MISSION: Southwest Research and Information Center is a multi-cultural organization working to promote the health of people and communities, protect natural resources, ensure citizen participation, and secure environmental and social justice now and for future generations

Educating the Next Generation of Doctors: Rx for Undoing Racism

UNM Medical School Training Program UNM is known nationally for its innovative medical education and public health programs that use "problem-based learning" methodologies in everyday curricula. These teaching methods have been widely adopted in other medical schools, including Harvard's School of Medicine, and allow students to learn from first-hand experiences with patients and in communities, in addition to traditional instruction from text books and lectures. The Family and Community Medicine Department at UNM has a national and international reputation for its community-based health care programs. These programs combine public health, community organizing, cultural competencies and primary care to address health problems from a broader perspective. By addressing underlying socioeconomic problems (for example, poverty) or behavioral patterns (such as smoking), physicians at UNM are better able to improve the health of the people they serve. And because studies have shown that ethnic minorities are often disproportionately exposed to environmental waste and toxins (see, e.g., Bullard, 1990; Newton and Ortega, 1991), physician training at UNM now includes a strong component on race and health in America. The Navajo tour and Undoing Racism training is an example of a problem-based approach that helps new physicians look at important underlying causes and impacts of environmental contamination.

This Was No Mid-Winter Vacation

For 18 first-year medical residents from the University of New Mexico's (UNM) Family and Community Medicine Department, a two-day tour of the Navajo Nation sounded like a nice respite from a grueling rotation at University Hospital. But learning about an important element of medicine that exists outside of the clinic - and a little bit about themselves and their attitudes toward race - was no mid-winter vacation.

The residents, along with eight members of the UNM Medical School faculty, boarded a bus on a crisp morning in early January to travel to the Eastern Navajo Agency to see first hand the consequences of five decades of uranium mining on the people and lands of Diné Bikéyah. The tour of mining-impacted communities was a component of a four-day training program designed to give new physicians real-world examples of what is meant by the terms "environmental health" and "environmental justice." The program also included a two-day workshop on Undoing Racism conducted by The People's Institute for Survival and Beyond that left some residents exhausted, and feeling a bit uncomfortable. During the four days, residents examined their own attitudes and knowledge about race and how it remains a large but unrecognized factor in health-care access and delivery.

The tour was organized by Dr. John Fogarty, a Medical School associate professor and family practice physician with the U.S. Indian Health Service in Crownpoint, N.M., and led by Chris Shuey, director of SRIC's Uranium Impact Assessment Program. Between Albuquerque and the Navajo community of Church Rock near Gallup, New Mexico, the Medical School group heard talks by "key community informants" - a term used widely in public health theory to describe lay people who possess knowledge and insight that cannot be found in textbooks or research laboratories - who have been directly affected by the impacts of more than 50 years of uranium mining on the Navajo Nation.

In a stop at the Uranium Mining Museum in Grants, New Mexico, Phillip Harrison, son of a Navajo miner who died of lung cancer and himself a survivor of kidney disease, told the group about how the dangers of underground uranium mining were never revealed to many of the Navajo miners. He also described how the unhealthy working conditions in the early mines contributed to an epidemic of fatal lung diseases among the non-smoking Navajo male population. In Milan, New Mexico, just west of Grants, the group looked at a "reclaimed" uranium mill and tailings pile, and learned how seepage from the huge dump had contaminated private water wells in low-income communities built within a mile of the facility.

At the Church Rock Chapter House 50 miles to the west, community services coordinator Edward Carlisle told the group that Chapter government has undertaken its own environmental monitoring program to determine the effects of abandoned uranium mines on nearby residences. He explained that development of new housing, infrastructure and other community improvements was impeded by lingering questions about the safety of the local environment. Many of the abandoned mining sites were first developed in the 1950s and 1960s, and several have had no reclamation.

