Race and Medicine
The Race and Medicine collection reflects NEJM’s commitment to understanding and combating racism as a public health and human rights crisis. Our commitment to antiracism includes efforts to educate the medical community about systemic racism, to support physicians and aspiring physicians who are Black, Indigenous, and people of color, and ultimately to improve the care and lives of patients who are Black, Indigenous, and people of color.
New federal policies permit immigration officials to enter health care facilities to conduct enforcement activities. How can health care professionals protect their patients, themselves, and their institutions?
Recognizing that financially strapped students find their residency choices constrained by cost-of-living considerations, Mass General Brigham began supplementing the salaries of residents in need.
As climate change exacerbates existing health disparities, a new curriculum arms residents to provide climate-informed patient care, advance climate advocacy, and improve health system sustainability.
The U.S. shortage of primary care physicians disproportionately affects underserved communities, and the inequities are compounded by the racial and linguistic diversity gaps between patients and doctors.
The deluge of legislative and policy attacks on diversity, equity, and inclusion efforts threatens the integrity of the health care workforce and will ultimately worsen the health of the populace.
A study of a health equity curriculum is stopped in its tracks by the ban on diversity, equity, and inclusion efforts in federal agencies. The study’s leaders see the sudden halt as a call to action.
A new Texas policy could deter immigrants, both documented and undocumented, from seeking help for serious medical concerns. Consequences of this measure may reverberate widely.
The components of transitional justice — truth telling, memorialization, accountability, and reparations — can help medical centers develop practical approaches to promoting health equity.
To achieve goals focused on diversity in clinical research, trials may need to enroll large numbers of U.S. participants. But diversity initiatives and multiregional strategies can be complementary.
More on Race and Medicine
A gallery of portraits of prominent alumnae of color at Harvard Medical School provides inspiration for diverse current students and makes past sexist practices visible to all.
Like morbidity and mortality conferences, the HER series elucidates root causes of adverse events, but with a focus on inequities in care and an emphasis on building skills and generating solutions.
Rhode Island is collaborating with community health workers to expand their role in creating a better-integrated health and social care system and addressing root causes of health inequities.
Reductions in the estimated number of new HIV infections in the United States have overshadowed disconcerting trends among Latino people. Increased visibility, political will, and resources are needed.
A storytelling initiative launched by health care, academic, and community organizations produces narrative interventions to help heal and empower the people most deeply affected by gun violence in Boston.
Tufts’ STEM+M Connect program uses multitiered near-peer mentoring to help students navigate key academic transition points by building career awareness, a sense of belonging, and social networks.
Covered California, the state’s health insurance marketplace, collects demographic data from applicants to inform its efforts to equitably increase health care coverage and reduce health disparities.
To reduce high levels of food insecurity among Black and Latinx residents of Chicago, three institutions partnered to create VeggieRx, a produce prescription program anchored by an urban agriculture facility.
Recognizing that public health crises often hit hardest in underresourced communities, two academic medical centers have partnered with the Chicago Department of Public Health to provide rapid responses to outbreaks.
Every year, approximately 70 million persons lack a right by law to emergency medical care during law-enforcement interactions. Passage of the Medical Civil Rights Act would establish such a right.
States and local governments have filed lawsuits alleging that oil companies have exacerbated the climate crisis. If broadly successful, such suits could help protect public health from related threats.
When a health inequities researcher finds herself in the ED, she sees and experiences firsthand the racially biased treatment she has worked hard to document.
A study assessed the clinical, occupational, and financial effects associated with changing from race-based to race-neutral equations for the interpretation of lung function on millions of patients.
Medical students and faculty at the University of Pittsburgh have been teaching middle-school students from marginalized racial and ethnic groups how to perform bystander CPR.
The Inclusive Dermatology Atlas from the University of New Mexico was designed to address disparities in diagnostic accuracy and thereby reduce disease burden, especially among patients of color.
In an effort to reduce racial disparities in prenatal health, a Yale-based transdisciplinary research team, clinicians, and payers developed a program to deliver prenatal care in a group format.
Over its history, the Journal circulated ideas about innate sex differences that facilitated essentialization of women to their reproductive roles and exclusion of women from medicine, among other ills.
Prioritization of individual social-needs screening in health care may strip energy, attention, and resources from the goal of advancing equity in patient experience and clinical outcomes.
The Supreme Court has imposed new legal principles that impede the ability of states, Congress, and agencies to use evidence to protect the public. It now has the opportunity to reconsider this approach.
Recent approvals of exa-cel for treatment of sickle cell disease and transfusion-dependent β-thalassemia mark the dawn of the era of gene editing in medicine. But ensuring access will be challenging.
During the social tumult of the 1960s and 1970s, the Journal opened its pages to advocates of reform in the profession and society at large, but it did not completely break with its troubled racial past.
The widening scope and scale of genetic tests are posing new challenges, and the need to address these challenges is becoming immediately relevant for all clinicians, not just genetics experts.
Between 1935 and 1944, the Journal remained all but silent regarding the heinous motives of Nazi science and medicine. What is the nature and significance of silence in the face of such oppression?
As leaders of diversity, equity, and inclusion efforts within academic, medical, and corporate institutions strive to improve equity and health for all, they are facing attacks from all sides.
The stress imposed by structural and individual racism on Black people may contribute to the development of preeclampsia. But use of race to guide prevention-related decisions could be problematic.
