By Nneka Nwabueze, Equal Justice Society, Summer Legal Intern & JD Candidate at Howard University School of Law ’27
To understand and address health inequity today, it is important to know that many of the disparities we see now are rooted in decisions and policies that were created over a century ago. One of the most consequential among them was the Flexner Report of 1910. Commissioned by the Carnegie Foundation and authored by Abraham Flexner, the report evaluated medical schools in the United States and became part of the foundation of the American medical education model.[1]
The Flexner report explicitly criticized Black medical schools as being deficient as a whole, even stating that these medical schools were wasting money and sending out undisciplined men who were untrained.[2] Flexner concluded that Black physicians were inferior to white physicians in both their ability and their intellect.[3] Flexner also prioritized the duty that Black physicians had to keep African Americans healthy enough not for their own benefit, but so as not to “contaminate” nearby white people who lived in close contact with Black people.[4]
Flexner’s report had lasting and devastating consequences.[5] As a direct result of the Flexner report, five Black medical schools were closed—Knoxville Medical College, Leonard Medical School at Shaw University, Louisville National Medical College, New Orleans University Medical College, and the University of West Tennessee College of Physicians and Surgeons.[6] By 1923, the only two remaining Black Medical Schools were Howard University Medical College and Meharry Medical College, both of which are still open today.[7] For decades, these schools have served as pipelines for aspiring Black physicians, overcoming numerous obstacles in their efforts to diversify the healthcare field.[8]
Despite the vital role that Howard and Meharry have played in educating Black physicians, the long-term impact of the Flexner Report is stark.[9] By 1968, Black students made up only 2% of those enrolled in U.S. medical schools.[10] A study conducted by the Journal of the American Medical Association in 2020 estimated that if all of the Black medical schools that existed in 1910 had remained open, the number of Black physicians in 2019 alone would have been 29% higher.[11] In the 1970s, Morehouse School of Medicine and the Charles R. Drew University of Medicine and Science were established.[12] These four schools comprise 3% of the country’s medical schools and, by 2015, had produced 18% of Black medical graduates.[13] This helps fill a critical gap but is not enough to make up for the deficit wrought by the Flexner Report.
As we strive to diversify the medical workforce and improve patient outcomes, it is crucial to understand how policies like the Flexner Report laid the groundwork for today’s disparities. The harmful effects of the Flexner Report extend beyond medical education and into the doctor-patient relationship.[14] Numerous studies have shown that African American patients feel an increased amount of trust and cultural understanding when being cared for by Black physicians.[15] This can be a matter of survival as studies have also shown that when Black newborns are cared for by Black physicians, rather than white physicians, their death rate is a third lower than it would be otherwise.[16]
The impact of the Flexner Report shows us that current disparities are intentional, not accidental. To repair its devastating effects, we must keep investing in and greatly expand Black medical education and work towards creating a healthcare system that truly represents and serves every community.
[1] Thomas P. Duffy, The Flexner Report –100 Years Later, Yale J. Biol Med. (Sept. 2011), https://pmc.ncbi.nlm.nih.gov/articles/PMC3178858/.
[2] Megan Tenant, Racial Inequality in Medicine: How Did We Get Here?, Georgetown Medical Review (July 27, 2021), https://gmr.scholasticahq.com/article/25142-racial-inequality-in-medicine-how-did-we-get-here.
[3] Id.
[4] Terri Laws, How Should We Respond to Racist Legacies in Health Professions Education Originating in the Flexner Report?, AMA Journal of Ethics (Mar. 2021), https://journalofethics.ama-assn.org/article/how-should-we-respond-racist-legacies-health-professions-education-originating-flexner-report/2021-03.
[5] Tenant, supra note 2.
[6] Id.
[7] Id.
[8] Laws, supra note 4.
[9] Tenant, supra note 2.
[10] Id.
[11] Id.
[12] Laws, supra note 4.
[13] Id.
[14] Tenant, supra note 2.
[15] Id.
[16] Charlie Plain, Black Newborns die less when cared for by Black doctors, University of Minnesota (Aug. 2020), https://www.sph.umn.edu/news/black-newborns-die-less-when-cared-for-by-black-doctors/.
