We hope this module will guide you in thinking about and executing ways to engage holistically with your patients/clients as full, authentic beings. By examining historical, social, economic and political forces that shape medicine and human health, we offer ways in which to reconceptualize healthcare through a social justice framework.

The first premise of this framework is that health practice must be truly patient-centered; and that happens when the whole patient is seen. All patients' intersectional identities shape their experiences and particularly inform their experiences with health and healthcare. Two foundational principles of do no harm and diversity drives excellence have helped shape and inform the orientation of this module.

Too often in Western medicine, we separate the person from the disease, and when we do this, we do harm. The intent of seeing disease, rather than the person, could be seen as promoting equity in care. However, this perspective only reinforced existing structures of bias and ultimately created greater healthcare disparities. The structures of dominance within a society are mirrored in that society's healthcare system. When a society is at its best, the disparities in healthcare may be minimized, but remain. When a society is not at its best, the disparities in healthcare are exponentially worse. The cost and damage are exponentially worse (National Center for Health Statistics, 2015).

Fortunately, all social systems are created and run by members of society and thus can be changed and improved. As participants in the U.S. healthcare system, we are both responsible for and capable of bettering this system. Establishing a social justice framework for healthcare provides specific approaches to decreasing disparities and dismantling structural inequities, such as racism. Racism is a public health issue and a root cause of many inequities faced by minoritized populations, greatly affecting their health outcomes. Therefore, learning about and understanding how to be anti-racist is a necessary competency for all health providers.

Research shows that diverse groups are smarter, more innovative and reap greater financial rewards. (Phillips, 2014). While the evidence is clear, the impact of inclusive and diverse practices has far-reaching implications for the future of healthcare practice, our communities and for the patients we serve. Leveraging diversity enhances the work we do, how we do it and with whom we do it. Diversity facilitates new knowledge, ways of seeing and empowerment that are of benefit to us all. We experience ourselves and each other in a more deeply connected way, which allows all of us to practice to the fullest extent of our competencies.

For all these reasons, we welcome you to this module, so you can learn to cultivate diversity in your teams, in your patient care and in your personal life. We believe that in doing so, you will achieve excellence and more satisfying careers in healthcare!

Though it is now widely recognized that race is a social construct, biases and stereotyping based on outdated notions of biological differences persist in medical practice. Throughout American history prominent physicians have conducted (pseudo) scientific studies and contributed writings to "racial science" that have supported notions of inferiority of people of color. Physicians and physician organizations such as the AMA have been openly racist in the past. Times are changing, though, and today’s healthcare students and providers can lead the way in providing just and equitable care to all.

Would you consider yourself racist? Perhaps the great majority of healthcare providers would deny that they are racist or let biases influence their patient care. Yet there are great disparities in healthcare and health outcomes between racial groups. Certainly, structural racism accounts for many of these disparities, i.e., policies that have affected access to care, insurance coverage, biases in hiring and lending that suppress earning potential of people of color and much more. Many studies suggest, though, that racism is a fundamental cause of adverse health outcomes for racial/ethnic minorities and racial/ethnic inequities in health. Williams provides an overview of the evidence linking the primary domains of racism—structural racism, cultural racism and individual-level discrimination – to mental and physical health outcomes (Williams et al., 2019). And many studies suggest that our country’s long history of racism has influenced healthcare providers to adopt unconscious racial biases that can affect patient care (Cooper et al., 2012; FitzGerald & Hurst, 2017; Maina et al., 2018).

Racism is present in healthcare training. Despite the modern understanding of race as a social construct, basic science courses often present race in biologic terms (Tsai et al., 2016). Racial biases that are common in the lay public are also common among medical trainees. In one study, 50 percent of White medical students and residents held false beliefs about biologic differences between Black and White people (Hoffman et al., 2016). There is a high prevalence of workplace discrimination experienced by physicians of color, particularly Black physicians and women of color, associated with adverse effects on career, work environment and health (Filut et al., 2020). Discrimination by patients and colleagues based on skin color appears to be common experiences of nurses as well (Wheeler et al., 2014). Students of color experience higher levels of mistreatment by faculty than White students (Hill et al., 2020). Students who are underrepresented in medicine are at greater risk of poor personal well-being, increased stress, depression and anxiety (Hardeman et al., 2016). Burnout is common among resident physicians, which can increase the expression of prejudices associated with racial disparities in healthcare (Dyrbye et al., 2019).

How did it get this way? While there has been spectacular progress in biomedicine, much of the progress has come at a cost to Black and Brown people. Until the modern era, there has been less attention to the science and art of attending to the personhood of patients and even less to the healing potential of the relationship between patient and provider. Teaching empathy, compassion and social justice in healthcare training is a relatively modern phenomenon. Before the 1970s, biomedicine ruled with patients being objectified and basically serving as the battlegrounds on which doctors and disease fought. Healthcare providers must be able to separate themselves from the personhood and suffering of others to dissect a cadaver, to cause pain to heal and to make objective decisions. Yet throughout the history of medicine in the U.S., this capacity for objectification allowed physicians to be affected by prevalent stereotypes of Black and Indigenous people and others of color, to see them as "others," to withhold empathy and to influence their science and their patient care.

By 1619, when the first enslaved people arrived in Jamestown, Virginia, persistent negative characterizations of Black people and people of color, in general, have justified enslavement, violence, unconsented experimentation, forced sterilization, discrimination in housing, employment, healthcare, incarceration and much more.

There is controversy about the origins of the idea of race. But Ibram Kendi argues persuasively that the social construction of race began in the early 15th century with the expansion of the African slave trade by Prince Henry the Navigator of Portugal. His biographer, Gomes Eanes de Zurara, created blackness by lumping together the various shades of brown and the ethnic groups that were being enslaved by his patron, Prince Henry. He described these enslaved peoples as bestial and slothful, and believed that enslaving them and bringing them Christianity would elevate them. The idea that blackness defined a group of people who were inferior and deserved to be enslaved spread widely and justified the lucrative slave trade (Kendi, 2016). Beliefs in the inferiority and other negative stereotypes of Blacks were enshrined in a steady series of laws and social policies that have persisted until the present.

Physicians played an important role in supporting notions of the inferiority of Blacks, and others of color, including the notion that Indigenous people were savages. Physicians were clearly influenced by widespread racial stereotypes and the acceptability of slavery. (For example, 12 of the first 18 presidents were slaveholders.) Though there were many healthcare providers who spoke out against slavery, slavery persisted for almost 250 years until its ending during the Civil War. And the entrenched biases of many in the North and South that justified slavery for so long persisted in Jim Crow laws (state and local laws that legalized enforced segregation and marginalization of Black people), government policies and the suppression of the Black vote until the Civil Rights Act in 1965. This law federally guaranteed Black enfranchisement, but that right has been whittled away ever since. Lynching throughout the South, as a means of terrorizing and keeping Black communities from advocating for their rights as citizens, persisted until the 1950s. Only in 2022 has a federal law been passed that labels lynching as a hate crime. And modern-day lynching (public killing of an individual who has not received due process), still occurs. Physicians are members of communities and are influenced by the dominant culture. They have not, until recently, been at the forefront of protest and change of structural racism.

In the 19th century, prominent physicians such as Samuel Morton, Louis Agassiz and Samuel Cartwright "proved" through their (pseudo) scientific studies that Blacks were animalistic, unintelligent, strong and designed for subtropical servitude. Morton, a prominent Philadelphia physician, through his studies of skulls in the early 19th century, claimed that each of five races had separate origins and that a descending order of intelligence could be discerned by different skull sizes that placed Whites at the pinnacle and Blacks at the lowest. His work was critical in "scientific racism," furthered by Agassiz, a professor at Harvard, who promoted creationism, argued against Darwin’s ideas and supported human polygenism, that Whites and people of color descended from different ancestors, fundamental to racist theories of the inferiority of Black people and others of color. Cartwright, a prominent physician and medical writer in antebellum New Orleans is remembered for his theories of "drapetomania," the disease that causes enslaved people to run away; "rascality," the disease that made enslaved people commit petty offenses; and "dysaesthesia ethiopica," which made enslaved people indifferent and insensible to punishment. These and other writings that taught the inferiority of Black people were enshrined in medical textbooks that guided young healthcare trainees (Byrd & Clayton, 2001).

J. Marion Sims, President of the American Medical Association (AMA) in 1876, and considered the father of modern gynecology, honed his innovative surgery by operating on enslaved Black women without their consent and without anesthesia. Scientific racism made possible the rise of eugenics, the notion that selected breeding could improve the human race, which led to forced sterilization to maintain the purity and dominance of Whites by limiting reproduction of people with undesirable traits, often people of color. Nazi Germany adopted eugenics with the extermination of Jews and many others. Eugenics was supported by many U.S. physicians. During the time of government sanctioned and supported forced sterilization from 1907 to 1981, up to 150,000 people were sterilized by physicians. The Tuskegee study, in which Black sharecroppers were recruited in 1932 for a study of the natural history of syphilis and were never treated despite the wide availability of penicillin by 1947, was shut down in 1972, but did irreparable damage to Black people’s trust in the medical profession. The AMA has a long history of racist practices that kept Black physicians out of medicine’s mainstream, for example, by excluding them from membership in the AMA. This created barriers to specialty training and professional development for Black physicians, directly harming minoritized communities who suffered from a dearth of access to qualified physicians. For example, in 1931, there were 25,000 subspecialty trained physicians in the U.S., and only two of them were Black. This is a history that the AMA now acknowledges and is working to build an antiracist future (Association, 2021).

Much of America's foundational wealth was built on the labor of enslaved people and the genocide and appropriation of the lands of Indigenous people. These actions were based on declaring that these people were "savages" and in other ways inferior to White settlers and pioneers who were creating a new country. We must acknowledge that U.S. physicians contributed to justifying racial attitudes and practices.

In this modern era of racial reckoning, we recognize that we are moral agents in healthcare. We not only have responsibilities to put our patients first and to treat all individuals as equals, but to work for social justice. We have a responsibility to become aware of and change our biases and behaviors to reflect the highest ideals of our professions. We have a responsibility to contribute to changing our institutions and laws to realize the potential and benefits of diversity, equity and inclusion. Healthcare education has recently focused on trauma informed care. So many of our patients have experienced adverse childhood experiences and other traumas that profoundly affect their health (Bellis et al., 2019). If we can elicit and understand the biologic and psychologic effects of that trauma, we can fashion effective therapeutic approaches to care. Similarly, our communities of color have undergone collective and individual traumas from structural and interpersonal racism. Recognizing and appreciating this trauma allows us to be responsible participants in the healing of our individual patients and of the society in which we all live.

Discussion Question 1

Discussion Question 2

Structural, cultural and individual racism enacts a severe toll on the health of Black, Indigenous and people of color (BIPOC) communities. This toll includes increased morbidity and mortality when compared to White communities due to many factors, including wide disparities in wealth, the ability to afford and access care, and inadequate healthcare delivery. We discuss the many causes of these disparities from government and private policies and the adverse psychophysiological effects of the stress of racism.

The COVID-19 pandemic highlighted racial health disparities. Black, Indigenous and Latinx Americans are more than twice as likely to be hospitalized and die from COVID than White Americans (Prevention, 2022). In a systematic review and meta-analysis of 293 studies, Paradies and colleagues (2015) determined that racism was associated with poorer general health, physical health and mental health. For many years, life expectancy for the Black population has been lower than for the White population, but by the height of the pandemic, the difference had increased to six years (Arias et al., 2021).

What is it about our psychology and our society that encourages the thriving of racism, as well as all biases? So many biases are prevalent: homo- and transphobia, anti-Muslim, anti-Asian, anti-immigrant sentiments, all "isms": sexism, ageism, ableism and more. There are related questions: how did the people who founded the United States justify, normalize and promote the enslavement of human beings? How did they rationalize taking the lands of Indigenous people and participating in their genocide? Since our country's founding there has been systematic oppression and the creation of vast inequities between White people and people of color. Are there particular processes common to the way humans think, feel and organize their societies that allow and even encourage racism?

A biopsychosocial approach is the most effective way to understand and treat patients' illnesses. Similarly, this approach can shed light on the questions above. Racism is multidetermined and has complex origins, but we can summarize a few key features of its origins in biology, psychology and the way we construct our societies.

