
who feel the same way.
    In relation to your comments about the relationship of 
religion and health, we have a mental hospital in my district, 
which was founded by the denomination I happen to belong to. 
That is neither here nor there, but they started it years ago 
and was designed to take into account this relationship between 
religion and mental health. They are now, I believe, the second 
largest mental hospital in the United States. And they don't, 
they are not restricted to religious people coming there, but 
they have a lot of people coming there just because they 
provide such excellent care. And that is one the factors, and I 
thought you might be interested in that.
    Dr. Barrett, oh, I have to comment, too, about the pigeons. 
I suspect the real reason everyone wanted to kill the pigeons 
had nothing to do with the disease carried. I live in an 
apartment building. It is just, my balcony is constantly 
littered.
    In any event, back to work. Dr. Barrett, this morning I 
heard on NPR a story about, which relates to what you are 
saying, about treating ADD, and that they found very frequently 
doing it without medication worked better as long as you, they 
say use the sorts of things you talked about. And so it is 
interesting to see that idea reinforced right here in your 
discussion. Just dealing with, and I wouldn't call it emotional 
literacy so much as just helping students cope with the real 
world, which is so different from their imagined world. So I 
thank you for reinforcing that.
    I had one other question, which slips my mind at the 
moment, and so I will simply pass at this point. Thank you.
    Chairman Baird. Dr. Lipinski.
    Mr. Lipinski. I am sitting here, and I have somewhere else 
I was supposed to be at 11:00, but I couldn't drag myself away 
here.
    So I am going to come back and ask everyone else. I asked 
Dr. Kenkel about his recommendations for what we should be 
doing in terms of funding and where we should be at, you know, 
funding for what research would be helpful. But I wanted to 
start out, you know, it can't be, we can't have some social 
scientists without having any questions about measurement and 
about variables.
    I want to ask Dr. Koenig about, I know you are looking at a 
lot of different studies, but I keep coming back to you, how 
exactly do they measure whether, is this a dicogless variable, 
someone is religious or spiritual or they are not? Or is there 
a, you know, is this some sort of scale of how religious or 
spiritual someone is? That sort of thing really stuck out. I 
was wondering how is this, how is it usually considered?
    Dr. Koenig. There are many ways of measuring religious and 
spiritual involvement. There is a book called, Measures of 
Religiosity, that has literally hundreds of measures with 
psychometric properties, all in this one place. It is 
oftentimes measured by church attendance, which seems to be a 
proxy for level of involvement in religion community. It can be 
measured in terms of a very simple question of how important 
religion is to you: very important, somewhat important, or not 
important.
    It can be measured with multi-item scales. There are many 
different scales. There is an intrinsic religiosity scale that 
has ten items that tries to capture to what extent the person's 
faith the object of their ultimate concern? Does it inform 
their decisions in life? To what extent does it direct their 
life and their life's decisions?
    So there are measures of quantifying, and it ranges from 10 
to 50, and you can then look at relationships with all sorts of 
mental and physical health outcomes.
    Mr. Lipinski. So, obviously that is going to have a big 
impact on, well, the measure is going to be based on probably 
the theory of what the mechanism may be and then that is going 
to have a big impact. It is hard to bring all of those together 
and sort of make a summary and try to talk about mechanisms 
when you have all these different measurements that are out 
there. And I just want to throw that question out there. I am 
not trying to, you know, knock down. I just wanted to get some 
sense from you about that.
    So let me turn back to the other question, if anyone else 
has any comments. Dr. Barrett.
    Dr. Barrett. Thank you very much. I have a lot of comments 
about this, so I will just try to keep it brief. I mean, I 
think that money, you know, investing money in individual labs 
or in research centers that tries to enhance social and 
behavioral research is great. You know, I work with economists. 
I collaborate with neuroscientists. I collaborate with 
neurologists, so creating spaces for people to have 
interdisciplinary discussions is great and important.
    But I think that there are other ways in which the Federal 
Government can invest that are really important and are 
lacking. For example, just having a well-trained, well-educated 
workforce, scientific workforce, we no longer really have that 
anymore in America. Most of the people that I know and this is 
also true for my own lab, have difficulty getting the post-
doctoral fellows that we need to work on research projects, 
whether it is within a discipline or across disciplines, from 
the United States.
