March 1, 2019
Editor’s note: The following is an edited version of the Olga M. Jonasson, MD, Lecture that Dr. Reede delivered at Clinical Congress 2018 in Boston, MA. The lecture has been modified to conform with Bulletin style.
It is through understanding the policies and actions of the past that we can better identify the antecedents and precipitants of today’s challenges. These are persistent issues related to disparities and exclusions, marginalization and minimization, but also challenges that have been met, if not head-on then at least from multiple directions, to lead us to where we are today. Hopefully, we can use our understanding to create vehicles for change—ways in which we can move our professions, our institutions, and our society closer to the principles of social justice and equity. If we look at this circle of time, we know that injustice is not new, nor is the fight to right injustice.
From the Civil Rights Acts of 1875, 1957, and 1964; to the 1920 19th Amendment to the Constitution that allowed women to vote; the Voting Rights Act of 1965 that ensured that people like me, blacks, could vote; to Title IX in 1972 and the Americans With Disabilities Act in 1990, there is a continuous cycle and struggle toward justice.1 This struggle toward justice and equity is long fought. It does not involve one incident; it does not involve one person or place in time, but many events culminating in change. This battle has included courageous individuals who are willing to be the first to enter, who are willing to lead and to foster real and sustainable change.
As a high school, college, and medical student, I was unaware of the many firsts who charted a course that opened doors for people who looked like me: from Elizabeth Blackwell, MD, the first woman to earn a medical degree from a U.S. medical school in 1849,2 to Mary Edwards Walker, MD, the second woman to earn such a degree from a U.S. school and the first woman surgeon in the U.S.3
Some of those firsts also occurred in Massachusetts, where I live and work. In 1889, Charles Eastman, MD, became the first Native American to receive a degree from a U.S. medical school. He would later go on to found 32 Native-American chapters of the Young Men’s Christian Association, and he helped to establish the Boy Scouts of America.4
When she graduated in 1864, Rebecca Lee Crumpler, MD, was the first African-American woman in the U.S. to earn a medical degree, and the first African-American woman to graduate from the New England Female Medical College, later known as Boston University.5 Twenty-five years later, Susan Picotte, MD, would become the first Native-American woman to become a physician.6
These individuals were not only first in terms of opening doors, but they continued to be firsts and to make significant changes in many ways.
Also in Massachusetts, Mary Eliza Mahoney, RN, graduated in 1879 from the New England Hospital for Women and Children, now Boston’s Dimock Community Health Center.7 She was the first African American to study and work as a professionally trained nurse in the U.S. She went on to co-found the National Association of Colored Graduate Nurses. In 1923, Susie Walking Bear, RN, graduated from Boston City Hospital’s School of Nursing, and in 1927 she became the first registered nurse of Crow descent and the first degreed registered nurse of Native-American ancestry.8
Turning to Harvard Medical School, Boston, often when I ask individuals, “When do you think Harvard Medical School became more diverse?” they say it had to be after passage of the Civil Rights Act of 1964, when actually the first blacks matriculated at Harvard Medical School in 1850. During the Civil War and Reconstruction, Edwin Howard, Thomas Dorsey, and later, in 1871, James Still (all MD) were the first African Americans to graduate from Harvard Medical School.9 Changes also were occurring at the dental school at that time. One of the two first matriculants at the dental school was Robert Freeman, DDS, who also was the first African American to earn a dental degree at an American institution. He has another claim to fame—he invented the golf tee.
In this period of change, John DeGrasse, MD, was the second African-American physician to graduate from a U.S. medical school. He would become a commissioned physician in the Civil War, but he also was the first black physician admitted to a medical society—the Massachusetts Medical Society in 1854.10 An important point is that the American Medical Association (AMA), founded in 1845, excluded blacks. Several years ago, when I served on the Sullivan Commission on Diversity in the Healthcare Workforce and we were taking testimony from across the country, an AMA leader said, “I don’t understand why you all started that National Medical Association [NMA]. I don’t know why you just didn’t all join the AMA.” I had to inform him that in 1895, when the NMA was established, we were not allowed to join the AMA.
