Last month, Monica McLemore and a team of scientists at the University of California at San Francisco were wrapping up research into a troubling pandemic disparity: Pregnant women of color with COVID-19 appear to be at higher risk for premature birth. It was a finding they hoped to publish in the Journal of the American Medical Association, or JAMA, one of the world’s most-read research periodicals.
But their plans abruptly changed when JAMA released a podcast episode in which its host, a top journal editor named Edward Livingston, dismissed the idea that systemic racism in medicine existed.
“Personally, I think taking ‘racism’ out of the conversation would help,” Livingston said on the Feb. 23 show, titled “Structural Racism for Doctors—What Is It?” “Many people like myself are offended by the implication that we are somehow racist.” Online, the journal promoted the podcast with a tweet that said, “No physician is racist, so how can there be structural racism in health care?”
Those statements sparked a furious outcry from the medical community. Doctors and researchers flooded Twitter and the journal’s inboxes with demands for explanations and complaints pointing out that racism very much exists in healthcare. The Institute for Antiracism in Medicine, a Chicago advocacy group, circulated a Change.org petition that now has more than 7,400 signatures.
Now a small subset of scholars, including McLemore, are taking their protest a step further. At least 10 doctors and researchers, including some who have previously published their work in JAMA, have publicly declared that they will not submit manuscripts to the journal until it addresses its failures. They say they no longer trust that JAMA has the knowledge and sensitivity to evaluate research on racial disparities, and want to see it diversify the mostly-white staff that selects which issues deserve JAMA’s enormous spotlight. Their boycott is an unusual move that could put them at great professional risk.
The backlash comes at a time when institutions across America, from corporations and universities to media outlets and law enforcement agencies, are reckoning with their histories of racist actions and the persistent inequities within their ranks.
Medicine is no exception. The percentage of Black physicians in the US has barely grown so far this century — from 3.3% in 2003 to 5% in 2018 — which doctors attribute to factors ranging from unsupportive and discriminatory work environments to a disproportionate lack of mentorship and promotions.
And as countless studies have shown, health providers are statistically more likely to give Black patients worse care. Compared to white patients with identical symptoms, Black people are less likely to receive cardiac medical procedures, less likely to be treated by cardiologists for heart failure, and less likely to be prescribed painkillers. Black patients have some of the worst health outcomes of any racial group in the US, including the highest maternal and infant mortality rates. Those disparities are starker than ever today, as the pandemic takes a disproportionate toll on people of color.
In medical research, few gatekeepers are more prestigious or more synonymous with the establishment than JAMA, which oversees a network of 13 journals. It is the independently operated publishing arm of the American Medical Association, the country’s leading physicians’ organization. With more than 293,000 subscribers, its flagship title claims to be the most widely circulated medical journal in the world. For clinicians and researchers, getting published in JAMA can be a ticket to securing a new job or getting promoted.
“People’s careers have been made by a single publication in JAMA — that’s how important it is,” McLemore, a professor who studies reproductive health and health inequities, told BuzzFeed News.
And the pandemic has elevated JAMA’s profile to new heights, as audiences hungry for new coronavirus information livestreamed interviews between its editor-in-chief, Howard Bauchner, and prominent scientists like Anthony Fauci.
But now the protests have become a full-fledged crisis for JAMA. Livingston stepped down from his editor role last month and, last week, Bauchner was placed on administrative leave while an independent committee conducts an investigation into how the podcast and the tweet were vetted. JAMA also said that it held a town hall with employees in March, is reviewing how all its content is created, and will hire a deputy editor with “specific expertise in the topics of racism and structural racism in health care”— something that the Change.org petition had asked for.
But to the scholars who are boycotting the journal, the podcast incident exposed the institution’s entrenched dismissal of race. Pledges alone can’t fix that.
“If you are bold enough or naïve enough to write a podcast and tweet that says ‘There are no racist physicians,’” McLemore said, “you can only imagine your ability, or lack thereof, to fail to understand how racism shows up in healthcare provision and the care that people provide.”
The podcast was intended as an explanation of “structural racism for skeptics.” That’s how Livingston framed his 15-minute talk with Mitchell Katz, who leads New York City’s public healthcare system and also serves as an editor at a JAMA journal.
Livingston began by saying that he, as “a child of the ’60s,” had watched the passage of federal civil rights legislation. “Given that racism is illegal, how can it be so embedded in society that it’s considered structural?” he asked.
