“The Right Thing to Do…The Smart Thing to Do”

Several presenters argued for a re-examination of the rationale for diversity in health professions, and, more specifically, the value of affirmative action as a tool for achieving diversity in health professions training settings. Mark Smith, president and CEO of the California Health Care Foundation, noted in a keynote address that the two traditional arguments presented in support of affirmative action, fairness and function, must be updated if advocates seek to overcome objections of some policymakers and the prevailing public sentiment.

Issues of fairness, Smith stated, have traditionally been at the heart of arguments in support of affirmative action, based on the fact that many racial and ethnic minorities have been traditionally excluded from economic and professional opportunities. Affirmative action policies were therefore established as a mechanism for redress and expanded opportunity. The contemporary challenge, he noted, is to update this understanding of fairness and make the mechanisms of redress more sophisticated to reflect social, economic, and demographic changes that have occurred since affirmative action policies were first implemented. For example, Smith noted that by pointing to minority individuals who have attained success and broken traditional economic and employment barriers, opponents of affirmative action argue that minorities now have equal, if not greater opportunities to succeed. Increasingly, he added, African Americans, Native Americans, and Hispanics have ascended to middle- and upper-class status, creating a perception that affirmative action is no longer needed. Opportunity, however, is still inequitably distributed, according to Smith—a point that will be lost should proponents of affirmative action not acknowledge the economic, political, and educational gains that minorities have made, he added.

Proponents of affirmative action must also address the perception that “merit” can be fairly and objectively assessed, according to Smith. This perception is bolstered, he noted, by the heavy reliance among some administrators on test scores in admissions processes. Test scores, Smith stated, create an aura of scientific precision without necessarily predicting the outcomes of interest—such as the kinds of skills necessary to be a good nurse. A silent form of “pseudo precision,” he argued, is conferred when quantitative measures are used without a clear understanding of how and when these data are useful. Such misunderstandings are a “constant threat” to notions of fairness that have been central to efforts to increase diversity, according to Smith.

Arguments in support of affirmative action that focus on the functional utility of a diverse workforce must also be updated, according to Smith. Noting that some research and anecdotal evidence supports the argument that a diverse health care workforce helps to improve access to care for minority communities and enhance trust and communication, Smith called for more critical analysis and research. Not all racial and ethnic minority health care providers will “click” with minority patients, he noted; similarly, one should not assume that nonminority providers cannot adequately serve minority patients. Research must better assess the key variables that affect the patient-provider relationship, such as trust, being treated with dignity, and mutual respect, and consider how the race and ethnicity of patients and providers influence these variables, he noted.

Smith concluded by drawing an analogy to common myths about the pyramids and other great artifacts of ancient Egypt. He noted that a common misperception about the pyramids is that their construction involved highly technical scientific achievements that were once thought unavailable to the Egyptians. This was not the case, he stated—in fact, much of the construction conformed to basic understandings, and was not “rocket science.” Much the same can be said about efforts to diversify health professions, Smith said, in that basic efforts such as mentoring, developing a critical mass of URM health professions students and faculty, focal and consistent support from leadership, and social and psychological support can all help to enhance diversity. “These are not sophisticated concepts,” he noted.

Another myth about the pyramids, Smith stated, is that stone materials used in their construction were brought in from miles away, across desert and waterways. In fact, he noted, the pyramids were built using materials that were readily available. Similarly, we need not look far for sources of future health professionals—tomorrow's dentists, doctors, nurses, pharmacists, and other health professionals are all around us, he said.

Finally, Smith related that the famous Sphinx was not planned, but, rather, was an artifact of another major construction effort that yielded a fortunate discovery. Ancient Egyptians were building a causeway, Smith stated, and came upon a large rock formation that blocked the causeway. Rather than try to remove the rock, the Egyptians carved the Sphinx into its surface. Similarly, proponents of diversity and affirmative action often encounter obstacles and political challenges, but these challenges must be addressed, Smith said. He noted that opponents who cannot be convinced of the need for diversity on political grounds can often be swayed on scientific grounds, heightening the need for creative and well-supported arguments. When “you've got lemons, you make lemonade,” he stated, adding that opponents can be swayed that affirmative action is not only “the right thing to do… [but also] the smart thing to do.”

