Mapping Care Project: The History of Black Nurses in Chicago

Lesson 1: Structural Racism and Social Determinants in Healthcare – Past and Present

 

Courses: Nursing History, Public Health, Population Health, Social Determinants of Health 

AACN Standards 

  3.4b Describe the impact of policies on population outcomes, including social justice and health equity (Entry-Level).
7.2b Recognize the impact of health disparities and social determinants of health on care outcomes (Entry-Level).
7.3d Recognize internal and external system processes and structures that perpetuate racism and other forms of
  discrimination within healthcare (Entry-Level).

Associated Nursing History Framework
Learning Objectives 
  1. Understand social determinants of health: describe how different kinds of inequalities were connected with health inequality during the Jim Crow era (AACN 3.4b, 7.2b). 
  2. Develop an analysis of the intersecting legacies of structural racism in social determinants of health and healthcare: make a claim about how health inequalities have changed and/or stayed the same for Black Americans in the last 100 years (AACN 7.2b, 7.3b). 

Essential Questions:
Introduction (Faculty)
Nurses may encounter complex and intersecting challenges when they serve patients and populations from racialized and marginalized groups, and it is therefore important for nursing students to develop a deep understanding of the historical political and social factors that shaped today’s realities.
In this lesson, students will examine the concept of Social Determinants of Health (SDoH) through the lens of life for Black people living in northern cities like Chicago in the early decades of the twentieth century. The provided sources will help students explore how long-running patterns of racial discrimination and segregation shaped the lives and health of Black Americans. Instructors may also challenge students to identify additional primary sources through their own research. Students will practice critical reading skills by analyzing primary sources for perspective, purpose, and bias. They will then take the information they’ve learned in analyzing the primary sources to create a community health assessment for Black Chicagoans living during this period in Chicago.  
This lesson also challenges students to consider how this history of structural racism continues to affect nursing, healthcare, and U.S. society today. The final assessment asks students to compare the Jim Crow era and today to develop an argument about where there has been progress towards equity and where policy, practice, and historical legacies continue to perpetuate health inequities. 

Historical Context (for faculty) (adapted from Black Public Health Nurses in History & Provident Hospital, 1930-1966)

In the early twentieth century, Black Americans increasingly died from preventable and curable diseases like tuberculosis and typhoid. During this time, the Great Migration saw millions of Black Americans move from rural Southern areas to urban centers in the North, seeking better opportunities and escaping systemic oppression. However, upon arrival in northern and southern cities, they often lived in crowded, segregated communities with few job opportunities, a situation exacerbated by the Great Depression.
Hospital care was improving in this era, yet Black Americans were denied the benefits of these advances. Black patients often could not get admitted to public hospitals or were sent to segregated wards. When they could receive hospital treatment, Black people were often treated by racist white medical staff, creating deep distrust within the Black community regarding the healthcare system. Public health data from that time indicate that while white Americans’ health outcomes were improving at the beginning of the 1900’s, the health of Black Americans was deteriorating.

For more resources on this subject, see:
Note on terminology: Historically, “negro” or “colored” were often terms used to refer to Black Americans in historical publications and documents. Please take time to explain that although historically accurate and relevant, when talking or writing about Black Americans in the present time, it is unacceptable to use this term. Encourage them to use “Black” or “people/person of color” instead. Students may appropriately use these terms in their writing if quoting a source document and including [sic] following the term, to signify that the term is used to preserve historical accuracy. They may also need to use the term when citing or listing references, in which case they should follow standard practice for the chosen citation style. For more information, you can read this explanation, A Note on Historical Language.  

Activities Summary: The following is a brief summary of activities included in this lesson. Faculty are encouraged to pick and choose the activities that work best for their students and course. Faculty may also modify activities through adding readings or changing learning modalities, instructions, or evaluation criteria as they see fit.
  1. Demonstrate an understanding of social determinants of health Students will post one question and one takeaway in a discussion forum and comment on at least 1-2 classmates' posts. Alternatively, they can work in small groups to generate and share takeaways and questions in class. Students will articulate the importance of considering social factors that impact health, not just individual choices. Asynchronously, they may find and share current news articles about SDoH in their community. 
 
  1. Develop an analysis of the intersecting legacies of structural racism in social determinants of health and healthcare Students will apply their understanding of Social Determinants of Health (SDoH) to historical contexts by analyzing key factors affecting the health of Black Chicagoans during the Jim Crow era. They will then compare these historical findings with current issues in health equity and SDoH for Black people in Chicago. Students will identify areas of progress and ongoing challenges, presenting their findings through presentations, papers, or op-eds.
________________________________________________________________________________________
Activity Plan 1: Understanding social determinants of health 

Preparation: Pre-Class Reading & Review of Reading
Students should prepare for class by becoming familiar with the historical context of this lesson. Have students read and/or watch videos. Take some time to check for students’ understanding and questions. Faculty are encouraged to select the material(s) most appropriate for their students’ learning level. 

Materials Related to Social Determinants of Health

Materials for historical context: Jim Crow & the Great Migration

Jim Crow:
The Great Migration
Main activity: Discussion and Primary source analysis
 
  1. Options for gathering students’ thoughts & questions on reading: 
Online/Asynchronous: Ask students to post one key insight they learned about historical SDoH, and one question from the reading in a discussion forum. Require students to comment on at least 1-2 classmates’ posts to answer each other’s questions.

Prompts example: 
In-Person: Divide students into small groups at the beginning and ask them to generate three takeaways and three questions as a group. Then have small groups share back to the class and discuss similarities and differences and the questions posed by each group.

Prompts example:
These strategies are designed to help the faculty understand how much students have prepared and understand about the concept of SDoH as well as about the basic relevant history.