From the early 20th century until well after World War II, the Journal amplified attention to eugenics and provided important support among medical professionals for the U.S. eugenics movement.
The University of Utah’s Family Medicine Residency program analyzed and continuously revised the rubric used to select candidates for interviews and introduced structural changes to support residents.
Collaborators from Massachusetts General Hospital, Community Servings, and the University of North Carolina provide medically tailored meals for people with chronic illness and food insecurity.
In partnership with local communities, the Duke University School of Nursing piloted a salon-based intervention to reduce barriers to the uptake of HIV preexposure prophylaxis among Black cisgender women in the U.S. South.
Working with the community, Ohio State University clinician–scientists curated trusting relationships that facilitated recruitment and retention of Black Americans in a clinical trial.
Although new weight-loss drugs are important, scholars and policymakers shouldn’t lose sight of population-level strategies that can prevent excess weight gain and obesity among children in the first place.
Resource constraints in safety-net systems mean that outlays for care must be measured against opportunity costs. What ethical framework should guide resource allocation and management decisions?
As the Journal explores its history and acknowledges its role in voicing and perpetuating racism and discrimination, it must examine how it grappled with the problem of difference.
Recent developments highlight the need to advance discussion about Asian Americans’ identities and status in the medical profession and their roles in disrupting U.S. medicine’s racialized hierarchy.
In 2023, CMS announced a new model that moves toward population-based payment at the state level and aims to curb cost growth, improve population health, and advance health equity.
Recent diversity efforts in academic medicine have failed to support retention of women of color by creating a truly inclusive and equitable climate in which all faculty members can thrive.
Has the laudable intention of ensuring patient equity caused medicine to deviate from its mandate to predict patients’ risk as accurately as possible?
Racism against Indigenous people infected Journal articles about civilization, Indigenous medicines, disease susceptibility, and possible Indigenous extinction, but the erasures are equally striking.
There are various possible futures for regulation of artificial intelligence in the United States. The history of rules governing the treatment of human subjects could hold important insights.
A new series examines biases and injustices that the Journal has helped to perpetuate over its history, in the hope that reckoning with our past will help us prevent harm in the future.
Founded by men whose families profited from slavery, the Journal provided a prominent forum where physicians perpetuated race hierarchies before and after the Civil War.
Community-engaged research is increasingly recognized as an essential approach to addressing intractable racial and ethnic health disparities in the United States.
Historical oppression fueled both the Lāhainā fires and the health inequities faced by Native Hawaiian communities. Healing and rebuilding should be shaped by community voices and perspectives.
In response to the new U.S. Supreme Court ban on race-conscious admissions, medical schools have an opportunity to refocus on affirmative action’s original vision.
Efforts to implement heat-safety protections for workers are falling short. Given these gaps, clinicians can help support their patients who may be at risk for heat-related illness.
Black residents face higher rates of remedial interventions and dismissal than do their White counterparts. Such overpolicing affects the mental health of trainees as well as their careers.
Policy discussions related to affirmative action have typically focused on its effects on education, employment, and earnings. But affirmative action may also play a role in shaping population health.
Research suggests that documentation can actually influence clinical decision making. The normative use of race in documentation therefore demands interrogation.
The evidence for breast cancer screening of women in their 40s is insufficient to support a new public health imperative, given the uncertain benefits and common harms for healthy women.
The Supreme Court’s decisions in two cases eliminate the consideration of race in university admissions. Regardless of the rulings, medical education can sustain efforts supporting diversity.
Expanding beyond practices for Covid-19, the U.S. government could require systematic data collection and public reporting for all vaccine-preventable infectious diseases in migrant detention centers.
About one third of DACA recipients are uninsured. A proposed rule would allow recipients to participate in the Affordable Care Act’s health insurance exchanges.
State Medicaid programs don’t all cover comprehensive lifestyle interventions or medication for obesity treatment. Expansion of such coverage could help address health disparities.
Although discrimination both by clinicians and by patients and families is relatively common in the United States, the laws that can be used to address these two types of discrimination differ substantially.
Events that culminated in a state of emergency for Jackson, Mississippi, highlight the ongoing burden created by poor water infrastructure in many historically racialized communities.
People with disabilities face inequities in social determinants of health, health care access and quality, and the impact of global crises, all of which compound the harms to the disability community.
An analysis of 2016–2019 Medicare claims data for patients with opioid use disorder showed that receipt of medications to treat OUD was more frequent among White patients than among Black and Hispanic patients.
Navigating racism as a Black physician often feels like being the first person in a group to walk through a spiderweb: those behind you watch as you panic, swatting the air to free yourself from an affront that no one else can see or feel.
Use of xylazine, most often in combination with other drugs such as fentanyl, is a rapidly growing health threat. People being harmed by this drug deserve rapid, comprehensive, and high-quality care.
Racial affinity group caucuses — facilitated sessions for learners who join groups according to self-identified racial or ethnic identity — can help integrate antiracism curricula into clinical practice.
Although abortion restrictions will negatively affect the health of all pregnant people, those most affected by this changing landscape will include low-income women and members of marginalized racial and ethnic groups.
The medical community treats sickle cell pain as a hematologic problem, while often overlooking the neurologic, psychological, and social aspects of chronic pain.
