Affirmative Action in Medicine: Improving Health Care for Everyone

by James Curtis

Overview

Affirmative action programs have significantly changed American medicine for the better, not only in medical school admissions and access to postgraduate training but also in bringing a higher quality of health care to all people. James L. Curtis approaches this important transition from historical, statistical, and personal perspectives. He tells how over the course of his medical education and career as a psychiatrist and professor--often as the first or only African American in his cohort--the status of minorities in the medical professions grew from a tiny percentage to a far more equitable representation of the American population.
Advancing arguments from his earlier book, Blacks, Medical Schools, and Society, Curtis evaluates the outcomes of affirmative action efforts over the past thirty years. He describes formidable barriers to minority access to medical-education opportunities and the resulting problems faced by minority patients in receiving medical treatment. His progress report includes a review of two thousand minority students admitted to U.S. medical schools in 1969, following them through graduation and their careers, comparing them with the careers of two thousand of their nonminority peers. These samples provide an important look at medical schools that, while heralding dramatic progress in physician education and training opportunity, indicates much room for further improvement.
A basic hurdle continues to face African Americans and other minorities who are still confined to segregated neighborhoods and inferior school systems that stifle full scholastic development. Curtis urges us as a nation to develop all our human resources through an expansion of affirmative action programs, thus improving health care for everyone.
James L. Curtis is Clinical Professor Emeritus of Psychiatry, Columbia University College of Physicians and Surgeons.

Product Details

ISBN-13:	9780472025022
Publisher:	University of Michigan Press
Publication date:	12/18/2009
Sold by:	Barnes & Noble
Format:	eBook
Pages:	256
File size:	3 MB

About the Author

James L. Curtis is Clinical Professor Emeritus of Psychiatry, Columbia University College of Physicians and Surgeons.

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Affirmative Action in Medicine: Improving Health Care for Everyone

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By James L. Curtis

University of Michigan Press

Copyright © 2003 James L. Curtis
All right reserved.
ISBN: 0472112988

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I. Affirmative Action: In U.S. Medical Schools

Affirmative action is a deliberate race-conscious recruitment goal designed to equalize access within a set time frame to the high-status jobs and professions such as medicine, from which Blacks have been unfairly excluded for many generations. The concept is based on the premise that relief from illegal racial discrimination is not enough to remove the burden of second-class citizenship from Blacks and other underrepresented minority groups in the United States. In the case of Blacks, for example, slavery and later the imposition of compulsory racial segregation and inferior public and private services were protected government actions. Affirmative action, aided by the same government, is therefore both justified and required to fulfill the objective of equal access. Meaningful equality can only be measured by equal results; otherwise equal opportunity lacks essential meaning, since the social system given a tendency to repeat past history will automatically militate against the equal treatment of minority groups.

Therefore, if the student body, faculty, and administration in a professional school reveal a pattern of minority underrepresentation, despite the presence of a qualified minority applicant pool from which more selections could have been made, it can be assumed that they are being denied essentially equal access or opportunity. Such an institution would be ineligible to receive federal funds and would be required by federal law to draw up a corrective affirmative action plan. This plan is updated annually and establishes the means and methods for recruiting a more equal proportion of minority individuals into the higher levels of the institution's status hierarchy. Affirmative action efforts are subject to federal review, which determines whether they have been carried out in good faith, are adequately documented, and have satisfactory results. The regulations cannot be satisfied by merely going through the motions and completing a set of forms. Affirmative action plans are not explicitly required for admission of students to graduate or professional schools, although they are required for hiring faculty and staff and probably also postgraduate trainees, who are both students and employees simultaneously. Proponents of affirmative action argue that student admissions are covered implicitly, inasmuch as entry to professional school is an absolute determinant of one's future access to professional employment as a faculty member, researcher, or medical practitioner (Institute for the Study of Educational Policy 1976; Fleming, Gill, and Swinton, 1978; C. J. Smith 1978).

The U.S. Commission on Civil Rights concurs that the same constitutional guarantees that protect equal minority access to employment also cover access to admission to professional schools because they are the gateway to professional employment (U.S. Commission on Civil Rights 1977, 1978). All preadmission tests must have a valid and demonstrable relationship to the applicant's ability to perform defined job-related tasks and cannot be used as a device to discriminate racially. The Carnegie Council on Policy Studies in Higher Education (1977, 2-18) concluded that the public policy gains from affirmative race-conscious admissions programs could be achieved without sacrificing essential academic standards, as long as only qualified minority applicants are accepted. This chapter focuses on medical school admissions past and present, and how admissions practices particularly have been changed by affirmative action policy since 1968. The study here provides a close-up view of the impact of affirmative action on the field of medicine.

