Part 1 of 2 Articles (Part 2 Here)
Rejection used to be common for medical sociologist Thomas LaVeist when he tried to get his research published on the effects of racism on the health of black people. “Now,” said the 60-year-old dean of Tulane University’s School of Public Health & Tropical Medicine, “I have those same journals asking me to write articles for them.”
LaVeist’s experience illustrates the dramatic transformation in medical research, accelerating in the past few years. While few would dispute that black Americans are more prone to chronic health problems and have shorter life expectancies than whites, the medical community generally sought answers in biology, genetics and lifestyle. Research, like LaVeist’s, that focused on racism was frowned upon as lacking rigor or relevance, an amateurish detour from serious intellectual inquiry.
Today medical journal editors are clamoring for a racial lens and apologizing for what they call their past moral blindness. In recent years, and especially since Black Lives Matter protests erupted last year, systemic racism has been transformed from a fringe theory to a canonical truth.
Medical researchers are now able to offer a sweeping socio-political explanation for racial health disparities by citing the hundreds of peer-reviewed articles authored by LaVeist and a host of others, thus conferring upon the study of systemic racism the imprimatur of scholarly authority and even settled science.
This year, top officials at the National Institutes of Health issued an apology to all who have suffered from structural racism in biomedical research. The NIH, the nation’s largest funder of biomedical research, announced that it is dedicating $90 million to the study of health disparities and structural racism, engaging in more than 60 diversity and inclusion initiatives, and committing “every tool at our disposal to remediate the chronic problem of structural racism.”
In an August special issue dedicated to racial health disparities, the prestigious Journal of the American Medical Association stated that systemic racism is a scientific fact beyond dispute, and disagreeing on this point is “wrong,” “misguided” and “uninformed.” Systemic racism is a reality to be assumed in medical research rather than a sociological hypothesis to be tested by skeptical researchers.
Deemed incontestable, systemic racism provides the political rationale for “dismantling” — in the words of no less an authority than the National Institutes of Health — the social institutions and cultural standards that, according to the framework’s advocates, were constructed and are maintained to uphold white supremacy.
The consequences of ignoring this new prime directive for racially focused research were made abundantly clear this year when the top two editors of JAMA were pressured to resign after the organization ran a podcast that questioned whether systemic racism explains health disparities between blacks and other Americans.
“When JAMA sends a call for paper on structural racism, when the NIH director sends out an apology letter for racism in the NIH and when the CDC for the first time uses the term ‘racism,’ these are highest-level determinants of what research will be done in coming years in this country,” said Shervin Assari, an associate professor of family medicine and urban public health at Charles R. Drew University of Medicine and Science in Los Angeles, one of four historically black medical schools in the nation.
“This is the first time the NIH has issued a call for research on structural racism. This is the first time JAMA fires an editor who said something wrong about racism,” said Assari, who has published more than 350 papers on race, social determinants and health equity. “Now NIH is paying good money to the best researchers in this country who are competing to understand how structural racism works, rather than if it exists.”
Systemic racism, generally unseen but known by its perceived effects, doesn’t directly cause diabetes, hypertension or depression, but it purportedly creates the living conditions in which chronic conditions opportunistically thrive, advocates say. Such living conditions include unsafe neighborhoods, aggressive policing, substandard schools, discriminatory workplaces, inferior medical care and the resulting stress, despair and self-destructive behavior, the theory states.
To institutionalize its new policy, JAMA is revising its peer review standards and diversifying its ranks to advance health care equity, a term that refers to narrowing or even eliminating racial health disparities in chronic conditions and life expectancies. Similar steps are being adopted throughout the medical profession — by the cluster-hiring of minority applicants, hiring of diversity and equity officers, and training staff on “white privilege,” implicit bias, microaggressions, and allyship.
A lead editorial in the August special issue, co-signed by 15 people, including JAMA’s newly installed executive editor and executive managing editor, along with other JAMA leaders, said all medical journals are morally obligated to assume systemic racism as a fact and document this fact in their research.
“At this point in the arc of medicine and scientific publication,” JAMA stated, “it is crucial for all journals to fulfill renewed editorial and journal missions that include a heightened and appropriate emphasis on equity and publication of information that addresses structural racism with the goal of overcoming its effects in medicine and health care.”
This rapid turn of events has blindsided traditional doctors, who are put off by the intense focus on race and the strong rhetoric.
“The spectacle of the gatekeepers of medical publications announcing a political blueprint that medical authors must follow — or else — is pretty breathtaking,” Thomas Huddle, who retired this year as professor at the medical school at the University of Alabama at Birmingham, said by email.
“The medical gatekeepers are in the grip of a moral panic,” said Huddle, who has published on medical ethics and edited several medical journals. “The JAMA convulsion over the podcast was positively Maoist in its fervor for achieving moral correctness and purging the impure.”
It's an open secret that some find the systemic explanation to be nothing more than leftist polemic, while others are skeptical it convincingly explains everything it claims to explain. These skeptics worry about the career implications of publicly dissenting from the new orthodoxy, but it's not inconceivable that blaming an entire national culture for racial disparities will prompt independent scholars and conservative think tanks to produce opposing research that explores black-on-black murder, racial disparities in IQ testing and other taboo subjects.