For efforts focused on increasing diversity in clinical trials, the promise of knowledge generation shouldn’t overshadow the goals of improving the trustworthiness and fairness of U.S. health care.
Many academic medical institutions have struggled to recruit diverse students, trainees, and faculty. Although key strategies for diverse recruitment may not be new, they are not in widespread use.
In this large study, the mortality benefits of reducing levels of fine particulate matter air pollution were greater for low-income and higher-income Black persons and for low-income White persons than for higher-income White persons.
This Sounding Board article reviews racial and socioeconomic inequities in the burden of climate change and discusses strategies for health professionals to advance environmental justice and health equity.
The limited new funding allocated to the “Ending the HIV Epidemic in the U.S.” initiative could be a first step toward building a national PrEP program for uninsured and underinsured people, but more action is needed.
Injuries disproportionately affect marginalized communities. There’s an urgent need for innovative approaches to address the structural drivers of injury-related inequities.
Since 1976, the Supreme Court has held that deliberate indifference to the serious medical needs of incarcerated people violates the constitutional prohibition against cruel and unusual punishment. What does this mean in practice?
Two Black surgeons have seemingly climbed the ladder of meritorious success. Yet they are constantly reminded that they have not traveled a great distance as Black men in the United States.
Although a Black residency program director strives to ensure that residents from groups that are underrepresented in medicine never have to experience the discrimination she faced during training, she knows that’s not currently possible.
The abysmal state of U.S. public health and safety cannot be separated from the destructive effects of mass incarceration. Undoing these harms requires abolishing oppressive systems and constructing infrastructure for repair.
From 2013 to 2022, the number of patients who underwent genomic testing for cancer increased. The percentage of these patients who were of African ancestry increased by 0.45 percentage points per year.
In 2017, Chicago’s Rush University System for Health adopted an anchor strategy to leverage its position as a large business in addressing social drivers of population health. The strategy offers an evolving case study.
Implementation of health-equity measures focused on health-related social needs by CMS is an important step, but additional efforts may be needed to reduce health disparities.
If an older Black man living on the streets becomes distressed when put in handcuffs, does he have a mental disorder? Should he “adjust” to this unjust reality, or does the disorder lie in the systems around him?
From 2013 through 2019, Black and Hispanic persons who had out-of-hospital cardiac arrest were less likely than White persons to receive bystander CPR at home or in public places.
The Dobbs decision rolls back fundamental rights for many people, and it is a direct assault on efforts to improve racial equity in health care. Indeed, abortion access is fundamentally a racial justice issue.
Applying an intersectional lens encompassing structural racism, reproductive injustice, and mental health makes it clear that the Dobbs decision will exacerbate health inequities.
Recent House legislation would codify recommendations that trial sponsors design diversity plans for enrollment, but it does not provide a mechanism for remedying inadequate progress.
Gun violence in the United States causes traumatic responses in those who are directly exposed and contaminates the consciousness of young people, particularly those with serious mental health problems.
The Dobbs decision rolls back fundamental rights for many people, and it is a direct assault on efforts to improve racial equity in health care. Indeed, abortion access is fundamentally a racial justice issue.
The history of race adjustment for x-ray dosing reveals how mistaken assumptions can be admitted into medical practices — and how those practices can be ended.
Since wealth is a fundamental driver of health, health equity strategies that fail to close the racial wealth gap may be ineffective. What can health systems do to help address this major social determinant of health?
The long-term physical, mental, and social sequelae of traumatic injuries are substantial and have often been neglected. This burden is especially high among members of marginalized populations.
Explicitly including race or ethnicity as a factor in government allocation of resources raises legal concerns. Litigation related to Covid-19 treatment guidance in New York highlights these issues.
Recent value-based payment models have often moved dollars away from patients and providers with fewer resources and toward those with more. A new model names promoting equity as a central goal.
Since no interventions for reducing implicit biases have been shown to have enduring effects, health care organizations should focus instead on eliminating discriminatory behavior and other harms caused by implicit bias.
Black women have derived less benefit from interventions such as mammography screening and adjuvant endocrine therapy than White women. Removing barriers to health care access could mitigate the racial divide in breast-cancer mortality.
Among the barriers to increased participation in clinical trials by members of underrepresented groups, one that requires governmental attention is the lack of robust, reliable data on race and ethnicity in patient databases maintained by clinical providers and insurers.
In a post-Roe America, Black women will be disproportionately affected by the lack of abortion access and overrepresented in pregnancy-related deaths. A Black physician aims to ensure that her patients can choose for themselves.
Climate change and air pollution, largely caused by the burning of fossil fuels, pose serious harms to children’s health. Children from communities of color and low-income communities are disproportionately harmed.
The editors announce a new NEJM Group series on climate change and the increasingly urgent health and care delivery challenges we face. Articles will appear in the Journal, in NEJM Evidence, and in NEJM Catalyst Innovations in Care Delivery.
Addressing the overdose epidemic requires eliminating racial and ethnic disparities — along with socioeconomic, gender-based, and geographic disparities — in substance use disorder prevention and care. Prioritizing research that informs policy could help advance equity.
In 2011, only 12% of surgical residents and 13% of nonsurgical residents identified as Black, Hispanic, or Native American or Alaskan Native, as compared with 30% of the U.S. population. From 2011 through 2019, the racial and ethnic representation in residency programs did not improve.
