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(NYT) A Prescription for More Black Doctors

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How does tiny Xavier University in New Orleans manage to send more African-American students to medical school than any other college in the country?

Norman Francis was just a few years into his tenure as president of Xavier University of Louisiana, a small Catholic institution in New Orleans, when a report that came across his desk alarmed him. It was an accounting of the nation’s medical students, and it found that the already tiny number of black students attending medical school was dropping.

It was the 1970s, at the tail end of the civil rights movement. Francis, a black man in his early 40s, had spent most of his life under the suffocating apartheid of the Jim Crow South. But after decades of hard-fought battles and the passage of three major civil rights laws, doors were supposed to be opening, not closing. Francis, the son of a hotel bellhop, had stepped through one of those doors himself when he became the first black student to be admitted to Loyola University’s law school in 1952.

Francis believed he was in a unique position to address the dearth of black doctors. Xavier served a nearly all-black student body of just over 1,300. At the time, most of Xavier’s science department was housed in an old surplus Army building donated to the college by the military after World War II. It had no air-­conditioning, and the heater was so loud in the winter that instructors had to switch it off to be heard. But the science program had always been strong, if underfunded, and began producing its first medical-­school students not long after the university was founded in 1925.

Today, Xavier’s campus is mostly wedged between a canal and the Pontchartrain Expressway in Gert Town, a neighborhood in the western part of New Orleans. It has some 3,000 students and consistently produces more black students who apply to and then graduate from medical school than any other institution in the country. More than big state schools like Michigan or Florida. More than elite Ivies like Harvard and Yale. Xavier is also first in the nation in graduating black students with bachelor’s degrees in biology and physics. It is among the top four institutions graduating black pharmacists. It is third in the nation in black graduates who go on to earn doctorates in science and engineering.

Xavier has accomplished this without expansive, high-tech facilities — its entire science program is housed in a single complex. It has accomplished this while charging tuition that, at $19,800 a year, is considerably less than that of many private colleges and flagship public universities. It has accomplished this without filling its classrooms with the nation’s elite black students. Most of Xavier’s students are the first in their families to attend college, and more than half come from lower-­income homes.

‘‘The question always comes: ‘Well, how did this happen, and why are we No.1?’ ’’ said Francis, who recently retired from Xavier after 47 years as president. We were sitting in the dining room of his stately home in the Lake Terrace neighborhood on a sweltering day in August as he thought about the answer. ‘‘We decided we could do something about it. And what we did, what our faculty did, was just plain common sense.’’

Xavier University exists within a constellation of more than 100 schools federally designated as historically black colleges and universities. To achieve this designation, colleges must have opened before 1964 — the year Congress passed the Civil Rights Act, which banned racial discrimination in all public facilities and institutions — and must have been founded with the express purpose of educating black Americans, though students of any race can, and do, attend them.

The first of these historically black colleges, now called Cheyney University, was opened by a Quaker in Pennsylvania in 1837, at a time when black students were barred from most institutions of higher learning in the North and the South. But after the Civil War, colleges for black students proliferated across the South to serve the millions of newly freed people. They were founded by churches, philanthropists and the federal Freedmen’s Bureau, and then by states, after an 1890 federal law required states with segregated schools to open at least one black land-grant college. By the 1920s, black colleges dotted every Southern state and a few Northern ones.

Around that time, a nun named Katharine Drexel, an heiress to a Philadelphia banker who has since been sainted, used part of her inheritance to open Xavier for black Catholics in New Orleans who were not allowed to attend the white Catholic colleges in town. It remains the only black Catholic college in the country. Its mission is the same as every other historically black college. While many colleges were started to groom the children of the nation’s elite, the goal of historically black colleges has always been to pull up through education the nation’s most marginalized — first the children of former slaves, then the children of sharecroppers and maids and today the children of America’s still separate and unequal K-12 educational system.

Pre-med students at Xavier with Norman Francis, who recently retired as university president after 47 years. Credit Brian Finke for The New York Times

Because of this mandate, the colleges have been one of the most important institutions in building the nation’s black middle class. The list of promi­nent Americans who studied within the classrooms of historically black colleges is striking. Among them are Julian Bond, Ta-­Nehisi Coates, Sean Combs, W.E.B. DuBois, Medgar Evers, Ralph Ellison, Nikki Giovanni, Alex Haley, Langston Hughes, Zora Neale Hurston, the Rev. Jesse Jackson, James Weldon Johnson, Spike Lee, Toni Morrison, Oprah Winfrey, Marian Wright Edelman and Andrew Young.