Katz, whose healthcare system serves more than 1 million New Yorkers from culturally diverse backgrounds a year, responded that structural racism “is not about whether someone is a racist or whether some individual person loves other people of a different ethnicity, or doesn’t like it.” Rather, he said, it “refers to a system in which policies or practices or how we look at people perpetuates racial inequality.” He pointed to how people of color in lower-income neighborhoods receive substandard education and healthcare.
In response, Livingston said, “I think the term ‘racism’ might be hurting us.”
Livingston explained that his “parents taught me never to hate based on what people’s colors are, or their religion, because they had suffered the most extreme violence because they were Jews, and they said that’s wrong.” They instilled him with the lesson to “never, ever even think about a person’s race or ethnicity when you’re evaluating them,” he said, “yet I feel like I’m being told I’m a racist in the modern era because of this whole thing about structural racism.” To him, he said, the problem apparently “isn’t their race, it isn’t their color, it’s their socioeconomic status.”
Many people have a “negative” response to the term “racism,” Livingston went on to remark, and “are turned off by the whole ‘structural racism’ phenomenon.” Then he asked, “Are there better terms we can use? Is there a better word than ‘racism’?”
At the end of the debate, Livingston seemed to be as skeptical of structural racism as he was at the outset. It was, he said, an “unfortunate term to describe a very real problem.”
On Feb. 24, JAMA tweeted out the episode with the declaration that “No physician is racist…” Thousands responded in incredulous fury.
Jessica Richardson, one of the three co-founders of the Institute for Antiracism in Medicine, said that they felt “a lot of anger at the very notion that there is no physician that is racist, and that racism is not a problem in medicine, nor can it be a problem in medicine — when we know, as three Black female physicians, that it is a huge problem in medicine.”
Brittani James, another cofounder, said that Livingston and Katz were not equipped to tackle the topic at hand. “We’re having a conversation with two white males over whether or not racism exists,” she said. “I would expect someone with true racial literacy to try to hand the mic to someone who either has a lived experience or has dedicated their life to the work.”
But, James added, she wasn’t surprised to hear prominent physicians debate the existence of structural racism. “What really astounded me was the fact that they did it in broad daylight, out in the open.”
Overnight, the incident became a test of the American Medical Association’s public pledge to combat racism, issued last summer, weeks after the killing of George Floyd sparked nationwide Black Lives Matter protests. Discrimination haunts the AMA’s own history: For more than a century, up through the late 1960s, the medical group excluded Black physicians from its ranks, which it publicly apologized for in 2008. And it wasn’t until 2019 that the AMA hired its first chief officer dedicated to making health disparities a core part of the organization’s focus.
On March 4, as the furor over the podcast grew, Bauchner apologized. The episode and the tweet were deleted. The CEO of the AMA said it was “deeply disturbed” by both. On March 6, the Institute for Antiracism in Medicine started its Change.org petition.
By March 10, when the AMA said that an independent committee would be investigating the incident and that Livingston had stepped down, the petition had amassed a couple thousand signatures — and a cadre of researchers were openly speaking of a boycott.
“I’ve decided that I will no longer read nor submit any manuscripts for publication to @JAMA_current nor their related journals,” tweeted Uché Blackstock, an emergency physician in New York City and the founder and CEO of Advancing Health Equity, a diversity consulting firm. “Their last tweet/podcast was not a mistake. It was part of a long line of racist and harmful content.”
“What really astounded me was the fact that they did it in broad daylight, out in the open.”
At UCSF, McLemore and her team were in the last stretches of drafting their paper about COVID-19 and preterm births. Based on what they believed was the largest dataset of its kind to date, they were planning to report that women infected with the virus, especially women of color, seemed to be more likely to give birth early, which is linked to higher rates of medical complications.
JAMA, they thought, would be their best and biggest audience. “Especially for someone like me, early in my career, if you have an opportunity for a paper that you think you might want to submit to JAMA, usually that’s seen, especially within academia, as a really important opportunity,” said Deborah Karasek, an epidemiologist leading the research.
But after McLemore heard the podcast, she said, she told her coauthors, “Y’all can take my name off that.” Instead, after a flurry of discussion, everyone agreed that McLemore’s name would stay and it would have to go elsewhere. “At this time, [JAMA] would be the last place we would want to publish,” said a third collaborator, Laura Jelliffe-Pawlowski.
Another UCSF professor, Margot Kushel, had just published a string of studies in various JAMA journals and had another in the pipeline. “We just pulled a paper--thank you, always, for your leadership,” she tweeted at McLemore on March 7.