The Necessity of Sustained Efforts

Lee Bollinger, president of the University of Michigan, delivered a theme similar to that of Smith in a keynote address that focused on Michigan's efforts to defend its affirmative action policies against two lawsuits that questioned the constitutionality of affirmative action. Bollinger, a constitutional law scholar, argued that the U.S. Supreme Court's ruling in the landmark 1978 Bakke case, which remains the preeminent ruling on affirmative action as of this writing, refutes the notion that race, ethnicity, and color cannot and should not be taken into account in admissions processes. To the contrary, the Bakke decision points out that U.S. society is not “color-blind,” as opponents have argued, borrowing civil rights-era language, according to Bollinger. Combating such arguments has been challenging, he said, in the wake of an increasingly conservative Supreme Court, nationwide efforts to bring suit against universities that have affirmative action policies, state referenda (e.g., Proposition 209), and public attitudes that indicate dwindling support for affirmative action. Bollinger noted that affirmative action proponents are often urged to “move on,” or to find some other way to accomplish diversity without explicitly considering race or ethnicity in admissions processes. Under his leadership, however, the University of Michigan won the lawsuit challenging its undergraduate admissions processes, and is appealing a ruling against the school's law school admissions policies. In the process, Bollinger stated, he has learned that: 1) higher education, when organized and ready to address challenges, is “hard to beat;” 2) it is important not to accept the attitudes of the times (e.g., that affirmative action has been beaten, and that other alternatives should be explored); and 3) one must never underestimate the necessity of sustained efforts in dealing with diversity issues.

Michigan's success in defending its affirmative action policies can be linked to two broad-based strategies, said Bollinger. The first was a legal strategy to provide support for the rationale in the Bakke decision, which assumes that a racially diverse student body leads to better educational outcomes for all students and serves compelling government interests. Michigan's defense drew from several sources, including social science research indicating that educational and civic outcomes were better for college students educated in more diverse environments. The second strategy, according to Bollinger, was a public education campaign that sought to “make the case, with complete openness and candor,” to inform the public about admissions processes and the benefits of diversity. Bollinger and his colleagues actively sought opportunities to present Michigan's rationale for diversity, while continuing to build allies among other higher education leaders, as well as businesses and corporations, such as General Motors.

In the process, Bollinger stated, Michigan was able to identify and debunk several misperceptions about affirmative action:

Race is no longer a factor in American life, and therefore should not be a factor in admissions processes. Bollinger responded to this charge by noting that the vast majority of Michigan students, both minority and non-minority, came from starkly segregated high schools. This suggests that college represents the first opportunity for many of these students to work and live with people from other backgrounds, in effect training them for participation in the working world.

Admissions processes should be based on applicants' credentials, not race. Like many other schools that have affirmative action policies, Michigan's admissions process considers applicants' academic preparation and achievements in conjunction with other factors—such as their geographic location, leadership, socioeconomic status, athletic abilities, and alumni status—to create a diverse student body, said Bollinger. Race and ethnicity are but two of the many factors that must be considered to assemble a class “like a symphony,” he said. Noting that the term “affirmative action” is not commonly used when universities consider applicants' “legacy” status (i.e., children of alumni), Bollinger said that people mistakenly believe that applicants' race or ethnicity is somehow given greater emphasis than other attributes when admissions committees attempt to assemble a diverse student body.

Diversity is not central to the educational mission, but rather an add-on. Bollinger refuted this argument, stating that diversity is critical to efforts that help students to “get outside of their own perceptions and viewpoints and encounter other perspectives. “This why we study history, law…and literature,” he said, noting that undergraduate curricula typically requires study outside of students' major field, to ensure breadth. Similarly, he argued, students should be exposed to other cultures, viewpoints, and perspectives.

Diversity does not work because students self-segregate on campus, nullifying its benefits. Bollinger acknowledged that students of different racial and ethnic backgrounds do segregate themselves, but believes such segregation is less prevalent than commonly believed. In part, this may reflect what students are most comfortable with, given that they arrive on campus with generally limited exposure to other racial and ethnic groups, he said. Further, he argued, such self-segregation occurs in society, but should not be an excuse for failing to encourage students to learn from each other.

College and university admissions committees can achieve diversity by striving for a socioeconomic mix, or by automatically admitting a percentage of the top high school graduates. Bollinger also refuted this argument. Using socioeconomic status alone as a key factor in admissions will not ensure racial and ethnic diversity, he argued, as most poor individuals are white. In addition, automatically admitting a percentage of the top high school graduates removes the discretion and autonomy of universities to choose the type of student body that they feel would create the best learning environment.

Can Diversity Among Health Professionals Decrease Health Disparities?

African Americans and Native Americans, and to a lesser extent Hispanics, experience rates of mortality and disability from disease and illness that are significantly higher than rates for white Americans. The excess burden of illness in these populations is due to many complex factors, including socioeconomic inequality, environmental and occupational exposures, direct and indirect consequences of discrimination, health risk factors such as overweight, cultural and psychosocial factors such as health-seeking behavior, biological differences, and less access to health insurance and health care. Because many racial and ethnic minority communities have a shortage of physicians, increasing the numbers of health professionals—and in particular, providers who are themselves racial and ethnic minorities—to serve in these communities has been proposed as one means of addressing the excess burden of illness among minorities.

