Portside

Ignorance is neither neutral nor benign, especially when it cloaks evidence of harm. And when ignorance is produced and entrenched by gatekeeper medical institutions, as has been the case with obfuscation of at least 200 years of knowledge about racism and health, the damage is compounded. The racialized inequities exposed this past year—involving COVID-19, police brutality, environmental injustice, attacks on democratic governance, and more—have sparked mainstream awareness of structural racism and heightened scrutiny of the roles of scientific institutions in perpetuating ignorance about how racism harms health.

This scrutiny is long overdue.

In particular, the ways the world’s leading gatekeeper medical journals produce ignorance about racism and health are ripe for review. In our analysis, we build on prior scholarship, including the 2018 study by Hardeman et al that focused on articles published between 2002-2015 in the 50 highest-impact public health journals and found that only 25 named institutionalized racism in their title or abstract.  Our novel contribution is three-fold: (1) we extend the analysis to include articles from 1990-2020, thereby expanding the time frame and capturing the past year of increased explicit discourse and action about racism and health; (2) we distinguish between articles that present viewpoints versus empirical scientific investigations; and (3) we deliberately focus on the world’s four leading medical journals, as well as bringing in selected comparators.

The results are not pretty. As we show, only in the past year have these leading journals begun noticeably increasing publication of articles on this topic, with the vast majority of even these papers solely viewpoints, not evidence-based empirical studies. Although such papers can be highly valuable for debating terms and expanding narratives, the implication is that these journals either do not value scientific investigations on this issue or do not deem there to be many worth publishing. But the science is there to be published.

And students, scholars, and clinicians across the health sciences are paying attention. Galvanized by the harsh inequities plaguing this nation, they have called for moving beyond declarations condemning racism. They are driving unprecedented steps by major biomedical institutions, health professional organizations, universities, and academic journals to expose and counter harms caused by structural racism. On March 1, 2021, the US National Institutes of Health announced a major new, multi-faceted initiative, cutting across all institutes, to address the impacts of structural racism on biomedical research; this initiative involves both the content of science and the scientific workforce. On April 8, 2021, the US Centers for Disease Control and Prevention (CDC) declared “racism a serious public health threat," unveiled a new website on “Racism and Health,” and announced it would make new and expanded investments to address health disparities and to foster greater diversity and inclusiveness in its workforce. The American Medical Association has likewise initiated, and the American Public Health Association has expanded, work to educate their memberships about racism and to address racism as a public health crisis.

Moreover, in January 2021 the University College London issued a major apology for its profound role in institutionalizing eugenics and scientific racism worldwide; it also announced new initiatives to redress the ongoing harm, through changes to its curricula and other academic practices. Additionally, a critical post published in Health Affairs Blog in July 2020 sparked 11 medical journals to amend their author instructions regarding research on racial health inequities. Beyond this, Health Affairs has hired a new equity project director and the Journal of the American Medical Association (JAMA) is in the process of hiring a new associate editor with expertise on racism and structural racism in health care.

Yet it is imperative to do more. Harms caused by the gatekeeping culture and practices of major medical journals in publishing—or not publishing—research on racism and health warrant review.

What We Examined And How We Did It

During March 2021, we conducted a literature search for the total number of papers including the word “racism” that were published between January 1, 1990 and December 31, 2020 by four leading medical journals (all with impact factors for 2019 exceeding 30). These journals were: the New England Journal of Medicine (NEJM), The Lancet, JAMA, and the British Medical Journal (BMJ). We focused deliberately on the term “racism” because naming racism is a critical step in addressing its impacts. And given evidence of some journals censoring its use, this focus allowed us to assess the extent to which use of this term has been permitted.

For comparative purposes, we also searched publications in one of the longstanding and leading global public health journals, the American Journal of Public Health (AJPH), and we additionally examined the Annual Review series for four disciplines (medicine, public health, sociology, and psychology) as a gauge of the extant evidence base. We conducted our search in two complementary ways: first, using PubMed, searching by journal name and filtering by time period (to identify the total number of articles published); and, second, directly searching each journal’s website for full-text mentions of “racism.”

We obtained PDFs for and reviewed papers identified by this search and manually coded whether each paper: a) was an empirical study or a review paper with a significant data component, or b) was not an empirical study or review paper with a significant data component. (As indicated in exhibit 2, due to library coverage and other issues, we were unable to obtain the full text of all papers identified by our searches, particularly for BMJ.) Two team members conducted this stage of the analysis, which identified 1013 papers: the first step was to compare coding for 20 papers, to ensure common standards, after which each team member separately reviewed their assigned papers, with spot checking of a random selection of papers to ensure comparability of coding. Among the papers identified as empirical investigations or having a significant data component, the two coders ascertained if they included any measure of racism (structural, institutional, interpersonal, or internalized), tested a hypothesis, or were explicit about their theoretical approach, with spot checks for comparability.

