By Victoria Houghton, assistant managing editor

In the early 1720s, the city of Boston was battling a devastating smallpox epidemic. Although the virus killed hundreds of people and infected thousands more, the outbreak represents a turning point in the field of science and medicine. Onesimus, a Boston slave, suggested to Rev. Cotton Mather that injecting infected material from a person with smallpox into a person not infected with smallpox could prevent the healthy person from catching the virus. Onesimus had learned about this theory when the technique was tested on him as a boy in Africa. Rev. Mather took Onesimus’s advice and it appeared to work (J Natl Med Assoc. 2002 Apr; 94(4): 266–271). While it took years for the concept of inoculation to take hold in America, the foundation for preventative medicine had been set. Skip forward 200 years to Chicago where Theodore Kenneth Lawless, MD, opened a dermatology clinic in a mostly African American community in 1921. Dr. Lawless received his medical degree from Northwestern University School of Medicine and is thought to be the first African American dermatologist in the United States. 

Although African American representation in medicine has evolved since the 1700s, the field continues to be underrepresented by minorities. According to the U.S. Census Bureau, only 4% of the physician workforce and 3% of dermatologists are African American, but 13.3% of the American population identified as black in 2016. For Sotonye Imadojemu, MD, MBE, director of the Cutaneous Sarcoidosis and Granulomatous Diseases Clinic at Brigham and Women’s Hospital, and instructor at Harvard Medical School, more work needs to be done to diversify the medical field. “I think that it’s important that medical professionals mirror the patient population that they serve. Also, by having a rich tapestry of people in academic settings alone, you can have a robust community of physicians who learn from each other and in general are better able to serve a similarly rich and diverse patient population.”

Dermatology World takes a look at the programs and institutions that paved the way for African Americans in medicine, and the challenges that still exist in diversifying the field.

Education

While education is requisite for anyone in the United States looking to break into the medical field, historically, the availability of educational opportunities for African Americans has been limited. “Before the Civil War, there was little-to-no education provided to Americans of African descent,” said Roselyn E. Epps, MD, a pediatrician and dermatologist who trained in pediatrics at Children’s National Medical Center, Washington, D.C., and in dermatology at Mayo Clinic, Rochester, Minnesota. Dr. Epps works at the U.S. Food and Drug Administration and is a member of the National Medical Association (NMA). “Before then, most people of color in medicine were educated in Europe or New England, if they were educated in the United States at all.” The segregation rules that were instituted in many states after the Civil War — and years later codified by the 1896 Plessy vs. Ferguson decision in which the U.S. Supreme Court decided that “separate but equal” was constitutional — kept many African Americans from joining their white colleagues at medical school.

Even before “separate but equal” was deemed constitutional in 1896, several schools were set up to provide African Americans access to higher education. These schools are now known as Historically Black Colleges and Universities (HBCU). “The HBCUs were founded by religious organizations and philanthropic individuals and they provided the bulk of education for African Americans and free slaves — men and women,” Dr. Epps said. Dr. Epps graduated from Howard University College of Medicine, located in Washington, D.C., which established its medical school in 1868. It wasn’t until 1965 when Congress passed the Higher Education Act, designating these schools — that were developed prior to 1964 — as HBCUs. With this designation, the 100 HBCUs located in 19 states, the District of Columbia, and U.S. Virgin Islands were finally eligible to receive federal funding along with other federally funded educational institutions. “Today, the HBCUs that are still in existence are quite a multi-cultural environment,” said Dr. Epps. “HBCUs have always welcomed everyone and they provide needed education for students and a rich experience and support system.”

With the 1954 Brown vs. Board of Education decision — that stated that separate but equal rules in education were unconstitutional — educational opportunities at other institutions started to open up for African Americans. Regardless, for Valerie Callender, MD, member of the Academy Board of Directors, founding member of the Skin of Color Society, and professor of dermatology at Howard University College of Medicine, the value of these HBCUs remains. “HBCUs help with student development when it comes to self-confidence and self-image because these schools are very nurturing,” Dr. Callender said. “If you’re in an environment where you feel that this is where you’re supposed to be and everyone around you is so supportive, that really helps self-confidence and your ability to learn.”