And seven miles north of the Chapter House, with a sharp winter wind blowing down the canyon, Arthur Hood talked about how he and other residents of Water Pond Road were never informed about the possible dangers of being constantly exposed to dusts and runoff from two huge uranium mining complexes that surround this Navajo "camp" of 15 homes. Several of the medical residents and faculty members braved the biting late-afternoon cold to hike up to the face of a 30-foot-high uranium waste dump to get a first-hand understanding of the magnitude of the problem faced by Mr. Hood and his neighbors. The residents and faculty members, most of whom are also physicians, joked about the magnitude of the extra radiation doses they may receive from the short time they spent next to the dump. But several said they understood that continually living next to these contaminated sites was no laughing matter for the local Navajos.

Uranium Mining Disproportionately Affected Native Americans

Such are the conditions in countless Diné communities where uranium was mined and processed from the 1950s through the early 1980s. Three generations of Navajos have been exposed to uranium mining, and health studies support the notion that this distinct racial group has been disproportionately affected by those exposures. For instance, mortality from lung cancer and respiratory diseases was found to be 3 to 5 times higher among Navajo miners compared with the "standard" U.S. population (Roscoe, et al., 1995). Through medical examinations, the criteria used to determine whether former miners qualified for compensation under the federal Radiation Exposure Compensation Act (RECA) were found to systematically underestimate diminished lung function among Native Americans, including many Navajos (Mapel, et al., 1997). And two-thirds of all new lung cancer cases among Navajo men between 1969 and 1993 were attributed to a single exposure, underground uranium mining (Gilliland, et al., 2000). If not for uranium mining, lung cancer would be virtually nonexistent in the non-smoking Navajo population, which has the lowest lung cancer mortality rate of all Native American groups (USIHS, 2001; Chart 4.31).

At the community level, the effects of uranium mining on the Navajo people is much less clear. Despite the presence of nearly 1,100 abandoned uranium mines on the Navajo Nation (about 25 percent of which still need cleanup), few studies of population effects have been conducted. Birth defects in children born to Navajo woman in the Shiprock area between 1964 and 1981 were found to occur at rates 2 to 8 times greater than the U.S. average, but their possible association with exposure to radioactive wastes from uranium mines was not conclusive (Shields, et al., 1992). Some Navajos who were born in uranium mining camps suffer from progressive deterioration of the hands and other extremities, neurological effects that are consistent with heavy metal poisoning, and which tests revealed were not related to genetic disease (Rosen and Mushak, 2000). Advocates for dependents of former uranium miners insist that rare diseases are numerous among their families, but no formal epidemiological studies of disease patterns in this group have ever been done (Badoni, 2002).

Eliminating Health Disparities

Evidence of health disparities among Navajos and other Native Americans exposed to uranium mining is but one example of a continuing trend in American health - that race, socioeconomic status, and educational levels are key determinants of health and disease. In 1998, the U.S. Department of Health and Human Services (HHS) identified the elimination of racial and ethnic health disparities as an overarching goal of Healthy People 2010. Racial and ethnic disparities in health have gained additional attention as a result of the work of the Institute of Medicine (IOM), which revealed widespread disparities in the treatment of minorities accessing the health-care system in its landmark report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (IOM, 2002).

Dr. David Satcher, former U.S. Surgeon General and director of the National Center for Primary Care at the Morehouse School of Medicine in Atlanta, recently told physicians, residents, and medical students at UNM's Health Sciences Center that race and ethnicity play a major role in health status. Satcher's report, "Our Commitment to Eliminate Racial and Ethnic Health Disparities," published in the Yale Journal of Health Policy, Law, and Ethics, contends that although disparities result from complex interactions among genetic variations, environmental factors, and specific health behaviors, there is plenty of evidence members of racial and ethnic minorities suffer from diseases at rates much greater than whites.

A recent report by Grantmakers in Health, "A Closer Look at Racial and Ethnic Health Disparities," identified other factors that affect health, such as:

• the condition of the environments in which racial and ethnic minorities live and work, including the quality of the air and exposure to other environmental hazards;
• the condition of the social environment, including racism and poverty;
• the level of access to care; and
• structural aspects of the health care delivery system that affect both quality of care and patient care experiences.

