DIVERSITY IN MEDICAL EDUCATION AND HEALTH CARE ACCESS: AFTER THE '80s, WHAT? Vivian W. Pinn-Wiggins, MD President, The National Medical Association Washington, DC It is truly an honor for me to have been invited to address such a distinguished group as you, during the program of the Minority Affairs Section at the 100th Annual Meeting of the Association of American Medical Colleges (AAMC). The theme which the association has chosen for its Centennial meeting, "Physician Education: Our Heritage and Future," is a very timely one and is especially applicable as we contemplate the issues of health access, health delivery, and health care professionals, now and in the future. As President of the National Medical Association (NMA), I am pleased to be able to share some thoughts in keeping with this theme, as seen from the perspective of the NMA and from my personal viewpoint. The National Medical Association is also approaching its Centennial celebration year in 1995. The NMA is the oldest black organization in the United States, having been founded in 1895 in Atlanta during the Cotton States Exposition. It was organized in the First Congregational Church because there was nowhere else for the meeting to be held. About 12 "Negro" physicians were present from Tennessee, North Carolina, Virginia, Georgia, and "one or two other states." The first name given was the "National Association of Colored Physicians, Dentists, and Pharmacists." At the second meeting which was held at Meharry Medical College in 1903, the name "The National Medical Association" was adopted, and thus truly began the organization which I have the privilege this year of serving as President and spokesperson. At present, the NMA represents over 16 000 physicians, most of whom are African-American or black. However, we both have and welcome as active particiKeynote address to the Association of American Medical Colleges, GSA-Minority Affairs Section, Minority Affairs Program, The Washington Hilton Hotel, Washington, DC, October 31,1989. Requests for reprints should be addressed to Dr Vivian W. Pinn-Wiggins, Professor and Chairman, Department of Pathology, Howard University College of Medicine, 520 W. Street, NW, Washington, DC, 20059. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 2
pants any health care professional who is interested in promoting the science of medicine and better health care for all Americans. We have members in all 50 states, the Virgin Islands, and Puerto Rico. The NMA is in a unique position, along with other minority health organizations, to actively voice opinions on issues of specific concern for minorities and to make suggestions-both proactive and reactive-for legislation which will affect our future. The NMA is in a unique position to take the lead in the continuing quest to preserve the right of minorities to enter health care fields, assuring that minority students have the guidance and assistance they need to become health care providers. One of our major priorities is to assure that the medically underserved populations of this country, which are predominantly minority or disadvantaged populations, have access to caring, concemed physicians or other providers who also appreciate their patients' ethnic and cultural heritage, who also appreciate the inherent barriers of the underserved home and community environments, and who also appreciate the effects of the years of struggle for achievement upon our pride, our bodies, and our spirits. We recognize the need for improving the self-esteem of those whom we would serve, if we are truly to have a healing influence upon those who are in need of our services. It is most encouraging that the Executive Council of the AAMC in 1987 reaffirmed its commitment to increasing opportunities for underrepresented minorities who wish to pursue careers in medical service, teaching, and research, and the activities which we have seen under the leadership of Dr Robert G. Petersdorf, President of the AAMC, have demonstrated that this is not just an idle statement. We all have benefited from the assistance of Dario Prieto, Director of the Section for Minority Affairs of the AAMC, who along with his staff has provided support, infonnation, and guidance to so many of us over the years. In recognition of Mr Prieto's role in minority 89
DIVERSITY IN MEDICAL EDUCATION
access to medical schools, the National Medical Association awarded him a Scroll of Merit. Now, the AAMC has expanded its scope to also establish a Division of Minority Health, Disease Prevention and Health Promotion, under the leadership of Dr Herbert W. Nickens, which should provide new dimensions to the AAMC's involvement in minority health issues. The NMA, the Minority Affairs Section of the AAMC, the National Association of Medical Minority Educators, and other minority medical organizations should and must work toward a unified and successful initiative in the 1990s, to assure that our commitment brings about measurable benefits; not just benefits in minority student recruitment, retention, and graduation, but benefits in minority access to all areas of health care, as well as improvement of the status of health and well-being for minorities and all other Americans. Our heritage and past experience in medical education is well known by most of you, but bear with me as I review just a bit for those who may not be as familiar with our history. Although I do not have ready access to the history of the beginnings of other underrepresented minority groups in American medicine, Dr