This article is part of State of Health, a series examining health disparities, how they affect Michigan's children and seniors, and the innovative solutions being developed to address them. It is made possible with funding from the Michigan Health Endowment Fund.

Countless children want to be a doctor when they grow up. But Micah Foster says that for many children of color, "that belief wanes" by fourth, fifth, or sixth grade.

"By the time junior and high school comes they can no longer see themselves in those positions," says Foster, executive director of the Grand Rapids African American Health Institute (GRAAHI).

He says that's due to a variety of factors, including socioeconomic factors that make higher education prohibitive, underutilization of afterschool programs, lack of social support, and a fear of not belonging. And in many cases it leads not only to a lack of diversity in the healthcare field, but poorer health outcomes for patients of color. An oft-cited study by the Institute of Medicine notes that patients of color tend to receive lower quality of care than white patients, regardless of their health insurance coverage.

Yesenia Murillo, health equity and cultural competency training coordinator for the Michigan Department of Health and Human Services (MDHHS), says that's often due to caregivers' implicit biases.

"We have set certain expectations of fields and individuals who work in certain fields to be impartial or to act in unbiased ways," Murillo says. "But we don't understand sometimes what those things are. We don't understand more profoundly how our brain operates and how it is socially conditioned to have certain categorizations and generalization of group memberships."

As a result, several Michigan initiatives are working to increase the diversity of the future healthcare workforce, something Foster describes as necessary to improve the healthcare system for everyone.

"There can sometimes be an inaccurate picture that if one boat gets raised the other boats have to get lowered," Foster says. "We are saying that by having a diverse workforce all boats get lifted at the same time."

Diversifying the pipeline

Foster and his colleagues at GRAAHI are working to achieve healthcare parity for African-Americans through education, advocacy, research, and community work.

Foster says there is a lack of knowledge of how to perform in the educational settings required to succeed in healthcare. He says schools usually do well in providing remedial services to students, but such programs are underutilized by students of color.

"Creating a social or societal norm that does not put a stigma on utilizing those services is important for first-generation students or those interested in pursuing a healthcare degree," he says. "You are operating outside of your cultural norm."

Micah Foster.

For the past year, GRAAHI has been involved in a planning grant called "Pathways to Careers in Healthcare," in partnership with numerous Grand Rapids-area schools, higher education institutions, and employers.

"We have all sat around the table to discuss the entire pipeline and how do we diversify the pipeline," Foster says. "We need more students entering healthcare programs. We need colleges shuttling those students ... through their healthcare curriculum. And we need employers to hire as those students come out."

Foster references a long-term study the University of Southern California conducted on how to diversify faculty on a university campus. He says the most effective and sustainable long-term method found was recruiting recent graduates and alumni to become adjunct professors and then participate in structured mentoring with senior faculty for retention. He says GRAAHI is considering a similar model for the healthcare system.

GRAAHI's next step is to design an initiative that will address barriers to increase the number of students of color progressing through healthcare degree programs and ultimately being hired as clinicians in West Michigan.

"What we need in the field is a critical mass, an infusion of a large number of students of color on this educational track ultimately getting employed to shift the paradigm," Foster says.

Developing future leaders

The University of Michigan's (U-M) Future Public Health Leaders Program (FPHLP) is one successful model for nurturing diverse healthcare professionals. It is one of several university programs across the nation funded by the Centers for Disease Control and Prevention's (CDC) Undergraduate Public Health Scholars Program.

Roughly 40 students participate annually in the 10-week summer program, which is open to undergrads studying in any field anywhere in the U.S. Students of color and economically disadvantaged students are strongly encouraged to apply. Students receive a stipend to cover living costs during the program, and housing and travel costs are also covered.

"The CDC is funding us to help increase workforce diversity," says FPHLP program director Dana Thomas. "The belief is, and the research shows, that people of different communities, whether people of color, LGBT, (or) people who are disabled, are likely to go back to their communities and work and advocate."

Dana Thomas.

Thomas says if the number of underrepresented young people going into public health can be increased intentionally, there can be a greater overall impact in under-resourced communities.

"(Public health professionals) are concerned about everyone," says Thomas. "Our approaches are group approaches. So when we talk about equity, which is different than equality, equity is about making sure communities and populations have what they need. It may not be equal because it may not need to be equal. It is meeting people where they are."

Thomas says a key part of the program is giving students the opportunity to think and process important topics together. Immigration and deportation were two main topics for FPHLP's 2018 session. Thomas recalls one session led by a Latino faculty member, in which a Latino student started crying.

"It overwhelmed her to see someone who she could relate to being in that role," Thomas says.

Students become mentors

Sade Richardson's experience as a FPHLP student was key to shaping her journey into a healthcare career. Richardson immigrated to America from Trinidad and Tobago. She discovered FPHLP in her search for a low-cost summer internship while attending the University of Rochester in Rochester, N.Y.

Richardson says her FPHLP mentors were influential in her life. One of her mentors in the program had dual master's degrees in social work and public health. Richardson received the same dual master's degrees from U-M in April 2018.

She completed an internship at YOUR Center in Flint during the program, which greatly impacted her decision to pursue a career in health. At the center, she learned about equity in health and the environment.

"The world is a diverse place. America is a melting pot of different cultures, different ethnicities, races, and a whole bunch of other diversity," Richardson says. "It is unfair to have a country that is so diverse and not have that kind of representation in the workforce when you're thinking about how to address issues that affect different populations."

Sade Richardson.

After graduation, Richardson began working at Altarum, an Ann Arbor-based nonprofit health research and consulting organization which aims to advance health for vulnerable populations. This summer her role with FPHLP will come full circle, as she becomes a mentor for the program herself.

"Working in the states gives me the opportunity to make sure we all have equal access to health," says Richardson. "To me (health equity) is a human right. It is not something that should be a privilege. We should all be able to access it if we want it, or even if we don't want it."

Afaf Humayun is a reporter, poet, artist, and activist who works to preserve and expand the future of the humanities while staying engaged on issues of inclusion. You can find some of her writings at The Keel Port Huron and The Arab American News. She lives in Ypsilanti.