George Q. Daley, M.D., Ph.D., served as moderator for the first panel featuring a data-driven analysis by Raj Chetty, Ph.D. (Harvard University), that served as a point of reference throughout the workshop. In addition, Louis Sullivan, M.D. (Sullivan Alliance), shared a historical perspective about Black representation in medical school and the medical workforce based in part on his decades of experience as a policy advocate, administrative leader, and physician.
NEW INSIGHTS FROM BIG DATA
Dr. Chetty explained he and his colleagues in Harvard University’s Opportunity Insights combine “big data” from multiple sources to provide insights on issues related to opportunity and mobility in America. Before homing in on Black Americans in science, engineering, and medicine (SEM), he underscored that while the “American dream is a multifaceted, complicated concept,” it can be distilled to one statistic that the data can systematically measure: the percentage of children who grow up to earn more than their parents did.
In a 2017 paper, Dr. Chetty and his colleagues tried to assess how America is living up to the American dream, as measured through upward mobility. They compared children’s incomes in their mid-30s with their parents’ incomes at around the same age, adjusting for inflation. Almost all children born in 1940 (92 percent) went on to earn more than their parents. However, only about 50 percent of children born in the 1980s have gone on to earn more than their parents. “This is a dramatic trend of interest to economists, as it is a fundamental change in the U.S. economy,” Dr. Chetty said. “It is also of interest in a social and political perspective because this trend underlies a lot of the frustration that people around the United States are expressing, including from underrepresented minorities who bear these challenges to a particularly acute degree.”
A correlated dimension looks at life expectancy (LE), Dr. Chetty explained, and shows a tight link between LE and income. Men in the
bottom 1 percent of income have an average LE of 72 years, versus an average LE of 87 years among men in the top 1 percent, a gap of 15 years. The difference in LE among low- and high-income women is about 10 years.
Fundamental changes in rates of upward mobility are associated with economic, health, social, political, and other outcomes, Dr. Chetty stated. Opportunity Insights also studies how to increase mobility by analyzing a broad range of interventions from childhood to adulthood, using what is referred to as a life-course perspective. The data reveal significant variations. “The starting point for a lot of our work is that the national picture masks very sharp heterogeneity and sharp local differences within America in rates of upward mobility and economic opportunity,” he said.
Variations in Mobility
Dr. Chetty shared a map of the country to show “the geography of upward mobility in the United States” (Chetty et al., 2018). He explained the map charts people’s life trajectories based on where they were born by combining data on 20 million children born in the early 1980s with anonymized data linking them to their parents’ tax returns. It divides the country into 740 urban and rural areas and computes a measure of upward mobility for the children who grew up in each area. Average income at age 35 is derived for children who grew up in low-income families (families who earned about $27,000 or less). There is a tremendous amount of variability, Dr. Chetty pointed out (see Figure 2-1). In some areas, children grow up to have higher levels of income across generations, while in others, the level is stagnant or lower. Parts of the Midwest show high rates of upward mobility from one generation to the next, while much of the Southeast shows lower rates of mobility, for example.
Dr. Chetty acknowledged that some patterns are surprising, using Charlotte, North Carolina, as an example. While Charlotte is considered a rapidly growing area, the children in the study had low mobility and lower earnings compared with their parents. According to Dr. Chetty, “What is happening is that Charlotte is importing talent—lots of people move to Charlotte for high-paying jobs—but low- and middle-income kids growing up in Charlotte, many of them African American, are not necessarily benefiting from that economic growth.” He added,
An area that grows overall does not necessarily lift all boats. That’s clear from that example [Charlotte, North Carolina] and, more
NOTE: Blue areas indicate more upward mobility; red areas indicate less upward mobility.
SOURCE: Raj Chetty, Workshop Presentation, April 19, 2021, from Chetty et al., 2018.
generally, looking at data across the U.S. What drives the variation and what are the drivers of economic mobility in the U.S.? I want to focus on the role that racial disparities play. For anyone familiar with the demography of the United States, you might recognize the potential connection between the variations on the map and racial demographics. The areas of the U.S. that have the largest African American populations tend to be the places that have the lowest levels of mobility. Part of what is seen as spatial variation could well be racial variation.
