Center for Teaching and Learning

Tips for Discussing Racial Health Disparities

General principles for addressing racial health disparities in class

1. Explain why you are sharing data on racial health disparities with your students.
   • For example, “Racial and ethnic health disparities are a stark demonstration of the real world consequences of structural racism. Because racial health disparities are a function of social structures, we can mitigate health inequities by fixing our social structures.
     • Racial health disparities aren’t a consequence of biological differences between races. In fact, there is no biological basis for the concept of race:
       • “Social scientists have long understood race to be a social category invented to justify slavery and evolutionary biologists know the socially constructed racial categories do not align with our biological understanding of genetic variation.” - Duello TM, et al. Evol Med Public Health. 2021.
       • “The completion of the Human Genome Project in 2003 confirmed humans are 99.9% identical at the DNA level and there is no genetic basis for race.” - Duello TM, et al. Evol Med Public Health. 2021.
       • There is often more genetic variation within a race than there is between races. As PBS's "Race: The Power of an Illusion" put it “Two random Swedes, for example, are likely to be as different as a Swede and a Senegalese” and “Two random Koreans are likely to be as genetically different as a Korean and an Italian.”
       • As the National Academies of Sciences puts it, race is not an accurate proxy of genetic variation. (Morever, “the [genetic] variation among [human] populations and continents is attributable to geographic distance, not race.” - Graves and Goodman. Racism, Not Race. Columbia University Press, 2022.)
     • Instead of a biological construct, race is a social construct, which means that racial and ethnic health disparities have social causes, and as such, can also have social solutions.
       • Rather than being rooted in biology, racial health disparities are rooted in inequal access to the Social Determinants of Health.
       • “A position of equity would acknowledge that race is a social construct and that therefore racism—not race—contributes to health disparities between certain groups”- Dr. Alden M. Landry, MD, MPH, assistant dean for Diversity, Inclusion, and Community Partnership at Harvard Medical School.
       • Understanding race as a social construct avoids perpetuating the false notion that differences in health outcomes along racial lines are due to biological differences between races and genders.
       • As geneticist Dr. Joseph Graves puts it “Race is a social classification based on assumptions about ancestry and appearance.” - Graves and Goodman. Racism, Not Race. Columbia University Press, 2022.
       • For example, if you ask most Americans how to distinguish people from different races, they often begin by describing skin color: many people in the US think of human races as consisting of Whites, Blacks, Hispanics, and Asians. Right away, this type of classification must be seen as problematic since some races are based on color and others by geographical location (Asia) or shared language (Hispanic). The reason for this problem is that races cannot be defined unambiguously by any combination of objective criteria that can be measured empirically.
       • Similarly, different countries and cultures across the globe define races differently, demonstrating that race is a subjective and culturally-defined concept, rather than an objective one.
       • As Dr. Graves puts it, “social definitions of race are historically and culturally contingent. The meaning of Black differs in various societies. In the United Kingdom, Black includes Pakistanis and East Indians. In Brazil, it includes many persons of African descent, who would be classified as something else in the United States. In the United States, Black includes anyone with detectable African descent. In the Caribbean, white includes anyone with any European descent, including people who would be classified as Black in the United States. … These categories are clearly not biologically justified.” - Graves and Goodman. Racism, Not Race. Columbia University Press, 2022.
       • Clarifying potential reasons for racial health disparities by discussing the structural reasons for health outcomes (e.g., racism, education, housing, access to care, insurance status, health literacy, immigration status, etc.) may help students move from the misguided notion that genetic/biological differences between “races” drive health disparities to developing a more nuanced understanding of how structural racism, socioeconomic status, unconscious bias, and other factors impact health care.
       • Identifying race as a social construct and emphasizing the structural reasons for health and disease helps educators convey to their students a more accurate understanding of the structural inequities that drive many of the disparities that exist and a better understanding of the role of biologic or genetic differences when they are important.
2. Recognize that racism, sexism, oppression, and historical marginalization affect patients’ health.
   • Acknowledge that these forces have affected the development of practices and policies that have historically disadvantaged minority populations; for example, Black patients have historically been undertreated for pain in the US (see "Taking Black Pain Seriously," "Black Americans are Systematically Under-Treated for Pain. Why?," "End the neglect of Black patients in US health care," etc...).
