Access to the university and medical education

Brazil maintains a post-colonial legacy of socioeconomic and racial inequalities regarding the access to university. Socially valued jobs are perpetuators of inequalities and not of democratization^{20), (21}. This is more evident in courses of greater social prestige, such as Medicine²², traditionally attended by whites, the wealthy and the upper middle class^22)-(24, although 54% of the Brazilians consider themselves as being of black or brown²⁵. In São Paulo, among the graduating medical population, only 0.9% are black or brown²⁶. Thus, it is possible to infer that these professionals do not share cultural characteristics with their assisted population.

In the USA, it has become evident that the higher the percentage of non-white professionals in a health unit, the more culturally appropriate their behavior is, making it possible to reduce health disparities²⁷. With the National Curriculum Guidelines for Medicine, the Brazilian federal government understood that a culturally-competent professional is trained to be exposed to diversity²⁸, and the curriculum “must also contribute to the understanding, interpretation, preservation, reinforcement, promotion and diffusion of national and regional, international and historical cultures, in a context of pluralism and cultural diversity”²⁸.

According to the 2016 higher education census, in Brazil only 14.05% of the teachers are brown, 1.81% are black and 0.12% are indigenous²⁹. In this situation, it is worth asking ourselves how we can possibly train culturally-competent professionals if the students are not exposed to diversity in the classroom.

Affirmative Action Policy in Higher Education

Among the initiatives to deal with this scenario, the social and racial quotas occurred under pressure from the Brazilian organized civil society¹⁸. Since the late 1990s, state governments and the federal government have been working to develop public policies to respond to this social demand. In 1999, the federal government created the ‘Student Financing’ (Fies) strategy³⁰. In 2003, Universidade de Brasília (UNB) and Universidade Estadual do Rio de Janeiro (UERJ) started the process of establishing quotas reserved for black and indigenous individuals and students from public schools. These initiatives were followed in 2005 by Universidade Estadual de Campinas (Unicamp) and in 2006 by Universidade Estadual de São Paulo (USP), by applying the policy of quotas in all of them³¹.

In the 2010s, the federal sphere unified the university admission exams through the Unified Selection System³¹. Two years later, Law n. 12.711/201232 defined that federal public universities should adopt affirmative action policies, guaranteeing access to groups that have been historically excluded from the universities. Such policies are institutional efforts aimed at improving the opportunities for these socially excluded groups³³, ensuring equal opportunities, a basic principle of a healthy meritocratic capitalist economy.

Affirmative policies originated in the early 20^th century in India, due to the inequality of the caste system³⁴, and have been adopted by more countries in the last 100 years. In the USA, such policies were initiated during the Kennedy administration through Executive Order n. 10925³³ in 1961, which resulted in the Presidential Committee for Equal Employment Opportunity.

In Brazil, the leadership of the anti-racist movement led the political struggle for the racial quota system¹⁸. Although the initial demand from the organized civil society was a racial issue, the debate was thwarted by conflicting interests. The Brazilian government, linked to the white elite and the discourse of a racial democracy, redirected the discussion towards the economic bias³⁵.

Therefore, Law n. 12,711 / 2012 marginally incorporated affirmative racial actions. According to this Law, 50% of the vacancies are reserved for public school students, the main inclusion criterion. Moreover, there are specific sub-quotas for blacks, browns, indigenous people, people with low income and the physically disabled ones³⁶. During the first seven years of its existence, greater economic democratization of access to most higher education courses was observed²⁰, as it was observed in previous experiences such as in Unicamp³¹ and UERJ. In the latter, there was even an increase in the associated curricular performance³⁷. However, Medical school, in particular, remains the most resistant to change and the fulfillment of the law objective, and its student profile has changed but little^{20), (22), (24}.

Study issue

Our hypothesis is that the law of affirmative policies in higher education (Law n. 12.711/2012)³⁶ selectively included poor white people in medical schools. If this is true, the law that would reduce racial inequities in access to medical education in Brazil - by bringing doctors closer to the Brazilian population profile - failed to address the structural racism of the Brazilian society³⁸.

This failure shows a double overlap:

Ferreira Filho⁴⁰ emphasizes the importance of empathy at the bedside, in which good practices are the essence of medical art. The author uses the term ‘empathy’ as the capacity to be aware of someone else’s feelings and emotions. Hence, the importance of understanding racism and poverty. The National Policy for Comprehensive Health Care of the Black Population⁴¹ recognized social and racial inequalities in Brazil as factors that interfere with health care. Racism is a fundamental determinant in health care access and quality^{9), (42), (43}. It is also known that black Brazilians have lower life expectancy and lower quality of health indicators^{44), (45}.