Black girls in America are harmed by intersecting racism and sexism, which manifest in biases, stereotypes, and practices that render them vulnerable to abuse, dehumanization, and death. Our silence about Black girls has clinical consequences throughout their life span.
Physicians’ dual loyalties to their academic institutions and to patients may not only constrain their ability to act in patients’ best interests, they may also reflect and perpetuate structural racism — a reality of which academic residency clinics provide a case study.
A case that would otherwise have set off an avalanche of investigations and therapeutics, family meetings, and consultations was quietly referred for charity hospice care, though Ms. M.’s immigration status made acceptance even by a hospice agency precarious.
Although the Covid pandemic drew renewed attention to problems in U.S. nursing homes, the underlying issues with long-term care are long-standing. Susan Mitchell moderates a Perspective Roundtable about shortcomings and possible solutions.
Among the barriers to increased participation in clinical trials by members of underrepresented groups, one that requires governmental attention is the lack of robust, reliable data on race and ethnicity in patient databases maintained by clinical providers and insurers.
Although reliever-triggered inhaled glucocorticoid therapy can reduce asthma exacerbations, this approach has not been well studied in Black and Latinx populations, who bear disproportionate asthma morbidity and mortality. In a pragmatic trial involving Black and Latinx patients, the asthma exacerbation rate was lower with reliever-triggered inhaled glucocorticoid use than with usual care.
There is no public health evidence that singling out asylum seekers or other migrants for exclusion from the United States is effective in stemming the spread of Covid-19; a federal order supporting such exclusion violates both international obligations and U.S. laws.
An analysis of data from the Association of American Medical Colleges from 1977 through 2019 showed progress in female representation among clinical faculty, full professors, department chairs, and medical school deans. Much less improvement was observed for racial and ethnic groups designated by the AAMC as underrepresented in medicine.
Digital inclusion is becoming intertwined with health care equity. The Infrastructure Investment and Jobs Act addresses drivers of digital health disparities, offers opportunities for community-based digital inclusion, and could be a lever for improving access to care.
The highest burden of dental and oral disease is shouldered by marginalized and chronically underserved groups. Moving forward, we will need to forge a path for oral health care that prioritizes overall health, prevention, expanded access, affordability, and equity.
In this study involving non-Hispanic Black members and non-Hispanic White members of the Kaiser Permanente Northern California health plan from 2000 through 2019, colorectal cancer screening increased markedly among both Black members and White members, and racial disparities in colorectal cancer incidence and mortality were virtually eliminated.
The neo-Nazi march on Brigham and Women’s Hospital and attacks on health equity interventions are stark reminders of the obligation of physicians to denounce White supremacism and reaffirm race-conscious antiracism efforts.
Much of the medical community continues to view socially defined races as if they are accurate reflections of biologic variation; the racialization of disease is further propagated in textbooks and licensing exams. How do we solve this deeply ingrained problem?
Hispanic Americans’ health profile doesn’t adhere to the paradigm in which minority ethnic or poverty status determines poor health outcomes. But the U.S. health enterprise has not used this information to recalibrate or rethink our models of health and risk factors.
Despite renewed awareness of deep health disparities, many of the clinicians who had gathered for a talk on obesity chose to leave afterward, rather than stay to hear about implicit bias and risk facing the uncomfortable aspects of themselves and our health care system.
Under the Reentry Act, Medicaid would be able to pay for health care for eligible people who are incarcerated starting up to 30 days before their release from jail or prison. Changes to this bill could bring care in these facilities in line with community standards.
If the clinical and translational research enterprise is to help resolve health crises and ensure that all people in the United States have the opportunity to live healthy lives, it must shift paradigms and begin to center equity, diversity, and inclusion in its work.
Despite an increased focus on community engagement in research, barriers persist, including burdensome institutional and federal policies regarding payment for research participation and inadequate mechanisms to support longitudinal commitments to community partners.
The Covid-19 pandemic has deepened commitments to enhancing the diversity of the populations participating in research studies. But people with disabilities have been left out of most of these initiatives.
New guidelines recommend expansions of the populations that should undergo screening for lung or colorectal cancer. Without other changes, a substantial increase in screening could exacerbate inequities in access and delay follow-up of abnormal test results.
Given persistent racism in medicine and the growing recognition that racial and ethnic categories are socially constructed and not biologically coherent, the practice of mentioning race or ethnicity immediately in case presentations is worth revisiting.
Aversive racism is defined as exhibiting racist tendencies while denying that one’s thoughts, behaviors, or motives are racist. Aversive racism is pervasive in academic medicine and impedes diversity, equity, and inclusion efforts.
In the quarter-century since H. Jack Geiger implied in an editorial that racism in the medical profession was contributing to health inequities between Black and White Americans, medical education has inched forward, but health equity remains elusive.
What we knew about Ms. Omega One was limited to her presentation: dark-skinned Black female, about 20 years old, with a gunshot wound to the neck — and most likely a new mother. And as with so many Black people killed in Black neighborhoods, there was no news report.
Load balancing among hospitals is a critical public health intervention during emergencies: failing to balance patient loads will cause unnecessary loss of life, particularly in historically marginalized racial and ethnic groups and rural or low-income communities.
To address root causes of health inequity, the University of Pennsylvania Health System developed a year-long experience in which community health workers mentor and educate executives about the realities of injustice and partner with them to create structural change.
