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GRAD 219 Course – The Black Experience in American Medicine – Week 1

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This is a guest post by Nebat Ali, PhD Candidate, UCSF Biomedical Sciences (BMS) Program

The readings from this past week displayed the many ways racist practices dating back to the era of slavery continue to permeate our scientific and medical institutions to this day. The harm caused as a result of failing to address the racist practices within these systems can be even more damaging when considering the pretense of objectivity they’re presented under. We are taught that science is built on integrity and our practices are free of bias when in fact many scientific and medical policies are rooted in racist ideologies. It’s also interesting to consider how our institutions are built to reward these practices. There are scientists who have been able to build their careers on the basis of attributing disease outcomes and biological observations to race. This erasure of the racist policies and socioeconomic factors that drastically impact a person’s biology and wellbeing is incredibly damaging and only takes us further from addressing the true source of health disparities in the first place. When findings from these works are translated and applied in the clinic as a means to save time and allow doctors to see more patients, they can result in misdiagnoses and delay medical intervention, ultimately causing more harm to groups that are already marginalized.

As a Black immigrant the basis of these practices is something I’ve thought about a lot as my family and I navigate the healthcare system here in the US. As someone who also has the privilege of having lighter skin, I also think a lot about how colorism and internalized racism in the context of healthcare can additionally impact one’s health and wellbeing. An individual’s proximity to whiteness and the way that is perceived by a physician or healthcare worker can have a strong influence on the nature and quality of the care they receive. Furthermore, institutional race-based practices likely reinforce internalized racism in health care providers, further compounding the harm done to Black and marginalized groups as a result.

GRAD 219 Course – The Black Experience in American Medicine – Week 1

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This is a guest post by Natasha Puri, PhD Candidate, UCSF Tetrad Graduate Program

In this class we have focused more on racism in medicine, but it has encouraged me to apply what we have talked about to research as well. When I read the very first paper for our class, Racial Categories in Medical Practice; How Useful are They? in PLoS Medicine, one thing that stood out to me was the author list. Many of the authors were experts and/or students in both STEM subjects like Cellular and Molecular Biology, Biochemistry, and so on as well as in fields like African American Studies, Women Studies, or Sociology. Many biologists like to think that they are searching for fundamental truths, but how honest are these when they are not considered within the context of our society? An example that comes to mind is the Covid vaccine. I hear people in my field talk about the vaccines simply as this amazing scientific achievement. And yes, the fact that the vaccines are so effective and started being distributed in the US so early is remarkable. But what is glaringly less spoken about in these circles is the inequities in the distribution of this life-saving scientific achievement, why many people of color have been unable to access the vaccine, or the reasons why some have been hesitant to get it. I think that it is too easy for scientists to brush off the people who don’t trust science, but we need to look more deeply into the roots of the distrust, and be more active in making research accessible, and transparent too. The paper also mentioned epidemiologists and other scientists who propose multi-level models for understanding racial disparities in health outcomes, from society to an individual’s lifestyle to the cellular level. This supports the idea that a holistic and interdisciplinary education is so valuable, especially when studying in health and medicine-related fields.

My last thought is that if we are to continue to educate ourselves and improve the health outcomes of historically marginalized groups, this research and others that focus on racism in medicine and science need to be well-supported and well-funded. That means that this research must get support in particular from faculty and research institutions themselves. While it is invaluable (and necessary) for medical and PhD students to learn the painful story of the Black experience in science and medicine, our professors need to learn these truths as well. I hope that Universities can start making more classes like this available not only to students, but available and mandatory for faculty as well.

GRAD 219 Course – The Black Experience in American Medicine – Week 2

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This is a guest post by Aris Tay, PhD Candidate, Bruce Wang and Diana Laird Labs, Developmental and Stem Cell Biology (DSCB), UCSF

Watching “Belly of the Beast: survivors of forced sterilizations in California’s prisons fight for justice” from an intersectional lens reminded me of social Darwinism. The theory of natural selection and survival of the fittest permeates biology and ecology. Faster lions are better at catching prey and thus are more likely to survive, so of course lions as a whole would prefer to select for speed and athletic prowess. However, does this apply to human society? It is theorized that humans implicitly select for attractiveness when choosing a partner and as a result the human race has supposedly gotten more attractive over the centuries. But with the industrial revolution, betterment of healthcare, and resultant increase in lifespan and quality of life, several “less fit” traits have been allowed to remain in the gene pool. There are several diseases, with genetic causes or predispositions, that are typically fatal without treatments. If these people died of such a disease, then the genetic mutation would not be passed on and eventually dwindle out from the gene pool. However, we are now able to treat such a disease and thus the mutation stays. 

