Addressing Discrimination as a Social Determinant of Health in the Classroom
Imagine carrying a weight you cannot see, a burden passed down through generations that influences everything from your trust in doctors to your body's response to treatment. This invisible weight is what we now recognize as discrimination—a powerful social determinant of health that operates through both historical injustices and present-day systems.
Perhaps no single story captures this reality more powerfully than the Tuskegee Syphilis Study, a 40-year medical experiment that forever altered the relationship between African Americans and the healthcare system.
This article explores how we can use this dark chapter not only as a history lesson but as a living metaphor for understanding how discrimination becomes biologically embedded, creating health disparities that persist across generations. By bringing these conversations into the classroom, we equip future health professionals with the tools to recognize, address, and ultimately dismantle these barriers to health equity.
Understanding medical ethics through historical context
Addressing disparities rooted in structural discrimination
Practical approaches for health professions education
The World Health Organization defines social determinants of health (SDOH) as "the conditions in which people are born, grow, live, work and age" and the broader systems shaping daily life 2 . These non-medical factors—including socioeconomic status, education, neighborhood environment, and exposure to discrimination—have a more significant impact on health outcomes than genetic predisposition or healthcare services alone 2 9 .
Health status follows a social gradient—the lower one's socioeconomic position, the worse their health outcomes 2 . This isn't just about poverty; even middle-income individuals experience worse health than those at higher income levels.
Factors like safe housing, education quality, job opportunities, and access to nutritious food create interconnected systems that either support or undermine health 6 9 .
Discrimination operates as a particularly potent social determinant of health, impacting individuals through limited access to resources, chronic stress from marginalization, and differential treatment within healthcare systems. The health impacts of discrimination are both measurable and significant—creating what some researchers call "weathering" effects that accelerate aging and increase vulnerability to disease.
The U.S. Public Health Service (PHS) initiated the Tuskegee Study in 1932 during the Great Depression, targeting hundreds of impoverished African American sharecroppers in Macon County, Alabama 1 5 . Originally envisioned as a six-to-eight-month study of untreated syphilis in Black men, the research continued for four decades despite the discovery of effective treatments 1 5 .
The study's design involved deliberate deception and withholding of treatment from participants:
Researchers enrolled 600 African American men—399 with latent syphilis and 201 without the disease who served as controls 5 8 . Participants were told they were being treated for "bad blood," a colloquial term encompassing various conditions including anemia and fatigue 1 5 .
Researchers deliberately withheld effective treatments even as they became available. When penicillin became the standard cure for syphilis in 1947, participants were actively prevented from accessing it 5 8 .
The research team went to extraordinary lengths to maintain their untreated subject pool, including intervening with military draft boards during World War II to prevent infected subjects from receiving treatment through military service 5 .
Researchers performed invasive diagnostic procedures like lumbar punctures (spinal taps) while misrepresenting them as "special free treatment" 1 5 . Participants received only placebos such as aspirin and mineral supplements despite believing they were receiving genuine therapy 1 .
The study continued for forty years, ending only in 1972 when Peter Buxtun, a social worker, leaked the story to the press 1 5 . The human cost was staggering:
| Category | Number Affected | Details |
|---|---|---|
| Original syphilitic participants | 399 men | All denied adequate treatment |
| Direct syphilis deaths | 28 men | Died directly from syphilis complications |
| Related complication deaths | 100 men | Died from complications related to syphilis |
| Wives infected | 40 women | Contracting syphilis from participants |
| Children with congenital syphilis | 19 children | Born with syphilis transmitted from participants |
| Survivors when study ended | 74 men | Only 74 of original 399 participants remained alive in 1972 |
The study's legacy includes not only these immediate harms but also a lasting breach of trust between the African American community and healthcare institutions—a legacy that continues to influence health-seeking behaviors and medical distrust today 5 8 .
While the Tuskegee Study represents a specific historical injustice, its power extends beyond those 40 years to become what medical anthropologists call a cultural trauma—a collective memory that shapes group identity and community responses to healthcare. As a metaphor, "Tuskegee" represents:
The study serves as a powerful symbol of medical exploitation and the devaluation of Black lives within healthcare systems.