The colleges, created as a result of the nation’s system of legal segregation, produced the very Americans who would eventually take down that system. Thurgood Marshall, who argued the Brown v. Board of Education case before the Supreme Court and later became its first black justice, went to Lincoln University in Pennsylvania and Howard University’s law school. Four freshmen at North Carolina A&T State University in Greensboro started the large-scale sit-in movement in 1960. Two Fisk University students, Diane Nash and John Lewis, the long-­serving congressman, helped found the Student Nonviolent Coordinating Committee and were pivotal in the struggle for civil rights across the South. The Rev. Dr. Martin Luther King Jr. is the most notable alumnus of one of these institutions; he entered Morehouse College in Atlanta at the age of 15.

With black students now attending schools that were once off limits, the percentage of black students who attend historically black colleges has declined from 90 percent in 1960 to just 11 percent today. But the role of these schools has not changed; they are still focused on addressing the needs of those whom privilege has passed over. Nearly three of four students at historically black colleges come from low-­income families, compared with about half of all American college students, and most are still first-­generation college attendees. Though the institutions account for just 3 percent of all colleges, they award 16 percent of the bachelor’s degrees earned by black students. Further, historically black colleges have always been incubators of black leadership; in the 1990s, the last time data was collected, graduates of these schools accounted for 80 percent of the nation’s black judges, 50 percent of black doctors and lawyers and 40 percent of black members of Congress. Along with Xavier, other historically black colleges like Morehouse, Howard, Hampton and Spelman are also among the top feeder schools for black medical students.

When that medical-­school report came across Francis’ desk all those years ago, he was certain of one thing: The small number of black students entering medical school was not a reflection of their capabilities. It was a reflection of the shoddy schooling so many of them received before they ever arrived at the college gate. If Xavier was going build a program to turn large numbers of its students into doctors, Francis knew the college was going to have to do more than just teach science. It was going to have to figure out how to overcome years of educational gaps.

Pierre Johnson was just the kind of student the college president had in mind. Johnson grew up in the 1980s on the South Side of Chicago, the oldest child of a single mother who emphasized the importance of education even as she battled drug addiction. School always came easy to Johnson; he worked hard in class and did his homework every night.

When Johnson was 10, his mother became pregnant, and he started accompanying her to doctor appointments. The science of how a tiny group of cells transforms in the womb into a baby, the magic and mystery of the birth process, fascinated him, and something else captured his attention, too, something he had never seen before. His mom’s obstetrician was a black man.

Brian Finke for The New York Times

The little boy thought about the way the white doctors at the public clinic had treated his mom with indifference and often disdain. But this black doctor, ‘‘he didn’t look down on her,’’ Johnson recalled. ‘‘He knew she was a good woman who had a problem. And he gave me, at least, something to say: ‘I can do that.’ ’’ Johnson thought to himself that he would become a doctor, too.

A few years later, he enrolled at an all-black, mostly poor South Side high school, where he continued to excel in all his classes and dreamed of a life as a physician. On his own, he paged through college guides at the local library, looking for schools with strong pre-med programs. He came across Xavier, which boasted of sending the largest number of black graduates to medical school. He had never been to Louisiana, but he decided, ‘‘That’s where I’m going.’’

Johnson graduated second in his class in 1998. He headed to Xavier full of confidence and expectations. As he moved into his dorm, he found it invigorating to be around so many smart young black people with similar goals. He felt as though he fit in. And then he took his first college science classes. ‘‘It was a pure shock,’’ he said. ‘‘I was extremely unprepared. Stuff that kids knew from high school, general physics and chemistry, I had no idea, none. I had never done poorly academically my whole life, and I realized for four years of high school, I had never been challenged.’’ Johnson’s high school did not offer the Advanced Placement chemistry and biology classes that some of his Xavier classmates had taken. But it was worse than that. Johnson’s high school did not even offer the basic high-school courses, like physics, that are needed to succeed in a typical pre-med program. ‘‘I wanted to be a doctor,’’ he said. ‘‘But I did not even know what the periodic table was.’’

Johnson’s experience is depressingly familiar to Francis. While many students at Xavier and other historically black colleges come from middle-­class homes, have gone to good schools and have parents who graduated from college, too many do not. ‘‘I used to say there was no relationship between being poor and being bright. I watched all of my life young people who were poor and very bright. But research shows if you are black and born poor, you are going to live in a poor neighborhood, going to go to a poor school, and by and large, you are going to stay that way,’’ Francis said. ‘‘To come out of that system, you would have to rise much higher than other youngsters who had every resource.’’

