It was an honor to sit down (via Zoom) recently with Dr. Louis Sullivan, former U.S. Secretary for Health and Human Services, founding dean of the Morehouse School of Medicine, and too many more distinctions to list. Dr. Sullivan and I met to discuss a shared priority: eliminating discrimination and advancing diversity and inclusion in the American health care system. Regular readers of this blog are well aware of my commitment and that of the Macy Foundation to this issue, but racism in the health professions is a reality that Dr. Sullivan, as the only Black student in Boston University Medical School’s class of 1958, has lived. His experiences have informed his career-long commitment to increasing diversity in medicine and the health professions.
Following his service as cabinet secretary, Dr. Sullivan headed the Sullivan Commission on Diversity in the Healthcare Workforce, which in 2004 released its landmark report, Missing Persons: Minorities in the Health Professions. The report issued 37 recommendations aimed at increasing representation of people from historically marginalized populations in health care. In fact, I asked to meet with Dr. Sullivan because a participant in the Macy Foundation’s ongoing “Taking Action” webinar series asked about the similarities between the Sullivan report recommendations and those published following the 2020 Macy Foundation conference on Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments. Today, Dr. Sullivan heads the Sullivan Alliance, a nonprofit focused on advancing diversity in the health professions, which in 2020 became a program of the Association of Academic Health Centers.
Below are some of the questions posed to Dr. Sullivan and me by a Macy Foundation colleague, who then edited our replies for clarity and length.
Questions and Answers with Dr. Sullivan and Dr. Humphrey
Question (Q): A variety of efforts have been made throughout the 20th and 21st centuries to increase diversity in the health professions, and while some progress has been made, we are still striving toward greater diversity today. How would you characterize the efforts that have gotten us to where we are today? Have we made progress? Have we failed?
Dr. Louis Sullivan (LS): Yes, we have made progress, but what is considered progress and how much we have made depends on your perspective. I look it at it through the lens of my own life experiences and the tremendous changes I have witnessed. In the 1950s, I was one of only three Black students at Boston University School of Medicine. Around the same time came the Brown vs. Board of Education Supreme Court case, which raised awareness about the need for equality in education and launched the integration of schools. Then, the Civil Rights era in the 1960s brought more awareness and medical schools began to admit more students of color. In the 1950s, minorities were about two percent of medical students, and by the 1970s, we were around four percent. Today, around seven or eight percent of medical students are Black, compared to 13 percent of the general population. So, progress has been made, but it hasn’t been what it should be or what it needs to be. Today, even though I can say I’ve seen tremendous progress, I can also say that we are doing far worse than anyone had hoped.
Dr. Holly Humphrey (HH): When thinking about progress in medical schools during the 20th century, many people go back to 1910 and the Flexner Report on the quality of the nation’s medical schools. That report put most minority medical schools in America out of business and certainly decreased the representation of people of color in medicine. But, Lou, in another measure of progress in your lifetime, you helped launch one of the first two new medical schools to open on a historically black college or university (HBCU) campus decades after Flexner caused many to close.
LS: As a country, we’ve always had a problem with diversity in health care; there has never been equity in terms of access to health care or access to health careers. Black people were first brought here as slaves. We weren’t admitted to medical schools until the mid-1800s. By the time Flexner issued his report in 1910, he found many substandard medical schools that functioned primarily as trade schools or degree mills. He recommended closing them down, including five of the seven HBCU medical schools that existed at that time. The Flexner report is credited with improving the quality of the surviving schools, but when those five historically Black schools closed down, so did many of the opportunities for Black men and women to become physicians.
Howard University Medical School and Meharry Medical College are the oldest HBCU medical schools and they were the two that survived Flexner—and they remained the only two until the Civil Rights era, when Morehouse came along in Atlanta and Charles Drew in Los Angeles. I was founding dean, in 1975, of the medical program at Morehouse College, which we grew into a fully accredited, four-year medical school. Morehouse School of Medicine came about because White and Black doctors and other leaders in Georgia saw the need for it, because the health of Black Georgians was so poor compared to that of Whites in the state.
