Deeply engrained structural racism within the healthcare system has harmed historically marginalized people for centuries. Recognizing their role in this, the largest medical association in the United States pledges to help eradicate inequity in medicine. We asked four experts for their opinion on how to do this in a meaningful way.

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Art by Diego Sabogal

The American Medical Association (AMA), one of the largest and most influential medical associations in the world — along with its publication, the Journal of the American Medical Association (JAMA) — has recently unveiled its “Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity.” The AMA has also publicly recognized its contribution to structural racism through harmful and unjust practices and proceedings.

Throughout this 3-year plan, the AMA vows to promote equity throughout its vast organization and within its “domains of influence.” This commitment to racial and social justice is long overdue and has the potential to bring much-needed restructuring to a healthcare system that, to this point, has severely underserved historically marginalized groups.

In this Special Feature, Medical News Today takes an in-depth look at structural racism and inequity in medical organizations, research, and health reporting. We also talk with four experts about some actions necessary to promote meaningful change.

Structural racism goes beyond individual prejudice. It is a perpetual inequity deeply engrained in social policy, legislation, law enforcement, the economic system, and the healthcare system, to name only a few of the areas that it affects.

It results from a pervasive, misaligned thought process that places one racial or ethnic group above another. This is often driven by white supremacist beliefs, underlying white privilege, and a failure to understand that all humans share 99.9% of their DNA.

Within the healthcare system, structural racism has profoundly impacted the mental and physical health of historically marginalized groups. For example, reports indicate that Black people have lower life expectancies than white individuals and that predominantly Black communities are more likely to experience a shortage in primary care physicians.

On a deeper level, the medical community has promoted structural racism throughout decades of biased research and papers published in medical journal publications. A staggering number of research studies fail to incorporate diversity in recruiting participants, and consumer-facing media have perpetuated the issue by continually assuming that their audience is white.

These practices have had a profound effect on the healthcare that historically marginalized people receive, as health conditions, reactions to medications, and risk factors for disease can differ among racial and ethnic groups.

Realizing its role in this, the AMA has openly acknowledged its history of actively harmful practices and longstanding silences that have promoted health inequity.

To promote racial justice and advance health equity throughout its organization and in its domains of influence, the AMA vows to incorporate the following strategies:

  • Embed racial and social justice in AMA businesses, cultures, systems, policies, and practices.
  • Build alliances and share power with historically marginalized and “minoritized” physicians and other stakeholders.
  • Ensure equitable structures and opportunities in innovation.
  • Push upstream to address all determinants of health and root causes of inequities.
  • Create further pathways for truth, racial healing, reconciliation, and transformation for AMA’s past.

AMA developments highlight continued ignorance

Despite its positive intonations, this call to action has brought upheaval and controversy to the AMA and unveiled a continued ignorance of racial inequity issues, as a small group of AMA delegates wrote in a letter in which they expressed concern over the pledge.

Also, recently, Dr. Howard Bauchner — editor in chief of the JAMAstepped down from his position due to an incident surrounding a previous JAMA podcast and tweet.

According to a news article in the BMJ, the podcast in question was promoted with a Twitter post claiming, “No physician is racist, so how can there be structural racism in healthcare? An explanation of the idea by doctors for doctors in this user-friendly podcast.”

In the AMA press release announcing the move, Dr. Bauchner says, “I remain profoundly disappointed in myself for the lapses that led to the publishing of the tweet and podcast. Although I did not write or even see the tweet, or create the podcast, as editor in chief, I am ultimately responsible for them.”

Despite the controversy and internal discord, the organization plans to push its 3-year plan into high gear and be the driver of health equity for “minoritized” people.

However, will this strategy be an effective solution to a problem deeply engrained within the medical community?

MNT spoke with four experts about structural racism in medical communities and ways to bring this deeply rooted issue to the forefront and promote impactful change.

Prof. Derek M. Griffith, Ph.D., is the director of the Center for Research on Men’s Health and professor of medicine, health, and society at Vanderbilt University in Nashville, TN.