Though our reptilian, mammalian and then primate ancestors had been evolving for about 320 million years, Homo sapiens emerged in Kenya and Ethiopia only 170,000 years ago. Their skins were certainly black, and all humans who are alive today are descended from those people. We all have black ancestors. Some of our ancestors migrated north, and over many years their skins became lighter to better manufacture vitamin D. Fortuitous mutations in the genes that controlled facial and tongue muscles emerged and facilitated the development of language. Other mutations that promoted increased brain growth emerged about 40,000 and then again about 6,000 years ago. Transmission of knowledge, culture, wisdom, the development of social structures and civilizations proceeded from these advances. But certain survival reflexes and instincts that evolved prior and subsequent to our emergence as Homo sapiens are still with us (Vaillant, 2008).

For all the years that we were hunter gatherers, our ancestors developed emotional capacities that define us today. To survive in family groups and tribes, our ancestors developed positive emotions of empathy, compassion, altruism, love, hope, joy and faith. These emotions were critical to the success and cohesion of family units and tribes, as well as the advancement of civilizations. In harsh times of scarcity, though, fear gave rise to negative emotional states. Selfishness, greed and dominance of others, competitiveness, fear of predators and others who could harm us or encroach on resources, anger, the capacity to "otherize" those who threatened us, and the use of violence were also survival strategies. Seeing enemies as "others" allows us to close off empathy for their suffering. Human history has been marked by a continual series of wars fueled by these negative emotional states. Fear and other negative emotions are foundational in the development of racism and other "isms." And protecting the integrity of one’s tribe persists today.

A full discussion of the human psychology that might support racism is beyond the scope of this section. There are some dynamics, though, that warrant special attention.

Human children develop into adults within long periods of dependency. On the way to achieving basic needs for autonomy, competence, and relatedness (Ryan & Deci, 2000), we go through developmental stages (Erikson, 1993; Kegan, 1982), each of which promote or undermine our sense of trust and safety in the world, and our emerging sense of competence, independence and self-esteem. Poverty, food and job insecurity, and social and emotional stressors can disrupt parental effectiveness and optimal development and promote the use of psychological defenses that support prejudice. Also, in childhood, the need for love, safety and protection from helplessness and vulnerability results in needs for affection, admiration for strong parental figures, and a need to gain power through words and fantasy. The need to be powerful, which we gain in relation to others, is a core dynamic in development and a core dynamic in hierarchical societies, such as our own. Attraction to strong authority figures is especially keen in times of societal instability, partially explaining the rise of authoritarian leaders, some of whom play off our fears of "the others" who commit crimes, take our jobs, or challenge our moral and religious views of right and wrong. Innate needs for autonomy, competence and relatedness can best be realized within stable societies. Many who benefit from the current structure have an investment in the stability of their societies, whether or not they are just.

To deal with anxiety and fear, humans have developed a hierarchy of psychological defenses, some of the most immature of which are projection and denial. (Mature defenses include sublimation, humor, altruism, anticipation, suppression and self-assertion (APA, 1994; Vaillant, 1977). Projection and denial protect our firmly held beliefs from being altered by facts and blame others for our troubles. Denial helps us, for example, ignore the reality of the findings of the human genome project that there are no biologic differences between races. Race is a social construct. We are one race – the human race. However, centuries of pseudoscience classifying people by race, which justified the enslavement and oppression of people of color, persist in our sensibilities today. Collective denial and projection can assure us that our beliefs and prejudices are "true." Other psychological defenses include isolation of affect, devaluing others and intellectualization, all of which can contribute to racist thinking and behaviors.

Kegan's (1982) work on adult moral development is relevant. He posits five stages of moral development and asserts that about 65 percent of the general population never make it past Stage 3, in which our moral reasoning relates to perceived cultural norms. If we are in Kegan’s Stage 3, we lack an independent sense of self, because so much of what we think, believe and feel is dependent on how we think others experience us. It is easy to see that if we grow up in a culture that benefits from structural racism, we accept it because it is a cultural norm. We can be mostly unbothered by the exploitation and oppression that makes our lives possible. If we are middle class Whites, we seek to live in White dominated communities that offer the best schools for our children. The fact that Black and other minoritized children receive under-resourced and inferior education is regrettable but does not move most of us to action. We benefit from cheap clothing made by forced labor of Uighur people in China or from the palm oil in cookies made from palm kernels picked by child laborers in Indonesia. If we are comfortable in our lives, other concerns – our relationships and social lives, our children’s educational achievements and sports activities, etc. – fill our worlds.

Another human capacity is relevant in support of racist ideas – our tendency to stereotype. With so many facts and sensations coming at us all at once, our brains cope by making snap judgments and by stereotyping. We are constantly judging and assessing others so that they fit into our preconceived notions and world views. Daniel Kahneman (2011) explains how we so often make cognitive errors in judgement, and how we can be blind to the obvious and also blind to our blindness.

There is no reality except the reality that we construct with others and agree on. We all have points of view that are limited by the scope of our vision, our family and cultural values, our shared history, and what we learn in school and in the media. Many of us learned that Columbus was a hero but didn’t learn that he was an enslaver. Some of the men who died valiantly at the Alamo, Davy Crockett and Jim Bowie among them, were also enslavers and were fighting so that Texans could be free to enslave Black people. They were engaging Mexico’s President General Santa Anna’s forces who were fighting for their land and who opposed slavery. It is often said that history is written by the victors. Our heroic version of our American history tends to neglect that our founders who crafted the legal bases of our country were also protecting the wealth of rich landowning White men. "All men are created equal" did not include women, Black people or Native Americans. Hundreds of laws, court decisions, private actions and economic and political forces reinforced the creation of structural racism over the last 400 years of our history in North America.

It is not human nature to be racist. We have to be taught. However, we live in a socially constructed reality that is supported by the dynamics of human psychology, cognition and development. They are components of our shared human nature that we can rise above. We create our lives within a society that supports vast disparities in wealth and opportunities. Even among those who have become aware and troubled about inequities, many do little to change the current order or to speak up when they observe insensitive racial slights of others. As healthcare providers, though, we can work to understand human nature better than others. We can strive to advance our own moral development. And we can use our knowledge and skills to advocate for just and equitable healthcare for all.

Discussion Question 4

Critical Race Theory (CRT) was developed in the late 1980s by a group of legal scholars. This group included Derrick Bell, Neil Gotanda and Kimberlé Crenshaw. The core idea is that race is a social construct and that racism is not merely the product of individual bias or prejudice but has become structural. Over hundreds of years government policies and legal decisions reflected cultural attitudes about minoritized groups to disadvantage them in housing, employment, education, healthcare, the justice system, etc. There are other tenets of Critical Race Theory, such as interest convergence, which stipulates that Black people achieve civil rights victories only when White and Black interests converge.

Furthermore, racism in the United States is normal, not aberrational: it is the ordinary experience of most people of color. Other tenets include "intersectionality" recognizing that one’s racial identity is only one of many ways people may identify themselves – and that multiple marginalized identities can be especially hurtful and confusing to identity formation; that marginalized people are in a unique position to tell stories about their lived experiences; and that people of color are characterized at various times with different racial stereotypes, based on the needs of the dominant White culture.

While a review of the history of race in this country would substantiate the truth of these observations, many conservative politicians have demonized the teaching of critical race theory. Yet this teaching is essential for healthcare students, who are learning their professions in an unequal and unjust healthcare settings, and who need to advocate for change. Tsai, Wesp and their colleagues describe how CRT education can transform medical and nursing education (Tsai et al., 2021; Wesp et al., 2018).

Let us further consider how these concepts apply to health systems. First, U.S. health systems were developed from the ground up within racist frameworks. The very fabric of how we deliver care and how we educate physicians is embedded in structural racism. It is no wonder, then, that there are significant health disparities in all aspects of healthcare.

The following video encapsulates the idea that race is a social construct:

  •   The Myth of Race Debunked in 3 minutes https://www.youtube.com/watch?v=VnfKgffCZ7U

Delgado, R., & Stefancic, J. (2017). Critical race theory: An introduction (Vol. 20). NYU press.

This concept was coined by legal scholar Kimberlé Crenshaw to explore the ways in which people with multiple marginalized identities experienced discrimination. The concept of intersectionality describes the ways in which systems of inequality based on gender, race, ethnicity, sexual orientation, gender identity, disability, class and other forms of discrimination "intersect" to create unique dynamics and effects. It is important to note here that intersectionality is not the "layering on" of identities; nor is it about any/all aspects of identity. Intersectionality focuses on identities that are marginalized and argues that the point of intersection between these marginalized identities results in an erasure of the individual that ultimately results in the person’s inability to find resolution to their experiences with discrimination. Bowleg (2012) points out that individual-level experiences of people at multiple marginalized intersections typically reflect social-structural systems of power, privilege and inequality.

Kimberlé Crenshaw's "Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics"
The Combahee River Collective Statement (1977)

This section addresses words we hear in popular media as "political terms" in the culture wars. However, these words are actually rigorous theoretical frames that directly address issues of culture, identity, privilege and power.

Colonialism is the process by which a government/nation occupies another nation and claims that nation, its land, its people, its resources and its existence for the benefit of the colonizing nation. Most often, these moves were justified by referring to "the White man’s burden." This phrase referred to the responsibility of "those made in the image of God" to bring civilization and salvation to savage and uncultured corners of the earth. This allowed colonizers to treat the people of colonized lands as "animalistic," "savage," uncivilized, uneducated, etc. While colonialism has existed since ancient times, modern western colonialism began in the mid-15th century when Prince Henry the Navigator of Portugal set up African trading posts and initiated the African slave trade.

The impacts of colonization are immense and pervasive. Various effects, both immediate and protracted, include the spread of virulent diseases, unequal social relations, detribalization, exploitation, enslavement, medical advances, the creation of new institutions, abolitionism, improved infrastructure and technological progress. Colonial practices also spur the spread of colonist languages, literature and cultural institutions, while endangering or obliterating those of native peoples (Wikipedia).

While presumed that the era of colonialism has ended, colonialism is still prevalent in current global politics and its impacts continue to reverberate throughout the world. Colonialism goes beyond "the takeover" of a country. It includes infiltrating the colonized country with the language, culture and values of the colonizing nation. For example, the British imported their train system to India. This was not simply the development of railroad systems for India. It also carried with it the values of "time and efficiency," marking them as important characteristics for a "successful" society. We see this in contemporary presumptions such as "progress" and "life-saving techniques." Colonialism also includes the taking of resources from the colonized peoples, which includes not only material objects (such as gold, diamonds or copper) but also cultural knowledge and practices and claiming them as "discoveries," negating the science and knowledge of ancient cultures.

Colonialism set the groundwork for western science to be seen as the "first" true science. It allowed for scientific discovery to be intertwined with the "salvation" of uncivilized peoples. This then allowed western science to describe non-western bodies and practices as inferior, as well as demonic, deviant, diseased, and pathological. These attitudes infiltrated the development of health systems and the care of marginalized people for centuries and persist today.

  •   Albert Memmi's "The Colonizer and the Colonized"
  •   Franz Fanon's "Wretched of the Earth" and "Black Skin, White Masks"

Racism is overwhelmingly thought to be "bad acts and beliefs by bad people." This frames it as an interpersonal, immoral, individual act. As the previous sections of this module explain, racism, like race, is a socially constructed phenomena and functions at society’s structural level. Individual, institutional and social acts of racism manifest through sustained structures that create and reinforce racism.

Structural racism in the U.S. can be defined as the normalization and legitimization of an array of dynamics – historical, cultural, institutional and interpersonal – that routinely advantage Whites while producing cumulative and chronic adverse outcomes for people of color. It is a system of hierarchy and inequity, primarily characterized by White supremacy.

Structural racism encompasses the entire system of White supremacy, diffused and infused in all aspects of society, including our history, culture, politics, economics and our entire social fabric. Structural racism is the most profound and pervasive form of racism – all other forms of racism (e.g., institutional, interpersonal, internalized, etc.) emerge from structural racism. Structural racism has shaped the delivery of care and the science of medicine. For example, many clinical algorithms used today are based on faulty or pseudoscientific observations of racial differences. Nyas and colleagues (2020) argue that we need to reconsider use of race corrections to ensure that our clinical practices do not perpetuate the very inequities we aim to repair.