Holzer and Neumark (2000) have given the most up-to-date critical review and assessment of affirmative action not only in college admissions but also in employment and job promotion and in awarding government contracts. Careful research, in their opinion, does not fully support those who either favor or oppose this hotly contested policy (483). The weight of evidence, however, "supports the view that the significant gains made in recent decades by minorities and women have been achieved with relatively small efficiency consequences" (559). Moreover, they conclude that past as well as current discrimination against these groups might well be worsened by a color-blind approach such as use of income level as a selection factor since low-income Whites outnumber Blacks by a wide margin (561).

HOW AFFIRMATIVE ACTION WORKS

The following scenarios depict the kinds of concrete situations that regularly confront medical school admissions committees.

Scenario 1. Suppose it is late in the admissions season. Two applicants are being considered at a medical school, but there is room to admit only one. One applicant, who is Black, is thought by a majority of the members of the admissions committee to be unqualified, and the rest consider him to be a borderline candidate at best. The other applicant is White and is considered by all members of the committee to be far from outstanding but definitely qualified.

In this case the White applicant would be accepted even if no Black students were enrolled at that medical school. Affirmative action does not require that unqualified minority applicants be admitted, and very likely the Black applicant would not be able to perform satisfactorily as a medical student nor subsequently as a competent member of the profession. It would not be good academic or public policy to favor his admission.

Some individuals persist in their beliefs that affirmative action means that unqualified applicants have to be accepted. It has even been suggested that some schools have knowingly admitted unqualified applicants in order to discredit minority admissions programs and give them short lives in their institutions. In 1969 one medical school in the New York area admitted 14 minority students, of whom only four performed satisfactorily in the first year; in the same year another school admitted eight, of whom five repeated the year and required extensive tutoring, creating serious faculty resistance (Curtis 1971, 123-24). Ten years later both schools had admitted only four to six students in subsequent years judging from enrollment data on minority students enrolled and graduating (AAMC 1982-83). Frequently, however, opinions differ on which of two applicants is more qualified, as well as on the operational definitions of such terms as qualified, borderline qualified, unqualified, or highly qualified. These judgments are influenced by the presence or absence of racial bias, as well as a host of other considerations. The complexity of this issue will be more fully explored later in this chapter, and more will be revealed about the way admissions committees struggle with these matters.

Scenario 2. Again two applicants are being considered, and only one can be offered acceptance. In the opinion of almost all members of the admissions committee one applicant, who is Black, is more highly qualified than the other applicant, who is White. The Black applicant seems best on the basis of grades and scores, letters of recommendation, admissions interview, extracurricular and community activities, and other indications of strong motivation and the likelihood that she will contribute to the medical profession as a leader. In this case the Black applicant should be accepted, and most persons correctly would not consider this to be an example of affirmative action. This Black applicant should be accepted even if Blacks are not underrepresented at that medical school. Affirmative action is intended to provide a minimally acceptable proportion of qualified members of minority populations; it establishes a floor, not a ceiling, to assure a minimally acceptable inclusion of members of an excluded group, not the exclusion of any group members after these equitable conditions are met.

Scenario 3. In this situation both the Black and the White applicant are qualified, although neither is exceptional as far as can be determined. This situation occurs far more commonly than either of the two preceding scenarios.

If only one candidate can be offered a place, it is in such an instance that the Black applicant should be accepted, provided that Blacks are significantly underrepresented in the student body of that medical school. This is affirmative action, when qualified members of underrepresented minority groups are admitted until there is a minimally equitable level of representation from the underrepresented group. Swain (2000) states that survey questions can be phrased in such a way, within various contexts, as to obtain contradictory findings on the controversial issue of affirmative action. She states, however, that in a scenario in which both a Black and a White applicant are equally qualified and only one can be accepted, 78 percent of Whites and 72 percent of Blacks believe that race should not be a factor in the admission decision. Some other basis should be found, such as adverse life circumstance versus a background of family comfort and privilege, to determine the admission decision.

The minority population and the size of the applicant pool at local, state, and national levels are useful in determining minimally acceptable and fair levels of representation. The rationale for such action rests not only on the laudable purpose of equalizing the civil and legal rights of all Americans, but also on the grounds that an ethnically diverse student body will, by its very composition, obtain a sounder medical education and as physicians be more responsive to the medical needs of the diverse American public.