Raynard Kington, Diana Tisnado, and David Carlisle explored this hypothesis in a symposium presentation, noting that the question of training minority health providers to serve in minority communities extends back at least to the 1910 Flexner report, which advocated that “Negro” doctors be trained exclusively to serve the African-American population (see Kington, Tisnado, and Carlisle, this volume). Kington and colleagues explored the impact of diversity among health professionals via three pathways: the effect of practice choices of minority providers; the quality of communication between minority patients and providers; and the quality of training in health professions training settings as a result of increasing diversity in these settings. Kington et al. addressed these questions using data for physicians, because these data are generally more available and reliable than data for other health professionals.

Kington and colleagues noted that African-American and Hispanic patients are less likely than whites to have a regular physician, to have health insurance, to have routine visits with a physician, and to receive some preventive and screening services. After gaining access to health care, however, minorities still do not fare as well as their white counterparts; African Americans, and to a lesser extent Hispanics, receive fewer diagnostic and therapeutic procedures than whites, even after controlling for clinical, co-morbid, and sociodemographic factors.

Not surprisingly, Kington and his colleagues note, physician supply is inversely related to the concentration of African Americans and Hispanics in health service areas, even after adjusting for community income levels. A consistent body of research, however, indicates that African-American and Hispanic physicians are more likely to provide services in minority and underserved communities, and are more likely to treat poor (e.g., Medicaid-eligible) and sicker patients. Some studies, according to Kington and his co-authors, indicate that on average, minority physicians treat four to five times the numbers of minority patients than white physicians do. These practice patterns appear to be by choice, according to the authors; studies of new minority medical graduates, for example, indicate a greater preference to serve in minority and underserved communities.

Kington and his colleagues also reviewed several studies that examine the quality of patient-provider communication across and within racial and ethnic groups. These studies indicate that for some minority patients, having a minority physician may result in better communication, greater patient satisfaction with care, and greater use of preventive services. However, the authors caution, there is little empirical evidence that cultural competence influences patient outcomes, or that increasing the numbers of minority physicians to serve patients of color improves outcomes through culturally appropriate care. In addition, although many speculate that increased diversity in medical training may expose physicians to a wider range of cultural backgrounds and improve their interactions with patients, there is little evidence that diversity within health care training settings (e.g., greater numbers of URM students in medical school) improves training for all medical students, according to Kington et al. The authors noted, however, that this question has not been subject to consistent, rigorous study.

Kington and colleagues concluded that increased diversity among physicians appears to be valuable for increasing access to care in minority communities. Minority providers, they argue, are more likely to seek to serve individuals of their own racial and ethnic backgrounds, and tend to positively influence minority patients' satisfaction with clinical encounters. Further, these providers are more likely to provide preventive and primary care services that are most needed among less healthy populations. Kington and his co-authors caution, however, that while the evidence supports increasing the numbers of minority physicians to meet health needs of minority communities, we must guard against the notion that minority providers should be trained primarily to serve racial and ethnic minorities, or that white physicians cannot adequately serve minority patients. Given the disproportionately low representation of minorities among the ranks of health professions, such simplistic assumptions are likely to widen the gap in access and quality of care for minority patients.

The Impact of Diversity in Health Professions Education

As Kington and colleagues noted, a potentially important aspect of the case for diversity in health professions is the impact of diversity within health professions education settings. Lisa Tedesco, Vice President and Secretary of the University of Michigan, explored the theoretical and empirical evidence for this argument. Tedesco cited a growing number of studies indicating that diversity in higher education settings is associated with positive academic and social outcomes for students, and argued that such benefits extend to health professions training, as well.

One such landmark study, said Tedesco, was described in The Shape of the River, a book by William Bowen and Derek Bok (1998). Bowen and Bok studied educational and career outcomes for two cohorts of white and minority students who attended 28 selective colleges and universities in the 1970s and 1980s. They found that minority graduates of these institutions attained levels of academic achievement that were on par with their non-minority peers (e.g., minority and non-minority students attained graduate degrees at approximately equivalent rates). Further, minority graduates of these schools obtained professional degrees in fields such as law, medicine, and business at rates far higher than national averages for all students. African-American students from selected schools in the 1976 cohort, for example, were seven times more likely to receive degrees in law and five times more likely to receive degrees in medicine compared with the general college population, according to Tedesco. Similarly, African-American students in the 1989 cohort of students in this study were only slightly less likely to earn doctorates than were white students. Significantly, Tedesco noted, civic engagement and community activity was higher among minorities from the selected schools than their white counterparts.