Discussion Question 5

Discussion Question 6

Gloria Yamato's essay "Something about it is hard to name", In Margaret L. Anderson and Patricia Hill Collins. eds. 2004. Race, Class, and Gender. 5th Ed. NY: Thomson/Wadsworth Pub. Pp. 99-103. (https://likeawhisper.files.wordpress.com/2010/03/somethingaboutthesubject.pdf)

Foundational concepts, principles, and duties guiding contemporary clinical ethics provide a clear mandate for antiracist action in the care of patients and communities. Key points for understanding include social contract, human rights, guiding ethical principles, essentials of caring, and virtue as personal commitment.

As members of healthcare professions, we are entrusted with the lives and wellbeing of our patients. Each profession enters into a binding contract with society. Society entrusts clinicians with powers and privileges to care for patients. As examples, society allows each profession sets its own standards and training. Clinicians are permitted access to patients’ bodies and personal information. We make treatment decisions that have consequences for patients’ lives. We are permitted unsupervised interaction with people during their most vulnerable times. As a student or practitioner, you enjoy these permissions and freedoms only because you are a member of your healthcare profession.

In exchange, all members of every healthcare profession are bound to a responsibility to serve the best interests of patients and society. Clinicians are guided in this by ethical principles and ethical commitments that have changed dramatically over time and continue to evolve. The emergence of autonomy and social justice as guiding ethical principles are two key examples that mark a sea-change in ethical thinking and action of antiracism in medicine and healthcare.

Historically and until around the 1950s-1960s, guiding principles in medical ethics were beneficence (doing the most good for a patient) and non-maleficence (avoiding harm to that patient). Physicians made treatment decisions based on their professional understanding of what was good or bad for the patient, often in disregard of patients’ values or choices.

In the US, the period around the 1960s was one of social change driven by movements related to civil rights, feminism and gender equality, rights of the incarcerated, rights of human research subjects, and consumer rights. Historically oppressed or disempowered groups demanded recognition as fully equal members of society and self-determination—control over one's own life and life decisions.

At the same time, rapidly emerging technologies such as ventilators, organ transplantation, and radical surgeries raised critical quality of life concerns: just because a treatment could be done, does not mean it should be, especially because the patient may not want to live with the consequences. In both of these contexts, social and individual, autonomy emerged as a central guiding principle of modern bioethics. Autonomy means having control over one’s own body, mind, and life decisions, free from oppression and coercion. It is a human right.

As modern bioethics emerged during the 1960s and 1970s, the principle of social justice featured as another fundamental, guiding principle. The interpretation and application of this principle has continued to develop and has gained increasing prominence and significance. Applications of the social justice principle have always included the equitable distribution of limited healthcare resources (distributive justice). Social justice also always informed the negotiation between individual autonomy and health of the public: individual autonomy must be curtailed at times in the service of public health (e.g., quarantine, mandated vaccinations, mandatory reporting of certain diseases and conditions). Belatedly, mainstream clinical ethics has now intensified and broadened its understanding of social justice to also address structures of racism and other social oppression and practitioner bias as they relate to patient care and outcomes and the health of communities.

Quality clinical care and ethical care are inseparable. It happens too often that an indicated treatment is provided, but in a way that undermines autonomy, injures the patient emotionally, and/or turns the patient away from seeking necessary care in the future. This is unfortunately an experience of BIPOC and other members of our community who have suffered discrimination, bias, or stigmatization.

On a more macro level, a patient may be presenting with a medical need that was caused or exacerbated by structural barriers to the determinants of health and survival (healthcare, food, income, education, safe housing, social integration). A child of color may have uncontrolled asthma because of unhealthy housing conditions resulting from generational disenfranchisement and redlining that placed affordable, healthy housing out of reach.

We must always see this inextricable joining of clinical and ethical care. Clinical questions are: what is the correct diagnosis and how do I administer the correct treatment? Simultaneous ethical questions are: How do my words and actions as a clinician respect patient autonomy, demonstrate my trustworthiness, and reflect the appropriate management of professional power to achieve the most good and avoid harm?

Clinicians view patient care through multiple ethical frames that ultimately justify antiracist objectives. These are:

PRINCIPLES. As already introduced in this discussion, contemporary clinical ethics employs guiding principles. These include respect for persons, autonomy, beneficence and non-maleficence, and social justice.

SOCIAL CONTRACT. Every patient interaction must fulfill the promise of this contract, use professional power and privilege only in the service of our patient. This is a contract of trust and trustworthiness, and all actions are to directly or indirectly promote trust. Trust is the foundation of any patient encounter and we do not take it for granted. We have come to increasingly realize the complex roots of patient distrust of the US medical system that include historic mistreatment and abuse of black, indigenous, and other people of color.

VIRTUE. Clinicians must develop their own capacity to be guided by ethical principles and uphold the social contract even under challenging and difficulty circumstances. Throughout our professional lives we deepen our capacities for compassion, excellence, moral courage, and other moral qualities in the service of patient care. Today we realize this must include overcoming race and other bias in ourselves, intervening to the extent we are able when witnessing racism or discrimination in the healthcare setting, and working to overcome structural racism and other barriers to health equity.

Medical ethics have been heavily influenced by racism, specifically through the false assumption of race as a biological difference rather than a social construct. Historical trauma has an impact across generations and has resulted in a high level of mistrust of patients toward clinicians. It is the responsibility of healthcare clinicians to understand the impact of structural racism and implicit bias as they relate to their own ethical decision-making.

Ethical decision-making as a clinician requires you to understand the professional code of ethics you are accountable to, relevant legislation, and the influence of history and tradition on the practice of medicine. Accountability to a code of ethics is a key element of defining any profession. Cruess et al. (2004) in their definition of "profession," emphasize that any profession "must be governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society." This social contract in the medical profession is heavily influenced by both legislation and tradition. You can see that your ability to adhere to the four principles of ethical decision making in healthcare can be influenced by implicit and explicit biases within a healthcare system that has been shaped by structural racism. These principles are: beneficence (doing good), non-maleficence (doing no harm), autonomy (giving the patient the freedom to choose freely, where they are able) and justice (ensuring fairness in care.)

The impact of racism on medical ethics is well-documented. Medical research has persistently maintained assumptions that there are physiologic and genetic differences based on race, though it is proven that race is a social construct. When medical researchers continue to search for false correlations between race and disease, the more important focus on public health and the roles that social determinants of health play in health outcomes for marginalized populations is lost (Perez-Rodriguez, & de la Fuente, 2017). Research that begins with the assumption of race as a biological rather than social construct leads to inherently unethical and unequal treatment decisions. To maintain an ethical social contract between you as the clinician and your patients, you must critically evaluate your understanding of the impact of historical trauma and unconscious bias. Your relationship with your patients must be informed by your understanding of these concepts, as well as the roles that social determinants of health may play in your treatment decisions and health outcomes for your patients.

Key Point: Medical ethics has been heavily influenced by racism, specifically through the false assumption of race as a biological difference rather than a social construct.

Historical Trauma Historical trauma is defined as the cumulative effect of harm that spans generations and can impact both physical and emotional wellbeing (Gameon & Skewes, 2020). Historical trauma is a barrier to full access to healthcare for people of color. The history of exploitation of people of color in the name of medical advancement and the resulting trauma undermines the trust between patient and provider. You are most likely familiar with many examples of unethical and traumatic medical mistreatment of Black people in the United States. The Tuskegee Syphilis Study, conducted by the U.S. Public Health Service, surgical experiments on Black women and the use of cancer cells for research without consent represent just a few of the many traumas inflicted upon Black people.

Access to healthcare was segregated from the beginning of the medical profession in the United States. Racial disparities in the delivery of care were intentional early in the history of medicine, and the result was consistently poor health outcomes for Black people and a deep mistrust of the medical profession (Miller & Miller, 2021). Patient/client trust in your care is essential for you to be able to deliver care on an ethical foundation. Mistrust in science and in healthcare clinicians is endemic in the U.S., as seen in vaccine hesitancy and reluctance to participate in clinical trials. A number of studies illustrate how the legacy of structural racism has generated mistrust in Black communities that contribute to stark healthcare disparities (Powell, 2019; Warren, 2019; Warren, 2020).

Historical trauma is not limited to the experiences of Black people. Asian American Pacific Islanders have also been subjected to racism and the resulting negative impact on health outcomes. Japanese Americans were detained in camps after the 1941 attack on Pearl Harbor. In subsequent studies on the intergenerational impact of internment it was found that there were disparate health outcomes for those who were detained in the camps, loss of family businesses and a negative impact on mental health for future generations, as well as a mistrust of the government (Patel & Nagata, 2021). In the 20th century, about one third of women of childbearing age in Puerto Rico were coerced into becoming sterilized. This was promoted and subsidized by the United States government through Puerto Rican public health institutions (Lazare, 2021). In the 1940s, U.S. Public Health Service researchers intentionally exposed over 1,300 sex workers, soldiers, prisoners and psychiatric patients to sexually transmitted diseases (STDs) without their consent to test the effectiveness of prophylactic interventions (Spector‐Bagdady, 2019).

These experiences of historical trauma represent just a small portion of the number of unique histories that people of color in the United States bring with them into their healthcare encounters. It is important for you to consider the possible impact of historical trauma on trust and confidence in your ability and willingness to care for your patients. It is critical that you take concrete steps to demonstrate that you understand the background, history and experiences of your patients, their communities and their cultures. There are ways to build trust so that you can work toward a more effective patient-physician relationship. Explicitly acknowledging the history of racism in medicine and encouraging patients to share their stories and their biases could lay the groundwork for a more trusting relationship. Asking patients what they need from you to build trust can also be a pathway to intentional conversations that will deepen the patient-physician relationship (Miller & Miller, 2021). Finally, you can continue to research and educate yourself on the complex intersection of the history of racism and medicine as it relates to marginalized populations so that you understand the perspective of these patients. Taking these steps will help you to develop your trustworthiness as a physician as you work with your patients toward better health outcomes.

Key Point: Historical trauma has an impact across generations and has resulted in a high level of mistrust of patients toward physicians. There are specific, intentional steps that you can take as a physician to mitigate the impact of historical trauma and support the ethical practice of medicine.

The COVID-19 pandemic amplified the need for ethical decision-making in medicine and further emphasized significant disparities in care for marginalized communities. The convergence of poor health outcomes due to existing social determinants of health and systemic disparities in access to care resulted in more people of color who were disproportionately in need of hospitalization due to the virus (Tochin et al., 2020). Once these patients arrived at the hospital, triage protocols in place to manage limited resources further disadvantaged people of color. Traditional methods of medical decision-making in allocating scarce resources falsely assume a baseline measure of health and do not take into account the impact of systemic racism and social determinants of health on diverse patient populations (Schmidt et al., 2020). This is just one example of many that represents the complexity of ethical decision-making in healthcare and the persistent negative impact of structural racism in the delivery of healthcare.

In a study examining disparities in the treatment of pain for Black and White patients, researchers examined the beliefs of medical students and residents about biological differences between the two patient groups (Hoffman et al., 2016). The study concluded that medical students who endorsed the belief about biological differences made unequal treatment decisions due to falsely held beliefs about biological differences between Black and White patients (Hoffman et al., 2016). In another study, Perez-Rodriguez and de la Fuente (2017) examined the interpretation of research studies on the prevalence of a particular form of breast cancer (TNBC) among Black women. The results of the study were reported solely based on the race of the women but failed to account for the fact that in each category of analysis, there was strong evidence that socioeconomic status and Medicaid as the primary insurance coverage were also significantly related to the presence of TNBC.

A study demonstrating how implicit bias can affect medical decision making showed videos of patients complaining of symptoms suggestive of coronary artery disease to 720 primary care physicians. The actors varied by age, race and gender but told the exact same stories of their symptoms. They found that women (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) and blacks (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) were less likely to be referred for cardiac catheterization than men and Whites (Schuman et al., 1999). The book Unequal Treatment by the Institute of Medicine documents the many ways that racial and ethnic disparities in healthcare are significant predictors of the quality of healthcare, even after accounting for the effects of socioeconomic conditions (Smedley, Stith, Nelson, 2003).