WHY AFFIRMATIVE ACTION WAS NECESSARY

Medical education was generally not available to Blacks until 1868, when Howard University Medical School in Washington, D.C., opened its doors. Meharry Medical College in Nashville began operating in 1876. For all practical purposes, these two schools were set aside for Blacks, at a time when all the other medical schools did not accept, or admitted only token numbers of, Blacks (Johnson 1967; Curtis 1971, 34).

The founding of Howard University in 1866 is an example of affirmative action in the period immediately following the Civil War. The NAACP Legal Defense Fund's amicus brief in the case of the Regents of the University of California v. Bakke pointed out that Congress, in framing the Fourteenth Amendment, demonstrated a belief that race-specific remedies are both necessary and permissible and adopted a series of measures that established special educational and medical programs solely for Blacks (NAACP 1976, 12-48). Indeed the Freedman's Bureau Act of 1866, under whose authority Howard and a number of other well-known Black colleges in the South were founded, was enacted over two vetoes by President Andrew Johnson, who opposed special aid for Blacks. A major purpose of the Fourteenth Amendment and its equal protection clause was to assure the constitutionality of the Freedman's Bureau Act. In an era when public education was open to only a few privileged Whites, it is not surprising that many Americans were opposed even to segregated elementary or high schools for Blacks, not to mention Black colleges or professional schools.

Blacks were for the most part excluded from the tremendously increased higher education opportunities that opened up for other Americans during the rapid and extreme expansion of the college and university system following the Civil War through the end of World War II, including the federally funded land grant colleges for Whites (Drake 1971). Had the segregated Black colleges not existed, as a kind of affirmative action program that was better than nothing, Blacks today would suffer a much more grave educational inequality than they do. Following the 1896 Plessy v. Ferguson decision of the Supreme Court, racially "separate but equal" facilities became the pattern in public institutions and accommodations, including schools. It was transparently inevitable that separate and inferior Black schools and colleges would permanently assure the systematic undereducation and subordination of Blacks to Whites. Therefore, Black colleges have served two different purposes, depending on the strength, wisdom, and motivations of their leadership. These colleges can promote an affirmative action mission by educating Blacks who otherwise would not be educated, or they can foster a lower standard of education for Blacks. White leaders more than Black have used these colleges for the latter purpose. Perhaps the best example of this is Meharry Medical College, one of the predominantly Black medical schools, which was founded in 1876. The Southern Regional Education Board consisted of representatives from 15 southern and border states to guide their higher educational policies, this policy for Blacks being "separate but equal." As recently as 1968 a majority of Meharry's first year class was set aside for Black students from those states whose education was partly financed to keep them from attending White medical schools in their states of origin (Cogan 1968, 5, 25-26, 59).

BLACK ENROLLMENT IN MEDICAL SCHOOLS

Table 1 shows Black enrollment in U.S. medical schools from 1938 through 1997. In 1938, Blacks were approximately 10 percent of the population but only 1.6 percent of all enrolled medical students. More than 87 percent of them were matriculated at Howard or Meharry. A decade later Black enrollment had increased to 2.6 percent, and just over 84 percent still were enrolled at one of the two predominantly Black medical schools.

In the late 1930s there began a decade of major legal challenges to the constitutionality of racially segregated education (Kluger 1976, 155-238). The NAACP launched a major attack on the separate and unequal graduate and professional schools of the southern states, at first demanding only equal educational treatment. It was thought to be strategically wise first to win a number of cases on the basis of the demonstrable inequality or absence of postgraduate and professional school facilities provided to Blacks, rather than to tackle the fundamental doctrine enthroned under the Plessy case, the pretense that racially separate schooling could be equal.

In 1935, Charles Houston, former dean of Howard University Law School and a graduate of Amherst College and Harvard Law School, and one of his extremely able former students, Thurgood Marshall, brought suit against the University of Maryland to admit Donald Murray, a recent Black graduate of Amherst, to its law school. Murray was accepted in 1938, following three years of litigation.

Another student, Lloyd Gaines, was admitted to the University of Missouri Law School after a legal contest also decided by the Supreme Court in 1938. As commonly was done in those days, Missouri had offered to pay tuition for Gaines to attend a law school in any other state in order to keep the state university all White. When he did not agree, the state offered a defense that there were too few Blacks applying to law school in Missouri to warrant the expense of establishing a law school for Blacks only. Chief Justice Charles Evans Hughes ruled that "the State was bound to furnish . . . within its borders facilities for legal education substantially equal to those which the State there afforded for persons of the White race."

