RACE, ETHNICITY, AND RACISM 101

What are we talking about when we talk about race, ethnicity and racism? 

Race is a social construct assigned to people based on factors like physical appearance and presumed ancestry [1]. A great deal of evidence suggests we cannot group people into races using genetics or other biological factors; the racial categories used in the United States are genetically diverse and lack clear boundaries [2].

Ethnicity refers to the collective identity of a population. Ethnic groups often have a shared national or regional background, as well as shared cultures, languages, histories, or customs. Like racial groups, ethnic groups are not clear-cut and change over time [3]. 

Racism refers to systematic discrimination on the basis of people’s racial or ethnic identities. Racism comes from a combination of racial prejudice and the power to act on that prejudice. It can occur on both individual and structural levels: it might manifest through explicit or implicit beliefs, or be reflected in institutions or laws [4]. 

Why do race, ethnicity and racism matter in healthcare?

Experts have deemed racism a pressing public health issue [5]. On the structural level, one example of the influence of racism on health is the case of racial residential segregation. Historical policies and practices created neighborhoods made up of predominantly Black and Latino people. Because of structural racism, some of these regions still face challenges such as poor housing regulations, low-quality schools, unemployment, and a lack of access to healthy foods. These factors contribute to increased rates of asthma, hypertension, kidney damage, and lung cancer [6,7]. 

Moreover, self-reported experiences of racial and ethnic discrimination have been consistently linked with poorer physical and mental health outcomes. One explanation is that the negative emotional reactions associated with discrimination harm health and health behaviors [8]. Thus, in the case of many diseases and conditions, Black people, Native Americans, Latinos, and members of other historically marginalized groups tend to have earlier onset, faster progression, and higher mortality rates, even after controlling for poverty. For example, rates of hypertension and cardiovascular complications are significantly higher among Blacks than among non-Hispanic whites or Asians [9]. 

Racism also impacts health through its direct effect on health care. Research has shown that Black and other minority populations receive lower quality care and fewer procedures than white patients. This disparity is partly because individual providers may provide unequal care based on their own racial biases. Racial and ethnic minority groups are also underrepresented in medicine and in medical literature, which can both reinforce racial biases among providers and harm diagnosis and treatment [10]. 

What do we know about race, ethnicity and racism in medical and health professions education?

Medicine in the United States has contributed to the perpetuation of racism. For instance, members of racial and ethnic minorities were targeted in countless unethical medical experiments, including the famous Tuskegee Syphilis Study. Physicians used science to justify racism through positing cranial differences between races, theories like eugenics, and diseases unique to Black people. These false scientific claims often served to support racist laws, and remnants of them persist within the educational system. For example, although race is a social construct with no biological basis, medical education often uses race as a proxy or risk factor for certain diseases, reinforcing the sense that race is biological [11]. 

The lack of racial diversity in medical education is also an issue. Black, Hispanic, Native American, and other minority students remain underrepresented in medical and health professions education [12]. Along similar lines, studies have found that racial minorities are underrepresented in a variety of teaching materials, including textbook images, lecture slides, and case studies. To address these problems, initiatives from medical education systems include implementing bias training, reforming medical curricula, and taking steps to increase diversity among their student populations [14].

How does the Bias Checklist address race, ethnicity and racism in health professions education content?

The Bias Checklist first asks: 

  • “Does the content include any mention of race or ethnicity?”

If you answer no, you will be prompted to consider whether your content should mention race, ethnicity or racism. 

The Bias Checklist asks the following related questions about content:

  • “Are explicit biological differences between racial or ethnic groups stated?”

  • If yes: Regarding content about EXPLICIT biological differences between racial or ethnic groups, check all that apply:  

    • This content is not essential to the lecture.  

    • This content is not scientifically accurate.  

    • The relationship of social or structural determinants of health to the racial or ethnic differences is not discussed.  

    • This content does not discuss the role of toxic stress (e.g., chronic exposure to racism) in contributing to biological differences between races.  

    • This content states that racial groups are biological constructs. 

    • Learners are told that this information is important for standardized examinations.  

    • None of the above applies to this content.

    • “Are biological differences between racial or ethnic groups implied?”

  • If yes: Regarding content about IMPLICIT biological differences between racial or ethnic groups, check all that apply:  

    • This content is not essential to the lecture. 

    • This content is not scientifically accurate.  

    • The relationship of social or structural determinants of health to the racial or ethnic differences is not discussed. 

    • This content does not discuss the role of toxic stress (e.g., chronic exposure to racism) in contributing to biological differences between races.  

    • This content implies that racial groups are biological constructs.  

    • Learners are told that this information is important for standardized examinations.  

    • None of the above applies to this content.

Below are some examples of common ways in which bias, shame, stereotype and stigma toward race and ethnicity can manifest in health professions education content:

  • Teaching the practice of race "correction" for highly variable physiological measures such as spirometry values and glomerular filtration rate, based on outdated studies and neglecting to recognize intrinsic variation within racial groups

  • Presenting associations between race and disease incidence without context

  • Showing two photos side-by-side during an obesity lecture: one depicting a family comprised of thin white individuals sitting down to a healthy dinner and one depicting a family of overweight black individuals sitting in front of fast food

  • Consistently showing images of black individuals when addressing diabetes or obesity 

  • Implying that all Latino patients are undocumented immigrants / migrant workers

  • Stating or implying that all patients from a particular culture participate in certain practices or reject certain medical interventions (e.g., "Muslim women are not permitted to be examined by male physicians")

  • Any comment about this subject that is meant to elicit laughter

Last, the Checklist asks: 

  • “Could the content be perceived as promoting stereotypes, bias, shame or stigma?”