To understand this question further, Dr. Chetty described a subsequent study that linked data from tax returns with U.S. Census data, which allowed the researchers to draw separate maps for Black men and white men (see Figure 2-2) using the same measures as above. “What you are seeing is the power of race in America,” Dr. Chetty stated. “It is almost like there are two different countries, one for Black men and one for white men, with nonoverlapping distributions in terms of rates of upward mobility.” Expressed differently, the very best places for Blacks in terms of upward mobility have lower mobility than the worst places for white men. “There is no understating the importance of race, even conditional, on class,” Dr. Chetty stated.
The data show similar rates of mobility for Black and white women who start out in families at the same income. “There is an intersectionality between race and gender,” with the disparities related to upward mobility particularly extreme for men, Dr. Chetty concluded.
In addition to upward mobility, Dr. Chetty said, “the converse channel of downward mobility is also important.” He and his team compiled data about income mobility for Black and white men raised in high-income families (those in the top fifth, or quintile, of income distribution). The aim was to see whether the children remain in this top fifth as adults. He characterized a “disheartening pattern” in which most whites remained in the top fifth of income, but Blacks showed more of a cascade downward into lower-income groups. This pattern illustrates a fundamental difference in economic trajectories between Black and white Americans, he said. He continued:
For white Americans, trying to achieve the American dream is like climbing a ladder from one generation to the next, but for Black Americans, it is like being on a treadmill. Even after you’ve
NOTE: Blue areas indicate more upward mobility; red areas indicate less upward mobility.
SOURCE: Raj Chetty, Workshop Presentation, April 19, 2021, from Chetty et al., 2018.
climbed up after a generation, there are tremendous structural forces that are pushing [Black men] down that make it necessary to have to make the climb again in the next generation. If we do not fundamentally fix the treadmill phenomenon, no matter what is done to help people rise up, it will not stick in the long run. There are strong forces leading to downward mobility in the next generation. This is a very important point to think of from a policy perspective.
Looking Locally
Dr. Chetty acknowledged that in looking at broad national patterns, one’s eyes gravitate to big differences across regions. However, difference can also be viewed at a more granular level within cities with the Opportunity Atlas, a free tool developed by his laboratory.1 Using New York City as an example, he illustrated how data can be viewed by census tract to reveal varying rates of upward mobility. Stark disparities emerge not only across regions or states but also within them. However, he termed this an encouraging result because he said it suggests that potential solutions may be local and perhaps can be replicated.
To elaborate on this point, Dr. Chetty zoomed in on an address in Brooklyn (531 Sutter Avenue) with a large Black population living in Van Dyke, one of the largest public housing projects in the city. The area shows low rates of upward mobility for Black children. In contrast, a nearby neighborhood with a mixed-income housing development called Nehemiah Houses shows more positive results for children. To understand how, what he termed, “very fine differences in environment” can dramatically change life course, the researchers used tax records to study income gain among 6 million children of families who moved into better neighborhoods. In the Brooklyn case, the children of families who moved from Van Dyke to Nehemiah earned more when they were adults; furthermore, the younger the children were when the families moved, the greater their earnings were as adults.
From this example, Dr. Chetty drew three key lessons:
First, where you grow up really matters. If you take a given child and move that child from one place to another, you see really
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1 The Opportunity Atlas is available at https://www.opportunityatlas.org/.
dramatic differences in that child’s life outcomes. Second, what seems critical is childhood environment rather than where you are as an adult. Third, there is a “dosage effect” so that for every extra year you are exposed to a better environment, the better your outcomes as an adult.
He and colleagues are now trying to answer what in a different environment helps people thrive. He stressed that none of the factors identified are necessarily causal effects, but are instead correlative and predictive. They include less concentrated poverty, more stable family structures, better school quality, and places with greater social capital and sense of community connectedness. In looking at neighborhoods that have the smallest disparities between Black and white men, a salient set of factors includes low poverty rates among the Black adults in the neighborhood, low levels of racial bias (explicit and implicit), and high rates of the presence of fathers (Chetty et al., 2018). Dr. Chetty noted the “phenomenon of missing Black men in the United States” created by high rates of incarceration and mortality has meant many children growing up in a family without a father. However, Dr. Chetty noted that there appears to be a correlation between fathers being present at the community level and higher rates of upward mobility, possibly related to mentorship, role models, or other reasons.