These examples emphasize that your responsibility as a clinician is to constantly engage in critical self-reflection to ensure that your treatment decisions are based on the individual factors for each patient and that your decisions are free from racial bias. Because implicit bias can influence your decision-making, you can seek objective input from other peers on a routine basis to ensure that you are aware of any blind spots or concerning patterns in your treatment decisions. Listen to your patients carefully and identify support people to help advocate for patients, such as social workers, community health workers, etc. Additional responsibility of the clinician is to effectively communicate with patients regardless of their preferred language. This includes effective use of professional interpretation services and knowledge of institutional policies.

Commit to continuing education to better understand the impact of implicit bias on medical decision-making. Finally, you can actively advocate for changes to the medical school curriculum that continues to teach that there are biological differences between races. Williams et al. (2018) found that when medical schools intentionally incorporate these concepts throughout their curriculum, their students are less likely to demonstrate biased medical decision-making behaviors.

Key Point: Structural racism has influenced the field of medicine and continues to inform research and medical education. It is a false belief that there are biological differences between races. It is the responsibility of clinicians to understand the impact of structural racism and implicit bias as they relate to their own ethical decision-making.

To ensure that your care is based on the ethical foundations of beneficence, non-maleficence, autonomy and justice, you have an ethical responsibility to understand the impact of structural racism on the practice of medicine. The resulting historical trauma experienced by multiple marginalized people negatively impacts the development of a trusting and effective patient-clinician relationship. Your treatment decisions are influenced by your unexamined implicit biases. You are responsible for actively working to build trust with your patients and for being aware of your biases and how they may be impacting your treatment decisions. As a clinician you have the capacity to challenge long held misconceptions in the field of medicine that uphold racist practices.

Discussion Question 7

According to Delgado and Stefancic (2001), race-consciousness is explicit acknowledgment of the workings of race and racism in social contexts or in one's personal life. In healthcare, this means acknowledging that racial health inequities are the result of racism, not the result of genetics. Applying race-consciousness to healthcare requires:

  •    an appreciation of the complex historical journey of Black people and/or persons of color;
  •    knowledge of disparities in health which may facilitate or inhibit optimal levels of care for these individuals and their families;
  •    and the self-appraisal of one's attitudes, feelings, beliefs and biases towards Black people and/or persons of color (Watts, 2003).

Race-consciousness is often juxtaposed to colorblindness, which acknowledges the arbitrary nature of race, yet ignores the inequities created as a result of structural racism.

Discussion Question 8

The following image depicts axes of privilege and oppression in different forms. Everything in the top half of the wheel represents the privileged part of the axis and everything below represents the oppressed part of the axis. This wheel gives examples of many types of "-isms" but is by no means exhaustive.

Discussion Question 9

The nature of racial conflict is introduced and contributing factors are discussed, especially in the context of healthcare. Racial conflict is inextricably linked to stereotypes, bias, privilege, discrimination, racism and inequities.

Racial conflict is a type of social conflict that results in threatened or actual harm to the targeted racial group based on perceived racial differences. Outright racism, oppression, discrimination, mistreatment, and offensive racist words and actions underlie racial conflict. After learning key concepts of race, racism and the history of racism in the U.S., it may be easier to grasp why racial conflict exists. The stereotypical perception and treatment of an entire racial group as "less than" inevitably results in grievances and eventually generates conflict as disadvantaged groups challenge the status quo and compete for power and resources. The additional context of the history of racism in healthcare (Hess et al., 2020), specifically, reveals the grim reality of systemic racial inequities leading to health and social disparities (Ricks et al., 2021; Sim et al., 2021). In the U.S. today, we see how minoritized racial groups continue to suffer restricted access to basic needs such as healthy foods, clean air and water, safe areas for exercise and access to healthcare (Johnson-Agbakwu, 2022). These same marginalized populations already face disparate health outcomes (Sim et al., 2021) and continue to be subjected to race-based chronic stress due to generations of exposure to discrimination and injustice.

Healthcare can be added to the list of resources for which minoritized racial groups must compete. Certainly, White privilege and fragility play a large role in maintaining a system that serves to sustain these inequities and serves to keep White people from fully grasping the depth and breadth of the problem (Hess et al., 2020). How can White people mitigate racial conflict? What are the processes and pathways for moving away from inequity and toward empathy, understanding and transformative change in healthcare (Hagiwara et al., 2019; Hess et al., 2020; Sim et al., 2021) for Black people and people of color? It is imperative to reckon with the historical racial discrimination and mistreatment, and to acknowledge the disparities that lead to shortening people’s life span by 20 years, simply as a function of their zip code. Trainees and healthcare professionals entering the field must shine a light on the role of racial conflict in ongoing health inequities, refuse to contribute to and/or sustain the distortions of racial bias and lead the transformation to equitable healthcare.

Discussion Question 11

Discussion Question 12

Bias is defined and presented as the root of racism and unequal healthcare treatment. Neuropsychology explains how stereotypes and bias develop, and research has identified possible ways to measure and mitigate bias.

Biases are learned beliefs and attitudes about others that may be positive or negative, like prejudice and stereotypes. Biases are formed early in life through exposure to biased media, education and people, and they are often culturally reinforced. Racialized medical theories from the 1850s that people of African descent have a higher threshold of pain, still contribute to bias today and affect medical practice. Studies show evaluation and treatment of pain for Black patients compared to Whites was negatively impacted by medical students who endorsed this racial bias. Racial bias is also closely linked to health inequities. Bias ranges from subtle microaggressions to more overt episodes of major bias, and both can be detrimental to health and well-being. Being targeted on a daily basis naturally leads to heightened watchfulness or even vigilance, which has serious implications for chronic stress and health. An APA article (2022) highlights vast disparities in access to healthcare that were exposed by the COVID-19 pandemic. One serious outcome is how people of color were hit harder by COVID-19 due to institutionalized racism. Psychologists assert that racism is the root cause of unequal healthcare treatment, policies and access in the U.S.

Black people and other non-White racial groups regularly face discrimination from healthcare providers. Providers may be aware or conscious of some bias and unaware of other aspects of bias (e.g., implicit bias). The human brain makes rapid and automatic associations, naturally putting things in categories to make sense of the world. Stereotyping is an automatic cognitive process of generalizing and placing people in categories, which is more likely to occur under conditions of stress. A stereotype is a generalization about a person or group of people without regard to individual differences. Even stereotypes that seem positive may have negative consequences.

Negative bias leading to mistreatment often stems from fear and misunderstanding of difference. Whether implicit bias, prejudice or stereotypes, these attitudes affect our understanding, actions and decisions. Since conscious and unconscious bias involve learned stereotypes, values and behaviors, it is believed that they can be unlearned and reduced through conscious attention. If you are a member of a minoritized group, negative stereotypes can undermine your self-esteem. One popular strategy for mitigating bias is to learn more about your own unconscious bias by taking the Harvard Implicit Association Test (IAT https://implicit.harvard.edu/implicit/), raising self-awareness and applying various strategies to become more conscious of how your biases may affect your behavior, decisions, and self-esteem. By slowing things down, people are likely to align their conscious beliefs, values and behaviors in more equitable treatment of others.

To cultivate a more diverse workforce in healthcare and positively affect patient outcomes and health equity, we must find ways to effectively intervene with our own bias and associated behaviors. Sometimes a biased response may be avoided by naming it, reflecting and replacing it with a more reasoned choice. Creating counter-stereotypic images can help to challenge the validity of a stereotype. Exposure to those who are different from oneself often provides specific information about group members that can prevent stereotyping in the future. It also helps trying on the perspective of others. Extensive research and discussion of these and other interventions are discussed in Science of Equality article (2014) about addressing implicit bias. Studies, such as Burke et al. (2017), are developing and testing new strategies for addressing implicit bias, stereotypes and prejudices held by providers.

Cultivating your emotional intelligence is essential to understanding the experiences of racially minoritized individuals and countering your implicit biases and stereotyping. Emotional intelligence is the ability to recognize your own and other people's emotions, label them appropriately and use this understanding in interpersonal relationships. It also involves the capacity to manage one's emotions (Goleman, 1996). Perhaps the most important and practical aspect of this concept is your ability to regulate your emotions. This is an essential skill in clinical care and in life. This involves intentionally pausing for a few seconds before you react emotionally, thinking about the likely reasons for the other person's statement that triggered you, how they might react to your intended reply and the consequences of that reaction. You may decide to react in a different, more conciliatory or helpful way. You can explore your EQ (Emotional Quotient) by taking a quick test at this website: https://www.ihhp.com/free-eq-quiz/

Nixon, S.A. The coin model of privilege and critical allyship: implications for health. BMC Public Health 19, 1637 (2019). https://doi.org/10.1186/s12889-019-7884-9

Overland MK, Zumsteg JM, Lindo EG, et al. (2019). Microaggressions in Clinical Training and Practice. PM & R. 2019;11(9):1004-1012. doi:10.1002/pmrj.12229

Steele, Claude M. (2010). Whistling Vivaldi: How stereotypes affect us and what we can do. New York: W.W. Norton & Company, Inc. Medical Student and Medical Trainee Change studies: https://www.diversityscience.org/changes/

When cultures collide, the only minimal chance for a partnership that values diversity is when one side is open-minded to understanding differences and demonstrates flexible behaviors. Positive outcomes of valuing diversity include improved communication, satisfaction, empowerment, partnerships, respect, optimal care, health and wellness.

Introduction
Leaders in various disciplines are increasingly realizing the importance of recognizing diversity and applying cultural humility for successful outcomes. The concept of diversity is vastly broad, including cultural differences that span from differences in beliefs among nations, communities and groups to diversity at the individual level—including diversity of thought. When a difference in perspective is misunderstood or not adequately considered, the resulting conflict interferes with accomplishment of goals and relationships. To guide healthcare professionals on how to appreciate diversity and apply cultural humility to advance mutual understanding and improve human interactions is the intent.

Cultural Humility Definition
Tervalon and Murray-Garcia (1998) coined the term cultural humility. In a seminal article describing multicultural training to physicians, they encouraged educators to shift away from the goal of achieving cultural competence to that of cultural humility. "Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations." (Tervalon & Murray-Garcia, 1998, p. 117) While both cultural competency and cultural humility involve a process, cultural humility is a process of lifelong learning.

Attributes of Cultural Humility
Attributes of cultural humility include addressing power differences and recognizing and minimizing power differences, promoting respect, focusing on not only the other individual but on yourself, being flexible, making bias explicit and adopting an ongoing process of self-reflection and growth in your appreciation of and ability to be enriched by differences (Yeager & Bauer-Wu, 2013). Flexibility is an endpoint and an attribute of cultural humility. The attributes were openness, self-awareness, egoless, supportive interactions, and self-reflection and critique. The outcomes were mutual empowerment, partnerships, respect, optimal care and lifelong learning.

Behaviors to Adopt Cultural Humility and Value Diversity
Enacting cultural humility involves a flexible mindset, a focus on others and self (as opposed to self only) and a perspective that the worth of all humans is on a horizontal plane, meaning that all human beings hold equal value and diversity is valued. Cultural humility involves supportive interactions, which may include verbal and/or nonverbal communications. Cultural humility is a process of self-reflection and lifelong learning resulting in mutually positive outcomes. In practice, cultural humility is expressed by being curious about cultural beliefs and how they impact attitudes and behaviors and expressing empathy and respect for patients/clients' choices influenced by their cultural beliefs. (Chou, Pearlman, Risdon. 2014) If you are aware of your biases and stereotyping, you can step away from these, and work on not letting them interfere with your generous listening in the service of understanding your patients and clients.

Conclusion
To thrive in a diverse, complex world, individual, group leaders or community leaders need to be able to embrace cultural humility. By being aware of diversity and power imbalances that affect perspective, conflict can be accepted and embraced in a positive way. By enacting behaviors that demonstrate cultural humility, mutual benefits result. When cultures collide, the only minimal chance for a partnership that values diversity is when one side is open-minded to understanding differences and demonstrates flexible behaviors. Positive outcomes include improved communication, satisfaction, empowerment, partnerships, respect, optimal care, health and wellness. Approaching diversity as positive and not centered on conflict, you will reinforce behaviors that flatten hierarchies, better value humankind and role model flexibility to resolve conflict positively. Diversity represented by sociocultural differences can affect communication and decision making and are directly linked to patient satisfaction, treatment plan adherence and overall care quality.

