Last August, the Journal of the American Heart Association (JAHA) published an article by University of Pittsburgh cardiologist Norman Wang, M.D., that accused educational affirmative action programs of sending ill-qualified Black and Hispanic trainees to some of the top medical schools in the country. Soon after its publication, the article was retracted and denounced as both racist and factually inaccurate. Though some saw the situation as resolved, Raymond Givens, M.D., says that he recognized it as a sign that the medical industry is still in the grips of white supremacy.
Reasoning that such an article would never have been published at a publication with true diversity and commitments to antiracism at its core, Dr. Givens decided to analyze the racial and ethnic makeup of those in charge of decision-making at some of the nation’s leading medical journals.
Givens’ research late last year revealed that of the 51 editorial board members at New England Journal of Medicine (NEJM), four were East Asian, two were South Asian, one was Black, and one was Hispanic, while the remaining 43 members were white. Similarly, at the Journal of the American Medical Association (JAMA), out of 49 editorial board members, three were East Asian, two were Black, two were Hispanic, and one was South Asian, while the 41 other members were white.
When Givens reported his findings to Eric Rubin, M.D., the editor-in-chief at NEJM, Rubin disagreed with the metrics and offered to discuss the issue, but never called. Howard Bauchner, M.D., then the editor-in-chief at JAMA, failed to respond at all.
One reverberation of this failure to take this dearth of diversity seriously was the scandal at JAMA after Edward Livingston, M.D., a deputy editor for the publication, claimed during a podcast episode in February with guest Mitchell Katz, M.D. that medical racism no longer existed because, he reasoned, racism had been resolved by landmark legislation which made it illegal and that health inequities were caused by socioeconomic issues and not racism.
The episode and its accompanying, now-deleted promotional tweet received widespread condemnation among medical professionals across Twitter, many of whom called for investigations into why they had been released.
As the fallout continued, Livingston resigned and the podcast was taken down and replaced with an apology from Bauchner, who was then placed on administrative leave while outside investigators from a law firm were hired to investigate how the podcast and tweet were developed. On June 1, without releasing the investigation’s results, it was announced that Bauchner would depart JAMA.
For Givens, who is Black and a cardiologist, as well as an assistant professor of medicine and associate director of the cardiac intensive care unit at Columbia University Irving Medical Center, the dismissal of two people in leadership was neither the goal, a cause for celebration, nor a sign that “racism was over.” Rather, he believes that in order to accomplish true change, “There has to be a civil rights movement for medicine.”
He recently spoke to TheBodyPro about what that means.
Juan Michael Porter II: Would you say that we continue to see offensive opinions like Livingston’s because people in power don’t have a problem with them?
Raymond Givens, M.D.: Yes. Or the insight to know that they’re completely wrong.
Porter II: What is it that journal publishers are missing?
Givens: I don’t know, but I tried to raise issues around whether the editors in chief at JAMA and NEJM were approaching things the right way back in October. That, despite the attention to anti-racism in response to George Floyd’s murder, the tone-deafness and lack of insight were still apparent.
Porter II: For instance, Norman Wang’s retracted article in JAHA about workforce diversity.
Givens: Insofar that we can have a debate about it, I’m not offended that Norman wrote something like that—or that there was a podcast expressing skepticism over structural racism. But when they’re presented without a counterweight to their 8,000 words in a reputable journal, that has me thinking about who is on these editorial boards, because there have been a number of problematic papers published by both NEJM and JAMA.
I reached out to the editors of those two journals to say, “I think you have a problem here,” as in, you don’t know what you don’t know. But they didn’t respond, and you’ve seen what’s happened. Even before Livingston’s podcast, there was a research letter published in JAMA in September that collected cells from inside the noses of a group of people of different ethnicities.
That study found that the cells from African Americans had a higher expression of the gene TMPRSS2 than all other groups. TMPRSS2 has been established as cooperating to help bring COVID-19 into the body, so the suggestion was that this might explain why there’s such a higher rate of COVID-19 infections among African Americans.
Porter II: Instead of actual exposure to the virus and cramped living situations?
Givens: Right. So again, there was an immediate backlash to conflating race with genetics, but what bothered me even more than that was the glaring error in the argument. We know that COVID-19 infection rates have been higher among Latinx people than white people, but their levels of TMPRSS2 expression were no different. And so, here it is hitting you right in the face when making a conclusion about Black people. But why did nobody catch this?
Porter II: Have you encountered this often?