3. Recognize that while the medical literature now describes many examples of health disparities by race, socioeconomic status, and other variables, the mediators of those disparities are not always known and, if known, are not always discussed.
   • This may leave some students with the misguided impression that genetic or biological differences drive such disparities.
   • Avoid using race as a proxy for environmental factors.
4. Some suggestions to help avoid stigmatizing language:
   • Avoid using race as a descriptor
     • Race has no biological basis and does not belong in oral and written documentation.
     • Use "34 year old who has hypertension" rather than "34 year old African American who has hypertension."
   • Do not label patients
     •  Be thoughtful and flexible about using person-first or identity-first language.
       • There isn't a universal consensus. Some communities prefer identity-first language, while others prefer person-first language. The ideal is, of course, to talk to people in those communities if you can and let them self-describe, or at least listen to their different perspectives.
     • Person-first language: e.g., “a person with diabetes” instead of “a diabetic” or “a person with schizophrenia” instead of “a schizophrenic.”
       • “Hypertensive” → “patient with hypertension”
       • “Obese” → “patient with obesity” (or a “high weight person”)
       • “Diabetic” → “Patient with diabetes”
     • Identity-first language: Identity-first language puts the descriptor first, and is more common among specific disability communities.
       • One such example is the deaf community, where “deaf person” is generally preferred over “person with deafness.”
   • Use the patient’s perspective / avoid judgement / be descriptive, rather than evaluative:
     • “No show” → “Person who did not keep their appointment”
     • “Patient admits …” → “Patient describes …”
     • “Patient denies …” → “Patient reports no …”
   • Avoid blaming individuals, patients, and clients:
     • “Did not refill diabetes meds” → “Transportation barriers prevented patient’s ability to refill diabetes medications”
   • Be mindful of language, attitudes, and behaviors.
     • Eliminate the use of outdated and imprecise terms, e.g., “Oriental” to describe an Asian person, or “Caucasian” to describe a white person.
     • Using precise gender-related language, e.g., “people with uteruses” instead of "women,” if the relevant point is about the presence of a uterus rather than the person’s expressed gender identity.
     • Avoiding stereotypes in examples (e.g., consistently referring to nurses as “she”).
5. Be inclusive in representations of healthy/“normal” and avoid stereotypes when describing illness/disease
   • For example:
     • A textbook may describe healthy gums as being “coral pink” in color, when in fact healthy gums of persons of color may be pigmented.
     • Most examples of couples are limited to heterosexual partners.
     • A discussion on sexually transmitted infections (STIs) may use focus on examples of men who have sex with men.
6. Acknowledge the limitations of research.
   • Medical studies can have a tendency to disproportionately enroll men or white people. The generalizability of those findings to women, persons of color, or other underrepresented populations may be limited or problematic.
   • If underrepresentation in study subjects by gender identity, sex, race, socioeconomic status, or another meaningful variable may limit the study’s generalizability, consider disclosing this as an educational point.
   • Call attention to the demographic tables in research. Diversity, or lack thereof, can affect the quality of a study.
7. Scrap stand-alone lectures on health equity. Instead, integrate it throughout the curriculum.
8. Don’t ask a single person to speak for their entire community.
   • Treat people as individuals, rather than as representatives of a demographic group.
   • No one should be expected to be the representative of any identities they hold.
   • There is a great amount of emotional labor involved in discussing a community’s culture, and even then, it is impossible to speak for everyone.
   • Approach students with empathy and curiosity to learn about themselves as individuals.
9. Recognize how your own social positionality informs your perspectives and responses.
10. Understand that words have effects on others; take responsibility for what you share. Speak with care.
    • If you learn that you have said something disrespectful or marginalizing, listen carefully to understand that perspective and learn how you can do better in the future.
11. Trust intent and name impact.
    • Believe that others are sincere in their comments and are actively trying to learn.
12. Hold each other accountable.
    • If someone says something harmful or inappropriate, it is okay to name their statement as problematic, oppressive, triggering, etc. We are all trying to learn together including students, facilitators, course leaders, and administrators.
13. Don’t pressure students to share personal experiences to raise the racial consciousness of others.
14. Emotions are okay and to be expected.
    • If you and/or your students feel discomfort, name the discomfort out loud (e.g., "I was worried that I wouldn't be able to manage this discussion well today")
15. Discussions should be confidential. Lessons learned from discussions can and should be shared, but what is said should stay in the group.
16. Listen attentively and respectively.
17. Do not interrupt.
18. Give and take air time.
    • Share responsibility for including all voices in the discussion. If others are dominating the discussion, ask them to take a step back and help invite others to share.