Themes of the Macy Foundation|
Since its inception in 1930, the Josiah Macy, Jr. Foundation has been dedicated to improving the way in which health professionals are educated and trained, in order to better serve and improve the health of the public. Mrs. Kate Macy Ladd, in her remarkably wise terms of endowment, enjoined the Foundation to invest in "a few things, not many..."; "to support institutions rather than individuals"; to "take more interest in the architecture of ideas than in the architecture of buildings and laboratories"; and to fund efforts across the whole range from biological to social sciences in order to improve health care. Her summary vision was that the Foundation would "devote its interests to the fundamental aspects of health, of sickness, and of methods for the relief of suffering."
More than seventy years later, her insight and wisdom continue to guide our philanthropy. Over the intervening decades, the kinds of grant-making activities undertaken have evolved with the times, while staying true to the founder's goals. In the years before and just after World War II, national funding for biomedical research was marginal, and the Foundation was able to use its leverage to lend momentum to avant-garde areas such as cybernetics, and to areas of research opportunity or need highlighted by the war, such as renal physiology, hematology, endocrinology, genetics and neuropharmacology.
With the development in the 1950s and 1960s of the National Institutes of Health in its modern configuration, the Foundation's use of scarce leveraging funds was redirected primarily to matters related to undergraduate medical education. By the 1990s issues of primary care emerged as dominant, since the national tendency toward increasing specialization made primary care physicians a seemingly endangered species. In no context was the consequence of that decline in primary care givers more evident than among underserved populations. That made the Macy mission more pertinent than ever, since an underlying theme throughout the Foundation's history has been increasing representation of minorities in the health professions.
As I took over the presidency of the Foundation in 1997, those issues of improving health professional education, of educating primary care professionals, and of increasing access and utilization of health care by the underserved were well established. The main theme added was that of interdisciplinary aspects of health care, which focus was achieved through both Macy Conferences and grant mechanisms. In those endeavors it became increasingly clear and worrisome that formidable "silos" surrounded each health profession, with a notable dearth of mutual respect and a resultant gap and/or redundancy between and among health professions. Improving the interfaces between and among the several health professions is a goal that would clearly contribute to the health care and well-being of the public.
Those are the themes represented in the grants and conference activities described in this report. However, given the particular attention currently being paid to increasing minority representation in the health professions, I have chosen to devote the remainder of my remarks to that theme, which is growing in importance steadily and which continues to represent a dominant emphasis for the Macy Foundation. In the context of recent "affirmative action" decisions by the U.S. Supreme Court, the lag in proportionate minority representation among students in most of the health professions, and the growing evidence that lack of such representation among health professionals leads to lower quality of care for many populations, special attention and emphasis has never seemed more timely.
Dividends of Diversity in the Health Professions
The desirability of diversity in the health professions seems on the face of it to be a remarkably straightforward matter, for diversity is at the heart of human history and is central to our identity and hope for future progress. The whole exciting saga of humanity exults in the variety and adaptability of our species; and indeed the phenomena of biology are fundamentally predicated on change. Thus one could be quite succinct in describing the need to accommodate to diversity and confident about the manifest benefits that would be expected to arise from such considerations in the specific context of health professional care for diverse populations.
What is more, even cursory reading of our nation's history shows that its very creation was impelled by a sense of the need to be free and to tolerate difference: the right to life, liberty and the pursuit of happiness. Since at least the first and third of these are predicated on optimal health, our specific concerns about diversity in the provision of health care follow naturally.
Sadly, despite their wisdom, the founding fathers neglected to incorporate all people in their remarkable vision, and we continue to this day to cope with the consequences, both the positive and the negative. On the one hand, the tradition of welcoming all comers to a land of opportunity is strong and durable. On the other hand, exclusionary thinking survives. Unfortunately, it is all too easy to espouse the principles of universal inclusiveness while performing sleights-of-mind that overlook inequities that persist and even grow; and nowhere is that more punishing than in the arena of health care access, utilization and delivery.
While those are rather simplistic assertions, I believe strongly that we must have clear rationales and ultimate goals firmly in mind when we begin to identify impediments that stand in the way of their achievement. And as we know, the underrepresentation of minorities in the health professions and the underserving of subsets of our increasingly diverse population are linked, have evolved inexorably, and have proved refractory to facile solutions. Furthermore these inequities have demonstrably adverse health consequences. The continued failure to resolve them will postpone full realization of our nation's wonderful potential.
Disparities in Health Care
Let me begin with diversity of health status, for in recent years that topic has been addressed with increasing rigor and presents us with evidence of serious problems that must be overcome. It is perhaps not surprising to learn that immigrant populations and those whose economic status or geographic locale put them at a distance from sophisticated centers of care are at a health disadvantage: birth weights are lower, longevity is curtailed, mortality rates from cancer, heart disease and the like are higher, and burdens from chronic diseases are greater. A number of recent studies have underscored the assertion that economic status alone plays a powerful role in determining health status and longevity, so persistence of poverty in our wealthy land contributes to health inequalities. Since the burdens of poverty fall disproportionately on women and especially on children, the dismal trajectory of disadvantage and, therefore, of ill health reaches far into the future.