Retired Brigadier General and dermatologist Norvell V. Coots, MD, MSS, president and CEO of Holy Cross Health, agrees and adds, “I think that there are still some diversity and ethnic biases in medical school. When I went to the University of Oklahoma for medical school, I was one of seven African Americans out of a class of 175. That was not reflective of the population of Oklahoma. I think that there is still a role for places like Meharry and Howard medical schools in providing a portal of entry for minority medical students.”

The military

Along with HBCUs, the military is also considered a significant player in the efforts to increase diversity in medicine, and is often thought to be ahead of its time in terms of diversity and integration. “The military has been historically one of the first large organizations that was integrated and had large numbers of minorities,” said William D. James, MD, from the department of dermatology at the University of Pennsylvania, and past Academy president. Dr. James began his academic career at the U.S. Military Academy at West Point and after medical school completed a medical internship at Walter Reed Army Medical Center in Washington, D.C., and his residency in dermatology at the former Letterman Army Medical Center in San Francisco. “The military had rules and regulations that you had to respect everyone and everyone was supposed to get equal treatment. It was an organization that historically had a culture of being more receptive to diversity.”

In fact, well before the Civil Rights Act of 1964, President Harry Truman signed Executive Order 9981 in 1948, which called for equality in the armed services. “Since the desegregation of the military, we have really been in the lead of the nation in terms of diversity and inclusion,” Dr. Coots said. “If you think about the military in general, we go all around the world, we marry people from all around the world, and we have children and we bring them back, so we are even more of a cultural melting pot than the nation as a whole.” U.S. Army Surgeon General and Commanding General of U.S. Army Medical Command, LTG Nadja West, MD, agrees and adds that the military’s emphasis on diversity has continued throughout the years. “In recent years in the Army we have really done quite a bit with initiatives to enhance diversity across the whole Army. In early 2017, there was an Army directive focused on promoting diversity and inclusion. It charged the Army leadership with developing and implementing a plan to ensure that we have a diverse pool of qualified talent…in all of our branches at all ranks, to foster diversity of thought; and also to cultivate a variety of leaders who can serve as role models for their troops.”

From a medical perspective, according to Dr. Coots, even before President Truman’s executive order, African Americans were serving in military medical roles as far back as World War I. “There were actually 104 black doctors who were serving with the two black divisions that deployed to Europe. However, Gen. John J. Pershing saw their value so he allowed several of the black physicians to stay behind in France after the war and get more training,” Dr. Coots said. “There was one in particular, Captain Charles O. Hadley, MD, who — after he returned from studying in France — opened his own dermatology and syphilology lab at Meharry. He may have actually been the first African American dermatologist. However, Dr. Lawless is the name we know.”

Today, the military’s emphasis on diversity and equality continues to play a strong role in diversifying the medical field. “Medicine is historically still underrepresented by minorities, but the factors that allow more blacks and other minorities to get into medicine have to do with education and the accomplishments they can achieve while enlisted,” said Col. Jeff Hutchinson, MD, associate dean and chief diversity officer at Uniformed Services University (USU) School of Medicine (SOM). To start, the Army, Navy, and Air Force offer the Health Professional Scholarship Program (HPSP) to both current and prospective medical students. These scholarships cover civilian medical school tuition in exchange for future service. “There aren’t necessarily any racial quotas that I know of,” Dr. Coots said, “but in the military they periodically take a look at the breakdown of enlisted and officer ranks, and professional and non-professional, to see if they need to make an attempt to bring in more African Americans, Asians, or Hispanics to make sure that they have the right ethnic mix to match the overall military population.”