Batista et al.³⁸ stated that racism is related to the quality of care, the profiles and estimates of infant mortality, preventable suffering or early deaths, mortality rates and profiles, maternal mortality indicators and coefficients. The racial bias of the medical staff may, heuristically, be co-responsible for health inequalities^46)-(49.

The present study is a pioneer in the analysis of the effectiveness of affirmative social and racial affirmative policies for black and poor students in medical courses in the West. Its objective was to assess changes in the racial and social profile of those entering medical school in the first five years of policy implementation; we chose the student body of the School of Medicine of a public university in the state of Rio de Janeiro.

Population profile

Table 1 lists the relative frequencies of the students for the variables: age group, gender identity, skin color, higher education degree in the family, parental education and schooling level of father and mother. The 658 responses for the age group show that 68.4% of the students in the sample are aged between 25 and 30 years. Age ranged from 18 to 41 years, with a mean of 23.6 (standard deviation = 3.1 years). As for gender, the question was asked by self-declaration and open. Of the 657 valid responses, 49% identified themselves as being males and 51% as females.

We have divided the 677 valid responses for the skin color item in each of the answer options. The profile found was mostly white (69.87%), followed by browns (23.78%) who together account for almost all students. Self-declared black students comprised 3.2%; yellow, 2.7%; those who declared themselves indigenous represent only 0.3% of the total participants. As this value was not statistically relevant, we made the methodological option of analyzing the data only with the white, yellow, brown and black categories, excluding indigenous people.

When asked if anyone in the family, regardless of degree of kinship, had a higher education diploma, students provided 676 responses, of which 86.5% were affirmative. In contrast, 13.5% of students said they were the first in their families to enter a university.

As for the level of paternal and maternal schooling, 666 responses were obtained. The results were aggregated into three variables: father and mother with higher education, which corresponded to 46.4%; only father or mother, with 30.2% and neither father nor mother with Higher Education degree, 23.4% of students.

Table 2 describes the variables related to the financial status of the students participating in the census. We evaluated monthly family income, housing conditions, personal financial status, work status, whether the student was receiving permanent assistance and was a scholarship recipient. The monthly family income, in Brazilian Reais (R$), was described in numbers of minimum wages received, taking into account the national value on 01/01/2018 and subsequently transformed into an annual income in US dollars (US$), with the exchange rate of 01/06/2018. We had 673 responses, in which 44.3% of the participants declared an annual income between US$ 8,640.00 and US$ 28,760.00; 42.6%, above US$ 28,760.00 and only 13.1% was in the lowest annual income stratum, up to US$ 8,640.00.

Of the 684 who answered about their personal financial status, 79.2% has no income of their own and their expenses were supported by the family. Regarding the work status, 685 answered the question, showing that 90.1% of the students during the assessed period, did not have a paid activity, being full-time students. answers

Table 3 shows the variables related to the academic trajectory of the assessed students. We observed that 85.2% graduated from traditional high schools and 13% from technical schools (675 responses); 60.5% came from private schools and 35.1% from public schools (729).

Regarding the method of admission at the university, the data collected were divided into each of the admission modalities provided for by Law n. 12.711/12³². Of the 643 valid responses, 65.9% declared they entered university through broad competition and 34.1% through affirmative action policies. After isolating the specification of quotas compared to the total number of students, we observed that the majority entered university through broad competition.

Among those benefiting from the quotas, the main forms of admission were, in descending order: attended only public school; attended public school, with an annual income up to US$ 8,640.00; attended public school, with an annual income up to US$ 8,640.00 and black or indigenous; attended public school and black or indigenous, regardless of income.

Chart 1 shows the racial profile of each of the modalities. In the admission mode through broad competition, whites predominate, with 82%; through the public school modality, regardless of other factors, they comprise 76% and through the public-school modality with income factor, it comprises 71%. In the modalities with mandatory racial component, there was a clear predominance of browns. Regarding the access through public school with an exclusively racial approach, 77% of the freshmen declared themselves to be brown. Considering the racial and income profiles, browns represented 84% of the answers. Two of the three admissions of people with disabilities with an racial approach were individuals that declared as brown.

