Just a few years ago, concepts such as \u201cwhite supremacy,\u201d \u201csystemic racism,\u201d and \u201cstructural intersectionality\u201d were not the standard fare of prestigious medical journals. These are now the guiding ideas in a February special issue<\/a> of \u201cHealth Affairs\u201d that focuses on medicine and race.<\/p>\n<\/div>\n Featuring nearly two dozen articles with titles such as \u201cRacism Runs Through It<\/a>\u201d and \u201cSick and Tired of Being Excluded<\/a>,\u201d as well as a poem called \u201cIdentity<\/a>,\u201d the Washington, D.C.-based, peer-reviewed journal analyzes racial health disparities not through biology, behavior, or culture, but through the lens of \u00a0\u201cwhiteness,\u201d along with concepts such as power, systems of oppression, state-sanctioned violence, and critical race praxis \u2013 a sampling of terms that come up in the February issue.<\/p>\n<\/div>\n But this scientific aspiration faces major challenges. Science demands verification, testability, and replicability, whereas race is a social construct that can be difficult to separate from factors like class or culture, and explaining the data often remains dependent on academic theories about systemic racism. The articles in Health Affairs indicate that elevating the concept of systemic racism from moral certitude to scientific fact will require developing new tools and methods \u2013 and even more theories \u2013 in the face of skepticism and resistance from dissenters who view this direction in research as unscientific and ideological.<\/p>\n<\/div>\n In a Health Affairs paper titled \u201cThe Intellectual Roots of Current Knowledge on Racism and Health,\u201d<\/a> researchers from Harvard University and the University of Maryland argue that turning the study of systemic racism into a scientific enterprise will require the scientific community to embrace terminology and research that \u201ccan be unsettling to some\u201d:<\/p>\n<\/div>\n Until recently, the language and terminology of racism has been contested, often ignored, and viewed as not relevant to, or acceptable for, accounting for and intervening on racial and ethnic inequities in health.<\/p>\n<\/blockquote>\n<\/div>\n The Harvard and Maryland scholars identify \u201cthe critical need for paradigmatic shifts that incorporate racism as a driver of inequities,\u201d noting that \u201cscientific language has the power to encourage normative standards.\u201d In another article, a team of five scholars calls for<\/a> \u201coutlining specific methodological approaches that will move the field forward.\u201d<\/p>\n<\/div>\n Those pushing the effort expect that it will take years to build up a knowledge base and critical mass of scholarly research. If successful, it would empower the anti-racist movement with what advocates expect to be recognized as unimpeachable scientific authority that could be used to support a myriad of diversity and equity policies and interventions that are now being advocated as moral and polemical arguments by legal scholars, educators, historians, and journalists.<\/p>\n<\/div>\n According to researchers now studying the relationship of medicine and race, racial inequalities in lifespans, health, income, and other metrics largely result from a single cause: cultural norms and unconscious beliefs that have the appearance of colorblindness but systematically privilege whites and males at the expense of groups that lack power and are oppressed.<\/p>\n<\/div>\n Since the murder of George Floyd by a Minnesota police officer in May 2020, the cultural elites advocating this view \u2013 whether one calls it wokeness, systemic racism, critical race theory, or just the truth \u2013 are no longer marginalized outsiders. They are now in charge of many leading institutions that produce culture and certify knowledge through the media, publishing, universities, scholarly journals, foundations and advocacy groups, large K-12 school systems, and the sprawling apparatus of the federal government.<\/p>\n<\/div>\n Although medical research informed by critical race theory has been conducted for decades, its broad embrace by the field\u2019s highest echelons has been both sudden and expansive.<\/p>\n<\/div>\n Alan Weil, Health Affairs\u2019 editor-in-chief, committed the journal<\/a> to \u201cdismantling institutional racism\u201d in January 2021. Scientists must question their assumptions about merit, quality, and excellence and make room for new research designs, methods, paradigms, and theories, Weil suggested, because traditional scientific protocols can make it impossible to study racism in the United States or recognize the problem within their own institutions.