Background

For several decades, state, federal, and educational entities have tried to increase the number of historically marginalized healthcare workers in under-resourced cities and communities.Reference Bouye, McCleary and Williams ¹ The lack of diversity among these professionals contributes to the inequities in health outcomes for people who live in these communities compared to their white peers.Reference Stanford ² This article aims to bring awareness to the need to apply the legal epidemiology framework to education in a new, holistic way, as education has historically been used to limit access to resources. To be succinct, we find that low socioeconomic Black communities need more diverse health professionals; however, the community cannot provide a career pathway pipeline program as their local educational schooling is not equipped to prepare students for a rigorous bachelor’s or post-graduate degree in healthcare fields.Reference Duncombe ³ The gap in diverse individuals causes issues related to access to patient care, perceptions of the care they receive, and the health outcomes for people in this community.Reference Zephyrin, Rodriguez and Rosenbaum ⁴ In addition, the gap can be related to the pipeline of students from the community graduating from local educational institutions, enrolling in a rigorous four-year institution, and entering a post-secondary program that leads the students back to their local community to provide support.

However, to address the healthcare pipeline, we investigated reading and literacy scores and parent involvement, as these are the foundation of learning and essential for matriculation through primary and secondary education.Reference Hull ⁵ We believe that legal epidemiology methods can help explore the barriers to K-12 educational attainment that can restrict access for communities in historically marginalized areas to receive quality education. Specifically, legal epidemiology can help further examine how education can add to the causes and influence of disease prevention, or the lack thereof, because of not having qualified trained professionals in the community.

Lack of Representation Contributes to Health Disparities

The healthcare gap for historically marginalized communities continues to grow as there is a lack of representation of healthcare workers in pharmacy, nursing, and medical doctors, which can cause inequities in patient care delivery.Reference Jean ⁶ A report by the Association of American Medical Doctors documents how Black/African American and Latin(x) populations have less than 6 and 8% of their population represented in the medical field, respectively, even though Black/African American and Latin(x) people make up 12% and 18% of the U.S. population.Reference Boyle ⁷

The lack of representation in medicine is nuanced and can be attributed to structural issues, like the systematic removal of Black/African American people from gaining entrance into the medical field.Reference Howard ⁸ There have been numerous aspirational goals to increase representation in healthcare fields established by the Health and Human Services Office of Minority Health and partnersReference Jackson and Gracia ⁹ and the University of California Programs in Medical Education (UC PRIME) that promote equity in rural communities with a specific program that focuses on the intersection of Anti-Black racism, medicine, and health outcomes. Although there are significant initiatives that seek to diversify healthcare professionals, they fall short due to continued persistent racial bias and subpar attitudes toward marginalized communities, especially Black patients, from healthcare clinicians.Reference Cooper ¹⁰

The bias is rooted in the historically false representations of marginalized communities and racism that have plagued this field for decades. To address these concerns, decision-makers have sought to research how policies, laws, and practices hinder equitable outcomes for historically marginalized communities. A possible solution to this issue can be the application of legal epidemiology to address the systemic gaps of healthcare professionals. Legal epidemiology is transdisciplinary and was established almost 50 years ago. ¹¹ The theory utilizes legal etiology, legal prevention and control, and policy surveillance methods to measure, evaluate, analyze, enable, and support healthcare laws and policies. Several scholars have covered the influence of legal epidemiology and its impact on Black/African American communities through Jim Crow laws, the Civil Rights Act, and addressing structural inequality within healthcare that relates to higher death rates for Black individuals with cancer.Reference Goodwin and Chemerinsky ¹² Yet there has been stagnation within the framework, and a shift is needed to understand the nuanced concerns of marginalized communities and how findings can be applied to help under-resourced Black/African American neighborhoods.

Expand Legal Epidemiology to Improve Diversity in Healthcare

To address gaps in research and application to impacted communities, we argue that the definition and, therefore, the views of legal epidemiology should be extended to include the holistic background of people. In this context, it should be applied to education as a way to explore how education has been used to limit access and shape the lived experiences of Black/African Americans. Horace Mann once argued that education “is the great equalizer of the conditions of men, the balance wheel of the social machinery.”Reference Holmes and Zajacova ¹³ Education provides self-efficacy, a sense of self, and context on social norms and can improve social mobility.Reference Haveman and Smeeding ¹⁴ Education can also exacerbate ills in society by reinforcing racist ideologies, gender-specific stereotypes, and who is deemed “worthy” of resource allocation. In the book Savage Inequalities, the author chronicles areas where predominately Black/African Americans lived, noting that schools in these areas tended to be patrolled by police officers, had bars on windows, were in disrepair, and were filthy.Reference Kozol ¹⁵ The schools often mirrored housing conditions in the neighborhood, and students were transient because they were housing insecure. In addition, research supports the lingering effects of redlining on education in cities that utilized these practices and policies in the 1930s specifically; the areas within the regions redlined have lower test scores compared to areas outside the redlined zones.Reference Burke and Schwalbach ¹⁶

Redlining is a term derived from drawing red lines around areas on a map that were viewed as “hazardous” areas to lend money. The Homeowners Loan Corporation created this tactic. Although the federal government tried to reverse some of these tactics in the 1960s and 1970s, we still see the effects of these policies today. For example, schools are intertwined with property values, which correlates with the quality of schools. ¹⁷ The foundation for many students’ educational attainment is already determined prior to birth based on a zip code or which side of town they are mandated to attend school.