More firsts, more action, and more movement forward—and two amazing firsts, both affiliated with the Ohio State University School of Medicine, Columbus. Clotilde Dent Bowen, MD, was the first African-American woman to graduate from that school and the first African-American woman physician in the U.S. Army.11 Olga Jonasson, MD, FACS, was the first woman chair of the department of surgery at Ohio State.12 More firsts, such amazing women: Alexa Canady, MD, FACS, who gave the Olga M. Jonasson, MD, Lecture two years ago, was the first African-American woman neurosurgeon,13 and Antonia Novello, MD, was the first Hispanic woman U.S. Surgeon General.14
It is important that our youth understand that there are people who blazed the trails that led to where we are today. Some firsts may actually be reading this article because of what they achieved in the past. But I also know that some of you will become firsts in the future. The role of the individual is important, but we should never underestimate the power of we, the power of standing up, the power of playing a role—of being seen and heard, be it in large and bold ways or small and deliberate ways. The power of being present was not and is not only about racial equality; it is not only about economic justice. It is about gender and disability and immigrant status. It is about being marginalized and excluded. It is about how we come together to form the power to create change.
So, you can talk about the “I,” like in the word individual, but we can talk about the “we,” W-E, in the word power, because it is what we can do collectively to create change that can be so important.
Some of you may know about the busing incidents that occurred in the 1960s and 1970s in Boston public schools. Well, Massachusetts banned segregation in public schools in 1855.15 We banned it, but in the 1970s we were fighting to end that same segregation. So, part of this story is about how we move forward.
Why is diversity important? Diversity and inclusion are important because they help us to realize our values, they help us to deal with complex issues and problems, and they ensure our viability as institutions and as professions.
I have been doing this work—improving diversity—for more than 25 years, and early on, in considering medicine and academic medicine, the thinking was that we needed more black physicians to treat more black patients, and we needed more Hispanic physicians to take care of Hispanic patients. But we were not thinking about the fact that we need more diverse physicians to be our department chairs and our deans and our presidents of institutions and leaders; the focus was on patients and communities.
I would put forward that we do need more diversity in terms of who is treating our patients, but it is not that a black patient needs to have a black physician. It is the responsibility of all of us to meet the needs of our patients. The equally relevant issue is how my presence as a black physician in an institution, an institution like Harvard, helps Harvard fulfill its responsibility and its mission.
So, I think of diversity not in terms of numbers, but rather about how diversity becomes embedded in the fabric of what we do. How should diversity be considered as we develop the policies, programs, and practices of our organizations? Not because it is Black History Month or National Hispanic Heritage Month or Women’s History Month, but actually every day in our work, do we have a diversity lens? How does a mix of backgrounds help us realize our values of social justice and equity? A diversity lens helps us realize the goals of accountable representation and distributed justice and access to the benefits of our system.
Often, when I talk about diversity, people think I am talking only about race or ethnicity; or they will ask, “Are you here for women’s issues alone?” My response is, “What if I am a black woman?” All too frequently, we forget about intersectionality—that each of us has multiple identities. So, when I think about diversity, I think about how we can all bring the best of what we have to the work that we do.
Is diversity defined on the basis of gender, race, or ethnicity, or a different kind of training, a different kind of social network, language, culture? How do all of those aspects of who we are come together to help us be more successful in our education, in our research, and in our service? Diversity is about all of us. The question we should be asking is: Who is in or out of the room?
Dr. Jonasson often asked questions about who was in the room. When we ask who is in the room, we can get very comfortable if they look like us. I think we also need to start asking about who is not in the room. The need also does not end with getting into the room, but includes whether you have a seat at the table. All too often, women have been let into the room, but even when given a seat at the table, our voices are not heard. So, it is not just getting into the room and to the table; it is making sure our voices are heard. How can we be part of the conversation and part of the dialog to create change?
Diversity can help us solve complex issues. If you look at the work of Scott Page, Leonid Hurwicz Collegiate Professor of Complex Systems, Political Science, and Economics, University of Michigan, Ann Arbor, known for his research on the benefits of diversity, you think about asking different questions, looking through different lenses, different heuristics. Diversity is about how we come together, across disciplines, to solve and work on very complex issues and problems. We are better when we work together.
When I started doing this work in building diversity many years ago, people would say, “All right, Joan, you are talking about diversity, and you are talking about change in the demographics in our country, but that will happen in another century. It is a lifetime away. We don’t need to think about that now.” Well, we do.
By 2050, our nation is going to be majority-minority. I am a pediatrician, and when I look at Boston, it is already majority-minority. When we look at our children, at who has graduated from high school, who is going to go to college and to medical school, and who will become surgeons, it is an increasingly diverse group. If we don’t capture that potential, if we don’t nurture those students’ interests, we won’t have those individuals for our profession and our future.
Looking at women and minorities based on reports from the U.S. Census, from our medical school graduates, our graduate medical education pool, our residencies and fellowships, and our practicing physicians, we see decreasing representation across all those groups. There isn’t parity. There isn’t adequate representation. I find that troubling.
