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Liu A. Breaking barriers: the urgent need for Black representation in medicine. HPHR. 2024. 85. https://doi.org/10.54111/0001/GGGG2
This article addresses the pressing issue of Black underrepresentation in healthcare and medicine, drawing attention to the pervasive racism within academia and its detrimental impact on healthcare outcomes. Based on the author’s experiences at Harvard School of Public Health, the essay highlights structural barriers hindering Black individuals from pursuing careers in healthcare, supported by scientific evidence demonstrating the benefits of racially concordant doctor-patient relationships. The essay argues for comprehensive changes at multiple levels, including K-12 education and academic medical centers, to dismantle systemic racism and ensure equitable healthcare for all. Through a call to action for targeted recruitment initiatives and anti-racism education, the op-ed emphasizes the imperative for a medical workforce that reflects the diversity of the communities it serves, ultimately striving for improved health outcomes for marginalized populations.
As I graduate from Harvard School of Public Health, a troubling reality weighs heavily on my mind: throughout my academic journey here, I have noticed a lack of Black representation among my peers and professors. Out of the roughly twenty courses I have completed for my MPH degree, only one has been taught by a Black faculty member. These disparities underscore the persistent challenges of racism within academia and a lack of diversity and inclusivity in institutions like Harvard. They also point to the negative impact of the Supreme Court’s decision to end race-conscious admission policies in higher education. Ending race-conscious admissions programs harms Black students, as evidenced by decreased enrollment in states that have eliminated affirmative action.1 Further, such disparities unveil a deeper systemic issue in higher education, rooted in historical exclusion and perpetuated by ongoing structural barriers.
Throughout history, Black individuals have faced immense challenges in pursuing careers in healthcare and medicine, stemming from institutionalized racism and discriminatory policies. From the exclusionary practices of early medical schools to the enduring legacy of the Flexner Report, structural barriers have hindered access to medical education and opportunities for Black aspiring physicians.2 The Flexner report aimed to standardize medical education, advocating for the training of African American physicians in “hygiene rather than surgery” and emphasizing their role as sanitarians with the purpose of “protecting whites” from diseases like tuberculosis.3 Historically, Black medical schools faced challenges implementing Flexner’s rigorous standards due to limited resources. As a result, although seven medical schools for Black students were established between 1868 and 1904, only two schools – Howard University Medical School and Meharry Medical School- remained by 1923.4 These Black medical schools had played a crucial role in closing workforce gaps, producing primary care physicians, and offering culturally sensitive care. According to estimated projections, if these schools hadn’t closed, they would have educated 30,000-35,000 Black physicians in the last century.5
Data from the Association of American Medical Colleges reveals a concerning trend: Black physicians remain significantly underrepresented relative to the demographics of the U.S. population, comprising only about 5.7% of physicians nationwide. This figure starkly contrasts with the estimated 12% of the U.S. population who are Black.6
Anti-Black racism continues to be pervasive in the U.S. healthcare system today. Discrimination, both overt and subtle, undermines the workplace experiences of Black doctors, leading to fewer opportunities for career advancement, lower pay, and higher rates of turnover. For example, research shows that Black physicians are more likely to experience workplace discrimination from both co-workers and patients than any other racial group. At least 71% of Black physicians reported experiencing discrimination “sometimes, often, or very often” throughout their careers, with 59% reporting similar frequencies in their current work settings.7 These physicians face both overt racism (e.g., being called a racial slur by a patient or referred to as “you people” by a supervisor) and subtle racism (e.g., having their interests in studying health disparities devalued).8,9 Persistent exposure to discrimination and microaggressions contributes to burnout and mental health challenges, prompting many Black doctors to leave their positions or the profession altogether.
This systemic issue is perpetuated by the minority tax, resulting in burnout and decreased well-being.10 For example, Black physicians are often expected to take on extra responsibilities related to diversity and inclusion initiatives within their workplaces. While these efforts are important, they can add to their workload and detract from time spent on patient care or personal well-being. The under-representation of Black physicians in leadership positions further compounds these challenges, fueled by lack of mentorship and implicit biases, ultimately leading to a disproportionately higher rate of Black physicians leaving residency programs and academic faculty positions compared to their White counterparts.11
The under-representation of Black Americans in medicine is not merely a statistical anomaly. The consequences of this under-representation extend beyond the medical profession, impacting healthcare provision and health outcomes for Black Americans. A study published in the American Economic Review assigned 637 Black patients to visit either a Black or non-Black doctor.12 Results revealed that in-person interactions with Black doctors led to a higher demand for preventive healthcare services, especially invasive procedures like flu shots or diabetes screenings. Black physicians played a crucial role in correcting misconceptions and boosting demand through their counseling and rapport with patients. The study showed a significant improvement in the health of Black Americans with increased representation of Black doctors.
Research indicates that Black patients exhibit lower mortality rates when cared for by Black physicians in contrast to their non-Black counterparts. For example, in the U.S., Black newborns face a mortality rate three times higher than White newborns, according to a study published in Proceedings of the National Academy of Sciences.13 The study authors attribute the notable differences in infant mortality rates to structural racism, such as restricted access to healthcare and education. The study, however, showed increased survival of Black infants when Black physicians were their providers. The authors propose that insufficient training on the unique challenges encountered by Black newborns, often with the prototypical patient being White, could be a factor.