The dramatic transformation sweeping through the health care profession is not happening in a vacuum. It mirrors social justice movements committed to exposing structural racism that allegedly pervades education, criminal justice, the arts, hard sciences and other domains of U.S. society. Activists in those fields, as well as medicine, talk of dismantling white supremacy and other “structures” that operate by means of race-neutral laws and colorblind norms that cause racial and gender power imbalances and harm non-white groups.
Skeptical physicians say that medical journal editors are essentially replacing the scientific method with a political ideology, namely critical race theory, and leaving little room for alternative explanations — such as personal agency or cultural differences.
“There’s a tremendous amount of groupthink,” said Stanley Goldfarb, a former dean for curriculum who taught about kidney disease at the University of Pennsylvania medical school before retiring this summer. “If you don’t agree with all that, you’re a bad person.”
“This is an argument that you’re not allowed to have — that’s the problem here,” said Goldfarb, who has served on the editorial boards of three medical journals and was editor-in-chief of a nephrology journal.
Racial health disparities underlie the four-year gap in black-white life expectancy in the United States. The factors that contribute to this disparity include chronic conditions, unintentional injuries, suicide and homicide, which is the leading cause of death for black males aged 44 and younger. Scholars committed to the systemic racism explanation blame the disproportionately high crime rates in poor black neighborhoods on discrimination, substandard schools and other manifestations of systemic racism.
The body of research into racial health disparities has broken into the mainstream after establishing credibility through the time-honored system of academic citations and referrals. Since LaVeist began his work in the 1990s, a small stream of articles has swelled into a critical mass that now allows medical researchers to assume systemic racism as a proven fact and cite the evidence in footnotes, as established knowledge, instead of arguing the case each time.
“When the weight of the evidence becomes so overwhelming that we reach consensus, we no longer continue to question whether or not [it is true],” LaVeist said. “We don’t question gravity anymore because the consensus is that gravity is a thing.”
One of the JAMA articles in the August special issue found that the major health care spending disparity is that whites spend more on dental, pharmaceutical, and outpatient care, while blacks spend more on emergency room and inpatient hospital care, suggesting that black people are more likely to be uninsured and otherwise lack access to routine medical care.
Instead of detailing the precise reasons that may explain this gap, the authors invoke previous articles: “There are many mechanisms that have already been identified that explain how structural racism shapes health and healthcare.”
In a phone interview, the lead author, Joseph Dieleman, associate professor of health metric sciences at the University of Washington in Seattle, said: “These are taken as a given by us. These are not to be debated, or being tested, in our analysis.”
Health Affairs, dubbed by a Washington Post columnist as “the bible of health policy,” is redoubling its focus on systemic racism, anti-racism, and equity, not only in its published content but also in attending to the racial makeup of its published authors and reviewers.
“We acknowledge that the dominant voices in our work are those with power and privilege,” Editor-in-Chief Alan Weil wrote in January. “Even as we have dramatically increased the volume of our content focused on equity, the narrative has primarily been written by those in power. We vow to change this.”
Weil, who was trained in critical legal theory, a precursor to critical race theory, as a Harvard law student in the 1980s, said in a phone interview that the concepts of merit and quality are often used to maintain power and privilege, and these structures must be examined for bias.
“We’re just talking about — forgive the language that is used by the believers — interrogating ourselves,” Weil said.
Systemic racism, a core tenet of critical race theory, doesn’t have a settled definition but it has broad applicability. One of the peculiar features of systemic racism is that the mechanism is not evident to those who are not initiated into the theory, but ubiquitous to its acolytes.
For best-selling and award-winning author Ibram X. Kendi, whose writings are considered essential reading at some medical schools, any disparity can signify racism. The concept can refer to all manner of disparate outcomes — in murder rates, arrest rates, life expectancies, education levels, school discipline, household income, standardized tests scores and grades — even in the fact that black people are nowhere to be seen in the corridor portraits of medical school dignitaries and are underrepresented in symphony orchestras.
“There is no ‘official’ definition of structural racism,” states a recent article in The New England Journal of Medicine. “All definitions make clear that racism is not simply the result of private prejudices held by individuals, but is also produced and reproduced by laws, rules, and practices, sanctioned and even implemented by various levels of government, and embedded in the economic system as well as in cultural and societal norms.”
One line of attack against the status quo is the movement to eliminate long-accepted practices to promote merit and excellence that, according to activists, operate as colorblind mechanisms to produce unequal outcomes: gifted and talented programs, gifted schools, and admissions tests for elite high schools, as well as standardized test scores for university admission. In medicine, the U.S. Medical Licensing Examination test is changing from a graded score to pass/fail to help minority students, while Northwestern University and its Feinberg School of Medicine are promoting diversity by eliminating a six-decade-old Honors Program in Medical Education.
Still, the concept provides special challenges for medicine. Unlike bacteria, for instance, systemic racism is an invisible force that can only be measured indirectly, by its perceived effects. Nevertheless, LaVeist is convinced that systemic racism is the best explanation for racial health disparities because the correlation of race and health is consistent across numerous studies for multiple chronic conditions.