For the AJPH papers, we used the journal’s classification as to whether the paper was an original study versus some other type of publication. For the Annual Review series, a team member searched for articles indexed by the term “racism”; for sociology and psychology, we further restricted our search to articles also indexed by both “health” and “disease.” We then reviewed the titles of the identified publications for relevance and documented the years of publication.

What We Found

As shown in exhibit 1, all four medical journals and AJPH had a dramatic increase in the number of articles including the word “racism” in 2020. Before this, however, the numbers were relatively low and unchanged for NEJM, JAMA, and The Lancet; increased then fell for BMJ; and showed a clear trend of consistently increasing for AJPH.

Exhibit 1: Number of published pieces that include the word “racism” by journal, 1990-2020.

Source: Authors’ analysis. AJPH = American Journal of Public Health; BMJ = British Medical Journal; JAMA = Journal of the American Medical Association; NEJM = New England Journal of Medicine.

Additionally, as shown in exhibit 2, the four medical journals published markedly lower numbers of papers including the word “racism” compared to AJPH, despite their publishing many more papers between 1990-2020 (14,192 for AJPH, vs. 40,411 for JAMA, 43,378 for NEJM, 63,971 for The Lancet, and 78,545 for BMJ). Although we did not include Health Affairs in this analysis, Rhea Boyd (one of the authors of this post) and colleagues noted in an earlier Health Affairs Blog post, “A quick search of the Health Affairs website reveals only 114 pieces include the word racism in the 39-year history of the journal.”

Exhibit 2: Analysis of article type for journal articles that included the word ‘racism.’

Source: Authors’ analysis. AJPH = American Journal of Public Health; BMJ = British Medical Journal; JAMA = Journal of the American Medical Association; NEJM = New England Journal of Medicine. Notes: (1) PubMed results by journal. (2) Obtained from each journal's website, searching for "racism" anywhere in the title, abstract, or text. For BMJ, the actual number of pieces (articles, letters, etc.) containing “racism” may be less than the total reported, since some files contain more than one piece and all pieces in the file may turn up in the search, even if not all the individual pieces in the file contain “racism." (3) Primarily for BMJ, we were unable to obtain copies of some articles due to incomplete library coverage and other issues. (4) Manually coded, except for AJPH, which categorizes and displays articles by type on its website

Moreover, for the four leading medical journals, upwards of 90 percent of the publications including the word “racism” for which we were able to obtain PDFs were commentaries, viewpoints, or letters. The percentage that were either original empirical investigations or review articles with a significant data component ranged from a low of 4 percent (BMJ and NEJM) to at most 10 percent (The Lancet) (exhibit 2). By contrast, for AJPH, 60 percent of the identified articles were empirical studies or review articles with a significant data component, and only 40 percent were commentaries, viewpoints, or letters.

The 64 empirical medical journal articles including the word “racism” for which we were able to examine the full text amounted to only 12 percent of the 535 such publications appearing in AJPH. Of these 64 medical journal articles, only 10 (15.6 percent) included any substantive discussion of theory guiding the research, and only 18 (28.1 percent) tested a hypothesis. Moreover, most used the term “racism” only in the discussion section, as a possible interpretation of the patterns observed in the study, or as an area needing more research—in no way the focal point of the paper. Fewer than 10 percent included any measures of either structural, institutional, interpersonal, or internalized racism.

Similar patterns are evident in the Annual Review journal series. The Annual Review of Medicine has published only 12 articles indexed by the word “racism” since its onset of publication in 1954. On further review, only three articles turned out to focus on racism; one was published in 2003 and the other two in 2021.

The Annual Review of Public Health, in its much shorter publication period (since 1980), has published 73 articles that use this term, with 66 appearing between from 1990 through 2020. Both Annual Review of Psychology (published since 1950) and Annual Review of Sociology (published since 1975) have also published numerous review articles indexed by “racism” and both “health” and “disease,” respectively accounting for 27 of the 91 (29.7 percent; 20 from 1990 through 2020) and 46 of the 226 (20.4 percent; 40 from 1990 through 2020) total reviews they have published indexed by the word “racism.” The presence of these review articles concerning racism and health suggests a large body of published literature exists to review on these topics, despite such publications being a rarity in leading medical journals.

The Impact Of The Non-Publication Of Work On Racism By Gatekeeper Journals

The lack of published scientific investigation on racism and health in the world’s leading medical journals, despite the documented existence of such research, points to structural problems that require remedy. The lack of racial and gender diversity among the editors and editors-in-chief of these and other health and science journals further underscores this point. Our purpose here is not to reiterate recommendations already published in the literature on how to change policies and practices that perpetuate racialized inequities, whether by academic, medical professional organizations, other medical institutions, or biomedical research institutions. Nor do we wish to repeat histories of racist systems of thought, including scientific racism, and anti-racist scientists’ work to refute their false premises.