Similar findings were obtained by Patricia Gurin, said Tedesco. Gurin, a professor of psychology at the University of Michigan, studied academic and civic outcomes of college students who attended racially and ethnically diverse colleges, and those who attended less diverse institutions. Gurin found that students at diverse institutions were more likely to be involved in community and civic activities, and were “better able to participate in an increasingly heterogeneous and complex democracy,” according to Tedesco. These students, she added, were better able to understand and consider multiple perspectives, deal with the conflicts that different perspectives sometimes create, and “appreciate the common values and integrated forces that harness differences in pursuit of the common good.” Gurin concluded that students can best develop the capacity to understand the ideas and feelings of others in an environment characterized by a diverse study body, equality among peers, and discussion of the rules of civil discourse.

“These factors are present on a campus with a racially diverse student body,” Tedesco stated. “Encountering students from different racial and ethnic groups enables students to get to know one another and appreciate both similarities and differences.” Significantly, Tedesco noted, diversity was also associated with a range of better cognitive and intellectual outcomes. Gurin found, according to Tedesco, that “interactions with peers from diverse racial backgrounds, both in the classroom and informally, is cognitively associated with a host of what are called learn-ing outcomes. Students who experience the most racial and ethnic diversity in classroom settings and in informal interactions with peers show the greatest engagement in active thinking processes, growth in intellectual engagement and motivation and growth in intellectual and academic skills.”

Tedesco noted that parallel data linking the benefits of diversity in graduate health professions training are not available. Nonetheless, she stated, the research by Gurin, Bowen and Bok, and others suggests that the rich learning environments associated with diversity in undergraduate settings probably extend to health professions education settings. In the best case, she noted, students from diverse undergraduate settings enter health professions schools with a growing sense of cultural competence and experience interacting across racial and ethnic boundaries, as peers and as students. These students can be expected to engage in rich and lively discussions, would likely be vigorous contributors to tutoring and mentoring programs, and would add a dimension of intellectual and social complexity to areas in the curriculum that require social analysis and clinical judgment. In addition, students learning in diverse health professions training settings would likely extend the reach of health professions schools into the community for preventive care and youth services. Tedesco added that research should be done to assess the contributions of diversity in health professions training, for “it would be an opportunity lost not to study what our students are bringing to us.”

Finally, Tedesco noted, students trained in diverse health professions education settings are likely to help improve the delivery of health care to minority and medically underserved communities. Observing that mistrust of the medical establishment has been linked to poor patient compliance, lack of participation in clinical trials, and low rates of patient satisfaction, Tedesco argued that diversity experiences can help health care providers and the patients they serve to develop bonds of understanding that will improve trust. Building an infrastructure of trustworthy health care professionals and health care institutions, she stated, has great potential to increase the health and well-being of individuals and the community, thus extending the benefits of diversity. In addition, noting that a lack of cultural competence among providers has become a barrier to care, Tedesco argued that diversity in health professions training settings is a step toward enhancing providers' understanding of cultural dimensions of care and their ability to work with diverse patient populations. Without this cultural skill, she stated, health care providers contribute institutionally and in other ways to patient non-compliance, premature end to treatment, and less than optimal treatment outcomes.

Standardized Testing and Educational Opportunity

Noting that “tests and assessments are the most powerful levers of opportunity to higher status education and employment,” Michael Nettles and Catherine Millett analyzed trends in the performance of African-American and Hispanic students on standardized tests, and discussed the implications of group differences in test performance for the participation of URM students in higher education (Nettles and Millet, this volume). In particular, they explored how test performance has become associated with “educational merit,” and discussed the use of additional criteria to provide a more complete assessment of applicants' intellectual capital. The authors concluded with an analysis of student demographic and school factors associated with higher test performance among URM students.

The central question posed by Nettles and Millet is: “What do we need to do to achieve greater diversity in American society at every level?” Diversity, they argued, is especially needed in the higher levels of a meritocracy. Standardized tests, however, have become a core indicator of merit in this country, serving as the gateway through which opportunity is allocated. The higher a student's score, according to Nettles and Millet, the more access she/he has to high-quality curricula, colleges, and professional schools, which translates into higher status employment and a better quality of life. In order to reverse the underrepresentation of minorities in higher education, the authors stated, their participation in and performance on the principal mediums of meritocracy—test scores and grades—must be improved.

Colleges and universities use a variety of criteria (e.g., test scores, GPA, class rank, essays, parental alumni status) when making decisions about admissions, Nettles and Millet noted, and use a variety of weighting schemes to assign relative importance to these criteria. Test scores, they asserted, represent the biggest challenge for African-American and Hispanic students in admissions to both undergraduate and graduate institutions. Nettles and Millet noted that many schools have begun to de-emphasize test scores—for example, some institutions have amended tests and still others have made them optional. However, test score data generally remain a key component in admissions. African-American, Hispanic, and Native American students generally perform poorly on standardized tests relative to their white and Asian-American peers, according to the authors. Data from the Scholastic Aptitude Test (SAT), for example, reveal that 80% of African Americans and 66% of Hispanics score below 1,000, while whites are fairly evenly distributed across the range of scores, with about 39% scoring below 1,000. The distribution of American College Test (ACT) and the Medical College Admissions Test (MCAT) reveals a similar pattern.