<\/p>\n<\/div>\n \u201cThe reason it\u2019s relevant is because if you decide only certain [research] methods are valid, then you have also decided that certain questions cannot be answered \u2013 they can\u2019t even be asked,\u201d Weil said in a phone interview. \u201cI view this as a call to researchers to try to look at questions that they might have historically passed by — or viewed as ones that couldn\u2019t be studied.\u201d<\/p>\n<\/div>\n The February issue of Health Affairs provides examples of how the new approach to research can be implemented to make the case for the pervasiveness of systemic racism in routine aspects of society.<\/p>\n<\/div>\n The first of the nearly two dozen articles<\/a> in the February issue sets the tone. The article describes an anti-racist initiative at the Mass General Brigham health system, where measuring and attaining equity \u2013 an ideal of equal health outcomes across racial groups \u2013 is now a core component of the institutional culture, like patient safety.<\/p>\n<\/div>\n One thing that system leaders are not doing: studying whether or not racism actually affects health outcomes. \u201cThey believe that this fundamental question has already been answered,\u201d the article states. The anti-racist initiative, called United Against Racism, will cost $40 million in the first year alone. \u201cThe initiative has no set end date,\u201d the article states, and a system executive \u201cexpects their budget to increase every year.\u201d<\/p>\n<\/div>\n Another article<\/a>\u00a0urges the need to teach white Americans \u201cthe truth\u201d about racial oppression, \u201cdespite the discomfort that it generates.\u201d True racial progress requires the \u201cunderstanding by White people of how they have benefited from systemic racism\u201d \u2013 and how much more they stand to gain from social justice.<\/p>\n<\/div>\n An article<\/a> about the generational trauma of racism recommends respect for \u201cIndigenous principles\u201d and adopting a policy of federal reimbursement to traditional Native American healers who perform ceremonial and spiritual interventions.<\/p>\n<\/div>\n As high-profile journals advance the systemic racism argument, other influential institutions are putting the contested ideas into practice.<\/p>\n<\/div>\n The American Medical Association\u2019s 86-page strategic plan<\/a> for racial justice and health equity also challenges the morality of prevailing standards of quality and merit as a strategy of protecting the privileged domain of white males: The AMA condemns \u201cequal treatment\u201d and meritocracy as \u201cmalignant\u201d white supremacist ideologies that obscure \u201ctrue power and site of responsibility.\u201d<\/p>\n<\/div>\n The Association of American Medical Colleges, which co-sponsors the accrediting body for U.S. medical schools, is working to establish an advocacy culture in medical schools that haven\u2019t yet gotten with the program voluntarily. The AAMC is expected to issue an update this year to its\u00a0recommended professional \u201ccompetencies<\/a>,<\/span>\u201d<\/span>\u00a0\u00a0the AAMC’s term for\u00a0professional standards and best practices, that medical schools would be encouraged to adopt.<\/p>\n<\/div>\n The proposed competencies include practicing self-reflection, \u201callyship,\u201d and cultural humility, as well as attaining fluency in the \u201cvarious systems of oppression,\u201d to wit: colonization, white supremacy, acculturation, and assimilation.<\/p>\n<\/div>\n For medical school faculty, the AAMC sets such professional expectations as teaching \u201chow systems of power, privilege, and oppression inform policies and practices and how to engage with systems to disrupt oppressive practices.\u201d<\/p>\n<\/div>\n Not surprisingly, the handful of people who are willing to risk their careers and reputations to publicly critique anything to do with systemic racism and equity say the medical establishment has become captive to a leftist ideological agenda. These dissenters argue that \u201canti-racism\u201d can be hard to distinguish from anti-science when it fixates on a single variable (race), selectively seeks out data to prove a hypothesis (confirmation bias), ignores plausible alternative explanations \u2013 and worst of all \u2013 silences criticism.