At the end of biology class, Ana, a sophomore, asked if she could talk with me in private.
"Ms. Lindahl, do you know who is a good cancer doctor in Portland?"
I was stabbed with sadness—we were in the midst of our cancer unit. I've included a study of cancer every time I teach mitosis. I love how it helps students see the powerful and personal implications of errors in cell division. But, without fail, painful stories arise during and after class.
I have spent the last six years teaching high school science in Southeast Portland. We are located in the heart of the largest immigrant area in our city, and at least 80 percent of our students qualify for free or reduced lunch. Every day I witness how poverty and language barriers create serious challenges in my students' lives.
Ana came to me with the desperate hope that I was an expert on cancer treatment. I'm not. I listened to her story. Her father had just been diagnosed with advanced cancer. They were looking everywhere to find treatment and they lacked insurance. Because her parents spoke little English, Ana was trying to negotiate a system that could confuse and intimidate the most privileged adult. She was frustrated and frightened. All I could give her was sympathy and general suggestions. I was impotent to provide any real comfort. Mixed with my grief for her was anger that she was in this position and that, as a society, we couldn't do better.
Ana's story was one among many. So many students have raised their hands on the first day of the unit to tell the class about a family member who has survived, is suffering, or has died from cancer. One year, a father came to parent conferences ravaged by the late stages of lung cancer. His son had shared his father's diagnosis with his classmates one day during the cancer unit. Not long after, I found out that his younger brother had also been diagnosed with cancer and was facing a series of surgeries.
As the years passed, I became more and more convinced that cancer rates, severity, and survival in this community were worse than in the white, upper-middle-class community I was raised in. As I began to look at research around cancer rates and mortality, my fears were confirmed. Race and class play a key role in who gets a cancer diagnosis and who lives to tell about it.
My unit had always started with students reading fictionalized stories of a diverse range of people who develop cancer (National Institutes of Health). As a class, we collected data on risk factors and the types of cancer their characters were diagnosed with. Students often pointed out that, in our scenarios, people with less access to health care were more likely to die from the disease. After these discussions, the students learned current theories about how and why cancer develops. The unit ended with each student taking on the role of an oncologist. I assigned them each a patient, and they created brochures that explained how a particular chemotherapy drug disrupted cell division and could stop that patient's cancer from spreading. Some years I gave students the additional challenge of performing in front of their peers; they acted in a short scene, meeting with their patients and teaching them about how their chemotherapy drug worked.
In many ways, this curriculum was innovative and effective. My students saw the real-life implications of cellular biology. They were involved in interactive role plays and they delved into writing about how chemotherapy works. Despite all that seemed to be going right, I became troubled.
I recognized that my curriculum never directly addressed the sadness and fear these lessons evoked in my students. I worried that I had used a topic because I knew it would generate an emotional response and draw them in, but that I wasn't directly acknowledging their fears, their pain, and their difficult questions:
"Why do so many people in my family get cancer?"
"What happens if we can't get insurance?"
"What if my whole family is eating the stuff you said we shouldn't be eating?"
I came to see that teaching about cancer needed to be about more than the specifics of mitosis and mutations. My students needed to hear the difficult and troubling story of this disease: We live in a world that puts some of us at more risk than others. I needed to develop a new curriculum that would teach the biology of cancer while also exploring its complex origins and outcomes. Finally, I needed to arm my students with the tools and knowledge to face this disease and to consider the kind of social changes necessary to address both its causes and effects. They needed a curriculum that could help them save their own lives.
So this year I spent time with cancer statistics. A lot of time. I combed through resources for information on cancer disparities and worked with other teachers to imagine what my lessons could look like. I faced a daunting task. I needed my students to understand that cancer is a disease of societal inequity, genetic predisposition, and personal choice—albeit choices rooted in the nature of our society. My lessons needed to take a hard and direct look at the uncomfortable questions I had sidestepped. And the curriculum had to guide students to a place of hope and activism.
I decided we would start off with the biology of cancer and the role play, but after that, students would analyze demographic disparities in rates of cancer diagnosis, treatment, and outcome. Then, I would assign students a specific community and they would delve deep into data that showed which cancers were most common in that community. They would read about the reasons behind these disparities. I knew I would expose my students to troubling data, so we needed to spend significant time thinking about how we might decrease these cancer inequities. Student teams would brainstorm ways to decrease disparities, design action campaigns, and present to one another. Finally, they would advocate for a community in real life.