Discussion Question 15

Microaggression is defined and explored in the context of healthcare. The harm and long-term consequences are discussed, including impact on a target's safety and their psychological and physical health.

In the 1970s, Harvard professor Dr. Chester M. Pierce coined the term "microaggression" to describe the insults and slights he had witnessed against Black people, noting the pervasive effect of multiple microaggressions by White people. Microaggressions are defined as verbal, nonverbal and/or environmental slights, snubs or insults that are either intentional or unintentional. They convey hostile, derogatory or otherwise negative messages to target persons based upon their membership in a structurally oppressed social group (Sue, 2010).

Individual microaggressions may appear small or insignificant, but part of the harm is the day-to-day accumulation of being targeted repetitively in a variety of different contexts over time. While a White person might see their microaggression as an honest mistake that should be shrugged off, someone who is structurally oppressed is more likely to experience microaggressions repeatedly, beyond a healthcare context, and to be more severely impacted (Freeman & Stewart, 2018).

Overland, Zumsteg, Lindo, Sholas, Montenegro et al. (2019) encourage practitioners to focus on the impact of microaggressions and their effect on the target rather than on defending one’s intentions or saying what the actor meant by the behavior. A common response after committing a microaggression is to frame it as a joke, which invokes another microaggression (invalidating the impact on the target). Microaggressions may be committed without racist intent, but perpetrators of the microaggressions often do not take responsibility for how their words might be landing. Only people of color are able to truly discern what constitutes a derogatory message or microaggression. Overland et al. (2019) also cite barriers to recruitment and retention of high-quality candidates as powerful reasons to change a culture permeated by microaggressions that demean and degrade physicians of color. The ripple effect of fewer practitioners of color is poorer patient care and outcomes, and greater healthcare disparities.

Microaggressions are committed by health providers against patients and trainees, by patients against clinicians, and they also occur on interprofessional teams and between colleagues. Microaggressions undermine these relationships, diminishing trust and affecting the care that can be provided. Stereotypes have led clinicians to overlook symptoms or not take a patient seriously. Some of the harmful consequences for people of color encountering recurrent discrimination by healthcare providers include added stress, distrust of healthcare practitioners, skepticism, and related delays in seeking medical care and following up, and not adhering to prescribed treatments or screening recommendations (Sabin et al., 2009).

It is important to be familiar with a range of marginalized and privileged social identities to understand how microaggressions might occur. it may be difficult to have empathy for those who are marginalized by the very privilege that one holds. Gaining exposure to the lived experiences of those who are targeted by racism takes intentional work and practice. Culture can be shifted by owning and understanding one’s own bias and microaggressions. Freeman and Stewart (2018) recommend that healthcare providers commit to understanding and recognizing microaggressions, the severity of resulting harm and be mindful to prevent committing microaggressions. See Cheung et al. (2016) for their protocol for targets and witnesses to take A.C.T.I.O.N. in responding to microaggressions: Ask about the intentions of the microaggressor ("I want to make sure I understand what you were saying. Were you saying...?"); Come from Curiosity instead of judgment, listening carefully; Tell others how the microaggression was problematic ("I noticed that…."); focus on the Impact, asking for or stating the potential impact of such a statement or action on others; Own your thoughts/feelings (When I hear your comment, I think/feel..."); discuss Next steps, requesting that appropriate action be taken and checking in with the target of the microaggression.

Banaji, M. R. and Greenwald, A. G. (2013). Blindspot: Hidden Biases of Good People. New York: Delacorte Press.

Jana, T., & Baran, M. (2020). Subtle Acts of Exclusion: How to Understand, Identify, and Stop Microaggressions. Oakland: Berrett-Koehler Publishers, Incorporated. https://ebookcentral.proquest.com/lib/vcu/detail.action?pq-origsite=primo&docID=6037198

Tweedy D. (2015). Black Man in a White Coat: a Doctor’s Reflections on Race and Medicine. New York: Picador.

Washington, E. F., Birch, A. H., & Roberts, L. M. (2020, July 3). When and how to respond to microaggressions. Harvard Business Review. https://hbr.org/2020/07/when-and-how-to-respond-to-microaggressions

In this section, you will learn about what discrimination is, some examples of racial discrimination throughout history, the impacts it can have on health and how it is a systemic issue.

Discrimination is the practice of unfairly treating a person or group of people differently from other people or groups of people. Discrimination is behavior, arising from shared cultural stereotypes and other mistaken beliefs about groups of people based on one aspect of their social identity, such as race, age or gender. Sexism, for example, is a form of discrimination based on a person's sex or gender that has been linked to stereotypes, expectations and gender roles. Sex discrimination may include the belief that one sex or gender is intrinsically superior to another. Extreme examples of sexism include sexual harassment, rape and sexual violence. Ableism favors non-disabled people and treats them as the standard of "normal living" while excluding and discriminating against people with disabilities. Stereotypes or prejudice can be positive as well as negative. Prejudice (similar to bias) means to prejudge a person or group of people; to have an opinion or make a decision based on insufficient information.

Racial discrimination is when this unfair treatment is based on the perceived race of the person or people. Amnesty International (2021) suggests that discrimination can come in different forms. They present three different types of discrimination: direct, indirect and intersectional. Direct discrimination is when there is an explicit distinction made between groups of people where some individuals are less able than others to exercise their rights. Indirect discrimination is when a policy or practice uses neutral terms, but disproportionately disadvantages a specific group or groups. Finally, intersectional discrimination is when several forms of discrimination combine to leave a group at an even larger disadvantage than others.

Racial discrimination or racism in the U.S. is discrimination based on skin color. Minoritized groups have historically had less access to privileges enjoyed by others, and the impact of unequal access and treatment has cumulative consequences. Racial discrimination in the field of healthcare includes historical and ongoing racially exploitative medical and public health practices; failing to take symptoms seriously, dismissing severity of pain and misdiagnosing illnesses (resulting in delayed treatment, unnecessarily advanced disease states and increased hospitalizations or death due to heart disease or cancer). This harm can be exacerbated for Black women, for example, when gender discrimination is layered on top of racial discrimination.

Discrimination affects not only those who self-identify or are categorized as being members of minoritized racial/ethnic groups but also harms those who are merely perceived by others as belonging to these minoritized groups. For example, in one study MacIntosh et al. (2013) noted in their discussion that U.S. adults who "self-identify as racial/ethnic minorities, but report being socially-assigned as non-Hispanic White," reported better healthcare outcomes and were less likely to report healthcare discrimination compared with those who were perceived as racial/ethnic minorities.

The United States has a long history of engaging in racial discrimination. Black people were enslaved in the United States from 1619 until the ratification of the 13th amendment in 1865 (Shah & Adolphe, 2019). In 1830, President Andrew Jackson signed the Indian Removal Act which authorized the forced relocation of thousands of Native American people west of the Mississippi (Indian Removal Act, 1830). In the late 19th century, Native American boarding schools were established in an effort to assimilate Indigenous youth to American culture and eradicate Indigenous cultures (Mejia, 2021). In 1882, the Chinese Exclusion Act suspended Chinese immigration to the United States and made it impossible for Chinese immigrants to apply for naturalization (History.com, 2018).

These are just a few examples of racial discrimination throughout U.S. history. You are encouraged to conduct further research on these instances and the many other examples of racial discrimination. It is essential to learn about the history of racial discrimination because of the impacts and implications it has on modern day society. In Sociological Perspectives on Racial Discrimination, the authors discuss the discriminatory housing practice of redlining and state that "though redlining eventually became illegal, the long-term consequences of these and other obstacles to homeownership for the black-white wealth gap, and for socioeconomic inequality more generally, surely lasted much longer" (Small & Pager, 2020, p. 56). Being aware of racial discrimination throughout history allows us to understand the implications of these practices. (Watch video on how redlining causes inequality from previous section: https://www.youtube.com/watch?v=O5FBJyqfoLM )

Many studies show that increased levels of perceived discrimination are associated with more negative mental and physical health. (Pascoe & Richman, 2009; Sabin et al., 2009) It is generally believed that racial discrimination causes stress, which has been shown to increase blood pressure, negatively impact sleep and raise the risk of developing kidney disease (Lewsley & White, 2020). It has also been found that people who said they had experienced racial discrimination were also cited as experiencing depression, anxiety, PTSD and other emotional distress (Lewsley & White, 2020). Studies that relate racial discrimination to negative impacts on physical and mental health suggest that racism and racial discrimination are a matter of public health. It is essential for incoming and current healthcare providers and researchers to become familiar with how real and perceived racial and ethnic differences can influence health outcomes (Nieblas-Bedolla et al., 2020).

It is important to note that discrimination is not simply an act that one person does to another, it is a system within our society. As you learned about in the "racial discrimination throughout U.S. history" section, discriminatory practices have been prevalent for centuries and undoing the negative implications of this history will take time. Due to historical and present-day racism, discrimination can be found throughout different arenas such as education, housing, medical treatment and the law. Discrimination works as a system, with discrimination in each institution potentially reinforcing disparities and discrimination in other institutions—and with the effects in some cases potentially reaching across generations (Lang & Kahn-Lang Spitzer, 2020). Although there is not one good answer on how to solve the issue of systemic discrimination, it is important to be aware of it if changes are going to be made.

This section defines health and healthcare equities, inequities and disparities, social and structural determinants of health, and racism as a determinant of health. We also examine how each of five social determinants likely impact overall health and explains how lack of access to oral health contributes to health disparities.

Interaction Institute for Social Change | Artist: Angus Maguire. https://interactioninstitute.org and http://madewithangus.com/

The World Health Organizations defines health as "a state of complete physical, social and mental well-being" (WHO).

Health Equity as defined by the Robert Wood Johnson Foundation (RWJF) "means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health, such as poverty, discrimination and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care" (RWJF).

Health Inequity is therefore a difference in health that is avoidable and unfair because it is connected to social injustices and structural racism. These social injustices, due to an unequal allocation of power and resources, make some communities more susceptible to poor health compared to others. Examples include differences in life expectancies, mental illness diagnoses and preventable deaths. As an example, Black/African American, American Indian and Alaska Native women are two to three times more likely to die from pregnancy-related causes than White women. This is not due to any biological reason and in fact, crosses socioeconomic boundaries. If one racial or ethnic group can access a high level of medical care, why not others?

Health Disparities are connected to health inequities as the differences in the presence of disease and treatment outcomes between different population groups and communities. There is a higher degree of illness, injury or mortality in one group relative to another. Health disparities are inextricably linked to access to care, health insurance coverage, quality of care and use of care. When there is health inequity, health disparities emerge.

Healthcare Equity means that everyone has access to fair and appropriate care regardless of who they are, where they live or their socioeconomic status. This means that everyone has the same opportunity to be healthy. Everyone receives the quality of care appropriate for their needs.

Healthcare Disparities refer to the differences in healthcare between groups such as in health insurance coverage, access to and use of care, and quality of care. These disparities are usually discussed in terms of race and ethnicity, but can also be influenced by gender, socioeconomic status and sexual orientation, to name a few. The Affordable Care Act sought to address healthcare disparities by addressing the uninsured status across groups and the barriers to accessing healthcare.

Social Determinants of Health refer to the circumstances of the settings in which persons live, work, play, worship, attend school and grow old, that affect health, quality of life outcomes and risks (DHHS). They include five domains:

• Economic Stability
• Education Access and Quality
• Healthcare Access and Quality
• Neighborhood and Built Environment
• Social and Community Context

Examples include access to nutritional food and places for outdoor exercise, polluted air and water, racism, discrimination and violence (DHHS).

Structural Determinants of Health include the governing process, economic and social policies that affect pay, working conditions, housing and education. The structural determinants affect whether the resources necessary for health are distributed equally in society or whether they are unjustly distributed according to race, gender, socio-economic status, social class, geography, sexual identity or other socially defined group of people (NAS, 2017).