James Lozada, an anesthesiologist who worked at Vanderbilt University at the time, relayed the news to colleagues he was working with on a study about opioid use in pregnant patients. “In light of what had happened, they were agreeable that [JAMA] was probably not the best place” to publish, he said.
Alison Gemmill, a reproductive health researcher at the Johns Hopkins Bloomberg School of Public Health, has published two papers in JAMA journals and was working on another to send its way. Like Karasek, her collaborator at UCSF, she is in the early stages of her career, and landing a third JAMA paper would be a big boost.
But once she saw that Karasek was joining a growing chorus of dissenters, she decided to follow suit. “I really wish I could send it to JAMA because it’s the ideal spot for this,” Gemmill said. “But I’m just not going to do it.”
It is not unheard of for scholars to boycott journals. High-profile boycotts in recent years have targeted journals for business models that put scientific research behind pricey paywalls. Thousands banded together against a new machine-learning journal’s plans to charge readers, and several universities cut ties with the publishing giant Elsevier over fees that they called exorbitant.
When the physicians at the Institute for Antiracism in Medicine launched their petition, they started hearing from researchers who had had upsetting encounters with the journal. One said that JAMA editors, including Livingston and Bauchner, stripped their work of mentions of racism and racial disparities. According to another, the editor-in-chief told them in 2016 that “the word racism could not be used for fear of losing readers.” (Livingston and Bauchner did not return requests for comment.)
The Institute shared a compilation of these anonymous anecdotes with more than 20 JAMA and AMA leaders last month, according to an email reviewed by BuzzFeed News. No one responded, the doctors said.
JAMA declined to comment, citing the ongoing investigation.
The CEO of the AMA, James Madara, said in a statement, “JAMA and the AMA intend to take actions that demonstrate we are committed to dismantling structural racism both within our organization and across medicine. To do so, we must and will partner with those outside our organization who are willing to join together to confront these issues.”
The podcast episode did not surprise Raymond Givens, a cardiologist at Columbia University Irving Medical Center, who contacted JAMA in the fall in an attempt to discuss his concerns about a lack of diversity among the journal’s staff.
On Oct. 26, Givens sent a frustrated email to Bauchner, as well as the editor of another top-tier outlet, the New England Journal of Medicine, or NEJM. “The emotional impact of this year’s events has led me to be far more vocal and candid than I have ever been previously,” began his note, which he shared with BuzzFeed News.
“I note with humor but absolute sincerity that there are more editors named David at your journals than Black and Latinx editors combined,” the email said.
According to a data analysis done by Givens, the staff of both journals in 2020 were each 80% white and 70% male. “I note with humor but absolute sincerity that there are more editors named David at your journals than Black and Latinx editors combined or East Asian and South Asian editors separately,” he wrote. (By his count, JAMA had 41 editors or board members who were white and eight people of color. NEJM had a similar breakdown, with 43 white editors or board members and eight who were nonwhite.)
“The fact that the gatekeepers are so unrepresentative — by race, gender, and geography — is unsettling,” Givens continued. “Without more diverse views, it is difficult for you to know what you don’t know.”
When asked for comment, NEJM editor Eric Rubin said that the journal doesn’t ask its editors or editorial board members to identify their race or ethnicity, but he estimated that Givens’s assessment of its racial makeup was incorrect, without specifying how. JAMA did not respond to a request for comment about this analysis.
Bauchner didn’t reply to Givens’s email, and Rubin offered to talk about it but never called, the cardiologist said. Over the next few months, though, the NEJM appointed its first African American deputy editor and published an essay written by Givens about how exhausting 2020 was for Black health providers.
Givens said he doesn’t plan to submit any work to JAMA anytime soon. Neither does Joia Crear-Perry, founder of the National Birth Equity Collaborative. “I don’t have faith that the current leadership would be able to navigate reviewing articles around structural racism and its impact on maternal health,” she said.
Compared to other journals, she said, JAMA has been slow to make race an editorial focus. A different medical journal, Health Affairs, pledged this year to include more underrepresented voices in its pages. Last summer, the Lancet, another high-profile science journal, invited Crear-Perry to write an editorial titled “Moving towards anti-racist praxis in medicine” as part of an ongoing series of articles and commentary.
These other journals “are really leaning into ensuring that they undo the harm that’s been caused by racism,” Crear-Perry said. “But we have not been able to get the same kind of pickup from JAMA.”
