Dr. Aletha Maybank joined the American Medical Association as its first chief health equity officer in 2019, determined to fight racial disparities in medicine.
That work grew more urgent in 2020 as the Covid-19 pandemic exposed deadly inequities in health care, and as George Floyd’s murder turned the country’s attention to the pervasiveness of systemic racism. The AMA issued a statement decrying racism as an urgent threat to public health, and Maybank focused on the organization’s efforts to “dismantle racist and discriminatory policies and practices across all of health care.” That included supporting training for medical workers on implicit bias, as well as advocating for solutions to problems that had not traditionally been a focus for the organization, such as housing inequities and police violence.
But by the fall of 2021, these equity initiatives were facing growing pushback from pundits, think-tank researchers and doctors — both liberal and conservative — who contended that the medical organization had overstepped its mission of supporting health care professionals and was now embracing a “woke” ideology. And out of public view, that backlash was turning vicious — particularly for Maybank.
After the AMA issued a communication guide last October describing words and phrases that doctors should avoid so as not to offend certain groups of patients, messages directed at Maybank, who is Black, escalated from trolling on social media to threats of violence. Maybank said she arrived home to discover someone had spray-painted a vulgar death threat on her front door in New York. The AMA hired a security detail for her and scrubbed her online presence in an attempt to restore her privacy.
“When it comes that close, it’s really scary,” Maybank, a physician who is also an AMA senior vice president, said of the harassment. “But I think it’s just really important that people do know about it — I’m not the only one.”
Over the past two years, the medical establishment has placed an unprecedented focus on addressing the barriers to medical care, and the poor health outcomes that people of color frequently face, according to Maybank and a dozen other doctors and academics who are doing this work. But these medical professionals, researchers and advocates have also experienced unprecedented pushback, ranging from lawsuits and attacks on cable news to harassment and death threats.
The barrage of criticism is the latest extension of the national furor over the teaching of racial history and the role of racism in American society, sometimes simplistically summed up as “critical race theory,” which has forced educators out of their jobs and overwhelmed school boards with legal claims. It’s also an extension of the harassment and threats public health officials have faced over pandemic mitigation policies.
Doctors and academics working on anti-racist initiatives say they’re exhausted and on edge — particularly after an extremist group protested outside Brigham and Women’s Hospital in Boston in January. The demonstrators held a sign claiming the hospital “kills whites,” and passed out flyers with the names and faces of two doctors who designed a pilot program aimed at improving cardiology outcomes for Black and Latino patients.
After WGBH reported that the protesters were linked to a neo-Nazi group, nearly 150 people participated in an emotional discussion held on Twitter’s Spaces platform, which was moderated by Dr. Brittani James, a primary care physician and anti-racism activist in Chicago. She started the conversation by explaining why the Boston protest had brought her to tears.
“It hit me hard because, selfishly, you just think as a Black woman in this space, doing this work, how long until my face is on a poster?” James said. “How long until I’m hunted?”
In the face of this harassment, doctors and academics are demanding more support from their institutions and professional organizations, and are strategizing on how to respond to the backlash and trolling.
“I fully expect that this will get worse before it gets better,” said Monica McLemore, a nurse and reproductive health professor at the University of California, San Francisco. “There will be more continued harassment, there will be more backlash, there will be more surprising situations, and I think we should be prepared for that.”
A flood of hate mail
Racial and ethnic health disparities in the U.S. have been well-documented for decades. Black, Hispanic and Native American people are more likely to have chronic and life-threatening health conditions, and they’re more likely to lack health insurance, according to the Kaiser Family Foundation.
Researchers have also uncovered evidence of racial bias in how medical professionals view and treat patients. A 2016 study found that one in five medical students surveyed believed that Black people had a higher tolerance for pain, and more than half believed that Black people had thicker skin than whites. A 2019 analysis found that software used by many hospitals was more likely to steer healthier white patients to specialized care programs than sicker Black patients.
But major actions to address these outcomes have lagged.
“Racism denial is like a black hole in our national landscape: It’s massive, powerful, you can’t see it, but it’s one of the huge barriers,” said Dr. Camara Jones, a physician and epidemiologist who has long called on public health scientists to confront racism in their work.
Some doctors acknowledge racial health disparities but attribute them to larger societal forces, such as housing issues or employment conditions, saying it’s not up to medical professionals to tackle areas in which they lack expertise.
“To me, it’s kind of an exploitation of your position in society,” said Dr. Sally Satel, a psychiatrist and fellow at the American Enterprise Institute, a conservative think tank. “Because, you know, doctors have a degree of cultural authority. We shouldn’t abuse it. We shouldn’t use it to advance our individual personal politics.”
Momentum for equity efforts shifted in 2020 amid the Covid-19 pandemic and wave of Black Lives Matter protests. Institutions across society began to reckon with racial discrimination. More than 200 city and state governments and health agencies across the country followed the AMA’s lead with similar declarations against racism in medicine.
“Not only were we talking about inequities, we were talking explicitly about racism and structural racism and its impact — words that had been so difficult for many Americans to even say,” Maybank said.
The Association of American Medical Colleges urged its members to deploy training to dispel unconscious bias, and to partner with local governments and community groups to “dismantle structural racism and end police brutality.” The American Public Health Association hosted 61 racial equity sessions at its annual conference. The AMA issued a report documenting the group’s own history of discrimination, such as supporting segregation and the Chinese Exclusion Act, and taking steps to keep women and Jewish students out of medical schools.
