Weeks after it was scrubbed from the Journal of the American Medical Association’s website, a disastrous podcast — whose host, a white editor and physician, questioned whether racism even exists in medicine — is surfacing complaints that JAMA and other elite medical journals have routinely excluded, minimized, and mishandled issues of race.
Recent examples include research blaming higher death rates from Covid-19 in African Americans on a single gene in their nasal passages; a letter claiming structural racism doesn’t play a role in pulse oximeters working less well on patients with dark skin because machines can’t exhibit bias; and an article claiming that students of programs designed to increase diversity in medicine won’t make good doctors.
Critics say such ideas, published in powerful journals that doctors look to for leadership and education, are serving to perpetuate and entrench health inequities that have long harmed and shortened the lives of many people of color.
“It’s the voice of medicine. They set the priorities,” said Brittani James, an assistant professor of clinical family medicine at the University of Illinois College of Medicine and co-founder of the Institute for Antiracism in Medicine. She helped start a petition calling for widespread change at JAMA that has attracted nearly 8,000 signatures.
While the podcast sparked the petition drive, James said the problem goes far beyond a single podcast or a single journal. The episode at JAMA, she said, merely exposed a culture of racism that runs rife though medicine. “It’s the tip of the racist iceberg,” she said of the podcast. That listeners of the podcast were offered continuing medical education credit, she added, only rubs salt in the wound.
The February podcast involved two white doctors — Ed Livingston, JAMA’s deputy editor for clinical content, and Mitchell Katz, an editor at JAMA Internal Medicine and CEO of NYC Health + Hospitals — who are not experts in structural racism, broadcasting a conversation about that topic on JAMA’s huge and powerful platform that came across as deeply offensive.
Livingston questioned whether racism could be embedded in society because it is “illegal” and said he did not consider himself a racist because he grew up in a Jewish family and was taught never to hate. He asked whether the term racism “might be hurting us” and whether there might be a better word because “the term racism invokes feelings amongst people.” Katz repeatedly affirmed his belief that structural racism exists but was later criticized by some for coddling Livingston. Katz has since condemned the podcast and said he was not involved in its production and firmly believes structural racism exists in medicine. Livingston has not commented publicly.
The uproar over the podcast led the journal to ask Livingston to resign. Howard Bauchner, JAMA’s editor-in-chief, apologized but was then put on administrative leave. He and other editors at JAMA have refused to comment, pending the outcome of an investigation of the matter by outside counsel. The journal is owned by the American Medical Association, the nation’s leading physicians organization, but has editorial independence.
Critics say problems at JAMA and its network of medical journals include limiting publication of scholarship on how racism affects health and suggesting papers involving racism be submitted not as research articles, which have the most clinical impact, but as opinion pieces or “Perspectives,” a series in JAMA Internal Medicine featuring “stories about the joys and challenges of practicing general medicine and truths discovered along the way.”
Other problems they cite include editors asking authors to scrub the term racism from their manuscripts even as they publish other manuscripts that include outdated and racist notions, such as the idea that genetic and not social factors may explain the higher rates of Covid-19 death and hospitalization among people of color.
Problematic articles have appeared recently and steadily in JAMA and other prominent medical journals, even as discussions of racism in medicine have taken center stage during the pandemic and as journals and medical associations have publicly affirmed the Black Lives Matter movement and their own commitment to racial equality.
A September JAMA paper suggested African Americans may have higher rates of Covid-19 because of differences in the expression of a certain gene in the nasal epithelium, despite the fact that the clinical relevance of that gene’s expression is unknown and Hispanic people, who also have higher death rates from Covid-19, do not have a higher rate of expression of the gene. “That’s biomedical racism to a T,” James said.
Critics say an October JAMA paper on the association between air pollution and poor birth outcomes failed to examine the role racism plays in environmental exposure to poorer air. And an article about the high rates of hospitalization among people of color with Covid-19 in California, published online in Health Affairs in May, initially questioned whether there could be “some unknown or unmeasured genetic or biological factors that increase the severity of this illness for African Americans.” In response to criticism, the paper was later revised to remove this language.
An article published in August in the Journal of the American Heart Association, arguing that students of educational programs intended to increase diversity would make poorer clinicians, was retracted after many physicians questioned how the article — rife with stereotypes and errors — made it past reviewers.