\u00a0<\/p>\n<\/div>\n \u201cConfounding science with political ideology is never good,\u201d said Michael Shermer, the founding publisher of Skeptic magazine, whose monthly column was terminated<\/a> at Scientific American after 18 years in a disagreement over what Shermer saw as woke ideology infecting the venerable publication.<\/p>\n<\/div>\n \u201cThey\u2019re saying we already know the answer \u2013 the answer is racism,\u201d Shermer said in a phone interview with RealClearInvestigations. \u201cWe\u2019re going to ignore all the other variables. They\u2019re just reducing complex problems to one variable.\u201d<\/p>\n<\/div>\n This embrace of systemic racism is piggybacking on a long tradition of public health research that attributes population health disparities to social conditions,\u00a0going back to a study<\/a>\u00a0by Friedrich Engels in the 1840s that said life expectancies in Liverpool, England, varied by the occupation of the city\u2019s residents. For generations, however, the mainstream medical establishment understood racial health disparities to be a matter of genetics, behavior, culture, class \u2013 or a combination of these factors. Public health scholars, meanwhile, have been pouring forth hundreds of scholarly articles that attribute racial disparities in heart disease, diabetes, mental illness and other key metrics to societal conditions.<\/p>\n<\/div>\n Health Affairs traces the evolution<\/a>\u00a0of racism as medical scourge through the release of \u201cUnequal Treatment,\u201d the groundbreaking 2003 Institute of Medicine (now National Academy of Medicine) report that said black people received inferior care in nearly every medical category. More recent is the 2019 declaration by the Pan American Health Organization, a regional arm of the World Health Organization, that structural racism is a key driver of health inequity, followed by the 2021 declaration from the Centers for Disease Control and Prevention that racism is a public health threat.<\/p>\n<\/div>\n The Health Affairs articles in the February\u00a0special issue<\/a>\u00a0rely on sociological theories,\u00a0personal testimonials<\/a>, and even\u00a0poetry<\/a> to augment traditional scientific protocols. Because there is no single correct way to measure structural racism, the five scholars \u201cencourage the use of a theory-driven approach\u201d to interpret data that would otherwise have to be treated as random or inconclusive.<\/p>\n<\/div>\n For such scholars, theory is often the connective tissue that can link practices or events that, to the untrained eye, might seem too remote or speculative or simply unrelated. Within the narrative structure of a productive theory, facts fall neatly into place, and hidden patterns emerge. Thus, theories are the key to linking sociological phenomena separated by 50, 100, and even 200 years.<\/p>\n<\/div>\n \u201cFuture studies should examine how modern health is shaped by a wider array of past forms of structural racism, such as slavery, lynching, unequal treatment in the criminal-legal system, forced sterilization, and other manifestations of racialized violence,\u201d\u00a0according to the quintet<\/a>\u00a0of academic scholars.<\/p>\n<\/div>\n \u201cTheory suggests inextricable links,\u201d they say, \u201cwith historical forms directing, constructing, and molding contemporary structural racism.\u201d<\/p>\n<\/div>\n Researchers from Duke University and Florida State University argue<\/a>\u00a0that depriving African American felons of the right to vote affects the health of the entire community. The co-authors acknowledge they can\u2019t directly prove that voting prohibitions for convicted felons harmed community health, but they noted that \u201cthere is a strong theoretical basis on which to expect that racialized disenfranchisement affects health.\u201d\u00a0<\/p>\n<\/div>\n The article states that living in states with higher levels of \u201cracialized felony disfranchisement\u201d is “associated with” worse physical and mental health among black people, such as more symptoms of depression and functional limitations. The article concludes that “enacting laws to dismantle racialized felony disenfranchisement would likely improve the health of Black people and make progress toward achieving health equity.”<\/p>\n<\/div>\n That claim includes footnotes that take the reader to three other articles \u2013\u00a0one based on \u201cecosocial theory<\/a>,\u201d another drawing on sociologist Bruce\u00a0Link’s theory of \u201cstigma power,\u201d<\/a>\u00a0and another resting on the\u00a0theory of \u201cfundamental causes<\/a>.