Moreover, disparities in diseases such as HIV/AIDS and infant mortality further emphasize the need for a more inclusive physician workforce. Black individuals are 6 to 14.5 times more likely to die from HIV, in part due to delayed access to antiretroviral therapies.14 A study in the Journal of General Internal Medicine revealed that Black HIV patients received therapies later from White providers compared to those treated by Black providers.15 In racially concordant doctor-patient relationships, effective communication is more common, improving patients’ acceptance of and engagement in antiretroviral treatment. A study in Annals of Internal Medicine showed that interactions between Black patients and Black doctors resulted in overall longer visits and increased satisfaction.16 Therefore, a healthcare workforce reflective of community diversity not only enhances patient openness to healthcare guidance but also contributes to better health outcomes.
In 2008, the American Medical Association publicly apologized for historically discriminating against Black physicians by favoring White members and imposing membership restrictions.17 Consequently, a commission was established to address healthcare disparities, employing a multifaceted approach.18 This initiative encompasses research endeavors, legislative actions, and reforms in political practices, all aimed at eliminating the pervasive racial health disparities afflicting the nation. Additionally, the U.S. Centers for Disease Control and Prevention officially declared racism a public health threat in 2021.19 While these are important steps toward recognizing issues of racism within the medical field, this is just the beginning of a long road.
Addressing the under-representation of Black Americans in medicine requires changes at multiple levels. Upstream programs in K-12 schools and undergraduate institutions can inspire and support aspiring Black physicians. One example at the K-12 level is the Health Careers Opportunity Program (HCOP). HCOP, funded by the Health Resources and Services Administration (HRSA), aims to increase the diversity of the health professions workforce by providing grants to schools and community organizations.20 These grants support programs that help economically and educationally disadvantaged students prepare for health careers. Activities often include summer enrichment programs, mentorship, academic support, and exposure to health professions.
At the undergraduate level, one successful example is the CUNY School of Medicine in Harlem. Through its BS/MD degree program, the school admits students straight from high school, facilitating the transition from undergraduate biomedical studies to the medical school curriculum. This integration eliminates the need for a separate medical school application process, reducing barriers and stress associated with the transition. This initiative is designed to enhance accessibility to medical education, particularly for individuals from underserved communities. Its effectiveness lies in a holistic admissions process and comprehensive support, ensuring students are well-prepared and committed to community-focused healthcare. Noteworthy is the program’s achievement in graduating over 2,000 alumni, most of whom have pursued careers as practicing physicians in underserved areas.21
Another solution is partnerships between medical schools and Historically Black Colleges and Universities (HBCUs). These partnerships can pave the way for joint degree programs and research collaborations that enrich the educational experience and strengthen the pipeline of Black students entering medical professions. By leveraging the resources and expertise of both institutions, supportive environments can be created that empower Black students to pursue careers in medicine. Medical schools must consider implementing programs like the CUNY School of Medicine’s BS/MD initiative or partnerships with HBCUs to address the under-representation of Blacks in medicine, recognizing their potential to advance health equity.
Additionally, initiatives to attract and assist faculty physicians and leaders from under-represented backgrounds within academic medical centers are essential. Incentives such as dedicated research grants, faculty development programs, and leadership opportunities should be introduced for Black physicians to pursue careers in academic medicine. By doing so, not only do we enhance the quality of care for minority patients, but we also foster inclusivity in both the educational and professional environments of healthcare institutions. For medical students, residents, and fellows who are under-represented in medicine and in specific specialties, the presence of mentors who share similar backgrounds and experiences is important. These mentors serve as invaluable role models and contribute to a more equitable landscape within the medical community. Healthcare organizations must take proactive steps to implement incentives and ensure that Black physicians are provided with the support and opportunities needed to thrive in academic settings.
Anti-racism education must be integrated into medical curricula to cultivate an understanding of historical structures and biases perpetuating healthcare inequities. Knowledge of the extensive history of racial structures within medicine is essential for all health professionals. One of the “Seven Values Targets for Anti-Racism Action” proposed by Dr. Camara Jones is understanding the origins of current circumstances to pave the route to a better future.22 This recognition encompasses, for example, being aware of the detrimental impact of the Flexner Report on historically Black medical schools, the diversity of the physician workforce, and the well-being of minoritized patient populations. Policymakers in all states must mandate comprehensive anti-racism training in medical schools to equip future healthcare professionals with the knowledge needed to address healthcare inequities head-on.
Certainly, there are hurdles to overcome in implementing these programs and initiatives. The success of upstream programs in K-12 schools and colleges is contingent upon factors like resource availability, participation, power sharing, and sustained commitment. Furthermore, efforts to recruit and support under-represented faculty physicians in academic medical centers may encounter institutional resistance. Given the limited data on effective anti-racism interventions in healthcare settings, more research is also needed in this area.23 Specifically, studies on the efficacy of anti-racism education should be conducted, such as assessing the impact of such training on medical students’ attitudes, behaviors, and clinical practice in providing equitable care to patients from diverse backgrounds. Future research and evaluations, particularly at the policy and community levels, are essential to build a robust evidence base for anti-racism efforts in healthcare. By acknowledging the obstacles and committing to concrete actions, we can begin to break down the structures sustaining racial disparities in medicine.
The under-representation of Black Americans in healthcare and medicine is a symptom of racism that demands increased awareness. Addressing this disparity requires a multifaceted approach, including dismantling historical structures, implementing targeted recruitment and support initiatives, restoring race-conscious admission policies and affirmative action, and prioritizing diversity and anti-racism within education and practice. Such changes are imperative to create a medical profession that reflects the rich diversity of the communities it serves and to ensure equitable health outcomes for all.
Alice Liu is a medical student at Dartmouth College. Her interests include health equity and improving healthcare outcomes for marginalized communities. She received her MPH from Harvard University and her undergraduate degree from the University of Pennsylvania.
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