    Right. I just recently hired four post-doctoral fellows, 
one of whom is from the U.S., and one is from Japan, and one is 
from China, and one is from France. Now, I am all for 
diversity, and I think it is wonderful, and I am not, you know, 
saying that we shouldn't have these kinds of collaborations 
across boundaries, national boundaries, but we really, there 
are just not enough people who are trained. There are not 
enough people who are trained within a discipline, let alone to 
be able to cross disciplines easily. And we don't pay people 
sufficiently so that the best minds come to science instead of 
going into finance, although the current situation might change 
things.
    But, you know, in addition to which I think some of the, 
there are real technological issues that have to be addressed 
that will allow basic social and behavioral sciences to 
interface with other disciplines, let us say for example 
neuroscience. So right now if you are interested in 
understanding how the brain creates behavior, you can measure 
behavior outside a scanner and then you put somebody into a, 
you know, a scanner that will image their brain where they have 
to lie completely and utterly still. Right. You can, and you 
can get really good measure of where neurons are activating in 
the brain, but you can't measure the time course of the 
activation. And it turns out that, you know, it, the brain, 
neurons don't turn on and off like light switches. There is 
this constant, you know, over milliseconds the pattern of 
neuronal activity changes, and these, you know, millisecond to 
millisecond changes are really important for understanding how 
the brain is producing particular behaviors.
    So these are challenges that, you know, our country faces 
if we want to move forward in a significant way, and I would 
also point out that, you know, I live in Boston, where there 
are a total of 12 research magnets that can do neuro-imaging, 
and there are, you know, I don't know, probably a thousand 
people who do research on this topic where they are trying to 
understand how the brain produces behavior. And there is very 
little access, you know. Even at an institution where, you 
know, there, I have a lot of federal funds and people's desire 
to be helpful, I have trouble actually getting access to the 
machinery that I need.
    So it is not just about funding labs. It is about creating 
a workforce and creating the tools, and I think we have a lot 
of work to do on both of those fronts.
    Mr. Lipinski. Anyone else have any, want to add anything?
    Dr. Jemmott. I would like to add something with regard to 
the area of HIV. I think there are three different things that 
are needed. One is more research on dissemination. We have been 
conducting HIV prevention research for quite a while in the 
United States, and we have a large number of efficacious 
interventions, but yet we are still seeing very high rates of 
HIV.
    And part of the problem is that these efficacious 
interventions are not being used in the community. And so we 
need to understand why. We have to understand why interventions 
are adopted and why they are not adopted. We need more research 
on that.
    We need more research on how a community can take an 
intervention and adapt it so that it is more suitable for their 
population, and that will include an understanding of what are 
the critical ingredients of an intervention that cannot be 
changed and which things can be changed.
    And then the third thing is to look at the issue of the 
effectiveness of the intervention when it is outside of sort of 
the social science laboratory where you have highly-trained 
facilitators, and it is very tightly controlled. In a real-
world environment is it still going to be effective and what 
are the factors that determine whether it is going to be 
effective in those settings or not. So that is a whole area, 
dissemination.
    The other thing I would say is even though we have a lot of 
interventions, we don't have interventions for one critically-
important population, and this is the population that is the 
population that is the highest-risk population in the United 
States. It is African-American men who have sex with men. They 
have rates of HIV that rival those that we see in sub-Saharan 
Africa. And yet to this day we still don't have an intervention 
for them that is based on a randomized, clinical-controlled 
trial. So we need more research on that.
    And then the third thing I would say is a controversial 
area that has come up, and that is the issue of abstinence 
only. We are spending tremendous amounts of money for 
abstinence only programs, but the data are just not there. We 
have a lot more data on efficacious, sort of comprehensive 
education programs. Where on abstinence only there is hardly 
any. And I believe that it is possible to develop abstinence-
only interventions that can be efficacious, but the problem is 
there is not much research going on right now on that issue. So 
there really needs to be a lot more research on abstinence-only 
interventions, especially given that they are so widely used 
and so widely encouraged.
