Improving Diversity Among Health Professionals in the United States: A Brief History

Americans have achieved significant improvements in their health status over the past century. The average life expectancy of an infant born in 1900 was 47 years, whereas the average life expectancy of an infant born in 2000 is 78 years.1 The major causes of death and disability in the United States also have changed dramatically. At the beginning of the 20th century, communicable diseases, including tuberculosis, smallpox, poliomyelitis, diphtheria, and pneumonia, were prevalent among the top ten causes of death. With better sanitation, improved nutrition, and other public health measures implemented throughout the 20th century, these infectious diseases have been greatly diminished or eliminated in the United States. Today, the top ten causes of death in the United States include chronic diseases, such as heart disease, cancer, stroke, kidney disease, liver failure, and HIV/AIDS. Advances in health care and new therapies resulting from biomedical research have contributed to this improvement. When we look more closely at the health of Americans, however, we see that the nation's minority populations have not enjoyed the full measure of improvement. This is especially true for the African American, Hispanic, and Native American populations. As a result, these populations have a shorter life expectancy (up to 6 to 8 years less than whites); higher death rates from heart disease, stroke, cancer, diabetes, kidney failure, and other disorders; and greater rates of disability from these and other conditions.1 Factors contributing to this disparate health status include fewer individuals in minority populations with health insurance coverage, less access to health care, poverty, discrimination, and lower rates of health literacy. However, a major contributing factor, in existence since the founding of this country, has been an inadequate number of minority health professionals, such as doctors, dentists, and nurses. In its report published in September 2004, the Sullivan Commission noted that, whereas more than 25% of the US population today is African American, Hispanic, or Native American, only 9% of nurses, 6% of physicians, and 4.6% of dentists are from one of these minority groups.2 The questions are often raised, “Why is it important to have a racially and ethnically diverse health professions workforce? Does it matter? Does it make a difference?” The evidence suggests that it does make a difference. Health care professions are rigorous, scientifically based disciplines practiced in a social environment. This environment has all of the flaws of any social setting, namely, bias due to ignorance and prejudice based on attributes such as race, sex, ethnicity, tribal clan, and geography. Komaromy et al3 reported that African American and Hispanic physicians are 3 to 4 times more likely than white physicians to establish their practices in communities that are predominantly African American or Hispanic. They also noted that these minority physicians provided care for a higher percentage of Medicaid patients and patients with no health insurance than did white physicians.3 Historically, efforts to increase the number of minority health professionals in the United States have included (1) the formation of predominantly black health professions schools; (2) the repeal of laws, regulations, and policies supporting segregation and discrimination; (3) affirmative actions to increase stu-dent diversity in health professions schools; and (4) a variety of individual and institutional initiatives undertaken by health professions schools themselves. The formation of predominantly African American health professions schools began in the latter half of the 19th century. In 1868, Howard University opened the nation's first African American medical school in Washington, DC, followed, in 1876, by Meharry Medical College in Nashville, TN. Between 1881 and 1900, five more predominantly African American medical schools opened: Louisville National Medical School (Louisville, KY), Leonard Medical School of Shaw University (Raleigh, NC), Flint Goodridge School of Medicine (New Orleans, LA), East Tennessee School of Medicine (Chattanooga, TN), and West Tennessee School of Medicine (Memphis, TN). In 1910, following the release of the Flexner Report, which was highly critical of the quality of many of the medical schools in the United States, medical schools began to close.4 In 1910, there were 148 medical schools in the United States. By 1925, that number had dropped to 80.4 Of the seven predominantly African American medical schools that existed in 1910, only Howard University College of Medicine and Meharry Medical College survived. In an effort to ward off a pending shortage of physicians in the United States, beginning in 1956, the federal government provided financial incentives that resulted in a surge in the formation of new medical schools; 46 new schools had opened by 1981.5 Of those, two were predominantly African American: Morehouse School of Medicine in Atlanta, GA, which admitted its first class in 1978, and Charles Drew Medical School in Los Angeles, CA, which enrolled its first class in 1981. The repeal of laws, regulations, and policies supporting segregation in the southern United States began in 1948, when the University of Arkansas School of Medicine admitted its first African American student. In 1954, the United States Supreme Court ruled school segregation unconstitutional.6 Additional medical schools in the South began admitting African American students, and by 1966, with the admission of the first African American students to medical schools at Duke University (Durham, NC) and Vanderbilt University (Nashville), all medical schools in the South had been integrated. A variety of affirmative action programs were initiated in the second half of the 20th century to facilitate the integration of institutions of higher education, including medical schools. Some of these programs have been criticized or attacked as unconstitutional because of the perception that they give preferential admission to African American, Hispanic, and Native American