Medical Journals Refuse to Address Racism, Critics Charge.
The departure of an editor at JAMA has prompted calls for a greater emphasis on racism and its consequences.
The editor-in-chief of JAMA, the prestigious medical journal, resigned on Tuesday following a backlash over comments about racism made by a colleague on a journal podcast. However, critics saw something more pernicious in the incident than a single blunder: a blindness to structural racism and the ways in which discrimination has permeated medicine over generations.
“The biomedical literature has simply not accepted racism as more than a topic of conversation, or as a construct that should guide analytic work,” said Dr. Mary Bassett, a Harvard University professor of health and human rights practice. “However, it is not just JAMA that is at fault — it is all of them.”
The long-standing issue has resurfaced in part as a result of the pandemic's exposure of health care inequities, as well as the recent Black Lives Matter protests. Indeed, an informal New York Times review of five leading medical journals discovered that all of them published more articles last year on race and structural racism than in previous years.
Racism was added as a searchable keyword in PubMed, the government's massive medical library, for the first time in 2013. However, in the intervening years, the five journals have published far more studies on race than on racism. According to the review, JAMA published the fewest studies mentioning racism.
Until the arrival of Dr. Eric Rubin, the journal's current top editor, in 2019, the New England Journal of Medicine rarely addressed racism. The British Medical Journal and The Lancet, both based in Europe, published the most studies on the subject, followed by the American Journal of Public Health.
Many medical journals, due to a “lack of scholarship,” take an approach to health care disparities that avoids discussing racism, according to Dr. Stella Safo, a Black primary care physician at Mount Sinai's Icahn School of Medicine.
“Let's have more editors with this background who understand how to speak responsibly about race and racism,” she said.
Medical journals such as JAMA, she and other critics said, prefer studies that link race or racial inequities to socioeconomic or biological factors. Their editors, who are predominantly white and male, accept fewer papers that examine how systemic racism shapes Black and brown people's health care experiences, they said.
JAMA's reckoning came in response to a podcast discussion in which Dr. Edward Livingston, an editor, suggested "removing racism from the conversation" about societal inequities, stating that "structural racism is an unfortunate term for a very real problem." He asserted that communities of color were harmed not by racism, but by socioeconomic factors and a lack of opportunity.
Dr. Livingston is white, and there were no scientists of color present during the conversation. A tweet promoting the podcast asserted that "no physician is racist," but was quickly deleted.
Dr. Livingston resigned as a result of the uproar. The American Medical Association, which is responsible for overseeing the journal, launched an investigation.
Following the podcast, Dr. Safo and Dr. Brittani James, a Black physician practicing on Chicago's South Side, started a petition, which has since garnered over 9,000 signatures, urging JAMA to restructure its staff and host a series of town hall meetings with patients who are Black, Indigenous, or people of color.
Earlier this month, the association's leaders admitted grave errors and proposed a three-year plan to "dismantle structural racism" within the organization and in medicine.
“I remain profoundly disappointed in myself for the lapses that resulted in the publication of the tweet and podcast,” JAMA's top editor, Dr. Howard Bauchner, said in a statement announcing his departure. “While I did not write or even see the tweet or create the podcast, I am ultimately responsible for them as editor in chief.”
The A.M.A., the nation's largest association of physicians and medical students, has a troubled history with race. Only in 2008 did the group apologize for its past exclusion of Black physicians and implicit support for segregationist policies.
“This is a critical time for JAMA and the A.M.A. to reinvent themselves from a foundation built on segregation and racism to one built on racial equity,” Dr. Safo stated.
Other medical societies, including the American Academy of Pediatrics in September and the American Psychiatric Association in January, have recently issued formal apologies for racist pasts.
However, some members have expressed opposition to the A.M.A.'s initiative, writing in a letter to the organization's leaders that "there is a general feeling that the firing of the editors involved in the podcast was perhaps precipitous, possibly a blot on free speech, and also possibly an example of reverse discrimination."
“No one in health care has done this completely correctly,” said Dr. Aletha Maybank, director of the A.M.A.'s Center for Health Equity. “As we walk, we are all paving the way.”
Dr. Maybank was one of four researchers who demonstrated in a recent analysis that while medical journals occasionally address racism, they do so in opinion pieces rather than evidence-based studies.
Two researchers described the difficulties they encountered while navigating the JAMA editorial process with their research on racism.