Those bad facts of life are intensified by our system of health care financing; for not only are the uninsured at risk of poor (or no) care, but increasing numbers of fully employed but relatively low income families must make choices between sustenance and health care. Our "safety nets" for such people have become dangerously ragged and frayed, even as health insurance costs drive more and more people into their ambit.
So the hard core facts of our nation's increasing diversity predicate problems by themselves. Were our health care providers truly representative of our diverse population, there would still be massive challenges, but the extent of their underrepresentation is striking and can be shown to contribute to the problem. Thus it was, several decades ago, that efforts to increase diversity in the health care workforce began and, for a while, succeeded.
Sadly, those trends toward more adequate representation have been reversed in recent years and are currently under considerable threat as quarrels about "affirmative action" run afoul of plans to attain wished-for progress to redress large gaps in our country's needs. The trend to increasing diversity in our population is accelerating, and the correlation of good health status with national strength, stability and productivity is readily shown. Disparities in health among various sectors of our population represent an increasingly glaring gap in the proclaimed goal of equality for our people.
Lack of Diversity among Health Care Providers
But there is more to it than that, for even the health care presently available to our population, when access and financing are accounted for, is demonstrably uneven, which raises the important issue of quality of care. That next step in this discussion must be taken carefully, for it brings up troubling matters of attitude and bias that most of us would like to think could not enter the sickroom.
But we must be clear-eyed and recognize that there is a serious hazard in assuming that the simple fact of educating more minority health care providers would be directly responsive to the needs of underserved populations. It is urgently necessary, and it would certainly help. But there are more benefits to redressing these ills than simple increase in numbers can achieve - our whole health care work force must learn what is needed to care for all people in need of care. And just as it has been argued that there is an intrinsic benefit to diversity among undergraduates during their education, so it is at least as much the case for health professionals.
It is widely perceived with some data to support it that health care providers from underserved parts of the population are more than usually likely to return to their communities and "take care of their own." Sadly, it is also established, with increasing clarity, that under present circumstances, minority populations receive a lower quality of care than do majority patients when cared for by majority physicians, even if access is assured.
It is unpleasant but useful to contemplate why that disparity might be. The harshest assumption is that such patients are deemed in some sense to be less "valuable" or worthy of the highest level of professional attention. I am old enough to be sure that some of that ugliness of attitude happens sometimes indeed, I have seen it rear its abominable head from time to time throughout my medical career.
But I think a more pervasive reason for that shortfall in quality of care arises from unfamiliarity and a sense of estrangement between patient and health care provider, and in both directions. Despite the gross statistics showing just how varied our population is, many people are put off by superficial aspects of diversity be it skin color or style of dress or manner of speaking. And in being distracted by those details, such people are incapacitated in their ability to identify and resonate with common themes of humanity. Paradoxically, it is in the context of life-and-death situations or the threat of illness and incapacitation that those common human threads are most visible, but also most apt to fray if unrecognized. As noted above, the failure to appreciate our commonality cuts both ways; and while we have moved rapidly toward ostensible variety in our society, continued separatism keeps us at a distance as strangers whose illness, on the one hand, and compassion, on the other, are filtered through prisms of misunderstanding. It would certainly help if we got to know each other better.
Cultural and Linguistic Competence
There is much talk these days about cultural competence. I do not want to seem to disparage it, for efforts to bridge gaps between cultures are clearly worthwhile and important. Similarly there is no question that linguistic divides can thwart severely any efforts to provide quality health care. But either consideration can prove to be crippling if addressed superficially or poorly.
Let me illustrate what I mean. This Foundation, known for its major theme of improving health professional education, receives numerous proposals that purport to improve the teaching of "cultural competence" or describe plans to insert specific modules of language instruction into curricula. I am struck by how few of those well-meaning applicants are aware of the enormity of the task, especially if it is approached in an uninspired or pedestrian fashion. Often the assumption is that brief representations of "black and Latino culture" will contribute to understanding; or that the addition of minimal Spanish (and in parts of New York, Chinese and Russian) vocabularies will help. Another approach, on the language side, is to propose that efforts be made to amplify available pools of interpreters. Again, I don't want to undervalue such efforts, although it is in their flaws that one must look for guidance concerning more helpful approaches.