Racial and ethnic gaps in high school and college test scores begin very early in students' careers, Nettles and Millet noted. Data from the National Assessment of Educational Progress (NAEP), which is administered in a variety of subjects, reveal that a large number of minority students are not achieving even basic levels of performance in early grades. By the fourth grade, Nettles and Millet stated, more than 65% of African-American and 60% of Hispanic children are performing below basic levels in math. These data are in contrast to the 22% of white students who perform below basic level on the NAEP. Nettles and Millet pointed out that these gaps do not tend to narrow as students advance, as indicated by the continued gap in SAT, ACT, and MCAT scores.

Several factors correlate with minority student performance on standardized tests, according to Nettles and Millett. Not surprisingly, they noted, the concentration of minority students in schools is inversely associated with students' test performance. For example, data from the NAEP illustrate that, in general, the greater the African-American and Hispanic enrollment of the school, the lower the 4^th grade math scores of students in that school. Interestingly, they noted, NAEP data reveal that some schools with predominantly African-American and Hispanic student populations scored above the white mean, and some predominantly white schools scored at or below the African-American mean. The schools in the survey are anonymous, but Nettles and Millet argued that if more can be learned from these schools, greater insight could be gained into factors related to teacher quality, curriculum, family involvement, and other influences, that may help raise scores for minority children.

Nettles and Millet also examined demographic and student characteristics and their relationship to standardized test scores. For all racial and ethnic groups, parents' socioeconomic status (levels of education and income) and the type and number of courses taken (particularly honors classes) were positively associated with student test performance. Students whose first language was English, who intended to major in a natural science field, and who attended private schools (and/or schools that offer Advanced Placement courses) were also more likely to have higher test scores. For African-American students, attending a high school where the majority of students are white and attending private school were associated with higher test performance. Further, for African-American males, participation in extracurricular athletic activities was associated with higher test scores. For white males, public versus private school and involvement in athletics did not predict test scores.

Nettles and Millett concluded that the strongest criteria available to potentially supplant or complement standardized test data are related to school curricula. “Students who experience the most rigorous curricula in school,” they noted, “and earn relatively high grades are the most promising prospects for success in college, graduate and professional school.” Public and private initiatives that enhance the academic preparation of minority students and expose them to an enriched curricula, they argued, should help to improve the performance of minority students on standardized tests, and subsequently, improve their educational options.

Strategies to Enhance Diversity in Health Professions: An International Perspective

New perspectives to address the underrepresentation of racial and ethnic minorities among health professionals in the United States can be gained by understanding how other nations deal with similar diversity questions, according to Alan Herman, M.D., Ph.D., Dean of the National School of Public Health at the Medical University of Southern Africa (MEDUNSA), who delivered an afternoon keynote address. Herman has a bicontinental perspective regarding diversity and education. He was born and educated in South Africa, and came to the United States in the 1980s, where he worked and taught at the National Institutes of Health. He was recruited back to South Africa in the mid-1990s to start the first American-style school of public health at MEDUNSA.

South Africa is a country of contrasts that is still in the grips of its own racism, stated Herman. Education, he noted, especially health professions education, is still defined and shaped by that racism. When founding the National School of Public Health, Herman stated, two fundamental principles had to be addressed. The first was equity, a term Herman prefers to affirmative action. According to Herman, equity is a fundamental principle that is intrinsic to the principles of liberty. “Equity is not important because it will close the gap between blacks and whites,” he stated. Rather, “It's important because it's important.” The second fundamental principle, according to Herman, is that the probability of success in health professions education for black South Africans is poorly predicted by quantitative metrics, such as standardized tests. “If you take my score from high school in mathematics,” Herman stated, “there was no way you could predict that I would become a methodologist.” He added, “…I did come from a slum and my cognitive ability was in fact clouded by the racism of my society. Until, I think, we move to that understanding, we won't be able to create equity in education nor will we be able to create equity in health care.”

MEDUNSA was created in 1980 by the apartheid regime to educate “second class doctors” to care for “second class people,” Herman stated. Since the end of apartheid, however, enrollment in MEDUNSA's medical school has increased, while enrollment in other medical schools (which are majority white) has decreased. The most recently admitted class at MEDUNSA comprised 300 students, while other medical schools had 120 to 130 students. Through its history, MEDUNSA has trained 70% of South Africa's black physicians, 90% of its black dentists, 100% of the country's black veterinarians, 50% of South Africa's black M.P.H. degree holders, 100% of the nation's black doctorates in public health, and between 40 and 100% of South Africa's black physician specialists, said Herman.