Disparities in Science, Engineering, and Medicine
Dr. Chetty discussed the implications of mobility research to understand African American underrepresentation in science, engineering, and medicine. He and colleagues focused on scientific innovation and economic growth and, specifically, the lives of 750,000 U.S. patent holders by linking patent records to tax data.
People who become inventors—which he characterized as a rough proxy for SEM achievement—are 10 times more likely to hold a patent if they are born to parents in the top 1 percent of income distribution than to parents with a median income or below. This may be related to childhood environment and quality, but he realized that another reason may relate to families’ quantitative aptitudes. Thus, to look at quantitative aptitude, patent rates were plotted against third-grade math test scores. Children in high-income families who scored at the top of their class in third-grade math were much more likely to become inventors than their low- and middle-income counterparts who had similarly high third-grade math
scores. In other words, “in America, you need two things to become an inventor or a scientist—high level of quantitative aptitude and being from a rich family,” Dr. Chetty said. A similar pattern related to race and ethnicity can be seen, he added, in that Black and Hispanic children who perform as well as white and Asian children in third-grade math are dramatically less likely to go into science and innovation careers as adults. “This leads to an enormous loss of talent in the pipeline that affects society going forward,” he said.
He also commented on the importance of exposure to opportunities. Children who grow up in “innovation hubs” such as Silicon Valley in Northern California or Austin, Texas, are more likely to engage in similar types of innovative activities. Patterns are also gender specific. If girls grow up seeing a lot of women in certain innovation fields, they are more likely to become inventors in those fields. “All that evidence suggests that what is going on is that a big part of the reason that Blacks kids are not going into [SEM] careers is they do not have exposure to them,” he said. “They are not around a lot of people who have these careers to begin with, which limits their connections, know-how, support, and the like. This has emerged as a key driving force in many studies.”
Beyond concerns about justice and equity, diversity in science matters for the nation’s strength and gross domestic product, Dr. Chetty said. Referring to “lost Einsteins,” his team’s work posits that if women, minorities, and children from low-income families invented at the same rate as high-income white men, the innovation rate in America would quadruple (Bell et al., 2019). In addition to an increased quantity of inventors and their inventions, more diversity would change the nature of innovations and improve downstream outcomes, he added.
Diversity also makes a difference in people’s health. He referred to an experiment by Alsan et al. (2019) that looked at how doctors’ race can affect patient outcomes. The researchers recruited 1,300 Black men in similar health in Oakland, California, and randomly assigned them to Black and white doctors. The patients were told about preventive services (such as diabetes and cholesterol screening) before and after seeing their doctor. After they saw their doctors, the patients assigned to Black doctors were more likely to elect to have the procedures. This is an illustration of the effect of downstream outcomes when there are more Black physicians, Dr. Chetty observed.
Research-Informed Policy Implications
Dr. Chetty concluded by describing how his group conducts research for policy makers. It is organized into three pillars: (1) reducing segregation by helping low-income families move to higher-income areas; (2) place-based investments to increase upward mobility in low-opportunity areas; and (3) improving higher education to amplify the impact of colleges on upward policy.
Related to the first pillar, a recent pilot study in Seattle, Washington, sought to help people move to higher-opportunity areas. The team’s mapping showed that people who receive federal housing vouchers tend to cluster in low-opportunity areas and not move to higher-opportunity areas. Working with local housing authorities, they tested if people do not want to move or if elements such as difficulties in the housing search or excessive paperwork create barriers. A randomly selected subset of families with vouchers received additional support to find housing in higher-opportunity neighborhoods, such as customized search assistance, increased landlord engagement, and short-term financial assistance. In the control group, 14.3 percent moved to a higher-opportunity area. In the treatment group, 54.3 percent moved. This small tweak, which added a 2 percent incremental cost to the program, greatly amplified the impact, Dr. Chetty noted. On average, each child who grows up in the higher-opportunity neighborhoods will earn an additional $200,000 over their lifetime. Dr. Chetty noted the results benefited Black people and people of other races and ethnicities, not just white people. The findings from the pilot have or are being used in several pieces of federal legislation.