Givens: I have. Especially recently, where the rational mind breaks down when it is met with race. I have colleagues who could whip off half a dozen ways to keep a sick patient who needs a heart transplant alive. But if you say, “Gee, we don’t have enough Black cardiologists here. How can we fix that?” They go quiet. So, this is not something that is going to be fixed by implicit bias training or one of these two-hour-long exercises.
Fighting Battles Inside and Outside the Clinic
Porter II: Not to be annoying and ask, “How do you solve racism?” But—
Givens: The solution is diversity. And not because it’s a nice thing to do, but because it’s about getting the story right. It would be foolish for me to weigh in on issues facing women in terms of getting equitable health care. I can study it, but I clearly don’t have all the insight. It would make more sense to bring in women who can actually talk about the complexity of the situation. So, I don’t know how to solve this issue. But I do know that if I don’t know, then the editors definitely don’t either. And that should disturb us all because they’re not even bothering to address the question.
Porter II: Have you always seen these issues so clearly?
Givens: I would say that it’s been a recent change. I won’t say that I’ve been a wallflower my whole career, but the culture of medicine is one of conformity, where if you stand up, you get cut down. And that makes sense to the extent that you don’t come into medicine to tell everybody else how it’s supposed to be done.
In the interest of patient safety, there has to be a degree of indoctrination. Which is to say that you can’t just make up your own recipe for how to treat somebody who’s having septic shock. You have to buy into an established and tested set of protocols for how things are done. So to some degree, this homogenization is needed. Beyond that, medicine still values its tradition and culture.
And as marginalized people speak up to say that maybe this is not right, there has been some backlash. Especially for Black medical students or trainees, who receive severe reactions. We’re often in that space of being treated severely.
Porter II: I’ve heard from many Black doctors that a lot of this starts in schools where a tradition of teaching scientifically untrue and racist beliefs continues. I’m thinking specifically of the lie that Black people are less sensitive to pain than white people. Or that we have thicker skin than our counterparts with lighter complexions.
Givens: Yes, though there have been changes in the culture of medicine since I started medical school two decades ago. It’s been slow and it’s nowhere near enough, but I think most physicians and institutions will acknowledge that there was mistreatment in the past or that there’s racism perhaps in an abstract context.
Porter II: What about accepting that racism still exists in the present and that they might be perpetuating the harm?
Givens: When you try to push people to nail down specifics about what happens and how clinical encounters between white doctors and their Black patients may result in different outcomes in the present, time and time again and very consistently, they run away from it. If you are junior enough or vulnerable, the first thing they’ll try to do is retaliate. If that doesn’t work or you make it clear that you’re not going to shut up, they will try every way to silence or ignore you; to exhaust, frustrate, or demoralize you until you give up.
Porter II: Do people give up?
Givens: Most people do because they figure, “This is not worth it.” I understand that. No one wants to fight this battle every day. As a Black physician, you’re already fighting battles outside the hospital and clinic that your colleagues can’t even comprehend.
For instance, the fact that this young man, Daunte Wright, was killed in the Minneapolis area while they were having the trial of the officer who killed George Floyd. I think a lot of Black people were really grieving, and we only had each other to call to cry on the phone with. Then Black physicians had to go into their clinics and hospitals to fight tooth and nail on a daily basis just to get racism put on the agenda. For a lot of people, it feels like too much.
I think that’s the reason why things don’t move forward as quickly as they could. Especially when you’re constantly encountering entrenched resistance.
Saying ‘Enough Is Enough’
Porter II: You’ve been very outspoken about these issues in the press and in confronting leading medical institutions. Do you ever feel like you’ve done enough?
Givens: Things are improving, but I’m not comfortable with the idea that “Things will get better someday,” because that means being comfortable with certain people dying. There has to be an aggressive mindset in the very same way that multiple COVID vaccines came to market in under a year, which was previously unheard of.
The typical timeline for something like this is 10 years, but we’ve demonstrated the really awesome power of science to get things done at a fast clip, even in the face of epic disruption. If we devote all the resources and brightest minds and are committed to getting it done as quickly as we can in a responsible fashion, and refuse to slow down just because somebody feels uncomfortable and refuse to accept excuses, we can do this. It just means we have to apply the same urgency and willingness to being disruptive that we’ve brought to tackling COVID. Until then, I keep going.
Porter II: I wish that same mindset was applied towards eliminating HIV.