From a purely logical, theoretical, and utilitarian standpoint, human society would probably be more “fit” if the people carrying these mutations were not treated and died. And because Darwinism and social Darwinism is such an accepted and prevalent theory in the medical community, parents undergoing in vitro fertilization are recommended to choose the embryo without any genetic mutation or harmful predispositions. Many disabilities, such as blindness, deafness, autism, and achondroplasia, are symptoms of or outright caused by genetics and are theoretically preventable during in vitro fertilization. However, many people in the disabled community take pride in their disability and the culture that has been created around it, not entirely unlike black American culture. If a medical professional did not discuss with the patients and chose to implant the undiseased embryo as opposed to one with a genetic mutation that could result in deafness, would this be equivalently morally reprehensible as the forced sterilization of incarcerated black women? Would this take society a step closer to eugenics? 

GRAD 219 Course – The Black Experience in American Medicine – Week 2

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This is a guest post by Karissa Hansen, Ph.D. Candidate, UCSF Developmental and Stem Cell Biology (DSCB) Program

During class this week, one major topic of conversation was the forced sterilization of incarcerated individuals in California, often people of color, along with the eugenic principles that this thinking perpetuates. Dr. James Heinrich, an OB-GYN at one of these prisons, was quoted in an NPR article1 claiming that the amount of money spent on these procedures was minimal “compared to what you save in welfare paying for these unwanted children–as they procreated more.” My jaw dropped when I read this horribly prejudiced statement. Every individual is entitled to personal bodily autonomy. Although he appears to be referring to surgeries that were completed voluntarily, when a person in a powerless position is under coercive pressure, there clearly cannot be consent.

 Although the forced sterilizations in the prison system being discussed are said to have occurred between the years of 2006-2010, such atrocities were occurring long before and continue today. In September 2020, a nurse working at a US Immigration and Customs Enforcement center in Georgia alleged that detained women were undergoing similar procedures, including unnecessary hysterectomies2. As of December, more than 40 individuals had submitted written testimony in a legal petition against the facility3.

So where do we go from here? I don’t have a good answer. Shutting down one problematic facility doesn’t prevent such procedures from happening at a dozen more. We are clearly unable to rid this system of the discriminatory beliefs it was built upon. As we’ve discussed, the roots of the issue must be addressed—and there are many.

References:

  1. Chappell, Bill. “California’s Prison Sterilizations Reportedly Echo Eugenics Era.” NPR, 9 July 2013, www.npr.org/sections/thetwo-way/2013/07/09/200444613/californias-prison-sterilizations-reportedly-echoes-eugenics-era.
  2. Narea, Nicole. “The Outcry over ICE and Hysterectomies, Explained.” Vox, 15 Sept. 2020, www.vox.com/policy-and-politics/2020/9/15/21437805/whistleblower-hysterectomies-nurse-irwin-ice.
  3. Bekiempis, Victoria. “More Immigrant Women Say They Were Abused by ICE Gynecologist.” The Guardian, Guardian News and Media, 22 Dec. 2020, www.theguardian.com/us-news/2020/dec/22/ice-gynecologist-hysterectomies-georgia.

GRAD 219 Course – The Black Experience in American Medicine – Week 1

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This is a guest post by Cambria Chou-Freed, Ph.D. Candidate, UCSF Biomedical Sciences (BMS) Program

This week, I was very interested in our class discussions about how race is used as a variable in medicine/biomedical research and about the contexts in which this might exacerbate vs. combat health inequities. I especially appreciated the UCSF debates over the use of genetic ancestry vs. race in eGFR and polygenic risk score calculations. What stuck with me was the question: how can we, as scientists and physicians, feel comfortable using race as a variable in the same way we use quantitative, measurable variables (ex: blood cell or RNA transcript counts) to make research claims and clinical diagnoses? We know that race is an inaccurate proxy for genetic ancestry in many cases. Furthermore, when we want to use race as a proxy for social factors, I wonder whether in the future we will move toward incorporating other, more precise variables instead (such as to what degree a person experiences racism in their life, or what neighborhood they live in, an example given in class). As a mixed-race person, it has always made intuitive sense to me that race is not clearly defined or discrete, even when I didn’t have the words or data to back this up. Similarly to what Dr. Grubbs argued in the debate, I wonder how researchers would calculate my risk for polygenic diseases if I don’t fit accurately or precisely into their race-based model?