    Mr. Lipinski. Is there a reason there isn't that research, 
abstinence-only?
    Dr. Jemmott. I think that most researchers haven't really 
been interested in it. They are of the mindset that, you know, 
young people are going to have sex. It is impossible to get 
them to stop. I think that is probably part of the reason. Some 
people promote abstinence from a religious perspective, and 
many researchers are not very religious, you know, so that is 
not going to motivate them to promote abstinence.
    So it is not seen as an efficacious strategy, but it 
actually hasn't been tested very rigorously.
    Mr. Lipinski. Thank you. Dr. Koenig, anything to add there 
if the Chairman will allow?
    Dr. Koenig. Yes. I appreciate exactly what you are saying, 
particularly about the fact that scientists are not very 
religious, and so when you are looking at the NIH or the 
National Science Foundation, you are looking at review sections 
that are made up of scientists who are in many respects biased 
against any traditional form of religious practice or activity. 
If you have a kind of a new age spirituality or a fringe area 
of alternative or complimentary medicine, they will fund those 
in a heartbeat. But if you even mention the word of God or 
anything related to God, it, immediately it turns sour. So I 
think in some respects making some interventions in order to 
overcome some of the bias on the review sections at the NIH and 
at NSF would be very helpful.
    Also, having awards or having programs where you train 
young investigators or senior investigators to conduct research 
in this area, provide them with the expertise to conduct the 
research. I think that would have big payoff in terms of them 
being able to write adequate grants that are competitive for 
funding.
    Mr. Lipinski. Thank you.
    Chairman Baird. I will recognize Dr. Bartlett. I would just 
note, though, in the context of this discussion, the vast 
amount of federal money that has been going towards abstinence-
only education based on scant research. We tend, and when Dr. 
Ehlers was saying earlier, a little bit too much, in my 
judgment, of this argument that there is an anti-religious 
sentiment certainly in the Presidential debate of late, and 
always the religious factor plays heavily. And I would say the 
abstinence-only advocacy and the vast funding that is going 
towards it in this country and internationally is driven not 
based on empirical basis but based on religious belief.
    And so on the one hand to say, well, we discriminated 
against religion in our scientific practice, and yet we mandate 
taxpayers to fund an intervention strategy that has at present 
relatively scarce demonstrated efficacy but is driven by a 
largely philosophical/religious. And then so we mandate that 
funding but then we say there is an anti-religious bias. That 
is a bit inconsistent. I would just, for the record suggest, 
and while we ought to study the efficacy, if those studies of 
efficacy give us differential results, we might want to modify 
our policy in some way, and that is a difficult thing. If the 
basis for the policy advocacy was not an empirical position but 
an ideological one, that is a challenge for us.
    Dr. Bartlett.
    Mr. Bartlett. Thank you very much. Dr. Kenkel, you 
mentioned that half the deaths in our country come from 
tobacco, sedentary lifestyle, and obesity. One would suspect a 
cause-effect relationship between the last two of these. I 
think some very bad trends started in our country when the 
economy and keeping up with the Jones drove the mother out of 
the home, into the workplace and replaced her with the 
television set.
    The first thing that happened was that there is a very 
positive relationship between the number of television sets in 
the country and the degree in SAT scores over 24 years. They 
still rattle around in the basement, and they are not coming. 
They are not coming up. Of course, as the kids sat in front of 
the television set and nibbled on fast foods, obesity became a 
problem.
    I understand that the next generation of Americans for the 
first time ever may live less long than this generation, 
primarily because of obesity. I tell audiences, this is a 
really great country we live in. The biggest health problem of 
our poorest people, those on welfare, is obesity. Now, isn't 
that a great country? That is really sad, isn't it, that we 
have that relationship.
    When you ask Americans do you think your kids are going to 
live as well as you lived, and a vast majority of them say, no. 
And when you ask people, do you think your country is on the 
right track or wrong track, more people than ever in our 
history today think that their country is on a wrong track.
    What can we in Congress do about these things? Which is why 
we are here today. Let us just start with Dr. Barrett. If you 
have a comment on the last exchange, I would be happy to have 
that, too.