There is, of course, no such distinctive, sharply defined thing as "black culture," and efforts to simplify such matters lead almost inevitably to stereotyping that is anything but helpful. As to "Latino" culture, on even superficial inspection it becomes evident that our "fastest growing minority" is comprised of literally dozens of subsets, who often consider each others' ways all but incompatible. As to communication, in our large cities, as many as 80 or 100 different languages may be used, and brief "medical lexicons" fall far short of the words needed for optimal (or even minimal) care.
Even in the context of supposed commonality of language, pitfalls arise. As an illustrative case in point: early in the years of the AIDS epidemic, the Centers for Disease Control launched a well-meaning effort to translate AIDS-prevention brochures and materials into Spanish from the original texts in English. A colleague of mine, who was a Mexican-American sociologist working in a public health department on the West Coast, examined the products of translation, which had been done by someone with a Puerto Rican heritage. He was initially shocked at the crudity of language in the brochure, he said, until he recognized the linguistic fact that assertions about sexuality that were delicately phrased for Puerto Rican consumption were positively lurid in Mexican-Spanish idioms and phrases (and, as he noted, the converse would have been true as well). The nuances of language usage in the two cultures were anything but interchangeable!
I do not make these points to be nihilistic. The improvement in teaching of communication skills in health professional schools has been a major focus of some of our grant-making. Efforts to improve cultural competence and to bridge the chasms of language must be made with skill and energy, and I have no doubt that success in those endeavors can make a notable difference in achieving equality of health care. But I feel that it is crucially important that students in the health professions be made aware at the very outset of their education and training that factors of culture, ethnicity and communication will be central to their success in delivering care to all their patients. Thus it is key that our rich diversity be represented among students of medicine, nursing, dentistry, public health, and the many other professions that contribute to effective health care delivery.
Identification, recruitment, retention and training of underrepresented minorities in the health professions
Thus there is a strong case to be made for increasing diversity among health professionals not only for purposes of equity but also for improving the quality of health care for all our citizens. A healthy citizenry is a national need of major importance, and it cannot be achieved without redress of substantial disparities, including more minorities in the health professions.
Similarly, it may well be possible to improve the attractiveness and feasibility of undergraduate programs that prepare students for health professional education to follow. Again, role models and mentoring both play an important part in sustaining interest and firing imagination; but in this context there arises the possibility of unequal opportunity that takes the form of unevenness in academic guidance and career advice. Some undergraduate institutions have well-structured advisory programs while others' are minimal; and even in the former, the need to stay up-to-date may not always be met due to changes in personnel or budgetary constraints. It is in this context that the Macy Foundation is currently engaged, in collaboration with Marc Nivet and using the background experience of the Associated Medical Schools of New York, in the creation of a nationally pertinent and current website that can offer access to excellent and appropriate guidance about health professional careers, thus contributing to a "leveling the playing field."
It is our intent that such access should open the way to preparation for a wide variety of health professional careers, so that students are in a position to decide for themselves which are most attractive. There is a serious hazard, in my mind, that guidance which leads inexorably and exclusively toward medical school will leave many students disappointed, often because there is a "mis-fit" between their particular skills and motivation and the deterrent effect of certain pre-medical requirements. One hopes that some of those requirements will be reexamined over time; but even as that happens, students should be made aware that there are several health professions for a reason, and that their tastes and skills can be adapted individually to a variety of options.
A final comment about avenues to pursue in expanding minority participation in health professions: we often talk about access and opportunity, but in addition to those pragmatic matters it is important to be cognizant of the need for aspiration. Surely it is in that context that mentors and role models alike play critical roles, especially for students who are the first in their family to reach beyond high school in their education. But the same factors are important at all levels, and thus efforts to improve representation and increase the visibility of such minority leaders at the faculty and academic leadership levels deserve serious attention and support as well.
In summary, there are steps to be taken at every stage of the educational pathway to the health professions and thus much work to be done. In the meanwhile, while careful awareness of legal constraints must be maintained, the urgency of need for a diverse health professional workforce cannot be overstated, and efforts to optimize the career goals of students currently "in the pipeline" can reclaim some of the momentum lost in recent years. The post-baccalaureate program of the Associated Medical Schools of New York is an example of such an effort, and while its successes (in absolute numbers) may represent only a modest step toward meeting a huge national need, models such as that deserve widespread attention. After all, the fruits of success in these efforts that is to say, the dividends of diversity will be measured not only in equity and equality of opportunity, but also in the health of our nation and its people.
In discussing how to achieve that goal, conversation always turns quickly to inadequacies in "K through 12." I fully agree that there is room for a lot of work to bring the excitement of fundamental knowledge, especially in the sciences, to the earliest stages of education. Efforts at enrichment in those early years can set the stage for great dividends to follow; and exposure to inspiring role models and mentors can contribute greatly. I am aware that many efforts have already been made in those regards; I am less sure that key elements of success have been identified consistently among them, and it would be very helpful to know why some programs work while others have little staying power.
June E. Osborn, M.D.