Why Are We Not Already More Diverse?

Many healthcare stakeholders, including clinicians, medical and nursing education faculty, policymakers, advocates, and organizers, have long sought to increase the diversity of the health professions. Key advocates in these efforts have been individuals from systematically and structurally excluded groups—including Black, Indigenous, and other people of color; women; individuals who are transgender or nonbinary or who have disabilities; and individuals who live in poverty—who have been disenfranchised through our nation’s history and faced barriers that have contributed to past and present inequities. Yet, despite decades of efforts, the US healthcare workforce still lacks representational diversity. Why?

Many conversations about our lack of diversity try to shift blame onto those who have been historically and systematically excluded in order to relieve organizations of the obligation to invest in hiring and building career pathways for diverse populations. But history demonstrates the purposeful exclusion of these populations as well as the development of systemic barriers that perpetuate lack of diversity. Slavery, the annihilation and forced assimilation of Indigenous peoples, and systemic and institutionalized racism have laid the groundwork for today’s disproportionately homogeneous healthcare system that was built to exclude, harm, and create inequities.

Setting aside broader social barriers (such as historical and modern redlining¹ preventing Black families from building wealth and making higher education prohibitively expensive for many) and just focusing on healthcare-related barriers, there are a multitude of examples. Here are just a few:

• The history of trauma and exposure of Indigenous peoples to infectious and chronic diseases that contributed to persistent health disparities, unfulfilled commitments related to the provision of healthcare, and the lack of access to care or healthcare infrastructure beyond the critically underfunded and understaffed Indian Health Service.²
• The postslavery decimation of Black community healthcare models, including the closure of historically Black medical schools and displacement of Black midwives through the 1910 Flexner Report³ on medical education and the Sheppard-Towner Act of 1921,⁴ resulting in limited career opportunities for Black clinicians.⁵
• The racial segregation of many US hospitals that persists today⁶ and the racial exclusivity laws and practices that prevented clinicians of color from attaining professional credentialing and certifications or working in segregated hospitals⁷ while also excluding them from historically all-white trade and professional associations like the American Medical Association.⁸

The fact that many systemic barriers remain in place today to prevent entry of historically excluded groups into the health professions makes knowing our history more important. Only by knowing about these barriers can we remove them. Barrier work must occur across K–12 and higher education and also focus on hiring and retention efforts that help individuals from systematically and structurally excluded groups secure positions in the healthcare workforce upon school graduation. The various leverage points allow anyone interested in the end goal to find a place to start.

Resources for Further Learning

Deep dive into the history of health inequities in the United States

• “How History Has Shaped Racial and Ethnic Health Disparities” (go.aft.org/weh)
• “Healing Histories Project: Disrupting the Medical Industrial Complex” (go.aft.org/yyq)
• Urban Institute Symposium, “Unequal Treatment at 20: Accelerating Progress Toward Health Care Equity” (go.aft.org/9ip)

History of healthcare inequities for Indigenous peoples

• “A Historical Perspective of Healthcare Disparity and Infectious Disease in the Native American Population” (go.aft.org/ux3)
• “Discrimination Against Indigenous Peoples Through the Eyes of Health Care Professionals” 
(go.aft.org/xat)
• “Inadequate Healthcare for American Indians in the United States” (go.aft.org/fqy)

More on the impact of the Flexner Report and Sheppard-Towner Act

• “Racial Bias in Flexner Report Permeates Medical Education Today” (go.aft.org/9n5)
• “Constructing the Modern American Midwife: White Supremacy and White Feminism Collide” 
(go.aft.org/vlv)
• “The Midwife Problem: The Effect of the 1921 Sheppard-Towner Act on Black Midwives in Leon County” (go.aft.org/vhe)

–K. J. T.

Endnotes

1. R. Rothstein, “Suppressed History: The Intentional Segregation of America’s Cities,” American Educator 45, no. 1 (Spring 2021): 32–37; and N. McArdle and D. Acevedo-Garcia, “Modern Day Redlining: How Contemporary Policies and Practices Continue to Deny Equitable Access to Opportunities,” blog, DiversityDataKids.org, Brandeis University, diversitydatakids.org/research-library/blog/modern-day-redlining.

2. J. Ehrenpreis and E. Ehrenpreis, “A Historical Perspective of Healthcare Disparity and Infectious Disease in the Native American Population,” American Journal of the Medical Sciences 363, no. 4 (April 2022): 288–94.

3. T. Laws, “How Should We Respond to Racist Legacies in Health Professions Education Originating in the Flexner Report?,” AMA Journal of Ethics 23, no. 3 (2021): E271–E275.

4. J.-M. Williams, “The Midwife Problem: The Effect of the 1921 Sheppard-Towner Act on Black Midwives in Leon County,” paper presented at the Southern Conference on African American Studies at Southern University and A&M College, Baton Rouge, Louisiana, February 2014, researchgate.net/publication/319631627_The_Midwife_Problem_The_Effect_of_the_1921_Sheppard-Towner_Act_on_Black_Midwives_in_Leon_County.

5. K. Taylor et al., Improving and Expanding Programs to Support a Diverse Health Care Workforce (Washington, DC: Urban Institute, May 2022), urban.org/sites/default/files/2022-05/Improving%20and%20Expanding%20Programs%20to%20Support%20a%20Diverse%20Health%20Care%20Workforce%20.pdf.

6. M. Vaughan-Sarrazin et al., “Racial Segregation and Disparities in Health Care Delivery: Conceptual Model and Empirical Assessment,” Health Services Research 44, no. 4. (2009): 1424–44.

7. Taylor et al., Improving and Expanding Programs.

8. National Medical Association, “History,” nmanet.org/page/History#:~:text=Under%20the%20backdrop%20of%20racial,broadening%20the%20expertise%20of%20physicians.

[Illustration by Elizabeth Montero]