Despite all my planning, I was scared to start, worried that I was launching into something too difficult and too depressing, fearful about effectively guiding discussions about race and class. Despite my misgivings, I knew it was time to take a leap.
When the day arrived, I started with a lesson on the deeper causes underlying common cancer risk factors. Many cancer risk factors, such as smoking and diet, are often thought of purely as issues of personal choice. However, these simplistic judgments quickly break down on deeper analysis. I wanted to get my students thinking about the role of risk factors in different stages of the disease. Some, like pesticide exposure, can increase cancer incidence, while others, like lack of cancer screening, can affect mortality.
To prepare students for this type of analysis, I assigned small teams several risk factors (e.g., eating fast food, living near a mine) and they placed them into risk categories: behavior, genetics, workplace safety, environmental safety, and access to health care. They discussed whether each factor fit in one category or multiple categories. They also considered if the risk factor affected cancer incidence, mortality, or both. As groups reached consensus on risk category assignment, I had each team present their ideas to the rest of the class. I asked them to pick the risk factor that required the most thinking and discussion. Some comments from that day:
I don't think it is right to say eating healthy food is only about choice and behavior. What if you don't have a lot of money? What if you live somewhere with only fast-food restaurants? I think that maybe it is environmental safety, too.
If you live near a mine and chemicals get into your water . . . that could increase your incidence. But we thought it could also increase your mortality because you get your cancer treatment, but then you go right back home to the environment that made you sick.
Who Is at Risk?
On our next day in class, it was time to move beyond speculation and spend time with real data. I gave each student a National Cancer Institute (NCI) graph on how incidence and mortality vary by race/ethnicity and by cancer type. As they examined it, I had them write about patterns and disparities. I asked them to think about potential problems with sorting people by race and ethnicity. One example students noted was that multiracial people are not identified at all.
After students shared their ideas in small groups, I gathered everyone together for a formal Socratic seminar. We went over norms for our discussion: Keep an open mind, build on each other's ideas, respect air time, use the text, and speak to each other. As I do before every Socratic seminar, I reminded my students that we were going to work together to explore complex ideas, and that all real data are open to multiple interpretations and further questioning. Careful listening and taking time to think before talking would help them reach a deeper understanding. I asked them to share what they noticed about disparities, to talk about reasons they think these disparities might exist, and to consider the strengths and weaknesses of breaking down cancer statistics in this way. Students started by identifying patterns they saw in the graph, and we started to explore risk factors that might be at work.
I was taken aback, again and again, by their careful and nuanced thinking. "I noticed that black women are less likely than white women to get breast cancer. But they have higher mortality. What if that is because of access to health care? If African Americans have higher poverty rates, maybe they aren't getting screened or treated in time?" or "Lots of Asian Americans still have a different diet because of their culture. In my family we eat a lot more fish because we eat Japanese food. Maybe that changes our risk."
One student questioned thinking about cancer through the lens of race: "How can a race like 'white' or 'black' mean anything? Not all people of a race have the same genetics. I don't think it is right to make this graph. I think it is racist." I pointed out how looking at statistics by race can help us see the effects of racism. But later I realized that I need to do more careful teaching on this point. Because a vulnerability to some cancers (e.g., breast and other gynecological cancers) can be genetically transmitted, it's easy to confuse race with genetics. Race is socially constructed—it's an institutional and historical category with no basis in biology. So when we're looking at racial statistics on cancer, we're looking at the structural impact of racism on communities.
Cancer and Social Justice
It was time for the students to dig deeper into how cancer affects specific communities. I assigned each small team a different group (e.g., African Americans, rural poor, the elderly, Asian Americans/Pacific Islanders). These groups, which obviously overlap, are identified by the Intercultural Cancer Council (ICC) as facing significant cancer disparities. I gave each student group a packet of data and fact sheets specific to that community. Each packet included ICC fact pages on cancer disparities facing this group and relevant NCI data and graphs. For example, the group researching Latina/os saw that cervical cancer incidence in this community is somewhat higher than average, but that cervical cancer mortality is extremely high. They read about reasons for this: late diagnosis, language barriers between doctors and patients, fear of screening.
