Diversity, Equity, and Inclusion in Healthcare and Society: A Historical Imperative, Ethical Framework, and Strategic Pathway Amidst Evolving Challenges

Some states adopted grandfather clauses, which exempted individuals from voting restrictions if their grandfathers had been eligible to vote. Since black Americans' grandfathers were enslaved and denied the right to vote, these clauses effectively disenfranchised them.5

Laws enforcing segregation in education, such as the "separate but equal" doctrine established in Plessy v. Ferguson (1896), permitted racially segregated schools and denied black students equal access to education resources and opportunities.6 Vagrancy laws were used to arrest and imprison African Americans for minor offenses or for simply being unemployed. These individuals were then leased out as forced labor to private companies, effectively re-enslaving them in a different form.7 Anti-Miscegenation Laws banned interracial marriage and relationships, further enforcing racial segregation and discrimination against people of different races.8

It is important to note that while many of these discriminatory laws have since been repealed or overturned through federal legislation and court decisions, their legacy continues to impact American society, and systemic racism persists in various forms. The struggle for racial equality and the dismantling of institutionalized discrimination against African Americans remain ongoing challenges in the United States. More recent practices like redlining and residential segregation refined how systemic racism was perpetuated less overtly. Government-backed practices utilized racial and income metrics to discriminate on loan and mortgage prices to encourage investment in certain communities over others. Today, the redrawing of congressional districts in Texas continues to be a contentious issue, with recent proposals accused of disenfranchising Black communities and diluting the political power of minority voters. Republican-led redistricting efforts in 2025 have targeted districts with significant Black and Hispanic populations, reconfiguring boundaries in ways that reduce minority representation or fragment their voting blocs—actions called out by critics as modern-day gerrymandering intended to secure partisan advantage and diminish the ability of Black communities to elect their preferred candidates.

Although as old as the over 500-year struggle for racial equity itself, DEI traces its formal linguistic terminology roots to the U.S. civil rights movement during the 1960s when the divide between Black and White Americans was high. In 1961, the executive order called the Equal Employment Opportunity (EEO) took effect. During the administration of President John F. Kennedy, the EEO sought to address systemic discrimination and provide more equal opportunities for Black Americans in particular, regardless of race, color, religion, or national origin for employment of government contractors.9 This executive order coined the term “affirmative action”.10 The scope of affirmative action expanded further through another executive order during the administration of President Lyndon B. Johnson within the education and employment realms. The movement of African Americans into corporate America during the 1970s was driven by the civil rights struggles of the 1960s and the increasing awareness of the need for diversity and inclusion in the workplace. Companies, including within the healthcare sector, began to make efforts to recruit and hire more African American employees, both in response to social pressure and recognizing the potential benefits of diverse perspectives in business 10

Despite these efforts, African Americans faced challenges such as limited access to high-level positions, unequal pay compared to their white counterparts, lack of mentorship and networking opportunities, and sometimes hostile work environments. Many African American professionals, including physician, nurses, and other allied healthcare experts, found themselves isolated and marginalized within predominantly white corporate cultures. There have been many challenges faced to affirmative action over the years to promote DEI in education and employment practices. The topic has been politically divisive, particularly amongst conservatives and the business community, and seen as government overreach and a threat to merit-based college admission and hiring decisions.11

Affirmative action grew even further through the 1978 Supreme Court ruling of Regents of the University of California v. Bakke which enabled race to be a factor of consideration for college admissions decisions in support of diversity.12 The Supreme Court continues to be the stage for questions regarding the legitimacy of affirmative action, such as Wygant v. Jackson Board of Education in 1986. During the 1970s, the first wave of African Americans entering corporate America faced significant challenges and barriers due to systemic racism and discrimination prevalent in society at that time. Despite the Civil Rights Act of 1964 prohibiting discrimination based on race, color, religion, sex, or national origin, many African Americans still encountered various forms of prejudice and exclusion in the corporate world. This was examined in detail in Rage of a Privileged Class by Ellis Cose showing isolation, marginalization, and lack of value shown to otherwise qualified black professionals, including physicians and other allied healthcare stakeholders.14 White fear as discussed in White Fear: A History of White Supremacy in America likely played a large role in propagation of corporate backlash against workforce diversity initiatives.