Another question that came up in class is how epigenetics might be used in medicine/biomedical research. Epigenetic marks are thought to encode experiences and environmental factors such as trauma and stress at the molecular level, and there is evidence that epigenetic changes to DNA can be passed on through multiple generations. Many people see epigenetics as an opportunity to study the effects of social factors such as racism on human health, and I certainly see the potential benefits of this. However, I also worry that some people will use epigenetics as the next generation of scientific evidence to back the claim of “biological differences due to race” and that a new form of discrimination could emerge as a result.

GRAD 219 Course – The Black Experience in American Medicine – Week 1

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This is a guest post by LauraAnn Schmidberger, Ph.D. Candidate, UCSF Tetrad Graduate Program

Assuming that the color of someone’s skin explains their life history seems ridiculous when it’s phrased that way, but it is easy to see how doctors can fall into the trap of using racial categories in their practice, especially given the pressure to assess their patients quickly. This article made me think of racial profiling—it is understandable that authorities would want a quick way to identify potential suspects, but to conflate race with the likelihood of committing a crime is inappropriate. Race is a much less important factor in both community safety and medicine than socioeconomic, geographic, and familial backgrounds. The author makes it clear that while taking the time to understand a patient’s background may not be as rapid, it is ultimately more efficient, because it will lead to fewer misdiagnoses.  False assumptions about a patient’s condition based on their outward appearance increases the time it takes for an accurate diagnosis, which in the worst cases can be deadly. A country largely segregated by not only race but also geography and socioeconomic status became a country in which the three were conflated and each race was assumed homogenous, when in reality our communities have never been more diverse. Each person has a unique background, and “if a physician simply diagnoses ‘race,’” that background, including “environmental exposures, family histories, the stress of dealing with racism, access to and quality of care [,] may be left unexamined.”

GRAD 219 Course – The Black Experience in American Medicine – Week 1

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This is a guest post by Mariko Foecke, Ph.D. Candidate, UCSF Biomedical Sciences (BMS) Program & Eliza Gaylord, Ph.D. Candidate, UCSF Developmental and Stem Cell Biology (DSCB) Program

Despite the profound advancements achieved by modern medicine, people with ovaries in the United States were at a 10% greater risk of dying from a pregnancy-related death (PRD) in 2017 than they were in 19871. Strikingly, this risk is even greater for the BIPOC community, as Black people with ovaries account for 41.7% of PRDs. This statistic is three times higher than PRD rates for White people with ovaries1. The Centers for Disease Control defines a PRD as “the death of a woman during pregnancy or within one year of the end of pregnancy from a pregnancy complication; a chain of events initiated by pregnancy; or the aggravation of an unrelated condition by the physiologic effects of pregnancy”2.

Recent research highlights variables that may contribute to disparities in PRDs for people of color, such as quality of and access to care, implicit bias, and psychological stress induced by structural racism1. Examination of disparities in PRDs across socioeconomic and educational backgrounds identified that African Americans with ovaries with at least a college degree were 5.2 times more likely to suffer a PRD than White people with ovaries with the same level of education. Furthermore, the mortality rate of infants of college-educated African American people with ovaries was 3.1 times higher than infants of high school or less-educated White people with ovaries3. Thus, as disparities in PRD and infant mortality rates continue to rise, there is a critical need to understand the physiological impact of social determinants of health during pregnancy and their potentially multigenerational effects.

African Americans with ovaries experience high levels of physiological stress due to social discrimination and systemic racism4. Additionally, racial discrimination is directly correlated with higher levels of depression14, a known consequence of stress15. For decades, it has been appreciated anecdotally that both pre-pregnancy and maternal stress contribute to adverse health and infant birth outcomes5. Maternal stress during pregnancy may lead to high blood pressure and changes in dietary intake, increasing the risk for gestational diabetes, preterm labor, and preeclampsia16. Additionally, exposure to physiological stress after pregnancy may lead to postpartum depression or substance abuse17, accounting for an estimated 14% – 30% of reported maternal deaths18. 

Concurrently, recent research has gleaned insights into the mechanisms underlying how the negative effects of maternal stress may persist for up to three generations6-8. In response to stress, fertility is known to decline as a consequence of a diminished ovarian reserve, which encompasses the quantity and quality of ovarian egg cells, or oocytes9,10. The incidence of oocyte aneuploidy, referring to an abnormal number of chromosomes, increases in response to maternal stress and is a known cause of infertility and disease11. Importantly, of the 10% of individuals with ovaries who struggle with fertility in the United States, 15% of them are affected by oocyte aneuploidy12. In fact, aneuploidy occurs in 5% of all clinically recognized pregnancies and is causal in 1 in 3 miscarriages13. 

