AMA’s new language guide is a step toward health equity

In the early 1990s, 10 Black children were treated for severe third-degree burns in a Chicago pediatric clinic. As a result, parents of three of the children were investigated for neglect, and one child was even temporarily removed from parental care.

That was a rush to blame, and these interventions re-traumatized families already facing a heartbreaking situation. Thanks to an observant and thoughtful pediatrician, all of the parents were exonerated and the negligent party was shown to be the Chicago Housing Authority.

The pediatrician, Kyran Quinlan, now the chief of general pediatrics at Rush University Medical Center, saw that nine of these children lived in the same Chicago public housing complex. During visits to their families, he immediately observed the source of the burns: exposed steam-heat pipes inside their apartments. Preventing these injuries required the simple fix of insulating the pipes.

Quinlan advocated on behalf of his patients and their families to the public housing agency to make the necessary remedies. Once the pipes were covered, the burn epidemic subsided.

Quinlan didn’t just treat these children’s burns. He used his authority as a physician to challenge the preventable structural determinants for the injuries, the root cause of the need for medical care.

Without Quinlan’s intervention, the ingrained narrative that Black parents neglect or harm their children would have once again unjustly and silently protected the Chicago Housing Authority from accountability. The burns, and the harmful judgements and assumptions about the parents’ fitness, would have continued.

Yet most medical schools do not teach or train future physicians in societal power dynamics and the roles of structural racism and white supremacy in creating and perpetuating harmful and deadly health inequities.

The American Medical Association recently published “Advancing Health Equity: A Guide to Language, Narrative, and Concepts.” It encourages doctors to address the upstream social causes of health inequities, such as unsafe housing conditions, and to center care around their patients’ lived experiences. It focuses specifically on language that guides physicians to think about the social causes of their patients’ illnesses and to avoid stigmatization.

As an example, the language guide explains that patients are not “marginalized.” Instead, they have “been marginalized.” This language change allows physicians to consider how historical acts of oppression such as redlining and other racist laws and practices might contribute to patients’ illnesses today.

The language clinicians use and the stories they tell about the people on the receiving end of health inequities must challenge systems and structures that oppress and contribute to their illnesses. Quinlan’s patients were not simply “burn patients.” They were burned as a result of unsafe housing conditions. This clarity of language, the AMA’s guide proposes, creates the possibility to identify and treat the upstream root causes of health inequities.

As two doctors who practice medicine in Chicago and routinely see the harmful effects of structural racism and poverty on our patients, we believe the AMA’s examination of language and dominant narratives is a step in the right direction toward reducing health inequities.

Although many people appreciate that structural and economic conditions are at the root of socially driven health inequities, many doctors have been taught that beliefs, behaviors, and biological factors are largely responsible for health outcomes. This narrative has its origins in the white supremacist eugenics movement of the 19th century. And while behaviors and biology certainly contribute to poor health, social and structural conditions like structural racism, trauma, access to care, and poverty account for the largest health inequities.

This has been apparent during the Covid-19 pandemic. Humans are 99.9% genetically identical, with the 0.1% difference existing within races rather than between them. Biological vulnerability to SARS-CoV-2, the virus that causes Covid-19, is manifest in everyone. Yet Black and Latinx people in the U.S. had three times the hospitalization rate and twice the death rate of white people. Social disenfranchisement led to a three-year loss in life expectancy for Black and Latino men in the U.S. in 2020 versus one year in white men.

Being Black or Latinx was not responsible for the life expectancy gap. That was due to the social conditions that put Black and Latinx people at risk. Societal conditions like structural racism, multi-generational housing, and high-risk working conditions placed people of color in harm’s way.

The AMA’s language guide asks physicians to consider the preventable social and structural causes of excess disease and death in some groups and reorient their language to align with this worldview. It is a simple but powerful shift — people like Quinlan’s patients are not inherently at risk for burns; they were burned because they were placed in harm’s way.

Our reading of the guide is not as a doctrinaire prescription but as a roadmap to guide physicians to address social and structural determinants of health in their practices.

The guide has been criticized, often by those invoking tropes from the Red Scare era. The Atlantic ran an essay entitled “The Medical Establishment Embraces Leftist Language” that accused the AMA of proposing language “policing that presumes far-left answers to a host of thorny questions.” Taken out of context, one might quibble with one or another of the examples. But as physicians and educators, we find the guide to be a useful tool. At the heart of the document is the promotion of a well-established model that pushes physicians to consider the systemic causes of health inequities in their treatment plans. These public health principles, based on prevention, are much needed in a medical system too focused on crisis care, pharmaceuticals, and insurance premiums. They are also needed in a system that is fraught with implicit bias, which is known to thrive where high cognitive workloads are needed in fast-paced environments, such as in health care providers.

The goal of raising the question of language and narratives is vital to the more important task at hand: eliminating deadly racial health inequities. And it isn’t just about words, but about action. In the field of patient safety, when a patient is harmed, identifying the key root causes is an essential first step to preventing others from being harmed in the future. In patient safety, a thorough root-cause analysis is essential to redesign patient care systems to eliminate harm.

The same is true for eliminating racial health inequities. By identifying the structural and societal causes of racial health inequities, such as structural racism, bias, economic deprivation, classism that causes poverty, and more, it becomes possible to develop structural solutions to eliminate health inequities. This comes at a time when we are starting to understand more about intergenerational trauma and adverse childhood experiences causing chronic diseases, including diabetes and heart disease. If patients or their genes are responsible for their poor health, it’s the patient who needs to be fixed. If the system is the problem, the system must be fixed.

This rethinking of language and considering the social causes of disease — not just the biological causes — is central to the broader work of American health care to advance racial justice and equity in medicine. By acknowledging how long-standing practices and beliefs — and language — have harmed the health of millions in the U.S. and shaped the unequal health system that exists today, we can imagine a future where physicians can truly partner with their patients, and everyone has an equal opportunity to live a healthy life.

David Ansell is an internal medicine physician and senior vice president for community health equity for Rush University Medical Center in Chicago. Vinoo Dissanayake is an emergency medicine physician, educator, and patient advocate at Rush University Medical Center, and a Public Voices Fellow of The OpEd Project and Rush University.