During Francis’ decades at Xavier, racial disparities in K-12 education remained firmly entrenched. Black public-­school students are more segregated now than at any time since the mid-1970s. Instead of receiving more resources to help them succeed, black students, almost without exception, get less. National data from the Education Department’s Office for Civil Rights show that black students are the least likely to attend high schools that offer algebra, physics and chemistry. A report released in July by the ACT and the United Negro College Fund laid out the tragic consequences: Nearly two-thirds of black students who took the ACT did not meet any of the test’s college-­readiness benchmarks, twice the national average.

At Xavier, Johnson found himself the embodiment of those statistics, and he was reeling. As he sat in his general biology and chemistry classes, in which even basic concepts were unfamiliar, he tried to quiet the rising panic, thinking that if he did what he had always done, just worked harder, he would get it. A few short months earlier, he was among the smartest kids in school; now he found himself studying all night only to eke out C’s and D’s on the weekly quizzes given by his professors. Johnson realized that if he was going to make it, he needed help. He scheduled an appointment with Professor J.W. Carmichael.

Carmichael, a chemistry professor, arrived at Xavier in 1970, not long after Francis was named president. At the time, Carmichael was young, untenured and brashly outspoken about what the college could be doing to place more of its students in medical schools. Despite its rigorous science program, Xavier was sending only about five to eight graduates to medical school each year.

Carmichael’s candor caught Francis’ attention, and he chose him to run the pre-med program and implement his vision. Francis believed that Xavier should not follow the example of most pre-med programs — ‘‘Look to your left, look to your right; only one of you will still be here at the end’’ — which work to weed out students. To him, that model squandered the talent of far too many students, especially black ones. Instead of compelling students to compete against one another, he said, it made much more sense, both morally and practically, to encourage better-­prepared students to help their classmates who weren’t as fortunate to catch up.

Carmichael, who is in his 70s now, is short and a bit frumpy and wears oversize glasses. He is white and grew up in a poor family in rural New Mexico, and he knew something about what students like Johnson experienced when they arrived at college. As the new pre-med adviser, Carmichael worked with faculty members across the sciences to set up a highly structured system to address students’ problems early and direct them toward help.

When Johnson walked through the door of Carmichael’s office, it meant the program was working as planned. The quizzes Johnson did so poorly on in his first few weeks were designed as part of Xavier’s early-­alert system. Carmichael believed that a student needed to know he was failing long before he took his midterm exam. He connected Johnson to tutoring centers set up for each of his science courses. There, Johnson met students from other classes, and they began holding large study groups led by a particularly brilliant classmate who would quickly learn the material and then teach it to others. Students would stay up until the wee hours of the morning helping one another. ‘‘You have almost a hundred kids asking questions, discussing the material,’’ Johnson said. ‘‘To see the material broken down that way was just amazing. And if you didn’t get it, they’d explain it again. And if you still didn’t get it, they’d explain it again.’’

These study groups encouraged just the sort of collaboration Francis had imagined. ‘‘It took the competition out of it,’’ Johnson said. ‘‘It wasn’t, ‘I’m mad because you got an A.’ It was, ‘How do we both do that on the next test?’ We had this feeling if we all stuck together and helped each other, we would make it.’’ Marybeth Gasman, an education professor and the head of the University of Pennsylvania’s Center for Minority Serving Institutions, which does research on and assists colleges that serve large numbers of black, Latino, Asian and Native American students, has carefully examined Xavier’s program and says no school is better at developing students’ shared responsibility for one another’s success. ‘‘It is dumbfounding to see,’’ she said.

What makes Xavier’s program most unusual is its strictly tailored uniform curriculum in freshman chemistry and biology. The faculty members collaborate on what they will teach and create a workbook for these courses that every professor must use. If professors want to teach something not in a workbook, they must present it to the faculty group for approval. The workbooks take the complicated material in science textbooks, which often overwhelms students, and specifies, step by step, everything students need to know for the class. The faculty members then incorporate regular tests and drills, not only to assess students but also to evaluate whether professors need to adjust their teaching. ‘‘This is fundamentally different than the way curriculum is taught across the country,’’ Gasman said. ‘‘What happens with faculty in general: We don’t want anyone telling us what to do in our classes; we pick our textbooks; we know what is right for our students. But they teach to where the students are and not just the way they want to teach.’’

