The February podcast involved two white doctors — Ed Livingston, JAMA's deputy editor for clinical content, and Mitchell Katz, an editor at JAMA Internal Medicine and CEO of NYC Health + Hospitals — who are not experts in structural racism, broadcasting a conversation about that topic on JAMA’s huge and powerful platform that came across as deeply offensive.
Livingston questioned whether racism could be embedded in society because it is "illegal" and said he did not consider himself a racist because he grew up in a Jewish family and was taught never to hate. He asked whether the term racism "might be hurting us" and whether there might be a better word because "the term racism invokes feelings amongst people." Katz repeatedly affirmed his belief that structural racism exists but was later criticized by some for coddling Livingston. Katz has since condemned the podcast and said he was not involved in its production and firmly believes structural racism exists in medicine. Livingston has not commented publicly.
The uproar over the podcast led the journal to ask Livingston to resign. Howard Bauchner, JAMA's editor-in-chief, apologized but was then put on administrative leave. He and other editors at JAMA have refused to comment, pending the outcome of an investigation of the matter by outside counsel. The journal is owned by the American Medical Association, the nation’s leading physicians organization, but has editorial independence.
Critics say problems at JAMA and its network of medical journals include limiting publication of scholarship on how racism affects health and suggesting papers involving racism be submitted not as research articles, which have the most clinical impact, but as opinion pieces or "Perspectives," a series in JAMA Internal Medicine featuring "stories about the joys and challenges of practicing general medicine and truths discovered along the way."
Other problems they cite include editors asking authors to scrub the term racism from their manuscripts even as they publish other manuscripts that include outdated and racist notions, such as the idea that genetic and not social factors may explain the higher rates of COVID-19 death and hospitalization among people of color.
Problematic articles have appeared recently and steadily in JAMA and other prominent medical journals, even as discussions of racism in medicine have taken center stage during the pandemic and as journals and medical associations have publicly affirmed the Black Lives Matter movement and their own commitment to racial equality.
A September JAMA paper suggested African Americans may have higher rates of COVID-19 because of differences in the expression of a certain gene in the nasal epithelium, despite the fact that the clinical relevance of that gene’s expression is unknown and Hispanic people, who also have higher death rates from COVID-19, do not have a higher rate of expression of the gene. "That’s biomedical racism to a T," James said.
Critics say an October JAMA paper on the association between air pollution and poor birth outcomes failed to examine the role racism plays in environmental exposure to poorer air. And an article about the high rates of hospitalization among people of color with COVID-19 in California, published online in Health Affairs in May, initially questioned whether there could be "some unknown or unmeasured genetic or biological factors that increase the severity of this illness for African Americans." In response to criticism, the paper was later revised to remove this language.
An article published in August in the Journal of the American Heart Association, arguing that students of educational programs intended to increase diversity would make poorer clinicians, was retracted after many physicians questioned how the article — rife with stereotypes and errors — made it past reviewers.
And a letter published just last week in the New England Journal of Medicine disputed use of the phrase "structural racism" when discussing the fact that pulse oximeters — oxygen sensors that are critical tools for COVID-19 care and were developed and tested largely on people with white skin — work less well on people with Black skin. "Medical devices such as pulse oximeters are blind to color and cannot exhibit such a bias," the author wrote.
Months before the recent podcast, Rhea Boyd, a pediatrician and public health advocate in Palo Alto, California, had taken to Twitter to call out JAMA's poor record on studies involving race. With colleagues Edwin Lindo, Lachelle Weeks and Monica McLemore, she wrote a piece in Health Affairs in July calling for a higher standard for publishing on racial health inequities. "The bar hasn't been high enough," she told STAT. "We don't treat scholarship around race the same way we do other health issues. When we do that, we sell this field short."
Boyd said researchers need to do a better job of defining race, specifying the reason they use it in studies, refraining from using genetic definitions of race that are not grounded in science, and citing experts who have rigorously studied the effects of racism. She said journals should reject articles on health inequities that don't examine racism, use reviewers who are experienced in the scholarship of racism, and consider compensating reviewers, particularly those of color, who are increasingly being asked to share their expertise for free.
Crucially, she said, scholars and journal editors must openly use the term racism, something many have clearly been uncomfortable with. "In doing this, we obscure ways that racism drives health inequities," said Boyd.