Racism as a Determinant of Health: Racism impacts overall health in various ways. In each social determinant there is an element that is affected by systemic racism. (1) A neighborhood or built environment with reduced access to healthy food, employment, housing and education and/or increased exposure to risk factors (e.g., avoidable contact with police); (2) Healthcare access diminished and adverse mental, social, emotional processes and associated psychopathology; (3) A lack of stability and quality healthcare, exposure to toxic facilities, fast food restaurants and alcohol outlets, connected to cumulative burden of life stresses and associated pathophysiological processes; (4) Lacking safe neighborhood and community spaces resulting in diminished participation in healthy behaviors (e.g., sleep and exercise) and/or increased engagement in unhealthy behaviors (e.g., alcohol consumption) either directly as stress coping or indirectly via reduced self-regulation; and (5) physical injury as a result of racially-motivated violence (Paradies et al., 2015).

In 2020, we witnessed the desolate collision of the social determinants of health, health disparities and access to care, as Native Americans, Black and Latinx communities faced much higher risk of COVID-19 infection (Johnson, 2020). This is not because their bodies were less able to fight the virus. Instead, health inequities made it more likely that they would be exposed to the virus and more easily infected. They were more likely to be working in the jobs that were considered essential, therefore exposed to more people and when they became infected, became more seriously ill. Lack of trust in their White healthcare providers, lack of insurance, lack of time and lack of access, also contributed to a higher likelihood of preexisting untreated chronic condition(s) that resulted in a reduced ability to fight the virus.

There are disparities in oral health that contributes to overall health disparities and must be addressed when considering the Social Determinants of Health (SDOH). Over time dental health providers have become a critical part of the healthcare team, and cannot only recognize the first signs of underlying systemic diseases found in the oral cavity, but address these factors with at-risk patients, as well as work to improve oral health (Tiwari, Palatta & Stewart, 2020).

Discussion Question 19

The pervasive impact of racism is systemic in its deepest and broadest roots. Therefore, to achieve racial equity we must explore and address oppressive policies, procedures and practices. Medical and scientific research which informs healthcare policies, procedures and practices must be intentional to use an inclusive approach that promotes health equity.

Structural racism can be described as the systemic oppression of certain ethnic and racial groups imposed by and embedded in laws, policies, procedures and practices in society. According to Kendi, "racism itself is institutional, structural, and systemic." Therefore, the antidote to this form of injustice is in making and enforcing changes to laws, policies, procedures and practices in society – one organization, one institution, one healthcare system, one community at a time.

Scholars have suggested the need for consistent definitions and accurate vocabulary for measuring, studying and discussing race, racism and health in healthcare organizations (Hardeman et al., 2016). Structural competency has been defined as "the capacity for health professionals to recognize and respond to health and illness as the downstream effects of broad social, political, and economic structures" (Neff et al., 2020). Health professionals need to consider not just the interpersonal strategies required to address overt racism in healthcare environments, but also the structural forces (laws, policies, procedures and practices) that shape the context in which they are embedded. Leaders of healthcare organizations must work to promote workforce inclusion and diversity in a way that addresses structural racism and how this may impact healthcare providers of color and the working environment.

Racial and ethnic minorities continue to receive lower quality care and suffer higher rates of morbidity and mortality despite advances made in the treatment of chronic diseases. The reasons for these continued health disparities are rooted in social injustices and the structural racism that continues to plague communities of color. Scientists have known for years of the lack of a genetic component of race. The racial categories recognized in society have no basis at the genetic level. With that we say it is a "social construct"; this means it does not exist objectively but because human beings decided that it exists. Despite proof that the concept of race is "biological fiction" it continues to be used in medical teaching, treatment and research.

Recently, the term "race norming" and its use in medicine has been in the national news, due in part to the way the NFL has compensated athletes suffering the effects of sports-related brain injuries. Race norming is the adjustment of medical test results or medical risk assessments based on a patient’s race. In other words, if you are Black, you might score differently than you would if you are White with the identical or similar set of symptoms simply because of the color of your skin.

The use of race-based norms embeds a number of assumptions about biological constructions of race that may potentially lead to erroneous and potentially harmful interpretations of racial differences. Further, the utilization of such norms not only reinforces biological constructions of race but fails to question or understand why such differences do exist. Efforts to improve equity in research need to include diverse populations that reflect the composition of the U.S. and examine the underlying factors that may lead to racial differences in health outcomes (Vyas, 2020).

Despite evidence that race is a social construct and has no genetic or biological basis, and that genetic studies consistently show that there are more differences within racial groups than between them, race-based protocols currently exist in medicine and can have a profound impact on perpetuating racial inequities. An example includes assessments of kidney function with equations that calculate estimated glomerular filtration rate (eGFR) such as the MDRD equation. This equation includes inputs based on race. If a patient is identified as Black, the MDRD will report a higher eGFR value, suggesting better kidney function. Higher eGFR values have significant influence on subsequent care such as decisions to utilize certain medications, referrals to specialist care, and meeting qualifications to be added to the list for kidney transplantation. As a result, inputs to the eGFR equation based on race amplify well known disparities in care such as White persons being at least four times more likely to receive a kidney transplant than Black persons.

Discussion Question 20

Antiracist approaches to clinical care begin with racial and ethnic representation. Increasing diversity in the healthcare workforce is accepted as an effective strategy for addressing access to care and health disparities in vulnerable populations. Documented increases in under-represented minority and disadvantaged graduates of healthcare professions have not kept pace with an ever-increasing diverse nation. Ethnic and racial diversity among dentists also does not mirror that of the U.S. population. In an increasingly diverse population, healthcare and public health workers are introduced to a broad spectrum of beliefs and various health related behaviors that are a result of different cultures.

As the landscape in the United States has and continues to become more diverse, health professions education and healthcare began to integrate concepts of cultural competence to improve healthcare delivery to people with diverse beliefs, attitudes, values, behaviors and languages. Cultural competence has been described as the behaviors, attitudes and policies necessary for a system, agency, program or individual to function effectively and appropriately in diverse cultural interactions and settings. Cultural competence aims to ensure an understanding, appreciation and respect of cultural differences and similarities within, among and between groups.

More recently, there has been a shift from cultural competence to cultural humility as "competence" implies an endpoint for mastery. The cultural humility framework, instead, recognizes that we can never be fully competent in understanding all cultures and appreciates that culture is dynamic, changing over time and by location. The cultural humility framework embraces a growth mindset, self-reflection, and lifelong learning where individuals are open to learning about another’s culture and also examine one’s own cultural beliefs and identities.

Public health physician Melanie Tervalon and Dr. Murray-García (1998) described three principles of cultural humility: 1) Continue learning throughout our lives, because we are ever-changing based on what is going on with us and with our patients; 2) Be humble about our level of knowledge regarding our patients' beliefs and values, aware of our own assumptions and prejudices, and active in redressing the imbalance of power inherent in the clinician-patient relationship; and 3) Recognize the importance of institutional accountability.

Source: https://thinkculturalhealth.hhs.gov/education/behavioral-health

Discussion Question 21

Not infrequently, healthcare providers of color are subject to overtly racist behaviors by patients which can lead to significant emotional harm. The profound harm is not merely generated by the overt racist behaviors themselves but intensified by the failure of organizations to respond to such acts, thereby neglecting to acknowledge their impact on the workplace environment and provision of healthcare. Scholars have brought attention to the dearth of policies and protocols that guide organizations on how to respond to racism in healthcare settings despite its common occurrence; how to balance ethical dilemmas involving the duty to provide care with the intention of creating a nondiscriminatory environment. While many organizations have issued nondiscriminatory proclamations and diversity statements, there needs to be a more substantive approach to delineating, implementing, and evaluating the impact of anti-racist policies on healthcare disparities, healthcare delivery, and the healthcare environment with consideration given to guiding ethical principles, legal frameworks, and organizational responsibilities.

Paul-Emile and colleagues (2016) outline a sequential approach to responding to racist patients that preserves appropriate patient care and the well-being of physicians who are the objects of racist (or sexist, homophobic, etc.) comments. Also, Dr. Holly Humphrey, President of the Josiah Macy Jr. Foundation discusses an approach more comprehensively in one of the Vital Voices podcasts of the Foundation: https://macyfoundation.org/news-and-commentary/vital-voices-episode-4

Watch the videos in Discussion Question 23 to generate your discussion on approaching a racist patient.

Discussion Question 23

Discussion Question 24

Performative allyship is when those with power/privilege profess solidarity with a cause, often to distance themselves from potential scrutiny or protect an institution brand (at the organizational level), or to get a virtual "pat on the back." It is "talking the talk" but not "walking the walk" (Medium, 2020).

So You Want to Talk About Race by Ijeoma Oluo (book).
Waking Up White by Debbie Iriving (book).
Raising White Kids by Jennifer Harvey (book).
The New Jim Crow: Mass Incarceration in the Age of Colorblindness by Michelle Alexander (book).
How to Be An Antiracist by Ibram X Kendi (book)
Seeing White (Podcast)
Vital Voices (A podcast series from the Josiah Macy Foundation)

• Antiracism in Health Care Module Overview
  
  
• Learning Environment Questionnaire
  
  
• Antiracism Module Videos Discussion Questions Guide
  
  
• Journeys Newsletter
  
  

National Center for Health Statistics (US). Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Hyattsville (MD): National Center for Health Statistics (US); 2016 May. Report No.: 2016-1232. PMID: 27308685. Phillips, K. W. (2014). How diversity makes us smarter. Scientific American, 311(4), 43-47.

Association, A. M. (2021). AMA’s Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity, 2021–2023. American Medical Association. https://www.ama-assn.org/about/leadership/ama-s-strategic-plan-embed-racial-justice-and-advance-health-equity

Bellis, M. A., Hughes, K., Ford, K., Ramos Rodriguez, G., Sethi, D., & Passmore, J. (2019). Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis. Lancet Public Health, 4(10), e517-e528. https://doi.org/10.1016/S2468-2667(19)30145-8

Byrd, W. M., & Clayton, L. A. (2001). Race, medicine, and health care in the United States: a historical survey. J Natl Med Assoc, 93(3 Suppl), 11S-34S. https://www.ncbi.nlm.nih.gov/pubmed/12653395

Cooper, L. A., Roter, D. L., Carson, K. A., Beach, M. C., Sabin, J. A., Greenwald, A. G., & Inui, T. S. (2012). The associations of clinicians' implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. Am J Public Health, 102(5), 979-987. https://doi.org/10.2105/AJPH.2011.300558

Dyrbye, L., Herrin, J., West, C. P., Wittlin, N. M., Dovidio, J. F., Hardeman, R., Burke, S. E., Phelan, S., Onyeador, I. N., Cunningham, B., & van Ryn, M. (2019). Association of Racial Bias With Burnout Among Resident Physicians. JAMA Netw Open, 2(7), e197457. https://doi.org/10.1001/jamanetworkopen.2019.7457

Filut, A., Alvarez, M., & Carnes, M. (2020). Discrimination Toward Physicians of Color: A Systematic Review. J Natl Med Assoc, 112(2), 117-140. https://doi.org/10.1016/j.jnma.2020.02.008

FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics, 18(1), 19. https://doi.org/10.1186/s12910-017-0179-8

Hardeman, R. R., Perry, S. P., Phelan, S. M., Przedworski, J. M., Burgess, D. J., & van Ryn, M. (2016). Racial Identity and Mental Well-Being: The Experience of African American Medical Students, A Report from the Medical Student CHANGE Study. J Racial Ethn Health Disparities, 3(2), 250-258. https://doi.org/10.1007/s40615-015-0136-5

Hill, K. A., Samuels, E. A., Gross, C. P., Desai, M. M., Sitkin Zelin, N., Latimore, D., Huot, S. J., Cramer, L. D., Wong, A. H., & Boatright, D. (2020). Assessment of the Prevalence of Medical Student Mistreatment by Sex, Race/Ethnicity, and Sexual Orientation. JAMA Intern Med, 180(5), 653-665. https://doi.org/10.1001/jamainternmed.2020.0030

Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A, 113(16), 4296-4301. https://doi.org/10.1073/pnas.1516047113

Kendi, I. X. (2016). Stamped from the Beginning: The Definitive History of Racist Ideas in America Bold Type Books.