Givens: There have been many failures in the fight against HIV, but it’s also been a story of success. The documentary, How to Survive a Plague, very beautifully illustrates how very young and committed activists told the government that its traditional ways of approving medicines weren’t acceptable. For want of a better word, they acted up.
Similarly, the advancements that African Americans have made didn’t come because white folks woke up one day and said, “You know what? We’re not treating Black people right. We’ve got to integrate the schools.” It came from the Black people of those times saying, “Enough is enough.”
Porter II: Martin Luther King Jr.
Givens: You know, the funny thing about Dr. King is that mainstream institutions conceptualize him as this teddy bear of peace. But no. People forget that his “Letter From Birmingham Jail” was not a metaphor. It was actually written when this man was in prison because he was arrested for protesting. It was his response to a letter from a group of clergymen who were admonishing him for protesting instead of letting the courts “deliver justice.”
His point was that we can’t wait and that the courts had already prevailed in favor of civil rights, but so many places were refusing to follow the law. His point wasn’t just unpopular among white people—there was a time when he was unpopular among a lot of Black people who felt that they had made it. They were doing about as well as they thought a Black person could do for that time, so convincing them to essentially jeopardize their seat—given that some people didn’t even have a place to stand—was tough. Funnily enough, it took Rosa Parks refusing to give up her seat to drive people to critical mass. And of course, that was planned. Yes, she was tired on that day, but she went in knowing what would happen and still decided that she was gonna do it.
That makes me think of John Lewis and his message about getting into “good trouble,’’ because everybody supports big trouble until you start making trouble for them. But then think about the Black folks who allowed their kids to go integrate schools when they were facing hostile mobs. For them, that was better than confining their kids to live as second-class citizens for the rest of their lives.
So for marginalized people it is time that we say, “We’re not going to play the game anymore,” and demand change because the world cannot ignore all of this or fire all of us. This is something that’s bigger than me. There has to be a civil rights movement for medicine, where we all stand up and say, “Enough.” Until then, we’re not going to make the kind of progress that we need.
Porter II: How do we start that?
Givens: Instead of trying to rehabilitate doctors who may have errant ways of thinking with implicit bias training, look at something that gives you concrete metrics. Like, what’s the difference between how you treat your Black patients from your white patients? And then compare the differential outcomes. If it’s substantially wider than the rest of your peers, we need to ask you why. We can sit with you and try to fix what the mechanics are, but this is a metric that we’re gonna keep bringing up with you. And if you cannot close this gap, then you should find employment elsewhere.
I don’t know that we will get too far trying to change the way people think. Looking at the diversity training industry, which generates $11 billion a year in revenue, I don’t think that’s what they want either. Because it’s not really intended to improve diversity or to reduce bias—it’s intended to avoid lawsuits by showing that companies are doing something to address a problem. But true change means, instead of focusing on how people think, pour those resources into measurable means with enforceable outcomes.
Porter II: Imagine what would happen if that approach was applied to law enforcement. Tell them, “You will lose 10% of your annual budget for every Black person you kill.” Or hospitals, regarding their mortality rate for pregnant Black women. I’m sure we would see immediate change. But until then, what keeps you going?
Givens: There’s a degree of stubbornness for African Americans who come from modest backgrounds, where we have been told as kids that society doesn’t think much of you. That it really doesn’t see us as people of merit. But if you get your education, follow the laws, pay your taxes, etc.—one day, it’s gonna let you in. But along the way, you’re just gonna have to learn to be comfortable existing in the little bit of space that society leaves for you.
I think that many of us have done that. I have two doctoral degrees, and I don’t need two damn doctor’s degrees. I even wonder whether getting a Ph.D. was a way of psychologically trying to legitimize myself in the eyes of society. But I have two sons—a 2-year-old and a 6-year-old. When I think about imparting that same lesson to them, I can’t do that in good conscience to my kids.
So instead of telling them to exist in this small space, I feel like it’s my duty as a father to turn to society and say, “Make space for my kids. They deserve as much happiness and freedom as all your kids do. It’s my job as their dad to do whatever I can to protect them as I try to make a way for them to do that.” If that involves fighting it out day after day until I drop, then I feel like I have to do that. That’s what keeps me going, my kids.
As with the Civil Rights Movement of the 1960s, we are in the middle of an ongoing revolution for liberation. It is time for that same radical change to overcome the medical field. The only way that will take place is by causing “good trouble,” regardless of the trouble it may cause those of us and society.