In admissions decisions, preference is given to disadvantaged students. “We will go to the poorest schools to find the smartest kids to bring them into medicine,” Herman stated. MEDUNSA's success in retaining and graduating these students, he noted, can be attributed to the faculty and administration's understanding of the needs of disadvantaged students. Remedial courses and mentoring are offered to help address gaps in students' prior academic preparation, and students are not removed from the university if they have difficulty successfully completing coursework. As an example, Herman noted that 15% of MEDUNSA's students fail in the first year. These students are placed into a supplementary program, however, and are able to repeat the first year. Most of these students are able to return and complete school. While this practice has been criticized, it has paid off, Herman argued, in that many of the students who take the longest time to complete their education practice in some of the most remote areas of the country.

MEDUNSA offers a formal academic mentoring program that is managed by senior students and faculty. Although the mentoring program is focused on students who do not complete the first year, informal mentoring is offered to all new students. MEDUNSA has also developed initiatives to assist secondary schools, such as academic outreach programs and a science mentoring program for high school students in physics, chemistry, biology, and math, that is organized and managed by the MEDUNSA student government. Outreach efforts, Herman stated, are enhanced by the creation of a “science bus” that tours the countryside with two science faculty members, teaching from school to school. MEDUNSA also helps to upgrade the skills of high school science and math teachers with refresher courses and university “open days.”

The end result of these outreach efforts, Herman stated, is that MEDUNSA has been able to make strides toward addressing South Africa's need for a diverse health care workforce. While many students of color choose to attend majority white schools because they have more resources, he stated, MEDUNSA has the advantage of being committed to helping students stay enrolled.

“Working the Demand Side of the Problem”: Algebra and Opportunity

Robert Moses expanded on the theme of improving educational opportunities for racial and ethnic minority children as he discussed the importance of math and science literacy in an increasingly globalized, high-tech economy. Moses, a mathematician, founded the Algebra Project 20 years ago to help minority children gain access to better-quality mathematics curricula than that typically provided in poor, predominantly minority school districts. After becoming frustrated because his daughter's school did not offer algebra, Moses was invited by her teacher to provide instruction for several advanced students. According to Moses, children must master algebra, as it is the gateway to college-preparatory curriculum and subsequently to higher education and increased opportunity in life. In the process of participating in the project, Moses stated, children gain a better appreciation of why math and science training is essential to help them become full participants in an expanding economy. The project also helps children recognize that this training can help them shape the technological advancements that will ultimately affect their lives. In this way, he argues, students and communities that have been traditionally left out of the economic and political mainstream gain a significant voice. “This is working the demand side of the problem,” he noted.

Moses began his career as a math teacher and was drawn to the south in 1960 to become a full-time worker in the struggle for civil rights. In Mississippi, he helped to organize the poor rural population, register thousands of voters, and train organizers in freedom schools. Moses drew analogies between the Civil Rights movement's goal to bring disenfranchised groups into the political mainstream, and the Algebra Project's effort to bring disadvantaged children into the economic and intellectual mainstream. Previously, he noted, industrial technology and physical labor was the driving economic engine of the country. Today, however, computer-based technology and intellectual labor drive the economy, and minority children must be prepared to participate.

“The new technology has brought with it a new requirement for literacy for citizenship,” Moses stated. “For example, in earlier days if people couldn't read or write they were the designated serfs of our industrial technology.” He contended that in the current era, people need a fundamental math literacy in addition to reading and writing skills. “Without that,” he says, “we are growing designated serfs.”

Unfortunately, Moses stated, today's schools still teach children—especially minority children—based on artifacts of the older technology, in effect dooming them to poorer career opportunities and second-class citizenship. He noted that the average student is graduating with the equivalent of an 8^th-grade education, making it difficult to obtain a job that will lead to a dignified life in this country. “The national discussion that we're having is misplaced,” Moses said. “We're having a national discussion about education as a selection process—who is going to go where.” As an example, he stated that the tendency is to not “fix” schools, but move students around, through voucher programs, busing, and charter schools. “What we need,” he challenged, “is a national discussion about education as an opportunity structure. It's the difference between discussing the ceiling and the floor. We need a discussion about the floor. What's the floor out here for everyone to stand on, so that if we provide this floor and they get on it then they have a real opportunity to be citizens.”

Lost Opportunities: The Journey to Higher Education for URM Students

Noting large disparities in educational outcomes between underrepresented minority (URM) and non-URM students, Patricia Gandara discussed points along the education pipeline where opportunities to improve minority achievement are lost (Gandara, this volume). Gandara pointed to large discrepancies in higher education achievement, such as the fact that white students are twice as likely as black students to earn a college degree, and that Asian students are more than five times as likely as Hispanics to earn a college degree. As the U.S. population is expected to become increasingly diverse, she noted, disparities in educational attainment are also expected to increase between underrepresented minorities and white and Asian-American students.