After July 1, 2021, Prof. Griffith will assume the role of founder and co-director of the Racial Justice Institute, founder and director of the Center for Men’s Health Equity, and professor of health systems administration and oncology at Georgetown University in Washington, D.C.

Dr. Tiffany Green, Ph.D., is an author and assistant professor of population health sciences and obstetrics and gynecology at the University of Wisconsin-Madison.

Dr. Winston Morgan, B.Sc., Ph.D., FHEA, is reader in toxicology and clinical biochemistry and the director of Impact and Innovation at the School of Health Sport and Bioscience at the University of East London in the United Kingdom.

Dr. Jameta Nicole Barlow, Ph.D., M.P.H., is an assistant professor of writing in The George Washington University’s University Writing Program and Women’s Leadership Program. She is also affiliated with Milken Institute of Public Health, holding secondary appointments in women’s, gender, and sexuality studies and in the Department of Health Policy and Management.

Dr. Barlow is also an affiliate faculty member in the Global Women’s Institute, the Africana Studies Program, and the Jacobs Institute of Women’s Health.

What meaningful steps can medical associations, professional groups, and researchers take to eliminate racism and promote health equity?

Acknowledging the structural racism present in the medical community is only the beginning of what needs to happen to advance health equity.

Dr. Morgan told MNT: “As someone who has been working on social justice for many years in education, science, and medicine — the strategic [AMA] plan represents a great start. When I read the document, I was pleasantly surprised at the content, what was being accepted and proposed by the AMA. It was obvious the document was written by individuals who understood the racial landscape, who are the key thinkers, and what needed to be done.”

However, Dr. Morgan noted the challenge of implementing such change in an organization as large as the AMA.

“Many inside and outside of the AMA of all races have been living in denial that the disparities in medical outcomes have nothing to do with them — this plan challenges that, and it will make members uncomfortable,” Dr. Morgan explained.

“The other challenge is that the AMA only represents a third of all doctors in the [U.S.] — at best, those in the AMA are more likely already to be accepting of some of these ideas — getting acceptance from the wider profession will be the greatest challenge,” he said.

Dr. Green recently addressed health equity in organizations in a commentary that appears in the journal Obstetrics & Gynecology.

To foster health equity, Dr. Green said, “we need to stop treating racism as just an individual-level problem and recognize it as a structural one that impacts every aspect of our lives (including medical care).”

Dr. Green proposed that actions to accomplish this need to include and prioritize the voices of historically marginalized groups, diversify leadership, and create environments that practice a zero tolerance policy toward discrimination and where Black scholars and other scholars of color can thrive.

“Finally, while medical care is critical, the social determinants of health matter far more when it comes to promoting health equity. Such an approach will mean addressing structural racism in housing, employment, and education in order to improve the health and well-being of marginalized groups,” Dr. Green said.

In addition to this, Dr. Barlow suggested, “professional groups and medical researchers can work with Black health organizations and researchers to create strategies and approaches to health equity.” She recommended reaching out to organizations including the Black Women’s Health Imperative, the Council on Black Health, the Community Healing Network, and the Association for Black Psychologists.

According to Prof. Griffith, organizations such as the AMA have perpetuated racist ideas for more than a century. Therefore, they need to initiate tangible actions with measurable definitions and use their influence to move issues of racism from the margins of the medical community to the center.

“[The] AMA and other medical associations should not presume to know how to solve these problems; they cannot know what is best for the lives, careers, medical societies, and institutions their actions have harmed. The AMA leadership, not the staff, should spend time listening to and hearing from the individuals, communities, [and] other professional organizations they have harmed to understand what remedies would be helpful to them.”

– Prof. Derek Griffith, Ph.D.

What about diversity training for eliminating racism in healthcare?

Using diversity training as a tool to mitigate structural racism is one concept that many feel would improve health equity. However, all four experts we spoke with said that there is little evidence to suggest that this type of intervention is effective.