HH: Yes, and that need for more health care access for Black residents of Georgia speaks to an important reason why we must continue to increase diversity in health care—because we see improved outcomes for diverse patients when they have access to diverse providers. Since the founding of Morehouse and Drew—beginning in the 1980s and ‘90s, and really accelerating in the 2000s—medical schools across the country began experimenting with and adopting more holistic admissions processes designed to admit a more diverse group of students. Holistic admissions look at students more broadly, assessing their life experiences and trying not to unfairly penalize them for lower grades and test scores; they recognize that successful students are more than a set of numbers. Today, the Association of American Medical Colleges offers resources to admissions directors and committees on how to conduct a holistic admissions process.
LS: Yes, holistic admissions has certainly helped with diversity because being an effective and successful health professional depends on having a strong science base, but much more than that, it requires being able to communicate well with the person you’re serving. Your patients need to understand you, trust you, follow your instructions, accept your advice. Achieving good outcomes with your patients depends on good science and on your interpersonal skills and your cultural competence.
Q: The Sullivan Commission’s 2004 Missing Persons: Minorities in the Health Professions report and the Macy Foundation’s recommendations from its 2020 conference on Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments looked at the issue of increasing diversity, equity, and inclusion in the health professions and issued recommendations for advancing the issue. Please talk a little about what you view as the essential lessons from those efforts.
LS: The Sullivan Commission said that medical and other health professions schools need to undergo a culture change, from having competitive learning environments to having collaborative learning environments. We felt—and I still feel—that the way to graduate the best-prepared and most diverse health care workforce is to educate learners in environments where students and faculty support each other, learn from each other, look out for each other. We also said that health care institutions need strong leaders who demonstrate their commitment to diversity and inclusion—the change has to come from the top.
And we called for students to have access to adequate financial resources because health professions education is very expensive and can lock out talented students who simply can’t afford to pursue it. Making health professions schools more affordable requires all of us to shift our perspective because financial support for students is looked upon as benefitting individual students, but what it really does is benefit society. It helps us prepare and graduate the kinds of health professional personnel we need to function effectively as a society. We need to view it as a societal return on investment because that is the true benefit.
HH: I agree with everything Lou said, and the Macy recommendations certainly align with those of the Sullivan Commission. The primary difference between the two is that, at our conference, there was a very strong call for the entire medical community—the entire health professions community—to go back to the historical underpinnings of our society and examine how slavery shaped our world, including missteps made by medicine and the other health professions. Those missteps allowed structural racism to thrive in health care and those same missteps are still being made today. Our health professions students need to be taught the racist history of health care in order to truly understand how it shaped the system we have today. But, we’ve only recently begun to acknowledge this need.
Another difference was that language was a big part of our conference; so much so that the conferees suggested we include a glossary in our report. They felt it was important to define the words we used to describe the issues we were speaking about. There was a real sense that we must call out structural racism and anti-Black racism and acknowledge that our curriculums may be racist and that students, faculty, and patients encounter racism in our institutions. When I read the Sullivan Commission report, there is a certain gentlemanly politeness in the language that is still used today, but our conferees rejected.
LS: Yes, that is a key issue that you’ve touched on, Holly. The reason the language in the Sullivan report is less confrontational is that we didn’t want to drive people away. That was considered to be the best approach; to frame difficult topics in ways that were thought to bring people into the conversation, being careful not to push them away so as to include everyone in the discussion of the problem and the solutions. It was very different from now. Now, both Black and White people feel that the healthiest approach is to put the issues out there very plainly and to move forward from there.
Q: Both reports mention the urgency and immediacy of the issue—how urgent is it to increase diversity in health care? Is it realistic to expect measurable progress? Why or why not?
LS: It is urgent in that it needs immediate attention and action, but it is also a long-term issue. We, as Americans, like quick fixes, but this is about expanding the lives of young people long before they come to health professions schools. Increasing diversity in the health professions depends on students’ experiences in grades K-12. It depends on their family opportunities. It depends on having supportive environments. There’s so much that needs to happen more consistently for students of color.
As a metaphor: back in 1964, the U.S. Surgeon General said that smoking causes lung cancer and heart disease. His report said that not one single good thing comes from smoking, it is all bad. When that report came out almost half of Americans smoked. Since then, there has been a lot of public health education. When I was Secretary of Health and Human Services, 27 percent of Americans smoked, and now it’s down to 15 percent. So, even though it is very obvious that smoking is terrible for our health and people know they need to quit immediately, actually changing overall behavior takes a long time. Increasing diversity in our health professions also takes a long time. We can and should take immediate steps, but we also have to be committed to change over the long term.