The report also disclosed that despite advances in medical science and improvements in the "nation's health," these advances have masked the fact that racial and ethnic minorities often fare worse than whites on a variety of health indicators. The impact of these disparities has become more pronounced within the last 20 years as the environmental justice movement gained momentum, and defined environmental racism as the disproportionate impacts of pollution and contamination on the overall health of communities of color. Indeed, the word "environment" has taken on a much broader definition, meaning "where we live, work, learn, play, and pray."

But despite issuance of Executive Order 12898 on Environmental Justice by former President Bill Clinton in 1994, mainstream environmental policy continues to neglect, and may even exacerbate, environmental health problems in low-income communities of color. While the environmental justice movement over the last 20 years developed strategies to address these issues, eliminating or reducing racial and ethnic disparities in health requires the combined efforts of community organizers, educators, advocates, and health-care providers. The Navajo tour and undoing racism training for medical residents was the first effort by UNM to amalgamate these key public sectors to begin the process of widening the definitions of medicine and health care to reduce health disparities in New Mexico's diverse racial profile.

The Undoing Racism Workshop

The People's Institute (PI) asserts that racism is the single most critical barrier to achieving social change. According the Institute, "racism has been consciously and systematically erected, and it can be undone only if people understand what it is, where it comes from, how it functions, and why it is perpetuated." (Visit www.thepeoplesinstitute.org for more information.) This principle guides the People's Institute's two-day Workshop on Undoing Racism that has been conducted in hundreds of communities and at scores of institutions over the past 20 years. Using presentations, dialogue, personal reflection and role-playing, the workshop challenges participants of all colors to examine not only society's attitudes toward race, but also, and especially, their own.

The January workshop at UNM, which included participation by African-Americans, Hispanics and Native Americans from several communities in New Mexico and Southern California, challenged medical residents and faculty members to analyze the structures of power and privilege that hinder social equity as it relates both to health care and to their roles as health-care providers.

PI trainers Barbara Major and Diana Dunn opened the workshop by asking participants to answer the question, "Who do you come from?" The question purposefully starts with the indefinite pronoun "who," instead of the more commonly used "where," to evoke the notion that each participant brings a historical context to their lives and work. Learning from history is a principle emphasized in the People's Institute workshops because history is society's collective guide to the future and an essential tool for effective community organizing.

During the rest of the workshop, residents and community members examined the history of race and how racism has influenced and continues to influence many American institutions and organizations. The participants then had an opportunity to examine their place and role within those institutions, and how, in some ways, we are all complicit with the ongoing problems associated with race in America.

The four-day training was not an easy or comfortable experience for most of the participants, perhaps because an examination of race and environmental racism in our country is rarely, if ever, included in American educational systems. Nonetheless, this work remains critical, as the legacy of institutional racism continues to affect many Americans, even to do this day.

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John Fogarty, Sylvia Ledesma and Chris Shuey contributed to this article. Comments are welcomed and can be sent to SRIC at info@sric.org.

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Environmental Impacts and Communities of Color Health statistics increasingly document the impact of environmental hazards on communities of color. Here are a few examples, based on the remarks of Peggy Sheppard, West Harlem Environmental Action, at the Grantmakers in Health 2002 Annual Meeting on Health Philanthropy, February 27, 2002 (reprinted from Erasing the Color Line): More than 90 percent of all lead poisoning cases in New York City involve children of color living in 10 key neighborhoods with substandard housing. Compared with the general population, a disproportionate number of Latinos, Asian Americans and Pacific Islanders live in areas that fail to meet the U.S. Environmental Protection Agency's standards for air quality. Cancer rates are much higher in New York's predominantly Dominican and African-American neighborhoods (Washington Heights and Harlem, respectively) than in more affluent parts of Manhattan. Asthma death rates are three times higher among African Americans than whites in the U.S. Moreover, African American children have been found to be three times more likely than white children to be hospitalized for asthma and asthma-related conditions, and four to six times more likely to die from asthma. Asthma is now widely viewed as an environmental disease resulting from exposure to both indoor and outdoor pollutants.