Still, Dr. Morgan pointed out that implementing diversity training as an integral part of medical training could be effective — as long as it takes place throughout the organization.

“Structural barriers will NOT be eliminated by diversity training and/or implicit bias training. However, they may contribute to improved medical interactions/patient experiences, provided the provider [does] the hard work required of reducing bias in their daily interactions.”

– Dr. Jameta Nicole Barlow, Ph.D., M.P.H.

Will enacting a ‘Marshall Plan’ strategy advance health equity?

On June 5, 1947, Secretary of State George C. Marshall proposed a post-World War II plan to help Western Europe rebuild infrastructure and aid economic recovery.

Adopting a Marshall Plan strategy may be effective in overcoming structural racism in healthcare. But would it work?

According to Prof. Griffith, “In terms of health equity, AMA journals and others could publish strategies to create the infrastructure needed to achieve and maintain health equity, or studies that describe, simulate, or test strategies to achieve and sustain equitable outcomes in health.”

Because of the correlation between socioeconomic status and health outcomes, Dr. Morgan believes that implementing a Marshall Plan strategy to address structural racism in the medical community would need to happen on a societal level to benefit health outcomes and promote an increase in Black medical and public health professionals.

Addressing the lack of diversity in medical research

One glaring example of structural racism in medical organizations is the noticeable lack of racially and ethnically diverse participants in scientific research.

According to Prof. Griffith, this exclusion limits the ability to effectively treat and improve the health and well-being of “minoritized” groups. It also inflicts an economic drain on healthcare and public health resources.

“We spend an unnecessary amount of money on providing care, paying for sick days, and wasting untold amounts of money because we did not spend the time and resources to test whether the benefits of medicines and other treatments are equally beneficial to all racial and ethnic groups.”

– Prof. Derek Griffith, Ph.D.

“If we required race and ethnicity to be part of the sampling strategy and research questions from the beginning, we would have fewer issues in terms of application and implications,” Prof. Griffith told MNT.

Dr. Morgan also explained: “Historically and paradoxically, clinical trials have always been carried out in or around communities linked to the more elite medical institutions, as that is where the most generously funded academic researchers and clinicians are based. These institutions are less likely to have representative numbers of certain groups, particularly [Black people].”

To help rectify the problem, he suggested that “just as important as having [Black people] as [participants] for clinical trials will be the number of [Black people] on the other side of the process; those involved in designing and interpreting the data. Once [those in] the Black population see people they know and trust running clinical trials, they will more happily take part.”

“Multiple stories need to be told,” Dr. Barlow explained. “So, depending on the context of the issue — papers that fail to take into account individual-, interpersonal-, [or] systems/structural-level actions should be encouraged to think through this. Journals can make these requirements as an effort to challenge the field — which will, no doubt, contribute to how researchers begin to understand the real issue.”

The root problem may rest in the hands of funding, according to Dr. Green. “Black scholars are less likely to be awarded NIH [National Institutes of Health] funding, in part because of doing the very work that is needed to address health disparities,” she explained.

Preventing performative allyship

Performative allyship refers to when privileged individuals claim solidarity with a movement or set of ideals without taking action to further the cause.

From Dr. Morgan’s perspective, preventing this would require many allies to lose their positions of power, which is a challenge to overcome for some people.

“One of the biggest obstacles to racial justice in any area is when those advocating for change [realize] that making effective change is a zero-sum gain [sic], particularly in the short term, as too many in our society are heavily invested in the status quo,” he explained.

For Prof. Griffith, the solution is simple. “Find ways, and others, to hold them accountable,” he said.

Despite ongoing health disparities, solutions are slowly emerging

Dr. Green informed MNT that Black women scholars are calling for a comprehensive plan to address these inequities, including making the diversity of research teams a scorable criterion and addressing bias in scientific review panels.

She also pointed out positive change through public workshops and a position paper from the Black Mamas Matter Alliance.