HH: You make a great point, Lou. The structural determinants of health in this country have disadvantaged people of color. Education presents a structural barrier for minorities, and it is a tough one to change because public education is tied up in local budget issues. Are there other structural barriers that are easier to remedy or are more amenable to change?
LS: Some are, but they all tend to be difficult because it’s really about poverty and a lack of high-quality education. It is important to remedy barriers that can be fixed—such as housing located near sources of pollution, for example—but in poor and minority communities, the fact is that you have more people living in tighter spaces because of poverty. Poverty is part of the reason why Covid-19 has disproportionately impacted communities of color; they have fewer job opportunities that allow them to sequester themselves. There is also distrust of health system among minorities and poor people. The Tuskegee syphilis study is fresh in many minds, but also during the Trump administration, there was a president that didn’t understand or respect science or follow the guidance of his own public health professionals. That causes confusion and does not help build trust in the health system. Health is really influenced by so many factors that one wouldn’t automatically connect to health.
HH: I have another question for you, Lou. I imagine this was an issue in 1950s, 60s, and 70s, but seems more so today, and that’s whether or not academic medicine and the power structure that controls it are discriminatory? I wonder if it is possible to thrive as person of color in academic medicine today because the whole environment is discriminatory?
LS: I think academic medicine is a reflection of our larger society. There is overt discrimination, yes, but there is even more unconscious bias that is harmful. There are some people who are genuinely working toward more diversity among students and faculty, but we need more of those people by a significant factor. I had mentors and faculty who worked very hard to be supportive of me. In 1958, I was the first Black internal medicine resident at New York Hospital/Cornell Medical Center. The head of the hospital, Dr. Hugh Luckey, asked to see me when I first arrived there. He said, “Lou, I intend for you to have a good experience here. Here is my private phone number, I want you to call me if you have any problems.” In the two years I was there, only one patient refused to have me see them and they were discharged within 10 minutes of me contacting Dr. Luckey.
So, there are people who genuinely want to change things. We need more of them.
Q: If the real change needs to come from the top, what can faculty, administrators, staff, and students in health professions schools and clinical learning environments do to begin reducing harmful bias and discrimination in their daily interactions with each other and with patients?
LS: Leadership must set the tone and be responsible for drawing out the best qualities in their people, but everyone else needs to amplify those leaders’ efforts. We need students who are cooperative and collaborative and willing to look inward to assess their own biases. We need to encourage self-discovery and personal development. We need to help people recognize their biases and be more welcoming of diversity.
HH: Yes, leaders must set the tone and model the commitment and behaviors that guide everyone else. I think Lou’s story about Dr. Luckey says it all: “I intend for you to be successful here and here’s my home number if you need anything.” That is a beautiful example of how tone gets established.
Q: Looking ahead, do you think we’re going to reach a tipping point any time soon with respect to achieving diversity, equity, and inclusion in health care? If not soon, when? Are we on the right track? What gives you hope for the future? What gives you pause?
LS: I am a cautious optimist. As a society, we have put a lot of effort into increasing diversity, but results haven’t been what we hoped, what we need. The opportunities are there, however. Today’s young people are committed to this issue. Covid-19 has laid bare the problems for everyone to see. I believe there will be some short-term gains, but we need to keep the pressure on. More effort is needed. Maybe, in five or 10 years, we’ll hit a tipping point, but that really depends on what we do right now to support our young people of color. We need to expose them early and often to health careers; teach them about the health care needs of society; and show them that they can acquire the skills, knowledge, and abilities to improve peoples’ lives. They need role models and mentors. We need to continue finding ways for anyone in our society who wants to pursue health professions education. We need to reduce financial barriers. We need to work until the hills are lower and the path is smoother.
HH: I share the same cautious optimism. I don’t think we’re near a tipping point; we have a very long way to go, and it will take at least a generation. We have to be willing to make the necessary investments in an entire generation and stick with it. My optimism comes from young people who are very activated and motivated around this issue. Equity is a priority for them. I know many medical students from marginalized communities who hold tremendous promise, but they need nurturing, they need the home phone numbers of their department chairs, just like Lou had.
I am also inspired by the many leaders of color who are in the junior ranks of the health professions right now. We need to develop them and appoint them to important leadership roles in our institutions; we need to grow them into deans. We see the Biden administration modeling that commitment to diversity right now in terms of who is being tapped to serve in key leadership positions.