Then, in September 2020, the Trump administration issued a directive to ban federal agencies from employing diversity training that discussed “white privilege” or critical race theory. The order kicked off a culture war, which was often summarized as being against critical race theory, an academic concept that posits racial discrimination is perpetuated by laws and policies imposed by governments and institutions.
At the time, Jones was preparing to lead a 13-week training for staff members at the Centers for Disease Control and Prevention on the impact of systemic racism on public health. When leaked excerpts from her course went viral, conservative activists accused the CDC of violating President Donald Trump’s directive. The White House ordered her course canceled the next day.
A flood of vulgar hate mail arrived in her inbox and also targeted a public health organization that was set to honor her later that week.
“That terrified me,” Jones said. “I hid for two weeks."
She added: “They do not understand that when we fight for justice, we’re not anti-white. And that is the confusion. Anti-racism is not anti-white — it is for the benefit of the whole society.”
Other doctors who promote anti-racism policies said trolls have commented on pictures of their children online, and they’ve received death threats that forced them to skip work shifts while they figured out safety plans. Some said they barely check social media anymore because of the incessant trolling.
“It feels like when we make one step forward, the racists make five steps forward,” said Dr. Stella Safo, an HIV primary care physician and professor at the Icahn School of Medicine at Mount Sinai Hospital in New York.
Using critical race theory
Unlike K-12 school administrators, who have largely fought back against claims that they’re teaching critical race theory, a number of doctors and researchers are explicitly drawing on the concept to design new race-conscious policies they believe can rectify long-standing racial disparities in health outcomes.
In 2019, Drs. Bram Wispelwey and Michelle Morse, physicians who teach at Harvard Medical School, found in a study with other colleagues that white patients with heart failure were more likely to be referred to cardiology specialists than Black patients.
Wispelwey and Morse then designed a pilot program at Brigham and Women’s Hospital to encourage providers to automatically refer Black and Latino heart failure patients to cardiology specialists, and check after a year to see if this improved equity resulted in better health outcomes. They said the program, called Healing ARC, was influenced by critical race theory.
“If the problem is racism, the solution has to be race-conscious,” Wispelwey said.
The program faced immediate backlash on Fox News and other conservative media outlets after the doctors publicized it in March 2021. Wispelwey said they received hate mail and death threats, culminating in the neo-Nazi demonstration in January outside the hospital, where protesters called the doctors “anti-white.”
Efforts to improve health equity have also faced lawsuits. In response to research showing that Latino, Black, American Indian and Alaskan Native people had been hospitalized and died due to Covid-19 at disproportionately high rates, while receiving monoclonal antibodies at lower rates, several states advised health care providers to consider race when prioritizing who should receive coronavirus treatments.
In January, a political group founded by former Trump adviser Stephen Miller sued New York state on behalf of a law professor who runs an anti-critical race theory website, alleging the state’s Covid treatment guidance amounted to racial discrimination. (New York has fought Miller’s lawsuit by asserting in court filings that it was merely offering guidance, so there was no punishment if a hospital did not follow it.) Miller also threatened to sue Minnesota and Utah over similar guidance, but those states changed their policies to drop race as a factor.
J.P. Leider, a University of Minnesota health policy researcher who oversaw the state’s tool to help Covid patients determine if they qualified for treatment, said that political groups may succeed in halting race-conscious policies, “but that doesn’t mean that those disparities don’t exist.”
“They’re very real, and they’re very measurable,” he said of health inequities.
Some medical professionals have pushed back on the utility of race-conscious policies in health care, saying they can interfere with the doctor-patient relationship.
“I would want to teach the trainees to look at each patient as an individual, and what their unique identity is, and the unique situation going on with them,” said Dr. Carrie Mendoza, a Chicago-based physician who leads the medicine chapter for the Foundation Against Intolerance and Racism, an advocacy group formed last year to oppose “woke ideology.” “Not lumping them into a group — that’s kind of dehumanizing.”
'This work is harder than ever'
McLemore, the UC, San Francisco professor, said she has received at least one death threat a week since she wrote an op-ed about famous biologists whom she criticized for holding problematic ideas that contributed to “scientific racism.” Someone contacted the school’s chancellor in an attempt to have her fired over it, she said.
“As long as we are stuck in the busy work of having to respond to all this ridiculousness, then we’re not doing the good work that we’re actually paid to do,” she said. “And it’s a defensive and a reactive stance, which is not powerful.”
In an email thread last month with other academics and doctors working on equity in health care, McLemore said they needed to develop a digital safety tool kit, and to call on their professional organizations and universities to help develop rapid response teams to deal with harassment.
McLemore said she began cataloging the threats and hate mail she received, in case the campus police needed it. She has also taken other steps, such as setting up public mailboxes to avoid giving out her home address, and using Google phone numbers that forward calls to her cellphone so that it’s more difficult to look up her personal information.
For now, these safety tips are spreading through word of mouth, which leaves many people unprepared.
“This work is harder than ever, in some ways,” said Morse, the Harvard Medical School instructor, who is also the chief medical officer for New York City. “And yet, we have even more of a responsibility to do better, because we’ve known about these racial inequities for so long and haven’t been able to make progress.”