Gaps in educational opportunity can be noted as early as the preschool level, according to Gandara. African-American and Hispanic children are more likely than white children to have multiple risk factors for school failure (i.e., living in poverty or in single-parent households, having a mother with less than 12 years of education, speaking a primary language other than English, and/or having a mother who is unmarried at the time of her child's birth). Further, Gandara noted that high-quality preschool programs, which have demonstrated positive effects on children's cognitive functioning, health status, and socioemotional development, are less available for those who cannot afford to pay. Some evidence suggests that the beneficial effects of preschool programming for at-risk students diminish when the program ends. However, other studies indicate that if intervention programs are applied early and intensively over a long period of time, intellectual gains for at-risk children may be sustained, she said.

Kindergarten and elementary schooling presents another opportunity to intervene to raise the achievement of URM students, according to Gandara, because data indicate that achievement gaps between URM and non-URM students begin to widen at this stage. African-American, Hispanic, and Native American children are more than twice as likely as Asian and white children to be in the lowest quartile in reading and math skills during their kindergarten year. By elementary school, for example, 39% of white students score at or above proficiency in reading, while only 10% of African-American and 13% of Hispanic children do so, according to 1998 NAEP data. Gandara noted that it is during this stage that a process of “disengagement” begins, in which low-income and minority students who are initially high performers experience a decline in grades one through six.

Middle school, Gandara noted, presents another stage at which URM students face educational risks, as this is a stage when curriculum tracking begins. Children who are held back in basic math courses, she stated, will have difficulty catching up and may not be able to complete college preparatory courses in high school. Compared to their representation in the K–12 population, African-American, Native American and Hispanic children are underrepresented in programs for “gifted and talented” students, according to Gandara. These programs are important because they predict placement in high-level math courses in middle school, and subsequently, high school. In addition, she stated, white and Asian-American students are much more likely to be assigned to algebra in grade 8 than African-American and Hispanic students. Not all of these differences can be explained by test scores, she noted, particularly for Hispanic students. Further, URM middle school students, independently of their families' socioeconomic status, are more likely to be taught by teachers with lower test scores and less academic preparation than white children. There is some evidence, Gandara noted, that higher-quality teachers (as assessed by test scores, the quality of the institution where teachers obtained their degree, and certification) are associated with higher student performance.

By high school, according to Gandara, URM students who face academic difficulty are often permanently lost to the educational pipeline. Dropout rates are higher for URM students. Persistence in high school, she noted, is related to social and academic integration. Students who are more active and involved in their schools and communities are at lower risk for dropping out. High residential mobility, a system that is indifferent to the needs of URM students, outside peer influences, and leaving school for employment all influence the likelihood that minority students will leave school prematurely, she said. Those students who do stay, according to Gandara, have varied academic experiences. URM students have lower GPAs and SATs scores than white and Asian-American students, even when controlling for family income.

Students' chances of achieving in high school are often limited by the quality of the school they attend. For minority students, these schools are likely to be less rigorous than schools in white and upper-income communities, according to Gandara. In low-income schools, for example, only 52% of classes meet college prep requirements, as opposed to 63% of classes in higher-income schools. Further, she noted, minority students are often locked in schools that are inferior and highly segregated by race. In 1997, for example, over one-third of Hispanic students attended schools that were 90%–100% minority. Even within nominally desegregated schools, she noted, minority students are more likely to be segregated in vocational and general education tracks. Furthermore, high school students with limited English proficiency are more likely to have teachers with inadequate training, to be in classrooms that do not take their language into account, and to be provided with poor-quality curriculum, according to Gandara. These students perform less well on achievement tests, even when compared with students from similar socioeconomic backgrounds.

Given the multiple barriers that URM students face in K–12 education, Gandara noted, it is not surprising that a lower percentage of URM students participate in higher education relative to white students. URM students are poorly represented in four-year colleges. Despite making up nearly one-quarter of the U.S. population, URM students attained only 14% of bachelor's degrees conferred in 1997, according to Gandara. Further, URM students are less likely to be enrolled in biological/life sciences or health professions, further diminishing the supply of potential health professionals.

Gandara concluded by noting that these disparities in educational attainment are projected to increase, particularly between Hispanics and all other groups. By one projection, she noted, Mexican-American adults in the United States, who were three times more likely than white adults to have fewer than 12 years of education in 1990, will be four times more likely to have this low level of education by 2015. By any measure, she argued—whether one assesses the public benefits of a well-educated workforce or the costs to the nation of unemployment, social welfare, and increased taxes—education is cost-effective.