What can we do to address this problem?

  • Example: Most of the examples of bias in race and ethnicity submitted to the Bias Checklist relate to slideshows only including images of skin conditions on white skin. These slideshows should be revised to include images of skin conditions as they appear on diverse skin tones. 

  • Example: Descriptions of an association of a particular condition with some racial or ethnic background should, whenever possible, mention structural or causal factors that create this association. For instance, the phrase "keloids have a familial tendency, particularly in persons of Asian or African ethnicity" was submitted to the Bias Checklist as being at risk of bias. This content could reinforce biases because it might be interpreted to mean that biological factors among all people of “Asian or African ethnicity” lead to increased keloids. However, people of “Asian or African ethnicity” are large, genetically diverse populations, as well as not being the only ethnic groups who might have keloids. If applicable, this statement should be rephrased to name a structural or causal reason why this association exists. Note also that some more recent research challenges this association: https://www.npr.org/transcripts/1197955918.

Where can I go to learn more? 

I learn best by…

Reading

  • Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present by Harriet A. Washington

  • Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-First Century by Dorothy E. Roberts

  • Hoffman, Kelly M., et al. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 113(16), 4296-4301. https://doi.org/10.1073/pnas.1516047113 → 

  • Amutah, Christina A., et al. (2021). Misrepresenting Race—The Role of Medical Schools in Propagating Physician Bias. New England Journal of Medicine, 384, 872-878. https://doi.org/10.1056/nejmms2025768 →

  • Bailey, Zinzi D, et al. (2021). How Structural Racism Works—Racist Policies as a Root Cause of U.S. Racial Health Inequities. New England Journal of Medicine, 384, 768-773. https://doi.org/10.1056/nejmms2025396 →

Watching

Listening

Need a consultation?

The following people have identified themselves as experts in this domain and are willing to be contacted with questions regarding your content.

  • Experts coming soon!

Have something to add? 

Email us at biaschecklist@gmail.com with any of the following:

  • Recommendations for additional important content to include above, or suggested corrections or clarifications → use the subject header “Race, Ethnicity and Racism 101 - Correction”

  • Suggestions for additional questions to add to the Bias Checklist → use the subject header “Race, Ethnicity and Racism 101 - Checklist Question”

  • Suggestions for additional resources for learning more → use the subject header “Race, Ethnicity and Racism 101 - Learn More”

  • Examples of curricular bias, including before and after versions of content → use the subject header “Race, Ethnicity and Racism 101 - Example”

  • Your name, credentials, affiliation, area(s) of expertise, and brief biography or summary of qualifications if you are willing to serve as an expert consultant → use the subject header “Race, Ethnicity and Racism 101 - Consultant”

References

  1. Harrison, Guy P. (2020). Science and Race: What We Really Know, Skeptic, 25(3), 24-29. 

  2. Yudell, M, et al. (2016). Taking race out of human genetics. Science, 351(6273), 564-5. 10.1126/science.aac4951

  3. Kaur, Harmeet (2023, May 30). The differences between race and ethnicity–and why they’re so hard to define. CNN. https://www.cnn.com/2023/05/30/us/race-ethnicity-difference-explainer-cec/index.html

  4. Alberta Civil Liberties Research Centre. (2021). Racism. Accessed September 18, 2023, from https://www.aclrc.com/racism

  5. Cobbinah, S.S., & Lewis J. (2018). Racism and health: A public health perspective on racial discrimination. Journal of Evaluation in Clinical Practice, 24(5), 995-8. https://doi.org/10.1111/jep.12894

  6. Williams, D.R., & Collins, C. (2001). Racial Residential Segregation. Public Health Reports, 116(5), 404-416. https://doi.org/10.1093/phr/116.5.404

  7. Williams, D.R. (1999). Race, Socioeconomic Status, and Health. Annals of the New York Academy of Sciences, 896(1), 173-188. https://doi.org/10.1111/j.1749-6632.1999.tb08114.x

  8. Williams, David R., et al. (2019). Racism and Health: Evidence and Needed Research. Annual Review of Public Health, 40, 105-125. https://doi.org/10.1146/annurev-publhealth-040218-043750

  9. Brondolo, E., et al. (2009). Race, racism and health: disparities, mechanisms, and interventions. Journal of Behavioral Medicine, 32, 1-8. https://doi.org/10.1007/s10865-008-9190-3

  10. Cho, Daniel, et al. (2021). Underrepresentation of Racial Minorities in Breast Surgery Literature. Annals of Surgery, 273(2), 202-207. https://doi.org/10.1097/sla.0000000000004481 

  11. Nieblas-Bedolla Edwin, et al. (2020). Changing How Race Is Portrayed in Medical Education. Academic Medicine, 95(12), 1802-1806. https://doi.org/10.1097/acm.0000000000004017

  12. Lett Elle, et al. (2019). Trends in Racial/Ethnic Representation Among US Medical Students. JAMA Network Open, 2(9). 10.1001/jamanetworkopen.2019.10490 

  13. Massie, Jonathan P., et al. (2021). A Picture of Modern Medicine. Journal of the National Medical Association, 113(1), 88-94. https://doi.org/10.1016/j.jnma.2020.07.013

  14. Afolabi, Titilayo, et al. (2021). Student-Led Efforts to Advance Anti-Racist Medical Education. Academic Medicine, 96(6), 802-807. 10.1097/ACM.0000000000004043

Contributing Writer(s)

Katie M. Farkouh, MD Candidate

Sophie Pollack-Milgate, BA

last updated January 29, 2024