W. Montague Cobb, Professor Emeritus of Anatomy at Howard University College of Medicine, Past President of the NMA, and Editor Emeritus of the Journal of the National Medical Association has provided through his many published articles an excellent appreciation of the early days of blacks in medicine.' We know that James McCune Smith of New York was the first black American physician, receiving his medical degree in 1837-but receiving it in Glasgow, Scotland, not in the United States. David John Peck was the first black to receive a medical degree in the United States, graduating from Rush Medical College in Chicago in 1847; however, it is reputed that he went to Nicaragua to practice medicine. Black women were known to have been "doctoring" during the days of slavery, but in 1864 Rebecca Lee became the first black woman to be formally trained as a physician in the United States, receiving her degree from New England Female Medical College.2 She is said to have established a successful practice in Richmond, Virginia after the Civil War. The second was Rebecca Cole, who graduated from Women's Medical College2 of Pennsylvania in 1867. Howard admitted its first black woman in 1872; Meharry soon after. It is of historical interest that black women were the first women to practice medicine in four southern states, Alabama, Mississippi, South Carolina, and Virginia. In the post-reconstruction era, eight "Negro" medical schools were established to train black physicians, including Howard, founded in 1868, and Meharry, 90
founded in 1876; Howard and Mehany were the only two of these eight institutions to survive. As recently as 1968, there were only 292 first year minority medical students in this country, with blacks representing 2.7% of all first year medical students. In 1969, 75% of all black medical students were enrolled at Howard and Meharry. The 1970 AAMC Task Force on Minority Student Opportunities in Medical Education provided an impetus during the 1970s for an increase in minority students and physicians, and we witnessed more minority students being enrolled at many of our nation's medical schools, such that, by 1979, only 20% of all black students were enrolled at Howard and Meharry. But as we know, the enthusiastically set goals for parity were never reached, and since 1975, when minorities represented 8.1% of the total medical student enrollment, there has been no significant change. In fact, AAMC data show that during this past year, 1988-1989, 5 of our 127 medical schools had no minority students in their entering classes. And, The New Physician's Annual Minority Admissions Scorecard published in April 1989 demonstrated that 61 schools had a smaller percentage of minority students during this past year than they had in 1983-1984.3 Such is our heritage, and such is our present status. Where do we place our priorities for the coming decade? How do we decide our priorities? What are the major issues which confront us? I believe that we can all accept the basic premise that we do not desire to increase minorities in medicine simply to increase the numbers or just to reach parity with the representation of minorities in the population of the United States. I believe that our desire for increasing the numbers of minority physicians, through an increase in opportunities for minorities to enter and graduate from medical schools and become licensed, practicing physicians, stems from our desire to improve the health status of the medically underserved, most of whom are minorities. There are an estimated 37 million Americans who lack health insurance; of these, 75% are members of working families-not the unemployed or "street people." There are about 15 million women of childbearing age and 11 million children who are uninsured. There is much discussion on the federal, state, and local levels about the need for comprehensive health care, while emphasis is also being placed on cost containment and decreasing or modifying physician reimbursement. As long as we recognize, as the Malone-Heckler Task Force Report of 19854 documented, that there is a striking disparity in the status of health of minorities and that there are excess minority deaths each year, probably greater than 60 000, because JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 2
DIVERSITY IN MEDICAL EDUCATION
of disparate minority health status and lack of access to appropriate health care, then we must affirm that we still have much to accomplish in health provider and care services. As a pathologist, and as one who firmly believes that minorities are needed to participate in all specialties, in academic medicine, and in academic research, I still advocate the promotion of medical specialty and academic careers for minorities. However, even for those who choose such careers, there must be a continuing awareness of the particular minority problems which specialty preparation can assist in alleviating. As we think about the disparity in minority health and the types of diseases which contribute to this disparity, we must recognize that behavior modification can alleviate many of the health problems of the minority community, such as smoking, violence, poor nutrition, unhealthy sexual practices, stress, etc.; poor minority health can also be alleviated by early detection of diseases which can be prevented, treated, or cured. We recognize the escalating costs of medical care, especially when too many tests may be performed because of a fear of malpractice litigation. Other causes of escalating