Addressing Challenges Faced by Underrepresented Biomedical Investigators and Efforts to Address Them: An NHLBI-PRIDE Perspective

Abstract

Junior investigators from groups underrepresented in the biomedical workforce confront challenges as they navigate the ranks of academic research careers. Biochemical research needs the participation of these researchers to adequately tackle critical research priorities such as cardiovascular health disparities and health inequities. We explore the inadequate representation of underrepresented minority investigators and the historical role of systemic racism in impacting their poor career progression. We highlight challenges these investigators face, and opportunities to address these barriers are identified. Ensuring adequate recruitment and promotion of underrepresented biomedical researchers fosters inclusive excellence and augments efforts to address health inequities. The Programs to Increase Diversity among Individuals Engaged in Health-Related Research (PRIDE), funded by the National Heart, Lung, and Blood Institute (NHLBI), is a pilot program by the National Institutes of Health (NIH) that aims to address these challenges yet, only a limited number of URM can be accepted to PRIDE programs. Hence the need for additional funding for more PRIDE or PRIDE-like programs. Here we aim to examine the challenges underrepresented minority biomedical investigators face and describe ongoing initiatives to increase URM in biomedical research using the NHLBI-PRIDE program as a focus point.

Introduction

Cardiovascular diseases (CVD) disproportionately impact Black, Indigenous, and Hispanic populations, a.k.a. underrepresented minorities (URM), compared to White persons.¹ Optimal cardiovascular health for all is impeded by the underrepresentation of investigators from diverse racial and ethnic groups and the persistence of health disparities and health inequities.² Underrepresented biomedical investigators in CVD often lack the training, resources, and support to address issues that affect the health of URM populations.³ A diverse cardiovascular (CV) research workforce may be instrumental in addressing these disparities.⁴ Well-trained and highly motivated URM scientists are more likely to work in underserved areas with minorities and low-income populations.^{5, 6} URM biomedical investigators tend to have similar backgrounds, experience, and cultural understanding of minority populations and can serve as effective pivots in facilitating effective recruitment, retention, and interventions.⁷ Race concordant patient-provider relationships may improve the quality of communication experienced by patients and subsequently adherence to treatment.⁸

Understanding challenges faced by URM scientists and proffering effective solutions can diversify the biomedical scientist pool. The National Heart, Lung, and Blood Institute (NHLBI)-sponsored Programs to Increase Diversity Among Individuals Engaged in Health-Related Research (PRIDE) has a proven track record of training diverse cohorts of junior faculty who achieve academic success and address CVD disparities.⁹ Here we aim to examine the challenges underrepresented minority biomedical investigators face and describe ongoing initiatives to increase URM in biomedical research. We conclude with recommendations for the sustainability of the ongoing initiatives.

Inadequate Representation of URM Biomedical Investigators

A diverse biochemical research workforce is advantageous because the diversity of viewpoints leads to a wider variety of novel research questions for studying emerging diseases, response to treatments, novel clinical decision-making tools, and ways to reduce health disparities. Biomedical research is being impeded by the underrepresentation of investigators from diverse racial, ethnic, and socioeconomic backgrounds.³ The lack of URM researchers is more a symptom of the society-wide effects of capitalism and racism on poor people and racial minorities rather than a cause of health disparities (Figure 1). Nevertheless, this underrepresentation plays a major role in massive health disparities. The 1985 United States Surgeon General’s report recognized that health disparities were prevalent and endemic, specifically showed that large disparities exist between minority populations (Black, Hispanic, and Native American/Alaska Native persons) and their White counterparts for many health indicators.¹⁰ There is a higher prevalence of risk factors for CVD risk factors such as obesity, and hypertension among URM.^{11, 12} The higher incidence of COVID-19 infections, hospitalizations, and mortality rates among Black, Indigenous, and Hispanic Americans have been linked to preexisting CV risk factors.^{11, 12} Health disparities may be due in part to disparities in access to care. For instance, Hispanic individuals were found to be less likely to receive cardiac medications after myocardial infarction,¹³ and discharge instructions.¹⁴ Black patients are less likely to have coronary artery bypass surgery,¹⁵ or receive care by a cardiologist when being treated for heart failure in the intensive care unit.¹⁶ Additionally, Black patients are more likely to receive lower-than-required doses of dialysis¹⁷ and less likely to receive kidney transplants.¹⁸ Almost four decades after the United States Surgeon General’s report, CVD-related health disparities persist partly due to a lack of investment in scientists who are more likely to find solutions to health-related issues in their community.^{1, 19}

Figure 1. Solutions to Challenges to Achieving a Diverse Biomedical Workforce and Health Equity.

