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.
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.
“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.
“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.
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.
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.”
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.”
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.
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.
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.’”
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.
There are those who say the medical establishment is not going far enough in this research direction.
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 percent 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.”