A Call for Antiracist Action

By David A. Ansell, M.D., M.P.H.; Brittani James, M.D.; and Fernando G. De Maio, Ph.D.
New England Journal of Medicine. February 16, 2022

On January 22, 2022, neo-Nazis marched on Boston’s Brigham and Women’s Hospital, with a banner claiming that the hospital “kills Whites” and flyers featuring photos of Drs. Michelle Morse, a Black woman, and Bram Wispelwey, a White man, who have led antiracism work at the hospital. The group denounced the physicians and the hospital for “creating preferential health care treatment policies for non-White patients.” This was not the first time that Morse and Wispelwey were attacked for their work.

On March 17, 2021, the two physicians published “An Antiracist Agenda for Medicine” in the Boston Review.¹ The article described the historical failure of color-evasive (or what many term “colorblind”) solutions to racial inequity in health care and offered a race-conscious approach they named “The Healing ARC.” They called for a structural shift in racial equity work toward holding health care institutions accountable, contending that only race-explicit programs will directly address the underlying causes of racial health inequities and mitigate the current impact of racism in medicine.

With other colleagues, Wispelwey and Morse uncovered racial inequities in the treatment of patients with cardiac failure at the Brigham.¹ They found that Black and Latinx patients were less likely than White patients to be admitted to the cardiology service, which was associated with better outcomes. Wispelwey and Morse implemented changes to rectify these practices. Their efforts to correct this disparity led them to rethink the approach to racial justice in medicine.

The Healing ARC has three components: acknowledgment, redress, and closure. Health care providers must acknowledge how racism has contributed to unequal health outcomes; redress the damage by providing restitution to the population that has been harmed, which involves offering pathways for access to services and care that have historically been denied; and facilitate closure, achieving reconciliation with the community that has been harmed by the health care system and reaching agreement that the harm has been redressed.

The framework applies the principles of applicative justice to racial health inequities at the level of the health system. It recognizes the need for race-conscious approaches in medicine. While it affirms that race is a sociopolitical construct with no biologic basis, a race-conscious approach allows the identification and rectification of long-standing racial health inequities. This effort is not about race-preferential treatment, as the neo-Nazis and others on the political right have claimed, but about eliminating obstacles to care that harm systematically excluded populations. The Healing ARC builds on the work of William Darity, Jr., and A. Kirsten Mullen calling for federal reparations for Black descendants of formerly enslaved people,² acknowledging that race-conscious approaches are necessary in medicine because colorblind approaches have not closed racial gaps in health outcomes.

Predictably, there was backlash. Fox News was the first major U.S. news source to attack the article and the authors in 2021. Extremist social media figures including an editor and supporters of Quillette — a known source of White supremacist hatred and discredited, racist “science” — amplified the Fox attack. Morse has been subjected to repeated racial slurs, harmful rhetoric, and threats to her safety.

In 2020, as racial gaps in Covid-related mortality and murders of Black people touched the national conscience, more than 200 health care organizations, including the American Medical Association (AMA), declared racism a public health crisis. They pledged to take steps to eliminate racial health inequities by removing systemic barriers that block people of color from achieving better health outcomes. This is a critical moment for health care leaders to publicly reaffirm their support through organizational actions for antiracism in medicine. The AMA and the Massachusetts Medical Society have issued statements, and a group of physicians and health care workers have signed a petition of support, but we believe that more leaders of national health care organizations should publicly express their support for Drs. Morse and Wispelwey and their antiracism efforts — and then put their words into actions.

The neo-Nazi protest in Boston is a reflection of reactionary efforts in both medicine and broader society to deny that racism exists or invalidate antiracism efforts as “anti-White.” A 2021 Commonwealth Fund survey found that 53% of Americans do not believe racism is a problem in the United States.³ Yet one out of three Black or Latinx survey respondents reported experiencing discrimination in health care during the previous year.³

Efforts to embed racial justice in medicine and advance health equity have been launched — and critiqued. There have been concerted attacks on critical race theory, whose precepts are central to health equity work: critical race theory acknowledges that race is a social construct, identifies the mechanisms by which racism is embedded throughout society’s systems and policies, and opposes colorblind solutions to racial inequities. Most recently, the mainstream media has promulgated attacks on the language of health equity, contributing to an environment in which extremism can thrive. In the days leading up to the neo-Nazi protest, right-wing media mischaracterized tenets of race-conscious medicine, claiming that efforts to overcome inequities would result in White people being denied medical care.

Since the first scientific study of poor health outcomes among Black Americans was published by W.E.B. Du Bois in 1899 (The Philadelphia Negro: A Social Study),⁴ deep and persistent inequities in health outcomes between Black Americans and White Americans have been well documented. Today, the toll of structural racism on the life expectancy of Black Americans is revealed in devastating statistics, with large inequities in the leading causes of death, including heart disease and cancer. The racial and ethnic disproportionality in hospitalizations and deaths during the Covid pandemic has highlighted the long-standing structural and social fault lines that have always divided our nation.

The Commonwealth Fund recently reiterated the persistent reality that in most states where data are available, Black people, American Indians, and Alaska Natives are more likely than White people to die early in life from conditions that are treatable with timely access to high-quality health care (see graph).⁵ A large body of literature demonstrates that these gaps in health according to race and ethnicity reflect racism, rather than genetic or biologic differences. Even analyses that control for socioeconomic status confirm that Black people in the United States have worse health outcomes than their White counterparts. A race-conscious approach to eliminating health care inequities is thus required across all our health care institutions.

White supremacism has proved resistant to eradication over centuries. It appears in different forms — as denial of structural racism, in simplistic narratives of individualism and meritocracy, in stories that lay the blame for health inequities on the beliefs, behavior, or biology of historically marginalized people. And yes, White supremacism appears in the swastikas and uniforms of “freedom” protests against vaccination mandates and antiracist doctors.

Martin Luther King, Jr., noted that, “In the end, we will remember not the words of our enemies but the silence of our friends.” The neo-Nazi march on the Brigham and our physician colleagues and the attacks on health equity interventions are stark reminders of the obligation of physicians, particularly White physician leaders of our national health care organizations, to denounce White supremacism and reaffirm race-conscious antiracism efforts. We recommend three immediate actions: publicly defending Drs. Morse and Wispelwey and others who have become targets of hatred and rancor because of their antiracism work; implementing and evaluating race-conscious, intersectional interventions such as the Healing ARC, especially given that colorblind approaches have failed to achieve meaningful gains in health equity; and publicly reporting progress toward achieving racial equity in health outcomes. Inaction in the face of White supremacism must not be an option.

https://www.nejm.org…

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