Medicine, which H.L. Mencken called a rich man's sport, may yet become one. Those concerned about this prospect were shaken recently when the Senate Budget Committee voted to curtail key programs that encourage or enable young people from low-income families to attend medical school. Although the funds were restored on May 10 by the full Senate, the growing financial hardship faced by these students casts a shadow on the future of health care for the poor. That the two are closely related needs to be recognized and acted upon.
The programs in question, costing $35 million, help low-income students as well as historically black institutions with long traditions of serving the neglected. They provide scholarships and loans and seek to stimulate the interest of disadvantaged youngsters in medical careers. They furnish temporary financial assistance to institutions and enable them to establish health-related programs in underserved communities.
It is certainly understandable in 1985 that the federal government would be eager to reduce its funding of medical educational programs. Federal support of medical education began at a time when a national shortage of physicians was widely perceived to be developing. Today, some 20 years later, the nation confronts an impending physician surplus that one major study has projected will be 15 percent by 1990 and 30 percent by 2000.
Unfortunately, these overall statistics conceal some critical deficiencies. In particular, there remains a chronic shortage of minorities in the health professions. At a time when blacks make up close to 12 percent of the country's population, they constitute only 6.8 percent of the current crop of first-year medical students, a drop from 7.5 percent in 1975. Hispanics, representing 6.2 percent of the national population, account for only 2.6 percent of the first year medical students. Because of the effects of past discrimination, blacks now make up only slightly more than 3 percent of the nation's doctors, a figure projected to rise to 5 percent by 2000.
These figures coincide with a continuing lag in the health status of minorities. For example, the life expectancy of American blacks today is five years less than it is for whites, and the rate of infant mortality is twice as high. Most neonatal deaths are related to low birth weight, which in turn is related to poor maternal nutrition and prenatal care. Today 38 percent of black women do not receive care in the first three months of pregnancy.
How are these inequities related to the shortage of minority physicians? Certainly minority doctors are not the only ones capable of caring for minority patients, nor should they feel obligated to do so. But the simple fact is that minority doctors are more inclined than their majority colleagues to practice where the need is greatest. Surveys of medical school graduates by the Association of American Medical Colleges have established as much, and the results square with our experience at Meharry Medical College, where 75 percent of the graduates practice in underserved areas.
The forthcoming physician surplus will undoubtedly increase access to health care in some parts of the country. In what has been termed a "spillover" effect, physicians unable to practice in the most desirable locations will move to areas where they are in greater demand. But no one has predicted that they will go where the need is greatest -- such as impoverished rural areas, the inner cities.
Indeed, the physician surplus, no matter how great, probably will not result in improved care for the poor without increased reimbursement for their care. No physicians, black or white, can practice where he cannot make a living. But even if that were resolved, there would remain great differences in the inclination and ability of doctors to work in poverty areas. If a physician's resourcefulness, resilience and dedication are no substitute for adequate health-care funding, they can turn adequate funding into that most elusive of goals for the poor -- quality care.
Four years ago, when this spring's graduates applied to the nation's medical schools, 13 percent of those who were accepted reported parental income of less that $15,000 a year. For last fall's entering class, the figure had dropped to about 10 percent -- 23.4 percent for minorities and 7.6 percent for nonminorities. Major reasons for the drop are ever-higher tuitions and the ever-greater burden of financial debt that confronts these students.
What is needed now is not to reauthorize current programs benefiting lower-income students, but to restore several that were recently eliminated or greatly reduced, such as the National Health Service Corps. A bill proposing as much has been reported out of the House Subcommittee on Health and and the Environment, chaired by Rep. Henry A. Waxman (D-Calif.). Legislation featuring innovative approaches to minorities in medicine will shortly be introduced by Rep. Louis Stokes (D-Ohio). Both bills deserve support.
One of the most disturbing cases I encountered as a medical student in Cleveland in the 1960s was of a 28-year-old woman who died in her eighth month of pregnancy from sickle-cell anemia complicated by pregnancy. She had never been diagnosed for the disease, a genetic disorder that can be discovered by a simple test. No one wants such incidents to happen. Shutting the medical-school door to low-income students will virtually ensure they do.