Maina, I. W., Belton, T. D., Ginzberg, S., Singh, A., & Johnson, T. J. (2018). A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Soc Sci Med, 199, 219-229. https://doi.org/10.1016/j.socscimed.2017.05.009

Tsai, J., Ucik, L., Baldwin, N., Hasslinger, C., & George, P. (2016). Race Matters? Examining and Rethinking Race Portrayal in Preclinical Medical Education. Acad Med, 91(7), 916-920. https://doi.org/10.1097/ACM.0000000000001232

Wheeler, R. M., Foster, J. W., & Hepburn, K. W. (2014). The experience of discrimination by US and Internationally educated nurses in hospital practice in the USA: a qualitative study. J Adv Nurs, 70(2), 350-359. https://doi.org/10.1111/jan.12197

Williams, D. R., Lawrence, J. A., & Davis, B. A. (2019). Racism and Health: Evidence and Needed Research. Annu Rev Public Health, 40, 105-125. https://doi.org/10.1146/annurev-publhealth-040218-043750

Alang, S. M. (2019). Mental health care among blacks in America: Confronting racism and constructing solutions. Health Serv Res, 54(2), 346-355. https://doi.org/10.1111/1475-6773.13115

Arias, E., Tejada-Vera, B., & Ahmad, F. (2021, February 2021). Provisional Life Expectancy Estimates for January through June, 2020. National Center for Health Statistics. Retrieved 4/2/22 from https://www.cdc.gov/nchs/data/vsrr/VSRR10-508.pdf

Eylem, O., de Wit, L., van Straten, A., Steubl, L., Melissourgaki, Z., Danisman, G. T., de Vries, R., Kerkhof, A., Bhui, K., & Cuijpers, P. (2020). Stigma for common mental disorders in racial minorities and majorities a systematic review and meta-analysis. BMC Public Health, 20(1), 879. https://doi.org/10.1186/s12889-020-08964-3

Lewis, T. T., Cogburn, C. D., & Williams, D. R. (2015). Self-reported experiences of discrimination and health: scientific advances, ongoing controversies, and emerging issues. Annu Rev Clin Psychol, 11, 407-440. https://doi.org/10.1146/annurev-clinpsy-032814-112728

Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., & Gee, G. (2015). Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PLoS One, 10(9), e0138511. https://doi.org/10.1371/journal.pone.0138511

Prevention, C. f. D. C. a. (2022, 3/25/22). Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity. CDC. Retrieved 4/2/22 from https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html#print

Stringhini, S., Carmeli, C., Jokela, M., Avendano, M., Muennig, P., Guida, F., Ricceri, F., d'Errico, A., Barros, H., Bochud, M., Chadeau-Hyam, M., Clavel-Chapelon, F., Costa, G., Delpierre, C., Fraga, S., Goldberg, M., Giles, G. G., Krogh, V., Kelly-Irving, M., . . . consortium, L. (2017). Socioeconomic status and the 25 x 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1.7 million men and women. Lancet, 389(10075), 1229-1237. https://doi.org/10.1016/S0140-6736(16)32380-7

Thames, A. D., Irwin, M. R., Breen, E. C., & Cole, S. W. (2019). Experienced discrimination and racial differences in leukocyte gene expression. Psychoneuroendocrinology, 106, 277-283. https://doi.org/10.1016/j.psyneuen.2019.04.016

Williams, D. R., Lawrence, J. A., & Davis, B. A. (2019). Racism and Health: Evidence and Needed Research. Annu Rev Public Health, 40, 105-125. https://doi.org/10.1146/annurev-publhealth-040218-043750

Williams, D. R., Lawrence, J. A., Davis, B. A., & Vu, C. (2019). Understanding how discrimination can affect health. Health Serv Res, 54 Suppl 2, 1374-1388. https://doi.org/10.1111/1475-6773.13222

Yearby, R., Clark, B., & Figueroa, J. F. (2022). Structural Racism In Historical And Modern US Health Care Policy. Health Aff (Millwood), 41(2), 187-194. https://doi.org/10.1377/hlthaff.2021.01466

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edn. Washington, DC: American Psychiatric Publishing.

Erikson, E. H. (1993). Childhood and society. New York: Norton; Chicago

Kahneman, Daniel. (2011) Thinking, Fast and Slow. New York: Farrar, Straus and Giroux.

Kegan, Robert (1982) The evolving self: problem and process in human development. Harvard University Press, Cambridge, MA

Ryan, R. M.; Deci, E. L. (2000). "Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being". American Psychologist. 55 (1): 68–78

Vaillant, G. E. (1977). Adaptation to Life. Boston, MA: Little, Brown

Vaillant, G. E. (2008). Spiritual evolution: A scientific defense of faith. Broadway Book

Bowleg, L. (2012) The problem with the phrase women and minorities: intersectionality-an important theoretical framework for public health Am J Public Health, 102 1267-73

Tsai, J., Lindo, E., & Bridges, K. (2021). Seeing the Window, Finding the Spider: Applying Critical Race Theory to Medical Education to Make Up Where Biomedical Models and Social Determinants of Health Curricula Fall Short. Front Public Health, 9, 653643. https://doi.org/10.3389/fpubh.2021.653643

Wesp, L. M., Scheer, V., Ruiz, A., Walker, K., Weitzel, J., Shaw, L., Kako, P. M., & Mkandawire-Valhmu, L. (2018). An Emancipatory Approach to Cultural Competency: The Application of Critical Race, Postcolonial, and Intersectionality Theories. ANS Adv Nurs Sci, 41(4), 316-326. https://doi.org/10.1097/ANS.0000000000000230

Wikipedia. https://en.wikipedia.org/wiki/Colonialism

Vyas, D. A. , Eisenstein, L. G., Jones, D. S. (2020) Hidden in Plain Sight - Reconsidering the Use of Race Correction in Clinical Algorithms N Engl J Med 2020 Vol. 383 Issue 9 Pages 874-882. The full article can be accessed at: https://www.nejm.org/doi/full/10.1056/NEJMms2004740

Cruess, S. R., Johnston, S., & Cruess, R. L. (2004). "Profession": a working definition for medical educators. Teaching and learning in medicine, 16(1), 74–76. https://doi-org.proxy.library.vcu.edu/10.1207/s15328015tlm1601_15

Gameon, J. A., & Skewes, M. C. (2020). A Systematic Review of Trauma Interventions in Native Communities. American journal of community psychology, 65(1-2), 223–241. https://doi.org/10.1002/ajcp.12396

Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (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 of the United States of America, 113(16), 4296–4301. https://doi.org/10.1073/pnas.1516047113

Lazar, A. (2021). La operación: Coerced Sterilization of Puerto Rican Women in the 20th Century and the Complexity of Free Choice. https://digitalworks.union.edu/cgi/viewcontent.cgi?article=3530&context=theses Accessed 5/7/2022

Miller, F. and Miller, P. (2021) Transgenerational trauma and trust restoration. AMA Journal of Ethics. 23(6): E480-486. Doi:10.1001/amajethics.2021.480.

Patel, R. and Nagata, D. (2021) Historical trauma and descendants' wellbeing. AMA Journal of Ethics. 23(6): E487-493. Doi: 10.1001/amajethics.2021.487

Perez-Rodriguez, J., & de la Fuente, A. (2017). Now is the Time for a Postracial Medicine: Biomedical Research, the National Institutes of Health, and the Perpetuation of Scientific Racism. The American journal of bioethics: AJOB, 17(9), 36–47. https://doi-org.proxy.library.vcu.edu/10.1080/15265161.2017.1353165

Powell, W., Richmond, J., Mohottige, D., Yen, I., Joslyn, A., & Corbie-Smith, G. (2019). Medical mistrust, racism, and delays in preventive health screening among African-American men. Behavioral Medicine, 45(2), 102-117.

Schmidt, H., Roberts, D. E., & Eneanya, N. D. (2022). Rationing, racism and justice: advancing the debate around 'colourblind' COVID-19 ventilator allocation. Journal of medical ethics, 48(2), 126–130. https://doiorg.proxy.library.vcu.edu/10.1136/medethics-2020-106856

Schulman, K. A., Berlin, J. A., Harless, W. et al (1999) The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med 340, 618-26 https://www.nejm.org/doi/full/10.1056/nejm199902253400806

Smedley, B.D., Stith, A.Y., Nelson, A.R. (Eds) (2003) Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Washington (DC): National Academies Press (US); 2003.PMID: 25032386, Bookshelf ID: NBK220358, DOI: 10.17226/12875

Spector‐Bagdady, K., & Lombardo, P. A. (2019). US Public health service STD experiments in Guatemala (1946–1948) and their aftermath. Ethics & Human Research, 41(2), 29-34. https://onlinelibrary.wiley.com/doi/10.1002/eahr.500010)

Warren, R. C., Shedlin, M. G., Alema-Mensah, E., Obasaju, C., & Hodge Sr, D. A. (2019). Clinical trials participation among African Americans and the ethics of trust: Leadership perspectives. Ethics, Medicine and Public Health, 10, 128-138.

Warren, R. C., Forrow, L., Hodge Sr, D. A., & Truog, R. D. (2020). Trustworthiness before trust—Covid-19 vaccine trials and the Black community. New England Journal of Medicine, 383(22), e121.

Williams, R. L., Vasquez, C. E., Getrich, C. M., Kano, M., Boursaw, B., Krabbenhoft, C., & Sussman, A. L. (2018). Racial/Gender Biases in Student Clinical Decision-Making: a Mixed-Method Study of Medical School Attributes Associated with Lower Incidence of Biases. Journal of general internal medicine, 33(12), 2056–2064. https://doi-org.proxy.library.vcu.edu/10.1007/s11606-018-4543-2

Delgado, R., & Stefancic, J. (2017). Critical race theory. New York University Press.

DiAngelo, R. (2018). White fragility: Why it's so hard for white people to talk about racism. Beacon Press. Hooks, b., Mesa-Bains, A. (2006) Homegrown: engaged cultural criticism. Cambridge, MA: South End Press

McIntosh, P. (1989) White Privilege: Unpacking the Invisible Knapsack, Peace and Freedom https://psychology.umbc.edu/files/2016/10/White-Privilege_McIntosh-1989.pdf (accessed 5/7/22)

Morgan, K.P. (1996) Describing the Emperor's New Clothes: Three Myths of Educational (In-)Equity ImprintRoutledge, eBook ISBN9780429496530

Romano, M. J. (2018). White privilege in a white coat: how racism shaped my medical education. The Annals of Family Medicine, 16(3), 261-263

Watts, R. J. (2003). Race consciousness and the health of African Americans. Online Journal of Issues in Nursing, 8(1).

Hagiwara, N., Lafata, J. E., Mezuk, B., Vrana, S. R., & Fetters, M. D. (2019). Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: challenges, solutions, and future directions for provider communication training. Patient education and counseling, 102(9), 1738-1743.

Hess, L., Palermo, A. G., & Muller, D. (2020). Addressing and undoing racism and bias in the medical school learning and work environment. Academic Medicine, 95(12S), S44-S50.

Johnson-Agbakwu, C. E., Ali, N. S., Oxford, C. M., Wingo, S., Manin, E., & Coonrod, D. V. (2020). Racism, COVID-19, and Health Inequity in the USA: a Call to Action. Journal of racial and ethnic health disparities, 1-7.

Ricks, T. N., Abbyad, C., & Polinard, E. (2021). Undoing racism and mitigating bias among healthcare professionals: Lessons learned during a systematic review. Journal of racial and ethnic health disparities, 1-11.

Sim, W., Lim, W. H., Ng, C. H., Chin, Y. H., Yaow, C. Y. L., Cheong, C. W. Z., ... & Chong, C. S. (2021). The perspectives of health professionals and patients on racism in healthcare: A qualitative systematic review. PloS one, 16(8), e0255936.

Abrams, Z. (2022, January). Prominent issues in health care: Racial bias and inequities. Monitor on Psychology, 53(1). https://www.apa.org/monitor/2022/01/special-prominent-issues

Burke, S. E., Dovidio, J. F., Perry, S. P., Burgess, D. J., Hardeman, R. R., Phelan, S. M., Cunningham, B. A., Yeazel, M. W., Przedworski, J. M., & van Ryn, M. (2017). Informal Training Experiences and Explicit Bias against African Americans among Medical Students. Social Psychology Quarterly, 80(1), 65–84. https://doi.org/10.1177/0190272516668166

Goleman, Daniel (1996). Emotional Intelligence: Why It Can Matter More Than IQ. Bantam Books.

