Racism in Academic Medicine
By Anthony L. Schlaff, MD, MPH
Director, Public Health Program
Professor, Department of Public Health and Community Medicine
Tufts University School of Medicine
One of our responsibilities in public health is to hold our health care system accountable for meeting the needs of the population. While it has been encouraging, in the aftermath of the George Floyd murder, to see new efforts among medical institutions and leaders to respond to societal, systemic racism, we still have a long way to go. The recent furor over a February 23, 2021 podcast in the prestigious Journal of the American Medical Association (JAMA) makes this abundantly clear. The podcast has been deleted, but if the controversy is new to you, you can get a quick summary of what was said and the response here.
To their credit, JAMA has clearly denounced some of the offensive comments made and have taken the podcast off their website. The deputy editor who made many of the concerning comments has resigned. Nevertheless, the moment serves to point out how far our profession and our society have yet to go to address racism within our institutions.
As I heard and read about the podcast, there were three arguments put forth that were frankly breathtaking in their cluelessness about what racism is and how it operates. The first was that doctors are good people and not racists and therefore the statement that structural racism exists in medicine is offensive to them. The second was that racism is illegal and therefore cannot be said to exist on a systemic basis in our society. The third is that the problem for people of color in America, particularly as it affects health, is not racism but socio-economic status.
Let us briefly take each of these arguments in turn.
The first, that physicians are not racist, first ignores the settled scientific reality of implicit bias that we all carry, and second, ignores the distinction between individual prejudice and structural racism. Setting aside that there are still white supremacists among us who deliberately and consciously express hatred of people of color, all of us are prone, unconsciously, to treat people of color differently – usually less well – than White people, and only by understanding this truth can we work towards a more equitable world. Most importantly, structures of racism are baked deeply into our institutions – into the context, policies, and practices that shape our lives. Irrespective of how people think or feel, our systems of education, employment, justice, health care, public health, and environmental protection all operate in ways that deny opportunities and protection to people of color. One need look no further than our system of mass incarceration or the COVID pandemic to see this is true. Structural racism will operate even in the face of “race neutral” attitudes unless deliberately anti-racist actions are taken.
The notion that structures cannot exist because they are illegal is simplistic at best. Culture and practice can operate quite separately from law. No one need take a deliberately illegal action against people of color – let alone one in which such intent can be proven – to preserve structures that continue to devalue people of color and deny them opportunity. There is no doubt that most of the police killings of Black people would not have happened had the person been White – and yet so far, the vast majority of these killings have been judged NOT to be crimes. The school-to-prison pipeline that sends five times as many Black as White men to prison is legal, even though at every step of surveillance, arrest, prosecution, and sentencing, Black people are treated in a systematically different and more punitive way. It was legal to make the punishment for crack cocaine, most commonly used in communities of color, dramatically higher than that for the powder cocaine used in White communities. What our system of law does do is, in fact, racist in outcome and possibly in intent. It makes it almost impossible to dismantle structural racism through the courts because of the need to prove, not just the predictably racist outcome of a practice, but also that the practice was driven by individual racist intent.
Finally, the claim that it is socio-economic status, and not racism, that accounts for the health disparities affecting people of color ignores both what we know of causal pathways and what we know of history. The 92% wealth gap and 60% wage gap between Black and White people in this country is entirely a consequence of our racist structures in the past and to the present day. Throughout the 20th century and into this one, Black people have been systematically and deliberately excluded from participating equally in virtually every sector of the economy and every mechanism of wealth generation that we have. It started with Jim Crow but continued through contract loans and exclusion from the mortgage market, land theft, exclusion from good jobs, exclusion from unions, and selective exclusions from New Deal programs including Social Security, the National Housing Act, and the GI Bill. It continues today with sub-prime loans, the criminalization of poverty, re-segregation of schools, disinvestment from our communities, and mass incarceration. So yes, the major (but not only) proximal pathway by which racism leads to poor heath is through socio-economic status, but it is racism that is the root cause.
So what does it mean that such a prestigious journal and such accomplished people in academic medicine can believe and freely state such nonsense? It reminds us how little most White people think about, reflect on, and take ownership of the racism that pervades our society. Responding to structural racism in society and in our professions does not come from statements of concern and attendance at a couple of rallies and discussions. It is going to take an on-going, massive, societal commitment across generations to undo the damage we have done. One of the early steps is to make sure that the leaders of our institutions understand the basics.