costs involve new interventional procedures which are expensive but which may benefit the patient in disease detection and the need for long-term care or treatment of chronic diseases. We also recognize that many complex, fatal, and costly illnesses in minorities and the disadvantaged might have been prevented by early access to a concerned health care system. Think, for example, of the benefits of screening for early detection and prevention, utilizing such programs as mammography for detecting breast cancer in the young as well as the elderly (mortality rates in blacks have been increasing in this area), PAP smears to detect cervical cancers early, testing for tuberculosis which has begun to rise in incidence in the inner cities, rectal examinations-both digital and for occult bloodfor early detection of colorectal cancer, and a simple checking of blood pressure to prevent severe cardiovascular diseases, strokes, myocardial infarctions, and end-stage renal disease. Think of the benefits of nutritional education through health prevention programs. It seems so logical to me that it is difficult for me to understand why there is not wide acceptance of the need for appropriate funding of preventive health services, with disease prevention and education; this is a relatively inexpensive type of health care compared with long-term care of the chronically ill, and more extensive medical and surgical therapy for those who have diseases which have progressed to advanced stages and for whom early intervention would have prevented a protracted yet fatal JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 2
outcome. Too many health plans, insurances, and government health coverage plans do not include the costs of such preventive measures; of course, our potential prevention patients would not have had access to these health care providers in the first place. Why must so many of our neighbors and friends not be able to obtain medical care until they are sick, really sick? Why should an American citizen, because he or she is poor, fear obtaining a physician's examination due to the cost or because there is not access to a primary health provider? Once detected, why should diseases progress because there is no money and no provision for obtaining the medications or therapies prescribed? Obviously, there are problems with our health care delivery system which are affecting the plight of our disadvantaged and minorities. Obviously, merely producing more caring, minority physicians will not solve the problem; however, more caring, concemed physicians who are involved in primary health specialties and providing longitudinal family care can make a difference in the health status of our people. As long as there are front page news reports that the life expectancy of blacks has declined over 2 to 3 successive years, then word that there is a surplus of physicians has no real meaning, particularly for those whose lives are prematurely ending. There is a recognized physician maldistribution, probably both in specialty choice and geographic location, and lack of access to health and behavioral care for too many which might prevent such a depressing set of statistics. We must address these problems also if we hope to make a difference in health care. We must continue to place emphasis on the need to admit more students to the health care professions, especially to medicine, who not only can demonstrate academic achievement and high MCAT scores, but who also recognize and understand the health problems of today and the future. We must make certain that those whom we, through our admissions committees, allow to enter medicine have a commitment to improving the health status of all Americans. We must make certain that financial assistance programs are in place which will allow those with such commitment to enroll in institutions once accepted and be able to practice in underserved areas without the fear of personal financial disaster or undue family sacrifice. While we hear much rhetoric about equal access to health care, which is indeed a worthy concept, let us also stress equal access to health care provision for those who have chosen medicine as a career exactly for the purpose of providing equal access to health care. In the 90s, we need to turn again to those concepts of looking at the individual applicant as a person, not just a set of GPAs and MCAT scores, as we 91
DIVERSITY IN MEDICAL EDUCATION
did before the impact of the Bakke and DeFunis court decisions; we need to turn to our elementary schools, our middle schools, our colleges, not just to help save those youths whose futures are in jeopardy, but to provide encouraging role models, hope, and opportunities so that the applicant pool will not be depleted in the next decades. There are new and not so new areas of medicine which must be addressed. Among these are the need to look at the effect of drug abuse on our communities, and the diverse effects such an epidemic is having upon our youth and our patients. Infant mortality is already a problem in our country. Just imagine . . . no, don't imagine, know that America ranks 19th among industrialized nations in the number of babies who die before their first birthday. Think of how little prenatal care costs in comparison to the cost of supporting a low birthweight infant. Recognize also that infant mortality is about twice as common in blacks as in whites in this country, as is low birthweight disproportionately found in our babies. Now, add the impact of drugs to this