Griffith, D.M., Mason, M., Yonas, M. et al. Dismantling institutional racism: theory and action. Am J Community Psychol 39, 381–392 (2007). https://doi.org/10.1007/s10464-007-9117-0

Nixon, S.A. The coin model of privilege and critical allyship: implications for health. BMC Public Health 19, 1637 (2019). https://doi.org/10.1186/s12889-019-7884-9

Penner LA, Blair IV, Albrecht TL, Dovidio JF. Reducing Racial Health Care Disparities: A Social Psychological Analysis. Policy insights from the behavioral and brain sciences. 2014;1(1):204-212. doi:10.1177/2372732214548430

Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. John Wiley & Sons.

The Science of Equality Volume 1: Addressing Implicit Bias, Racial Anxiety, and Stereotype Threat in Education and Health Care. (2014). In Medical Benefits (Vol. 31, Issue 23, p. 12–). Aspen Publishers, Inc.

Cheung, F., Ganote, C. M., & Souza, T.J. (2016). Microaggressions and microresistance: Supporting and empowering students. Faculty Focus Special Report: Diversity and Inclusion in the College Classroom. Magna Publication. http://ww1.facultyfocus.com/register/free-reports/main.html?product_id=520 .

Freeman, L., & Stewart, H. (2018). Microaggressions in clinical medicine. Kennedy Institute of Ethics Journal, 28(4), 411-449.

Overland, M. K., Zumsteg, J. M., Lindo, E. G., Sholas, M. G., Montenegro, R. E., Campelia, G. D., & Mukherjee, D. (2019). Microaggressions in clinical training and practice. Pm&r, 11(9), 1004-1012.

Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. John Wiley & Sons.

Sue, D. W., Alsaidi, S., Awad, M. N., Glaeser, E., Calle, C. Z., & Mendez, N. (2019). Disarming racial microaggressions: Microintervention strategies for targets, White allies, and bystanders. American Psychologist, 74(1), 128.

Discrimination. Amnesty International. (2021, June 1). Retrieved from https://www.amnesty.org/en/what-we-do/discrimination/

History.com Staff. (2018, August 24). Chinese Exclusion Act. History.com. Retrieved from https://www.history.com/topics/immigration/chinese-exclusion-act-1882

Indian Removal Act, S. 102, 21st Cong. (1930). A Century of Lawmaking for a New Nation: U.S. Congressional Documents and Debates, 1774 - 1875 (21AD). The Library of Congress. Retrieved from https://memory.loc.gov/cgi-bin/ampage?collId=llsl&fileName=004/llsl004.db&recNum=458 .

Lang, K., & Kahn-Lang Spitzer, A. (2020). Race Discrimination: An Economic Perspective. Journal of Economic Perspectives, 34(2), 68–89.

Lewsley, J., & White, M. (2020, July 28). The effects of racism on health and mental health. Medical News Today. Retrieved from https://www.medicalnewstoday.com/articles/effects-of-racism#adults

MacIntosh T, Desai MM, Lewis TT, Jones BA, Nunez-Smith M (2013). Socially-Assigned Race, Healthcare Discrimination and Preventive Healthcare Services. PLoS ONE 8(5): e64522. doi:10.1371/journal.pone.0064522

Mejia, M. (2021, July 18). The U.S. history of Native American Boarding Schools. The Indigenous Foundation. Retrieved from https://www.theindigenousfoundation.org/articles/us-residential-schools

Nieblas-Bedolla, Edwin MPH; Christophers, Briana; Nkinsi, Naomi T.; Schumann, Paul D.; Stein, Elizabeth (2020). Changing How Race Is Portrayed in Medical Education: Recommendations From Medical Students, Academic Medicine: December 2020 - Volume 95 - Issue 12 - p 1802-1806 doi: 10.1097/ACM.0000000000003496

Pascoe, E., & Richman, L. (2009). Perceived Discrimination and Health: A Meta-Analytic Review. Psychological Bulletin, 135(4), 531–554.

Roediger, D. (2021, December 16). Historical Foundations of Race. National Museum of African American History and Culture. Retrieved from https://nmaahc.si.edu/learn/talking-about-race/topics/historical-foundations-race

Sabin, J. A., Nosek, B. A., Greenwald, A. G., & Rivara, F. P. (2009). Physicians’ implicit and explicit attitudes about race by MD race, ethnicity, and gender. Journal of Healthcare for the Poor and Underserved, 20, 896-913.

Shah, K., & Adolphe, J. (2019, August 16). 400 years since slavery: A timeline of American history. The Guardian. Retrieved from https://www.theguardian.com/news/2019/aug/15/400-years-since-slavery-timeline

Small, M., & Pager, D. (2020). Sociological Perspectives on Racial Discrimination. Journal of Economic Perspectives, 34(2), 49–67.

Smedley BD, Stith AY, Nelson AR, editors (2003) Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press.764 p.

Chou C., Pearlman E., Risdon. 2014 Understanding Difference and Diversity in the Medical Encounter: Communication Across Cultures. DocCom Module 15 https://webcampus.med.drexel.edu/DocCom/

Deliz, J. R., Fears, F. F., Jones, K. E., Tobat, J., Char, D., & Ross, W. R. (2020). Cultural competency interventions during medical school: a scoping review and narrative synthesis. Journal of general internal medicine, 35(2), 568-577.

Foronda, C. (2020). A theory of cultural humility. Journal of Transcultural Nursing, 31(1), 7-12.

Josiah Macy Jr. Foundation. (2018). Improving environments for learning in the health professions. Retrieved from https://macyfoundation.org/assets/reports/publications/macy_mono-graph_2018_webfile.pdf

Leininger, M. M. (1988). Leininger’s theory of nursing: Cultural care diversity and universality. Nursing Science Quarterly, 1, 152-160.

Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9, 117-125. doi:10.1353/hpu.2010.0233

Yeager, K. A., & Bauer-Wu, S. (2013). Cultural humility: Essential foundation for clinical researchers. Applied Nursing Research, 26, 251-256. doi:10.1016/j.apnr.2013.06.008

Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. https://health.gov/healthypeople/objectives-and-data/social-determinants-health

Johnson, G. (2020). COVID-19’s assault on Black and Brown communities. Penn Today.

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States; Baciu A, Negussie Y, Geller A, et al., editors. Communities in Action: Pathways to Health Equity. Washington (DC): National Academies Press (US); 2017 Jan 11. 3, The Root Causes of Health Inequity. Available from: https://www.ncbi.nlm.nih.gov/books/NBK425845/

Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., ... & Gee, G. (2015). Racism as a determinant of health: a systematic review and meta-analysis. PloS one, 10(9), e0138511.

Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html

Tiwari, T., Palatta, A., Stewart, J., Guidelines, P. M., & Evidence Standards Working Group. (2020). What is the Value of Social Determinants of Health in Dental Education?. NAM perspectives, 2020.

WHO. https://www.who.int/about/governance/constitution

Child trends. https://www.childtrends.org/wp-content/uploads/2019/09/RacialEthnicEquityPerspective_ChildTrends_October2019.pdf

Child trends. https://www.childtrends.org/publications/five-guiding-principles-for-integrating-racial-and-ethnic-equity-in-researchhttps://www.childtrends.org/publications/five-guiding-principles-for-integrating-racial-and-ethnic-equity-in-research

Hardeman, R., Medina, E., & Kozhimannil, K. B. (2016). Dismantling structural racism, supporting Black lives, and achieving health equity: The role of health professionals. New England Journal of Medicine, 375(22), 2113–2115.

Heeju Sohn (2017). Racial and Ethnic Disparities in Health Insurance Coverage: Dynamics of Gaining and Losing Coverage over the Life-Course. Population Research Policy Review. 36(2): 181–201

Konkel L. (2015). Racial and Ethnic Disparities in Research Studies: The Challenge of Creating More Diverse Cohorts. Environmental health perspectives, 123(12), A297–A302. https://doi.org/10.1289/ehp.123-A297

Metzl, J. M., & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science and Medicine, 103, 126–133. https://doi.org/10.1016/j.socscimed.2013.06.032

Neff, J., Holmes, S. M., Knight, K. R., Strong, S., Thompson-Lastad, A., McGuinness, C., ... & Nelson, N. (2020). Structural competency: curriculum for medical students, residents, and interprofessional teams on the structural factors that produce health disparities. MedEdPORTAL, 16, 10888. Structural competency: Curriculum for medical students, residents, and interprofessional teams on the structural factors that produce health disparities.

Vyas, D. A. , Eisenstein, L. G., Jones, D. S. (2020) Hidden in Plain Sight - Reconsidering the Use of Race Correction in Clinical Algorithms N Engl J Med 2020 Vol. 383 Issue 9 Pages 874-882. The full article can be accessed at: https://www.nejm.org/doi/full/10.1056/NEJMms2004740

Abby Ellin (2021). 'Death Doulas' Provide Aid at the End of Life (Links to an external site.). The New York Times.

Ada Stewart (2019). Cultural Humility Is Critical to Health Equity (Links to an external site.). American Academy of Family Physicians.

Amutah, C., Greenidge, K., Mante, A., Munyikwa, M., Surya, S. L., Higginbotham, E., ... & Aysola, J. (2021). Misrepresenting race—the role of medical schools in propagating physician bias. New England Journal of Medicine, 384(9), 872-878.Vyas D, Eisenstein L, Jones D, Hidden in Plain Sight – Reconsidering the Use of Race Correction in Clinical Algorithms, NEJM, 2020, DOI: 10.1056/NEJMms2004740

Cahn, P. S. (2020). How interprofessional collaborative practice can help dismantle systemic racism. Journal of Interprofessional Care, 34(4), 431-434.

Garran, A. M., & Rasmussen, B. M. (2019). How should organizations respond to racism against health care workers?. AMA Journal of Ethics, 21(6), 499-504.

Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative.

Legha, R. K., & Miranda, J. (2020). An anti-racist approach to achieving mental health equity in clinical care. Psychiatric Clinics, 43(3), 451-469.

Paul-Emile, K. (2019). How should organizations support trainees in the face of patient bias?. AMA journal of ethics, 21(6), 513-520.

Paul-Emile, K., Smith, A. K., Lo, B., & Fernández, A. (2016). Dealing with racist patients. New England J. Med., 374, 708.

Kendi, Ibram X. How to Be an Antiracist. New York, NY: One World, 2019.

Roberts, D. (2011). Fatal invention: How science, politics, and big business re-create race in the twenty-first century. New Press/ORIM.

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of health care for the poor and underserved, 9(2), 117-125.

Tressie McMillan Cottom (2019). "I Was Pregnant and in Crisis. All the Doctors and Nurses Saw Was an Incompetent Black Woman." (Links to an external site.) Time.

World Professional Association for Transgender Health (WPATH) (2012). Standards of Care, Version 7 (Links to an external site.).

Anne Bishop, Becoming an Ally, 3rd Edition: Breaking the Cycle of Oppression in People. Fernwood Publishing, Halifax, 2015

Atcheson, S. (2018). Allyship-The Key To Unlocking The Power Of Diversity. Forbes Magazine.

Burack, J.H., Irby, D.M., Carline, J.D., Root,R.K., and Larson, E. B. (1999) Teaching Compassion and Respect: Attending Physicians’ Responses to Problematic Behaviors. J Gen Intern Med. 14(1): 49–55.

Brown, K. T., & Ostrove, J. M. (2013). What does it mean to be an ally?: The perception of allies from the perspective of people of color. Journal of Applied Social Psychology, 43(11), 2211-2222.

Cihangir, S., Barreto, M., & Ellemers, N. (2014). Men as allies against sexism: The positive effects of a suggestion of sexism by male (vs. female) sources. Sage Open, 4(2), 2158244014539168.

Medium.com; Holiday Phillips May 9, 2020

Sue, D.W., Alsaidi, S., Awad, M.N., Glaeser, E., Calle, C.Z., Mendez, N. (2019) Disarming Racial Microaggressions: Microintervention Strategies for Targets, White Allies, and Bystanders American Psychologist 74, 128–142