Diversity, Equity and Inclusion in Health Care: The Time for Action Has Come

Mark D. Johnson, MD, PhD, Marlina Duncan, EdD, Milagros C. Rosal, PhD, MS, Brian Gibbs, PhD

Disparities in disease prevalence, treatment and outcomes in the United States are widespread and disproportionately have adverse effects on certain racial and ethnic groups. Indeed, the Centers for Disease Control has amply documented that Latino, Black and Indigenous populations have been disproportionately affected by COVID-19 in the U.S., bringing the existing health disparities in these groups into the spotlight once again. The places where people live, work, learn and play affect the rates of COVID-19 infection, severe illness and death. The COVID-19 pandemic has clearly demonstrated how social factors such as race, ethnicity, education level, income, neighborhood, access to health care, physical environment, occupation and others shape the landscape of disease risk, health care delivery and patient outcome. Additionally, pre-existing disparities in the prevalence of medical conditions – e.g., obesity, diabetes, cardiopulmonary disease, renal disease and others – which correlated with worse outcomes among patients with Sars-CoV-2 infection, also have contributed to the greater burden of severe COVID-19 illness and death borne by some racial and ethnic communities. The observation that COVID-19 vaccination rates for Hispanic/Latino and Black populations have lagged far behind those for white individuals reinforces the notion that many of the health inequities that we see derive from societal policies, practices and institutions that perpetuate them, and are not solely the result of intrinsic biological differences among these groups.

The interplay between all of these factors and the powerful impact that they have on the health of our communities are undeniable . Many health inequities mirror inequities in other areas of our society that are the result of decades of widespread, institutionalized and harmful discriminatory practices. Those of us in the medical profession must embrace the professional and moral imperative to correct the numerous health disparities that we see among different patient populations. The importance of doing so is underscored by the rapidly growing diversity in our society. Indeed, a recent analysis of 2019 U.S. Census Bureau data by William Frey of the Brookings Institution shows that our nation is diversifying faster than predicted. (https://www.brookings.edu/research/new-census-data-shows-the-nation-is-diversifyingeven-faster-than-predicted/). For the first time in history, the white population in the U.S. declined during the 2010-2020 decade, largely because the number of deaths among white individuals exceeded the number of births and because white immigration to the U.S. did not completely make up for the difference. Overall, the percentage of white persons in the U.S. declined from about 69% of the population in 2000 to about 60% in 2019. Importantly, nearly all of the 6.3% annual population growth during the nine-year span from 2010 to 2019 occurred among non-white racial and ethnic groups, with the Hispanic/Latino and Asian populations showing the greatest gains. Currently, four out of 10 Americans identify as non-white. Studies have shown that patients whose doctors resemble themselves in terms of race, ethnicity or gender are more likely to follow medical instructions, keep follow-up appointments and have better outcomes. As we work to rectify health inequities, we must therefore ensure that the diversity of our physician workforce reflects the diversity of the patients we serve.

Data from the U.S. Census Bureau reveals that Worcester is already a diverse city, with a population that is roughly 69.2% white, 13.3% Black, 7.4% Asian, 0.6% American Indian and Alaska Native, and 0.1% Native Hawaiian and Other Pacific Islander (https://www.census.gov/ quickfacts/worcestercitymassachusetts). About 5.5% of Worcester residents identify as being from other races and 4%are from two or more races. Hispanics and Latinos of any race make up 20.9% of the population in Worcester and women make up a slight majority, 50.9%, of the population. Importantly, about 22% of Worcester’s population was born outside the U.S. This relatively large immigrant population originates from numerous countries, including Brazil, Puerto Rico, Vietnam, Ghana, the Dominican Republic, Albania, Mexico and others.

Data on the racial and ethnic composition of the physician workforce in Worcester County was not immediately available. However, national data from the American Medical Association for 2019 indicated that about 51% of physicians in the U.S. are white, 5.5% are Hispanic/Latino, 4.2% are Black, 15.3% are Asian American and 0.3% are Native American. The race/ethnicity of about 22.3% of physicians is unknown. International medical graduates make up about 22.4% of physicians. Based on this data, the National Institutes of Health has defined Hispanic/Latino, Black and Indigenous physicians as “underrepresented in medicine.” It is very likely that Hispanic/Latino, Black and Indigenous physicians also are underrepresented in Worcester County just as they are underrepresented across the nation more broadly. Thus, efforts to optimize the diversity of the local physician workforce are critical for adequately addressing the health disparities that are present in our diverse city.