In medicine, diversity at all levels is an essential component of efforts to achieve equity. But there has been little or no progress in recent years in the relative diversity of medical school matriculants and faculty.
Traditional Medicare still lacks dental coverage, which has contributed to inequities in pain, edentulism, and unmet need among lower-income people, people of color, and older adults. The federal government is now closer than ever to enacting a Medicare dental benefit.
Clinicians need look no further than their own institutions to find large groups of employees facing economic and social deprivation. Racial justice in health care cannot be achieved without addressing the economic and social neglect of our low-paid colleagues.
In this video roundtable, moderated by Dr. Michele Evans, experts from a range of clinical and biomedical backgrounds analyze and discuss complex questions about race in medicine, seeking common ground on which to build a system of equitable health for all.
Equations for estimating GFR with serum creatinine overestimate measured GFR in Blacks. The authors report new equations, without race as an inflation factor, using cystatin C and creatinine that reduced errors in estimation between Black participants and non-Black participants.
The use of race in equations that estimate the glomerular filtration rate is problematic. In this study, the use of the serum creatinine level to estimate the GFR without race (or genetic ancestry) introduced systematic misclassification. Estimating GFR with cystatin C generated similar results but eliminated negative consequences of race-based approaches.
At our medical institutions, we immerse trainees in a two-tiered system. We teach them that some kinds of patients see residents and other kinds of patients see attendings. And worst of all, we teach them to pretend not to notice.
Though the mounting resolve to address structural racism in U.S. medicine and public health is welcome, the theory and empirical grounding for this work was laid out more than a century ago by W.E.B. Du Bois and his colleagues in the Atlanta school of sociology.
A subtype of structural racism, environmental racism includes the use of racist practices in determining which communities receive health-protective, and which health-harming, infrastructure. What can physicians do about this underlying and often missed diagnosis?
When a Black, nonbinary Ob/Gyn residency applicant didn’t match to a position, they reexamined their experience: Was the discrimination their grandfather had overcome to become Arizona’s first African American board-certified physician still at work decades later?
This analysis of 2016 and 2017 claims data for disabled Medicare beneficiaries compared filled opioid prescriptions between Black and White patients treated within the same health systems. The mean annual opioid dose was 36% lower among Black patients than White patients. In 75% of the 310 health systems studied, the mean annual dose was at least 15% higher among White patients than Black patients.
Code switching involves adjusting one’s style of speech, appearance, behavior, and expression to optimize others’ comfort, in exchange for fair treatment. As a Black physician, the author has found code switching essential to her success in academic medicine.
How does one honor and protect the sanctity of one’s own Blackness while also giving so much of oneself to a health care system that in many ways continues to dismiss, ignore, and mistreat Black people? How can either of my existences thrive while the other survives?
Black faculty members are often expected to engage in diversity initiatives, a drain on their time and resources known as the “minority tax.” But taxes can be reformed, and several strategies could help reduce the negative sequelae of the minority tax.
We were supposed to be talking about these Black teenagers’ aspirations to become doctors, not their fears about becoming patients. I wanted to tell them not to worry, that they could trust all doctors. But I didn’t. Because they can’t.
An important step in addressing racism as a U.S. public health crisis is accurate measurement of progress necessary to hold ourselves collectively accountable. Public Health Critical Race Praxis provides guiding principles for analyzing myriad health equity challenges.
Standing between the author and a residency match was an act of contortion: conveying her passion about closing racial disparities in maternal health without triggering a “White fragility” response in her interviewer. And she’d finally gotten the interview she feared.
Eliminating racial health inequities requires a movement away from disparities as the focus of research and toward a research agenda centered on achieving equity by dismantling structural racism.
The percentage of women enrolled in U.S. medical schools doubled during the past four decades; now, more than half the students are women. The percentage of Asian enrollees increased substantially. The percentages of enrollees from Black, Hispanic, and other underrepresented racial and ethnic groups remain well below the respective percentages of these groups in U.S. Census data.
On his first day in office, President Biden signed an executive order on advancing racial equity and supporting underserved communities. This policy presents an opportunity to implement lessons from health disparities research that target systemic racism.
In the 1960s, Pittsburgh’s Freedom House Ambulance Service supplanted the police in a role in which they were not effective, reimagined the role of Black citizens in improving community health, and helped establish national standards for emergency medical care.
As Covid vaccines are rolled out, it’s time to shift the focus from a sole emphasis on changing hearts and minds among members of BIPOC communities to ensuring that institutions are trustworthy, transparent, and engaged with communities.
Lack of workforce diversity in medicine has detrimental effects on patients and clinicians. The evolution of the modern quality movement represents a useful parallel for achieving a complicated goal like equitable representation in health care.
Ideally, race will be replaced with genetic ancestry as a variable in medical research and practice. But until more ancestry data are available, ignoring race and extrapolating research findings from European-ancestry populations to others is neither equitable nor safe.
On top of the social, emotional, and psychological effects of the Covid pandemic, many Asian American patients are feeling the stress of increased anti-Asian sentiment. Physicians can take practical steps to tailor their practices to meet this moment.
This letter describes early outcomes and challenges associated with a face transplantation in a Black patient.
I often reflect on how our society decides who deserves punishment and who deserves redemption. I think about grace, and how Black people get so little. And I think about the varied manifestations of Ms. A.’s pain — how no one, me included, offered her a sanctuary.