Figure 1 shows the challenges impacting the representation of underrepresented minority in biomedical research and suggested solutions to address the challenges.

The National Institute of Health (NIH) has identified the need for URM faculty in academia. Nevertheless, biomedical investigators from racial and ethnic groups face herculean challenges when navigating through the ranks of biomedical research careers.² In a study of NIH R01 applicants’ successful funding based on race/ ethnicity (FY 2000 and FY 2006), results indicated that Black and Asian applicants were respectively 13 and 4 percent points less likely to be awarded funding compared to their White counterparts. This disparity persisted after controlling for the applicant’s educational background, training, previous research awards, publication record, and employer characteristics.²⁰ The authors posited that the racial/ethnic gap in NIH funding is associated with cumulative and structural disadvantages, including a lack of resources and mentoring.²⁰ Fifteen years after this landmark study, the racial funding gap in research persists, with Black and Asian scientists representing 3% and 23% of NIH-funded investigators, respectively, compared to Whites (73%) (Figure 2). Although the NIH prioritizes the recruitment and retention of biomedical investigators regardless of ethnicity, race, disability, gender, or socioeconomic background, barriers to retention remain. These barriers create an “untapped potential” of scientific discovery.

Figure 2. Trends in Race/Ethnicity of NIH-Supported Ph.D. Recipients & Number of NIH Principal Investigators Funded by Grant Mechanism and Race 2020 (Adapted from the National Institutes of Health).

Figure 2: The left side picture was adapted from: https://report.nih.gov/nihdatabook/report/270 and the right side was adapted from https://report.nih.gov/nihdatabook/report/30

Barriers to recruitment and retention, such as lack of mentorship and funding of URM investigators, create an “untapped potential” for scientific discovery. Despite the fact that the NIH has a long history of striving to diversify its intramural and extramural biomedical research workforce, the effects of these efforts remain lukewarm. Alternative sustainable strategies are needed as the current system has only marginally improved the underrepresentation of URM in biomedical research, who may be more invested in communities afflicted by cardiovascular disparities. The widening chasm of the health disparities illuminated by the COVID-19 pandemic’s affliction of URM makes a case for further urgent, innovative, inclusive, and aggressive recruitment and training of a diverse workforce.

Impact of Structural Racism on Underrepresented Minority in Academia

Structural racism refers to “the normalization and legitimization of an array of dynamics–historical, cultural, institutional and interpersonal–that routinely advantage White individuals while producing cumulative and chronic adverse outcomes for people of color.”²¹ It leads to “differential access to the goods, services, and opportunities of society by race,” determines societal values and power hierarchies, and underlies persistent health disparities in the US.²² The widening chasm of racial inequality and the concurrent civil unrest in the US in 2020 following the murders of unarmed Black men and women has led to a re-examination of the role of structural racism in the American biomedical research workforce.²³

As of July 1, 2019, 5% (45,534) of US physicians identified as Black or African American, 5.8% (53,526) as Hispanic and 0.3% (2570) as American Indian or Alaskan Native, and 0.1% (941) as Native Hawaiian or other Pacific Islander.²⁴ This underrepresentation reflects systemic racism rooted in academic medical institutions, traditionally the bedrock of biomedical research. In the early 20th century, most U.S. medical schools did not admit Black individuals, and neither did hospitals grant privileges to Black physicians.²⁵ Black physicians mainly attended historically Black colleges and universities (HBCUs)—including Howard University College of Medicine or Meharry Medical College, the two schools that survived the 1910 Flexner Report,²⁶ which recommended shuttering other existing Black medical schools. The Hospital Survey and Construction Act of 1946 (also known as the Hill-Burton Act), which provided federal support for separate-but-equal hospitals, further eroded diversity in medicine.²⁷ To this day, HBCUs remain central to the training of many URM scientists, and almost 92% of Black medical school graduates come from two HBCUs: Xavier University and Howard University. Yet, HBCUs have secured less than 1% of the funding available at NIH over the years. The NIH Small Business Program Office (SBPO) has taken part in key initiatives to support and address the underfunding challenges facing HBCUs. The SBPO’s partnership initiative will help HBCUs expand their research ecosystem, generate new revenue streams, and continue contributing to the advancement of discoveries and groundbreaking technologies.

