Psychological Factors That Contribute to the Dearth of Black Students in Science, Engineering, and Medicine: Proceedings of a Workshop (2023)
Chapter: 5 Bringing Systemic Changes through Important Sectors of Influence
Garth Graham, M.D., M.P.H. (Google, Inc.), moderated a panel on bringing systemic changes to influencers in the private and public sectors. He stressed the need to identify the “10,000-foot mental health issues” that can undermine career advancement for Black and Brown men and women in science, technology, engineering, and mathematics (STEM). The panel consisted of Laurie Zephyrin, M.D., M.P.H., MBA (Commonwealth Fund); Marie Bernard, M.D. (National Institutes of Health [NIH]); Cora Marrett, Ph.D. (University of Wisconsin–Madison); and Nwando Olayiwola, M.D., M.P.H. (Humana).
ADVANCING HEALTH EQUITY AT THE POLICY LEVEL
Dr. Zephyrin began with a macro-level picture of how health policy can lead to systems change. A high-performing health-care system cannot be created without advancing health equity, she stressed. The goal of the Commonwealth Fund is to eliminate unequal treatment, experience, and outcomes in health and health care for people of color by dismantling systemic racism in health-care policy and practice. Three focus areas underpin the framework to achieve this goal: dismantling racism in care delivery; using policy to bring about equitable access; and changing culture, beliefs, and attitudes.1
Dr. Zephyrin underscored that strategies for health-care delivery system change involve what happens not only within the walls of a healthcare institution, but also in the broader community. Strategies include diversifying and training the workforce; engaging with partners; and dis-
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1 For more information on the Commonwealth Fund, see https://www.commonwealthfund.org.
aggregating data to measure outcomes, experience, and quality over time. The Commonwealth Fund is committed to creating an ecosystem and roadmap as organizations develop their antiracism agendas, she explained. Strategies for health policy change extend to all sectors of society:
Policy helps drive systems change and individual actions on the ground. Federal and state policy makers can adopt policies and procedures that can advance racial equity and address racism in health care. This can include incorporating equity in value-based care arrangements to incentivize payment to ensure that health systems are advancing health equity and that policies are achieving intended outcomes.
Related to the workshop focus, Dr. Zephyrin pointed out that comprehensive primary health care can make mental health care available and accessible. Health-care fragmentation is reduced through multidisciplinary provider teams; integration of digital health tools; community engagement; and integration between physical health, behavioral health, and health-related social needs.
Policy makers and health systems leaders have important roles to implement change, she concluded. They can help use program and policy levers; promote systemic change and antiracism in health policy and payment models; center community-based solutions; promote institutional change through new models of care in delivery systems; measure the progress of health-care delivery systems toward achieving equity; and disseminate resources on how systemic racism manifests in health-care systems.
ADDRESSING RACISM AT NIH AND IN THE EXTRAMURAL COMMUNITY
The NIH UNITE Initiative came about in 2020 in recognition of the ongoing reality of racial injustice and responsibility of everyone to address it, reported Dr. Bernard. Discussion among NIH Institute and Center (IC) directors identified initial issues to undertake. Self-assembled affinity groups, including a group of early-career scientists, came forward to “speak truth to power,” she said. They brought data and case studies to the attention of NIH Director Francis Collins, M.D., Ph.D., and Principal Deputy Director Lawrence Tabak, D.D.S., Ph.D., that showed that the racism seen in society existed at NIH. Senior scientists of color and an
already-established Anti-Harassment Steering Committee reinforced the message that led to the next steps. “We have arrived at a shared commitment to address structural racism,” said Dr. Bernard. “We must not allow this pivotal moment to pass.”
Initial issues identified include ensuring that biomedical research, and the administrative system that supports it, is devoid of hostility grounded in race, sex, or other federally protected characteristics, Dr. Bernard said. This means a commitment to delineate elements both within NIH and in the extramural community that lead to a lack of personnel inclusiveness, equity, and diversity. All ideas must be given an equal and fair review, without regard to current dogma, precedents, or who presents the idea. As COVID-19 made clear, health disparities and inequities persist, and it is essential to redress their fundamental causes and identify research programs and effective interventions.
Formally announced on February 26, 2021, the NIH UNITE Initiative consists of five interacting work streams: (1) understanding stakeholder experiences through listening and sharing; (2) new research on health disparities, minority health, and health equity; (3) improving the NIH culture and structure for equity, inclusion, and excellence; (4) transparency, communication, and accountability with internal and external stakeholders; and (5) extramural research ecosystem changes in policy, culture, and structure to promote workforce diversity.
