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Embedding Racial Justice and Advancing Health Equity at the American Medical Association

      Introduction

      We write in response to a recent article in this journal calling for the American Medical Association (AMA), the Association of American Medical Colleges (AAMC), the National Medical Association, and organized medicine in general to support an antiracist reimagining of medical education and health care to address “unhealed wounds and unmet needs.”
      • deShazo RD
      • Hoesley CJ
      • Vickers SM
      Ending racial bias in American medicine: a call for help from the AMA, NMA, AAMC, and the rest of us.
      We agree with the authors’ historical review of institutional racism in organized medicine and the role of the AMA in that history. We also appreciate the AAMC's response offered in in this journal by Drs. Acosta and Skorton, who stated the following: “The ‘ghosts of our past’ live on today in both implicit and explicit manifestations of structural racism. There is reason and a need to identify these manifestations because they remain invisible to many in organized medicine and society.”
      • Acosta DA
      • Skorton DJ
      Making `good trouble': time for organized medicine to call for racial justice in medical education and health care.
      We agree, “There must be a better way.”
      • deShazo RD
      • Hoesley CJ
      • Vickers SM
      Ending racial bias in American medicine: a call for help from the AMA, NMA, AAMC, and the rest of us.
      We also agree that collaborations between medical educators, clinicians, students, social scientists, curricular specialists, and others to “scrub present medical school curricula of racial bias, to develop an anti-racist curriculum, and to test its effectiveness” is a necessity,
      • deShazo RD
      • Hoesley CJ
      • Vickers SM
      Ending racial bias in American medicine: a call for help from the AMA, NMA, AAMC, and the rest of us.
      combined with new standards for research on racial differences,

      Weil A. An editor's view of race, racism, and equity. Available at:https://www.healthaffairs.org/do/10.1377/hblog20210125.123273/full/. Published 2021. Accessed January 26, 2021.

      Boyd RW, Lindo EG, Weeks LD, McLemore MR. On racism: a new standard for publishing on racial health inequities. Available at:https://www.healthaffairs.org/do/10.1377/hblog20200630.939347/full/. Published 2020. Accessed January 21, 2021.

      • Flanagin A
      • Frey T
      • Christiansen SL
      AMA Manual of Style Committee
      Updated guidance on the reporting of race and ethnicity in medical and science journals.
      rejection of race-based clinical algorithms,
      • Vyas DA
      • Eisenstein LG
      • Jones DS.
      Hidden in plain sight - reconsidering the use of race correction in clinical algorithms.
      and widespread calls for an anti-racist reimagining of medicine.
      • Cerdena JP
      • Plaisime MV
      • Tsai J.
      From race-based to race-conscious medicine: how anti-racist uprisings call us to act.
      ,
      • Crear-Perry J
      • Maybank A
      • Keeys M
      • Mitchell N
      • Godbolt D.
      Moving towards anti-racist praxis in medicine.
      It is clear that there is a window of opportunity for profound transformation and healing. This change requires us to not only acknowledge our collective history of harm, but also design and implement change in systems of oppression and exclusion that continue to operate in and drive medicine today.
      In this brief response, we highlight critical new policies passed by the AMA House of Delegates and the bold vision of the AMA's Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity.

      American Medical Association. The AMA's strategic plan to embed racial justice and advance health equity. Available at:https://www.ama-assn.org/about/leadership/ama-s-strategic-plan-embed-racial-justice-and-advance-health-equity. Published 2021. Accessed May 25, 2021.

      We also explore the collaborative effort between the AMA and the AAMC Center for Health Justice that led to the publication of Advancing Health Equity: A Guide to Language, Narrative and Concepts in late 2021, a document that examines how the “ghosts of our past” live on in narratives employed and language used in health care. These developments are not isolated acts or products; they are part of a much larger trajectory, the active movement toward racial justice and health equity in medicine.

      The AMA's Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity

      At the 2018 House of Delegates meeting, AMA members called for a sustainable plan toward health equity with the creation of an AMA institutional unit to facilitate work in this area. In response, the AMA launched a Center for Health Equity in 2019 led by the inaugural chief health equity officer, Dr. Aletha Maybank.
      • Jaffe S
      Aletha Maybank: AMA's chief health equity officer.
      Teams with expertise in health equity were formed to design and implement the Center's vision, bolstered by equity-focused hires in units across the organization. Equity was explicitly named by senior leadership as a priority and defined as an AMA-wide “accelerator” (along with advocacy and innovation) that would support the AMA's efforts to remove obstacles to patient care and prevent chronic disease. This mirrored major developments in the AMA House of Delegates, which in 2020 named racism “a public health threat,” and called for the elimination of “race as a proxy for ancestry, genetics, and biology” in medicine.
      • Keeys M
      • Baca J
      • Maybank A.
      Race, racism, and the policy of 21st century medicine.
      In May 2021, the AMA released its Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity.

      American Medical Association. The AMA's strategic plan to embed racial justice and advance health equity. Available at:https://www.ama-assn.org/about/leadership/ama-s-strategic-plan-embed-racial-justice-and-advance-health-equity. Published 2021. Accessed May 25, 2021.

