At a recent event held at the School of Public Health, I had the privilege of hearing Dr. Maricela Gomez speak. She is in many ways for me a model of physician activism; trained as a clinician and scientist at Hopkins, she has engaged in direct action and organizing with communities of East Baltimore, particularly around Hopkins’ use of eminent domain in the Middle East neighbourhood to make room for expanded research facilities. She has since distanced herself from the institution almost entirely (returning only, and on rare occasion, on student invitation), and does most of her work in the communities of East Baltimore, conducting research projects and continuing to organize on issues of development and displacement.
Her talk was part of a block that was meant to discuss an open data initiative that students at the school were hoping to kick off, with an eyes towards making the research and academic resources that the school produces and on which it builds its reputation – not to mention its considerable financial resources – accessible to the communities around Hopkins that either are directly impacted by its presence or have in some way involved in that research. The idea is a compelling one, and a real, thoughtful movement towards addressing the way that research, particularly in underserved and marginalized communities, often perpetuates a pattern of resource extraction and objectification rather than working against the injustices it is studying. Dr. Gomez, however, pushed the audience to take a step back and think about our positionality as affiliates of Hopkins, and what it means that this is the research we are doing and claiming and, whether financially or professionally, profiting from. In this discussion she made a particular link that I had not really considered before. She noted the way that the displacement and gentrification that she has been working against, that so many see as defining the relationship that Hopkins has with its surrounding communities, is being driven in part by a pressure on the school to be at the top of its field, to be cutting edge, and how that pressure is coming from the way in which students and faculty select their institutions. She spoke about how what we look for in institutions and what we hope to gain is often measured by the resources and opportunities they can offer, and often that means that schools need to expand, needs to build new shiny new labs and new teaching buildings. And that in turn means they continue to extract those resources from the communities around them, and engage in practices of displacement and gentrification and the perpetuation of oppressive systems.
I had been thinking for a while about my complicity in the damage that medicine, and Hopkins more specifically, enacts. A lot of that has focused on how my presence in the school, my financial support of it as a paying student, my affiliation with it, is a silent condoning of its actions. Something I haven’t thought about as much is how my choice to come here in the first place, and the criteria that I use to make that choice, are also something that drive this school – and others like it – to take the actions that I now condemn. And her analysis does ring true for me; the resources that a school has and is able to show off, from how nice their buildings are to the achievements of their faculty, those are things that I did think about in making my choice. More directly, and more ashamedly, the prestige and status of the schools I was looking at was also definitely a factor that impacted my choice, the freedom or advantage that a degree from any given school would give me in making future steps in my career.
It was a difficult and uncomfortable point to come to realize, that my complicity in the things I criticize extends to even before I became a part of this institution. But it was a point that also opens new avenues for thinking about how to work against that complicity. If the idea is that the criteria that students and faculty are now using to choose their academic home require schools to take potentially harmful and exploitative action, why not change the criteria? Why not encourage students to base their decision on where to go to school on other standards, like how responsibly a school engages with its community, how its curriculum addresses issues of social determinants of health and structural injustice, how diverse its student and faculty bodies are? This idea has been around for a little while; most notably, a paper by Mullan and colleagues in the Annals of Internal Medicine in 2010 proposed an alternative ranking of medical schools using criteria that aimed to capture the ‘social mission’ of medicine. The authors used three main measures: the percentage of graduates who go into primary care, the percentage who work in health professional shortage areas (as defined by the Health Resources and Services Administration, a branch of HHS), and the percentage of graduates who are underrepresented minorities (defined as African American, Latina/o or Indigenous/Native American). Using these measures, they constructed a composite score for each of the 141 medical and osteopathic schools in the USA: needless to say, their rankings look very different from the ones typically paraded around by the big name schools. Top three on their list were Morehouse, Meharry and Howard. I’m embarrassed – though not particularly surprised – to see my own school listed dead last in their ranking. Other trends in their results were also notable reflections of the sorts of priorities that medical schools have thus far developed, and that we as prospective attendees have encouraged them to develop: NIH funding was inversely related to rankings, and public and community-based schools (schools that are focused on creating a workforce that will serve the community in which the school is based) scored higher than private and non-community based schools.
So what does this mean? For one it means that students interested in using medicine as a path towards achieving a social good should be using other criteria for selection that those they might be most readily exposed to, and that those students – and all students – should have access to those criteria in the way they have access to the US News and World Report. In fact, the development and dissemination of a standardized ranking like the one discussed above might be of even greater value because the things they measure are not things that are quite so easy to see as how new the buildings are or how famous the lecturers are. In particular, understanding a school’s commitment to a ‘social mission’ not just through the doctors it produces but also through the actions it takes as an institution requires a level of knowledge and context that school’s rarely provide their applicants.
More than the choices made by individual students who are seeking out these measures, though, a project like this also means that there are ways we can define progress and advancement in medicine that don’t necessarily encourage an institution to perpetuate practices that are fundamentally oppressive or exploitative. All of us can think more critically about what it is we’re looking for in the institutions we affiliate with, and we can hold our schools to different standards. Whether or not they meet those standards is of course still uncertain, and requires additional work from activists and organizers inside and outside an institution. But creating measures like this and publicly tracking a school’s performance on them is one way to apply the external pressure that’s needed to force institutional change. Because if there is one thing I know from my time in these kinds of places, it’s that none of them like being last on a list: what we just need to control is what kind of list that is.