We Must Establish More Black Medical Schools

It's clear that Black medical schools produce a disproportionate share of Black graduates, why are there only four?

If it is clear that Black medical schools produce a disproportionate share of African-American graduates, why are there only four? I am glad you asked, we will get to the infamous Flexner Report.

Detailed Map of Medical and Osteopathic Medical Schools Credit: BYU PreMed

The United States is home to 141 accredited medical schools and 37 osteopathic medical schools. Morgan State University is slated to become the 38th osteopathic medical school and first HBCU with such a program in 2023. In total that makes 178 accredited medical schools and including Morgan State would make 5 accredited medical schools at HBCUs, which would mean HBCUs represent roughly 3%(2.8% for those who want to be precise) of such schools. Using the Association of American Medical Colleges’ most recent data we learn that there are roughly 45,000 African-American physicians who represent 5% of all physicians in the United States, yet using Census data we know that African-Americans make up 13% of the population. Coincidentally, 5% of America’s lawyers are African-American as well.

The four current HBCU medical schools, Howard University College of Medicine, Morehouse School of Medicine, Meharry Medical College, and Charles R. Drew University of Medicine, produce a disproportionate amount of Black physicians. Pilfering through data from the Association of American Medical Colleges(AAMC) and other studies, I found that there were 1,463 Black medical school graduates in 2018–2019. The four HBCU medical schools produced 206 Black graduates in 2018–2019, representing 14% of the total Black medical school graduates. There are 141 accredited medical schools and the 4 historically black schools produced 14% of the Black graduates. The numbers are damning and speak for themselves. If it is clear that Black medical schools produce a disproportionate share of African-American graduates, why are there only four? I am glad you asked, we will get to the infamous Flexner Report.

Below is a table compiling the total Black medical school graduates over the past four years and comparing it with the number of Black graduates from Black medical colleges over the same period.

Once upon a time at the start of the 20th century, there were eleven(!!!) Black medical colleges operating in the United States at one time. This would be the absolute peak for Black medical colleges because while discrimination, limited resources, and low enrollment would plague many of these institutions, the Flexner Report would prove to be the nail in the coffin. In 1910, Abraham Flexner produced a report for the Carnegie Foundation assessing medical education in the United States. One of the key components of this report was that education in the basic sciences was an essential prerequisite and complement to clinical experience in the training of physicians. As it related to medical education provided by Black medical colleges, Flexner recommended that only two Black medical colleges remain operational, Howard and Meharry. Flexner stated that these two colleges were the only two that had any capacity to meet the new requirements that his report demanded. It did not matter that some of these medical colleges were increasing enrollment and graduation numbers, post-Flexner report the medical community viewed these schools as incompetent. At the time of publishment, there were seven Black medical colleges in operation. By 1923, there would only be two Black medical colleges in operation, Howard and Meharry. It would stay this way for 47 years when in 1970 Charles R. Drew University of Medicine would host its first students. Morehouse School of Medicine would be founded shortly thereafter in 1975 and have its first residency program in 1981. It’s a factual statement to say we had two black medical colleges longer than we have had four. To go on a brief tangent, there are many parallels in the Flexner Report to the “American Negro College” report that spawned the “Negro Ivies” term. Both reports essentially stated the majority of black institutions were inadequate, disaster areas that should cease to operate. Only the select few institutions they deemed adequate would have any potential for being even an average institution. Anywho, in the 111 years since the Flexner Report, Charles R. Drew University and Morehouse School of Medicine have been the only two black medical colleges founded afterward.

On the front of making the physician population more representative of the United States, I see a ton of energy going into creating pipeline programs for Black and/or HBCU undergraduate students to medical colleges, however, I have not seen discussions centered around the creation of more Black medical colleges. Using the Association of American Medical Colleges data, it is clear that these black institutions are the most successful in graduating Black physicians. Therefore, it seems intuitive to create more of these colleges to educate our Black physicians. It should not be surprising that black medical colleges have the most success in graduating Black physicians. At the undergraduate level, HBCUs have similarly been the most successful in preparing Black students for medical school. For instance, one study found that, although HBCUs represent approximately 3% of the degree-granting institutions in our country, HBCUs represented 17% of the colleges that contribute the most African-American applications to medical schools in 2013. Schools like Howard and Xavier University at certain points in the past decade have accounted for up to 92% of our graduating African-American medical students. For perspective, that number was larger than combining the top four Predominantly White Institutions(PWIs) producers of African-American medical school graduates.