The most obvious consequence for withholding research from JAMA is that it won’t be seen by the journal’s large audience — giving even less attention to relatively understudied issues such as racial inequities.
Jelliffe-Pawlowski, one of the UCSF researchers working on the COVID-19 preterm birth study with McLemore, said that one big reason that JAMA was initially attractive to them is that it has a special channel to rapidly publish short research. A lot of coronavirus findings have been released in this format, allowing scientists to quickly update the world on the ongoing crisis. “There are not a lot of other mechanisms like that,” Jelliffe-Pawlowski said.
Openly protesting such a high-profile outlet — which many told BuzzFeed News extends to peer-reviewing other scholars’ manuscripts if asked — could have career consequences beyond lost publications. It could also, some researchers fear, bring reputational harm.
“In order for us to promote ourselves up the academic ladder, we have to get our papers into these journals,” said Ebony Hilton, an associate professor of anesthesiology at the University of Virginia who is researching how much access racial minorities with COVID-19 have had to scarce medical equipment, like ventilators. Hilton said her team will not be submitting the final research to JAMA.
“When you are only 5% of a population of people,” Hilton added, referring to the percentage of doctors who are Black, “if you speak out against that population, if you speak out against that system, you are putting a target on yourself in many ways.”
To some academics, even those who strongly disagree with JAMA’s actions, boycotting may feel like too great a sacrifice, or not the most effective form of protest for them personally.
“For every individual person, they need to do and respond in a way that’s empowering to them,” said Taison Bell, a critical care and infectious disease physician at the University of Virginia. That could be through signing petitions, boycotting, talking to JAMA staffers, or something else.
“It’s a much bigger discussion than ‘Do I withhold scholarship from this one journal?’”
Bell, who has previously published in a JAMA journal, isn’t planning to boycott — though he noted that this would be less of a sacrifice for him anyway, since research is not his main focus. In a recent essay in the NEJM, he wrote about the need to create more opportunities for Black physicians in academic medicine. And he told BuzzFeed News that that effort involves rethinking the connection between promotions and “prestigious” publications, given the lack of diverse staffing at the latter.
“It’s a much bigger discussion than ‘Do I withhold scholarship from this one journal?’” he said, pointing out, “The same issues are going to be at the next journal I might be considering. For the most part, I would bet the same issues apply.”
Those who are boycotting JAMA are actively figuring out what it will take to feel comfortable bringing their work to the journal again.
As the internal investigation into the podcast episode continues, it’s unclear how the JAMA will come down on Bauchner, who has served as editor-in-chief since 2011. But to many, last week’s news that he was being at least temporarily placed on leave looked like a victory.
“We did it!!” tweeted James, one of the petition’s leaders. “I always believed that [since] we were on the side of right, JAMA would eventually realize that,” Crear-Perry said by email.
Givens hoped that other journals would see the incident as a cautionary tale. “A group of Black physicians who are fed up banded together and helped to make this happen,” he wrote by email. “Many Black doctors, and other doctors from marginalized groups, have simply had it with medicine’s hypocrisy and resistance to positive change.”
What meaningful change looks like, however, will look different to different people.
On March 16, before he was placed on leave, Bauchner conducted a livestreamed interview with three Black medical experts about structural racism in medicine. It was a discussion he had promised to hold in his earlier, written apology, and he opened by again expressing regret for the journal’s “inaccurate, offensive, hurtful” comments.
But several Black scholars said that the apology — as well as the journal’s decision to delete the episode and force out Livingston — wasn’t enough.
Like others, Givens will be paying close attention to the outcome of the investigation that is being conducted by the AMA’s independent committee. As he recently pointed out to JAMA leadership, six of the seven committee members are white.
And if Bauchner ultimately steps down, Givens said he would carefully watch to see how his replacement is selected — and how other editors are chosen going forward.
“I don’t think drawing new editors from the same old small network would represent progress,” he said. “I do think the new voices should not merely [be] diverse but bold, willing to push medicine forward forcefully toward greater inclusion.”
McLemore, too, is waiting for concrete signs of bigger change. Shortly after Bauchner was sidelined, she expressed concern that he would be replaced with someone who could repeat the same mistakes.
“I would need to see some consistent behavior change over time,” she said. But she was hopeful: “I’m not going to sit here and say I’ll never submit something to JAMA again or review something again.”
“I have to believe in redemptive narratives,” McLemore added. “I believe in repair from rupture.” ●
This story has been updated to include that JAMA declined to comment, citing the ongoing investigation.