Related to the second pillar, Dr. Chetty urged participants to engage in “thinking hard about how to invest in neighborhoods,” since not everyone can move. His laboratory is involved in an ongoing project, called the Charlotte Opportunity Initiative, that uses a life-course approach, starting with infancy, to change the pipeline of opportunity.2
Finally, related to the third pillar, he said, institutions of higher education can do more to contribute to upward mobility. His group has collected data to understand how well students from lower-income families do in achieving upward mobility (going from the bottom 20 percent to the top 20 percent of the income distribution) after attending college. While elite institutions do well in this metric, only a fraction of students from
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2 For more information, see https://opportunityinsights.org/wp-content/uploads/2020/11/OI-CharlotteReport.pdf.
low-income families attend these schools. Most low-income students attend other colleges, including community colleges, that generally have poorer outcomes related to mobility, although with exceptions. He suggested two approaches: expanding access to elite schools and improving outcomes from community colleges.
He concluded that his research points to limitations in improving science, technology, engineering, and mathematics representation without a broader approach. First, he said, it is critical to improve the pipeline of opportunities starting at birth. Second, it is important to reduce downward mobility of affluent Black Americans. Third, exposure and social supports matter beyond just providing financial incentives.
A HISTORICAL PERSPECTIVE
Dr. Sullivan presented a historical perspective to inform the discussion. From the beginning of the American colonies, an equitable environment for Black people has not existed, including for the health care they received. Health care for the Black community came from within the Black community, he related. The first medical schools, formed in the mid-1700s in Philadelphia and New York, did not admit Black students for a century. In 1868, Howard University opened the first medical school for Black students, and seven others, most notably Meharry Medical College, followed in the late 1800s. Medical schools for both Black and white students at the time were largely proprietary institutions with little structured curriculum and often served more as apprenticeships. In the early 1900s, when the Carnegie Foundation commissioned what became known as the Flexner Report3 Abraham Flexner visited all 153 medical schools and found many of them deficient. His report, which recommended adoption of the model used at Johns Hopkins University, sent a shock wave through the medical education establishment, Dr. Sullivan related. Many schools closed, and there were only 80 in 1925. Among Black medical schools only Howard and Meharry continued to operate. The white establishment deemed them necessary to educate some Black physicians to care for the Black community, out of fear that otherwise, contagious disease would pass from the Black to the white community, Dr. Sullivan related.
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3Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, published in 1910 by the Carnegie Foundation, New York City.
SOURCES: Louis Sullivan, Workshop Presentation, April 19, 2021, based on Minority Graduates of U.S. Medical Schools: Trends, 1950–1998, Washington, DC: AAMC, 2000; and Diversity in Medical Education Facts and Figures, 2012, Washington, DC: AAMC, 2012.
The federal government led an expansion in medical education starting in the middle of the 20th century because of a projected shortage of physicians. The number of graduates doubled from 8,000 to 16,000 annually, and 47 medical schools opened in a 25-year period. One-third of the medical schools in the 1950s were in the South; except for the University of Arkansas (which had one Black student), they did not admit Black students. Elsewhere in the country, schools had an occasional one or a few Black students. In the 14 years after the U.S. Supreme Court’s Brown decision, medical schools in the South had to open up to Black students.4
The number of Black medical students increased to 800 in the early 1970s and 1980s, then plateaued (see Figure 2-3). After the assassination of Martin Luther King Jr., universities, including medical schools, made an effort to increase diversity. The Association of American Medical Colleges (AAMC) formed its first committee on Black students in medical schools in 1968, on which Dr. Sullivan served. The committee’s bottom line was that medical schools had to be more proactive to integrate and increase the number of Black students. Initiatives increased the percentage of African American students to about 7 to 8 percent of the total medical student population by the end of the century. Now medical schools graduate about 1,600 to 1,700 Black students annually. Of interest, Dr. Sullivan noted, is
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4Brown v. Board of Education of Topeka, 347 U.S. 483 (1954).
the increasing number of Black women and decreasing number of Black men: two out of three Black medical students are women, he reported.