\u201d\u00a0These articles provide the so-called theoretical basis for concluding that stripping felons of the right to vote affects community health.\u00a0(The Link theory\u00a0posited that “stigma is a form of power” used to control, exploit, and\u00a0dominate people with mental illness.)\u00a0<\/p>\n<\/div>\n \u201cSkeptics dismiss structural racism as a slippery concept for which robust empirical evidence documenting its effects is lacking,\u201d the two researchers declare in their paper. \u201cThis study provides empirical evidence that makes it harder to dismiss the links between health and structural racism manifested as disproportionate Black felony disenfranchisement.\u201d<\/p>\n<\/div>\n Dr. Stanley Goldfarb, a kidney specialist who retired last year from the University of Pennsylvania\u2019s Perelman School of Medicine, agreed to review this article for RCI. A former associate dean of curriculum at Penn\u2019s medical school, Goldfarb said the Health Affairs article contains all the mandatory caveats about its methodological limitations, and then ignores them.<\/p>\n<\/div>\n \u201cThis approach just drives me crazy. It\u2019s basically finding associations and claiming it proves\u00a0causality,\u201d Goldfarb said.\u00a0\u201cThey are going to find evidence for their theory because they are trying to do everything they can to prove their theory. That\u2019s why they keep saying: We have to find the evidence.\u201d\u00a0<\/p>\n<\/div>\n Alan Weil declined to discuss critiques of individual Health Affairs articles, and the lead author of the felon study and of the hospital study didn\u2019t respond to RealClearInvestigations\u2019 emails. But Weil, and others, say the anti-racist imperative in medicine is no more of an ideological \u201cagenda\u201d than the quest to discover a cure for cancer. Moreover, the advocates assert that the imperative to dismantle systemic racism is more urgent because it is more lethal than cancer.<\/p>\n<\/div>\n \u201cThese sociopolitical exposures are exposures, just like we study in cancer research,\u201d said Katherine Theall, a social epidemiologist and professor of public health at Tulane University. \u201cAnd they\u2019re even more powerful in many ways across a host of health outcomes.\u201d<\/p>\n<\/div>\n One way of summarizing this dispute is that traditionalists like Goldfarb are suspicious of scholarly activism as a corrupting influence on science, whereas researchers like Weil and Theall are suspicious of neutrality and colorblindness as an invisibility cloak for systemic racism.<\/p>\n<\/div>\n \u201cWe want objective science, but there\u2019s a point in public health, too, where we need\u00a0to be doing\u00a0more consequential work,\u201d said Theall, a co-author of\u00a0one of the Health Affairs articles<\/a>. \u201cWe should be doing more advocacy, we should be trying to change these factors that we know matter for health.\u201d<\/p>\n<\/div>\n Weil describes researchers as \u201cheroic\u201d for trying to make sense of a complicated problem for which there is no single measure, but whose existence is beyond dispute.<\/p>\n<\/div>\n \u201cI don\u2019t find the existence of systemic racism to be a controversial or difficult question to answer,\u201d Weil said. \u201cI see it around me all the time. I think the evidence base is so clear that I don\u2019t want to spend a lot of my time trying to figure out whether or not the problem exists.\u201d<\/p>\n<\/div>\n Other articles in Health Affairs seek to document evidence of systemic racism in unexpected places. The team of scholars that includes Theall suggests<\/a> that urban policing, specifically stop-and-frisk encounters, can lead to domestic violence and violent crime, as well as to poorer community health.<\/p>\n<\/div>\n Theall said there are a number of theories scholars can \u201cpull off the shelf\u201d to analyze the effect of stop-and-frisk encounters on community health and local crime. But the causality is complicated, she said, because some effects, like heart disease and obesity, can take years to develop. Other effects, like rates of smoking or inadequate physical activity, could happen relatively quickly.<\/p>\n<\/div>\n And taking this tack requires scholars to connect smoking for the alleviation of stress, or a reluctance to go outside for exercise, to police harassment \u2013 as opposed to connecting it to, say, gang terror. Theall said it takes years of effort and reams of studies to create a convincing case, patiently building evidence and refining methods.