The first panel of the workshop featured presentations on the barriers and challenges Black boys and men face across their life spans. The panel especially focused on circumstances and events outside of the educational system that can influence their achievement. Camara Jones, M.D., M.P.H., Ph.D., described racism as a fundamental root cause of the lack of Black men in medicine. Drawing from his own experience, Roger Mitchell, Jr., M.D., described the importance of role models and socioenvironmental barriers, such as mass incarceration and unsafe and underresourced neighborhood environments. Arthur C. Evans, Jr., Ph.D., discussed psychological issues that are barriers for Black men to entering medical careers. Wizdom Powell, Ph.D., led a brief discussion following the presentations.1
Camara Jones, M.D., M.P.H., Ph.D. Senior Fellow Satcher Health Leadership Institute Morehouse School of Medicine
Racism is a system of power that structures opportunity and assigns value, and which can occur via acts of commission or acts of omission (such as inaction in the face of need), Jones began. She described the low prioritization of the shortage of Black men in medicine as an act of omission and a form of racism and defined racism on three levels—institutionalized, personally mediated, and internalized racism. Institutionalized racism is the
1 Jones is senior fellow at the Satcher Health Leadership Institute at Morehouse School of Medicine. Mitchell is chief medical examiner for the District of Columbia. Evans is chief executive officer of the American Psychological Association. Powell is director of the Health Disparities Institute at UConn Health.
“constellation of structures, policies, practices, norms, and values that taken together result in differential access to the goods, services, and opportunities of society by race.” Examples of these goods, services, and opportunities include
- Medical facilities
- Clean environment
Jones also described valuing people differently by race and ethnicity and the disproportionate incarceration of racial and ethnic minorities as examples. Personally mediated racism refers to “differential assumptions about the abilities, motives, and intents of others by race, and then differential actions based on those assumptions.” It also captures discrimination, prejudice, and conscious and unconscious bias. Jones identified several examples of personally mediated racism, including
- Police brutality
- Physician disrespect
- Shopkeeper vigilance
- Waiter indifference
- Teacher devaluation
Internalized racism is the “acceptance by members of stigmatized races of negative messages about our own abilities and intrinsic worth . . . accepting limitations to [our] full humanity of the box into which [we have] been placed.” Examples of internalized racism include
Jones continued by briefly presenting the Gardener’s Tale, an allegory about a gardener with two flower boxes, one with rich soil and one with poor soil, and red and pink flowers. The allegory illustrates the three levels of racism and is a tool to provide a common language to understand racism, to talk about racism, and to structure how to think about intervening to mitigate the influence of racism on health. In this allegory, the gar-
dener represents the government or those with power to make decisions and to act, as well as who controls access to resources. The flower boxes represent structural factors that separate rich soil (advantaged environments) from poor soil (disadvantaged environments). The flower colors represent traits (e.g., race). The gardener’s preference for red flowers over pink represents normative aspects of institutionalized racism.2 Using this allegory, Jones underscored the importance of understanding how racism is operating with respect to the dearth of Black men in medicine. She explained,
But we need to know how [to] answer the question, “How is racism operating here?” It is a system with identifiable mechanisms that are in our structures, policies, practices, norms, and values. Different aspects of decision making structures are the who, what, when, and where of decision making. Who is at the table and who is not? How are the policies written? What are the unwritten practices and norms? How and why do we assign values?
Jones finished her presentation by identifying potential mechanisms of racism that could be targets for interventions to increase the number of Black men in medicine. Some of these mechanisms are
- The medical education pipeline as a structure,
- Funding public education through property taxes as a policy,
- The lack of Black faculty and community members on medical school admissions committees as a practice,
- The shortage of Black men in medicine not being understood as a societal problem requiring an urgent solution as a norm, and
- The view of Black men as inherently threatening as a value.
Roger Mitchell, Jr., M.D. Chief Medical Examiner District of Columbia
Mitchell reflected on his own experience becoming a physician and as a medical examiner to identify potential barriers to medical education. Mitchell began by describing the “heavy backpack” of social factors young Black men carry. These challenges include
2 To read Jones’s Gardener’s Tale, see http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.90.8.1212 (accessed February 21, 2018).
- Difficult social and familial relationships,
- Interactions with the criminal justice system, and
- Living in neighborhoods high in violence and low in socioeconomic position and educational opportunity.
Mitchell identified several actions that could address these negative influences on Black boys and young men to help them pursue medical education and careers. First, Mitchell encouraged the audience to promote access and exposure to science, technology, engineering, and medical (STEM) education from a young age. Second, Mitchell highlighted the importance of role models and having a “mirror of relevance.” He asserted,
That mirror of relevance is extremely important, to put that up in front of other Black men that you want to become physicians. They have to see it as relevant to who they are and who their culture is.
Mitchell elaborated that providing role models could facilitate changing “the narrative of who Black men are” by changing norms and values, especially on Black boys and young men’s own expectations and aspirations. Finally, he encouraged action to address the social and environmental factors around some Black boys and men to help these boys and men to develop a positive self-narrative, “to create an environment where they can see themselves as physicians.”
