Continuing the conversation about the role of policy in creating system change, Sudip Parikh, Ph.D. (American Association for the Advancement of Science [AAAS]), moderated a panel that looked at the nexus of science, policy, and business. He posed a series of questions to Kafui Dzirasa, M.D., Ph.D. (Duke University); Michellene Davis, Esq. (National Medical Fellowships, Inc.); and Samsher Singh Gill (Doris Duke Charitable Foundation).
OVERCOMING PERSISTENT BARRIERS
Before becoming president and CEO of National Medical Fellowships (NMF), Ms. Davis worked in a leadership position at a large academic health center in New Jersey. She reflected on that experience in discussing barriers to equity and a more diverse health workforce:
We can call it strategic tension, we can call it the interest in keeping the status quo, we can call it what we like, but we know not just that structural or systemic racism exists within institutions, but that, quite frankly, white supremacist culture in organizations helps to keep it as embedded as it has always been.
In her view, until opportunities for diverse physician-leaders improve, that “strategic tension” will remain in place. In her new position at NMF, she said she hears about the experiences of students who have been discouraged from pursuing medicine, see few role models, experience lack of economic and social capital, and have little access to opportunities. Ms. Davis added her background in politics serves her well in advancing health equity because it has made her aware not just of social determinants of health but also of political determinants of health created by laws, regulations, and policy.
Dr. Dzirasa stressed the importance of centering on both overt and systemic racism. In engineering terms, he elaborated, overt racism stems from a policy in which two groups are treated differently and is clearly measurable. Systemic racism is more complicated, he continued. While there is a lowering of the effect size in each individual part of the system, putting all the parts together—elementary education, high school, college, transitioning, National Institutes of Health (NIH) funding, and more—shows the effect size is large. “That means you have to look at the whole system,” he stressed. “What we are really looking for are catalysts that can transform an entire system.”
Mr. Gill noted that Doris Duke and other foundations are challenged by implicit bias in allocating resources. He pointed to two features that characterize the role of independent philanthropy as capital allocators. On the one hand, total philanthropic funding is small-scale compared with federal, private, or higher education expenditures. However, he continued, it is also the most independent capital in the world without constraints from investors, public shareholders, or political incentives unless self-imposed. “The theory behind this form of capital is that private wealth aggregation oriented toward the public interest is an important source of innovation and progress,” he said.
Related to the first feature about the relative amount of total resources, he related that funding in the science funding community has moved from being catalytic to more incremental, given the high costs of entry to support basic science. Related to the second feature, he continued, “This set of questions—how to build a more inclusive and equitable scientific enterprise—is a phenomenal place for independent capital to be used.” Many institutional foundations have adopted commitments to a more equitable enterprise and to dismantling barriers, but, he commented, “we have all done it in our own way; we have become inefficient.”
Dr. Parikh described the effort at AAAS to identify barriers. For example, as publisher of Science, AAAS is a significant enabler of the scientific enterprise, but the editorial team has historically consisted mostly of white males because hiring practices gave preference to applicants with certain pedigrees. He asked the panelists about other policy changes they have been involved in.
Ms. Davis shared two examples. First, she suggested that health centers look at longstanding policies and practices, often not written down, that have created a more monolithic health system despite the goal of being more place-based. Her organization, which operated 16 hospitals, reexamined human resource policies, such as the language of job descriptions and eligibility requirements, to promote local hiring. As another example, a hospital in the system wanted to plant a vegetable garden to provide fresh food to neighborhood residents receiving government food assistance. This required changing a statute from 1941 that prohibited using government subsidies in small-scale vegetable production. She noted the statute change benefited not just that neighborhood but also other communities across the state. In addition, she pointed out, it was not explicitly a diversity, equity, and inclusion policy, which “shows why it is important to have both traditional and nontraditional partners in the policy space.”
Dr. Dzirasa said he spoke from his perspective as a biologist, engineer, and psychiatrist. “It’s important to wrestle with why we haven’t made changes thus far. We as human beings are a social species, and we have an innate preference toward sameness,” he commented. He described a study that showed the acceptance of ideas from so-called in-groups compared with those from out-groups. Using machine learning, doctoral theses written over the past 30 years were analyzed to see how the ideas they contained entered the field. Ideas from the in-group were more likely to have an impact.1
Intellect is universally distributed across the population, Dr. Dzirasa stated. “If intellect is universally distributed and not everyone has an opportunity to participate, then it is a suboptimized system,” he continued, and policies that bring the best talent forward are essential:
As the population becomes more diverse and intellect is universally distributed, it means there is less talent over time to be drawing upon. If we care about how this country is going in terms of innovations and treatment, particularly within a global enterprise, we are becoming less fit to do that every single year. The beginning of every policy change is a human question—are we prepared to wrestle with the question, “Do we believe that intellect is universally distributed?”