Challenges faced by URM lead to underrepresentation, which may impede efforts to address the health disparities. From a health equity perspective, the COVID-19 pandemic had the dual effect of 1) exposing the stark health disparities in CV health with worse health outcomes in ethnic minorities and 2) limited training and mentoring opportunities exacerbated by lack of physical interaction, access to technology and broadband internet, which were implemented as necessary safety measures. The COVID-19 pandemic led to increased mortality among ethnic minorities and increased gender and racial inequalities with associated job/income losses which further widened the wealth gap and has been called the “pandemic of inequality”.³⁰

Challenges facing URM Biomedical Investigators in Academia

From a pipeline perspective, the cascade effect of structural racism leads to the lack of “cumulative advantage” across the span of scientific educational experience from kindergarten through graduate school and “variability in access to mentoring and resources”- two important contributory factors to the underrepresentation of minorities in biochemical sciences (Figure 2).

Lack of effective mentorship from URM investigators from graduate schools³² weakens the foundation to build their academic careers. The National Center for Education Statistics reported that, in 2015, non-Hispanic Whites comprised 71.33% of full-time faculty in degree-granting postsecondary education; compared to Hispanic and Black faculty (at 4.43% and 5.47%, respectively).³³ This dismal statistic leads to few mentors of color and can lead to junior URM scholars leaving academia at higher rates.³⁴ Fewer URM mentors can lead to a lack of attention to the needs of the individual minority faculty leading to social isolation in navigating unfamiliar academic terrain.³⁵ Often, the commitment of the academic institution to the advancement of the minority faculty is touted publicly but not seen in the institutional culture, and there is a lack of reward system for the few committed faculty mentors who are expected to perform multiple diversity initiatives.

Research funding enables research conduct, and successful investigator-initiated NIH R01 grant funding and publications are standard metrics for assessing research funding success. However, Black applicants reported fewer publications and had fewer citations in journals with lower impact factors that may contribute to less success with grant applications.³⁶ Funding agencies utilize metrics such as the number of publications and prior research experience and funding. Based on the lack of a “cumulative advantage”,³¹ URM faculty may not meet the “expected” benchmarks for funding because their number of publications and/or citations may not be considered competitive. Inextricably, the lack of federal funding may, in turn, decrease URM faculty opportunities to obtain promotion and tenure.

Mentorship, obtaining funding, and publications are interconnected, leading to promotion and retention (Figure 4). Lack of promotion, retention and advancement of successful academic research career for junior investigators is usually due to two commonly reported challenges: 1) insufficient time to focus on research; and 2) conflicting work expectations, including high teaching or clinical loads while pursuing research.³⁷ Black women are underrepresented among tenured faculty.³⁸ The success of an academic career reflects the cumulative effects of lifetime education.³⁹ Due to a lack of an educational “cumulative advantage,” URMs enter academia at older ages than their White counterparts, taking longer to accumulate a comparable number of publications before being considered for tenure.⁴⁰ URM faculty have cited lack of mentorship and sponsorship, barriers to promotion and advancement, and lack of supportive -and sometimes hostile -work environment as factors in their attrition from academia.

Figure 4: Integration Plan for Career Advancement of URM Investigators.

Figure 4 shows an integration plan focusing on necessary components of career advancement.

Diversity initiatives by academic institutions are often within the purview of the few minority faculty. To ensure an antiracist mission and diversify leadership structures, institutions call on Black and minority faculty for assistance. Such service is important but often not recognized by academic institutions as an essential metric of academic success compared to funding and publications. The overtime spent on diversity initiatives comes at a cost for minority faculty - a toll known as the “minority tax.”⁴¹ In addition to the typical obligations of academic faculty, they are often expected to execute “diversity” efforts such as chairing diversity committees and mentoring minority trainees in addition to achieving their research goals. Another factor that leads to URM attrition in academic ranks is that promising URM researchers are often recruited into administrative posts at the NIH or their universities, effectively ending their research and mentoring careers. Summarily, they are tasked with the complex chore of remedying the structural outcomes of centuries of institutionalized racism for which they are rarely recognized or compensated.⁴² Better funding for early schooling (middle/high schools) located in racially segregated neighborhoods, as well as early introduction to STEM mentoring programs, which are crucial in creating a future biomedical profession, are factors that need to improve the pipeline of talent within Black/URM communities. Inadequate financing and low teacher motivation are preventing these hurdles from being overcome.

