This story was updated March 5.
March 4, 2021 -- A 16-minute podcast from JAMA: TheJournal of the American Medical Association that attempts to discuss structural racism in the U.S. health care system has stirred conversation on social media about the handling and promotion of the episode.
Published on Feb. 23, the episode is hosted on JAMA’s learning platform for doctors and is available for continuing medical education credits.
“No physician is racist, so how can there be structural racism in health care? An explanation of the idea by doctors for doctors in this user-friendly podcast,” JAMA wrote in a Twitter post to promote the episode. That tweet has since been deleted.
The episode features host Ed Livingston, MD, the deputy editor for clinical reviews and education at JAMA, and guest Mitchell Katz, MD, the president and CEO for NYC Health + Hospitals and deputy editor for JAMA Internal Medicine. Livingston approaches the episode as “structural racism for skeptics,” and Katz tries to explain how structural racism deepens health disparities and what health systems can do about it.
“Many physicians are skeptical of structural racism, the idea that economic, educational, and other societal systems preferentially disadvantage Black Americans and other communities of color,” the episode description says.
In the podcast, Livingston and Katz speak about health care disparities and racial inequality. Livingston, who says he “didn’t understand the concept” going into the episode, suggests that racism was made illegal in the 1960s and that the discussion of “structural racism” should shift away from the term “racism” and focus on socioeconomic status instead.
"What you're talking about isn't so much racism ... it isn't their race, it isn’t their color, it's their socioeconomic status,” Livingston says. “Is that a fair statement?”
But Katz says that “acknowledging structural racism can be helpful to us. Structural racism refers to a system in which policies or practices or how we look at people perpetuates racial inequality.”
Katz points to the creation of a hospital in San Francisco in the 1880s to treat patients of Chinese ethnicity separately. Outside of health care, he talks about environmental racism between neighborhoods with inequalities in hospitals, schools, and social services.
“All of those things have an impact on that minority person,” Katz says. “The big thing we can all do is move away from trying to interrogate each other’s opinions and move to a place where we are looking at the policies of our institutions and making sure that they promote equality.”
Livingston concludes the episode by reemphasizing that “racism” should be taken out of the conversation and it should instead focus on the “structural” aspect of socioeconomics.
"Minorities ... aren't [in those neighborhoods] because they're not allowed to buy houses or they can't get a job because they're Black or Hispanic. That would be illegal,” Livingston says. “But disproportionality does exist.”
Efforts to reach Livingston were unsuccessful Thursday. Katz distanced himself from Livingston in a statement released late Thursday.
“Systemic and interpersonal racism both still exist in our country — they must be rooted out. I do not share the JAMA host’s belief of doing away with the word ‘racism’ will help us be more successful in ending inequities that exists across racial and ethnic lines,” he said. “Further, I believe that we will only produce an equitable society when social and political structures do not continue to produce and perpetuate disparate results based on social race and ethnicity.”
Katz reiterated that both interpersonal and structural racism continue to exist in the United States “and it is woefully naïve to say that no physician is a racist just because the Civil Rights Act of 1964 forbade it.”
He also recommended JAMA use this controversy “as a learning opportunity for continued dialogue and create another podcast series as an open conversation that invites diverse experts in the field to have an open discussion about structural racism in healthcare.”
The podcast and JAMA’s tweet promoting were widely criticized on Twitter. In interviews with WebMD, many doctors expressed disbelief that such a respected journal would lend its name to this podcast episode.
B. Bobby Chiong, MD, a radiologist in Bronx, NY, said although JAMA's effort to engage with their audience about racism is laudable, it missed the mark.
"I think the backlash comes from how they tried to make a podcast about the subject and somehow made themselves an example of unconscious bias and unfamiliarity with just how embedded in our system is structural racism," he said.
Perhaps the podcast's worst offense was its failure to address the painful history of racial bias in this country that still permeates the medical community, says Tamara Saint-Surin, MD, an assistant professor at the University of North Carolina at Chapel Hill.
"For physicians in leadership to have the belief that structural racism does not exist in medicine, they don't really appreciate what affects their patients and what their patients were dealing with," Saint-Surin says in an interview. "It was a very harmful podcast and goes to show we still have so much work to do."
Along with a flawed premise, she says, the podcast was not nearly long enough to address such a nuanced issue. And Livingston focused on interpersonal racism rather than structural racism, she says, failing to address widespread problems like higher rates of asthma among Black populations living in areas with poor air quality.
The number of Black doctors remains low and the lack of representation adds to an environment already rife with racism, according to many medical professionals.
Shirlene Obuobi, MD, an internal medicine doctor in Chicago, said JAMA failed to live up to its own standards by publishing material that lacked research and expertise.
"I can't submit a clinical trial to JAMA without them combing through methods with a fine-tooth comb," Obuobi said. "They didn't uphold the standards they normally apply to anyone else."
Both the editor of JAMA and the head of the American Medical Association issued statements criticizing the episode and the tweet that promoted it.
JAMA Editor-in-Chief Howard Bauchner, MD, said, “The language of the tweet, and some portions of the podcast, do not reflect my commitment as editorial leader of JAMA and JAMA Network to call out and discuss the adverse effects of injustice, inequity, and racism in society and medicine as JAMA has done for many years.” He said JAMA will schedule a future podcast to address the concerns raised about the recent episode.
AMA CEO James L. Madara, MD, said, “The AMA’s House of Delegates passed policy stating that racism is structural, systemic, cultural, and interpersonal and we are deeply disturbed—and angered—by a recent JAMA podcast that questioned the existence of structural racism and the affiliated tweet that promoted the podcast and stated ‘no physician is racist, so how can there be structural racism in health care?’”
He continued: “JAMA has editorial independence from AMA, but this tweet and podcast are inconsistent with the policies and views of AMA and I’m concerned about and acknowledge the harms they have caused. Structural racism in health care and our society exists and it is incumbent on all of us to fix it.”