The Role of Historically Black Colleges and Universities in Training the Health Care Workforce

Abstract

Historically Black colleges and universities (HBCUs) continue to be overlooked as a resource to address health care workforce shortages and growing needs for a diverse health workforce, despite our commitment as a nation to health equity and eliminating health disparities.

Health workforce graduation rates help illuminate the roles of institutions of higher education in meeting workforce needs. Effective approaches to eliminating disparities invest and leverage resources that address our health workforce and diversity deficits.

We must recognize HBCUs as a valuable resource for educating underrepresented groups as health professionals. Increasing resources and enhancing support for building the capacity of HBCUs to produce health professionals is vital to addressing disparities and achieving health equity for our nation.

People of color are disproportionately represented in health professional shortage areas. They represent more than 25% of the total population, but only 10% of health professionals.

Historically, people of color have been underrepresented in all of the primary health professions. According to one source, between 2000 and 2006 the profession with the highest proportion was pharmacy (9.9%) and with the lowest was dentistry (5.4%). Public health was the only profession studied that had a substantial increase in African Americans during this period. In medicine, dentistry, nursing, and pharmacy, the percentage remained virtually unchanged.¹ In 2006, the Association of American Medical Colleges called for a 30% expansion of the total enrollment in medical schools.²

In 1996 there was one dentist for every 1700 persons but only one African American dentist for every 6150 African Americans. In 2002, an estimated 27 million persons lacked a dental provider, and 4300 more dentists were needed in the United States.³

The Health Resources and Services Administration estimates that the shortage of nurses will reach 29% by 2020. In 2000, only 4.9% of registered nurses were African American.⁴ The capacity for training nurses is severely inadequate. The National League for Nursing estimates that 99 000 applicants to nursing programs were turned away in 2008 because of inadequate capacity.⁵

In 2000, only 4.7% of pharmacists were African American and 3.2%, Hispanic. The pharmacist shortage decreased in the first decade of this century, and projections of its future magnitude differ.⁶ Effective July 1, 2007, the Accreditation Council for Pharmacy Education determined that the PharmD degree is the sole professional practice degree for pharmacy in the United States. It is too soon to determine the impact of this major modification in the pharmacy profession.

The ratio of public health workers declined from 220 per 100 000 population in 1980 to 158 in 2000.⁷ This decline is exacerbated by the absence of formal training in public health among four out of five public health workers. Approximately half of all public health workers will be eligible for retirement within the next decade. This looming insufficiency is most dramatic among public health nurses, who were 39% of public health workers in 1980 but were 17.6% in 2000. States report that the shortage of epidemiologists is approximately 50% and that 20 000 more public health laboratory professionals are needed. Although environmental professionals account for only 4.5% of the public health workforce, the need for such expertise is growing.⁸

The Integrated Postsecondary Education Data System comprises interrelated surveys conducted annually by the National Center for Education Statistics that provide demographic data on graduates.⁹ We reviewed data from this system from 2000 to 2008 and found information relevant to the role historically Black colleges and universities (HBCUs) can play in achieving the goals of health equity and the health professional education of African Americans.

MINIMAL PROGRESS

Despite the attention to ethnic health disparities in 2000 to 2008, the number of doctor of medicine degrees awarded annually to African Americans increased by only 88, from 1013 to 1101. The proportion of African Americans among recipients of these degrees increased only minimally, from 6.8% in 2000 to 6.9% in 2008. During this period, the number of medical degrees conferred by HBCUs increased by 2.8% and for all institutions by 7.4%. Only 1.43% of all medical degrees were conferred by HBCUs in 2000; this figure dropped to 1.37% in 2008.

Between 2000 and 2008, the total number of dental degrees conferred annually rose slightly, from 4171 to 4833. African Americans received 186 dental degrees in 2000 and 203 in 2008, a 9.14% increase. HBCUs awarded dental degrees to 82 African Americans in 2000 and only 78 in 2008, a 4.9% decrease. The number of degrees conferred by HBCUs was never higher than 2.9% of the national total. During this period, the number of dental degrees conferred by HBCUs increased by 2.5%; the increase for all institutions was 15.9%. Only 2.83% of all dental degrees were conferred by HBCUs in 2000; this figure dropped to 2.5% in 2008.

The number of baccalaureate degrees in nursing awarded to African Americans increased from 7760 in 2000 to 13 993 in 2008. However, the percentage of degrees awarded to African Americans was steady at 9.6%. During this period, the number of nursing graduates from HBCUs increased by 46.9%; for all institutions the increase was 80.1%. HBCUs conferred 2.04% of degrees in 2000 and 1.66% in 2008.

The number of pharmacy degrees conferred on African Americans was 557 (6.6%) in 2000 and 755 (6.7%) in 2008. In 2000, 48.7% of African Americans received their degrees from HBCUs and 46.2% in 2008. During this period the number of pharmacy degrees conferred by HBCUs increased 38% and by all institutions, 34.5%.