Other admissions suits against law schools in Oklahoma and Texas in 1946 were decided similarly in 1948 and 1950. Even though the Court avoided a ruling on the "separate but equal" doctrine, it had already made it clear that a state could not provide an equal professional education for Blacks by setting up a small pretense of a school, which lacked comparable student-faculty-alumni supportive networks, comparable libraries, or comparable reputations for excellence. Writing for a unanimous Supreme Court on June 5, 1950, Chief Justice Vinson stated that in both Oklahoma and Texas "we cannot find substantial equality in the educational opportunities offered White and Negro law students by the state" (Kluger 1976, 282). A 1942 U.S. Office of Education survey of higher educational opportunity for Blacks in the seventeen southern and border states revealed that segregated schools were mandatory in all of them either by state constitution or statute, that professional and graduate educational offerings were not equal anywhere, and that, for example, in sixteen states a law curriculum was offered for Whites but was available in only two states for Blacks. In 1940 about 80 percent of all Blacks lived in those states; 70 percent still lived there in the 1950s. Medical education was offered to Whites in thirteen of the seventeen states and the District of Columbia, but was offered to Blacks only in the two states where Howard and Meharry were located.

When I was admitted to the University of Michigan in 1943 I was the only Black student in a class originally of 175 and of whom 145 graduated. Probably I was the only Black student that year as a consequence of military service. Already accepted into the Medical School I was drafted and as a result of my test scores was made a member of the Army Specialist Training Corps for Blacks, since the military was at that time segregated. I was slated to study engineering, but because I had already been accepted for the Michigan Medical School, Albion College and the University of Michigan requested that I go to Medical School. On arriving I noticed that each class had two Black students, and in the course of my years there each year they admitted two or three Black students. All enrolled students were members of the Army Specialist Training Corps (ASTP) or the Navy V12 program except for the small number of six or so women in each class. Men lived in the Victor Vaughn Medical Dormitory for men except for those preferring to live in their White fraternity house. That was the first year Blacks lived in the dormitory for men because dormitories at Michigan then were segregated. When I was in my junior year and the war ended, I completed school as a civilian and was required to rent quarters off campus. During those medical school years I made many friends of different races since all of my earlier schooling had been in racially integrated schools where I was the only or one of only a few Blacks in a class. In my graduating class of 145 I finished twenty-eighth.

LEGAL DESEGREGATION

The Supreme Court's 1954 decision in Brown v. Board of Education ended the Plessy doctrine of "separate but equal." Chief Justice Earl Warren found that to segregate children racially in public schools in and of itself deprived minority children of an equal education guaranteed them by the equal protection clause of the Fourteenth Amendment. Public schools in the lower levels were inherently unequal simply by virtue of their being racially segregated.

Some of the southern states refused to recognize that Brown applied to graduate and professional schools as well as elementary and high schools. North Carolina, Alabama, Tennessee, Georgia, Louisiana, Mississippi, and Florida all brought legal tests of the issue. In Frazier v. the Board of Trustees of the University of North Carolina the Supreme Court stood firm in its 1956 decision that the reasoning in Brown applied with equal force to colleges: "Indeed it is fair to say that they apply with greater force to students of mature age in the concluding years of their formal education as they are about to engage in the serious business of adult life" (Amicus brief in California v. Bakke, National Fund for Minority Engineering Students 1976).

The legal struggle to maintain segregated higher education dwindled in the mid-1960s. However, in 1968, fourteen years after Blacks had won a major constitutional law victory, only twenty-two more Black students were enrolled in the nation's medical schools than were registered when the Supreme Court pronounced the verdict in Brown. At this time, though, the entire nation developed a mood of willingness to begin to correct the social injustices long inflicted on Blacks. Reasons for this change included the nonviolent civil rights movement led by Martin Luther King Jr.; the student protest against the Vietnam War and social injustice generally; the urban riots by Blacks, especially following King's assassination; and the development of increasing Black militance (Grimshaw 1969; Ludmerer 1999, 250-53).



Continues...

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Table of Contents

INTRODUCTION I PART I I. Affirmative Action in U.S. Medical Schools 13 II. Affirmative Action at Cornell 35 III. Civil Rights in Health Care 58 PART II IV. Geographical Distribution of Minority Residents 79 V. Comparing Specialty Choices 103 VI. Affirmative Action in Graduate Medical Education 118 PART III VII. Thirty-Year Progress Report: Geographic Location of Practice and Medical Specialty Distribution 149 VIII. The Future of Affirmative Action in Medicine 179 EPILOGUE 212