Dr. Melissa Simon is the director of Northwestern University's Center for Health Equity Information and a member of the US Preventive Services Task Force, an expert panel that advises physicians on best practices.
She recalled numerous unpleasant interactions with members of the JAMA staff, including being discussed on podcasts. “I'm actually relieved that they exposed their biases to the public, as many of us have been experiencing these biases with JAMA for some time now,” she said.
Dr. Simon, a Latina, submitted her research on the high death rates among pregnant Black women to JAMA last summer for consideration. Dr. Bauchner, she claimed, omitted the term "racism" from the manuscript and watered down the conclusions. The paper was rejected following numerous rounds of revisions.
Dr. Simon was taken aback. “You cannot discuss maternal mortality without addressing racism,” she stated. “In the United States of America, you simply cannot.”
After editors at JAMA and other journals attempted to "whitewash" her papers, she stated, "I have ceased submitting, or even attempting to submit, manuscripts for possible publication in certain journals."
Dr. Bassett, a Black physician, recalled a very similar experience following the submission of a paper to JAMA on the long-term impact of historical redlining on preterm birth. According to her recollections, Dr. Bauchner omitted references to racism from the paper, which was eventually rejected.
Both articles were eventually accepted for publication in the American Journal of Public Health.
The A.M.A. declined to comment on the researchers' experiences or on Dr. Bauchner's departure during the course of the investigation. The Journal of the American Medical Association did not respond to requests for comment.
Dr. Bauchner declined several interview requests, but told The Times last month that JAMA had published "more than 100 articles in the last five years on topics such as social determinants of health, health care disparities, and structural racism."
He also noted that JAMA accepts only a small percentage of manuscripts submitted. The journal received over 20,000 submissions last year and accepted less than 4%. Dr. Bassett stated that she could not rule out the possibility that her papers were rejected due to their failure to meet the journal's quality standards.
However, she noted that JAMA had also rejected her analysis of Covid-19 mortality rates by race and age, while publishing another paper proposing that racial variation in a coronavirus-specific cellular receptor could account for the pandemic's disproportionate impact on Black people.
According to Dr. Simon, "there are gatekeepers at every step along the path to producing science," from admission to Ph.D. programs and project funding to publication of results and invitations to speak at conferences. Publication in journals such as JAMA may influence which academic researchers receive tenure and which research subjects receive funding.
“They bear a tremendous amount of responsibility, given the influence they wield over science,” Dr. Simon explained.
Certain prestigious journals are almost entirely staffed by white men. Dr. Raymond Givens, a cardiologist at Columbia University in New York, noted that 93 percent of editorial leaders at JAMA were white.
Dr. Givens began compiling data on the race, gender, and ethnicity of editors and editorial board members at the JAMA network of journals and the New England Journal of Medicine following JAMA's podcast. According to him, the current editor of JAMA Dermatology may be the "only nonwhite editor in the history of all those journals."
Dr. Givens, who is Black, stated that he had no objections to the podcast's content. However, he said, debating whether structural racism exists without the presence of experts on the subject or Black physicians was a “complete breakdown of scientific thinking.” “If that isn't structural or even meta-structural racism, I'm not sure what is.”
Dr. Givens contacted Dr. Rubin, editor-in-chief of the New England Journal of Medicine, and Dr. Bauchner in October, highlighting the disparities in staffing at their respective journals.
“I note with levity but sincerity that your journals have more editors named David than Black and LatinX editors combined, or East Asian and South Asian editors separately,” he wrote. Dr. Rubin responded and scheduled an appointment to learn more. According to Dr. Givens, Dr. Bauchner did not respond.
“People are simply averse to the possibility that they might be labeled a racist or that we might suggest they harbor racist views or ideas,” Dr. Givens explained. “And as a result, there is this reluctance, or rather, this tendency, to terminate the conversation whenever it enters that territory.”
Dr. Rubin acknowledged in an interview that the journal's staff was not diverse enough, but noted that the low turnover among editors made hiring new people difficult.
Since his arrival, the journal has added four editors and four editorial board members, as well as a Race and Medicine section to its website in June. Although the journal does not collect self-reported data on race, he noted that half of the new hires are people of color, and three are women, including the new executive editor.
This is a positive step, but journals must also learn to address racism more directly in order to improve lives, Dr. Bassett said. She made confronting racism a central part of her work as New York City's health commissioner from 2014 to 2018.
“Obviously, if you can't see what's in front of you and can't talk about it, you can't solve it,” she explained. “That is simply not acceptable.”