My sentiments of creating black medical colleges to increase our Black physician population have been echoed by a report published in 2020 that examined the impact of the black medical colleges that closed in the 20th century. The study found that if the five black medical schools examined had not closed, they could have “produced a 29% increase in the number of graduating African-American physicians in 2019 alone.” To me, it is clear that the question should not be, “if we should create additional black medical colleges?” but “how should we go about creating additional black medical colleges?” I will now attempt to provide the framework for a solution to the latter question.

Credit: Projected Estimates of African American Medical Graduates of Closed Historically Black Medical Schools Study

Presently, there are 85 public medical schools compared to 56 private medical schools. All of the current black medical schools are private. On the undergraduate and graduate levels, private institutions in higher education on average leave graduates of their institutions with higher debt loads. At medical schools, this trend is no different. An analysis by the AAMC, which gathered data on the cost of attendance data over ten years, found that private medical schools’ four-year cost of attendance was $306,200 while public medical schools’ cost of attendance was $232,800(for students were paying in-state tuition). This means medical students attending public schools paying in-state tuition saved $73,400 in comparison to the average private medical school student. We know underrepresented minorities are disproportionately affected by debt so it is imperative to keep their borrowing costs as low as possible.

If you have read my previous columns, you likely understand my sentiments towards state governments’ efforts to their state-sponsored(public) HBCUs. Yet, I believe that there would be a vested interest in state-sponsored black medical colleges in certain states. (I am skeptical if this interest is enough) HBCUs are geographically clustered in the South, which is where the majority of our African-American population lives. Morehouse School of Medicine President and Dean, Valerie Montgomery Rice, M.D, penned an opinion article in the Atlanta Journal-Constitution educating people on the cause of training more black physicians after Michael Bloomberg gave $100 million to the four historically black medical schools. The most important piece of the article came when Dr. Rice said the following:

“We know that Black patients tend to have better outcomes, in almost every medical discipline, when their care is shepherded by a Black doctor. There are cultural, psychological, and medical reasons for this, and whether the bias is real or perceived, the lack of physicians of color, as well as other healthcare professionals, contribute to the reluctance among minorities, particularly Black males, to seek out healthcare as symptoms occur and declining health becomes prevalent.”

With this truth in hand, it is clear that the geographical region HBCUs are clustered in is the same region where most blacks live and thus where black physicians are needed most. HBCU medical schools are a perfect fit for the needs of the constituents in the area they would operate.

As I said before one aspect of this vested interest state governments should have is best serving the needs of their African-American population. However, another demographic of these states would benefit from black medical colleges. According to the United States Census Bureau, 60 million people lived in areas classified as rural which translates to roughly one in five Americans living in rural areas(19%). We have many HBCUs that operate in rural areas of the South and many of these areas are in “medical deserts”. Medical deserts are defined as a “populated region more than 60 minutes away from the nearest acute-care hospital”. It has been estimated that nearly one in five residential areas in the United States do not have reasonable access to an acute-care hospital and this can be the difference between life and death. Furthermore, these areas are often Health Professional Shortage Areas(HPSAs). As you will see in the graphic provided by the Health Resources & Services Administration, most of the Southern population lives in HPSAs. With the lack of access to quality healthcare, people living in rural areas are subject to disparate health outcomes when compared to their urban and suburban peers. If you are Black, this means you are subjected to a double whammy living in areas with inadequate access being exacerbated by the fact that once you do receive healthcare assistance it oftentimes inadequate. It is in the best interest of Southern states to find solutions to the healthcare crisis that affects many of their constituents, race aside, and black medical colleges would be a remedy. Simply put, more black medical colleges will not only improve outcomes for Black populations, but they will also improve the healthcare outcomes of entire regions.

The higher the score, the greater the priority.

After examining some of the benefits black medical colleges could spawn in the South, it is time to show the feasibility of such programs. Due to the scope of this article, I will only use one HBCU to show feasibility but there are many more HBCUs that would be worthy candidates of black medical colleges. Ten HBCUs have nursing programs and being able to complement a medical school with an already established nursing program would be optimal. As seen in the legend, the state of Mississippi is almost entirely operating in Health Professional Shortage Areas. Mississippi is the state with the largest proportion of the population identifying as Black at 37.6%. (DC has a higher proportion but is not a state) The state of Mississippi has one medical school, the University of Mississippi School of Medicine. According to US News Rankings, this school ranks in the top 4 of the most graduates practicing in rural areas and medically underserved areas. However, using data provided to us by the AAMC, we can find that for 2019–2020, the University of Mississippi only graduated 11 Black physicians. This represented 7.5% of the graduating class in a state that is five times as black.