We spent one class period identifying the most worrying disparities and likely causes: Was family income and lack of access to health care a driving force? Could workplace or living conditions account for these disparities? As they discussed their ideas, I circulated around the room and talked with teams.
Many students quickly identified risky behaviors as a cause for disparities. When I heard this, I pushed each group to move beyond the simplistic view that cancer is a result of unhealthy personal choices. "Which causes are beyond the control of that community?" I asked. "How might corporate and government policies, pollution, and racism play a role?"
Finally, students brainstormed actions that would decrease cancer rates in this community. "If you had the power to help this community in the best ways possible, what could be done to lower cancer rates and increase survival?" I asked. "These solutions will likely look different in different communities. Imagine the many small solutions that could eliminate the big disparities you've been seeing."
Ideas for solutions, small and large, began to pour out of my students. Some saw the need for education ("Could we help Asian kids understand how important it is not to smoke?"), others saw how targeted cancer screening could help ("How do we increase rates of pap smears among Latina women?"), and many students identified the need for making both screening and treatment more affordable ("How do we pass a law to bring health care to everyone?"). Working in their small teams, my students were charged with planning a step-by-step action campaign for their community. What disparity were they most disturbed by? What were its causes? What were some possible solutions? What stakeholders would need to be involved in this effort? Each team created a poster that proposed a way to "narrow the health gap" in their community.
A team researching the rural poor produced a particularly thoughtful action campaign. On reading that rural poor women have elevated rates of breast cancer (both incidence and mortality), they determined that lack of access to health care was a major barrier for this group of women, especially in Appalachia. They read that many of these women live far from medical facilities, work long hours, and report that visits to the doctor are prohibitively difficult and expensive. The team determined that the best way to help these women would be to bring free mobile breast cancer screening clinics to work sites.
Other teams focused on education and legislation. One proposed K-12 education programs on healthy eating and several groups presented on the need for universal health care legislation. Other groups designed billboards and storyboards for public service announcements. On our presentation day, students shared their campaign ideas with classmates and ended the day writing about which approaches they thought would have the biggest and best effect.
With the first semester drawing to a close, we needed to move on to our genetics unit, but I organized biweekly lunch meetings for the students who wanted to take action. One student created a refrigerator checklist she gave to all of her family members. It provided concrete steps for protecting against skin cancer, a common diagnosis in her family. Two other students began exploring the need for medical interpreters in Oregon. They have been contacting local immigrant rights organizations and are discussing the need for new legislation in our state.
I won't deny that this project scared me. As my students began asking probing questions about injustice, racism, and poverty, I was often overwhelmed and unsure of how to answer. I was also asked, more than once, why we weren't doing our usual labs and science content. As each day of new curriculum drew to a close, I was painfully aware of my missteps and fumbles. Still, despite my misgivings, I ended the unit with the growing certainty that I was heading in the right direction. When the bell rang at the end of each period, students lingered and wanted to talk. I saw more hope than sadness. When my students evaluated the unit, they wrote about their desire for action, on both personal and larger scales. They were glad we spent time with real data. They felt well informed and equipped to fight cancer inequities.
I realize that other science teachers may balk at the idea of trying to tackle so many social issues in a biology class. Believe me, I had the same misgivings. Each previous year, I had been lulled by the little voice that insisted, "Isn't teaching the health inequities in our society somebody else's responsibility? Aren't social studies teachers supposed to do that?" Overwhelmed with the science standards and skills I am responsible for teaching, I had made my excuses and walked away from the hardest questions my students ask. But, as I look back and face those questions more honestly, I see that our students need and deserve a new curriculum. As science teachers, we must guide and support them as they grapple with the difficult questions our lessons inspire. Our students are ready to look at the prejudice and inequities in our society straight on. They are waiting to be taught how to demand a better and healthier world. Let's help them do it.
Notes and Resources
National Institutes of Health, Cell Biology and Cancer Curriculum Supplement
National Cancer Institute, Epidemiology and End Results
Intercultural Cancer Council