Instead, we wish to underscore the damage done by the scientific production of ignorance, as compounded by the social production of what philosopher Charles Mills in 1997 termed “white ignorance,” an idea he has extended to issues of scientific ignorance (Chapter 10). Common to both analyses is an appreciation of, in Sheila Jasonoff’s words, “the co-production of science and social order.” At issue is how powerful agents—whether afforded power by their credentials, positions within governance, assets, or membership in dominant socially defined groups forged by intertwining forms of injustice involving social class, racism, sexism, heterosexism, and gender binarism—seek to preserve their power by bolstering ideas favorable to their status, and by challenging, distorting, or suppressing knowledge that questions the legitimacy of their power.

In brief, we submit that the non-publication of existing credible scientific research on racism and health by gatekeeper medical journals has four adverse consequences, all of which need to be documented and analyzed in more detail. The first is that non-publication of this research conveys the message that racism and its impact on people’s health are not important and not topics that warrant scientific study or publication, thereby minimizing concerns about these harms among scientists, funding agencies, and the broader public.

Second, non-publication of scientific research on racism and health by leading journals, especially in this era of evidence-based clinical medicine, fosters ignorance about these issues among health professionals, who as trusted sources of information then transmit this ignorance to their patients, clients, and the broader public. Third, this non-publication of evidence undercuts and limits the important kinds of evidence needed by policy makers, health agencies, funders, lawyers, and advocates for their complementary work to prevent racism and rectify how it harms health.

Fourth, non-publication of this work effectively excludes scholars who study racism and health from high-impact journals, harming not only knowledge dissemination but also potentially the career pathways of these scholars. It also perpetuates ignorance among reviewers, requiring authors with expertise to repeatedly have to divert time to educating reviewers and editors about the impacts of racism on both health and scholarship. As should be evident, these harms build on and compound each other.

Supporting our conclusions are two strands of work. One is scholarship on socially produced ignorance, or “agnotology”—a word coined in 1995 by historian of science Robert Proctor (p. 8). The term was prompted by Proctor’s research on the manipulation and fabrication of scientific uncertainty by the tobacco industry, which infamously boasted “doubt is our product.” Ongoing work on the production of scientific ignorance, especially in relation to climate change and workplace and environmental hazards, continues to this day. This work attests to the power of gatekeeper institutions to legitimize, or to silence, evidence relevant to understanding and contesting socially produced harms.

Predating and enriching this work are over two centuries of scholarship on how systems of thought and power, interwoven with white supremacy, have used gatekeeper institutions to undermine and silence evidence regarding the human and health impacts of racist systems of enslavement, subjugation, and expropriation of both labor and land. One recent illustration of the workings of “white ignorance” was provided by anthropologist Clarence Gravlee; he analyzed the March 2021 production and removal of an ignorant and offensive JAMA podcast on structural racism and health. Explicitly drawing on the work of both Mills and Andrea Gibbons, Gravlee’s essay underscored how “white ignorance” thrives on the fallacious equation of personal ideology, conjoined with reliance on limited knowledge afforded by gatekeeper institutions, with actual study of and expertise on the histories, realities, and adverse impacts of structural racism.

A Research Path Forward

Our analysis provides striking evidence of the failure of leading medical journals to publish extant scientific research on racism and health. As we have demonstrated, the problem is not an absence of publishable work. Our intent is to motivate scholarship to investigate the reasons for this production of scientific ignorance about racism and health by leading journals; this research would complement work already underway to address how racism harms not only health but also the culture and practices of medical, public health, research, and academic institutions.

Topics warranting exploration include histories of article submissions, editor and reviewer comments, and rejections. Subsequent publication of rejected articles in alternative venues and their citation histories could provide evidence of the utility of, and scientific discussion regarding, the published studies. Future reviews using additional search terms (e.g. “racial discrimination”) could explore the extent to which published literature has focused on racism and health without using the term “racism,” and, if feasible, ascertain reasons for the terminology employed.

In keeping with our critique of the production of scientific ignorance, and “white ignorance” in particular, no one should be left ignorant as to the causes of racialized health inequities. The lack of publication of research on this critical topic by gatekeeper medical journals is an affront to domestic and global health.

Authors’ Note

The opinions expressed in this post are the authors’ and do not necessarily reflect the policy of the American Medical Association or any other entity. We thank Preeya Waite for her assistance in coding the medical journal articles. We additionally thank Iqra Hashwani and Zain Qusair, who assisted with obtaining articles via inter-library loan and acquiring PDFs of the published literature we reviewed.

Portside thanks co-author Nancy Krieger for permission to reprint this article.