Source: Elaborated by the authors

Chart 1 Distribution of the absolute frequency of students according to race by type of admission to the School of Medicine (2013-2017). State of Rio de Janeiro, Brazil, 2018 

Only two students identified themselves as indigenous; one entered university exclusively through the racial quota and the other through broad competition. Only one student (white) entered through the modality dedicated exclusively to the disabled and none entered through the modality for the disabled subject to income.

Comparative analysis of the categories social class and race/skin color

Regarding the family’s financial support, 96.5% of broad competition students receive it, in comparison to 90% of those who entered through the quota system. Among the broad competition students, 3.5% do not receive this support, in comparison to 10% of those who entered through the quota system. Although the difference is small, students who entered university through the quota system, regardless of the modality, have a higher proportion of those who do not receive help. When assessing the financial situation of the family, 3.9% of the broad competition students have an annual income of up to US$8,640.00, while among the quota students, they represent 27.6%. Among the broad competition students, 38.1% have an annual family income between US$8,640.00 and US$28,760.00 against 57.6% of the quota students (Table 4).

Of the broad competition students, 58.1% have an annual family income above US$28,760.00, while among quota students they are 14.7%. Regarding the parental education level, 57.9% of broad competition students have both parents with higher education; among the quota students, they are 24.7%. On the other hand, 28.9% of broad competition students have only a father or only a mother with a higher education degree; among quota students, they are 33%. Of the broad competition students, 13.2% have parents who did not graduate from high school; among quota students they are 42.3%. Of the students who have both parents with a higher education degree, broad competition students are in the majority. Among the students of whom none of the parents have a higher education degree, the quota students are the majority (Table 4).

When comparing students according to self-declared race/skin color and high school background, we observed (Table 5) that 73% of white students and 81.3% of yellow students attended private schools. On the other hand, this percentage is 29.9% for browns and 27.3% for blacks. Regarding receiving financial assistance from the family, 95.1% of white students declared they received it, as well as 77.8% of yellow students. Among brown students, 91.4% do, whereas 71.30% of black students receive family support.

When dividing students by monthly family income ranges and associating them with self-reported skin color, we noticed that of the white students, 8.6% have an annual family income of up to US$ 8,640.00; of the yellow students, it is 11.1%. Once again, the data shows the opposition in the comparisons of whites and yellows with browns and blacks, since 25.8% and 19% of them, respectively, are in the lowest income strata.

In the range between US$8,640.00 and US$28,760.00 there are 39.9% of white students; 33.3% of yellow students; 56.6% of browns, and 52.4% of blacks. When evaluating those with an income above US$ 28,760.00, more than half of the whites have the annual family income in this stratum (51.5%); of yellow students, 55.6%; of browns, 17.6%, and of blacks, 28.6%.

Regarding the parental level of schooling, 54% of whites, 62.5% of yellows, 26.4% of browns and 22.7% of blacks have both parents with a higher education degree. Among the whites, 29.9% have only a father or only a mother with a higher education degree; of the yellow students, 25%; of browns, 32.7%; and of blacks, 22.7%. Of the white students, 16.1% have neither parent with a higher education degree; of yellow students, 12.5%; of browns, 40.9% and of blacks, 54.5%.

Among students whose both parents with a higher education degree, most are white and yellow students. Among students whose neither parent has a higher education degree, the majority are brown and mainly black students.

On the one hand, table 5 shows that browns are closer to whites than blacks regarding the item “Receives financial support from the family”. On the other hand, in relation to high school background and parental level of schooling, browns, as well as blacks, and differently from whites, who have mostly attended public schools. The same is observed among those with the lowest family income, and with parents who do not have a higher education degree.

Yet in table 5, the data regarding the comparison between blacks and browns and browns and whites, demonstrated that regarding the high school background, family income and parental level of schooling, whites differ, with statistical significance, from browns, while blacks do not. The only item in which browns and whites are similar is related to the family’s financial support, and there is no difference between blacks and browns. Although blacks are the largest group that does not receive help (almost twice as many as browns and four times as many as whites), most of them still receive it.

Temporal analysis of the racial and economic profile

In 2013, the first year of full adoption of the quota law by the university, of the incoming students, 26.4% were black and brown and 73.6% were white and yellow. According to the data in Table 6, there is a reduction in the proportion of blacks in 2014 and an increase in the following years, with no statistical significance in any of the years.

Regarding the income analysis, since 2013 there has been an increase in the number of admitted students at the lowest income stratum and a decrease in those at the highest income stratum. Although the difference between the first year of law enforcement and the years 2014 and 2015 is not statistically significant, it is possible to see a significant difference in the years 2016 and 2017 (Tables 7).