Optional Introduction to the Concept of SDoH  
Show students this graphic, created by the U.S. Department of Health and Human Services. 

Explain that this graphic shows the central idea of today’s lesson: “Social Determinants of Health.” 

Prompt students to list examples of where they see SDoH in their own lives or city today. 
Asynchronous option: require students to find and briefly summarize and apply a current news article and its relationship to SDoH in their community.

Ask students to articulate: How do SDoH impact a person’s health and their individual choices or health behaviors? 

Emphasize that by the end of this lesson, students will be able to describe the SDoH for Black people in northern cities during the Jim Crow era and draw connections to SDoH for Black people and other marginalized groups in the U.S. today. 

This lesson thus aims to help them to understand the origins - the why - of the many inequalities and injustices that they will encounter in their clinical practice.

 

  1. Analyzing Primary Sources from the Jim Crow Era (Individual online or group work in-class) 

Note: this step encourages students to practice critical reading and analysis skills by considering the purpose and perspective of primary sources. However, instructors could shorten this lesson by having students skip the primary source analysis worksheets and go straight to developing the community health assessment.

Explain to students that they will now be analyzing primary sources about life for Black people in Chicago during this era. Emphasize that although Jim Crow laws were technically not enforced in northern cities, white individuals and organizations still practiced rampant racial discrimination against Black Americans, Jewish people, and other people of color. 

Encourage students to watch: Introduction to Historical Study I: Analyzing Primary Sources to gain foundational skills necessary for engaging critically with historical artifacts.

Pre-teach: Source images include “visiting nurses,” explain that these were nurses usually hired by government agencies to go to people’s neighborhoods and homes to care for them, because they did not have other access to healthcare. For many Black nurses, this was the only employment option in this era because private, white-run hospitals would not hire them, and white nurses often refused to treat Black patients or enter Black communities.

Sources here: SDOH Gallery Walk

Have students choose 1-3 sources for which they will complete an analysis worksheet for each source:
EvaluationRubric for Primary Source Analysis - photo.docx or Rubric for Primary Source Analysis - written.docx 
 

  1. Optional extension or substitution: Researching SDOH through Historical Newspapers. Instructors could also challenge students (individually or in groups) to find additional primary sources about life for Black Chicagoans at this time.  

 
  1. Black newspapers can be a wealth of information about the experiences of the Black community in this era.
 
  1. The Library of Congress has an online photo archive with lots of relevant images

Instructors should model how to filter and search with Boolean logic.
Recommended search terms: 

 
Students can build a collective set of primary sources for each other by sharing images and articles on a Jamboard, Google Slides Presentation, Padlet, etc. Faculty can opt to include a reflective writing prompt regarding the activity, an in-class discussion or debriefing, or evaluate based on participation in the activity. 
 

Activity Plan 2: Develop an analysis of the intersecting legacies of structural racism in social determinants of health and healthcare 


Main Activities: SDoH Analysis and Presentation
 

  1. SDoH Analysis of Historical Black Chicago (Two Options) 

Note that likely both options below will require students to do some outside research. Remind them to use scholarly or reliable sources and documents, and to cite their references appropriately. 
 
  1. Sectors of SDoH analysis and reflection
Using a Social Determinants of Health (SDoH) Analysis Worksheet students will identify one key factor for each of the five sectors of SDoH theory with the primary sources featured in the SDoH Gallery Walk:Rubric for SDOH Analysis
 
  1. Community Health Assessment 
You can use this lesson as an opportunity to introduce students to the idea of a Community Health Assessment (CHA) and have them conduct a CHA of the Black neighborhoods of Jim Crow-era Chicago: 

Community Health Assessment Worksheet
Rubric for Historical CHA
 

2. Comparing Historical and Contemporary SDoH for Black Chicagoans (individual asynchronous paper or presentation; asynchronous or in-class group presentation)


In this concluding assignment, students will draw parallels between the primary sources that they studied and current issues in health equity and SDOH. Encourage students to consider how historical and ongoing structural racism has influenced SDoH challenges and affected health data collection and reporting, particularly for marginalized communities. Remind students to be critical of sources and aware that data on marginalized communities has often been incomplete or biased. This acknowledgment can help students approach historical data limitations and modern challenges with a more nuanced perspective.

Students will compare the themes and issues identified in the primary sources with SDoH challenges for Black people or other people of color in Chicago today. However, for schools located in or near other communities, it may be more useful, appropriate, or engaging to have students choose their own communities rather than Chicago.

Students will be asked to identify one (or more - instructor choice) area of SDoH where there has been marked progress in the last 100 years, as well as one (or more - instructor choice), where there has been slower progress (or perhaps even regression) in the last 100 years. 

Assignment Description & Rubric: SDOH Past-Present-Description & Rubric

Resources for students’ contemporary research:
Options for formats of assignments:
  1. Individual/Group Presentations: groups/individuals sign up to research different sectors of SDOH and do a presentation for the class.
  2. Individual/Group papers: groups/individuals write a reflection essay in response to prompt
  3. Individual/Group op-ed: groups/individuals write an op-ed highlighting the chosen issues. Op-Eds can give students the opportunity to practice important skills, including developing their own voice, honing well-crafted arguments, and learning to communicate complex health issues to a public audience.
Op-Ed in classrooms resources: 


Students should use both historical and contemporary sources in their assignment. 

For all options, instructors are encouraged to find opportunities for students to share their work with each other and identify common themes or questions. Feedback and discussion with classmates (synchronous or asynchronous) can help create an atmosphere of intellectual engagement and curiosity with this very broad and crucial topic.
 

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