And a letter published just last week in the New England Journal of Medicine disputed use of the phrase “structural racism” when discussing the fact that pulse oximeters — oxygen sensors that are critical tools for Covid-19 care and were developed and tested largely on people with white skin — work less well on people with Black skin. “Medical devices such as pulse oximeters are blind to color and cannot exhibit such a bias,” the author wrote.
Months before the recent podcast, Rhea Boyd, a pediatrician and public health advocate in Palo Alto, Calif., had taken to Twitter to call out JAMA’s poor record on studies involving race. With colleagues Edwin Lindo, Lachelle Weeks, and Monica McLemore, she wrote a piece in Health Affairs in July calling for a higher standard for publishing on racial health inequities. “The bar hasn’t been high enough,” she told STAT. “We don’t treat scholarship around race the same way we do other health issues. When we do that, we sell this field short.”
Boyd said researchers need to do a better job of defining race, specifying the reason they use it in studies, refraining from using genetic definitions of race that are not grounded in science, and citing experts who have rigorously studied the effects of racism. She said journals should reject articles on health inequities that don’t examine racism, use reviewers who are experienced in the scholarship of racism, and consider compensating reviewers, particularly those of color, who are increasingly being asked to share their expertise for free.
Crucially, she said, scholars and journal editors must openly use the term racism, something many have clearly been uncomfortable with. “In doing this, we obscure ways that racism drives health inequities,” said Boyd.
A number of researchers told STAT they have been explicitly told to remove the word racism from their work and replace it with less direct terms that white doctors won’t find offensive, such as socioeconomic status. A systematic review of more than 250 top-ranked journals in public health found that of all articles published between 2002 and 2015, only 25 named institutional racism or used related terms in their titles or abstract. Not a single article from either JAMA or the New England Journal included articles that named racism in their title or abstract.
“Scholars have been essentially told to whitewash race from their work,” said Stella Safo, an HIV primary care physician and assistant professor at the Icahn School of Medicine at Mt. Sinai who worked with James to start the petition for change at JAMA. “If you can’t call something by its name, how can you address it?”
NEJM Editor-in-Chief Eric Rubin said in an emailed statement that his journal was “committed to addressing racism as a public health and human rights crisis” and had published 70 articles on race and medicine in the last two years and featured them on a new topic page created in June. Asked about the letter published last week, he said it is important to view the letter together with a response the journal also published from the original paper’s authors. Printing the letter, he said, “allowed the original authors to make an important point in their response — that even if the pulse oximeter isn’t inherently racist, ignoring the systematic errors introduced by differences in skin color results in racial bias which has been ignored.”
Many critics said the podcast was a symptom of systemic racism embedded within prestigious medical journals, publications that they said have shown little interest in publishing research about issues of race.
“I’ve been rejected so much, it’s gotten to the point that I don’t even try to submit to these journals,” said Melissa A. Simon, vice chair of research and professor of clinical gynecology at Northwestern University Feinberg School of Medicine, and director of the school’s Center for Health Equity Transformation. “Why waste my time?”
Simon said much important health inequity research is dismissed outright because it is qualitative and involves in-depth interviews with smaller numbers of participants, rather than large amounts of data that might be found in more quantitative studies like clinical trials. “We understand centering people’s voices, especially people from our communities, is critical, but this work is rejected far and wide at top-tier journals like JAMA and the New England Journal,” said Simon, who is Latinx. “It’s not even reviewed — and this excludes a whole body of research.”
“I’ve been told, ‘Why don’t you just create a Viewpoint or opinion piece about this because it just doesn’t make the mark as a manuscript,” she said. “And when you do submit as an opinion piece, the language gets whitewashed. References to structural racism get removed or softened.”
Simon said the cost can be steep. “Opinion pieces go in a different category on your CV. They’re not as valued in many ways,” she said. “The metric of success is to publish and all along the way, I was told you have to publish in high-impact journals, but how can we if they are so biased?”
Another researcher told Safo their empirical work analyzing racial inequities has encountered reviewers at several journals who said that the findings were not “really” about race or that the research needed to take socioeconomic status into account rather than race.