Alcorn State University(Jefferson County, MS) is marked in Red

Alcorn State University’s Cora S. Balmat School of Nursing offers nursing degree programs at the associate’s, bachelors’, and doctoral levels. Alcorn State University is located in Lorman, Mississippi which is in southwest Mississippi, and the nursing school is located about 40 miles south in Natchez. The University straddles the border with Louisiana and as you can see from the graphic, regions in Southwest Mississippi and Northeast Louisana are in the greatest need of healthcare professionals. With a well-established nursing program operating in a region that desperately needs medical professionals, Alcorn State would be an optimal candidate for a medical school. I have not even gone down the rabbit hole that Ayers v. Fordice created and showed the inequities the Mississippi state government exacerbated.

At this point, I believe the argument for black medical colleges is sound and we have just scratched the surface of the potential benefits. The obstacles to creating and funding Black medical schools are much more difficult to traverse. Using our hypothetical situation of erecting a medical school at Alcorn, I will illustrate some of the difficulties we would likely encounter. Rural areas are extremely unlikely to have adequate medical facilities and thus they will have to be constructed, which will cost significant capital. Rural hospitals in the present are closing rapidly and the NC Rural Health Research Program has found that 38% of rural hospitals suffer from unprofitability. There is a myriad of issues that afflict these hospitals but ultimately I believe it will be on state governments to entice private businesses to operate in these areas or for states themselves to erect and sustain adequate healthcare infrastructure. Moreover, the costs for building a medical school itself can be a 9 figure investment. The Osteopathic Medicine school being built at Morgan State has a projected cost of over $100 million. Morgan State is a public university but its Osteopathic Medicine program will be operated by a privately funded, for-profit medical school meaning no state funds are involved. While outside the scope of this column, I am vehemently against for-profit medical schools and the outcomes stemming from these types of schools.

The last obstacle I want to highlight is the American Medical Association(AMA). To create another medical school under present regulations, it would likely need the support of the AMA. The AMA historically has artificially limited the number of medical schools and physicians in the workforce while consistently lobbying to protect its’ monopoly. To this day the AMA has a significant say in which residency programs will receive Medicare funding through the Accreditation Council for Graduate Medical Education. A study from Duke concluded that

“the solution to our medical problems lies in increasing the output of physicians, in making the number of physicians in the community responsive to the desires of the community. To accomplish this goal, the AMA should be stripped of its power to control the output of physicians.”

That being said, the importance of elected officials and other dignitaries seeing the vested interest they should have in the establishment of black medical colleges is essential. Creating a not-for-profit medical college will require a significant commitment by a state government or nonprofit organization to start such a program but the everlasting effects these programs could have on a state would make pursuing such endeavors worthwhile.

As I have written about extensively, state governments have faced lawsuits from HBCUs alleging they have been discriminated against in favor of their Predominantly White Institutions(PWIs). States committing dollars to black medical colleges is one step towards racial equity that has evaded these states since their founding, not to mention that the states in question have a significant portion of Black taxpayers. Historically, we could create a long list of initiatives Black taxpayers have helped pay for but been denied the right to benefit from so this is a worthwhile opportunity to use their hard-earned dollars on initiatives that would not only definitively benefit them but all constituents.

All in all, establishing new black medical schools are necessary to make systemic change in the number of Black physicians being produced. Though the Flexner Report was an integral part of the closing of most of our black medical schools, we can put ourselves back on track. Evidence shows that black medical schools would also benefit the communities they serve in while operating as a proxy for helping eliminate medical deserts in the areas they operate, thus increasing the healthcare outcomes for constituents. While the evidence and data resoundingly support these conclusions, it remains to be clear will the message be heard by those in power or will the call to action continued to be ignored. Only time will tell, but if we are committed to improving the healthcare outcomes of communities that have been historically disadvantaged in our country, black medical schools are a necessary part of any proposed solution.

Works Cited and References for additional reading:

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