Medical education and practice have not evolved to reflect advances in understanding of the relationships among race, racism, and health. Instead, race remains one of the most entrenched and polarizing topics in U.S. medical education.
In this analysis involving patients treated in Minnesota during protests after George Floyd’s death, 89 patients were identified who had been injured by less-lethal weapons (45 by projectiles, including rubber bullets; 32 by chemical irritants; and 12 by both). A substantial number of patients sustained serious injuries, including injuries to the head and neck.
Susan Moore, Chaniece Wallace, Breonna Taylor. In 2020, even as Black people continued to die and get killed at disproportionate rates, Black health professionals continued to show up every day during the dual pandemics of Covid and police brutality.
When we hyperfocus on a few historical racist atrocities, we ascribe current Black health experiences to past racism, rooting our present in immovable past events and undermining efforts to combat mistrust. Everyday racism, by contrast, can be tackled in the present.
U.S. health inequities won’t be eliminated by abandoning the use of race and ethnicity in research and clinical practice, since these variables capture key epidemiologic information. But incorporating genetic ancestry, genotypes, or biomarkers requires further study.
Although many experts agree that we should reconsider the use of race in equations for estimated glomerular filtration rate and in medicine more generally, precisely how eGFR equations should change remains unclear.
When a virtual White Coats for Black Lives “march” was disrupted by racist intruders, the organizers persevered. The diverse perspectives and collective support that allowed them to move forward are the tools needed for the long game of antiracism.
The question of whether pulse oximetry measurements vary according to race has not been adequately studied, despite the wide use of this measure in clinical care. In this analysis, Black patients who had hypoxemia were more likely to have a normal pulse oximetry reading than were White patients.
Being interviewed as a Black applicant at the medical student, resident, fellow, or faculty level involves a collision of microaggressions and feelings and experiences related to stereotype threat, tokenism, imposter syndrome, and homophily.
As a legacy of African enslavement, structural racism affects both population and individual health in three interrelated domains: redlining and racialized residential segregation, mass incarceration and police violence, and unequal medical care.
Mental health conditions are ubiquitous, and it is critical to seek help for them. For Black people, however, help comes with substantial risk. One manifestation of this risk ended Daniel Prude’s life, but it does not have to end his story.
To become something, you must see it first — whether in the faces of those who have gone before you or in your own mind. The importance of role models is one reason why representation in medicine matters, because Black students need to see people who look like future versions of themselves.
Throughout the United States, health status and outcomes, access to care, and SES vary by race and ethnic group. An Interactive Perspective using data aggregated by the HOPE Initiative allows readers to view and compare data on a range of indicators for each state and for six racial and ethnic groups.
When an adolescent psychiatrist interviews parents of Black boys, he frequently comes away with a similar narrative — a story in which normative behavior is characterized as aberrant or behaviors classically associated with common diagnoses are misattributed.
Just as interactions between Black people and police outside the hospital put our patients at risk, so does their criminalization within the health care system, which can be particularly harmful in the context of pregnancy, childbearing, and reproductive health.
Investing in community health workers and community-based organizations can help address the social determinants of poor health that disproportionately affect low-income, minority populations and that are magnified during times of crisis.
If Black communities are to participate in Covid-19 trials, clinicians, investigators, and pharmaceutical companies must provide convincing evidence — sufficient to overcome the extensive historical evidence to the contrary — that they are, in fact, trustworthy.
In this Graphic Perspective, an eager Black medical student wonders how she can compete when, lacking the generational privilege held by many White students, she is behind from the start. Her secret weapon is the mentorship of an accomplished senior professor.
The Black–White health gap is inseparable from the enormous gap in resources between U.S. Blacks and Whites. The radical implication of this link is that what really needs fixing is access to resources. One means for fixing it is Black reparations for slavery.
Reversing the effects of hundreds of years of racism is a daunting undertaking, but academic medicine can begin by adopting an antiracist approach to training and supporting physicians with adequate representation, increased influence, and institutional resources.
Our health care system is a microcosm of U.S. society: its resources are not allocated fairly among races. Though various factors influence prevention and management of chronic diseases, access to care through stable insurance coverage may have the most profound effect.
Among nearly 2400 men with prostate cancer, next-generation sequencing of 474 genes showed differences among racial groups in the frequency of mutations in certain genes. Such variations could affect both prognosis and response to therapy in these patients.
Though the factors underlying racial and ethnic disparities in Covid-19 in the United States are multifaceted and complex, long-standing disparities in nutrition and obesity play a crucial role in the health inequities unfolding during the pandemic.
We have seen medical institutions being compelled to deliver statements on diversity and inclusion, with subsequent mandatory training on cultural competence, health disparities, and the like. These approaches fail because they do not reveal racism — they cover it up.
The onus of advocacy for suffering Black patients has been placed almost solely on this country’s disproportionately few Black clinicians — an unsustainable situation, particularly since they are already shouldering the effects of systemic racism on their own lives.
“We’re Black,” said my teenage patient’s aunt, “and we know how the system works.” Having lived her life in a system that didn’t work for people of color, how could she see my unilateral decision to make her dying nephew DNR in any other way?
This report from a level 1 trauma center located near the site of protests describes several serious injuries resulting from use of beanbag munitions by police for crowd control.