But there is more to “unpack.” In our medical schools, we see a higher percentage of women at lower ranks, at the ranks of instructor and assistant professor, and the percentages drop when we look at the level of professor. Again, we need to disaggregate, we need to further unpack. When we look at women full professors among basic science and clinical faculty in 2015, we find only one Native-American faculty member (see Table 1). In the basic sciences, 16 black women were full professors. In the clinical departments, we find 179 black women full professors. These departments are found in institutions that have historically and predominantly served minority populations, including Howard University, Washington, DC; Morehouse School of Medicine, Atlanta, GA; and the University of Puerto Rico, San Juan. Today, the U.S. has 229 African-American women full professors out of more than 170,000 faculty.16,17 We need to unpack; we need to disaggregate.
Table 1. Female basic science and clinical full professors in U.S. medical schools, 2015
An additional issue that I want to stress, because it is so important, is the racial ethnicity of women department chairs. Although slightly better today, in 2015 there were 15 African-American women department chairs in the U.S., there were fewer than 30 Asian women chairs, and fewer than 25 Hispanic women chairs—a critical issue for all of us as we think about leadership and we think about the future.18
What are some of the barriers to achieving diversity? At the individual level, we can think about resilience, preparation, opportunity—opportunity to explore, to dream, to think, to believe.
The Biomedical Science Careers Program (BSCP) was started after I gave a talk at the New England Board of Higher Education program at the Massachusetts Institute of Technology (MIT), which brought students together from across the northeast to think about careers in science, medicine, and graduate-level training. A young woman came to me at the time and said, “I didn’t know that there were black women physicians.” I said, “Did you know that there were black male physicians?” She said, “Yes,” and I asked, “How?” She said, “How does anybody know? The Cosby Show.” Just think about it. Her vision of the world was what she saw on television, so, I was this anomaly. I was an example of the fact that it was actually possible to be black, a woman, and a physician.
If we think about our society—the policies, the politics, and the economics—or we think about the culture and the policies within our institutions that historically excluded, and sometimes still exclude, minorities and women, the problem becomes clear.
Think about that young woman who spoke to me that day at MIT. She did not attend MIT, but she was at the meeting. Think about images in popular culture and what these images tell our youth about what is possible. I went to Google to grab some images, and I want to show you what came up (see Figure 1). Look at the images for “smart person.” What do you see? Look at the images for “professor,” and for “doctor.” The results were similar for “surgeon,” “chief executive officer,” and “president,” but not for “assistant professor.” I talked about this issue of intersectionality and the messages that we send our youth, so I Googled “professional hairstyles.” Look at the results in Figure 2. What do you see? What do you see when you Google “unprofessional hairstyles?” So, I want you to think about the images that we send youth in the media.
Figure 1. Messages we send
Figure 2. Messages we send
There are barriers and challenges (see Table 2), there are stereotypes and stereotype threats, there is tokenism and lack of validation, isolation, and exclusion. Minorities are hyper-visible and invisible at the same time.
Table 2. Examples of barriers and challenges experienced by diverse individuals
I co-led a two-day session centered on women of color in the sciences as part of a National Institutes of Health (NIH) course on mentoring women in the sciences. At the end of the first day, the individuals from the NIH who were sponsoring the course came to me and said, “You know, Joan, this is not working. We are not getting where we need to go. These women of color are talking about women’s issues.” I said, “Could it be that women of color have women’s issues?” They said, “Maybe.” So the next day we discussed other aspects of diversity. I came away from that meeting with the sense that, except for the moments when people were talking specifically about women of color, we could have been invisible and not present at the meeting. So, women are hyper-visible and invisible at the same time. How many of you have experienced this scenario: “That’s an excellent suggestion, Miss Triggs. Perhaps one of the men here would like to make it” (see Figure 3).
We also have a disability bias, which is often left out of discussions. I find this omission interesting, because people often think of disability in terms of mobility challenges. I bring up this issue because sometimes when I am at a meeting, people say, “Well, Joan, I hear you, but it’s not a big issue here.” Then the next person says, “Would you please sit on the other side of me because I can’t hear well in this ear.” The disabilities that we see in our patient populations exist in our colleague population, as well as in our student population.
I want to turn briefly to what we did at Harvard Medical School and the response within my office. I draw on the power of paying it forward, understanding our history and our past, and understanding that we have an opportunity to contribute to a better future.
I run the Office for Diversity Inclusion and Community Partnership. Part of what we do involves pipeline programs; but I have a problem with even the concept of “pipeline,” because people often talk about it as a leaky pipeline. For me, a leaky pipeline means that I have driven my car someplace, and when I drive off, a puddle or pool is left behind. That is not people. That is like throwing people out. It is saying that because you took a wrong turn or something went wrong, you can never get back on track.