Dr. Pierre Johnson in his office in Decatur, Ill. Without Xavier, he said, ‘‘I wouldn’t have made it.’’ Credit Brian Finke for The New York Times

For Johnson, when the workbooks and the study groups weren’t enough, he would spend hours after class in his professors’ offices as they patiently walked him through the material. By the second semester, Johnson was exhausted, but he was earning A’s and B’s again.

Excelling in biology and chemistry is only part of what gets students into medical school. Just as critical to Xavier’s success is the blueprint it created to help students navigate every step in the process of becoming desirable medical-­school candidates. ‘‘Our formula is built on believing there is no point in time where a pre-med student at this university shouldn’t know what they ought to be doing to get into medical school,’’ Quo Vadis Webster, Xavier’s current pre-med adviser, told me. By the end of the first semester, Johnson and other pre-med students needed to turn in the first of many personal statements that were critiqued by the university’s writing center. These essays, written and rewritten several times, would eventually become the ones included in their medical-­school applications.

Johnson attended weekly meetings with Carmichael, at which he continually received checklists and timelines, learned of research and internship opportunities and met graduates who spoke firsthand about getting into medical school. The pre-med office had Johnson and his classmates gather their letters of recommendation early, made sure they were good enough and then kept them on file until they were needed. Johnson prepared for his MCATs with the help of professors, whom Carmichael had instructed to take the exams themselves so they would know what their students should expect. Wearing a suit and tie, Johnson took part in mock interviews. And when the time came, Carmichael looked over every inch of Johnson’s application to make sure it would pass muster before he sent it out. Webster noted that wealthy students at elite schools pay thousands of dollars to agencies that help perfect their medical-­school applications and for courses that help prepare them for the medical exams. Xavier’s pre-med office, with a dedicated staff of two, provides nearly all of these services free.

Former students told me again and again that Carmichael’s involvement was something akin to fierce parenting; he believed in his students and would not let them fail. He would stand in the hall, near a wall decorated with the photos of smiling Xavierites who had become doctors, and reprimand students who professors reported had missed a class or a deadline. Students had to turn in cards signed by their professors showing how they had done on quizzes. Carmichael would send letters to parents on brightly colored paper saying, ‘‘Your child wants to go to medical school,’’ but warning that for some reason, the student hadn’t done x, y and z. If that didn’t work, he would pick up the phone and call a student’s home. ‘‘There is a constant monitoring,’’ Francis said. ‘‘We expect you to learn, and if you need support, you are going to get it.’’ He has a name for this system: love and pain.

The system worked for Johnson. After his rocky start, he graduated from Xavier on time in 2002 with a B average. Though the holes in his education continued to challenge him — he had to take the MCATs three times — he attended medical school at the University of Illinois in Peoria, where he was the only black student in his class. It was jarring to go there from Xavier’s nurturing environment. Johnson said he felt like a man on an island; no one seemed to care if he succeeded or failed. But he pressed on, and two years ago, Johnson, who is now 35, completed his ob-gyn residency. He works in a practice in Decatur, Ill., where he sees mothers with sons who remind him of his 10-year-old self, before he learned how hard it would be for a kid like him to become a doctor. Without Xavier, he said, ‘‘I wouldn’t have made it.’’

Historically black colleges like Xavier have written the guidebook on how to educate the nation’s neediest students, but they have always done so with less, and many of these schools are now struggling to survive. Though federal law required states to treat them and predominantly white colleges equally, states never did. Lawsuits over the years have argued that states still fail to do so. In 2004, Mississippi agreed to pay three historically black colleges $503 million when it settled a 30-year-old lawsuit accusing the state of discrimination in how it funded and supported its black public colleges. Alabama settled a similar case in 2006, and in 2013, a federal judge found that Maryland discriminated against its historically black colleges. Louisiana is home to three public, four-year historically black colleges. Last year, the University of Pennsylvania’s Graduate School of Education published a study showing that while these three colleges awarded 40 percent of all bachelor’s degrees earned by black students at the state’s public universities, they bore the largest percentage of state funding cuts.