    Dr. Barrett. I have comments on almost every comment that 
has been made. I am trying to sit here and not make them. I 
would suggest, I mean, the comment that you just made, you 
know, it seems to me that the fact that obesity is a major 
health challenge in the United States and that the children, 
our children are not going to live as well as we do may have 
something to do with the fact that mothers are no longer at 
home or the fact that fathers don't stay home.
    But it also has to do with the fact that if you walk into a 
supermarket, you, you know, there is a very narrow strip of 
fresh fruit at one end, and at the other, and the rest of the 
supermarket is filled with things that are bad for you.
    And my understanding from, you know, scientists who study, 
social and behavioral scientists who study obesity is that this 
problem has a lot to do with the fact that, the way that food 
is marketed, what food is available, and the fact that 
carbohydrates apparently, you know, which are very, you know, 
very bad for you, you know, actually trigger the same kind of 
process as an addiction to other kinds of things that are bad 
for you.
    So it seems to me that this example is an example of a 
problem that isn't going to have a quick fix, that there are 
multiple causes and multiple factors that need to be addressed 
and that there is not going to be any single kind of quick fix, 
which I think brings to the forefront the point that a lot of 
us have been making today and that I think is a sympathetic, 
people are sympathetic to, and that is that, you know, sciences 
have to work together, no science can solve the problem. Right. 
There is not going to be a pill that, you know, solves, that 
cures obesity. You are not going to find a gene that cures 
obesity. It is not going to just be providing people with 
cheap, you know, produce that will, you know, cure obesity. I 
mean, none of those things in and of themselves are going to 
solve that particular problem.
    I would say that I think as a general rule one of the 
reasons or at least what I see is that this is a country that 
is anti-intellectual compared to other countries but doesn't 
understand science. It doesn't, really deeply just does not 
understand the value of science for producing better outcomes 
in life. And some of that has to do with education and, you 
know, at all levels, just, you know, how well do we train our 
students about science, how well do they understand what 
science can really do for you?
    Some of it has to do with, you know, actually what I have 
been hearing today a little bit, which is, you know, I have to 
disagree, Dr. Koenig. I sat on review panels, grant review 
panels for the past 10 years. I sit on the editorial boards of 
almost every major psychology journal in my field, and I have 
never seen bias against questions of religion. What I do see is 
what I also see here today, which is that all of us are the 
product of the Enlightenment. You know, we are all the product 
of the belief that faith is something different than reason, 
that reason has, it is not Freud's fault. I mean, a lot of 
things are Freud's fault, but that, this isn't Freud's fault. I 
mean, you know, it goes all the way back to Descartes and even 
further, that, you know, we believe that reason is something 
different than faith, that cognitive things, you know, that we 
could solve the current economic crisis by looking at cognitive 
mechanisms, when, in fact, we know that within the brain 
cognition and emotion are intimately entwined and that some of 
the things that Canaman and Diversky discovered are actually 
emotional effects, that, you know, we just, we don't, that we 
use these kind of common sense beliefs in the kinds of 
questions we ask and the kinds of things that we fund, and it 
has consequences in, for, you know, in the end, for the 
outcomes of our children.
    Mr. Bartlett. Mr. Chairman, thank you very much for a good 
hearing, and thank you, panel. What we really need, of course, 
is a cultural change, a culture gets what it appreciates. You 
might ask yourself how often does the White House invite an 
academic achiever there to slobber all over them the way they 
do sports figures and entertainers.
    Thank you very much for a good hearing, sir.
    Chairman Baird. Thank you, Dr. Bartlett, for your insight.
    We are almost finished, but if there is any final comments 
anyone wants to make, I would like to open that up very 
briefly. We don't have--Dr. Koenig.
    Dr. Koenig. I have actually a comment with regard to Mr. 
Bartlett's question about obesity future lifespans.
    You know, it is interesting that the demographic that you 
are talking about with the highest rates of obesity is also the 
same demographic that has the highest rates of religious 
attendance. These people are at all ages in churches, half of 
them, more than half every Sunday. So what a marvelous place 
potentially to take advantage of some of this science that, 
with regard to health education within churches concerning 
diet, concerning exercise, concerning lifestyle changes.
