By JIll Mari Embry: CEO/Founder of Balance Innovation CEnter

I have been lucky, yet challenged, to have worked in a profession I love. Creating and developing medical solutions is a very rewarding experience. The projects we, as engineers, work on improve or save lives. Unfortunately, the technologies we create are not designed for all the patients that need them or all  the physicians that use them. One of the fundamental reasons for this is the lack of diversity in the research and development teams that design them. Also, a lack of diversity in the medical advisory boards that consult the development teams on product needs.

Although we are making efforts to train a more diverse STEM work force, barriers still exist to moving the training into practice. Hiring is still, often based on a “looks like me=thinks like me” mentality. There are also the biases that exist that are barriers to acceptance of diversity in engineering and scientist roles. Sadly, this lack of diversity in the development teams in companies is also seen in many medical specialties. All of this translate to a, still, very prevalent disparity in health care for both women and minorities.

Many believe that there is improvement in these areas, but it is small.  Women make up only  39% of physicians  in the United States (2022).,but represent  50.8% of the population.

 There are also disparities in ethnicity/race, in medical practice. Of all US physicians,  63.8% of physicians are white. The second largest ethnic group of physicians is Asian, at 20%. . Those identifying as   two or more races represent a little over 1% The number of black surgeons and physicians is 5.6%. This has not changed in 120 years. Hispanic/Latin physicians represent 6.9% of all US physicians.  Native American and Pacific Islanders are captured under “Other” make up less than 1.% of physicians. To give a point of reference, in the USA, White = 57.8%, Hispanic/Latin = 18.9%, Black = 12.1%, Asian Americans = 5.9%, Native Americans = ~1% of the overall US population.

For Engineering, using the same USA overall population references (also keep in mind this is not strictly medical device, but all engineering professionals),. Women make up 12.5% of all engineers. For ethnicity,   The most common ethnicity of professional engineers is White (66.8%), followed by Asian (12.6%), Hispanic or Latino (11.7%) and Unknown (4.7%).  And  5% of all professional engineers are LBTQ (5.7% of the population. . (Reference). The male to female ratio has changed little from 2010 to 2021, despite efforts to increase the number of women in STEM. The same can be said across ethnicities.

Gender	Engineers	Physicians	Population
Women	12.50%	39.50%	50.80%
Men	87.50%	60.50%	49.20%

Race/Ethnicity	Engineers	Physicians	Population
White	66.80%	63.80%	57.00%
Asian	12.60%	20.60%	5.90%
Hispanic or Latino	11.70%	6.90%	18.90%
Unknown/Other	4.70%	1.60%
Black or African American	4.00%	5.70%	12.10%
American Indian and Alaska Native	0.20%	0.40%	1.00%
2 or more Races		1.00%	10.20%

Several factors account for this, but the primary one is due to biases that still exist in our society. Most women and minorities that are engineers and physicians have stories. Those of us who have been around keep hoping for change, but here are a few.

Example:

Recently, I was speaking to a young woman, who is a student in her senior year, studying biomechanics. She was interviewing for internships. At an interview with a women’s health company, all white male development team, she was told she was not a cultural fit. I have been told this in several different variations.   The worst was, “we are like a family in our organization. We don’t think you will fit in.” I have been told, “I don’t know how the guys will take reporting to you.” And of course, in all white environment, that I was not a cultural fit. All of these “cultural fit” comments are based on assumptions, knowing nothing about our backgrounds.

Example:

One of our Chief Technical Officers and I were speaking with a employee, representing the philanthropy group at one of the largest medical device companies in the world. Both of us are African American. The meeting had been arranged, following our sending the Balance innovation Center Pitch Deck to the Venture Group at this company. We assumed that we were sent to the philanthropy group because we have a mission, focusing on diversity (Balance is for profit). Most of the conversation centered around what this company was doing from a Diversity, Inclusion and Equity (DEI) perspective. One of their initiatives was to give scholarships to HBCUs(Historically Black Colleges and Universities). Without missing a beat, the woman told us, “we may have to lower our standards”

Example:

This is an older example. But considering the percentage of black physicians hasn’t changed in 120 years, I am going to make the leap and assume that the attitudes are the same. While in medical school, the week before finals, I was in the infirmary with bronchial pneumonia. I was released in time to take exams and took all the written exams. I had two classes that had practical’s, anatomy and histology. I went to both professors to ask for a week to study for the practical exams. The anatomy professor gave me the. option to take a summer lab course at University of Vermont. This would allow me to move forward with the rest of my class. When I went to the histology professor), I was told, “We let you people in, and then you do not want to work.” Given that it was easy to check to confirm that I was, indeed, in the infirmary and that I had passed the written exam, his comment was nothing but racist. Due to his racism, I was required to start the year over, just to take Histology. I did not go to class. And they let me know how angry they were, when I got the second highest grade on the exam, missing only one slide.

Example:

Recently, when interviewing a female associate professor, for a part time position with Integrity Research and Development, I turned on my camera, and she exclaimed, “You look like Buckwheat”, followed by, “It’s okay.”. Yet she had to be told on multiple occasions that she could use technical terms. That I was, indeed, an engineer.

I could go on, but the examples are just to highlight that things have not changed, drastically. Over the years. What is important is the impact of the lack of diversity on our health care system.