Arthur C. Evans, Jr., Ph.D. Chief Executive Officer American Psychological Association
Evans began by describing mental health disparities experienced by Black men. He proposed that understanding health care disparities is important for understanding not only the health of Black men, but also other life outcomes, including higher rates of incarceration and worse educational outcomes. He commented, “If you care about the pipeline of African American men and boys being available to go into careers in science and in medicine, you have to care about behavioral health challenges.” He added that, importantly, although the prevalence of serious mental illnesses is similar among Black men compared with women and other racial and ethnic groups, how these illnesses play out differs greatly. He offered that the different outcomes can be attributed to increased expo-
sure to violence and to barriers to care. He expanded that addressing these barriers to care and thereby improving life outcomes among Black men therefore requires a systems change, and proposed re-conceptualizing behavioral health care.
The next part of Evans’s presentation focused on how the behavioral health care system can better meet the needs of Black boys and men to improve their health and life outcomes. He continued with what he described as two major problems with the current health care system. First, he said individuals with severe or even diagnosable mental and behavioral health challenges comprise only a small portion of the total population. He added that even in the majority of the population considered to be healthy, some may have subclinical issues that will quickly develop into a mental disorder above the diagnostic threshold, but for which no mechanisms or resources to deal with them exist. Second, he said that although resources are heavily focused on the provision of health care, many other factors (such as social determinants of health) influence health status and remain unaddressed. Thus, he proposed the need for a population health approach to behavioral health care. Such an approach targets healthy individuals and those at risk for disease (i.e., those with undiagnosed or subclinical mental health issues) and not merely those with severe mental illness or a diagnosable mental disorder.
For those at risk of developing mental health disorders, such as those who have experienced trauma either directly or vicariously, Evans proposed the need for evidence-based treatments. As an example, Evans offered screening children for traumatic stress in pediatric settings. Second, Evans proposed the need to change norms about mental health, especially among Black men and described the “Engaging Males of Color” initiative to “get men to reframe and think about their mental wellness differently,” such as by changing the language through storytelling.
Beyond the clinical disorders and care, Evans discussed the need to “address the psychological barriers [to entering the mental health professions], anticipate them, start much earlier . . . in elementary school, and follow kids all the way through the educational pipeline into [health professional] careers.” These psychological factors include the beliefs and expectations of others, self-perceptions, self-efficacy, and perceived racism. He proposed ways to address these psychological barriers such as through “mentorship programs . . . [to] help people navigate through the educational system, building broader networks of social support.” He also proposed addressing perceived discrimination such as by promoting a strong and positive racial identity and promoting resilience. Finally, Evans discussed the need for research on these mental and behavioral issues.
Valerie Montgomery Rice, M.D.,3 posed a question about resilience, asking whether any current research seeks to identify characteristics that have helped Black male physicians to succeed despite the barriers and challenges they faced. She suggested that looking at positive characteristics associated with success rather than just focusing on negative challenges and barriers to achievement may be important. Evans responded that resilience is an emerging but growing area of research and echoed the need for more research. Jones cautioned against focusing on resilience as an individual characteristic at the expense of seeking structural solutions. Using the allegory of the Gardener’s Tale, she said:
Although resilience is very important, we need to be attentive to the soil [or, structures and environment]. Because if you talk about the resilient ones, sometimes it’s a counterexample: “Well, this one made it despite that, so you should just try harder.”. . . [This is] a variation in the strength of the seed [i.e., individual differences]. But what we need to do is have such rich soil that you don’t have to be that superstar or whatever to make it, just like you don’t have the red seed [a member of a privileged group]. . . . I think that resilience is important in the short term, but if it diverts our attention from addressing the quality of the soil, then it could actually do us a disservice.
Responding to Jones’s comment, a participant offered that the choice between examining resilience as an individual characteristic and structural barriers need not be binary. The participant asserted,
What we assume is that there are superstars. And what I’m saying is that a lot of people are not superstars, and they all have the same soil. So there’s something else that’s going on. We from a research perspective need to begin to look at what that something else is.
Mitchell echoed the sentiments of this participant, offering that, based on his own experience of becoming a doctor, resilience may be a product of the individual and the environment in which he is embedded and “many of us know intuitively or through our own experience what [that resiliency] was.” However, research to quantify and qualify that subjective experience of resilience through rigorous research would be welcome.
3 Montgomery Rice is president and dean of the Morehouse School of Medicine.
Reflecting on Jones’s definition of racism, Cato T. Laurencin, M.D., Ph.D.,4 emphasized that racism “is an assignment of value [and] the creation of these different structures . . . is justified on the basis of inferiority of Black people.” Jones expanded on this comment, suggesting a need to look at how “white supremacist ideology [and] cultural racism” as societal values that structure society are fundamental drivers of the problem of a shortage of Black men in medicine. She elaborated on the importance of calling out this racism as “a problem requiring urgent solution” and added that, without addressing this fundamental cause, the system of medical education will continue to disadvantage Black students while privileging students of other races and ethnicities regardless of the pipeline programs implemented to mitigate the effects of this racism on the representation of Black men in medicine.
4 Laurencin is university professor, Van Dusen Distinguished Professor of Orthopaedic Surgery, and director, The Raymond and Beverly Sackler Center at the University of Connecticut.