Reparación de daños: El informe Flexner y el futuro de la educación médica afroamericana
By Nneka Nwabueze, Equal Justice Society, becaria legal de verano y candidata a doctora en jurisprudencia en la facultad de derecho de la Universidad de Howard ’27
Para entender y abordar la inequidad actual en la salud, es importante saber que muchas de las disparidades que vemos en el presente nacen de decisiones y políticas creadas hace más de un siglo. Una de las más dañinas de ellas fue el informe Flexner de 1910. Encargado por la Carnegie Foundation y redactado por Abraham Flexner, el informe evaluó las escuelas de medicina de EE. UU. y se convirtió en uno de los fundamentos del modelo de educación médica estadounidense.[1]
El informe Flexner criticó explícitamente a las facultades de medicina afroamericanas por considerarlas deficientes en su totalidad, e incluso indicó que estas facultades de medicina estaban malgastando dinero y produciendo profesionales indisciplinados con una capacitación deficiente.[2] Flexner concluyó que los médicos afroamericanos eran inferiores a los blancos tanto en sus capacidades como intelectualmente.[3] Flexner también priorizó el deber que tenían los médicos afroamericanos de mantener saludables a los afroamericanos no para su propio beneficio, sino para no “contaminar” a la gente blanca que vivía en contacto estrecho con personas afroamericanas.[4]
El informe de Flexner tuvo consecuencias duraderas y devastadoras.[5] Como resultado directo del informe Flexner, se cerraron cinco facultades de medicina afroamericanas: Knoxville Medical College, Leonard Medical School at Shaw University, Louisville National Medical College, New Orleans University Medical College, y University of West Tennessee College of Physicians and Surgeons.[6] En 1923, las únicas dos facultades de medicina afroamericanas restantes eran Howard University Medical College y Meharry Medical College, que existen hasta la fecha.[7] Durante décadas, estas facultades educaron a aspirantes de medicina afroamericanos superando numerosos obstáculos en su esfuerzo por diversificar la industria de la atención médica.[8]
A pesar del papel vital que han tenido Howard y Meharry en la educación de médicos afroamericanos, el efecto de largo plazo del informe Flexner es extremo.[9] Para 1968, los estudiantes afroamericanos conformaban solo un 2% de los estudiantes matriculados en facultades de medicina en EE. UU.[10] Un estudio llevado a cabo por la Asociación Médica Estadounidense (American Medical Association) en 2020 estimó que, de haber permanecido abiertas todas las facultades de medicina afroamericanas que existían en 1910, la cantidad de médicos afroamericanos en 2019 solamente hubiera sido del 29% o más alta.[11] En la década de los 70, se fundaron Morehouse School of Medicine y Charles R. Drew University of Medicine and Science.[12] Estas cuatro universidades conforman el 3% de las facultades de medicina del país y, para 2015, habían producido el 18% de los graduados de medicina afroamericanos.[13] Esto ayuda a cerrar la brecha crítica, pero no es suficiente para superar el déficit causado por el informe Flexner.
En la lucha por diversificar la fuerza de trabajo médica y mejorar los resultados para los pacientes, es esencial entender el modo en el que las políticas como la del informe Flexner sirvieron de fundamento para las disparidades de hoy. Los efectos dañinos del informe Flexner van más allá de la educación médica e invaden la relación entre los pacientes y los médicos.[14] Numerosos estudios han demostrado que los pacientes afroamericanos sienten más confianza y comprensión cultural cuando son atendidos por médicos afroamericanos.[15] Esto puede ser un asunto relacionado con la supervivencia ya que los estudios también han demostrado que, cuando los recién nacidos afroamericanos están al cuidado de médicos afroamericanos y no blancos, su tasa de mortalidad es un tercio más baja que cuando es al revés.[16]
El efecto del informe Flexner nos muestra que las disparidades actuales son intencionales y no accidentales. Para reparar sus efectos destructivos, debemos invertir en y expandir la educación médica afroamericana y trabajar para crear un sistema de atención médica que realmente representa a la comunidad y la sirve.
[1] Thomas P. Duffy, The Flexner Report –100 Years Later (El informe Flexner: 100 años más tarde), Yale J. Biol Med. (Septiembre de 2011), https://pmc.ncbi.nlm.nih.gov/articles/PMC3178858/.
[2] Megan Tenant, Racial Inequality in Medicine: How Did We Get Here? (Inequidad racial en medicina: ¿Cómo llegamos aquí?), Georgetown Medical Review (27 de julio de 2021), https://gmr.scholasticahq.com/article/25142-racial-inequality-in-medicine-how-did-we-get-here.
[3] Id.
[4] Terri Laws, How Should We Respond to Racist Legacies in Health Professions Education Originating in the Flexner Report? (Cómo deberíamos responder a los legados racistas en la educación de profesionales médicas originados por el informe Flexner?, Jornal de ética de la AMA (Marzo de 2021), https://journalofethics.ama-assn.org/article/how-should-we-respond-racist-legacies-health-professions-education-originating-flexner-report/2021-03.
[5] Tenant, supra nota 2.
[6] Id.
[7] Id.
[8] Leyes, supra nota 4.
[9] Tenant, supra nota 2.
[10] Id.
[11] Id.
[12] Leyes, supra nota 4.
[13] Id.
[14] Tenant, supra nota 2.
[15] Id.
[16] Charlie Plain, Black Newborns die less when cared for by Black doctors, (Los recién nacidos afroamericanos mueren menos cuando están al cuidado de médicos afroamericanos) University of Minnesota (Agosto de 2020), https://www.sph.umn.edu/news/black-newborns-die-less-when-cared-for-by-black-doctors/.
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