problem. Too many of our minority and black mothers are having babies without any prenatal care, are abandoning these beautiful babies, many of whom are born addicted to drugs or are born HIV positive, yet are abandoned by their mothers who leave in search of a "fix." Too many city hospitals are having to deal with the problem of the "boarder baby," those abandoned infants who learn to walk and talk in the hospital environment, many of whom have never been seen or held by their mothers. Think of the increase in AIDS and sexually transmitted diseases, especially among our young. We need physicians who can truly relate to our youth, our women, our men, and let them know that they are indeed caring physicians, that they can be trusted with discussions of sexual practices and activities, and that they can provide educational information to prevent such diseases or at least therapeutically modify the effects on patients' lives. Such qualities in physicians will not be ascertained by pure quantitative test scores-we should and must return to evaluating our applicants by also looking at the total individual's attributes and that individual's humanistic interests and communicative skills. The NMA has many priorities for this and coming years which are shared by many of you. Not only are we concerned about the need to address the decline in the minority applicant pool, with a special look at the loss of the black male from this pool, but also to pay special attention to developing health care delivery programs and coverage in this country. There are other priorities, such
92
as organ donation from and to minorities, the decline in the black hospitals, networking with other health and community groups, and many more issues which there is not time to discuss. Entry into graduate medical education is a concem which we share, but this topic will be addressed by other programs during the AAMC meeting. Regardless of what the future holds for physicians and the practice of medicine, we must think logically, objectively, and both with and without emotion, about the real needs of our communities. We must think long and hard about the role of the physician in the delivery of health care in the 90s, and let that be our guide in determining who will be entering through our medical school doors. With documentation from the AAMC, as well as other published articles, that many more minority graduates intend to practice in underserved areas, where there are large numbers of medically indigent, underinsured, or uninsured patients, this must mean that we place emphasis on the minority in medical education and medical practice. Frederick Douglass, Father of the Civil Rights Movement, said: If there is no struggle there is no progress. Those who propose to favor freedom and yet depreciate agitation, are men who want crops without plowing up the ground. They want rain without thunder and lightning. They want ocean's majestic waves without the awful roar of its waters.
Let it never be said that the National Medical Association or the Minority Affairs Section of the AAMC or any concerned health educator or professional has not continued the struggle, but that, with optimism, hope, and hard work, we shall have made more progress than those who preceded us in our quests for a better future for health care and the health of all Americans. Resources 1. Cobb, W.M: The black American in medicine. J Nat/ Med Assoc. 1981 ;73(suppl):1 185-1244. 2. Davis, M.W., ed. Contributions of Black Women to America. Vol. 2. South Carolina: Kenday Press, Inc; 1981:357420. 3. The new physician's annual minority admissions scorecard. The New Physician. April 1989:22-23. 4. Report of the Secretary's Task Force on Black and Minority Health. Vol. 1, Executive Summary. Bethesda, MD: Department of Health and Human Services. National Institutes of Health; 1985.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 2
pants any health care professional who is interested in promoting the science of medicine and better health care for all Americans. We have members in all 50 states, the Virgin Islands, and Puerto Rico. The NMA is in a unique position, along with other minority health organizations, to actively voice opinions on issues of specific concern for minorities and to make suggestions-both proactive and reactive-for legislation which will affect our future. The NMA is in a unique position to take the lead in the continuing quest to preserve the right of minorities to enter health care fields, assuring that minority students have the guidance and assistance they need to become health care providers. One of our major priorities is to assure that the medically underserved populations of this country, which are predominantly minority or disadvantaged populations, have access to caring, concemed physicians or other providers who also appreciate their patients' ethnic and cultural heritage, who also appreciate the inherent barriers of the underserved home and community environments, and who also appreciate the effects of the years of struggle for achievement upon our pride, our bodies, and our spirits. We recognize the need for improving the self-esteem of those whom we would serve, if we are truly to have a healing influence upon those who are in need of our services. It is most encouraging that the Executive Council of the AAMC in 1987 reaffirmed its commitment to increasing opportunities for underrepresented minorities who wish to pursue careers in medical service, teaching, and research, and the activities which we have seen under the leadership of Dr Robert G. Petersdorf, President of the AAMC, have demonstrated that this is not just an idle statement. We all have benefited from the assistance of Dario Prieto, Director of the Section for Minority Affairs of the AAMC, who along with his staff has provided support, infonnation, and guidance to so many of us over the years. In recognition of Mr Prieto's role in minority 89
