Introduction

Events such as the COVID-19 pandemic, police brutality, and climate change have exposed how structural factors such as politics, economics, and infrastructure impact human health, particularly the health of Black, Indigenous, and People of Color (BIPOC). Structural racism is defined as “the totality of ways in which societies foster racial discrimination, through mutually reinforcing inequitable systems (in housing, education, employment, earnings, benefits, credit, media, health care, criminal justice, and so on) that in turn reinforce discriminatory beliefs, values, and distribution of resources.”^1,2 Numerous studies have demonstrated the blatant yet pernicious nature of structural racism in human medicine—across the scale from individual clinical decisions to broad institutional policies—and how structural racism leads to adverse patient outcomes.^2–7 For example, at the individual, clinical level, Black and Hispanic/Latino patients presenting to the emergency room are less likely to receive analgesia compared to White patients, despite no difference in patient pain level or physicians’ ability to assess pain.^8–10 At a broader institutional level, until this past year,¹¹ the standard of practice has been to use race-based, estimated glomerular filtration rate (eGFR) equations to assess kidney function. These eGFR equations use a higher coefficient for Black patients, assuming higher kidney function than white patients with equivalent blood chemistry (ie, serum creatinine) and consequently delaying time to diagnosis of kidney failure and dialysis.^12,13 The above are only a sampling of the numerous examples of how structural racism transcends scales of care and can lead to health inequalities and poor patient outcomes in human medicine.^14,15 Cerdeña et al¹⁴ write, “It is increasingly clear that medicine is not a stand-alone institution immune to racial inequities, but rather is an institution of structural racism.”

Veterinary medicine, as with human medicine, is not immune in its role as an institution of structural racism. Many of the same disparities that negatively impact the quality of care for human patients extend to animal patients and limit the agency that clients have to advocate for the health, welfare, and inherent value of their animals. For example, inequitable access to transportation and consequently to medical care transcends both human and veterinary medicine. Staff and educational materials outside a client’s native language affect quality of care delivered and downstream compliance—whether the patient is a human, companion animal, or production animal. Yet the effects of structural racism within veterinary medicine are grossly underemphasized in both published literature and veterinary professional training. Compared to human medicine, veterinary medicine can more easily deny its role in institutional racism because of its focus on animal health and well-being.

Currently, veterinary students receive little, if any, curriculum on structural racism or the ways in which it influences client relationships and patient care. Most veterinary prerequisites do not include social science coursework (anthropology, sociology, political and social geography, etc) that challenges students to critically evaluate the social components that influence health. Further, clinical medicine training has primarily focused on understanding the molecular basis of disease, producing a “desocialization” of medicine.¹⁶ By only training students in biology-based curricula, veterinary students and the profession as a whole lose sight of the fact that medicine is a biosocial phenomenon.¹⁶ This greatly curtails the type of future clinicians we are training and subsequently impacts how medicine is practiced and the care our patients receive. While veterinary programs are increasingly committing themselves to Diversity, Equity, and Inclusion (DEI) through strategic plans, diversity statements, and building diversity committees, to date, only a handful of studies have been published on how veterinary colleges have integrated DEI into medical training.^17–19 What information is available generally focuses on diversity modules^20,21 and competency-based education^22–25—particularly cultural competency training. Yet it is imperative that US veterinary institutions move beyond these efforts and instead train students to think about how social biases, stigma, internalized racism, and power dynamics shape perceptions of health and disease.^2,26 Recently, the AVMA Council on Education (COE), the only accrediting body for US veterinary colleges, updated their accreditation standards for veterinary medical colleges to emphasize incorporating:

Opportunities throughout the curriculum for students to gain and integrate an understanding of the important influences of diversity and inclusion in veterinary medicine, including the impact of implicit bias related to an individual’s personal circumstance on the delivery of veterinary medical services.²⁷

In addition, prospective veterinary students can now use an online tool from the American Association of Veterinary Medical Colleges to evaluate schools on the basis of their DEI programs.²⁸ Between both the top-down pressure from the COE and bottom-up pressure from prospective students, veterinary colleges must thoughtfully implement DEI into their curricula to provide more socially just care. Here, we define veterinary curricula to include all medical, clinical, and professional development training in veterinary colleges. To meet the standards outlined above from the COE—and the needs of the veterinary community—veterinary colleges must integrate DEI throughout veterinary training and invest in cultural shifts to ensure that the veterinary profession represents and serves all members of the community. Therefore, we need practical steps to develop this type of training into veterinary curricula within the US.²⁹