As the connection between physiological stress and poor health and infant outcomes, particularly for Black women, become increasingly clear, there is a dire need for immediate and effective action to close the persistent PRD and infant mortality gaps. In addition to implementing policy designed to protect vulnerable populations from stressful, discriminatory experiences in professional and higher education environments3, implicit bias training for healthcare professionals should be required to decrease disparities in prenatal and postpartum care19. Finally, legislation to provide federal support that increases access to mental health care and social services specifically to people of color with ovaries before, during, and after pregnancy19 is necessary to reduce this devastating maternal health crisis. 

Bibliography:

  1. Pregnancy Mortality Surveillance System. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. (2019).
  2. Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths. Centers for Disease Control and Prevention. (2019).
  3. Fishman SH, Hummer RA, Sierra G, Hargrove T, Powers DA, Rogers RG. Race/ethnicity, maternal educational attainment, and infant mortality in the United States. Biodemography Soc Biol. (2020).
  4. Howard JT, Sparks PJ. The role of education in explaining racial/ethnic allostatic load differentials in the United States. Biodemography Soc Biol. (2015).
  5. Dole N, Savitz DA, Hertz-Picciotto I, Siega-Riz AM, McMahon MJ, Buekens P. Maternal stress and preterm birth. Am J Epidemiol. (2003).
  6. Crews D, Gillette R, Scarpino SV, Manikkam M, Savenkova MI, Skinner MK. Epigenetic transgenerational inheritance of altered stress responses. Proc Natl Acad Sci U S A. (2012).
  7. Ward ID, Zucchi FC, Robbins JC, et al. Transgenerational programming of maternal behaviour by prenatal stress. BMC Pregnancy Childbirth. (2013).
  8. Kiss D, Ambeskovic M, Montina T. et al. Stress transgenerationally programs metabolic pathways linked to altered mental health. Cell. Mol. Life Sci. (2016).
  9. De Felici M, Klinger FG, Farini D, Scaldaferri ML, Iona S, Lobascio M. Establishment of oocyte population in the fetal ovary: primordial germ cell proliferation and oocyte programmed cell death. Reprod Biomed Online. (2005).
  10. Broekmans FJ, Soules MR, Fauser BC. Ovarian aging: mechanisms and clinical consequences. Endocr Rev. (2009).
  11. Mikwar M, MacFarlane AJ, Marchetti F. Mechanisms of oocyte aneuploidy associated with advanced maternal age. Mutat Res. (2020).
  12. Eisenberg E, Brumbaugh K, Brown-Bryant R, Warner L. Health topics: infertility. Office on Women’s Health in the U.S. Department of Health and Human Services. (2019).
  13. Hassold T, Hunt P. To err (meiotically) is human: the genesis of human aneuploidy. Nat Rev Genet. (2001).
  14. Hudson DL, Puterman E, Bibbins-Domingo K, Matthews KA, Adler NE. Race, life course socioeconomic position, racial discrimination, depressive symptoms and self-rated health. Soc Sci Med. (2013).
  15. van Praag HM. Can stress cause depression? World J Biol Psychiatry. (2005).
  16. Stress and Pregnancy. March of Dimes. (2019).
  17. Postpartum Depression. Office on Women’s Health in the U.S. Department of Health and Human Services. (2019).
  18. Maternal Mortality May Be Even Higher Than We Thought. Columbia University Irving Medical Center. (2019).
  19. Bailey SR. Our Black maternal health crisis is an American tragedy. American Medical Association. (2021).

GRAD 219 Course – The Black Experience in American Medicine – Week 1

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This is a guest post by Jackie Roger, Ph.D. Candidate, UCSF Program in Bioinformatics (BI)

Towards the end of this past week, several of the readings and videos discussed the intersection of racism and OB-GYN. We learned about the medical experimentation on black women’s bodies (Linda Villarosa’s article in NYT), the mutilation and subsequent museum display of Sara Baartman’s genitalia (Dr. Deirdre Cooper Owens’s talk on Youtube), and the black maternal health crisis (Dr. Susan R. Bailey article on the AMA site). These examples illustrate how the historical legacies of anti-black racism are embedded in present-day OB-GYN research and medicine. One component of this is disparities in the maternal mortality rate, which was the focus of Dr. Bailey’s piece.

