In late February 2021, the Journal of the American Medical Association (JAMA) published a podcast called “Structural Racism for Doctors — What Is It?” The podcast was meant to be an educational tool, but it ended up being a teachable moment for much different reasons than intended.
Structural racism is a key determinant of health, impacting health through residential segregation, health care access, incarceration, police violence, pollution, maternal mortality, psychological stress, and many other avenues. Rather than delve into these connections, the host, former JAMA deputy editor Dr. Ed Livingston, questioned whether racism still exists, suggested that we stop using the word racism because it offends white people, and said we should focus not on racism but on socioeconomic status to fix racial inequities.
“The use of race for any sort of transactional activity was made patently illegal by the civil rights legislation passed in the 1960s,” said Livingston, who is white, on the podcast. “Given that racism is illegal, how can it be so embedded in society that it’s considered structural?” The other podcast participant, head of NYC’s public hospital system and JAMA Internal Medicine editor Dr. Mitchell Katz, tried to explain structural racism to Livingston, but did not push back very hard against the host’s assertions.
Many listeners were shocked to hear an editor of a major medical journal display such lack of awareness and readily dismiss the impacts of racism. Others, especially people of color in medical research, were upset but not surprised, because they’ve seen how publishers treat structural racism as a research topic. The podcast and subsequent fallout has inspired researchers to speak out on their experiences with medical journals and demand accountability. These researchers assert that the podcast is a symptom of the much larger problem of prestigious medical journals dismissing or downplaying issues of race in health research.
Afraid of the word racism
On the JAMA podcast, Livingston bristled at the use of the word racism. “Personally, I think taking racism out of the conversation would help,” he said. “Many people like myself are offended by the implication that we are somehow racist.”
The tendency not to use the word racism when talking about the causes of racial inequities is a common theme in medical publishing. In a recent op-ed in the Washington Post, Dr. Ron Wyatt, co-chair of the Institute for Healthcare Improvement’s equity advisory group and faculty member of the IHI Pursuing Equity Initiative, shared that he had submitted a paper to JAMA with the title, “Racism in Health and Healthcare: Challenges and Opportunities.” The editor-in-chief told Wyatt and his co-author that he would not publish the title as-is, because using the word racism would lose them readers.
“Solving systemic racism in public health must start with naming it. We must publish the word. We must say the word.”
Dr. Ron Wyatt
In another case, a major healthcare trade magazine changed “racism” in the title of Wyatt’s accepted article to “intolerance.” This pattern is not new; in fact, from 2002 to 2015, there were no articles in JAMA or the New England Journal of Medicine that used the word racism in their title or abstract. But it has continued in recent years, despite major players in the medical field promising to address racism in medicine. “I still sometimes feel that survival mechanism kick in to compromise and veil the truth that structural and systemic racism is a root cause of preventable harm and death across U.S. health care,” wrote Wyatt.
Race as a research topic
Researchers are also concerned that journals are not taking enough care to ensure that use of race in research is done consistently and rigorously. In a piece in Health Affairs last summer, Dr. Rhea Boyd, pediatrician and director of equity and justice for the California Children’s Trust, and colleagues discussed some of the pressing issues with race and research. Boyd and colleagues write, “There is no uniform practice regarding the use of race as a study variable and little to no expectation that authors examine racism as a cause of residual health inequities among racial groups.” The lack of strict standards makes it more likely that researchers attribute racial differences to genetic or biological factors when racism is really the underlying cause.
Others have noted the way in which journals treat race in medicine as different from other medical specialties, often not requiring the same level of expertise. The JAMA podcast itself is a great example of this. It’s hard to think of other topics that a leading medical journal would create a podcast about with no actual experts in the field on the episode.
“This podcast was for CME credit. If they were teaching about any other subject, like glaucoma, they would have had experts, and neither of these men are experts.”
Dr. Clarence C. Gravlee
“This podcast was for CME credit. If they were teaching about any other subject, like glaucoma, they would have had experts, and neither of these men are experts,” said Dr. Clarence C. Gravlee, associate professor in the department of anthropology at the University of Florida, in Stat News. Gravlee has made the transcript of the episode available as a lesson for his classes on medical racism. His recent essay, “How Whiteness Works: JAMA and the Refusals of White Supremacy,” uses the podcast as a real-world example to show how white people often refuse to understand and deny racism.
The CDC takes a stand
When research on racism is stifled or whitewashed, researchers and the broader health care community are harmed. Recognizing the impact of racism on health, creating standards for research, and investing in this research is necessary to learn more about how to dismantle racist systems that cause poor health.
There already may be some progress on this front– besides the growing movement to hold medical journals accountable, the Centers for Disease Control and Prevention (CDC) recently declared racism a public health threat, and launched a new agency-wide initiative called Racism and Health, to refocus the CDC’s public health efforts on researching and taking action on this issue. The declaration of racism as a public health crisis is long overdue, but it points to an encouraging trend of health care institutions finally listening to researchers like Drs. Camara Jones, Nancy Krieger, Mary Bassett, David Williams, and many others who have been shining a light on the problem for decades.