Opportunities to address challenges facing minorities in academia

In 2006, the National Heart, Lung, and Blood, Institute (NHLBI) established Programs to Increase Diversity Among Individuals Engaged in Health-Related Research (PRIDE).^{2, 9, 43} PRIDE is a summer institute designed to address challenges faced by URM junior investigators and increase the numbers of scientist and research-oriented faculty who are historically underrepresented in biomedical research. PRIDE brings together URM across the USA for training in grant writing, mentorship and didactics, exposure to potential mentors, and fosters peer mentorship. Figure 3 is a timeline of multiple NIH efforts to improve the diversity of the biomedical workforce.

Figure 3. Timeline of NIH Diversity Initiatives.

Figure 3 shows the timeline of multiple NIH efforts to improve diversity of the biomedical workforce

PRIDE has ensured a diverse cohort with a high representation of URM trainees.³⁷ In a recent PRIDE study conducted between 2006–2018, there were 297 applicants, but only 136 junior faculty from 93 US institutions were retained due to limited slots available.⁹ These were: African-Americans (n=107; 79%), Hispanic-Americans (n=26; 19%), Native-Americans (n=3; 2%); 90 (66%) women; 96 (70%) PhDs (or equivalent doctoral degree), 36 (26%) MDs, and 4 (3%) MD/PhD’s.⁹ Grants submitted/awarded during and after two years post-training after excluding data from 19 individuals from the 2017–2018 cohort who were still in training were 187 peer-reviewed grant applications submitted by 117 mentees and 123 grants awarded (success rate: 66%).⁹ Additionally, 1,211 peer-reviewed manuscripts were published by 117 mentees, representing 3.3 times the number of publications (n=365) prior to participation. Finally, forty-one (35%) mentees were promoted to Associate Professor or Professor; of these, 37 (27%) to Associate Professor and 4 (3%) to Professor.⁹

PRIDE fosters mentoring of URM investigators by matching mentors with mentees of similar interests. By ensuring that mentees have mentors, PRIDE plugs a mentorship gap that has been touted as a source of early attrition of URM investigators. It has also aided career advancement by allowing for a better understanding of research procedures and the ability to undertake research.⁴³ It has also helped participants to increase knowledge about CV health-disparities focused research, successfully obtain research grant funding, and form a network with underrepresented colleagues and faculty.⁴³

The PRIDE program makes an intentional investment in career success through holistic review and dedicated career-path programming to ensure junior faculty development. These initiatives can address challenges that impede the career success of URM investigators and solve faculty attrition while increasing diversity in the cardiovascular research workforce.⁴⁴ In the 2019 iteration of PRIDE, the program added funding for the Small Research Project as seed money for generating the critical and needed preliminary data for grant applications. For many participants, securing grants is their first external step placing them on the path to promotion and successful careers. Despite the onset of the COVID-19 pandemic, PRIDE showed remarkable flexibility in transitioning to an entirely virtual program and effectively facilitated networking, promoted mental wellness, and allowed continual collaboration and mentorship.⁴⁵

Besides PRIDE, the NIH implements a diversity supplement and other NIH initiatives, including the UNITE, which is intended to tackle structural racism in the NIH and the greater scientific community.⁴⁶ Additionally, several requests for applications (RFA) through the National Research Mentoring Network to improve diversity in biomedical research exist.⁴⁷ While the NIH is open to suggestions and strategies to increase inclusivity and diversity in science; there should be intentionality by inviting and giving mentors of diverse backgrounds opportunities to lead these initiatives. That is, revising rules and guidelines that were not initially aimed at improving diversity in the first place instead of bending existing rules to achieve inclusivity and diversity. The Federal government has also bolstered these efforts via the Diversity, Equity, Inclusion, and Accessibility (DEIA) program, which aims “to cultivate a federal workforce that draws from the full diversity of the Nation and that advances equitable employment opportunities.” This initiative is unique because it included a roadmap to advance the DEIA.⁴⁸