In public health, the number of degrees earned by African Americans was 820 in 2000 (11.5%) and 1859 in 2008, an increase to 15.6%. This was the only profession in which we found a substantive increase in the percentage of African Americans receiving degrees. During this period, the number of public health degrees conferred by HBCUs rose 16.1% and in all institutions, 67.2%. In 2000, 2.26% of all public health degrees were conferred by HBCUs; this figure dropped to 1.57% in 2008. No HBCU has an accredited school of public health, but at least two institutions made strenuous efforts toward achieving this objective during the period we studied.

Despite increasing numbers of African American graduates, the percentage of African Americans obtaining health degrees from HBCUs decreased over the period we analyzed. Medicine was the sole health profession of the five examined with an upward trend in HBCU degrees awarded to African Americans: 13.7% in 2000 to 14.6% in 2008. Dentistry degrees declined from 44.1% to 38.4%, nursing from 11.2% to 9.1%, pharmacy from 48.7% to 46.2%, and public health from 17.4% to 8.2%.

The source of our data was not complete, and improved data quality and accurate reporting would improve our knowledge. However, the differences we found were so dramatic that better reporting and documentation would not change the patterns.

A NEGLECTED RESOURCE

The 105 HBCUs in this country are a significant and underused resource in the effort to achieve health equity. HBCUs have played an important role in the education of people of color for more than 150 years. During the last quarter of the 20th century, their role was questioned, and the number of African American students in traditionally White institutions increased dramatically. During the first decade of the 21st century, however, student enrollment in HBCUs increased, along with the number and variety of degrees they pursued.

The Institute of Medicine report Unequal Treatment,¹¹ the Sullivan Commission report,¹² and many other publications have detailed the underrepresentation of people of color in the health professions. They have documented that people of color prefer providers of color and that providers of color are more likely to serve minority communities. In addition, underrepresented minority students admitted to medical schools under affirmative action programs are as likely as nonminority students to graduate, pass licensing tests, and enter practice, despite having lower Medical College Admissions Test scores and grade point averages.¹⁰

Most health professional training programs function within universities with a broad commitment to diversity, but only 3% of health professional schools have a specific commitment to diversity.¹³ However, the Grutter v Bollinger Supreme Court decision presents an ongoing justification for considering race and ethnicity in admitting students.¹⁴

HBCUs have a specific commitment to use all resources possible to provide a college education for all potentially capable students of color. They use qualitative as well as quantitative assessments in student admission, people of color are integral to their admissions process, and financial barriers to students are usually lower. They are still relevant and needed today despite the progress made in integrating the educational system in the United States. Yet their contribution to the education of a diverse health workforce has been minimal.

A review of African Americans receiving science doctorates from all institutions in 2006 revealed that more than one quarter received their bachelor's degrees from HBCUs.¹⁵ Furthermore, HBCUs graduated more African American with doctorates that year than did any other type of institution.¹⁵ Students at HBCUs have also been found to have better academic performance, greater social involvement, and higher occupational aspirations than do Blacks attending traditionally White institutions.¹⁶

The mission of HBCUs is to serve as a major provider of education for African Americans. Why are they not playing a larger role in the education of African American health professionals as we seek health equity? Why are the enrollments of some critically needed health professionals increasing dramatically in traditionally White institutions while they remain stable or are decreasing in HBCUs? Is there a need to address the number of accredited programs in HBCUs?

The number of degrees conferred by HBCUs in the five health professions we reviewed underscores the inadequacy of the number of programs in HBCUs, their funding, their value in the eyes of prospective students, and the overall support they receive for their potential to address the nation's most important health goals.

In medicine and dentistry, the need for practitioners of color has been recognized for decades, yet prospective students can apply to only three HBCU schools of medicine and two of dentistry. Although HBCUs’ graduation of African American practitioners increased slightly between 2000 and 2008, it did not keep pace with the increasing need nor with the graduation of African American medical and dental professionals from traditionally White institutions. The situation was even worse in nursing and public health.

In pharmacy, African American graduates of HBCUs increased slightly. This was the only profession with an HBCU graduation rate increase greater than the increase in traditionally White institutions. The HBCU pharmacy programs may serve as models for other health professional programs at HBCUs in increasing their marketability to African American students. This profession stood out because of its progress, but in 2008 only 7% of doctoral degrees in pharmacy were awarded by HBCUs.

CONCLUSIONS

HBCUs have traditionally played a key role in the education of African Americans and are positioned to play a critical role in the education of African American health professionals. Although the nation has undertaken a struggle for health equity, the capability of HBCUs to provide professional training for this population is being overlooked. Evidence shows that the performance of graduates with health professional degrees from HBCUs equals that of graduates of traditionally White institutions. Health professionals of color are accepted more readily by communities of color—often the least healthy communities. However, no meaningful increase in degrees conferred by HBCUs has occurred in recent years, despite the substantial increase in the total number of degrees awarded to African Americans in nursing, pharmacy, and public health.

A focused national strategy to enhance the role of HBCUs in the training of health professionals would increase the representation of people of color in the primary health professions and the effectiveness of the health equity strategy. The American Public Health Association has suggested restructuring titles VII and VIII of the Public Health Service Act to reestablish the key role of the Health Resources and Services Administration in the training of health professionals, particularly minorities.

Elimination of health disparities and achievement of health equity will redound to the benefit of the entire population. These goals cannot be achieved and the health of those most in need cannot be improved without vigorous support for and from HBCUs.