In my years of teaching science courses, I have seen the positive impact of discussing the intersection of societal issues with the scientific material we cover in the class. From previous surveys of my students, I learned that the majority believe that all their science classes should discuss these issues and not try to pretend that science exists in a bubble, free from politics and human biases. I have heard from a number of graduating seniors in the MCB major that my stem cell class was the only time they ever considered the ethics and societal impacts of new scientific discoveries. This provided the motivation to develop a series of discussion assignments about medical racism for my human physiology course.

Discussion assignment format
Discussion topics
     1. Introduction to medical racism
     2. Birth control clinical trials
     3. Stereotypes related to pain perception
     4. BiDil race-based medication
     5. Race-based estimate of kidney function
Response from students
Lessons learned and best practices
References

Discussion assignment format

We used the Discussion tool in the Canvas learning management system to conduct asynchronous discussions. Every couple of weeks a new page about a medical racism topic was published that introduced students to the problem. Students had to either watch a video or read an article about the topic and answer a couple of questions in the discussion. After submitting their response to the questions, they could view responses from the other students in their discussion section and they were required to reply to someone else’s posting. Our graduate student instructors also conducted discussions on the topic during their sections, which were optional to attend and participate in.

I chose five discussion topics that address different aspects of medical racism and connect with the scientific material we cover in class.

Discussion topics

1. Introduction to medical racism

Students were introduced to the topic of medical racism and we emphasized that race is not biological, but a social invention that can very much affect a person’s health. We also discussed ground rules and community agreements for the discussions and the proper terminology to use when referring to different groups of people.

The assignment consisted of watching two TED talks and discussing how racism plays a role in one of the examples in the videos.

2. Birth control clinical trials

This topic teaches students about the history of unethically using people of color as research subjects. We discussed how birth control pills work in a module about the reproductive system, so this discussion goes over how the original clinical trials were done with poor Puerto Rican women who were not properly informed about the experimental nature of the trials.

Students read an article about the history of how the pill was developed and tested, and discussed what made the trials unethical and how this could have been improved.

  • Pendergrass DC and Raji MY. 2017, Sept 28. The bitter pill: Harvard and the dark history of birth control. Harvard Crimson.

How do the biases and stereotypes healthcare workers have affect patient treatments and health? In this discussion, we focus on a pervasive and incorrect stereotype that Black people have thicker skin and do not feel as much pain. You can directly trace this belief back to when slave owners made up medical differences between Black and white people in order to justify slavery and the harsh treatment of slaves. The skin of Black people is exactly the same as the skin of any other race, but the stereotype still persists among healthcare workers and medical students.

We had students read two articles, one of which discusses the stereotype, while the other focuses on the health consequences for Black patients.

4. BiDil race-based medication

BiDil is a medication that was approved by the FDA to treat heart failure specifically in Black patients. Because Black people have different heart anatomy or function? NO! Race is not biological. This medication was targeted to Black patients, because of a flawed clinical trial and it allowed the pharmaceutical company to extend its patent. Even though there was no reason to approve a medication for only one race, many leaders in the Black community endorsed BiDil, because finally someone was paying attention to the health of Black patients.

Students read an article that explained the history behind the development of this race-based medication. They discussed why some people viewed this as a positive new treatment, while others actively fought against its approval because of what it implied about the biology of race.

5. Race-based estimate of kidney function

A number of measurements in medicine have a race-correction factor that alters the final measurement based on a person’s race. During our module on the urinary system, students learn about a commonly used equation to estimate glomerular filtration rate (a measure of kidney function). If a patient self-identifies as Black, then a different multiplier is used that results in an artificially higher estimate of filtration rate. These numbers are used to qualify for certain treatments like kidney transplantation. A Black patient needs to be sicker than other patients in order to get a low enough filtration rate to get on a kidney transplant list.

The article for this discussion explains the race-based calculation and the problems that result for Black patients. Students have to try to explain this problem to someone who has not studied physiology or medicine, as if they were talking to a family member. Thankfully, this correction factor is being removed from filtration estimates, but many more race corrections exist in medicine.

Response from students

I conducted two anonymous surveys before the first assignment and after students had completed all the discussions. 98% of students said they were glad that we had discussed medical racism in our course and 85% thought it was important to discuss these kind of topics in science classes. Students commented on the course evaluations that they appreciated learning about medical racism. There was also a shift in how students thought about race with 45% thinking there were physiological differences between races at the start of the semester to only 6% after the assignments.

Lessons learned and best practices

A couple of issues came up while doing this assignment for the first time in summer and fall 2021, some of which we solved and others we are still working on.

Terminology

After our first discussion we learned that some students do not know the proper way to refer to people from different races and they sometimes used old terms that were offensive. Because of this, I wrote a detailed terminology page and linked to it in every discussion assignment. We sent out announcements about what terms to use and why, and we deducted points when students did not follow the proper format.

Harm to students of color

Some students were very aware of medical racism through direct experiences their families had in medical settings. One student reached out to me to ask if there was some way they could be excused from the assignment, because of the trauma it caused them. Because of this we created a form for students who felt they needed accommodations for the assignment, either skipping it completely or only having to write their discussion posts but not respond to other students. Out of a class of 415 students, only two students asked to skip the assignment. If the goal of this assignment is to educate people about medical racism, these students were already painfully aware and there was no reason to come up with an alternative assignment for them. Likewise, it is important to be aware of the toll for graduate student instructors of color to read and grade posts that may use incorrect terms or not totally understand the point of the readings.

Attributing other reasons for health inequities

Although students generally got the main points for each topic, they still made some mistakes in their thinking, falling back on racist ideas. The two most common mistakes were (1) to attribute racial inequities only to differences in socioeconomic class and (2) confusing the genetics of an individual with the genetics of an entire race.

  1. Although money and where someone lives affects health, students missed the point that racist policies have directly affected who lives where and who makes money and owns property. I tried to address this by including the TED talk by David R. Williams, which covers some of this. I think I also need to include more information in the introduction to the assignment, maybe making my own video introduction.
  2. The genetics issue came up during the discussion about race-based medicines. I would see a student explain that race isn’t biological and then in the next sentence that medicines for specific races are a good thing. We need to emphasize more that a group of people may share a genetic variant that affects their physiology, but it will not be shared by an entire race. There is a difference between personal medicine and race-based medicine.

Again, data from the survey shows that most students are understanding that race is not biological and what medical racism is. I think expanding the introductory material will help address some of these problems as well as giving students more incentive to attend discussion sections where the graduate student instructors can help clarify the fine points.

limited coverage of material

Most of the examples we covered related to Black patients in the United States. Some students suggested we include material related to other countries, other races and immigrants. I chose these specific topics because they cover different aspects of medical racism and relate directly to the physiology we learn in class. Students have an opportunity to research another example of medical racism for a final paper. Common topics included the role of medical racism in the COVID-19 pandemic, how racism affects maternal care and other race-based medical corrections, like for lung functions. I think this gives students a chance to apply the concepts they have learned to a specific example that might be more relevant to their lives.

References

I used the following resources to develop the material for the assignment (besides the papers the students read). I highly recommend both of the books for people who want to learn more about medical racism!

The Institute for Healing and Justice in Medicine – This website was developed by students in the UC Berkeley-UCSF Joint Medical Program (many of my GSIs come from this program). Take a look at their full report for specific examples of medical racism.

Roberts, Dorothy. Fatal invention : how science, politics, and big business re-create race in the twenty-first century. New Press, 2011.

Washington, Harriet. Medical Apartheid: the dark history of medical experimentation on Black Americans from colonial times to the present. Doubleday, 2006.