• With over 50% of the USA population being women, only a small percent of those developing products for them contribute to their health and wellness.
  • Although there is a biochemical difference between men and women, clinical trials for drugs often are carried out with predominately male patient populations. This impacts the dosing, the side effect prevalence,, etc.
  •  Women health products are less of a focus, thus treatments for menus and menopause, urinary incontinence, etc. are insufficient
  • Device designed to be used by physicians are sometimes not able to be used by female physicians due to size or mechanical strength disparities
  • The USA infant mortality (deaths for children 5 years or younger is expected to be 5.1/1000 live births, (Reference) . This is 173^rd out of 227 countries, with Slovenia, having 1.8 deaths out of 1000 live births, at 227^th. This may not sound horrible, but given the amount of money invested in our health care system, this is not great.
    
    
  • Products designed for women are designed by men. This is apparent in many of the designs. They lack consideration for the anatomical, physiological, biochemical impact of the product on the female body. An example of this is the IUD and its insertion. Watch a video of the procedure for insertion and translate the cervix for the penis.
  • “As recently as 2019, women accounted for roughly 40% of participants in clinical trials for three of the diseases that most affect women — cancer, cardiovascular disease, and psychiatric disorders — despite representing 51% of the U.S. population, according to a 2022 study by researchers at Harvard Medical School.Mar 26, 2024”-

AAMC  “This may contribute to health care disparities, as biological sex can play a role in physiological, metabolic, hormonal, and even cellular differences that can influence how diseases present and the effectiveness of pharmaceuticals and medical devices. Failure to study medications and other interventions in a broad sampling of women has contributed to women experiencing adverse effects from medications at twice the rate of men. One 2013 study found that women with metal hip replacements were 29% more likely than men to experience implant failure, possibly due to anatomical differences and inadequate testing in women. And, despite heart disease being the leading cause of death in the United States for both men and women, the medical field only recognized that women experience different symptoms of the disease than men when the American Heart Association published a Guide to Preventive Cardiology for Women in 1999. Separate from biological sex differences, women also are less likely to receive appropriate prevention and management of heart disease due to gender bias.”

In addition to gender disparities in health care, the ethnic/racial disparities are as great, if not greater.  

• In looking at recent trends in Telemedicine using AI and imagery, complexion implications in algorithms are often overlooked. White complexion is the standard, without testing in a range of skin tones.
• With so few physicians being minorities, implicit biases are present in care. Example: I went to see an internal medicine physician (female), when I was in perimenopause. I gained a significant amount of weight (size 5 up to a 16 in less than a year was riding 3+ horses a day, eating 5 small, all  unprocessed, healthy food, which had kept me at  the size I had been since high school. After the nurse had taken my vitals, the physician came in (female) and indicated that she would not be doing my physical. That they were unable to do them on, and she used a term I had not heard of before. I indicated that I did not know what that was. She repeated it, with irritation. Again I told her, “I don’t know what that is”. Her response, “Medicaid” My insurance card United Health Gold Premium” was attached to my file. When I asked why she thought I was on Medicaid, she belligerently told me, “Well, I will not be examining you.”.  

This is just one example of many. Data to be aware of:

• Among adults with any mental illness, Hispanic (40%), Black (38%), and Asian (36%) adults were less likely than White adults (56%) to receive mental health services as of 2022.
•   lack (10.9 per 1,000) and AIAN (9.1 per 1,000) infants were at least two times as likely to die as White infants (4.5 per 1,000) as of 2022. Black and AIAN women also had the highest rates of pregnancy-related mortality.  (Reference)
• The NIH publishes data for participants in their clinical trials, based on gender and race (Reference). It is a large amount of data, so I will just give one indicator, the lowest percentage of white participants. Keep in mind that some of the treatments are for diseases that have a higher prevalence in people of color.  Selecting just a couple of examples, studies for back pain, 70% of the participants were white.  In most studies, most have over 70% of the participants as white.

Although many want to believe that the disparities are due to economic challenges. This is not the only factor. People of color, that are financially secure run into many of the same issues regardless of our ability to pay, insurance status, etc. Harvard University, (s well as other universities) actually offers a course, in an attempt to address the racism in medical care. Personally, I am not sure if having a course is going to change things much. Racism can not be addressed by a course. Those that want to help, may take the course, but they typically are not the issue. Racism is embedded , deeply, in the psyche of this country, as well as around the globe. We are not born being racist, but through so many channels, we are exposed to biases early on, which continue to shape biases in everyone.

The other challenge to addressing disparities in health care is the fundamental reason I wrote this article. With the profound misrepresentation of the minorities at the table, throughout the process, from concept through to treatment, the understanding of what  our unique differences that need to be considered in research, development, clinical trials, and physician care, are missed. This includes those who write the grants, approve the studies, and sign off on the projects in a company. This also includes who is funding projects (black women receive 0.1% of VC funding, women 2%) as well as government and foundations awarding grants. This also includes the advisors in companies developing products.

The final challenge we have is relevant to the above. Without representation in academia, in scientists, engineering, physicians, it is hard to put  seats at the tables everywhere they are needed, for diverse thought. With the Supreme Court ruling on affirmative action, as well as certain players going after Diversity, Inclusion and Equity programs in corporations, industry is Destin to either stay as it is or go backwards.  I don’t intend to be doom and gloom. But I have listened to my peers and experienced the industry as it is. It is how the concept of Balance Innovation Center came about. We don’t just want to make diversity the norm. We also want to provide those coming behind us, and companies/corporations with the tools they need to change the trajectory.