Over the years, the field of DEI has developed out of the affirmative action movement. In the 1980s-1990s, “diversity” and “inclusion” became popular terms in the corporate world to recognize the value of having individuals of diverse backgrounds, included related to race, gender, sex, national origin, and ability level, in the workforce. This expanded from African American to include White woman, Latinos, Asian American, gay, and disabled.

The emergence of globalization and the recognition of the value of diverse perspectives in driving innovation and creativity further fueled the importance of DEI initiatives within companies, including healthcare systems and medical educational institutions. Today, DEI has become a critical focus for organizations across sectors as they aim to create inclusive environments where all individuals are valued, respected, and provided with equal opportunities for growth and success.13 There was immense backlash to black professionals entering predominant white corporate settings in society, including as physicians, allied healthcare professionals and c-suite leaders in the medical industry, particularly as being a threat to the ideals of meritocracy.14

In the 21st century, “equity” has emerged as an important term that recognizes that there are disparities in the ability of individuals of diverse backgrounds to fully advance to their fullest capacity within leadership roles. Within corporate and academic spheres, DEI has played a growing role in both promoting fairness and driving innovative performance by supporting contributions of a diverse workforce.

Furthermore, the struggle for “equity” has expanded due to the Black Lives Matter (BLM) movement. This movement began in 2013 after the acquittal of George Zimmerman, a white man, in the case of the shooting death of Trayvon Martin, a Black teenager, in Florida in response to the acquittal and the broader issue of systemic racism and police brutality against Black individuals in the U.S. The founders include Alicia Garza, Patrisse Cullors, and Opal Tometi who have started an expanding movement of activism in response to continuing instances of police brutality. The movement of BLM seeks to address structural racism and create racial equity. BLM’s scope has expanded to include efforts for reparations to address the systemic racism wrongs made over generations to promote financial equity.15 Reparations have begun to be realized in the setting of Evanston, Illinois, starting in 2020 when a housing assistance program was started. However, there is a long way to go from the “40 acres and a mule” that remains an unmet promise post-Civil War toward formerly enslaved black Americans for economic equity.16

In 2021, corporate pledges of $50 billion were made toward DEI in response to the aftermath of the death of George Floyd, another pivotal BLM moment advocating against police brutality.17 This collective commitment was a major movement away from reparations toward improving DEI education, hiring, and promotion practices as well as making financial commitments toward social justice/community organizations.

Unfortunately, these pledges have not fully manifested.

The U.S. house of representatives in recent years has even introduced legislation to examine the impacts of systemic racism and discrimination over the course of U.S. history to then propose remedies which may include reparation in some form. In 2021, the house introduced HR 40, known the “Commission to Study and Develop Reparation Proposals for African Americans Act.” This bill promised to examine U.S. slavery, discrimination, and systemic racism practices toward Black Americans from 1619 to the present and determine appropriate reparations accordingly. However, this bill had minimal impact on the movement toward making reparations a reality on a larger scale and did not move forward from proposal toward passing.18 This move of DEI away from reparations is not even scratching the surface of righting the wrongs of systemic racism over 400 years. DEI practices are viewed as beneficent charitable practices rather than financially profitable ventures. Corporations directly benefit from diverse leaders in the decision-making skills, innovative practices, sense of communal belonging/employee retention, positive brand image, and abilities to connect with the global marketplace.

