The article by Campbell et al1 in this issue of JAMA Network Open examines the closure of historically Black colleges and universities coincident with the Flexner report of 1910, assesses the consequences of this report for the number of African American medical school graduates, and uses steady expansion and rapid expansion models to estimate the progress that might have occurred in the diversity of the medical profession if those colleges and universities had remained open. Based on their analyses, which are innovative and interesting, the authors suggest that an increase in African American graduates could be achieved today with the creation of more medical schools at historically Black colleges and universities. The Campbell et al1 article raises important questions regarding how to respond to the documented lack of progress in the medical profession toward achieving the widely stated value of a diverse and inclusive discipline and the proportionate representation of physicians in the diverse communities of the US.
A review of the Campbell et al1 article merits an analysis of the context that necessitated the opening of historically Black colleges and universities and a comparison of the realities of that era with those of the 21st century, with a fundamental question in mind: are we in a postracial period in the history of the US? This question has changed the calculus on the need for historically Black colleges and universities. What were the circumstances that brought about the formation of historically Black colleges and universities that might inform our present strategies in higher education? Historically Black colleges and universities were explicitly created to educate Black citizens after the cessation of slavery as an economic structure, which had curtailed nearly all educational opportunities, including higher education, for Black Americans. The history has been reviewed by many,2 and the development of historically Black colleges and universities was initiated by the Freedmen’s Bureau of the federal government with the assistance of White citizens (abolitionist missionaries and northern philanthropists) and the African Methodist Episcopal Church. Historically Black colleges and universities were, until the mid-1960s, the only option for higher education among most African Americans because segregation existed in all sectors and aspects of the lives of Americans until that time. It should be noted that while historically Black colleges and universities supported the education of Black physicians, the segregation of clinical care continued in hospitals, and medical organizations, such as the American Medical Association and honorific societies, remained closed to African Americans.3
So, what is the current context for higher education, and what are the implications for historically Black colleges and universities? Although change has occurred from the Jim Crow period at the turn of the 20th century to the turn of the 21st century, structural inequities and systemic racism persist and sustain a medical profession and a health care system that is visibly segregated and noninclusive. The advent of the civil rights movement in the 1960s brought about affirmative action policies in an effort to remedy the segregation in higher education and academia in general. However, documented legal actions, with claims of reverse discrimination, derailed many of these efforts.4 In 1978, Allan Bakke challenged the affirmative action policy of the School of Medicine at the University of California, Davis. In the court’s ruling, the vague term of diversity was considered to be a “compelling state interest”4 and a key constitutional and social justification for the use of affirmative action policies in higher education; however, as some understood, this ruling also contained the “seeds of its own (affirmative action) destruction.”4 The next 40 years would bear witness to debates and legal actions over race-conscious policies that addressed admission to nonhistorically Black colleges and universities, slowing the progress of the medical professional workforce toward the achievement of true equitable representation, with its inherent benefits for underserved populations, the sciences, and society at large. A recent commentary in this journal, written in response to an article by Lett et al,5 indicated that despite the Standards on Diversity 2009 accreditation guidelines of the Liaison Committee on Medical Education, little change has occurred in the landscape of medical education, with no substantive progress made in diversifying the physician workforce.6
The current low health status ranking of the US among countries in the Organization for Economic Cooperation and Development and the persistence of health disparities that mirror the current socioeconomic divide by race and ethnicity in the US is evident in the current coronavirus disease 2019 (COVID-19) pandemic. Adding to the tone of the country are multiple incidents of racial unrest associated with the killings of unarmed Black men (most recently, George Floyd) and women by police officers, the continued divestment in programs addressing poverty and educational attainment, and the responses of the Black Lives Matter movement for human rights.7 A discussion of the current state of higher education for medical trainees requires a review of educational opportunities throughout the life course, beginning with opportunities for Black children aged 0 to 3 years, access to universal preschool, equitable financing of kindergarten through grade 12, and universal access to free undergraduate education in preparation for entry into medical college without the burden of substantial debt, all within the context of an educational system that would value, respect, and welcome the individual and the individual’s culture.
In the absence of a truly just society, historically Black colleges and universities have served the role of educating traditionally underserved students in a more supportive environment despite the presence of many obstacles, a responsibility that was not borne equally by most nonhistorically Black colleges and universities. The lack of cultural change in the implementation of policies and practices at every level of the academic infrastructure to address the underlying factors associated with the lack of equitable representation among medical trainees, faculty, and staff of all backgrounds is evident in the absence of bona fide partnerships with communities or transformative educational curricula that associate the teaching of science with measured improvements in the health status of all individuals. The persistence of practices such as legacy admissions policies signals an investment in those who need the least help and a divestment in the notion of diversity and inclusion.
Given the complex context of current medical education, would the creation of medical schools at additional historically Black colleges and universities ameliorate and accelerate progress toward the achievement of health equity through the development of a more representative workforce? The answer is yes. Campbell et al1 point to missed opportunities for the creation of intentional strategies to improve diversity, reporting that, to their knowledge, none of the nearly 30 new medical schools that have opened since 2000 were located at historically Black colleges and universities. The criteria set for the establishment of new medical schools (eg, financial resources and location) have not explicitly included the health care needs of communities or the lack of equal distribution of health services, although the rationale for the creation of new schools was that they were needed in response to a projected shortage of physicians in the 21st century. An impetus for the development of some new schools has been the economic benefits these schools could provide as major employers, but there was no explicit focus on health disparities.
Historically Black colleges and universities have indicated the ability to provide training to Black medical students at rates substantially higher than those of nonhistorically Black colleges and universities, and these efforts are important to the improvement of the quality of care, the availability of physicians in medically underserved areas, the responsiveness of medical educators in the training of cultural humility, the breadth and depth of medical research, and the existence of bold leadership.8 The conclusions of Campbell et al1 are compelling and suggest that historically Black colleges and universities are an avenue, alongside a comprehensive national and systemwide approach, to address the weaknesses of higher education and the underlying factors of disadvantage that are associated with health. Let us celebrate our diversity, eliminate the elitism and exclusivity of higher education, and envision and strive for excellence in medical education that is open to all.
Published: August 20, 2020. doi:10.1001/jamanetworkopen.2020.15246
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Laraque-Arena D. JAMA Network Open.
Corresponding Author: Danielle Laraque-Arena, MD, New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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Laraque-Arena D. Historically Black Universities and Medical Colleges—Responding to the Call for Justice. JAMA Netw Open. 2020;3(8):e2015246. doi:10.1001/jamanetworkopen.2020.15246
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