As medical leaders around the United States issue statements denouncing racial injustice and calling for the dismantling of racism, we must ensure that these pledges translate into durable improvements for patients with sickle cell disease.
To provide the necessary data for generalizing efficacy and safety outcomes across racial groups, Covid-19 clinical trials must prioritize inclusion of patient populations that reflect the demographics of the ongoing pandemic, especially in the United States.
A confluence of events has substantially increased the likelihood of undercounts of non-White populations in the U.S. census, at a time when such undercounts might be particularly damaging to urgent societal efforts in the coming decade to improve racial and ethnic equity.
I was grateful that in this final hour, the hospice nurse wanted to examine the details of my mémère’s health, to unpack her pain. But throughout her life, there had been no liberation in health care for the poor, just symptom containment.
It’s striking that the conversations about race being had by many racial justice allies are new to them. For many Black Americans, such talks are a nearly daily occurrence. And it has often fallen to Black medical students to have these conversations with Black patients.
A lack of competency in engaging with Black patients is the reality in Canada, where Black communities have been undertreated for their pain and have reported barriers to Covid-19 testing. Reforming medical education and addressing institutional racism are the answers.
Why could I establish trust that White clinicians could not? Was it just the color of my skin? I believe that in this Black patient, I saw someone I knew, a story I recognized. I saw him, and his family knew that.
The disproportionate effect of the Covid-19 pandemic on African Americans, Latinx Americans, and Native Americans is not unforeseen. Inequities in health, health care access, and quality of care are ingrained in our health care system, and they must be addressed now.
To go beyond declarations and move forward with fighting racism in medicine, we must understand the racial biases in our responses to past and present public health issues and plot an ethically and structurally different path to a new future.
Many underrepresented-minority physicians have left academic medicine because they felt invisible and voiceless, lacked mentorship and support, and faced microaggressions. But some have stayed, recognizing that the voiceless cannot be heard without representation.
Academic medical institutions’ idea of addressing institutional and systemic racism often begins and ends with naming a diversity-equity-inclusion chief. But in this unprecedented time, perhaps they will take real action to address these issues within their own walls.
The Covid-19 pandemic clearly illustrates the intersection of structural racism, social risk factors, and health. But with a concerted effort that encompasses multiple sectors, we can change the entrenched factors that lead to disparities in health.
U.S. health inequities have structural causes warranting policy-level solutions. The Covid-19 health equity disaster carries some lessons from which we can derive actionable policy targets for both advancing health equity and improving the pandemic response.
Medical subspecialties continue to have extremely low numbers of racial and ethnic minority faculty, and their resistance to diversification can impede the success of minority hires. But there are ways to cultivate the retention and promotion of such faculty members.
In the wake of George Floyd’s public execution, uprisings have ignited in cities throughout the United States. The words “I can’t breathe” hang heavy in the air. Black people cannot breathe because we are currently battling at least two public health emergencies.
For a Black physician, “professionalism” can be exhausting, back-breaking. It often means suppressing her rage, biting her tongue, wiping her tears over racist outrages, and wearing forced smiles to cover the layers of sadness she feels.
Even as we focus greater attention on combating racist violence, we should remember that racialized language and discriminatory behavior can also have dire consequences, including effects on mental and physical health. We need to fight racism in all its manifestations.
How does racism affect our patients? What traumas do they face daily? And what can physicians do about it? In pondering these questions, a psychiatry resident realizes that medicine itself, with its inherent bigotry, has conditioned him to silence: he’s lost his voice.
A retrospective cohort study analyzed data from a Louisiana health system whose population is 31% black non-Hispanic. A total of 76.9% of the patients who were hospitalized with Covid-19 and 70.6% of those who died from the disease were black. Black race was not associated with higher in-hospital mortality after adjustment for patients’ baseline characteristics.
If medical students and trainees are taught to recognize symptoms of disease in only white patients and learn to perform lifesaving maneuvers on only male-bodied mannequins, medical educators may be unwittingly contributing to health disparities.
In this poem, a surgeon reflects on civil rights activism in response to killings of black people. He touches on both family history and the complexity of being black in America.
Diagnostic algorithms and practice guidelines that adjust or “correct” their outputs on the basis of a patient’s race or ethnicity guide decisions in ways that may direct more attention or resources to white patients than to members of racial and ethnic minorities.
Our country’s long and troubled history of racism has permeated the physician–patient relationship with mistrust. Now, amid an acute public health crisis that is transforming medicine, perhaps we have an opportunity to reset our priorities to face this deeper, more chronic crisis as well.
Capitalizing on the urgency generated by the Black Lives Matter movement, residents and faculty at an academic health care institution take steps to recognize racism within the hospital environment and act to address it.
In this audio interview conducted on June 10, 2020, the editors are joined by Dr. Michele Evans of the National Institutes of Health to discuss a new study examining the disproportionate effect of Covid-19 on minority communities.
Recent state-based crisis standards of care that provide a color-blind process for determining whether a patient with Covid-19 respiratory failure lives or dies are alarming, since color-blind policies result in discrimination against communities of color.
In documenting Covid-19 racial disparities, we must contextualize such data with adequate analysis. Disparity figures without explanatory context can perpetuate harmful myths and misunderstandings that actually undermine the goal of eliminating health inequities.