The Impact of Reversing Affirmative Action

Improving Access to Quality Education and Health Careers for Minority Students

Improving URM Student Achievement in Primary and Secondary Schools

Two small discussion groups reacted to presentations focused on improving the achievement of URM students in K–12 education. Rapporteurs for these groups stated that health professions must “de-isolate” themselves from communities, particularly minority communities that may serve as the source of future health professionals. Health professions organizations should advocate to improve the quality of teaching, one stated, by urging additional funding to help better prepare teachers, particularly in math and science. This rapporteur also noted that health professions should seek roles in assisting school reform, such as converting large urban schools into smaller segments (e.g., “schools within schools”) to develop more supportive relationships with students. Support for teaching should also include advocacy to ensure that all students have access to high-quality curriculum. Health professions should take a lead role, another rapporteur noted, in assisting teachers and providing them with effective resources, such as tools to improve students' analytical reasoning and literacy skills. These interventions should not be focused solely at one or a handful of schools, the rapporteur stated, but rather toward coalitions or regional alliances of schools.

Another discussion group considered the impact of high-stakes standardized testing on URM student achievement in K–12 settings. The rapporteur for this group urged that the health professions education and policy communities should carefully consider the messages that are conveyed in their use of test data, such as MCAT scores. The community should consider what these tests measure and how they are used in admissions processes, as educational leaders will be influenced by how health professions view and use such tests. Health professions should also highlight important issues in high-stakes testing, such as differences in teaching, curricula, and educational resources across schools that can have an impact on student performance.

Recruiting, Admitting, and Retaining URM Students in Health Professions Education

Three discussion groups explored strategies to recruit, admit, and retain URM students in health professions education programs. Sustaining URM students in undergraduate pre-medical and pre-health career tracks, one rapporteur noted, can be accomplished with a variety of academic, peer, and economic supports. Health professions organizations should invest in education and professional development for health careers advisors, and reward faculty for serving as advisors and mentors for pre-health career URM students. This can be accomplished by providing financial and logistical support to faculty advisors, considering such work in tenure decisions, and developing networks for advisors to share strategies and provide junior advising staff with resources and supports, the rapporteur stated. Additional financial supports should be provided to prehealth students so that they can be less reliant on outside jobs; in addition, economic barriers to applying to health professions schools (e.g., costs of MCAT and other tests, application fees, travel) should be addressed. Finally, health professions should tap pools of URM students who are “nontraditional” or mature students. These students may require remediation, child care, and/or economic support, and could benefit from post-baccalaureate programs or other initiatives that consider their special circumstances.

New admissions strategies can be successfully developed that address the need for racial and ethnic diversity in health professions training settings while acknowledging the shifting policy contexts regarding affirmative action, another rapporteur noted. Drawing on Maldonado's example of new admissions strategies and criteria used at the Texas A&M College of Medicine, the rapporteur urged that all health professions schools adopt admissions criteria that give greater consideration to applicants' non-cognitive attributes, such as life experiences and commitment to serving poor and minority communities. Changing admissions criteria, however, will require integration of these changes into institutions' mission and goals. Faculty, administrators, and staff must “buy in” to new admissions processes and the consequences of such changes, such as the fact that new students may be admitted who flourish under different learning conditions and different teaching styles. Finally, the rapporteur noted that because admissions efforts are limited by the quality of the pool of applicants, greater outreach efforts are needed to “beat the drums a little more loudly to get people to start thinking about health professions careers” earlier than college.

Similarly, retaining URM students in health professions training settings will require a re-examination of the institution's goals and priorities, according to another rapporteur. Institutions must conduct honest assessments to determine how the climate of the institution affects progress and learning for both URM and non-URM students. Research is also needed to better understand the reasons why students withdraw from health professions schools. Some research has focused on the difficulties that medical students face in the first year, for example, but little is known about the third and fourth year, when evaluation is more subjective. The rapporteur suggested that greater support be provided for mentoring, particularly where URM faculty currently offers informal mentoring. These roles could be more formalized and institutional support provided so that minority faculty are not disproportionately burdened. Finally, the rapporteur urged that health professions educators revisit the way that students are trained. The style of teaching and grading typically used in these settings may disproportionately affect URM students, as Rainey noted above, and should be re-evaluated to improve learning for all students.

A closing panel discussion on the first day of the symposium featured reactions and commentary from several leaders in health, public health, and education. One of the panel members, Vanessa Northington Gamble, Vice President of the Division of Community and Minority Programs at AAMC, noted that efforts to enhance diversity in health professions must be expanded to address educational inequities beginning at primary school levels. These effects will be enhanced by building coalitions and educating the public about the importance of diversity in all levels of education and in the health professions. “We have to really raise the expectations of our children, and also raise expectations of other people for children and of our communities,” she stated, noting, “This is not a minority issue—this is an American issue.”