The groups responsible for each area regularly report on recommendations and progress, with the first such report in June 2021. She noted the NIH director published an apology to “those individuals in the biomedical research enterprise who have endured disadvantages due to structural racism.”2 NIH also committed to aggressively implementing approaches to address the “Ginther Gap,” and enhance portfolio diversity. She explained that the term stems from research published by Donna Ginther, Ph.D., and colleagues that documented that Black and African American scientists receive disproportionately fewer R01 grants than white applicants (Ginther et al., 2011). The research led to the establishment of the position that Dr. Bernard currently holds, the chief officer for scientific workforce diversity. Data since then have shown progress, but a gap in success rates and overall numbers of Black and Hispanic applicants still exists. “This is what we are committed to work on until you cannot predict based upon a person’s
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2 For the full statement and other information, see https://www.nih.gov/ending-structural-racism.
demographics the likelihood that a researcher will be successful with NIH funding,” she said.
NIH launched a multi-phased, tiered, and integrated Common Fund Initiative to support transformative health disparities research initiatives. Two Common Funding Opportunity Announcements (FOAs) were released in March 2021 that initially commit up to $24 million to this research.3 A robust NIH-wide commitment to support an FOA by the National Institute on Minority Health and Health Disparities on the health impacts of structural racism was also announced, with commitments of up to $30.8 million from other ICs.
Going forward, priorities include additional funding for research on health disparities, minority health, and health equity research for the four ICs that have the most underrepresented minority researchers applying for R01 funding; FOAs in other ICs; programs to spur changes in institutional culture change (including Faculty Institutional Recruitment for Sustainable Transformation, or FIRST);4 and support for the Science Education Partnership Award (targeted at K–12 students) and minority-serving institutions, including Historically Black Colleges and Universities.
Dr. Bernard called attention to posting of a notice about how to report harassment or discrimination to NIH, published in August 2021. She concluded that the strength of the program is its systemic and comprehensive effort (Collins et al., 2021).
RESEARCH IMPERATIVES FOR SYSTEMS CHANGE
The mission of the National Science Foundation (NSF) is to keep the nation at the cutting edge of innovation and to attend to the education of the populace. Dr. Marrett drew on her experience in NSF leadership positions to summarize NSF’s efforts to fulfill that mission and discuss ways in which the workshop can help NSF further strengthen its contributions through an equity lens.
Given the focus of the workshop on broader contexts for psychological well-being, Dr. Marrett expressed dismay that only limited research has been conducted on the impact of institutional forces on psychological dis-
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3 As of this writing, the deadline for FY 2021 submission has passed and applications are under review.
4 This program provides an estimated $241 million over 9 years. For more information, see NIH Faculty Institutional Recruitment for Sustainable Transformation (FIRST) program at https://www.commonfund.nih.gov/first.
tress. “We know a lot more about the consequences of particular kinds of relationships or dislocations than the larger socio-cultural context and systemic forces,” she observed. Examples of this more specific research include the consequences of violence or of COVID-19 on psychological distress. She noted that support across several NSF directorates recognizes that the well-being of a population can be indicated by more than what one sees at the level of the individual. For example, the Engineering Directorate is funding a study on the effect of mental wellness on retention in engineering programs. As another example, the ADVANCE Program, which focuses on promoting women in STEM fields, has been on the NSF agenda for some time.5 When it was launched in 2001, there was discussion about whether to focus on individuals or institutions. While the initial decision was to try to do both, the institutional emphasis came to prevail over time.
Dr. Marrett called for ways to bring together entities that are potentially related to each other to expand the agenda to change systems. She elaborated:
The research that is available tends to be less expansive and provides far less coverage of the Black population than might be warranted. We need to attend to the question of greater collaboration. NSF is influential but cannot be the sole source for unraveling complexities. Other national agencies, especially within the sphere of health care, play critical roles. That means there is an imperative for collaborations if the nation is to profit from models that center on systems and not just individuals.
She also suggested that health plans and other organizations share resources and ideas to produce outcomes for conducting research, delivering services, finding solutions, and mobilizing amid complexity. Influencers, including NSF, can contribute to the building of capacity, advancement of scholarship, and provision of resources to shape policies. She urged rigorous research on some issues emerging out of the workshop, such as the value of cultural wealth.