Little progress has been made between the number of Black applicants and matriculants, Dr. Sullivan continued. In 1978, 38 percent of Black men applicants were admitted, and the percentage had not changed 40 years later, in 2018. About 4.5 percent of medical school faculty are Black, and they are less probable to receive National Institutes of Health (NIH) research funding than white applicants (Ginther et al., 2011). Although NIH has initiated a mentoring program and other efforts to improve success rates of Black investigators, “this shows that in the part of the public health system that is supposed to be objective and is allegedly free of bias, this is not the case,” Dr. Sullivan said.
Approaches to improve the number of Black medical students and physicians have included mentoring, counseling, and the existence of role models. “We have the challenge in the coming decades—we have made progress, but the amount of progress we have made is far less than what we had hoped for and expected,” Dr. Sullivan concluded. He expressed great interest in Dr. Chetty’s studies and especially the granularity that his data can bring to find solutions.
DISCUSSION
Dr. Daley commented that the data presented by Dr. Chetty are fascinating but sobering. He noted that Dr. Sullivan made a key connection when he pointed out the modest increase of Black women in medical school but flat or decreasing numbers of Black men, and he connected that trend with Dr. Chetty’s data about the mobility gap for Black men. “Understanding that and its root causes is absolutely essential. It’s hard not to imagine that structural racism is playing a major factor,” Dr. Daley said. The reasons behind the differences might provide important insights, a participant suggested. Dr. Chetty said the answer is not fully known, but it might include issues related to the criminal justice system. Data show in some neighborhoods, upward of 50 percent of Black men are incarcerated on any specific day. Contact with the criminal justice system limits economic and other opportunities going forward. He pointed out that the outcomes of boys of all races are influenced by fathers’ presence or, more generally, what the men in their lives are doing. Dr. Chetty added that there is a need to address these factors at a local level and within institutions, not just rely on federal policies changing.
Dr. Sullivan suggested the productivity of Black colleges may be not only because of their academics but also because of role modeling, noting he experienced the effects himself as an undergraduate at Morehouse College. Dr. Chetty agreed that many Historically Black Colleges and Universities (HBCUs) stand out as serving low-income families and have good outcomes. To understand why, he said, one piece of evidence relates to reducing the rates of students who start but do not complete their education. Often, hurdles or shocks (such as a parent losing a job or health problem) derail progress. Targeted support may be inherent in schools with strong social networks such as exist at many HBCUs. It is hard to legislate that approach, he noted. “You have to have people who care about you, people who want to invest in you. That’s the message that emerges and the question is how to scale that,” Dr. Chetty commented. Dr. Daley also reflected on Dr. Chetty’s comments about the importance of early exposure, and he suggested the Roundtable on Black Men and Black Women in Science, Engineering, and Medicine advocate for such programs.
Roundtable member Shirley Malcom, Ph.D. (American Association for the Advancement of Science), commented that some race-attendant policies are experiencing policy and judicial backlash and suggested advocacy and public engagement to make the case that training more Black physicians will lead to better health outcomes. Dr. Sullivan said COVID-19 revealed disparities in the system, and the challenge is to make improved investments permanent.
REFERENCES
Alsan, M., O. Garrick, and G. Graziani. 2019. Does diversity matter for health? Experimental evidence from Oakland. American Economic Review 109(12): 4071–4111. DOI: 10.1257/aer.20181446.
Bell, A., R. Chetty, X. Jaravel, N. Petkova, and J. Van Reenen. 2019. Who becomes an inventor in America? The importance of exposure to innovation. The Quarterly Journal of Economics 134(2): 647–713. DOI: 10.1093/qje/qjy028.
Chetty, R., J. N. Friedman, N. Hendren, M. R. Jones, and S. R. Porter. 2018. “The Opportunity Atlas: Mapping the Roots of Social Mobility.” National Bureau of Economic Research Working Paper 25147. DOI: 10.3386/w25147.
Ginther, D. K., W. T. Schaffer, J. Schnell, B, Masimore, F. Liu, L. L. Haak, and R. Kington. 2011. Race, ethnicity and NIH awards. Science 333: 1015–1019.
