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Systemic Anti-Black Racism in the Financing of Education

Marc A. Nivet, Ed.D., M.B.A. (University of Texas Southwestern Medical Center), moderated a discussion on financing and dealing with the costs of medical education. Louis W. Sullivan, M.D. (Sullivan Alliance), and Vivian W. Pinn, M.D. (National Institutes of Health), shared views from their perspectives as academic and government leaders. Dr. Nivet launched the discussion by noting that over the past 35 years, most medical students come from the top two deciles (i.e., top 20 percent in income earners) of the population. The disparities that result have ramifications for the health care of people, especially Black people and other minority populations.

ESCALATING COSTS AND DEBT

Dr. Sullivan called attention to the steady escalation of costs in medical education. Federal aid to students was reduced in the mid-1970s under the assumption that medical professionals are high earners and therefore should fund their own education through loans. This has proven to be a catastrophe for low-income and minority students gaining access to careers in the health professions, he said. The amount of educational debt for students who enroll in medical school upon graduation has steadily increased over this period. According to American Association of Medical Colleges (AAMC) data, the average student debt in 2012 was $160,000; for the past 2 years, it has been $200,000 (Youngclaus and Fresne, 2020). More than half of medical students come from the top income quintile population: that is, he clarified, 20 percent of society provides 56 percent of the students entering medical school, and the concept of “equal opportunity for all” becomes meaningless. Consequences include a shortage of physicians from racial and ethnic minority groups and the lower health status of Black individuals, he said.

The past 18 months have seen changes as a result of George Floyd’s murder and the COVID-19 pandemic, Dr. Sullivan observed. However,

inequitable access to health care, caused in part by a lack of diversity among health professionals, has been long revealed. In 1996, Komaromy and colleagues published an article in the New England Journal of Medicine that showed that Black and Latinx physicians are more likely to practice in communities of color and are more likely to care for Medicaid patients than white physicians (Komaromy et al., 1996).¹ Other studies have shown that concordance in the race/ethnicity between provider and patient does lead to more positive health outcomes, he added.

Dr. Sullivan emphasized that education financing undergirds the ability to have a more diverse workforce. It is in the U.S. national interest to invest in its young people, as he pointed out that China is doing in its own country, as well as in South America and Africa. “What we are interested in can be justified not only for the experiences and lifestyles of Black Americans but also for the nation to maintain its leadership position in science and technology,” he stated. “That is the return on investment that we will get—for humanitarian, economic, and political reasons.”

Dr. Pinn underscored Dr. Sullivan’s comment that financial need should not be the determining factor in who becomes a physician. She noted that besides tuition, living costs and other associated expenses have increased without an increase in revenue and support. In the 1970s and 1980s, philanthropy was interested, then shifted away to supporting other aspects of medical education such as research or foreign travel. However, as Dr. Pinn observed, without being able to afford their education, students cannot take advantage of travel and the like. Programs like National Medical Fellowships² and the National Health Services Corps³ are essential, she said.

UNDERINVESTMENT ALONG THE PIPELINE

Dr. Nivet recalled that a summer science, technology, engineering, and mathematics (STEM) program he attended in middle school cost $35; it is now thousands of dollars. With this example, he asked how to invest along the pipeline to allow students opportunities.

Dr. Pinn replied that the first step is to get students interested through the right education and curriculum. She suggested Mentoring in Medicine

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¹ This can create and further exacerbate inequities in income earned by physicians by race.

² For more information, see https://nmfonline.org.

³ For more information, see https://nhsc.hrsa.gov.

as a model of working with students at an early age to negotiate the pathway.⁴ In addition to philanthropy, she called on industry to not only provide exposure but also fund opportunities for students.

Dr. Sullivan seconded these comments. He also pointed out that K–12 funding is based on a local community’s wealth. In less-resourced districts, young people are not given the educational development and exposure they need to become successful professionals in a continuum that starts in the early years. He urged partnering more effectively with the K–12 system to provide academic, counseling, and mentoring support. Waiting until college may be too late for proper preparation and orientation, he warned. Investments in the K–12 system are the ultimate way for more diversity, he added. While he welcomed contributions to Historically Black Colleges and Universities (HBCUs) and other institutions over the past 18 months, he noted that these schools have been underfunded for years. “Gifts must be sustainable over decades after 150 years of underfunding,” he said. “I would love to see ways we can work with citizens so they will see gifts like that as a major investment for all.”

Several medical schools have eliminated tuition costs or taken other steps so that students will graduate with no or lower debt, Dr. Nivet raised. Dr. Pinn expressed some concern whether these programs increase opportunities if they are not based on need. She also related that schools without the backing or endowments to take these measures are concerned about competing for the best students. She suggested looking at the implications of tuition- or debt-free programs for expanding opportunities and increasing diversity. She also concurred with Dr. Sullivan about the need to ensure that the recent support for HBCU and minority programs continues. “We have the challenge of pointing out the need for long-term investments so initial achievements can be sustained,” she said.

Dr. Nivet noted the student loan industry is a business with the goal to make money. Institutions partner with these companies, he pointed out, and asked about ways to address debt, such as lower interest or school subsidies for lower-income students. Dr. Sullivan said his first priority would be grants and scholarships for students who need support so they do not need to borrow money. Second would be low-interest government-guaranteed loans. Third would be to improve utilization with greater trust in the system. When funding is limited, systems are needed to get the dollars

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⁴ For more information, see https://medicalmentor.org.

available to low- and middle-income students. Dr. Pinn added that local and state programs are also positive and urged their expansion.

Dr. Nivet asked Dr. Sullivan and Dr. Pinn to comment on the idea of a new Black medical college as a solution to the lack of Black students in medical education. Dr. Sullivan said the concept is appealing and possible, although developing a new school today would be far more difficult than when he became the first president of Morehouse School of Medicine (MSM). At that time, the federal government invested in medical education to avoid a projected physician shortage, and Morehouse was one of the schools that received support. The civil rights movement also worked to foster MSM’s establishment, Dr. Sullivan recalled. The assumption that Black medical schools are not needed is false, he stated. In the efforts to eliminate racism, institutions of all types that recognize the Black experience are needed, he said; moreover, non-Black students who graduate from them can better understand the culture of the Black community and experience and thus relate to Black populations in a more effective way. Dr. Pinn agreed that a new HBCU medical school would be valuable. However, she pointed out, it may start with 75 or 80 students in a class. In contrast, if the existing 120 medical schools each increased its number of underrepresented minorities by five students, “there would be a more meaningful increase of those representing diverse populations.” Dr. Sullivan agreed that the growth of predominantly Black medical schools does not mean the larger community does not have a responsibility. “The importance of Black schools is to show that Black students can be successful,” he observed. “The talent is developed so that when they graduate, they can compete for residency appointments at the top hospitals and enter various specialties.” In his view, majority institutions have difficulty recognizing the talent of their Black students. Dr. Pinn pointed out that majority schools can have programs to recognize and develop talent. “Where this has happened, it’s been a great success. I don’t want to let majority institutions off the hook; they can do it,” she said.

Dr. Nivet thanked Dr. Sullivan and Dr. Pinn for their shared history and continued commitment. Dr. Sullivan closed by emphasizing the responsibility to educate fellow citizens about the value of investing in education and health care. “If we can accomplish this, we will be a better nation in 100 years,” he said.

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