The Multicultural Veterinary Medical Association (MCVMA) was formed in 2014 with the mission to “lead veterinary medicine toward the racial and ethnic diversity, equity, and inclusivity that our profession needs to serve a multicultural society.”³⁰ The MCVMA, along with 9 other diversity, equity, and inclusion affinity organizations, developed a list of actionable items that was presented to the AVMA to address systemic racism in the veterinary profession.³¹ The 7 actionables included (1) Self-Assessment, (2) Accessibility, (3) Accountability and Transparency, (4) Expanding Membership, (5) Organizational Commitment, (6) Investment, and (7) Outreach and Engagement. In this paper, we employ the MCVMA actionable items to provide a framework for how to integrate anti-racism into the veterinary curriculum. Each heading that follows represents a specific MCVMA action item, or pair of items, as we have translated them to the development and deployment of veterinary curricula, including the following: (1) Accountability and Transparency; (2) Accessibility, Outreach, and Engagement; and (3) Expanding Membership, Organizational Commitment. By focusing on tangible efforts veterinary colleges can and should make, we believe the proposed framework can better serve the veterinary profession and our communities.

Accountability and Transparency: Implement Processes for Which COE-Accredited Colleges Will Be Held Accountable in Regard to Diversity, Equity, and Inclusion Curricula

To hold veterinary colleges accountable for meeting DEI accreditation standards, we draw not just from the growing veterinary literature but also from the extensive experience of human medical training programs. Human medical training has included standards for “cultural competency” since the early 2000s,³² and in recent years, veterinary medical education has made moves to implement cultural awareness and competency training.²⁰ In this section, we first discuss some key limitations of the cultural competency framework and then offer a path forward through 2 complementary approaches: structural competency and cultural humility.

Accessibility, Outreach, and Engagement: (1) Ensure Student Training in Equitable Clinical Practice and Access to Care, and (2) Advance Lasting Diversity, Equity, and Inclusion Initiatives Between Academic Institutions, Veterinary Practices, and Communities

In their systematic review, LaVallee et al⁴⁸ identify several barriers that clients face in accessing veterinary services for their pets, including cost, accessibility, veterinarian-client relationships and communication, cultural and language differences, and lack of education about the importance of routine veterinary care. Such barriers sow mistrust of veterinary providers and widen divides in access to care and pet health, mimicking similar trends in human health care.⁴⁸ As in human medicine, structural barriers create significant challenges for veterinary clients, which often surpass our animal-centered veterinary knowledge and demonstrate the need for diversity within the profession.

Existing person-focused veterinary courses are often limited to clinical communication curriculum where building trust between the veterinarian and client is focused primarily on client compliance and delivering scientific information in plain language^49,50 versus understanding (a) where our mutual biases influence clinical reasoning, (b) how different sociocultural backgrounds affect power and trust between the veterinarian and client, and (c) what our client’s individual challenges, needs, and preferences are for care.

When DEI is incorporated into client communication courses as “culture,” diverse worldviews are depicted as a deviation from Western medical and scientific standards. The presumption that these standards are correct and superior is how settler colonialism becomes embedded in veterinary teaching, research, and practice. When “tolerance” becomes the predominant message, students learn white supremacy by “allowing” these differences to exist instead of understanding how diverse perspectives are additive to veterinary education; they enrich the profession and grow our practice toward real earned trust and real equitable care delivery. Experiential learning opportunities, like outreach clinics and service learning programs, make trust restoration, equity, and professional enrichment possible^48,51–53 because veterinary students learn directly from knowledge-holding clients. Service learning programs have notable benefits in developing students’ confidence, clinical reasoning, client communication, and clinical skills.⁵³ These programs also teach students to adapt their communication styles and information delivery to clients who have varying degrees of access to health education and personal, social, and cultural beliefs about pet ownership. Sample et al⁵² describe 2 extracurricular student-run veterinary free clinics at the University of Minnesota College of Veterinary Medicine that provide preventive care services for pets and pet owners historically excluded from accessing veterinary care. These programs serve urban communities in Minneapolis, Minnesota monthly and 6 Native American communities in outstate Minnesota several weekends per year who have been disproportionately impacted by historical and intergenerational trauma. The programs work closely with community leaders to build healthy university-community partnerships, understand community needs, and amplify existing community or traditional knowledge about pet guardianship. Under the supervision of licensed veterinarians, preclinical veterinary student volunteers in years 1 to 3 learn to navigate clinical conversations with cultural humility, develop diverse and novel strategies for delivering care, and integrate herd and environmental health into clinical decision-making. King et al⁵¹ describe similar community partnership building at the Tufts Cummings School of Veterinary Medicine’s Tufts at Tech community clinic. This 3-week service-learning clinical rotation is required for all veterinary students in their clinical years. The rotation incorporates time for reflection and increases students’ self-awareness and civic engagement, working “with community members in a way that encourages them to critically examine their own held biases and attitudes toward underserved communities.”⁵¹ In addition to the extracurricular programs for preclinical students described earlier, the University of Minnesota College of Veterinary Medicine runs an elective, 2-week clinical community medicine rotation for fourth-year veterinary students at an area non-profit veterinary clinic where students challenge their own internally held biases. One student reported:

“Because of this rotation, [I] can definitively debunk the misconceptions [about] pets that live in under-resourced communities. The human animal bonds these clients have were the strongest I [have] ever seen, and I hope to learn more about how we as the veterinary community can keep working with these owners, as a team, to provide the best care for their pets. Not only did I learn about empathy, humility, and One Health, I actually learned a lot about myself, which I did not expect coming into this rotation. I have always doubted my racial identity, especially after moving to the United States, where the majority of the population does not look like me or talk like me. However, working with clients from a diverse background was very eye-opening and a very welcomed change from what I am used to.”

While students are encouraged to seek out service learning and outreach opportunities like these to learn about diversity in veterinary medicine, to only include it in the context of underserved clients can perpetuate exclusion and White saviorism. It is critical to provide veterinary care in historically excluded communities and prepare students to practice along a spectrum of care. However, if these experiences are students’ only context for DEI and BIPOC clients, this reinforces top-down approaches to medical decision-making, upholding the inherent hierarchy of power versus working toward dismantling it. Therefore, in addition to providing experiential learning opportunities for students, we recommend that veterinary schools integrate similar ideologies about social awareness⁵⁴ and the value of community-level knowledge throughout the didactic curriculum.¹⁷ Hammond and Runion⁴⁷ describe a 1-week, AAVMC-led intensive course on DEI piloted at North Carolina State University College of Veterinary Medicine. The voluntary course provides an immersive learning experience for second- and third-year students who have a professional interest in the content. In addition to cultural humility and implicit bias, students learn about classism, social justice, identity development, and access to care through facilitated discussions with trained faculty members, active learning exercises, self-reflection, and critical assessment of systems of oppression. Coupled with service learning programs, this pilot course can serve as a model for transformative learning and provide a foundation for integrating specifically designed DEI courses throughout all 4 years of the veterinary curriculum.

Expanding Membership, Organizational Commitment: (1) Identify Opportunities to Create a More Diverse, Equitable, and Inclusive Curriculum and (2) Ensure That Faculty and Administrative Educational Staff Are Trained in Structural Competency and Cultural Humility and Acting in the Best Interests of All Students

A wealth of publications and efforts are working to address DEI in admissions standards, and we direct interested readers to this important work.^55–58 Here, we focus on DEI within veterinary curricula, for which “expanding membership” may best be represented by increasing efforts to involve and support a more diverse body of veterinary instructors. The lack of diversity in the veterinary profession creates a dearth of same-race role models for prospective and current veterinary students. Research in ecology and evolutionary biology—a field that, similar to veterinary medicine, has historically excluded BIPOC communities but has had high representation of women—has found that access to more same-race role models is a significant predictor of interest in graduate school.⁵⁹ A diverse body of veterinary faculty thus provides critical mentoring opportunities for undergraduate and veterinary students. Evidence suggests that STEM fields in the US are associated with persistent racial and ethnic inequalities and “opportunity hoarding” (privileging of white and excluding BIPOC students in fields with high social and economic value).⁶⁰ In this context, the absence of diversity among veterinary faculty is likely to only exacerbate such opportunity hoarding through the privileging of white and exclusion of BIPOC representation among instructors and mentors.

