The Institute of Medicine’s landmark report Unequal Treatment (1) concluded that “racial and ethnic minorities experience a lower quality of health services and are less likely to receive even routine medical procedures than are White Americans” (1). This report also posited that many health disparities were the result of biases and stereotypes that occur during clinical encounters, not just social determinants (1). We use the definition of racism by Dr Camara P. Jones, one of the report’s authors: “Racism is a system of structuring opportunity and assigning value based on the social interpretation of how one looks that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society” (2). Health care providers with limited interaction with minority populations may exhibit some nuanced negative behaviors because of stereotypes about the lifestyle or health behaviors of their Black and Brown patients. These stereotypes may influence providers’ quality of care. In turn, patients’ health decisions might be in response to the clinician’s and staff’s behavior or past mistreatment during medical encounters. The issues identified in Unequal Treatment led to 21 recommendations for improvement in medical care financing, allocation of care, and the cross-cultural training of health care providers, yet the problems persist. The life expectancy of Black Americans is still 5 years fewer than that of White Americans (3). The Centers for Disease Control and Prevention estimated that in 2019, there were 70,000 premature deaths among Blacks from treatable chronic diseases. (4). This is an increase from the 1985 Secretary’s Task Force on Black and Minority Health, which estimated 60,000 excess deaths of Blacks versus Whites. This report was a major driving force for identifying solutions to health disparities and advancing health equity in the US (5). The COVID-19 pandemic both revealed and exacerbated the health disparities and health care inequities between Black and White Americans (6).

Medical academic centers and professional health organizations, including the American Medical Association, have examined their practices and developed policies to dismantle racism. They have begun to use an equity lens in hiring practices and created offices of diversity, equity, and inclusion (DEI). Additionally, anti-racism education and training of students in the health professions are recommended.

The Morehouse School of Medicine (MSM) Department of Community Health and Preventive Medicine introduced its Community Health Course (CHC) in 1998 (7). The purpose of the course is to use service-learning to train first-year medical (MD1) students to become community-oriented physicians who will provide care for diverse populations. CHC also provides instruction on ways to recognize and address racism as one of the social determinants of health (SDOH) to achieve optimal community health and health equity. This innovative course reflects the mission of MSM to provide MD1 students with the tools, skills, and self-efficacy to work comfortably with populations with which they may have had no previous experience. Further, CHC provides learners with a knowledge base of health promotion and disease prevention and control, as well as skills of community engagement, during the 2 semesters with their community partners. Competencies for the course include those outlined by the American Association of Medical Colleges (AAMC) under the domains of DEI (8). Students interact with communities and observe the reality of SDOH, including substandard housing, lack of sidewalks and transportation, and food insecurity. These examples of structural racism as a social determinant come clearly into view.

Although systemic and structural racism are often used interchangeably, each has a slightly different meaning. Systemic racism refers to entire systems, be they health care, economic, educational, or legal and includes the structures that support and maintain the systems’ race-based attributes. Systemic racism includes structural racism, which refers to the role of the structures (laws, policies, institutional practices, and entrenched norms) that support the systems (9,10). For example, historically, decisions about where major highways were constructed resulted in the destruction of communities of color, including schools and businesses. Communities that are in the shadow of these highways have higher rates of noise and air pollution and illnesses like asthma (11).

Lisa Howley, PhD, AAMC senior director of strategic initiatives and partnerships noted, “In 2018, only 40% of medical schools reported teaching about racial disparities” (12). Additionally, although SDOH have been viewed as a primary driver of health-related inequities, SDOH medical education curricular approaches have at their core under-resourcing and cultural competence instead of systems, practices, and policies that foster a focus on content rather than skills development (13–17). Thus, evolving instruction to structural-based competency in medical education is critical and produces a more substantive approach to addressing health inequities (16) — the express intent of the CHC (17,18).

The onset of the COVID-19 pandemic in 2020, intersecting with the high-profile murders of Ahmaud Arbery, Breonna Taylor, George Floyd, and others, brought to focus the roles that systemic and structural racism can play in the health outcomes of individuals and communities (19). Following these events, many publications were generated on conscious and unconscious bias in medicine and health care and recommendations on how to tackle it (19–22). Responses to the Black Lives Matter movement in the medical community include required training and continuing education among staff in medical schools and businesses and the creation of DEI offices to provide oversight and accountability. Educating medical students earlier in their training, as they are developing their ideas of what kind of physicians they will be, is imperative. Our CHC has been doing this for nearly 25 years.

The objective of this article is to describe how the CHC integrates AAMC DEI competencies into the curriculum for first-year medical students to teach the impact of racism on the health of communities and equip future physicians with skills to develop interventions to improve health outcomes.

The CHC is a required first-year course for medical students that provides an interactive service-learning approach to teaching medical students about the impact of racism on the health of a community. Assessment and co-development of sustainable interventions are components.

Learners can begin to address their biases and stereotypical thinking of Black and other minority populations. Learners also address preconceived ideas in a learning environment of diverse peers who identify with populations of similar racial and ethnic backgrounds.

