While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
The Robert Wood Johnson Foundation (RWJF) has been in the forefront of efforts to eliminate disparities in health, health care and the medical workforce for decades, through unique programs for students and professionals. Yet now, when the United States is more ethnically and culturally diverse than at any other time in history, progress toward eliminating disparities in the medical professions seems to have slowed. Here, grantees from the family of RWJF Human Capital programs focused on reducing disparities, talk about where we are and their efforts to move forward.
Progress Proves Elusive
In 1990, 3.5 percent of America's physicians were African American and 4.9 percent were Hispanic, according to U.S. Census data. In 2011, the American Medical Association reports that those numbers are essentially the same, advancing roughly 1 percent since the 1980s. "We are stalled in our efforts to increase the number of physicians and other medical professionals from underrepresented groups," explains James Gavin, MD, PhD, national program director for the RWJF Harold Amos Medical Faculty Development Program. In his 19-year tenure as head of the program, Gavin has witnessed a great deal of progress, but it has been tempered, he says, by new barriers to change.
"The reasons are multifactorial," Gavin says. "First, we've faced legal headwinds that have made it difficult to target our outreach to specific populations. These laws have also made it hard for other organizations and federal entities to work to reduce disparities."
The economic climate also poses significant challenges. A recent study, "The Educational Pipeline for Health Care Professionals: Understanding the Source of Racial Differences," published in the Journal of Human Resources (Winter 2010 issue) emphasized the impact of "poverty and other pre-collegiate factors and … the full chain of educational decisions [when attempting to] understand racial disparities in professional healthcare occupations."
Undaunted by such barriers Gavin says, "the current environment puts an even greater onus on Harold Amos," and other RWJF programs, such as New Connections: Increasing the Diversity of RWJF Programming, Project L/EARN and the Summer Medical and Dental Education Program (SMDEP), to bring about change.
Grantees Enriching the Pipeline
By any measure, RWJF grantees have taken up this challenge. James Guevara, MD, MPH, a 2010 RWJF New Connections grantee, is starting at the faculty level. "I became interested in the importance of diversity in the medical profession while working with children in vulnerable populations," says Guevara, a professor and pediatrician at The Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine.
"For my New Connections project, I am examining programs designed to diversify faculty at 130 of the nation's medical schools. I'm looking at mentorship, career development programs targeted to minority faculty, whether social environments are welcoming, and the availability of funding to assist faculty in research, to determine what types of programs are most successful," Guevara says. "We only have preliminary results, but we know that only one-quarter of the schools surveyed have diversity programs. Our premise is that diverse faculty are more responsive to the needs of diverse students and tend to conduct research on health issues in minority communities," he says.
"Since they are the gatekeepers to the healthcare workforce pipeline, it is also important to have diverse faculty on medical and dental school admissions committees and that is still largely uncommon," Gavin adds.
The Diversity Dividend
Several recent studies confirm Guevara's theory. Physicians and scientists from medically underserved communities are much more likely to help those populations during their careers.
This connection is easily understood by Deidra Crews, MD, a 2009 RWJF Harold Amos Medical Faculty Development Program scholar. "I'm studying how race and socioeconomic factors interact to contribute to disparities in kidney disease among African Americans," Crews says. Rates of kidney disease are disproportionately high among Blacks, "yet race and socioeconomic issues do not fully explain the differences," Crews explains. "When you compare low income Blacks to low income Whites, Blacks still have higher rates of kidney disease. This suggests that access, high quality health care and aspects of discrimination are at play," says Crews, who is also an assistant professor and nephrologist at Johns Hopkins University School of Medicine. "My observation is that people in medicine who are members of racial and ethnic minority groups tend to be drawn to research that helps those communities. I know that my background, in part, gave me a strong desire to make a difference in the community I come from."
Yamalis Diaz, PhD, a professor and clinical psychologist at New York University's Child Study Center in the Department of Child and Adolescent Psychiatry, agrees. A 1999 graduate of RWJF's Project L/EARN, Diaz says, "I am bilingual, which allows me to work with Latino families. I have also conducted research related to cultural factors in providing treatment to Latino children with ADHD and other disruptive behavior problems, which helps me adapt treatment in culturally meaningful ways," Diaz says. "There are also not that many bilingual providers in my field."
At a time when only 3.5 percent of dentists are black and only 4.9 percent are Hispanic, according to the American Dental Association, Donna Henley-Jackson, DDS, is also committed to working in communities that are often without needed health care services. "I focus on the role of dentistry in public health," says Henley-Jackson, a 2002 alum of RWJF’s SMDEP, who volunteers in dental clinics for the underserved. In addition to her work as a pediatric dentist, Henley-Jackson says, "I'm doing outreach to students from underrepresented groups, in high schools and middle schools, to help with the barriers they will face in pursuing a dental career."
Each One Reach One
After years of observing grantee efforts, Gavin says, "every student that finds their way into a medical career can contribute to eliminating disparities. I've seen the creativity of our scholars build a grassroots pathway for bright, young people interested in this work."
Project L/EARN alumnus (2005) Danielle Wright, who is currently pursuing an MPH and MD (she plans to become an obstetrician), understands just how much one person can contribute. "When I got to medical school, I realized that there were not a lot of people there who looked like me, so I became interested in minority recruitment," Wright says.
Recognizing that there are many ways that even the most ambitious students can fall through the cracks, Wright started a high school student outreach program at Vanderbilt University, primarily for minority students, when she was just an undergraduate there. "It gave them a chance to see people who looked like them doing the work they hoped to do as health professionals. I wanted to help because getting through medical school is hard for everyone, but it's even harder if you're from a disadvantaged background," explains Wright, who someday hopes to run a clinic that does community-based participatory research.
Helping other young people recognize their own potential is also an important activity for Nelvin Acevedo-Valle, a 2011 winner of an SMDEP Student Ambassador award for recruiting the most new students to the program. As Acevedo-Valle pursues his pre-med coursework at the University of Puerto Rico-Mayaguez, he says, "I recruit students from other majors and let them know about the benefits of the SMDEP. I'm studying to become a pediatric neurosurgeon, but I also do community service work, so I would like to help other minority students realize their dreams."
The Pipeline to a Brighter Future
As for the challenges that lay ahead, Gavin says, "the best advice I can give to those organizations working to reduce disparities is to stay the course. In the Harold Amos program, for example, we are now seeing the third generation of change. Our grantees from 25 years ago have generated mentees who are now sending their own mentees to the program. As a result, we are seeing one of the highest, persistent, rates of grantees engaged in academia for any program of our type. Expanding these activities, along with community and political support for eliminating disparities, will someday lead us to more broad-based success."
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