DIVERSITY IN MEDICAL EDUCATION
access to medical schools, the National Medical Association awarded him a Scroll of Merit. Now, the AAMC has expanded its scope to also establish a Division of Minority Health, Disease Prevention and Health Promotion, under the leadership of Dr Herbert W. Nickens, which should provide new dimensions to the AAMC's involvement in minority health issues. The NMA, the Minority Affairs Section of the AAMC, the National Association of Medical Minority Educators, and other minority medical organizations should and must work toward a unified and successful initiative in the 1990s, to assure that our commitment brings about measurable benefits; not just benefits in minority student recruitment, retention, and graduation, but benefits in minority access to all areas of health care, as well as improvement of the status of health and well-being for minorities and all other Americans. Our heritage and past experience in medical education is well known by most of you, but bear with me as I review just a bit for those who may not be as familiar with our history. Although I do not have ready access to the history of the beginnings of other underrepresented minority groups in American medicine, Dr W. Montague Cobb, Professor Emeritus of Anatomy at Howard University College of Medicine, Past President of the NMA, and Editor Emeritus of the Journal of the National Medical Association has provided through his many published articles an excellent appreciation of the early days of blacks in medicine.' We know that James McCune Smith of New York was the first black American physician, receiving his medical degree in 1837-but receiving it in Glasgow, Scotland, not in the United States. David John Peck was the first black to receive a medical degree in the United States, graduating from Rush Medical College in Chicago in 1847; however, it is reputed that he went to Nicaragua to practice medicine. Black women were known to have been "doctoring" during the days of slavery, but in 1864 Rebecca Lee became the first black woman to be formally trained as a physician in the United States, receiving her degree from New England Female Medical College.2 She is said to have established a successful practice in Richmond, Virginia after the Civil War. The second was Rebecca Cole, who graduated from Women's Medical College2 of Pennsylvania in 1867. Howard admitted its first black woman in 1872; Meharry soon after. It is of historical interest that black women were the first women to practice medicine in four southern states, Alabama, Mississippi, South Carolina, and Virginia. In the post-reconstruction era, eight "Negro" medical schools were established to train black physicians, including Howard, founded in 1868, and Meharry, 90
founded in 1876; Howard and Mehany were the only two of these eight institutions to survive. As recently as 1968, there were only 292 first year minority medical students in this country, with blacks representing 2.7% of all first year medical students. In 1969, 75% of all black medical students were enrolled at Howard and Meharry. The 1970 AAMC Task Force on Minority Student Opportunities in Medical Education provided an impetus during the 1970s for an increase in minority students and physicians, and we witnessed more minority students being enrolled at many of our nation's medical schools, such that, by 1979, only 20% of all black students were enrolled at Howard and Meharry. But as we know, the enthusiastically set goals for parity were never reached, and since 1975, when minorities represented 8.1% of the total medical student enrollment, there has been no significant change. In fact, AAMC data show that during this past year, 1988-1989, 5 of our 127 medical schools had no minority students in their entering classes. And, The New Physician's Annual Minority Admissions Scorecard published in April 1989 demonstrated that 61 schools had a smaller percentage of minority students during this past year than they had in 1983-1984.3 Such is our heritage, and such is our present status. Where do we place our priorities for the coming decade? How do we decide our priorities? What are the major issues which confront us? I believe that we can all accept the basic premise that we do not desire to increase minorities in medicine simply to increase the numbers or just to reach parity with the representation of minorities in the population of the United States. I believe that our desire for increasing the numbers of minority physicians, through an increase in opportunities for minorities to enter and graduate from medical schools and become licensed, practicing physicians, stems from our desire to improve the health status of the medically underserved, most of whom are minorities. There are an estimated 37 million Americans who lack health insurance; of these, 75% are members of working families-not the unemployed or "street people." There are about 15 million women of childbearing age and 11 million children who are uninsured. There is much discussion on the federal, state, and local levels about the need for comprehensive health care, while emphasis is also being placed on cost containment and decreasing or modifying physician reimbursement. As long as we recognize, as the Malone-Heckler Task Force Report of 19854 documented, that there is a striking disparity in the status of health of minorities and that there are excess minority deaths each year, probably greater than 60 000, because JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 2