Dr. Green also noted: “Black medical students and other medical students of color have really led the charge when it comes to addressing race in medicine. For example, at the University of Washington, medical students and the UWSOM [University of Washington School of Medicine] Anti-Racist Action Committee successfully lobbied to have race removed as a criterion for determining the estimated glomerular filtration rate (i.e., kidney function). And now, we’re seeing medical institutions across the country working to do the same thing.”

“Sometimes it really does take one person [or group of people] to be the start of real change,” said Dr. Green.

Additionally, Dr. Morgan highlighted positive change occurring with Food and Drug Administration (FDA) guidance that recommends that clinical trials include a certain percentage of Black, Asian, and Hispanic people.

According to Prof. Griffith, peer reviewed journals should follow the NIH, which is already requiring studies to report on the inclusion of racial and ethnic minorities. Additionally, Prof. Griffith said, “journals should reject research papers that don’t follow this guideline before sending them out for review.”

“To be clear, papers should not be rejected if the sample is 100% white,” Prof. Griffith clarified. “We need to know about the health of the white population in the U.S. in the same way that we need to know about the health of ‘minoritized’ groups. The authors, however, should explicitly note this in the title, limitations, and implications and discuss how race affected their study in the same way we expect ‘minoritized’ populations to.”

He added: “The American Public Health Association [APHA] is an organization that has been a leader in this area. Not only [has it] been led by scholars and practitioners who have expertise in these areas, [but also] APHA Press and the organization’s flagship journal, the American Journal of Public Health, and [the] APHA annual meeting have dedicated considerable resources and scholarly space to grappling with these issues and providing thought leadership in these areas.”

To continue on a positive path, Dr. Barlow suggested:

“Organizations and journals can take cues from Black professional organizations and journals that center the experiences of Black communities and are in tune with the nuances that occur when engaged with these communities.”

The power of the written word to facilitate change is incontestable. However, consumer-facing health media — including MNT — have not historically done their best to combat structural racism through news and feature stories.

We have played our role in perpetuating structural racism in the medical community and have fallen short on many aspects of our medical coverage regarding racial disparities.

Last year, Robin Hough, our editor in chief, released a statement acknowledging our shortcomings and outlining our rebuilding process to ensure greater representation of, and relevance for, Black people and all People of Color in the content we create.

However, although we and many others say that we recognize the problem, our efforts should continue to focus on effective ways to rectify it. We asked our experts, “What is the best way for health media companies, writers, and journalists to address structural racism in medicine effectively?”

Dr. Morgan told MNT, “Health journalists should emphasize the impact of social rather than biological factors in medical outcomes linked to race.”

Dr. Morgan also indicated that although the genetic differences between races are negligible, “many common diseases and medical outcomes are linked [to] or dependent on the social determinants of health [that] are deeply affected by race, [so] it is important we do not have white as the default.”

Health journalists should also “make sure that they report such limitations of research and not presume that the findings apply equally to all people. Journalists should seek out the expertise and comment of people who can appropriately contextualize such research findings,” according to Prof. Griffith.

Because there is a long history of excluding “minoritized” groups in media coverage, Dr. Barlow suggested that consumer-facing media can make up for this “by telling the stories that haven’t been told — including them in history, the present, and preparing for the future.”

Additionally, Dr. Barlow said: “Media organizations can center historically excluded communities and not center whiteness. This can occur in the stories [and] perspectives and explicitly name why this perspective tells a more nuanced issue of the issue.”

‘Many allies would have to lose their positions of power’

In health media organizations as well, however, avoiding the pitfall of performative allyship is key. As Dr. Morgan reiterated, “the main stumbling block is the realization that in the short term, real change is a zero-sum gain [sic], and many allies would have to lose their positions of power.”

“Some of the biggest advocates for change come from the middle classes, but they are the [ones] in the key positions blocking change, although they don’t realize it.”

“Having [a] guest editor is not the same as having a full-time editor or several journalists. If we want real change, then leadership has to be brutal in their decision making.”

– Dr. Winston Morgan, B.Sc., Ph.D., FHEA