The CHC has 25 multidisciplinary faculty consisting of physicians, nurses, health educators, public health researchers, and behavioral scientists. These faculty have devoted their careers to clinical, educational, and research endeavors that advance health equity among racial minorities and underserved populations. Faculty are provided the professional development and resources needed to reinforce course concepts and provide culturally informed instruction.

This year’s MD1 class comprises 126 racially diverse students who are divided into 12 learning communities. The MD1 class is representative of the MSM MD Program student population, which is 75% Black.

Each learning community is assigned to 1 community partner site. Sites are recruited at the recommendation of the CHC faculty or by the invitation of community organizations. The CHC seeks organizations that support MSM’s mission of serving underserved communities, have staff with the time and interest to act as site liaisons, and have available space for the weekly small group meetings. Partner sites do not receive compensation for participating in the course; however, each student group receives a budget ($500 in the 2023 academic year) that is used to support community activities and provide participant incentives. Current community partners include pre-K and K-12 schools, after-school programs, independent senior living facilities, church outreach services, and a refugee social service agency in predominantly communities of color. Figure 1 illustrates the yearly timeline of the CHC engagement with its community partners. Most of the partner sites are located in Atlanta, which is divided into Neighborhood Planning Units (NPUs). NPUs were established in Atlanta to provide residents the opportunity to serve in an advisory capacity with the city government (22). Of the 5 NPU partnering sites, 82% to 93% of residents are African American (Figure 2).

The CHC has several notable strengths, weaknesses, opportunities, and threats (SWOT) in teaching first-year medical students to mitigate the impacts of racism on communities of color. These should be considered for similar course or experience development, implementation, and evaluation.

Strengths include involving a diverse, multidisciplinary, and multi-ethnic faculty, medical student body, and community that contribute to formal and informal learning and skills-building to address the impact of racism on a community’s health. Interwoven throughout CHC is the philosophy of “community as patient” and the AAMC DEI competencies that map course objectives with activities and ensure bidirectional evaluation that is beneficial to both learners and the community. A weakness of medical school instruction on racism is that knowledge and awareness can be increased, yet many factors, such as the medical school schedule, time allotted in the community, and lack of resources, may preclude a thorough assessment of the impact of racism on community health and the development of robust mitigation strategies. Medical student longitudinal rotations in the community with a commensurate evaluation of impact, as well as a commitment to sustainable interventions, are plausible solutions. Opportunities exist for collaborations with other degree programs and professionals, such as the Physician Assistant and Master of Public Health students and the Satcher Health Leadership Institute fellows, to sustain and increase the impact of community interventions. Indeed, interprofessional education is widely supported and fosters training and preparation to address racism in health and health care. Opportunity also exists to bolster the evaluation of student and course outcomes. The greatest threat to CHC is the finite community sites for which growing numbers of health professions students and degree programs seek opportunities for training. Related is the need to establish long-standing, meaningful partnerships to assess and mitigate the impact of racism. To address this, a memorandum of understanding for long-term partnerships should be established among a directory or resource list of “preferred partners.” While the effects of racism on health inequities increase, additional training is needed for health professionals to contribute to solutions.

The long-term success of the course is attributed to its focus on addressing the impacts of SDOH, the long-time tenure of most of its faculty, the continued collaboration with community partners, and the support of MSM. CHC has also scaled up and evolved to accommodate increased class sizes, expanded its reach in the surrounding communities, and diversified its community partnerships to serve other vulnerable populations (ie, refugees, asylum seekers, and victims of torture). Additionally, CHC has been adopted by several of MSM’s graduate and residency programs (24–27), thereby expanding the efforts of MSM to address racism and other SDOH through various educational activities. Medical schools’ curricula could be modified to include more longitudinal community-based educational offerings. Institutions could also replicate the individual course components such as the large group lectures; small group activities via in-person, online, or flipped classroom formats; and reflective short essays. For example, the course converted its curriculum to an online format during the COVID-19 pandemic.

As CHC continues to evolve, we look forward to continuing to develop this important course, educating about racism and health inequities and developing a workforce that incorporates not only the practices and principles of community health but also advances health equity practice by addressing the needs of racially marginalized communities and others disproportionately affected by poor health and health care.

Medical education can play an active role in mitigating racism and its resulting health inequities. It is important to train medical students to understand the effects of racism on the access to and delivery of quality health care and that medically underserved communities are particularly vulnerable to these effects. Medical students should also recognize the structures that facilitate ongoing racism in our health care system and be made aware of their roles and responsibilities as health care providers in this context. Medical education curricula must continue to encourage students’ self-examination and awareness of their own biases and educate them on effective strategies for advocating for disenfranchised communities and patients.

The application of AAMC DEI competencies in the education and training of first-year medical students serves as a useful guide for medical school curricula to address the impact of racism on health care disparities in the US. When developing and implementing such curricula, it is also imperative to involve and include the perspectives of communities most impacted by racism.