A report by the Shott Foundation (2024) ¹⁸ found that life expectancy for Black/African American people has declined by five years, while improvements in K-12 and higher education levels can add 10 months to the average life expectancy; there is a continual downward trend on students enrolling in post-secondary education. The authors further stated that despite increases in high school graduations, there was a decline (26% in community colleges, 16% in Historically Black Colleges and Universities [HBCUs], and a 39% drop in Black male enrollment) in postsecondary attendance for individuals between the ages of 18–24. The low graduation rates, per the report, can be attributed to poverty and underemployment, unjust living and learning communities, and segregation and housing affordability. ¹⁹ As a result, the Schott Foundation created the Loving Cities Index from 10 cities with large Black/African American populations to help policymakers evaluate if students have equitable access to living and learning supports. The index found that none of the ten cities offered over 55% of the support for children in the community to thrive. ²⁰

Similarly, Black students who take the ACT have the lowest test readiness scores of any group in English, mathematics, reading, and science. ²¹ The low high school graduation rates and low test readiness can be attributed to the lack of representation of Black doctors, pharmacists, and faculty members who teach in these programs.Reference Gallegos ²² This is in conjunction with Republican pushback against affirmative action policies and advancements through diversity, equity, and inclusion strategies that help address the gaps in diverse representation in healthcare professionals.Reference Sausser ²³

The crux of this is the demand to increase more diverse healthcare professionals; however, the educational structure is incompatible with supporting this pipeline. We speculate that the lack of support due to systemic racist policies by redlining and its cascading effects place many Black/African American communities behind and causes a cascading effect that results in fewer Black/African American students matriculating, graduating, and entering the healthcare profession. However, we also suggest it can be connected to inequities within the education system that limit later professional opportunities because of poor educational offerings in the K-12 settings.

How Broader Policies Affect Educational Opportunity

Education policies shape the lives of Black/African American children and families that reside in the inner city and urban areas, primarily through educational attainment and the opportunities afforded to young adults within the parameters of the community compared to their affluent peers with higher home values. A report by The Commonwealth Institute found that high-poverty schools in Virginia paid their teachers 21% less than low-poverty schools ($46,000 compared to $57,000), are majority Black (around 60%), and only about one-third of these schools are fully accredited. ²⁴

To better understand the implications of education on workforce development, we conducted an intervention that investigated students in the second, third, fifth, and eighth grades and their perceptions and attitudes toward reading and writing. We chose literacy and writing as indicators because these are the foundations of problem-solving and all future learning. ²⁵ A report by the Annie E. Casey Foundation found that 36% of the nation’s fourth graders were proficient in reading. When analyzing by race/ethnicity, only 18% of Black fourth graders are proficient, and there is a strong correlation between reading levels and income inequality.

Furthermore, the report found that 31% of Black/African American students who did not pass the third grade proficiency mark failed to graduate compared to 22% of poor whites.Reference Hernandez ²⁶ Because these students were unable to graduate because of systemic barriers associated with a lack of resources related to literacy and writing, they are not able or academically prepared for the rigor of post-secondary education. Moreover, Hull (2020) suggests that parent involvement is one of the greatest indicators of academic achievement for students. They mention that parent involvement in reading at any level and language, although challenging in this economic environment, can shape their student’s academic outcomes. ²⁷

In addition, the participants interacted with a Black/African American author and illustrator. The author and illustrator visits were designed to expose students to stories and books where characters and stories reflected their culture and linguistic acumen. Literacy and writing are the foundations of learning and can be a laborious task to grasp, which can be considered an unnatural act to understand the structures of the words and the sounds they make.Reference Treiman ²⁸ Also, they are the foundation of knowledge acquisition and, if deficient in the primary levels, can result in concerns in the student’s later education endeavors. ²⁹

Our findings suggest that parent involvement is one of the most significant factors that can increase reading outcomes. Specifically, as the frequency of parental involvement in reading increases, students’ perceptions of reading increase. This is evident for all student groups, and we find that self-confidence in eighth-grade students increases when they read with their parents.

Parental involvement has the most significant outcomes for students, and the collaboration between them is essential to ensure students have the necessary reading skills to be proficient in their academic endeavors.Reference Liontos ³⁰ Parental involvement must be considered as one of the critical indicators for increasing reading fluency, comprehension, and self-confidence.Reference Gay, Sonnenschein, Sun and Baker ³¹ The involvement and care for a student can tremendously increase academic achievement outcomes.Reference Kleitman, Moscrop, Efklides and Misailidi ³²