However, recruiting more BIPOC students and faculty does not equate to crafting a truly racially inclusive and equitable environment.⁶¹ For example, the critical mentoring we described often results in extensive undocumented and unappreciated effort (commonly referred to as “invisible labor”) among BIPOC scholars:

That invisible labor reflects what has been described as cultural taxation: the pressure faculty members of color feel to serve as role models, mentors, even surrogate parents to minority students, and to meet every institutional need for ethnic representation.⁶²

This pressure on BIPOC faculty to meet the needs of all ethnic representation can be all the more prevalent when the diversification of the student body outpaces that of faculty.⁶² In addition, BIPOC and female faculty are more likely to experience negative bias in student evaluations (which are often considered in hiring and tenure processes) of teaching compared to their White, male colleagues.^63,64 To recruit and retain diverse faculty, veterinary colleges must create a fundamental DEI cultural shift within their institutions. For example, colleges should consider progressive performance evaluations and alternative performance metrics for faculty and staff—including within the tenure process—such that BIPOC scholars are rewarded for their otherwise invisible labor. Formally acknowledging these efforts would highlight DEI as a priority within an institution, rather than a side effort. We would also point out, however, that institutions should provide mentoring and resources to BIPOC scholars to support their agency in setting their career and professional development priorities, given the extensive service requests placed upon their time. BIPOC faculty should be rewarded for their service and mentoring labor but also have the choice to say no if service demands do not align with their priorities.⁶¹

Institutional culture shifts that increase the involvement and support for BIPOC faculty not only “expand membership” within veterinary curricula but also help demonstrate organizational commitment to DEI. These efforts must be augmented, however, by additional organizational efforts to ensure these culture shifts are experienced across all faculty, staff, and students. For example, most veterinary teaching faculty receive little to no formal training in teaching in higher education,⁶⁵ let alone teaching structural competency and cultural humility. Structural competency and cultural humility approaches take time and require faculty from diverse fields to lead, particularly those in the social sciences including biological, social, and medical anthropologists; social epidemiologists; and historians.² If veterinary colleges are truly committed to prioritizing how structural factors influence health outcomes, then veterinary colleges must hire faculty from outside of veterinary medicine who are trained and actively engaged in this work. Without training and support for faculty to engage with students in these often sensitive discussions, DEI efforts are likely to be localized within a select few teaching opportunities and may result in poor outcomes (eg, rejection of structural competency training if presented by an instructor who does not fully understand these concepts). To demonstrate organizational commitment to DEI in veterinary curricula, it is therefore imperative that veterinary colleges invest in personnel with DEI expertise and that faculty instructors receive the DEI training and support required to best serve themselves, their students, and the veterinary profession.

Conclusion

To address structural racism’s effects on patient care from individual to institutional scales, veterinary medicine must progress in its approach to DEI curricula. We have highlighted how the MCVMA’s actionables can help direct these efforts through the following:

1. 1. Accountability and transparency: Shift to teaching structural competency and cultural humility, and implement mixed approaches to evaluate student growth.
2. 2. Accessibility, outreach, and engagement: Extend DEI curricula beyond client communication and use models such as service learning programs to train students in equitable clinical practice. Service learning programs can serve as a starting point for how to teach DEI in didactic coursework.
3. 3. Expanding membership, organizational commitment: Recruit and support a diverse body of faculty and staff, and support institutional cultural shifts to make DEI a core tenet in improving animal health and well-being.

All of these efforts require investments—in time, personnel, and financial resources—from veterinary colleges. The MCVMA’s actionables translate well here: veterinary colleges must provide financial and structural commitments to improve the state of diversity, equity, and inclusion in veterinary curricula. Unpaid, volunteer DEI committees are not enough. To prove that every college website’s DEI page is more than lip service, veterinary schools must recruit, support, and retain the expert staff needed to contribute to curriculum development and improvement and commit to the efforts needed for major cultural shifts in veterinary programs.

These investments are long-term ones, and the actionables we have outlined here should not be treated as a static set of recommendations. They are written from the perspective of veterinary medicine as it exists in our present. We further recognize that veterinarians work across a broad array of fields (eg, small and production animal practice, academic research, public health, etc) that each operate within racist structures, which cannot all be addressed in a single viewpoint article. As we grow in knowledge as institutions, our strategies for creating diverse, equitable, and inclusive veterinary colleges will need to adapt and evolve. Mistakes will be made. But by amplifying the voices advocating for change in our profession and always striving to do better, we can craft a profession best equipped to fulfill the bonds of our veterinary oath long into the future.