In the past year, the murders of Ahmaud Arbery, Breonna Taylor, and George Floyd have galvanized a long-overdue reckoning with institutional racism in the U.S. We know that systemic oppression of Black Americans is not contained within policing, but rather permeates institutions across the country from criminal justice to health care to housing. We, as part of an academic institution, are not immune to institutional racism. As many institutions attempt to grapple with racial discrimination among their ranks, we wanted to draw attention to how it presents in public health academia and practice, and in turn how disproportionate representation of whiteness impacts how we study, understand and change the world around us.
The Problem in Public Health and Maternal and Child Health
The COVID-19 pandemic has underscored the importance of quality public health measures and research for the health and well-being of society. Those who study and practice public health do not proportionately reflect the demographic composition of the U.S. population, and especially not of vulnerable and marginalized groups some public health practitioners seek to serve. In 2017, though academia is much more diverse now than it was a few decades ago, 74.5% of public health faculty members at universities were white and only 5.7% were Black. In addition, Black faculty members were more likely to hold assistant professor titles, the lowest rung on the professorship ladder. 81.1% of professors, the highest professor ranking, were white, whereas 2.8% were Black. This phenomenon is not unique to academia; in 2016 (the last year data were available), about 76% of employees funded through Title V state maternal and child health programs were white. Thus, in both public health academia and public health practice, racial and ethnic minorities are underrepresented.
Underrepresentation in public health and medicine has real consequences for population health. A wealth of research has suggested that health professionals who come from racially, ethnically and socio-economically disadvantaged backgrounds are more likely to study and serve those populations in medicine or through research. They are also more likely to demonstrate cultural competence, a term that encompasses the ability to understand and effectively communicate with individuals from different cultures. Communities who perceive a higher level of cultural competency among their public health care providers also reported better satisfaction with their care, communication with their providers and likeliness to recommend the hospital or facility to someone else.
It’s critical to build trust between researchers and the communities they are trying to understand. This doesn’t mean that you have to be a Black person to study Black people. However, particularly given the historical trauma inflicted upon Black and Brown communities for the sake of medical and public health research, public health researchers have the onus of proving to racial/ethnic minority communities that they are trustworthy. A researcher who shares a racial, ethnic, socioeconomic or cultural background with the populations they seek to serve could be better equipped to build those relationships. Right now, the vast majority of people in this field are white, middle-to upper-class women. How easy would it be for a vulnerable community to trust a group of people who are both very different from them and has historically marginalized and oppressed them? This disconnect is especially critical as it relates to maternal health issues such as preventing maternal mortality, promoting maternal mental health, and increasing access to prenatal care, where we see significant and enduring disparities along racial and ethnic lines.
This is true to many fields, however, in public health, especially maternal and child health, representation is particularly important and has direct consequences for health outcomes. Families represent the building blocks of society. If our public health research continues to alienate or fail to properly account for the reality children and families face, we as a society will continue to fail them. We see this across the board, with single-parent households facing higher rates of poverty and discrimination. We continually see major racial and ethnic disparities in maternal, neonatal, and infant mortality and health. We must continually move towards equitable representation as reflecting the population we serve is of utmost importance to developing a trusting and health-promoting relationship with the community.
However, representation is never where commitment to racial justice and equality should end. All public health practitioners, especially those in maternal and child health must commit to reducing the effects of systemic racism and discrimination. Otherwise, these pernicious racial and ethnic disparities will continue to exist and harm the health of our society as a whole.
Where Do We Go From Here?
We’ve seen an institutional recognition of these gaps, and federal leaders have taken steps to address them through increased funding opportunities to train racial/ethnic minorities in MCH. However, goals to increase the number of racial and ethnic minorities being funded will only benefit those who have already reached graduate-level education, which is woefully insufficient. Many who may have excellent potential to serve in maternal and child health face systemic barriers to quality education from pre-K all the way through college and into graduate school. Only addressing the gap in representation in maternal health leadership and academia at the graduate and doctoral level could be too little, too late.
The University of Chicago’s English Department adopted a perhaps radical approach, announcing that they will only admit graduate students who plan to work in Black studies. The department itself cited the Black Lives Matter movement and their own role in promoting prejudiced racial hierarchies in making this decision. It is yet to be seen whether this approach will foster racial and ethnic diversity among PhD students in the department, especially given no commitments regarding the background of admitted students.
The hard reality is that there are no quick fixes to addressing these challenges. The problem encompasses a complicated mix of many factors including poor preK-12 education access and quality, poverty, and parental wealth/employment opportunities. However, a few changes to higher education access could go a long way. First, we should further increase funding for college and graduate-level opportunities for under-represented minorities. Graduate schools could also move away from traditional admissions requirements or benchmarks. The GRE, the standardized test requirement for graduate school entry, is often more a proxy for a student’s ability to commit both the money and the time to study for and take the test rather than their potential as a future public health student and practitioner.
Academic institutions should also establish comprehensive support systems for first-generation and low-income college students, who again are disproportionately likely to be non-White. A peer mentoring program at Smith College, an institution that has transformed its admissions and financial aid processes to make it more accessible, has demonstrated success in that students of color who participate are 18-23% more likely to graduate with a degree in the sciences compared to science majors who do not participate.
Finally, academicians, especially maternal and child health academicians, must put their training to work supporting and raising communities of color. Academic and community partnerships in which university systems work closely with community and nonprofit leaders are essential both to inform research and practice and to ensure that the benefits of research and higher education are equitably dispersed in society. Centers of Excellence in Maternal and Child Health, MCH training programs supported through the Health Resources and Services Administration (HRSA) are practicing this, by actively seeking out and fostering relationships with community partners throughout the nation.
These solutions may still not be enough to fully meet the issues that under-representation present. Being a Black woman in America, for example, is not a uniform experience; single women living in extreme poverty face distinct challenges compared to women who grow up middle class and in two-parent households. If maternal and child health departments in universities and public agencies prioritize hiring Black women to work on projects designed to serve primarily poor Black families but fail to consider other demographic characteristics, they may still end up with a workforce that does not fully represent the people they’re attempting to serve.
Over-representation of white people in maternal and child health has measurable consequences for population health. Like other institutions grappling with systemic racism, these challenges will not be easy to overcome. However, the work that we do to include, uplift, and strengthen the health of the most vulnerable communities could most effectively address these issues. We must continue to invest not only in the internal promotion of those who make it into the system, but also low-income communities and communities of color to ensure that they have any equitable chance to participate in the system in the future.