Similarly, the USU School of Medicine offers a draw to potential medical students that the civilian medical schools cannot: no tuition. “We offer the ability to be educated in exchange for service,” said Dr. Hutchinson. According to its Diversity and Inclusiveness Accomplishments for 2016, USU has seen a steady increase in the percentage of African American matriculants — up to 5.3% in 2016 from 2.3% in 2011. Moreover, “The people we train end up becoming instructors in other places. All of the influence we have here to ensure that the 170 graduates per year understand the importance of diversity, really spreads to the entire military medicine. Additionally, when people get out of the military, that influence really goes out into the rest of medicine too.”

The value of diversity

For physicians and patients alike, the value of diversity in medicine is significant. According to a study published in JAAD, “race-concordant visits are longer and have higher ratings of patient positive affect than race-discordant visits” (2016: 74(3):584-587). “From the patient’s perspective, everyone wants to feel that they are understood. There are only so many physicians that you can see before you suddenly realize that you’re not seeing yourself,” Dr. Coots said. Additionally, “There’s something cultural that people do miss.” Dr. Coots remembers working at a dermatology clinic with another dermatologist who gave a prescription for Eucerin to all of the white patients with eczema, but told the African American patients to use Crisco from their kitchens. When asked about why he was differentiating his recommendations the physician replied, “‘All black people fry their food, so everybody has a can of Crisco on the shelf.’ I thought to myself, ‘I don’t remember ever seeing a can of Crisco in the kitchen growing up,’ but that’s what he believed. If you don’t have diversity in physicians, then you will forever treat people with whatever bias you have in mind.”

From the clinical side of things, Dr. Imadojemu argues that having a more diverse medical field may provide more comprehensive patient care. “While medicine is often thought of as being scientific — analyzing and using data to set recommendations — there’s a huge component of medicine that is subjective and intangible. For example, when LTG West was completing her dermatology residency, she encountered an African American female patient who had recently seen one of LTG West’s colleagues for itchy scalp. The patient was in tears. “He had asked her how often she washed her hair and she replied once a week. His reply was, ‘Once a week?!’ She was in tears because she didn’t want him to think that she had poor hygiene.” Unfortunately, LTG West’s colleague didn’t understand that African American hair may require different hair care practices. “We tend to have really dry, brittle hair and we can’t wash our hair every day. We can’t or we won’t have any if we keep doing it on a routine basis,” said LTG West. Turns out, “The problem was that she had seborrheic dermatitis. My colleague said that it was eye opening for him because he said he needed to learn about all of his patient populations.”

Additionally, “From the physician’s perspective, it’s important to interact with others and learn about other cultures and ethnicities that may affect patient care,” Dr. Epps said. When it comes to caring for patients of color, “In dermatology it’s important because there are differences, not only in skin color but also with ethnicity and genetics,” Dr. Epps said. “We’re moving toward an era of precision medicine, and medicine will be practiced on the level of individual genes. There are medications and other therapies that are geared specifically toward specific genotypes, so it is important to understand different ethnicities.”

In the near future, the demand for expertise in treating African American hair, nails, and skin may increase, as a recent report issued by the U.S. Census Bureau indicates that the United States is becoming more diverse. Between July 2015 and July 2016, the African American population in the U.S. increased by 1.2 percent to 46.8 million, while the white population grew by only 0.5 percent to 256 million. As the U.S. population becomes increasingly diverse, Amit Pandya, MD, chair of the Academy’s Diversity Task Force, argues that unless the specialty becomes more representative of the general population, the consequences for the nation’s health care system could be dire. “Health care disparities are very high in America — America ranks on the lower end of the spectrum among industrialized countries in the world and it turns out that the greatest health care disparities in America are present in African American, Hispanic, Native American and rural communities,” Dr. Pandya said. However, “Multiple studies have shown that physicians from these groups are more likely to take care of those populations and accept Medicaid. So diversification of the United States’ physician workforce can actually decrease health care disparities.”