According to projections by the American Association of Medical Colleges, the U.S. will face a shortage of up to 139,000 physicians by 2033 as the number of retirement-age Americans soars by 45%. As that time approaches, demand for two-thirds of the new doctors will be driven by the growth of racial and ethnic groups. For example, nearly 45,000 new doctors will be needed to care for members of the Hispanic/Latino community, which is the nation’s fastest-growing ethnic group. Are we on a path that will lead to the diverse physician workforce that we need now and in the future? Sadly, the answer is no. Women now outnumber men among matriculants to medical school and thus the need for more gender diversity among physicians should be met over the next few decades. However, the 2018-2019 AAMC data shows a continued and troubling lack of racial and ethnic diversity among medical school matriculants. In all, 7.1% of matriculants were Black, 6.2% were Hispanic/Latino, 0.2% were American Indian or Alaska Native, 0.1% were Native Hawaiian or other Pacific Islander, and 9.5% were of multiple race/ethnicity. White individuals constituted 49.9% of the matriculants and Asians were 22.1%.

Part of the challenge in increasing diversity in medical schools lies in the composition of the applicant pool. In 2018-2019, white applicants, 46.8%, and Asian applicants, 21.3%, made up the largest subgroups of applicants, while Black applicants constituted 8.4% of applicants and Hispanic/ Latino applicants were 6.2% of the applicant pool. Left unchanged, this pattern will perpetuate the disparately low numbers of Hispanic/Latino, Black and Indigenous people among the U.S. physician workforce. Since 12% of the U.S. population is Black and 18.5% of the population is Hispanic/ Latino – together they account for nearly one in three Americans – these groups are expected to remain underrepresented among physicians for the foreseeable future. However, that is not what the AAMC, the AMA, the Worcester District Medical Society or the public are trying to achieve and it is thus clear that the current racial and ethnic pattern of medical school admissions must change, just as it has changed with respect to gender diversity.

To accomplish this objective, a broad-based, coordinated effort that spans K-12 and undergraduate education must be initiated with the goal of reinforcing efforts to effectively teach science, technology, art, engineering and medicine disciplines at an early stage to all students, including those from groups that are unrepresented in medicine. In addition, physicians must engage as mentors with learners more purposefully and at an earlier stage, helping disadvantaged students successfully navigate the path to medical school and serving as a counterweight to the many societal forces that would throw them off that path. Medical schools must develop better methods for successfully selecting potential matriculants from the applicant pool that rely less heavily on tools and metrics that introduce bias against individuals that are underrepresented in medicine including those from low income backgrounds and members of racial and ethnic groups.

Addressing disparities in health and health care that have historically plagued our communities must include, but is not limited to, strategies to diversify our physician workforce so that it reflects our patient population. The time has come for the medical profession to actively work to ensure that diversity in health care reflects the diversity of the communities we serve and to accept nothing less than that. This will benefit the lives and the livelihoods of our patients. Identifying and developing talent from an early age is a necessary step toward eliminating the myriad health disparities that are exacerbated by the structural and systemic inequities which are so pervasive in our society and so damaging to the lives and well-being of all of our patients.

Additionally, addressing systemic and structural inequities in under-resourced communities is tantamount to eliminating racial and ethnic disparities in STEAM education. Eliminating structural inequities in education, ranging from K-12 all the way through medical education and residency training requires partnerships and collaborations with community-based organizations, including outreach and funding support from local hospitals and community health care foundations (Increasing Diversity in Science and Health Professions: A 21-Year Longitudinal Study Documenting College and Career Success | SpringerLink). A collective and coordinated effort from every segment of our community will be required to redress the original wrongs of our country, i.e., slavery, oppression, segregation and racism, and the long-term destructive impact that systemic racism has on K-12 education, health equity, generational wealth and cultural exposure. +

References

1.Mark D. Johnson, MD, PhD, FAANS Maroun Semaan Professor of Neurological Surgery, Chair, Department of Neurological Surgery, Senior Consulting Vice Provost for Mentorship, Leadership and Transformation

2.Brian Gibbs, PhD – Chief Diversity and Inclusion Officer, UMass Memorial Health Care

3.Marlina Duncan, EdD – Vice Chancellor for Diversity and Inclusion, University of Massachusetts Medical School

4.Milagros Rosal, PhD, MS – Vice Provost for Health Equity, University of Massachusetts Medical School

Mark D. Johnson, MD, PhD, (1,2) Marlina Duncan, EdD, (1) Milagros C. Rosal, PhD., MS, (1) Brian Gibbs, PhD (2) 1. University of Massachusetts Medical School, Worcester, MA 2. UMass Memorial Health, Worcester, MA