This spring brought a shake-up within medicine's old guard: the American Medical Association, or AMA, and its associated journal, the Journal of the American Medical Association, or JAMA. Established in 1847 and 1883, respectively, the association and its journal set health standards used around the world.
The controversy began in February, when a JAMA senior editor hosted a podcast that questioned the existence of racism in medicine.
The controversy began in February, when a JAMA senior editor hosted a podcast that questioned the existence of racism in medicine. The outcry — including a petition calling for JAMA to restructure its staff — led to the resignation of the journal's veteran editor-in-chief and a commitment to more equitable practices, including greater diversity in the editorial team and the journal's content.
All of this coincided with the release last month of the AMA's three-year health equity strategic plan, a project in play since 2018, when an internal task force suggested establishing a Center for Health Equity. The goal of the center would be to embed health equity in all of the AMA's work; the original charter established the working definition of health equity as "optimal health for all."
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Optimal health for all, as a concept, is not controversial; it makes intuitive sense, and any perversion of the statement ("suboptimal health for some") feels wrong. And the pursuit of health equity is threaded throughout national health plans, including Healthy People 2030 and Health Resources & Services Administration's current strategic plan. Last year, in the pandemic's sharp inequities and national attention to racially driven violence, hospitals and health systems across the country declared a commitment to address health equity and racism with urgency.
The journal's turnover and the AMA's new push to grapple with health equity are, therefore, fitting manifestations of a growing consciousness. However, the process is also a textbook example of what happens when vague equity sentiments give way to something sharper and clearer, including stark statements acknowledging historical and ongoing, living racism, as well as an actual plan to eradicate it — one with direction, form, decisiveness, benchmarks and accountability.
Members of the AMA delegations from South Carolina, Florida, Oklahoma, Louisiana and Arizona submitted a letter to the AMA's board of trustees and James Madara, the organization's CEO and executive director, objecting to the unseating of the editor-in-chief and the editor who led the podcast, alleging free speech violations in the way the podcast controversy was handled and objecting to the strategic plan's "use of unfamiliar, multisyllabic terms" to discuss racism, among other things.
When a bunch of doctors protest a document because the words are too long, something is very wrong. We're responsible for the tongue-twisters "borborygmus," "pseudopseudohypoparathyroidism" and "choledocholithiasis." So the problem is not that "institutional racism" or "intersectionality" or "marginalization" are too hard (particularly since the document includes a primer on all key terms). It is that the particular syllables in the AMA's strategic plan add up to that most painful and feared word: change.
Change is an upsetting possibility to those whose lives remain untouched by — or those who have benefited from — racism.
Change is an upsetting possibility to those whose lives remain untouched by — or those who have benefited from — racism. The specter of change is why the anti-racist pledges and promises of transformation of 2020 are giving way to the silent complacency of 2021 across industries. In health care, this manifests in a determined passivity that leaves race-based calculators and homogenous leadership in place, budgets for equity and inclusion work small, and goals toward equity vague. The #BLM hashtags remain, unironically, along with implicit and explicit reassurances that actual change is too hard, too inconvenient and better left for a distant future.
And yet change is coming, at least in the long term, not only because of the rise of more progressive medical students and residents, and not simply to make people feel virtuous or allow them to click boxes off on some performative list. Change is coming, ultimately, because science dictates that we need new approaches to racism in health care. Organizations committed to improving the health of the nation must confront the drivers of poor health. And racism, grown in our current systems, perpetuated by our current structures and policies and practices, advanced and glossed over by our choice of words, is one of those drivers. Logic, evidence and moral imperative have converged to ask for pivotal change.
It is fair to empathize with those who feel that good intentions should be enough to protect our population from the toxic effects of racism, but frustratingly, they are not enough. It is also understandable to feel overwhelmed by the new world represented in equity plans and to want a moment or two to grapple with it.
And yet, those who do not understand racism cannot be in charge of the push to end it. Ophthalmologists or dermatologists may not successfully protest a change to unfamiliar-sounding heart failure guidelines. If the ophthalmologists want a thorough explanation of the jargon or need to be convinced that the guidelines are needed, they can get that information — but their ignorance cannot delay the change.
Likewise, those affected by racism cannot afford to wait. Lives are at stake, and what we have been doing is not working.