Many researchers who work on health inequities have suspected their articles were being rejected by top medical journals at high rates because they tackled racism head on. Safo said the podcast and ensuing events, with their revealing insight on how some editors view racism, confirmed suspicions that journal leadership neither understood the issue of racism nor took it seriously. “It was almost like we got to listen in on the conversations these people have on their own,” she said. “Now we know.”
For many, the podcast itself was outrageous, but Bauchner’s response worsened matters. The editor-in-chief took responsibility for the original podcast, and on March 16 offered up what he called a follow-up podcast. But a podcast by definition is an audio file, and Bauchner’s “podcast” aired on YouTube, showing him on screen with three esteemed Black scholars who, he repeatedly pointed out, had published in JAMA.
Many critics saw the video as a crass attempt by Bauchner to save his job, and emblematic of the way mainstream medicine highlights the work of Black scholars only when convenient. “It was a, ‘Here are my Black friends moment,’” said Safo. “I could not even bring myself to listen.”
Siobhan Wescott did listen. An Alaskan Native physician who teaches public health at the University of North Dakota, Wescott said she wanted to give Bauchner the benefit of the doubt. But she was disappointed and angered by the presentation, which asked naive and simplistic questions such as, “Do you have an idea of why the term racism is so charged for white people like me?”
“He had over two weeks, and likely had access to experts who could have helped him understand structural racism, and this was his best response?” she said.
Wescott has long been an active member and leader within the AMA and said the experience has been largely good. “Sometimes I’m the only Native physician among thousands of people at a meeting, but I still feel welcome. They listen to my voice.” But she has wrangled with JAMA, and Bauchner in particular, over one particularly odious piece that she said Bauchner declined to retract.
It’s an article from 2000 titled “Five Miles from Tomorrow.” Written by a medical student who visited a rural area of Alaska, it described watching a Yupik elder who walked out onto the ice to die because he felt he could no longer contribute to his community. The article was completely false.
“The problem is, this patient never existed. And there is no such tradition,” Wescott said. Despite the attending physician sending a letter to JAMA saying the student’s account was false, the story has spread widely and has been taught in classrooms as a way of dealing with end-of-life issues, Wescott said. She said Bauchner (who wasn’t JAMA’s editor when the article was published) declined to retract the piece and instead told her she could write a response, and that her piece would need to go through the review process.
Wescott said she was open to writing an article about how problematic the original article was; she even had a title: “Five Miles from Ethical.” But she said she couldn’t write the piece because the Yupik community, which reveres its elders, was so hurt by the original article, they would no longer talk to outsiders. “That piece needs to be retracted,” Wescott said. “It’s a travesty.”
Many Black doctors say the painful podcast — and a tweet promoting it that claimed, “No physician is racist, so how can there be structural racism in health care?” — may prove valuable in the end. They have served as a flashpoint, angering many physicians who had previously stayed silent about racism in medical journals but are now willing to speak publicly. “A lot of people with M.D.s were terrified to speak out about JAMA because they were afraid of retaliation,” said James. “There was a culture of fear. People truly fear their careers will be hurt and that allows them to keep us silent.”
Journals are not only gatekeepers of what research gets published, they are also gatekeepers of career advancement. Promotion in academic medicine depends heavily on being able to publish in the most prestigious journals. “You live and die by publishing,” said James. “It materially hurts your career when your ideas don’t have access.”
Speaking out against journal editors was especially risky for doctors of color like James who are the first in their families to become physicians or hold academic positions. “I was terrified because when you speak out you’re marked,” she said. “If we were talking even two years ago, I don’t know if I would have the courage, but this pandemic has done something. To see brown and Black folks dying at such high rates, there was no going back.”
The podcast, scholars say, provides an opportunity to see structural racism in action. “It was so ironic that they were trying to talk about structural racism and they created a perfect exemplar of what it is,” said James, in part by not including anyone who has experienced racism as part of the discussion. Many called the podcast “whitesplaining racism” and said the questioning of whether racism exists in medicine was the ultimate gaslighting of Black physicians and patients.
For Clarence Gravlee, the podcast was literally a teachable moment. An associate professor in the department of anthropology at the University of Florida who researches medical racism and is currently teaching a class on whiteness, Gravlee was so unsettled by what he heard, he used it for discussion in both his undergraduate and graduate courses. The podcast, he said, provides a kind of litmus test: His white students were shocked. His Black students were not, and some told him once the content of the podcast became clear, they had to tune out to protect themselves.