I think of careers as journeys. I want all of you to think about where you were in middle school or high school. At that time, did you know you would be where you are today? Did you go down one path and then switch to another, be it a major or a school or a field of interest? I know I struggled in medical school with whether to do surgery or pediatrics. I loved playing with the kids, and I loved surgery—the precision of surgery. I could have gone in either direction.
So, when we talk about a pipeline, I want us to move toward thinking of careers as having multiple points of entry, exit, and re-entry. I want us to think in terms of continuity—continuity across the academic continuum. It is wonderful to have programs for middle-school students or high school students or college students, but how do we bridge them to the next level? All too often, we maintain that we cannot find the kids, but that shortage is often because our programs are not linked to other programs targeting individuals at earlier stages.
I started the Minority Faculty Development program at Harvard Medical School in 1990. Several years later, some of the leadership came to me and said, “You know, Joan, you have not solved the diversity problem for Harvard.” My response was, “How many hundreds of years did you have to create the diversity problem at Harvard?” Diversity is not something that you wake up one morning, snap your fingers, and you fix; it takes consistency of effort over time. It takes collaboration, and understanding that if we are going to reach the kids who will be our future physicians, we need to get to them when they are in middle school and high school. We need to partner with the schools, and we need to make sure there is strong science teaching in the classroom.
When I looked at middle schools for my daughter, I visited several private schools. At one school, the head of science wanted to talk to me when he found out that I was at Harvard, figuring he could get an in at Harvard. Now, you know something about that private school, because there was a head of science. A student knocked on the door of his office, and because I wanted to observe how he interacted with the student, I said, “Why don’t you take his question?” The student asked about a problem he was having with the electron microscope. Later that same day, a group of science teachers from Boston Public Schools visited my office, and we discussed preparation for their school science fairs. The teachers told us what they had been given as supplies for the science fairs, which were primarily boxes of markers. So think about it: electron microscope versus boxes of markers. Are the children in Boston less bright, or is part of this problem related to lack of opportunity and exposure?
Achieving diversity is about being creative and not doing the same things we have always done. When individuals from training programs call me and say, “I’ve been trying to get diversity, and I just can’t find anybody.” I say, “What have you tried?” They will tell me, and I say, “What else have you tried?” “Oh, I’ve just been sticking with this.” “And how long have you been sticking with this?” “Oh, about 10 years.” “Has it worked?” “Nope, I’m just sticking with it.” The issue is: how do you examine what you are doing and do something different, and how do you start to recognize that if there is no diversity in your social network and that is the only network you use to find diversity, you’re probably not going to find diversity? So, how do you expand that network? Broadening contacts includes how we communicate, and for me this is an area that is hardest.
How do we communicate with the kids today? It needs to be very different than in the past. I do not use Snapchat or any other social media. I don’t even know how to use them. But people in my office know because it’s important. The BSCP program that I mentioned earlier was started with my office in conjunction with the Massachusetts Medical Society (MMS) and the New England Board of Higher Education. The MMS publishes the New England Journal of Medicine. I was at the MMS office, and they said, “You know, Joan, we need to let the youth know, let the teachers know that we are really interested in diversity, and that we want them in medicine and in science. Can you write an article for the New England Journal of Medicine about this?” How many high school students read the New England Journal of Medicine? So, how do we communicate with the students that we want to reach? We need to consider intersectionality and recognize the multiple forms of diversity, as well as focus on commitment—from the bottom up and from the top down.
Our educational outreach program includes curriculum development: curriculum development locally, curriculum development that is disseminated nationally, teacher professional development—and that includes programs during the academic year and in the summer for middle school and high school students. We also offer a clerkship program that brings students to Boston to participate in one-month rotations at Harvard Medical School-affiliated hospitals. In any given year, 10 to 15 percent—and up to 25 percent—of these students have matched to a residency, and some have gone on to serve as faculty. These outcomes provide an example of the importance of considering continuity across the academic spectrum (student, to trainee, to faculty) and of including consistency over time in the delivery of diversity programming (see Table 3).19
Table 3. Seven Cs for Advancing Diversity
The Commonwealth Fund Fellowship is designed to prepare individuals who want to become leaders in health care and address issues of minority and vulnerable populations. Some of our success stories include Joe Bettencourt from the Disparity Solution Center; Monica Bharel, Commissioner of Public Health in Massachusetts; Yvette Roubideaux, MD, former director of the Indian Health Sections Service; and Nawal Nour, MD, founder of the first African Women’s Health Center in Boston. These are individuals who have been policy advisors to senators, and three of them head foundations. Other examples include Kim Rhodes, MD, FACS, a surgeon at University of California, San Francisco, and Mallory Williams, MD, FACS, a surgeon at Howard. Plenty of individuals want to enter leadership positions within our organizations. How do we identify them and nurture their interest? The vast majority of individuals who come for this fellowship hold academic appointments in medical schools or schools of public health. All of them have remained committed to vulnerable populations and minority populations. They publish. They get grants. They are visible. They are creating change.