DIVERSITY IN MEDICAL EDUCATION
of disparate minority health status and lack of access to appropriate health care, then we must affirm that we still have much to accomplish in health provider and care services. As a pathologist, and as one who firmly believes that minorities are needed to participate in all specialties, in academic medicine, and in academic research, I still advocate the promotion of medical specialty and academic careers for minorities. However, even for those who choose such careers, there must be a continuing awareness of the particular minority problems which specialty preparation can assist in alleviating. As we think about the disparity in minority health and the types of diseases which contribute to this disparity, we must recognize that behavior modification can alleviate many of the health problems of the minority community, such as smoking, violence, poor nutrition, unhealthy sexual practices, stress, etc.; poor minority health can also be alleviated by early detection of diseases which can be prevented, treated, or cured. We recognize the escalating costs of medical care, especially when too many tests may be performed because of a fear of malpractice litigation. Other causes of escalating costs involve new interventional procedures which are expensive but which may benefit the patient in disease detection and the need for long-term care or treatment of chronic diseases. We also recognize that many complex, fatal, and costly illnesses in minorities and the disadvantaged might have been prevented by early access to a concerned health care system. Think, for example, of the benefits of screening for early detection and prevention, utilizing such programs as mammography for detecting breast cancer in the young as well as the elderly (mortality rates in blacks have been increasing in this area), PAP smears to detect cervical cancers early, testing for tuberculosis which has begun to rise in incidence in the inner cities, rectal examinations-both digital and for occult bloodfor early detection of colorectal cancer, and a simple checking of blood pressure to prevent severe cardiovascular diseases, strokes, myocardial infarctions, and end-stage renal disease. Think of the benefits of nutritional education through health prevention programs. It seems so logical to me that it is difficult for me to understand why there is not wide acceptance of the need for appropriate funding of preventive health services, with disease prevention and education; this is a relatively inexpensive type of health care compared with long-term care of the chronically ill, and more extensive medical and surgical therapy for those who have diseases which have progressed to advanced stages and for whom early intervention would have prevented a protracted yet fatal JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 2
outcome. Too many health plans, insurances, and government health coverage plans do not include the costs of such preventive measures; of course, our potential prevention patients would not have had access to these health care providers in the first place. Why must so many of our neighbors and friends not be able to obtain medical care until they are sick, really sick? Why should an American citizen, because he or she is poor, fear obtaining a physician's examination due to the cost or because there is not access to a primary health provider? Once detected, why should diseases progress because there is no money and no provision for obtaining the medications or therapies prescribed? Obviously, there are problems with our health care delivery system which are affecting the plight of our disadvantaged and minorities. Obviously, merely producing more caring, minority physicians will not solve the problem; however, more caring, concemed physicians who are involved in primary health specialties and providing longitudinal family care can make a difference in the health status of our people. As long as there are front page news reports that the life expectancy of blacks has declined over 2 to 3 successive years, then word that there is a surplus of physicians has no real meaning, particularly for those whose lives are prematurely ending. There is a recognized physician maldistribution, probably both in specialty choice and geographic location, and lack of access to health and behavioral care for too many which might prevent such a depressing set of statistics. We must address these problems also if we hope to make a difference in health care. We must continue to place emphasis on the need to admit more students to the health care professions, especially to medicine, who not only can demonstrate academic achievement and high MCAT scores, but who also recognize and understand the health problems of today and the future. We must make certain that those whom we, through our admissions committees, allow to enter medicine have a commitment to improving the health status of all Americans. We must make certain that financial assistance programs are in place which will allow those with such commitment to enroll in institutions once accepted and be able to practice in underserved areas without the fear of personal financial disaster or undue family sacrifice. While we hear much rhetoric about equal access to health care, which is indeed a worthy concept, let us also stress equal access to health care provision for those who have chosen medicine as a career exactly for the purpose of providing equal access to health care. In the 90s, we need to turn again to those concepts of looking at the individual applicant as a person, not just a set of GPAs and MCAT scores, as we 91