students over better qualified white students. As a result of these criticisms, many affirmative action programs have been either greatly reduced or terminated. Beginning in 1968, the Association of American Medical Colleges (AAMC) undertook a series of activities to improve racial diversity in US medical schools. In that year, the Group on Student Affairs (GSA) established a Committee on the Medical Education of Minority Groups. This committee has stimulated and coordinated the efforts of individual medical schools, regional and national groups, and other GSA committees to increase minority group representation in the medical sciences.7–9 In 1969, the AAMC established the Office of Minority Health with a grant from the US Office of Economic Opportunity to help medical schools recruit, admit, and graduate underrepresented minority students. The AAMC published the first edition of Minority Student Opportunities in United States Medical Schools.10 This biennial publication compiles for applicants information about every medical school's minority recruitment, admissions, students, and graduates. The AAMC created the Medical Minority Applicant Registry (Med-MAR) for applicants from underrepresented and disadvantaged groups. The Med-MAR program distributes biographic information on prospective medical school applicants to admission offices of AAMC members and certain health-related agencies interested in increasing opportunities for students from underrepresented groups and for economically disadvantaged individuals. In 1976, the AAMC Executive Council recommended that a formal Minority Affairs Section (MAS) be established within the GSA and that each medical school dean be encouraged to appoint one individual to serve as a representative to the Group on Student Affairs-Minority Affairs Section (GSA-MAS). The AAMC Executive Council approved the formation of GSA-MAS. In 1990, the AAMC launched the Minority Faculty Career Development Seminar for junior minority faculty who aspire to leadership positions in academic medicine. In 1991, Project 3000 × 2000, based on the premise that academic medical centers are an integral part of the communities they serve, was launched to address the long-standing underrepresentation of African Americans, Mexican Americans, mainland Puerto Ricans, and Native Americans in medical school.11 Due to these and other efforts, the percentage of physicians in the United States who are African American increased from 2.0% in 1950 to 4.5% in 2004.1 The increase in the number of African American and Hispanic physicians—the net result of a half century of initiatives—was far less than had been either expected or desired. In 2003, two studies were launched to analyze the status of minorities in the health professions: (1) the Institute of Medicine (IOM) Committee on Institutional and Policy-Level Strategies for Increasing the Diversity of the U.S. Healthcare Workforce and (2) the Sullivan Commission on the Health Professions. In 2004, these two groups released reports detailing their respective findings and recommendations.2,12 Both reports indicated that progress had been made in increasing the diversity of the student bodies in US medical, dental, and nursing schools. However, there remains a great shortage of African American, Hispanic, and Native American individuals among US health professionals and in the classrooms of US medical, dental, and nursing schools. The reports further correlated these health staffing shortages with disparities in health status and lack of access to health care. In January 2005, members of the IOM committee and the Sullivan Commission joined to form the Sullivan Alliance to Transform America's Health Professions. The purpose of the Sullivan Alliance is to serve as a national catalyst for the implementation of the 25 recommendations of the IOM committee and the 37 recommendations of the Sullivan Commission.2,12 A second outcome of the Sullivan Alliance was the formation, in September 2004, of the Virginia-Nebraska Alliance. This alliance includes all five of the historically black colleges and universities in Virginia (Hampton, Virginia Union, Virginia State, Norfolk State, St. Paul's College), the J. Sergeant Reynolds Community College, the University of Richmond, and the health science centers at Virginia Commonwealth University, the University of Virginia, Eastern Virginia Medical College, and the University of Nebraska. The purpose of this consortium is to increase the rate of success of undergraduate students from these institutions in gaining admission to and graduating from a health sciences program in medicine, dentistry, nursing, or an allied health discipline. The core of the program includes student summer research experiences at one of the participating health sciences centers. Faculty from the undergraduate institutions also have opportunities to do research at the health sciences centers, with the goal of enhancing their research capabilities. A third outcome of the Sullivan Commission was the creation, in January 2005, of the Commission to End Health Care Disparities, by the American Medical Association, the National Medical Association, and the National Hispanic Medical Association. One of the goals of this commission is to work for a more racially and ethnically diverse health care workforce in the United States. The Future The success of future efforts to increase diversity in the US health care workforce will depend on increased understanding nationwide of how workforce diversity can lead to improved access to care, improved quality of care, improved health literacy, and greater efficiency (and lower costs) in the delivery of care. This will require continued activities and support at local, state, and national levels. It will also be influenced by the quality and quantity of upcoming committed, qualified minority health professions students. Adequate career counseling, appropriate and adequate student financial aid, and strong public school and college academic preparation must be in place to ensure this supply of qualified students. A healthy nation is required for the United States to compete successfully in the global economy and the global marketplace.