The current revival of activism among U.S. medical students can be understood in the context of a dissenting tradition in medical training. Though never in the mainstream, trainee-activists have repeatedly reimagined what the profession could be at its best.
The story of Henrietta Lacks’s treatment by the medical system remains relevant today. Black American patients still express greater concern than white ones about the likelihood of experiencing harm from participating in clinical trials, and they are right to worry.
Creating narratives based on race is both a cultural norm and a primal response to a desire to understand our world. By acknowledging how much race shapes our identities and interactions, we can begin documenting our experiences as perpetuators of these narratives.
What do racist images in a 1980s medical school yearbook mean for medical education today? The real and persistent fear among medical students of color is that we are all so bathed in a culture of racism that we are blind to the biases that lie hidden within us.
A woman on Chicago’s primarily black South Side is seen for a breast lump at a community hospital that lacks the resources for high-quality cancer care. A navigator from the Metropolitan Chicago Breast Cancer Task Force reroutes her to a qualified medical center.
Although patient-experience data are important to U.S. health care organizations, the best way to interpret them remains elusive, in part because such variables as race–race concordance between physician and patient correlate with improved patient satisfaction.
After an uninsured Puerto Rican man with back pain, other chronic conditions, and a history of incarceration admits to a doctor at a free clinic that he’s bought oxycodone illegally, he refrains from filling his prescription or returning to the clinic, fearing rearrest.
I am racist, shaped by the sometimes subtle tendrils of white supremacy deeply embedded in our culture. I mean this not as a sanctimonious admission of guilt, but as a call to self-reflection and action for us white physicians.
Structural racism leads to increased rates of premature death and reduced levels of overall health and well-being — an epidemic affecting our whole society. As clinicians and researchers, we wield power, privilege, and responsibility for dismantling structural racism.
U.S. medical students have staged “white coat die-ins” in support of the #BlackLivesMatter movement, but should the medical community do more? Should health professionals be accountable for fighting the racism that contributes to poor health in the first place?
Biases within academic medical centers affect the lives of black people in the United States. Doctors' racial stereotypes can influence their clinical decisions, and black–white disparities persist in patient outcomes, medical education, and faculty recruitment.
In this sample of enrollees in Medicare HMOs, control of blood pressure, cholesterol, and glycated hemoglobin was better for whites than for blacks. Disparities in 2006 persisted in 2011, except in the West, where Kaiser Permanente plans closed the gap in these measurements.
In this study, performance improved between 2005 and 2010 on quality measures for white, black, and Hispanic adults hospitalized for myocardial infarction, heart failure, or pneumonia. The 2005 differences in quality of care for whites and minority groups were smaller by 2010.
This trial tested whether intensive blood-pressure control retards the progression of chronic kidney disease in black patients with hypertension. Although there was an apparent benefit among patients with baseline proteinuria (urinary protein-to-creatinine ratio, >0.22), those with a normal protein-to-creatinine ratio had no benefit. Among all patients, intensive blood-pressure control had no effect on disease progression.
This study compared treatments and outcomes after myocardial infarction according to sex and race from 1994 through 2002. As compared with white men, black men and both white and black women had lower rates of reperfusion therapy and coronary angiography, and black women had higher mortality. Sex and racial differences did not change substantially between 1994 and 2002.
More than a decade ago, it was established that there were significant differences in the rates of major surgical procedures between blacks and whites. These investigators examined nine surgical procedures and found that the racial differences noted in 1992 persisted in 2001.
In this study examining trends from 1997 to 2003 for white patients and black patients enrolled in Medicare managed care, performance on all nine quality measures improved for both blacks and whites, and racial disparities narrowed for seven of the nine measures. These findings suggest that efforts to improve care for all patients result in reductions in racial disparities.
There is concern that minority groups and women are underrepresented in research trials and are less likely to receive experimental treatments for human immunodeficiency virus (HIV) infection. This study of patients with HIV infection in the United States found that blacks and Hispanics were less likely to participate in trials than whites and to have received experimental medications. Women were not underrepresented in trials and were as likely as men to receive experimental treatments.
Because of misperceptions about risks, people with sickle cell trait in the United States may receive inequitable and potentially harmful treatment, with implications for autonomy, privacy, and justice.
NEJM Podcast: Intention to Treat
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Race-Based Diagnosis, Part 3
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Investigating Injustices in the Journal’s History, Part 1
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Over its 200-plus years, the Journal has sometimes published articles that have perpetuated injustices against various groups of people. A new Perspective series explores that history and its lessons. -
Race Relations and the First Paramedics
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This episode tells the story of the Freedom House Ambulance Service — a group of Black laypeople in Pittsburgh who underwent intensive training to become the first paramedics in the United States.
Featured Multimedia
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Interview with Dr. Eric Rubin, Dr. Lindsey Baden, and Dr. Michele Evans on the impact of Covid-19 on minority communities. (19:17)
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Interview with Dr. David Ansell on racial disparities in health that result from unequal distribution of power and resources. (09:55)
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Interview with Dr. Kenneth Poole on the challenges involved in interpreting patient-experience ratings, including bias against black physicians. (11:55)
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Interview with George Karandinos on high rates of incarceration among racial and ethnic minorities as a driver of health disparities in the United States. (14:06)
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Interview with Dr. Mary Bassett on factors contributing to poorer health outcomes among black Americans and what physicians can do to reduce racial disparities. (07:24)