Mr. Gill commented that “scale is the word of the moment…. But the question is how to use lower investment amounts to trigger larger amounts to be sufficient for transformational change.” He said foundations come at scale from two directions: by lowering the transaction costs to adopting a good idea or by changing the level of ambition, for example, through advocacy or building movements. The clarity and urgency of the argument for justice is at a high level and, once the concept of universal distribution of intellect is accepted, there is a huge competitive interest in not leaving talent on the sidelines. The flaw in these arguments, he contended, is the assumption that all the nodes in a system remain static and good ideas are populated across the system. But, he countered, some parts of the system are exacerbating problems, while others are working to solve problems beyond their resources. He suggested doubling the funding that goes to Historically Black Colleges and Universities and math and science initiatives as an effective example of a way to populate the science, technology, engi-
___________________
1 For more information, see https://www.pnas.org/doi/10.1073/pnas.1915378117.
neering, and mathematics (STEM) workforce. “We already have a solution at scale that just needs more resources,” he said.
Dr. Dzirasa referred to the book Built to Last (Collins and Porras, 1994) that urges visionary companies to “try a lot of things and some will work.” He noted this approach extends to workforce challenges. Successes have occurred, but there is no systematic way to evaluate what does and does not work. “One of the policy challenges is we need a national system to think about the whole enterprise, figure out what has worked, and scale those things. We need a PI [principal investigator] for that experiment,” he suggested.
TRACKING GOOD IDEAS
Mr. Gill said there is an abundance, almost an overabundance, of ideas. He agreed with the idea of a PI-type experiment and a national strategy. It is important to keep what works, not just keep what is already happening, he commented. After rigorous experimentation, he urged investing in the things that work.
Ms. Davis noted that policies set the stage for who has access to funding and opportunities. Who makes the policies is also important. “It’s important for funders to look at how decisions are made and if they are being made equitably,” she said. Mr. Gill added that funders should be more self-critical. “Philanthropies can be sanctimonious about their mission and values, but less willing to do the hard work,” he said, such as looking at how funding evaluation criteria may be unintentionally excluding some populations.
In terms of other concrete changes, Dr. Dzirasa observed that scientific trajectories have changed and most Ph.D.’s are not on academic routes today. A critical need is to promote and share role models of scientific professionals outside of academia, he suggested.
NEXT STEPS
Dr. Parikh noted possibilities related to opportunity, scale, and funding. AAAS is advocating for employee-like benefits for graduate students in NIH and National Science Foundation (NSF) grants and for NIH to make changes in funding decisions. He asked each panelist for other ideas.
Ms. Davis stressed the need for representation and targeted funding to support the hiring and advancement of a diverse STEM faculty. She also noted the need for student debt management and reduction.
Dr. Dzirasa returned to the idea of a PI-type experiment, perhaps set up through the National Science and Technology Council, to establish a national science and technology initiative, an idea that he and colleagues proposed in an April 2021 article in Science (Tilghman et al., 2021). Through such an initiative, a 5- to 10-year experiment could be organized with funding streams from NSF, NIH, and other entities, coordinated across administrations.
Mr. Gill noted that the Doris Duke Foundation found caregiving needs are a critical vector for equity among physician-scientists. A pilot project was set up to provide grants for projects at risk because of researchers’ caregiving needs. The foundation has also challenged institutional leadership, including university boards and presidents, to consider this to make longer-term progress. “We have to manage against a set of goals as if they are existential because they are existential,” he said. “If we don’t do that, it will be a continued profusion of small steps and incremental progress.”
In response to a participant’s comment about changes in language and taxonomies, Mr. Gill noted that one of the foundation’s major programs is directed at early-career physician-scientists. A program audit found that women and people of color had low participation. Among the steps taken was a change in the language used in describing the award. Although other changes were made, so it is difficult to pinpoint a single factor, he shared that applications and participation increased among underrepresented groups.
Dr. Dzirasa agreed with the need to “meet people where they are.” The tendency in talent recruitment is for everyone to look to the same places. “This is why I always go back to the idea that intellect is evenly distributed. If so, your best return is to go to the place where no one else is going. We have set up systems that do not tap talent that exists in certain places,” he said.
Roundtable chair Cato Laurencin, Ph.D. (University of Connecticut Health), commented that in talking about diversity and inclusion, the typical programs do not work because they do not address racism adequately. He called for a path that also encompasses diversity, inclusion, antiracism, and learning, for example in NIH funding.
In concluding the first day of the workshop, Dr. Shirley Malcom (AAAS) reflected on the discussions that positioned the Black community as a science community. Housing disparities and other environment assaults counter that sense of community and send the message, “You are not valued, you are not worth investing in,” she said. Children either push back on that message or absorb it, she observed. “The issues of financing, belonging, finding peers and a community—that is what we are looking
at when we put antiracist vision on policies in place. The issue is how to create a new norm, rooted in diversity, equity, justice, and fairness. We can see the benefits that accrue to a scientific community that is building from the excellence of the talent pool that is out there,” she said.
REFERENCES
Collins, J., and J. Porras. 1994. Built to Last: Successful Habits of Visionary Companies. New York: Harper Business.
Hofstra, B., V. V. Kulkarni, S. M.-N. Galvez, and D. A. McFarland. 2020. The diversity–innovation paradox in science. Proceedings of the National Academy of Sciences Vol. 117, No. 17. https://doi.org/10.1073/pnas.1915378117.
Tilghman, S., B. Alberts, D. Colon-Ramos, K. Dzirasa, J. Kimble, and H. Varmus. 2021. Concrete steps to diversity the scientific workforce. Science 372(6538): 133–135.
This page intentionally left blank.