<\/p>\n<\/div>\n \u201cOur thesis is that even if you\u2019re not a perpetrator of violence, for example, that level of community stress, of over-policing, is important for health,\u201d Theall said. \u201cAnd it\u2019s important for that production of violence, whether that\u2019s additional violent crime in the neighborhood or maybe the stress of living in a stressful neighborhood and what that might do for domestic violence.\u201d\u00a0<\/p>\n<\/div>\n Theall\u2019s article focuses on data from New Orleans. The article notes that the city had the fourth-highest murder rate in the United States in 2019 \u2013 a rate five times the national average.<\/p>\n<\/div>\n Much of the action in Theall\u2019s article takes place in the substratum of footnotes. The cited research relies on an array of sociological, psychological, and criminological theories that associate cops with harmful effects, including stress and distrust, the latter presumably causing residents not to call 911 for police assistance when they need it.<\/p>\n<\/div>\n One of the articles cited<\/a> by Theall (in footnote 27), in turn, cites previous articles that have been passed down from paper to paper. And it is here, burrowing into the footnotes, where one can find explanations and theories that speculate on how policing can lead to crime and poor health.<\/p>\n<\/div>\n \u201cPolicing may also have epigenetic implications,\u201d the reader learns, \u201cwhereby chronic exposure to stress from a particularly imposing police presence can lead to altered gene transcription\/expression and epigenetic changes that can be passed on to subsequent generations.\u201d<\/p>\n<\/div>\n But with so many theories to choose from, could a researcher be tempted to cherry-pick a theory, or just make one up, to make the data tell a coherent story about how cops are escalating crime and violence and community illness?\u00a0\u00a0<\/p>\n<\/div>\n \u201cI don\u2019t know the best answer for that, but I see where it can be a critique,\u201d Theall said. \u201cI would just think that\u2019s probably not the route most researchers are taking in terms of analyzing their data, and then finding a theory to fit it.\u201d\u00a0<\/p>\n<\/div>\n To the contrary, Theall believes some scholars are so scrupulous that they \u201covercontrol\u201d for random factors and end up with research findings that are inconclusive. She said that because papers with negative findings tend not to get published as often as papers with splashy results \u2013 a research phenomenon called publication bias \u2013 a misimpression can result, that anti-racist scholars find racism everywhere they look.\u00a0\u00a0<\/p>\n<\/div>\n Still, there is a theory<\/a> in criminology called \u201cthe Ferguson effect<\/a>,\u201d developed after the 2014 shooting of Michael Brown in Ferguson, Missouri, that posits the opposite of Theall\u2019s: that crime increases when cops reduce pro-active policing.<\/p>\n<\/div>\n Chris Ferguson, a psychology professor at Stetson University in DeLand, Fla. (not related to the Ferguson effect theory), agreed to read Theall\u2019s paper for RCI. He described this scholarship as a classic example of stubborn data being shoehorned into an uncooperative theory.<\/p>\n<\/div>\n \u201cThis feels like an example of institutional capture, where you\u2019re only good if you buy into the theory,\u201d he said, \u201cand therefore everything is seen through the lens of that theory, no matter how much you have to torture the data to make that happen.\u201d<\/p>\n<\/div>\n Ferguson is a hardcore skeptic of this sort of research. In a Quillette article<\/a> last December, he described his resignation from the American Psychological Association as a protest against the organization\u2019s embrace of wokeness. In the long run, Ferguson predicted, this research approach will prove unsustainable.<\/p>\n<\/div>\n \u201cWe\u2019re in this confirmatory mode where people try to find evidence and not look at alternative explanations,\u201d he said. \u201cThat\u2019s the best way to form a consensus \u2013 just exclude the scholars who disagree.<\/p>\n<\/div>\n \u201cWhat happens is, other scholars begin to pick at it and it falls apart,\u201d Ferguson added. \u201cTwenty years out this is going to look like a huge embarrassment.\u201d<\/p>\n<\/div><\/div>\n\n