Recently the NIH published RFA-MD-21–004, “Understanding and Addressing the Impact of Structural Racism and Discrimination on Minority Health and Health Disparities (R01 Clinical Trial Optional),” with the posted date of March 23, 2021. The deadline was August 25, 2021. Another initiative that began in 2021 was the Plan for Enhancing Diverse Perspectives (PEDP), where investigators are asked to submit a plan for including URM in research. The NIH BRAIN Initiative aims to ensure participation, engagement, partnership, use of project infrastructure, training and mentoring, transdisciplinary collaborations, and inclusion of community-based partners.⁴⁹ In addition to the PEDP, we suggest an integration plan (Figure 4). Funding is integral to academic career success. Successful retention of URM faculty requires comprehensive institutional commitment to changing the academic climate and deliberative programming to support productivity and advancement. All these challenges were addressed in the PRIDE programs and the latest NIH initiatives.

Improving URM in the biomedical workforce will require a culturally affirmative societal shift so that diversity and inclusion become the standards, the modus operandi, leading to excellence. The NIH and the academic institutions must be applauded for their efforts to improve diversity in the biomedical research workforce. However, further energy must be dedicated to ensuring that these initiatives are followed by tangible actions taken to measure their short- and long-term impacts. In fact, increasing the representation of URM in biomedical research will require enhancing access to more accurate and relevant data — like more information on certain characteristics of NIH applicants’ institutions. The absence of such data and more might perpetuate the challenge of identifying diversity and achievement gaps. This culture must start with childhood experiences and increasing resources for families. Research and investment efforts must address the disparities in elementary and secondary education that ultimately influence the progress URM students make throughout the higher education pipeline.

Additionally, expanding mentoring programs can help reduce the high turnover rates among URM faculty. NIH and academic institutions should further consider rewards and incentives for faculty mentors who invest time and energy in the career development of minority faculty. Table 1 illustrates multiple initiatives to dismantle structural racism that can lead to a diverse biomedical workforce, inclusive excellence, and health equity.

Table 1.

Some of the ongoing initiatives to promote diversity

Initiatives	Objectives/Mission
Programs to Increase Diversity Among Individuals Engaged in Health-Related Research (PRIDE)	“This initiative addresses the difficulties experienced by junior investigators and transitioning postdoctoral scientists in establishing independent academic research careers and negotiating through the academic ranks”
Diversity, Equity, Inclusion, and Accessibility (DEIA)	“Established and affirmatively advancing equity, civil rights, racial justice, and equal opportunity is the responsibility of the whole of our Government.”
National Research Mentoring Network	“To provide researchers across all career stages in the biomedical, behavioral, clinical, and social sciences with the evidence-based mentorship and professional development programming that emphasizes the benefits and challenges of diversity, inclusivity and culture.”
MOSAIC Postdoctoral Career Transition Award to Promote Diversity (K99/R00)	“To enhance workforce diversity by facilitating a timely transition of promising postdoctoral researchers from diverse backgrounds.”
Plan for Enhancing Diverse Perspectives (PEDP)	“Is a summary of strategies to advance the scientific and technical merit of the proposed project through inclusivity. Broadly, diverse perspectives refer to the people who do the research, the places where research is done, as well as the people who participate in the research as part of the study population”

Limitations

All the authors of this paper are affiliated with the NHLBI PRIDE program as faculty or scholars. Although every effort has been made to be objective in the analysis, authors may be more favorably predisposed towards describing PRIDE due to their overall positive experience with the PRIDE program..

Conclusion

URM investigators face peculiar challenges which can lead to isolation and attrition. Reducing barriers to academic success and promoting research areas will enhance the diversity of the biomedical research pool. Career development programs targeting URM investigators such as the NHLBI-PRIDE program can foster mentorship, lessen attrition, provide adequate funding for generating preliminary data, create a pool of mentors and lead to career progression in academia. Diversifying the biomedical research pool with well-trained underrepresented minorities may reduce health disparities, better science, and better health outcomes for all.

Abbreviations:

NHLBI

National heart Lung Blood Institute

PRIDE

Programs to Increase Diversity Among Individuals Engaged in Health-Related Research

CVD

Cardiovascular Disease