To counter opposition effectively, it is essential to address misconceptions about DEI. DEI is not a zero-sum game. Critics often view diversity efforts as taking opportunities away from one group to benefit another. However, research shows that inclusive environments benefit everyone by fostering collaboration and innovation.21 Companies like Salesforce have implemented programs that enhance belonging across all employee groups while improving retention rates.22 Equity is about fairness, not favoritism. Equity ensures fair treatment by addressing systemic disparities rather than offering unearned advantages. For instance, Banco Pichincha’s gender-focused financial initiatives in Ecuador have closed the financing gap between men and women by 16%, demonstrating how equity promotes overall economic growth.22 Long-term success requires commitment. The failure of some DEI programs stems from insufficient commitment or poorly trained facilitators. Organizations must invest in passionate educators and robust strategies to ensure sustainability.23

Pew Research Center Workplace Diversity Equity and Inclusion in the workplace article states that 56% of Americans say DEI is good at work. Wide partisan differences in DEI 78% Democrats support compared to 30% of republicans. Many challenges for universal recognition and support for DEI-related efforts remain. When Black leaders get to 55-58 years of age, they get moved out of corporate America. There are only 9 Black CEO of fortune 500 companies. America needs the help of the other 491 White CEOs with DEI.19

Social determinants of health - such as belonging to an underserved racial/ethnicity group, low socioeconomic status, uninsured/underinsured status, and low health literacy - have been shown to drive inequities. Limitations in workforce diversity and inclusion in turn drives these disparities in outcomes. DEI will be very important in addressing these health disparities and improving the health of a diverse America overall.

To preserve the vision of DEI amidst opposition, organizations must adopt proactive measures such as data driven approaches. These can include different measures highlighted in Table 1. Successful companies like PepsiCo use data to track progress in representation and inclusion while adapting strategies to local contexts. Such transparency builds trust and accountability. There must be leadership buy in. Strong leadership commitment is critical for embedding DEI into organizational culture. Leaders must champion these initiatives as integral to long-term success rather than optional add-ons. Education and awareness are vital. Educating people about the benefits of diversity fosters understanding and reduces resistance. For example, Heineken’s Women in Sales program increased female representation in leadership roles by creating awareness about gender equity challenges. We need everyone help to ensure diversity. Al Neuhart CEO of Ganet, made decision to make his company a leading company for diversity. He stated, “If any you have a problem with tying your bonuses to diversity in the company’. then you can leave.” Many whites left but there was an explosion of diversity and growth in his company. This forced other companies to change. Unfortunately, there were not enough Al Newhart’s to fully change the industry.20

Diversity is good business. Mark Cuban stated,

Section snippets

Conclusion

Diversity, Equity, and Inclusion are not mere buzzwords but essential frameworks for building equitable societies and thriving organizations. This is particularly vital for the development of just, effective, and responsive healthcare systems. By demystifying these principles and addressing criticisms constructively, strategically with education and advocacy and resistance in the current environment we can preserve their vision and continue advancing toward a more inclusive future.

References (21)

FC. Stanford

The importance of diversity and inclusion in the healthcare workforce

Journal of the National Medical Association

(2020)

L.R. Coleman et al.

The importance of diversity, equity, and inclusion for effective, ethical leadership

Clinics in Sports Medicine

(2023)

M.L. Wang et al.

Aligning employee health and diversity, equity, and inclusion initiatives in the workplace: a call for synchronization

(2024)

RF. Wintersmith

Police and the black community: A survey of their historical relationships and alternative models for contemporary improvement

(1973)

B.C. Schmidt

Principle and prejudice: The Supreme Court and race in the progressive era. Part 3: Black disfranchisement from the KKK to the grandfather clause

Colum L Rev

(1982)

HE. Groves

Separate but equal–The doctrine of Plessy v. Ferguson

Phylon (1940-1956) (1951)

JE. Black

A crime to live without work: Free labor and marginal workers in industrial Chicago, 1870 to 1920

Michigan Historical Review

(2010)

D. Gevrek

Interracial marriage, migration and loving

The Review of Black Political Economy

(2014)

H. Hill

The equal employment opportunity acts of 1964 and 1972: A critical analysis of the legislative history and administration of the law

Indus Rel LJ

(1977)

SM. Collins
Black corporate executives: The making and breaking of a Black middle class

(1997)

There are more references available in the full text version of this article.