DIVERSITY IN MEDICAL EDUCATION
did before the impact of the Bakke and DeFunis court decisions; we need to turn to our elementary schools, our middle schools, our colleges, not just to help save those youths whose futures are in jeopardy, but to provide encouraging role models, hope, and opportunities so that the applicant pool will not be depleted in the next decades. There are new and not so new areas of medicine which must be addressed. Among these are the need to look at the effect of drug abuse on our communities, and the diverse effects such an epidemic is having upon our youth and our patients. Infant mortality is already a problem in our country. Just imagine . . . no, don't imagine, know that America ranks 19th among industrialized nations in the number of babies who die before their first birthday. Think of how little prenatal care costs in comparison to the cost of supporting a low birthweight infant. Recognize also that infant mortality is about twice as common in blacks as in whites in this country, as is low birthweight disproportionately found in our babies. Now, add the impact of drugs to this problem. Too many of our minority and black mothers are having babies without any prenatal care, are abandoning these beautiful babies, many of whom are born addicted to drugs or are born HIV positive, yet are abandoned by their mothers who leave in search of a "fix." Too many city hospitals are having to deal with the problem of the "boarder baby," those abandoned infants who learn to walk and talk in the hospital environment, many of whom have never been seen or held by their mothers. Think of the increase in AIDS and sexually transmitted diseases, especially among our young. We need physicians who can truly relate to our youth, our women, our men, and let them know that they are indeed caring physicians, that they can be trusted with discussions of sexual practices and activities, and that they can provide educational information to prevent such diseases or at least therapeutically modify the effects on patients' lives. Such qualities in physicians will not be ascertained by pure quantitative test scores-we should and must return to evaluating our applicants by also looking at the total individual's attributes and that individual's humanistic interests and communicative skills. The NMA has many priorities for this and coming years which are shared by many of you. Not only are we concerned about the need to address the decline in the minority applicant pool, with a special look at the loss of the black male from this pool, but also to pay special attention to developing health care delivery programs and coverage in this country. There are other priorities, such
92
as organ donation from and to minorities, the decline in the black hospitals, networking with other health and community groups, and many more issues which there is not time to discuss. Entry into graduate medical education is a concem which we share, but this topic will be addressed by other programs during the AAMC meeting. Regardless of what the future holds for physicians and the practice of medicine, we must think logically, objectively, and both with and without emotion, about the real needs of our communities. We must think long and hard about the role of the physician in the delivery of health care in the 90s, and let that be our guide in determining who will be entering through our medical school doors. With documentation from the AAMC, as well as other published articles, that many more minority graduates intend to practice in underserved areas, where there are large numbers of medically indigent, underinsured, or uninsured patients, this must mean that we place emphasis on the minority in medical education and medical practice. Frederick Douglass, Father of the Civil Rights Movement, said: If there is no struggle there is no progress. Those who propose to favor freedom and yet depreciate agitation, are men who want crops without plowing up the ground. They want rain without thunder and lightning. They want ocean's majestic waves without the awful roar of its waters.
Let it never be said that the National Medical Association or the Minority Affairs Section of the AAMC or any concerned health educator or professional has not continued the struggle, but that, with optimism, hope, and hard work, we shall have made more progress than those who preceded us in our quests for a better future for health care and the health of all Americans. Resources 1. Cobb, W.M: The black American in medicine. J Nat/ Med Assoc. 1981 ;73(suppl):1 185-1244. 2. Davis, M.W., ed. Contributions of Black Women to America. Vol. 2. South Carolina: Kenday Press, Inc; 1981:357420. 3. The new physician's annual minority admissions scorecard. The New Physician. April 1989:22-23. 4. Report of the Secretary's Task Force on Black and Minority Health. Vol. 1, Executive Summary. Bethesda, MD: Department of Health and Human Services. National Institutes of Health; 1985.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 2