“The fact that white people could be shocked by that discourse shows the way white people have been insulated from these issues,” he said.
“A lot of the ways people talk about racism are abstract. This podcast made it very concrete. You hear all of the ways white people misunderstand racism, and you hear it all in just 15 minutes,” said Gravlee, who wrote a widely lauded essay analyzing how the conversation in the podcast demonstrates what scholars call the “epistemology of ignorance.” In the essay, Gravlee walks through how the short broadcast includes examples of each of five classical ways white people refuse to understand and deny the harms caused by racism, denials that Gravlee said lie at the very heart of white supremacy.
Gravlee remains mystified by how editors at a leading medical journal could produce a podcast “completely oblivious to the history of racism in medicine” and not turn to the wealth of experts on the issue or other excellent podcasts about structural racism. “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,” he said.
Gravlee’s dissertation research two decades ago was sparked by a 1970 paper in JAMA suggesting that a genetic trait linked to darker skin color, and not factors like discrimination and poverty, might be the driver of higher rates of blood pressure in African Americans. But he warned that people shouldn’t just focus on the podcast, its two speakers, or JAMA alone because the issue of systemic racism is widespread in medicine, and elsewhere. “We need to shift our attention to where the problem really lies, and that is white racism and white supremacy,” said Gravlee, who is calling for JAMA to repost the podcast, with proper context, as an educational tool.
Much of the anger continues to center on JAMA’s promotional tweet for the podcast declaring that no physician is racist. It’s a ludicrous statement, given that the AMA is now reckoning with the racism of its own founder, Nathan Davis, who was also the founding editor of JAMA and who actively blocked the inclusion of Black physicians into the AMA, a racist legacy that continued until the 1960s.
JAMA is the Journal of the American Medical Association and while JAMA has editorial independence from the AMA, the relationship is complicated. The AMA’s chief equity officer Aletha Maybank called the podcast appalling, said her team was not consulted, and tweeted that she was “furious,” but the AMA’s Journal Oversight Committee is the group that commissioned the investigation of the podcast.
The physicians who started the protest say that they don’t want to “cancel” JAMA but that they won’t let up on either the journal or the AMA until they see the structural racism in both organizations further dismantled. Rather than no physician being racist, they say, many physicians have been the very architects of racist scientific ideas and medical policies that have long harmed people of color.
“I took an oath to do no harm and I take that seriously,” said James. “They are doing immense harm with their racism and misogyny and ignorance, and I’m not just going to sit here while they are killing folks.”
Absolutely critical to analyze such subject matter.
Top journals must have POCs in their editorial ranks (at a minimum) and not reject, as a matter of policy, manuscripts submitted to them (JAMA, NEJM, Annals, etc) based on the opinion of a single ‘editorial member’. Rather, every manuscript must be sent for review and then a decision be made based on recommendations. Why an article is rejected must be made clear. All such top-tier journals must receive manuscripts wherein the authors/institutions are encrypted and reviewers are blinded to who the authors/institutions submitting the manuscript are.
As for the allegations raised in this stunning article, let the investigation begin and lead the way to a better tomorrow.
Failure to investigate potential genetic contribution to any disease is a failure of scientific rigor. I don’t see why calling out potential genetic contribution to increased fatality in the black community during the pandemic is in any shape and form a racist remark. Let’s not let politics take over science. This will not benefit people of color, of which I myself belong.
As a former investigator of Discrimination complaints and EEO officer, State of Ill, I applaud the author’s summary of the problems that are faced in getting people to address systemic racism. Hopefully, her article will stimulate discussion of this issue. Understanding and solutions can not occur without such discussion and they will not occur when the issue is denied and those raising it are suppressed.
If the racism is not informed by evidence – clear causation – then you are using a complex theory to push a personal agenda to get personal advantage by exploiting people’s morality. As such, notions of intersectionality and critical theory and so on are rightfully taken with skepticism. We do not live in the 60s with rampant discrimination, we live in 2021. If you want to be inclusive of disenfranchised groups, why do I not see more people with mental illness/ disability included? Why is this all just about race and trans?
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