Behavior Routinely on Biomedicine’s Back Burner

Saris filter out cholera
As women at a village pond in Bangladesh wash utensils and vegetables, the woman on the right is putting a sari filter onto a pot to filter water of the cholera pathogen, a behavioral change with a clear medical benefit. (Photo: Anwar Huq, University of Maryland Biotechnology Institute/CC BY 2.5)
The recent report from the World Health Organization focusing on the response to the Ebola outbreak again highlights the importance of including the social sciences in any health situation. The report notes:  “Social science expertise is critical to understanding local beliefs, behaviours and customs. These experts can inform those who are at the front line, enabling them to better understand the context and work more effectively with communities to change behaviour. This must become part of standing protocols and standards for health emergencies.” As Robert Dingwell has written eloquently in his blog on these pages, “It [the social sciences] must become part of the working knowledge of any national or international agency dealing with pandemic or emerging infectious diseases.”

Yet, the challenge of infusing the social sciences into what are generally viewed as biomedical issues has been a long and difficult one. A 1982 report from the Institute of Medicine (now the National Academy of Medicine), Health and Behavior: Frontiers of Research in the Biobehavioral Sciences, became the touchstone for those advocating for the inclusion of the social and behavioral sciences in research on medical conditions.  When I first came to the Consortium of Social Science Associations (COSSA) in 1983, we were always noting its conclusion that most of the causes of mortality were behaviorally related.  However, convincing the biomedical community and the National Institutes of Health (NIH) to fund research in these areas was an uphill fight.

Howard J. Silver
Howard J. Silver served for a quarter century as the executive director of the Consortium of Social Sciences Agencies. His blog appears monthly at Social Science Space.
The IOM report noted that “both access to health care and regard for its advice are behaviorally influenced” and that “the burden of illnesses and disabilities in the United States and the world is closely related to social, psychological, and behavioral aspects of the way of life of the population.” It identified cigarette smoking, excessive alcohol consumption, other substance abuse, unhealthy dietary habits, sedentary lifestyles, and non-adherence to effective medication regimens as areas for more study. Many of these continue as significant areas of exploration today.

In addition, the AIDS epidemic, which arrived at about the same time as the IOM report, also provided another instance where, in the absence of drugs and a vaccine, social and behavioral factors would play a significant role in coping with the disease. In the years since the early 1980s there has been a growing recognition that the health of individuals and the public health of a society can be affected by social and behavioral factors. One major example has been the large reduction in smoking in the United States, which occurred through vigorous campaigns based on social and behavioral science research.

After a long advocacy effort by COSSA and other groups in the social and behavioral science community, Congress, led by former Representative Henry Waxman, D-California, directed NIH to establish an Office of Behavioral and Social Sciences Research in 1993. It took NIH two years to find the first director for OBSSR and to get the office up and running and the recent celebration of its 20th anniversary included a major symposium as well as a reception on Capitol Hill.

Former NSF Director Rita Colwell’s willingness to credit the social sciences for influencing her research on cholera in Bangladesh also helped.  With the help of sociologists, Colwell was able to change the behavior of Bangladeshi women so that a simple water filtration device, their saris, could prevent cholera. Using other social research on communication helped spread the word.

Another factor that has helped infuse social and behavioral science into the health research agenda has been the recognition of the importance of health disparities based on socio-economic status. NIH got on the bandwagon and created an Institute for Minority Health and Health Disparities to support studies in this area.

Furthermore, the aging of the population and the retirement of the baby boomers and their impact on government programs such as Medicare and Social Security led the NIH to fund the Health and Retirement Study. This longitudinal study has “explored the changes in labor force participation and the health transitions that individuals undergo toward the end of their work lives and in the years that follow.”

Things have come a long way in 33 years. NIH, with OBSSR as catalyst, supports social and behavioral research throughout its institutes and centers. Of course, some institutes do it better than others. The National Institute on Aging has had a thriving Behavioral and Social Research program for a long time. The Eunice Kennedy Shriver National Institute of Child Health and Human Development has been in the forefront of research on how children learn and the study of population dynamics. The National Institute of Mental Health, despite some blips along the way, has been a significant player in investigating the psycho-social aspects of mental illness. The National Institute on Diabetes and Digestive and Kidney Diseases has supported long-term studies of lifestyle effects on diabetes. Even, the National Cancer Institute has a significant social and behavioral science component, including supporting research on cancer incidence in disadvantaged communities.

In addition, trans-NIH programs, such as the Common Fund, now include money for an initiative called the Science of Behavior Change. In this year’s proposed FY 2016 budget there is also significant funding for research into adherence to medicine regimes, an issue on which COSSA presented a congressional seminar many years ago. NIH’s Office of AIDS research now spends around $400 million on social and behavioral science research related to the disease.

Congress, from time to time, has challenged NIH’s support for social and behavioral science research related to health. In the late 1980s and early 1990s, it was NIH support for research on sexual behavior that raised a ruckus. Thanks to the intervention of former Representative Patricia Schroeder, D-Colorado, in which she circumvented the objections to a teen sex survey, the National Longitudinal Study of Adolescent to Adult Health, or Add Health, was born. Add Health “combines longitudinal survey data on respondents’ social, economic, psychological and physical well-being with contextual data on the family, neighborhood, community, school, friendships, peer groups, and romantic relationships, providing unique opportunities to study how social environments and behaviors in adolescence are linked to health and achievement outcomes in young adulthood.”

In recent years, the House has tried to eliminate NIH’s support for research on health economics. The Coalition for the Advancement for Health Through Behavioral and Social Science Research (CAHT-BSSR), a COSSA-led group, along with others, played a significant role in responding to these threats. CAHT-BSSR has also helped highlight these sciences and their relationship to a healthy nation and world through briefings on Capitol Hill and other public events.

The world of disease will always seeks remedies that will prevent, manage, and cure health difficulties in the most effective way possible. This has usually meant searches for vaccines and other drugs and an emphasis on biological research. Over the years, lifestyle issues and other to social and behavioral factors have gained recognition as important areas for investigations. Yet, as the WHO report suggests there is still some distance to go.

Stay healthy and have a great rest of the summer!

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Howard J. Silver

Howard J. Silver served as the executive director of the Consortium of Social Science Associations (COSSA) in Washington, DC, from 1988 to 2013. He has testified before Congress, spoken on federal funding of science at many professional meetings, and written extensively on executive-legislative relations, the federal budget process, and science policy as it affects the social and behavioral sciences.

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