Every aspect of human life-from access to food, housing and health care-impacts how we interact with microbes and microbial ecosystems. "Microbial communities are found everywhere," Dr. Sue Ishaq, assistant professor of animal and veterinary services at the University of Maine said at ASM Microbe 2022. "There's really no aspect of our lives that doesn't involve microbes, and we posit that the microbiome has the capacity for social impact and vice versa."
Thus, it is important for microbiologists to think carefully about how their work relates to health disparities, understand and correctly use definitions to discuss issues pertaining to social equity, learn about historical implications (and unlearn previous assumptions) when approaching research questions and design and consider how these lessons can be passed to early-career microbiologists.
Disparities in Health Outcomes
Social equity is a process of ensuring access to resources with the assumption that people start from different vantage points, and the acknowledgement that people need different types of help. Dr. Ariangela Kozik, research investigator at the University of Michigan and co-founder and vice president of the Black Microbiologists Association, emphasized the importance of equity (e.g., meeting individuals where they are), not just equality (e.g., being treated equally), in health care and research settings.
"As a society, both nationally and globally, we are lacking in health equity," Kozik said. "Unfortunately, achieving that ideal requires us to do something that, historically, humans haven't been very good at, and that's valuing everyone equally, and then intervening when evidence and outcomes run counter to that ideal."
Historically underrepresented racial and ethnic communities disproportionately experience poor health outcomes. For example, Black children living in the U.S. are twice as likely to develop asthma and 4 times as likely to die from asthma compared to white children living in the U.S. Additionally, Native American, Alaska Native and Black patients with the capacity for pregnancy are 2-3 times more likely to die from a pregnancy-related cause than white patients. Kozik noted that economic and educational advantages would not necessarily alter the health outcome of a patient from a historically underrepresented racial and ethnic group-these advantages do not diminish the racial discrimination a patient may face while seeking health care. She explained that the pregnancy-related mortality ratio for Black patients with the capacity for pregnancy with at least a college degree is 5 times as high as white patients from similar educational and economic backgrounds.
Defining Key Terms
Researchers-both past and present-equate race classifications and differences in appearance to biological differences. This is not accurate, and one of the reasons Kozik says providing definitions of terms like 'race' and 'ethnicity' is so important. At the time of the first census in the U.S. in 1790, "the prevailing thought was that race was a fixed biological characteristic," Kozik said. "People could be sorted into different buckets based on appearance, and that's why race is used as a proxy term for racism." In a talk at ASM Microbe, Kozik provided the following definitions:
Race: A social and political construct that assigns significance and symbolism to different types of human bodies based on observable characteristics. Race is not fixed in biology, genetics, time or geography.
Racism: The belief that race is the primary determinant of human traits and capabilities, and the system of oppression based on race. Racism has both individual (e.g., microaggressions) and systemic (e.g., redlining) manifestations.
Systemic Racism: A system, consisting of structures, policies, practices and norms, that structures opportunity and assigns value based on phenotype, or the way someone looks.
Ethnicity: The grouping of characteristics that people may have in common, which can include elements such as language, religion, shared regional history, traditions, customs and culture.
Ancestry: A person inherits each segment of their DNA from specific ancestors (e.g., a family tree may identify who you are biologically related to).
Without a widespread understanding of these terms, microbiologists may continue to perpetuate the problematic research practices of the past.
Past Assumptions Impact Current Practices
Throughout history, researchers used race as a biological variable-a practice that has frequently informed current studies. Kozik explained that racial and ethnic classifications were socially constructed based on "perceived biological differences" and subsequently used to justify systems of oppression. "Conflation of race with biology and the study of health disparities promotes research priorities that focus on identifying individual or group deficiencies while minimizing or ignoring altogether larger systemic, environmental and structural forces that can influence outcome," she said.