It exemplifies how withholding information and manipulating vulnerable populations creates lasting harm.
The study demonstrates how racism becomes embedded in institutions, including those dedicated to healing and scientific advancement.
The Tuskegee metaphor manifests in measurable health outcomes today. Consider these contemporary examples:
| Health Indicator | Disparity | Connection to Social Determinants |
|---|---|---|
| Life expectancy | 18-year difference between high and low-income countries 2 | Reflects unequal distribution of resources and power |
| Under-5 mortality | 8 times higher in Africa than European region 2 | Shows impact of geographic and economic disadvantages |
| COVID-19 outcomes | Higher mortality in racial/ethnic minorities 9 | Links to crowded housing, employment conditions, healthcare access |
| Chronic disease | Higher rates in low-income communities | Connects to food deserts, environmental stressors, limited preventive care |
This metaphorical understanding helps explain why African American communities exhibited higher vaccine hesitancy during the COVID-19 pandemic—not because of ignorance, but as a rational response to historical and ongoing medical mistreatment 9 .
The metaphor also illuminates why people from marginalized groups often receive less pain management and are referred less frequently for specialized procedures—manifestations of the same devaluation of certain lives that enabled Tuskegee.
Integrating Tuskegee and social determinants of health into health professions education requires moving beyond simple historical recounting to active engagement with ethical reasoning and systemic thinking.
Using storytelling techniques to humanize the participants of the Tuskegee study, presenting them not merely as victims but as individuals with families, aspirations, and community roles 7 .
Training students to recognize how structures and systems—not just individual behaviors—produce health disparities, enabling them to identify points for intervention 9 .
Studying and addressing discrimination as a social determinant of health requires specific methodological approaches and conceptual tools:
| Tool/Method | Function | Application Example |
|---|---|---|
| Community Health Assessments | Identify health priorities and disparities through data collection | CDC's collaboration with health departments on community health assessment 9 |
| Health Equity Frameworks | Provide structured approaches to address root causes of disparities | Pathways to Population Health Equity (P2PHE) framework 9 |
| Policy Analysis Methods | Examine how legislation and institutional policies create health impacts | Analyzing historical housing policies' impact on current health disparities |
| Qualitative Interviewing | Capture lived experience of discrimination and its health effects | Documenting patient narratives of medical mistrust |
| Spatial Analysis | Map distribution of health resources and outcomes across communities | Identifying "hot spots" of health disparities and resource deserts |
Present students with contemporary cases that echo Tuskegee's ethical dilemmas but in modern contexts, such as genetic research involving vulnerable populations or AI algorithms that perpetuate health disparities.
Partner students with community organizations working to address social determinants of health, creating mutual learning opportunities that center community expertise.
Challenge students to develop intervention plans targeting specific social determinants, applying the "Creating social, physical, and economic environments that promote attaining the full potential for health and well-being for all" goal from Healthy People 2030 6 .
The Tuskegee Syphilis Study represents far more than a historical footnote—it serves as both a cautionary tale about ethical failures in medicine and a powerful metaphor for how discrimination operates as a social determinant of health. By understanding this history and its contemporary resonances, health professionals can better comprehend the skepticism they may encounter from marginalized patients and recognize it as a rational response to historical and ongoing injustices rather than ignorance or stubbornness.
The classroom becomes a crucial space for transforming this difficult history into a tool for building more equitable healthcare systems.
When we teach Tuskegee not just as history but as a living metaphor, we empower future health professionals to become agents of change who understand that addressing discrimination is not peripheral to healthcare but fundamental to its practice. As we strive to create what the World Health Organization describes as "the highest possible standard of health for all people," we must acknowledge that this goal requires confronting medicine's complicated legacy and building new relationships based on transparency, respect, and justice 2 .
The full weight of Tuskegee's legacy means the work must be both historical and forward-looking—acknowledging the past while building a more equitable future. This is perhaps the most important lesson we can carry from the classroom into practice: that repairing trust requires not just technical competence but moral courage, not just clinical skills but cultural humility, and not just treating disease but championing health in its broadest, most inclusive sense.