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5 For more information on the ADVANCE Program, see https://www.nsf.gov/crssprgm/advance/.
OPPORTUNITIES FOR HEALTH PLANS
Dr. Olayiwola began by expressing appreciation to Dr. Marrett for highlighting that health plans have a role to advance health equity. When she began her position at Humana, she said, she published an article on what health plans can do to use their domains of influence in tackling structural racism and moving to a more equitable health-care ecosystem (Olayiwola, 2021). She said health plans can be leaders to address the social and structural determinants of health; deliver comprehensive clinical care, especially for those who have been marginalized; provide an enhanced consumer journey; build capacity through academic partnerships and workforce development; and leverage capital to empower community engagement and partnerships. It requires a focus on data analytics and creating a skilled workforce, being nimble about innovation, and implicit bias (see Figure 5-1).
Black and Hispanic workers remain highly underrepresented in the STEM workforce, she reminded the group, with challenges both in entering and advancing in the field. Intersectionality compounds disparities, she continued, quoting poet and activist Audre Lord, who stated, “There is no thing as a single-issue struggle because we do not live single-issue lives.” For example, scientists and engineers with disabilities have higher unemployment, receive fewer grants and other support, and were only 1 percent of medical students in 2019. This inequity is more pronounced for individuals of color who also have disabilities. Dr. Olayiwola reflected on the role of health plans like Humana:
Our industry in the payer space has a great imperative to not only develop the pipeline of Black men and Black women that enter into the STEM professions but also stay in the pipeline. The areas where we should focus on, and we have the opportunity to focus on, are in the early spaces … educational opportunities, mentoring and career advancement, and removing barriers and addressing biases in our practices.
She described several Humana-supported programs for pregnant women, young girls, and other populations. Along with organizations, Humana supports the OneTen Coalition to upskill, hire, and promote 1 million Black Americans over 10 years. Other investments address food and housing insecurity to remove barriers to mobility and education. The organization is also working on policies and practices within its own workforce.
SOURCE: Nwando Olayiwola, Workshop Presentation, September 14, 2021.
“It’s time for health organizations to lean into our role and our opportunity,” Dr. Olayiwola concluded. “If health plans can align on this kind of work and imperative, we have a lot of data, influence, and members. We can make a difference.”
DISCUSSION
Dr. Graham commented that structural racism has been hundreds of years in the making, and posed the question about the levers to pull given this complexity. Dr. Bernard suggested that embedding changes in the federal government may have a ripple effect. Dr. Marrett pointed out that the National Academies of Sciences, Engineering, and Medicine has placed the issue high on its agenda, and she urged taking advantage of the National Academies’ stature in scientific and policy-making circles. Dr. Zephyrin also pointed to the importance of policy making because “policies drive incentives and help drive action.” Dr. Olayiwola agreed, but she also urged taking a “hard and humble look at the data” to understand progress and gaps. She commented that while health plans compete on a number of fronts, addressing the social determinants of health is an area for strengthening and collaboration.
In terms of federal support, Dr. Marrett and Dr. Bernard both urged not waiting to respond to funding announcements or requests for proposals but to be proactive in contacting NSF, NIH, and other agencies.
REFERENCES
Collins, F. S., A. B. Adams, C. Aklin, T. K. Archer, M. A. Bernard, E. Boone, J. Burklow, M. K. Evans, S. Jackson, A. C. Johnson, J. Lorsch, M. R. Lowden, A. M. Nápoles, A. E. Ordóñez, R. Rivers, V. Rucker, T. Schwetz, J. A. Segre, L. A. Tabak, M. Webb Hooper, C. Wolinetz, and NIH UNITE. 2021. Affirming NIH’s commitment to addressing structural racism in the biomedical research enterprise. Cell 184(12): 3075–3079. https://doi.org/10.1016/j.cell.2021.05.014.
Ginther, D. K., W. T. Schaffer, J. Schnell, B. Masimore, F. Liu, L. L. Haakand, and R. Kington. 2011. Race, ethnicity, and NIH research awards. Science 333(6045): 1015–1019. https://doi.org/10.1126/science.1196783.
Olayiwola, J. N. 2021. Five keys to realizing health equity in U.S. health plans. Health Affairs Forefront (blog). https://doi.org/10.1377/hblog20210518.626084.
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