    And you cut your populations right there. How can you 
motivate churches to develop these faith, health ministries 
where they address these issues in the congregation that could 
extend longevity, that could reduce the need for health 
services. Religion and medicine and health care are parallel 
ways of enhancing health in many respects, but they are just 
not communicating.
    Chairman Baird. Dr. Kenkel.
    Dr. Kenkel. Actually I would like to also say something 
very quickly, and I think it actually compliments several of 
the other comments here about the role of information as 
providing consumer incentives. We, and how that could play out 
with obesity and perhaps, you know, with the religion education 
or with various other dissemination of information.
    And I was struck a few years ago when the Atkins Diet came 
out how quickly all of a sudden there were all sorts of low 
carb products just all over the place. And this is an example 
of, you know, the economist sees this as an example of how the 
market responds with what consumers want. What happens, though, 
is we have to be sure that the consumers get the information 
that helps them want healthy things.
    And one of the comments made earlier by Mr. Bartlett was 
that the high prevalence of obesity among low socioeconomic 
status, you know, among the poor, that is also very true for 
smoking, and we are coming up with a situation where, you know, 
increasingly some of these big health problems like obesity and 
smoking and others are really confined to people with low 
education, low income, and at the same time for people at the 
higher incomes who have access to all these great products and 
all the great information, we can become increasingly healthy.
    And so this, a lot of interest in disparities in health 
linked to these kinds of behaviors and trying to figure out 
interventions, again, that could help eliminate those 
disparities and motivate people that are, the groups that are 
in the most need of getting this information to use these new 
products I think is a very exciting area for public policy and 
research.
    Chairman Baird. It has interesting foreign policy 
implications in the developing world we have gone in many 
cases, there is still starvation, but in many developing 
countries we have gone from the leading death cause is not 
starvation but the non-communicable diseases like diabetes, 
obesity, cardiovascular, and things.
    Dr. Jemmott, did you have a final comment?
    Dr. Jemmott. I would just say that I agree that we should 
focus on obesity and sort of food consumption, nutrition, et 
cetera, but I think we should also remember that physical 
activity is very important as well. And I think a lot of 
Americans know a lot about, you know, food and what they should 
eat and shouldn't, and should not eat, but when it comes to 
physical activity, they don't know how they can fit it into 
their daily routine, yet it is so important.
    So it seems like we need to have more focus on that as 
well.
    Chairman Baird. Again, I thank the panelists and the folks 
in attendance today. Thank my colleagues. With that the hearing 
stands adjourned. I am grateful for your presence. Thank you.
    [Whereupon, at 11:45 a.m., the Subcommittee was adjourned.]
                               Appendix:

                              ----------                              


                   Additional Material for the Record


                      Statement of David B. Abrams
                           Executive Director
                 The Steven A. Schroeder Institute for
                  Tobacco Research and Policy Studies
                      American Legacy Foundation

    There is strong evidence that half of all deaths in the U.S. can be 
attributed to behavioral factors such as smoking, poor diet, 
overeating, and physical inactivity. In addition, behavioral and social 
factors contribute to the staggering costs of preventable morbidity and 
mortality.
    Even with the dramatic contributions that behavioral and social 
sciences research has made to date, much more needs to be done to 
understand the role of behavioral and social factors in disease and, in 
turn, to use that knowledge to improve the Nation's health.
    Behavioral and social sciences research is critical to improving 
public health overall, but is especially important in addressing youth 
smoking prevention and adult tobacco cessation. Tobacco use is the 
single most avoidable cause of disease, disability, and death in the 
United States. Eighty percent of all smokers have their first cigarette 
before age 18 and 90 percent start smoking before age 20. Within days 
or weeks of smoking your first cigarette, symptoms of nicotine 
dependence may appear. Although nearly half of all smokers attempt to 
quit each year, less than five percent are successful, with the 
majority going back to smoking within just seven days.
