ABSTRACT
Common approaches to medical and public health pedagogy that are grounded in the biomedical model and social determinants of health theory often fail to address structural racism as a root cause of health inequities.1 Structural racism refers to how societies foster discrimination through inequitable systems.2 These pedagogical approaches tend to promote reductionist views of disease, suggest that social determinants of health are immutable, and neglect the role of White power and privilege in driving unfair differences in health outcomes.1 Critical theoretical frameworks for public health education are needed to enhance understanding of how the field may be failing to address and eliminate health inequities and that contextualize health within power structures that marginalize and oppress.1 With its emphasis on the evolving practice of interrogating the roles of race and racism in society, critical race theory (CRT) is an important framework for informing how and what we teach the next generation of public health leaders to eradicate health inequities and drive social change.3 Striking racial disparities in rates of COVID-19 morbidity and mortality,4 recent surges in cases of police brutality against people of color, and public debate over teaching about racism have brought renewed attention to CRT. KEY TENETS OF CRITICAL RACE THEORY CRT provides a paradigm for equipping public health students with the knowledge and skills needed to recognize and eliminate social structures, practices, and discourses that perpetuate racism and health disparities.1,3,5 Key tenets of CRT include recognizing that race is socially constructed;understanding that racism is embedded throughout institutions, systems, structures, and policies;and embracing the lived experiences of people of color, including their experiences of oppression.1,3 Intersectionality involves conceptualizing and understanding how an individual's multiple marginalized social identities (e.g., related to gender identity, race, socioeconomic status) and intersecting structures of power and inequality shape their worldviews and lived experiences.1,8 Application of CRT to health instruction involves attending to how an individual's or group's unique "layered identities" converge with systems of oppression (e.g., racism, sexism) to better understand their health outcomes.1 APPLICATION TO PUBLIC HEALTH EDUCATION The following are our three teaching recommendations for public health faculty. Are there learning goals or objectives that are explicitly linked to antiracism and equity? A statement in the beginning of a syllabus conveying a commitment to equity and antiracism has been linked to student perceptions of a warm and supportive learning environment.8 This statement can include a proclamation of the instructor's respect for diversity, their expectations with respect to classroom climate, and a note that micro- and macroaggressions will not be tolerated.8 This statement can also be used to contextualize the course readings and materials, such as by acknowledging the subjectivity of science and the potential for overt and covert biases in course material.8,10 Similarly, we should explore how to "decolonize" our public health syllabi by disavowing those structures that reinforce superiority and exclusion, promoting critical consciousness, and centering the public health work of those from marginalized backgrounds.8 Account for Intersectionality Intersectionality is a key aspect of CRT that involves reflecting on identity and its relationship to power.11 Individuals' multiple socially constructed identities (e.g., race, sex, sexual orientation) exist within a matrix characterized by interlocking systems of oppression that may heighten their vulnerability to bias and how they experience that bias.1,8,11 We must define this concept in our course syllabi and commit to teaching approaches that promote "matrix thinking" through interrogation of how individuals' multiply marginalized identities converge with sociocultural systems that are mutable.11 Our courses must prioritize critical and multidimensional examination of how different forms of inequality, power structures, and oppression intersect to shape the health outcomes of all people and identify potential solutions to address these inequities.8,11 Wide-ranging social systems that inequitably distribute power and privilege need to be explicitly examined in all public health courses. In the field of health promotion, reflexivity provides a means of developing alternative modes of thinking related to social inequities, power dynamics, social justice, and contextually situated health issues.15 Reflexivity in action occurs when individuals engage in reflection while doing an action and adjust their practices accordingly (e.g., What am I learning about this population, and how might this learning affect the next steps of my action?);reflexivity on action occurs after an action has taken place and involves stepping back and reflecting on one's own actions (e.g., What could I have done differently?);and reflexivity underlying action involves questioning power dynamics or assumptions that underlie a field, such as public health (e.g., What power structures might this kind of practice be creating, supporting, or modifying?).15 As public health educators, we would benefit from institutional training on how to integrate this typology into our curricula to help students and ourselves become more skilled in contextualizing health decision-making and more attuned to potential biases and power imbalances.15 We can use CRT to train a legion of change agents to advance antiracismand health equity-centered programs, policies, and practices.