The People's Institute (PI) The People's Institute for Survival and Beyond was founded in 1980 by long-time community organizers Ron Chisom of New Orleans and Jim Dunn of Yellow Springs, Ohio. The People's Institute was created to develop more analytical, culturally rooted and effective community organizers. Over the past 24 years, the People's Institute's Undoing Racism™/ Community Organizing process has reached nearly 100,000 people both nationally and internationally. Through this process, PI has built a national collective of anti-racist, multicultural community organizers who do their work with an understanding of history, culture, and the impact of racism on communities. These anti-racist organizers build leadership in and accountability to the constituencies where they are organizing. The People's Institute believes that effective community and institutional change happens when those who would make change understand how race and racism function as a barrier to community self-determination and self-sufficiency. As stated in Undoing Racism: A Philosophy of International Social Change, Second Edition (Chisom and Washington, 1997), "...[W]hen a society is structured on the basis of race, conformity to the norms of racial roles maintains both inequitable treatment and pathological relations. Undoing Racism™, with an understanding of the construct of race in America and the role that it plays in community, enables the organizer to be transformed and begin the process of community empowerment." Today, the People's Institute is recognized as one of the foremost anti-racism training and organizing institutions in the nation. In a 2002 Aspen Institute survey of 11 top racial justice organizations, five credited the People's Institute with having the most effective anti-racist analysis. In the last three years alone, the People's Institute has trained more than 12,000 community organizers to implement anti-racism principles through practices in neighborhoods, programs and institutions where they work and provided leadership for a new national Anti-Racism Training Institute, with sites in Albuquerque, Seattle, New Orleans and Broward County, Florida.

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References

• Badoni G. Research Proposal of the Navajo Nation Dependents of Uranium Workers Committee. Shiprock, N.M. (undated; produced in 2002).
• Bullard RD. Dumping in Dixie: Race, Class and Environmental Quality (Westview Press), 1990.
• Gilliland FD, Hunt WC, Pardilla M, Key CR. Uranium mining and lung cancer among Navajo men in New Mexico and Arizona, 1969 to 1993. Journal of Occupational and Environmental Medicine; 42(3):278-83, March 2000.
• Institute of Medicine (IOM). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. BD Smedley, AY Stith, AR Nelson, eds. IOM Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. National Academies Press (Washington, DC), 2002.
• Mapel D, Coultas DB, James DS, Hunt WC, Stidley CA, Gilliland FD. Ethnic Differences in the Prevalence of Nonmaglinant Respiratory Disease among Uranium Miners. American Journal of Public Health; 87(5):833-838, May 1997.
• Roscoe RJ, Deddens JA, Salvan A, Schnorr TM. Mortality among Navajo uranium miners. American Journal of Public Health; 85(4):535-40, April 1995.
• Rosen J, Mushak P. Metal and Radiation-induced Toxic Neuropathy (TN) in Two Navajo Sisters. Toxicological Sciences; No. 378 (abstract only); 54(1):80; 2000.
• Shields LM, Wiese WH, Skipper BJ, Charley B, Benally L. Navajo birth outcomes in the Shiprock uranium mining area. Health Physics; 63:542-51, Nov. 1992.
• Newton KC, Ortega F. Beyond Ankle-Biting: Fighting Environmental Discrimination Locally, Nationally and Globally. The Workbook (Southwest Research and Information Center), 16:3, Fall 1991.
• U.S. Indian Health Service (USIHS). Regional Differences in Indian Health 1998-1999. U.S Department of Health and Human Services, USIHS, Office of Public Health, Division of Community and Environmental Health (Rockville, MD), 2001.