    As we examine how to reverse the tobacco epidemic in this country, 
we must pay special attention to the role of behavior change. Young 
people are especially vulnerable to the advertising tactics of the 
tobacco industry and their power to affect behavior is undeniable.
    Last month, a new report from the National Institutes of Health, 
Monograph 19: The Role of the Media in Promoting and Reducing Tobacco 
Use, concluded that much tobacco advertising targets the psychological 
needs of adolescents, such as popularity, peer acceptance and positive 
self-image. Advertising creates the perception that smoking will 
satisfy these needs.
    The report also concludes that mass media campaigns can reduce 
smoking, especially when combined with other tobacco control 
strategies, lending further credibility to existing media campaigns 
that have been proven to curb youth smoking, such as the American 
Legacy Foundation's award-winning truth campaign. In its first two 
years, truth was credited with 22 percent of the overall decline in 
youth smoking, but the annual budget for truth is less than the $36 
million our competitors in the tobacco industry spend in just 24 hours 
to market their deadly products to consumers in the U.S.
    Behavioral and Social Sciences have also provided effective smoking 
cessation treatments for tobacco dependence as well as for other 
addictions and mental illnesses like depression and anxiety. The 
national smoking cessation campaign called EX is geared to taking what 
we know and reaching the 45 million current smokers--the majority of 
whom want to quit, but have not accessed the available effective 
resources in previous quit attempts. Despite the concerns of the 
obesity epidemic and the escalating costs of health care, we should not 
forget that tobacco use is still the single biggest preventable cause 
of death, suffering and excess cost to our health care system.
    Investments in behavioral and social sciences have paid off. We 
have contributed to child health and human development, to improving 
quality of life as we age, and we have cut HIV-AIDS incidence in half 
in less than 20 years, and many other examples, using principles and 
practices of Behavioral and Social Science. We know a great deal about 
how to reverse the type 2 Diabetes epidemic. However, putting what we 
know into practice and policy has fallen far short of what is needed 
and could be achieved to improve our nation's health. If we put all of 
what we know in behavioral and social sciences into practice and policy 
at every level of health care and public health delivery, we could 
dramatically reduce chronic disease burden, disability, death and huge 
preventable expenses to our nation. We can do this with what we know 
today.
    Despite considerable success over the past decade in tobacco 
control, tobacco use still accounts for nearly one-third of cancer 
deaths in the U.S. and worldwide, and tobacco-attributable mortality is 
predicted to increase in the coming decades if current smoking patterns 
continue. Tobacco use is also a major contributor to heart disease, 
pulmonary disease and it complicates and makes worse almost any other 
disease. If this trend is to be reversed, an in-depth understanding of 
the behavioral and social factors that underlie tobacco use as well as 
effective prevention and treatment efforts must inform the debate and 
guide the way to effective policy changes. Behavior change is at the 
center of the translation of new discoveries in the biomedical, socio-
behavioral, and population sciences into practices and policies to 
improve our nation's health.
    The Steven A. Schroeder National Institute for Tobacco Research and 
Policy Studies at the American Legacy Foundation advances the science 
behind social marketing, smoking cessation and tobacco control policy 
to facilitate the translation of empirical findings to practical public 
health interventions. The American Legacy Foundation is dedicated to 
building a world where young people reject tobacco and anyone can quit. 
Located in Washington, D.C., the Foundation develops programs that 
address the health effects of tobacco use, especially among vulnerable 
populations disproportionately affected by the toll of tobacco, through 
grants, technical assistance and training, partnerships, youth 
activism, and counter-marketing and grassroots marketing campaigns. The 
Foundation's programs include truth, a national youth smoking 
prevention campaign that has been cited as contributing to significant 
declines in youth smoking; EX, an innovative public health program 
designed to speak to smokers in their own language and change the way 
they approach quitting; research initiatives exploring the causes, 
consequences and approaches to reducing tobacco use; and a nationally-
renowned program of outreach to priority populations. The American 
Legacy Foundation was created as a result of the November 1998 Master 
Settlement Agreement (MSA) reached between attorneys general from 46 
states, five U.S. territories and the tobacco industry. Visit 
www.americanlegacy.org.

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