BSCP is unique because it is focused on the idea that there are individuals out there with potential who are highly motivated, and we need to connect them with advisors and mentors. When I first proposed the concept, people at Harvard called it “Joan’s fantasy.” They would not even acknowledge that it could be a program; it was just a fantasy. The reality is that more than 14,000 students have come through this program. At our last conference, we had 1,200 students and more than 250 advisors; 45 of those advisors, who are now physicians and scientists, entrepreneurs, and heads of companies, had come through this program as students. BSCP involves collaboration between academics and industry. It is a collaboration that has lasted through Prop this and Prop that, and all the anti-affirmative action efforts, largely because it takes no public funding and is supported by the community—a community that comes together to address issues of diversity.
The New England Science Symposium (NESS) brings 300 to 400 students who are interested in research together at Harvard annually. There are college, medical, and graduate students, as well as post-docs. We have had as many as 80 post-docs in attendance. I tell you this because often when I go places, people will say, “I would if I could, but I cannot find any minorities. They are not out there.” I tell you: they are there.
The fact is that these individuals do excellent work. I am reminded of one of our scientists and leaders, who asked if the program was remedial. He then attended a NESS conference and later e-mailed me, saying that he spoke to someone he thought was post-doc for 15 minutes only to learn that he had been talking to a third-year college student. Talent is out there, and we need to identify it and nurture it and get these individuals to stay the course.
What are some of the lessons I have learned over time? We need to recognize history and context. We need to be prepared to recruit, nurture, and retain a diverse workforce. We need to create cultures where individuals can feel valued and comfortable and in which they can contribute. We each need to deal with our own biases and perspectives. We need to turn to data and evidence. We need to start building the evidence base for what we are doing and why we are doing it.
At the individual level, we have to survive, so for me, addressing diversity is about self-preparation and self-preservation—thinking about career development, building resilience, and avoiding burnout. Some of the research my office is doing involves asking if particular aspects of burnout are not being captured for people who are on the margins. We need to serve as mentors and sponsors and help build networks. For me, having and being a mentor or sponsor is like being one of the Power Rangers: it is the collective power of what we can do together, how we can dream and believe and actually act together.
Part of the work I do and my commitment to it is because of my story and about my journey. One of my fondest memories of my youth is walking down the railroad tracks behind my grandmother in Florida. She was a tall, proud, deeply spiritual black woman. One side of the road was paved, where the white families lived, and the other side of the road was crushed shell, where my grandmother lived. We would walk down these tracks together and go downtown, where I experienced the signs telling me where I could not go in or the counters where I was not supposed to sit. More recently, my uncle, my mother’s brother, gave me a ride to work, and he brought up this subject and talked about a friend of his, somebody named Jelly Roll, whom he called an old-timer. You have to understand that my uncle is 87, so when he talks about an old-timer, you really start to wonder. He told me that a long time ago Jelly Roll was talking to my uncle about seeing my grandmother for the first time walking down these railroad tracks, holding her grandmother’s hand. Her grandmother was born a slave, so that makes one think of the possible: here is this woman who was born a slave, and here is my grandmother who cleaned houses, and here I am a dean, a professor.
We each have the power to achieve our potential if we recognize, learn from, and honor our past, and set our priorities in ways that are aligned with our purpose and our passion. Each of us can make a difference: a difference in our families, in our patients, in our community, the institutions where we work, the professional organizations that we have joined. We can make a difference in our nation and the world.
Dr. Martin Luther King, Jr.’s, words still ring true: “[T]oday our very survival depends on our ability to stay awake, to adjust to new ideas, to remain vigilant, and to face the challenge of change.”20 As stewards of the health of our patients, our community, and our nation, we must be committed to advancing social justice and equity. Over time, the march may take on different appearances, it may change due to technology and how we communicate, but we need to keep moving toward social change.
Each of us has an opportunity to be informed by our values, to be guided by a vision—a vision of equity, secured by our vigilance and understanding that we cannot turn our eyes away, maintained by our voice. Our voices need to be heard. It is not okay to just say, “I don’t like what is out there.” We need to do something about it and be strengthened by our victories, big and small.