She described two initiatives to reduce this disparity: the MOMMA Act to extend coverage for post-partum care and the Release the Pressure campaign to promote heart health and healthy blood pressure. The MOMMA Act seems like a good start, and could reduce both overall maternal mortalities and the racial disparities in maternal mortalities. The Release the Pressure campaign calls upon black people to take steps in their own lives to improve their heart health (since heart disease is one of the leading causes of pregnancy-related death). There are so many aspects of systemic anti-black racism within the medical system and beyond that directly contribute to increased risk of heart disease. A campaign that asks them to offset these things by “taking a few more steps a day” etc seems insulting. I think that truly addressing disparities in OB-GYN will require structural changes in the healthcare system.

GRAD 219 Course – The Black Experience in American Medicine – Week 1

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This is a guest post by Aris Tay, PhD Candidate, Bruce Wang and Diana Laird Labs, Developmental and Stem Cell Biology (DSCB), UCSF

In session 3 of UCSF’s racism and race: the use of race in medicine and implications for health equity discussion, as well as many other works centered around race in medicine, it was mentioned that race, as we use it colloquially, is a social construct. Due to my own identity, I often think about how gender is a social construct and how scientists often use the two terms sex and gender to separate out what is and is not scientifically and empirically biological and hard-wired. However, until this course I had not made the connection that race and racial identity is a social construct just like how gender is.

In many large scale observational genetic studies, specific genetic signatures (typically single nucleotide polymorphisms) are often found to be associated and even predicative for certain diseases. These genetic signatures are often correlated with self-identified racial groups. Thus, the field has often incorrectly assumed that race causes these genetic signatures which leads to a predisposition for disease, and that this is why I often hear statements such as “Tay-Sachs is most common is Ashkenazi Jews” or “Sickle cell anemia is more common in black people”. However, it is difficult, in these large observational studies, to separate lifestyle, family history, etc from the check box self-identified categories that patients are asked to bin themselves into. Self-identified categories of gender and race are much easier to draw correlations from; however, it is now coming to light that detailed family history and lifestyle is much more accurate. Social constructs of gender and race often make up core aspects of someone’s identify. This will definitely affect one’s choices and lifestyle which could then affect which diseases one is predisposed to. However, jumping directly from A to C eliminates a large majority of people that did not follow the most common path, thus disenfranchising them from receiving accurate medical care. Eliminating social constructs from medical treatment and diagnosis is an endeavor that the entire field should embark on.

On the other hand, when it comes to recruiting participants for large scale observational studies, clinical trials, etc. whether or not social constructs such as gender and racial identity should be accounted for is an outstanding question. Using clinical trials as an example, ensuring that the proposed experimental treatment works well on all races and genders is of utmost importance and has often been overlooked in historical trials. However, would using lifestyle in order to recruit not serve the same purpose? And be more accurate? Would taking detailed history and lifestyle cause too much strain during recruitment and completely offset its advantages? Would statistics be too difficult to run on family history and lifestyle when we know it’s possible and established using gender and racial identity. I leave you with some food for thought.

GRAD 219 Course – The Black Experience in American Medicine

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This is a guest post by Antoine S. Johnson, Ph.D. Candidate, UCSF History of Health Sciences.

The 2020 police killings of Breonna Taylor and George Floyd facilitated important dialogue about racism being a public health issue. It also led to myriad student demands at college campuses throughout the nation, including at UCSF. Students demanded course curriculum addressing racism in science and medicine, with the hopes that such information and classes would be integrated in their field. One of the results were Grad 202: Racism in Science, which was taught in the Fall 2020 quarter by Dr. Aimee Medeiros and me. Almost 200 students enrolled in the course, causing us to create two sections. As a Ph.D. candidate in UCSF’s History of Health Sciences program, this was an invaluable experience that allowed me to build community with several students in the class who are now working on an article on the importance of such classes in science programs.

Demand remained high after the class, culminating in mini courses, including this one, that would continue such conversations and answer student requests. Grad 219: The Black Experience in American Medicine, examines ways Black people have not only been the victims of medical racism, but also how they contributed to the creation and expansion of medicine and science; how they have operated in their respected fields; and the harm caused by biological deterministic arguments of so-called racial differences. Although only three weeks long, students will leave this class with an understanding of the medical community’s relationship with African Americans from the antebellum period to the present. From an analytical perspective, this class will foster honest and open conversations about the assigned material. Additionally, students will have the opportunity to share their thoughts on any conversation, reading, video, or observation through weekly blog posts that will be published here, on the UCSF Archives & Special Collection, Brought to Light blog. These are not polished submissions but are rather their takeaways on things that stood out to them. In doing so, they will be able to offer one another constructive feedback by commenting on each other’s posts to continue pertinent conversations.

Thank you, and welcome to Grad 219 Course: The Black Experience in American Medicine.