This type of framing around health care issues was visible at the start of the COVID-19 pandemic, when data showed historically underrepresented racial and ethnic communities were dying of the novel coronavirus at higher rates. At the time, Kozik said researchers began to develop hypotheses with the preconceived notion that historically underrepresented racial and ethnic communities may be more susceptible to contracting the virus based on their genetic makeup. Research early in the pandemic showed that Black patients had almost 3 times the frequency of hypoxemia-when blood oxygen levels are below normal-that was not detected by pulse oximetry (a test that measures blood oxygen levels and is typically used to determine if patients are put on a ventilator) compared to white patients. Researchers initially assumed that differences in health outcomes for Black patients were directly related to their race, with the assumption that race is a genetic factor. This is not the case, and recent studies on COVID-19 found these health differences could be attributed to racial biases in health care and research, not race and ethnicity.
A follow up study published in May 2022 revealed that there were delays in treatment for both Black and Hispanic patients due to this identified discrepancy as a result of inaccurate pulse oximetry measurements being used to determine which patients were admitted to the hospital for further care, which patients were eligible for ventilator support and which patients were prescribed medication that was in short supply. These imprecise measurements were due to the pulse oximeter not being designed to accurately obtain readings from patients with darker skin tones.
In a January 2022 study, researchers considered the technology behind pulse oximeter measurements, and how this may lead to inaccurate readings for patients from historically underrepresented racial and ethnic communities. Arterial oxygen saturation is estimated by measuring differences in light absorption through the patient's skin at 2 wavelengths. Researchers found this process to lead to an overestimation of oxygen saturation in patients from historically underrepresented racial and ethnic communities, and presumed that when pulse oximeters were first developed, test subject groups lacked participants from historically underrepresented racial and ethnic communities.
"Higher COVID-19 mortality rates have been seen in communities of color across the United States from the get go," Kozik said. "There were studies that looked for biological reasons for this. One study claimed that Black people had a higher expression of a gene and suggested that might be why Black people were so affected by COVID-19. In order to move toward equity in biomedicine and microbial sciences to promote health, we need to radically adjust the assumptions that inform our approaches."
Teaching Social Equity at the Undergraduate Level
Challenging assumptions and incorporating social equity into microbiology practices and discussions should start early in a scientist's career. Dr. Carla Bonilla, Ph.D., assistant professor of biology at the University of San Diego, has more than 10 years of experience teaching undergraduate students. Previously, Bonilla worked as an associate professor at Gonzaga University, where she employed a student-centered pedagogical approach, a practice that allows students to influence the curriculum and goal-setting for a specific course. "As teachers, it's not just about how we are helping students get to where we want them to be, but who they want to be, and how can we help them do that as scientists, as doctors, as whatever their goals are," Bonilla said. "That humanistic approach means that I can talk to my students about seeing the intersection between social justice in science, specifically microbiology."
When applying transdisciplinary ideas concerning the intersection between social equity and microbes, Bonilla considers the pedagogical tool of examining positionality (e.g., what are the impacts of our actions, whether intended or unintended, based on the privileges or marginalized identities that we hold). Through this thought exercise, Bonilla's students consider how their identities influence their future research designs. "Ultimately, we would like to write and then apply social justice principles and practices and actually do them in the research design, whether it's health interventions, environmental health or whatever it is that you do to eventually apply it-I want to do this in the classroom," she said.
When engaging in conversations with students about racism and social equity, Bonilla said it's important to create an environment where students feel comfortable to share their ideas and experiences while challenged in a way that does not cause them to "shut down" and evade a topic because it conflicts with previously held beliefs or is unfamiliar to them. Bonilla explained that meeting in person, if possible, and reminding students to engage in a productive dialogue, where listening is prioritized over arguing, are integral to facilitating these types of conversations.
Research in this article was presented at ASM Microbe, the annual meeting of the American Society for Microbiology, held June 9-13, 2022, in Washington, D.C.
Read the mSystems article from the Microbes and Social Equity (MSE) Working Group on opportunities for integrating microbiology and social equity work.
