April 2003 Bulletin

Thoughts on Diversity and Affirmative Action

By Augustus A. White, III, MD, PhD

I am grateful for the opportunity to discuss this complex and emotionally charged topic. These comments relate more to a helicopter view rather than to specific legal elements and technicalities. I wish to address the general issue of affirmative action, where it stands, where it ought to stand and why it ought to stand there.

Diversity is an evolving concept. It is a notion that I deeply respect because it requires wisdom far beyond my own. The perception of diversity is changing and developing, much as the concepts of freedom and democracy did many years ago. Diversity has reached no endpoint, it has a long way to go. Some of its ramifications, indications, utilizations and judgments remain to be determined.

I believe the American Association of Medical Colleges (AAMC) represents the thoughts of leadership in our profession as regards education. I think that we want to recognize their experience and expertise and to support their recommendation. The AAMC recognizes that affirmative action is, and has been, necessary to achieve diversity and change the ongoing under- representation of minority physicians. This is necessary to meet various prevailing societal needs.

I think it is proper, in another way, that the medical profession has taken leadership here. In my view, we, as clinicians and as physicians, should be societal leaders in issues of affirmative action, and in issues of racial bias and injustice. We in the medical profession have a humanitarian bent. We are trained to approach problems analytically, objectively and humanely. In other words, we are equipped to address racism clinically. Thus, it is appropriate that we take leadership in combating the various inequities that exist around issues of racial bias.

Let’s review some things that affirmative action does and does not do.

What affirmative action does not do

Affirmative action does not give advantages to minorities in our society. Affirmative action does not even level the playing field.

Evidence for this is ubiquitous. Andrew Hecker published an enormously important book in 1995: Two Nations: Black and White, Separate, Hostile, Unequal. This book is a virtual encyclopedia of statistical documentation of disparities and inferiority in just about any quality of life issue that you can imagine. The referenced data in the book show that minorities in our country today exist in a distinctly inferior and disadvantaged status.

If you are a college graduate and you’re African-American, your earning capacity is 75 percent of that of someone who is not a minority. A recent Institute of Medicine report thoroughly documents innumerable health care disparities for minorities in our nation today. The playing field is not level.

Affirmative action does not constitute reverse discrimination. That is impossible. A subordinate group cannot dominate, nor discriminate. In order to discriminate, you have to be dominant, you must have the power. You must be in control. So, the concept of "reverse discrimination" is an oxymoron.

What affirmative action does do

There are some things that affirmative action does do. It helps to create larger numbers of solid, well-educated, contributing, tax-paying citizens who add to the quality of our society. Derek Bok, a past-president of Harvard University, and William Bowen, a past-president of Princeton University, together wrote a book about an extensive study of 45,000 students over a 20-year period. The study compared students admitted to our elite colleges on an affirmative action protocol with students admitted through the usual procedures. All students were followed through a good part of their college and post college careers. The regularly admitted students got better grades and graduated at a higher rate. However, the affirmative action students entered medical, law, business, and graduate schools at a higher rate and were more active in civic affairs.

Another study, done with medical students at the University of California/ Davis, had essentially the same design and found that regularly admitted students received higher grades in the basic sciences and had a somewhat higher graduation rate, 97 percent versus 94 percent. This group also had a higher pass rate on the first sitting of Step 1 and Step 2 National Board exams. However, there were no differences between the groups regarding specialization, practice characteristics or performance as residents. There were no significant differences in the rate of accolades and honors received as house staff.

John Gartland, MD, a past-President of the American Academy of Orthopaedic Surgeons (AAOS), has also conducted a similar study of Jefferson Medical College alumni. His investigation shows comparable performances by the usual professional standards. However, a slightly greater percentage of African-American students went into academic careers. A recent study at Harvard Medical School and the University of California/San Francisco showed that medical students in those two schools felt that having a diverse student body contributed to the quality of their education, particularly in cultural sensitivity and understanding.

I’d like to share a story that is cogent to this dialogue. Between 1977 and 1981, Clifford Alexander, an African American Harvard alumnus, served as Secretary of the U.S. Army. As the tradition goes, the list of officers being considered for promotion to general is brought into the Secretary of the Army for review. During this process, Secretary Alexander asked the colonel who brought in the list, how many minority candidates it included. The Colonel was a bit taken aback and said, "I’m not sure." He retreated, then returned the Secretary, "Well, sir, there aren’t any.’ Secretary Alexander asked, "Do you mean to tell me in the whole United States Army, there are no minority officers eligible to be considered for promotion to general officers?" The Colonel once again retreated and later returned with a list that had some new names added. On the augmented list was the name of Colonel Colin Powell, who went on to became a Brigadier-General, Chairman of the Joint Chiefs of Staff and the Secretary of State.

There are some other things that affirmative action does do. The Army needs general officers to reflect the men and women that they’re leading. Football teams need quarterbacks. String quartets need cellists. College alumni associations need first, second and third generation alumni legacies for fundraising opportunities. These are advantages diversity and affirmative action can bring that fulfill societal needs, institutional needs, organizational needs, leadership needs, educational needs, cultural needs and financial needs.

Momentum for diversity

The AAOS has built considerable momentum around issues of diversity. It started about six years ago, when then AAOS president Doug Jackson, MD, established an ad hoc committee chaired by Anthony Rankin, MD, to look at diversity. Subsequently, the Diversity Committee was established and we have seen progress since. You can see it in the editorial by our past President, Vernon Tolo, MD, in the AAOS Bulletin (December 2002), where he describes a mentoring program, culturally competent care education, a diversity award, and other accomplishments that the AAOS achieved in this area. This represents some healthy momentum, pun intended.

Our momentum and mantra is "diversity, culturally competent care and elimination of musculoskeletal health disparities." I think this momentum is an admirable achievement on the part of our Academy. Moreover we are probably ahead of most other medical organizations in having a diversity committee and having an institutionalized commitment to diversity.

The freedom to use affirmative action has to precede achievements of diversity. So far, the best methodology for achieving diversity in any particular realm of our society is affirmative action. So, affirmative action needs our continued support. If the Supreme Court strikes down affirmative action, not just our profession but the entire nation will lose some valuable momentum. Freedom and opportunity are part of our national heritage and part of our national brilliance.

Why AAOS should support affirmative action

We should support affirmative action because of our high humanitarian and democratic ideals, so well-stated in the Preamble to the Declaration of Independence: "We hold these truths to be self-evident, that all men [and women] are created equal, and endowed by their Creator with certain unalienable rights. Among these are Life, Liberty, and the Pursuit of Happiness."

These very high ideals are quite compelling. We also are motivated by enlightened self-interest to keep affirmative action alive. Properly managed diversity is one of our greatest strengths. If it is mismanaged, it will tend to perpetuate the blemishing part of our national, democratic heritage. We must make these societal and medical disparities right, so that we can move on as a strong, democratic nation.

You are orthopaedic leaders, you are physician leaders and you are also national leaders. I trust that you will keep the positive momentum of affirmative action alive for the good of our orthopaedic profession, for the good of our medical profession, for the good of our patients and for the good of our Nation.

Augustus A. White, III, MD, PhD, is immediate past chair of the Diversity Committee. This article is based on remarks he made to the AAOS Board of Directors at their February 3, 2003 meeting as retiring chair of the Diversity Committee. At the time the BOD was considering whether or not to sign the American Association of Medical Colleges’ amicus curiae brief in support of the University of Michigan Law School policy that considers race as one factor among many in making admissions decisions.

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