As they have fought to get their equal share of government funding, these colleges have also struggled to build endowments. Nationally, black students are the most likely to borrow money to pay for school, and they also graduate with the highest student-­loan debt. That means it takes them much longer before they can write checks to their alma maters instead of to their loan holders. Although the colleges helped build the black middle class, the black middle class is often not in a position to give back. Even in the best of economic times, the unemployment rate for black college graduates is more than twice that of white college graduates. An August study released by the Federal Reserve of St. Louis found that a college degree did little to protect black wealth — the median net worth of black college graduates dropped nearly 56 percent from 1992 to 2013, while it rose 86 percent for white college graduates during that same pe­riod. The average black family has managed to accumulate about $7,000 in wealth, compared with $111,000 for the average white household, making it difficult for historically black colleges to find parents and grandparents affluent enough to write big checks for buildings, programs and scholarships. Alumni do give, Francis said, but the donations are often small.

The endowments at the nation’s black colleges reflect this stark reality. Howard University in Washington has the largest endowment of all the colleges by far, at $586 million. (The largest endowment among historically white institutions is Harvard’s $32 billion.) Over all, the gap between the endowments of historically black colleges and others has doubled in the last two decades.

Without big endowments, the colleges rely heavily on tuition, making them extremely vulnerable to stagnating or declining enrollments. Because they are designed to serve students with little wealth, they cannot make up the shortfall by raising tuition. The average tuition of private historically black colleges is half that of private predominantly white colleges. This means they are often not in a position to pay competitive faculty salaries and build the fancy buildings and other facilities that college students shop for

Families of students at historically black colleges rely heavily on PLUS loans, federal loans that parents can take out to help pay their children’s tuition. In recent years, the tightening of lending criteria for PLUS loans has caused a sharp drop in enrollment at historically black colleges. In 2012, the Education Department rejected the PLUS loan applications of 14,616 students going to historically black colleges, costing the institutions an estimated $168 million.

Some of the colleges, both private and public, have started buckling under the financial pressures of meeting very high student need with very few resources. Morehouse College laid off some 50 staff members in 2012. The South Caro­lina Legislature threatened to shutter for a year the state’s only historically black college, South Carolina State University, because it could no longer pay its bills after years of declining enrollment and funding cuts. In 2013, after Grambling State University in Louisiana lost one-third of its state funding over five years, the football team protested its crumbling facilities and 31-hour bus rides to other schools by refusing to travel to a game. Cheyney State, the first historically black college, is deeply in debt, and a Pennsylvania state auditor has called the school’s outlook ‘‘bleak.’’ The most unthinkable occurred in 2013, when a board member at Howard, long considered the black Harvard, warned that without significant changes, the venerable institution would be insolvent within a few years.

Xavier is trying to weather its own financial struggles. The university reached its highest enrollment in school history, some 4,100 students, in August 2005. Two weeks later, Hurricane Katrina hit, swamping the campus under as much as six feet of water. Xavier was forced to make repairs and take out loans. One thousand students never came back. ‘‘Our enrollment is at a standstill,’’ Francis said. ‘‘The next few years are going to be very difficult for small schools, and particularly for black schools.’’

This summer, in the weeks before he stepped down as the longest-­serving college president in the United States, Francis traveled across the country on what he called a legacy tour, visiting alumni and raising money for a scholarship campaign. Under his tenure, the school has helped produce thousands of doctors, enrollment has more than doubled and the endowment has grown from $2 million when he started to $161 million today.

But sitting in his cool dining room this summer, Francis said he also felt discouraged. With just 3,000 students, Xavier is ‘‘too small to be the No.1 institution sending African-­American students to medical school.’’ The college’s ranking, he said, says as much about America’s failure as it does about Xavier’s success.

Despite all of Francis’ efforts, and those of other historically black colleges, the number of black doctors is still meager; black Americans make up 13 percent of the population but account for barely 4 percent of the nation’s doctors — about the same as it has been for decades.

In August, just weeks after Francis retired, the Association of American Medical Colleges, the same organization that issued the report some 40 years earlier that he took as a call to act, published another report. Just 515 black men entered medical school last year. Even though the nation’s black population is much larger now, that number is 27 fewer than the 542 black men who went to medical school in 1978.

The way Francis sees it, those statistics should be the nation’s shame. American schools have not absorbed the lessons that historically black colleges have to teach about how to better develop and support talented students stifled in poor communities across the land. Too many universities, he said, are content to recruit the most privileged and high-­achieving students in the United States and other countries. He said he saw historically black colleges ‘‘as the conscience of the nation.’’ But, he added, ‘‘I am not as sanguine about whether this nation fully understands the role we play — what we’ve done for this country with so little.’’

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