“We cannot make direct causal inferences. The best we can do is look at plausible causality,” LaVeist said. “What we have is a case where once you’ve ruled out all of the plausible explanations, the only thing left is systemic racism.”
LaVeist and Weil agree that health and other disparities can have other causes than systemic racism, and good scholarship should be cognizant of other potential variables. LaVeist said that without allowing for other factors, people of color would have no free will, but it is important to note that African American culture is also shaped by white racism.
One of LaVeist’s early co-authored papers that was rejected by several journals before finding a publisher concluded that black people who experience rudeness at the hands of white people have longer life expectancies if they blame systemic racism, or some other external factor, for being treated disrespectfully.
An implication of the study: Even if the rude behavior by the white person isn’t caused by racism or an external factor, it’s strategically beneficial for black people to attribute the rudeness to someone else’s racism, boorishness or insensitivity, rather than blaming themselves.
“Yes — racism, or some other external attribution,” LaVeist said. “If you make an external attribution, that is going to be healthier than you thinking, ‘Oh they’re right, I am a bad person, I deserve to be mistreated.’”
Assari specializes in the study of “diminished returns” in quality of life and health that black people and other marginalized groups experience as they gain education and income in U.S. society. His research contends that black people reap fewer benefits — such as income and health — as they rise in education, compared to white people, which he attributes to structural racism. He has written half of the 300-some academic papers on that subject cited by the National Library of Medicine.
He makes connections that would not be self-evident to someone who lacks training in his specialty. One of his recent papers, published in the Journal of Health Economics, says that Americans are less likely to smoke as their income level rises. But that rule doesn’t hold for high-income Chinese Americans, who are more likely to smoke as they generate more income. So Assari postulates that upwardly mobile Chinese Americans resort to nicotine as a means of coping with the anti-Asian bias they encounter in this country’s elite institutions.
Yet, he also said that even though the anti-racist movement seems invincible now, overweening claims about systemic racism will eventually invite scholarly criticism, especially if equity policies and interventions now being implemented fail to deliver results.
“I think there will be a very strong backlash against critical race theory very soon,” Assari said. “I don’t think it is sustainable. And it is falsifiable. So there would be an anti-CRT movement among other group of social scientists.”
Nevertheless, Assari said systemic racism is a reliable theoretical framework because it parsimoniously explains the marginalization of many racial groups.
“This is one model which explains many of our observations,” Assari said.
“A theory is [reliable] when an observation or assumption holds regardless of the context, setting, place, population, design, sample. It is replicated many times across a diverse group of settings, age groups, resources, and outcomes.”
LaVeist said segregation, much of it rooted in historical practices such as redlining and Jim Crow, is the primary driver of disparities. Poor neighborhoods are generally more polluted, closer to highways and industrial zones, and have less access to quality restaurants, grocery stores, public schools, and green spaces. Such environments tend to breed despair, which leads to crime and an overly aggressive police response.
The constant stress of dealing with these hassles and micro-aggressions wears on the body, research into health disparities says, echoing arguments made by critical race theorists in the 1980s. One medical paper, published in The Lancet in 2017 and cited more than 1,500 times as of November, says that residential segregation is the foundation of structural racism, and notes that “growing research is linking interpersonal racism to various biomarkers of disease and well-being, including allostatic load, inflammatory markers, and hormonal dysregulation.”
There are those who say the medical establishment is not going far enough in this research direction.
The STAT News health information website reported in September that anti-racism and equity have become so trendy that “white scholars are colonizing research on health disparities.” According to the STAT investigation, white researchers are caught up in “a gold rush mentality” and “rushing to scoop up grants and publish papers.” The white scholars are replicating work done by black researchers without giving sufficient credit, a new form of exploitation practiced by “health equity tourists” and “opportunistic scientific carpetbaggers.”
One of the worst offenders: JAMA’s August special issue on health disparities. “Not one of the five research papers published in the issue included a Black lead or corresponding author, and just one lead author was Hispanic,” STAT reported.
Weil sympathizes with these concerns and said Health Affairs is creating a mentorship program to help scholars of color get their papers published in the journal. Weil, who said about 5% of submitted papers are accepted for publication at Health Affairs, is confident that dismantling power and privilege won’t necessitate compromising standards of excellence, and he considers such criticisms to be “generally false and intentionally inflammatory.”
“Equitable representation should be the outcome of an equitable process, not the jerry-rigged result of a change of standards for one group — that is not where we want to be,” Weil said. “So if the fix here is an equitable outcome by lowering standards for a certain group, our readers will notice, and that’s not the end point I’m looking for.”
Weil’s biggest concern is not that the anti-racist movement in medical research will go too far, but that the momentum and resolve will fizzle out.
“I think it’s very hard to tell where you are on a swinging pendulum when you’re in the middle of it,” he said. “I am much more concerned that this will become a rote exercise where everyone genuflects to anti-racism but does nothing about it, than I am that this is an overcorrection.”