      The plan lays out a bold agenda and a sense of urgency that calls attention to the harm of the status quo, promising to right the injustices of the AMA's past. The plan describes the need for the AMA to center the experiences, expertise, and ideas of those most marginalized and excluded, and to promote an anti-racist and intersectional consciousness in all its efforts. It also lays out a strategy for countering “malignant/dominant” narratives pervasive in health and calls out the need to embrace public health frameworks of health, acknowledging the structural and social causes of health inequities. The plan is rooted in 5 strategic approaches, described in Table 1.
      Table 1Summary of the AMA's Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity (2021-2023)
      ApproachDescription
      Embed racial and social justice throughout AMA enterprise culture, systems, policies, and practices
      • Build the AMA's capacity to understand and operationalize anti-racism equity strategies via training and tool development
      • Ensure equitable structures, processes, and accountability in the AMA's workforce, contracts and budgeting, communications, and publishing
      • Integrate a trauma-informed lens and approaches
      • Assess organizational change (culture, policy, and process) over time
      Build alliances and share power with historically marginalized and minoritized physicians and other stakeholders
      • Develop structures and processes to consistently center the experiences and ideas of historically marginalized (women, LGBTQ+, people with disabilities, and international medical graduates) and minoritized (Black, indigenous, Latinx, Asian, and other people of color) physicians
      • Establish a coalition of multidisciplinary, multisectoral equity experts in health care and public health to collectively advocate for justice in health
      Ensure equitable structures and opportunities in innovation
      • Embed racial justice and health equity within existing AMA health care innovation efforts
      • Equip the health care innovation sector to advance equity and justice
      • Center, integrate, and amplify historically marginalized and minoritized health care investors and innovators
      • Engage in cross-sector collaboration and advocacy efforts
      Push upstream to address all determinants of health and the root causes of inequities
      • Strengthen physician knowledge of public health and structural/social drivers of health and inequities
      • Empower physicians and health systems to dismantle structural racism and intersecting systems of oppression
      • Equip physicians and health systems to improve services, technology, partnerships, and payment models that advance public health and health equity
      Foster pathways for truth, racial healing, reconciliation, and transformation from AMA's past
      • Amplify and integrate often “invisible-ized” narratives of historically marginalized physicians and patients in all that AMA does
      • Quantify the effects of AMA policy and process decisions that excluded, discriminated, and harmed
      • Repair and cultivate a healing journey for those harms
      AMA = American Medical Association; LGBTQ+ = lesbian, gay, bisexual, transgender, queer (or questioning).
      Source: The AMA's Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity.
      The strategic plan's goal is that the AMA will become an anti-racist, diverse, and multicultural organization that advances health equity across the country. The plan is an organization-wide plan, and not solely the work of the AMA Center for Health Equity. The plan identifies responsibilities for all AMA stakeholders and the need to “excavate and re-examine”

      American Medical Association. The AMA's strategic plan to embed racial justice and advance health equity. Available at:https://www.ama-assn.org/about/leadership/ama-s-strategic-plan-embed-racial-justice-and-advance-health-equity. Published 2021. Accessed May 25, 2021.

      the past, with a commitment to uncovering and addressing the harm done to marginalized groups. The plan also recognizes that the harm caused by the AMA is not just in the past, and that it persists to date: “We are working extensively to name and reconcile present day harms caused by AMA policies and actions.”

      American Medical Association. The AMA's strategic plan to embed racial justice and advance health equity. Available at:https://www.ama-assn.org/about/leadership/ama-s-strategic-plan-embed-racial-justice-and-advance-health-equity. Published 2021. Accessed May 25, 2021.

      Although not exhaustive, the discussion opens a vitally needed reconciliatory process, and it cautiously recognizes the AMA's steps to advance equity in the 1995-2020 period as necessary but not sufficient. Building on the Strategic Plan, the AMA House of Delegates passed a resolution in 2021 to “establish a task force to guide organizational transformation within and beyond the AMA toward restorative justice to promote truth, reconciliation, and healing in medicine and medical education.”

      American Medical Association. Promising practices among pathway programs to increase diversity in medicine D-350.980. Available at:https://policysearch.ama-assn.org/policyfinder/detail/Promising%20practices%20among%20pathway%20programs%20to%20increase%20diversity%20in%20medicine%20?uri=%2FAMADoc%2Fdirectives.xml-D-350.980.xml. Published 2021. Accessed December 21, 2021.

      Words and Actions: Naming and Challenging Harmful Narratives

      The AMA and the AAMC Center for Health Justice published Advancing Health Equity: A Guide to Language, Narrative and Concepts in October 2021.

      American Medical Association and Association of American Medical Colleges. Advancing health equity: a guide to language, narrative and concepts. Available at: www.ama-assn.org/equity-guide. Accessed January 29, 2022.

      Launching the guide, AMA President Dr. Gerald Harmon acknowledged the harmful effects of dominant narratives and recognized the importance of language in creating an environment of change.

      Harmon GE. Our words matter. It's time to get them right. Available at: https://www.ama-assn.org/about/leadership/our-words-matter-it-s-time-get-them-right. Published 2021. Accessed December 3, 2021.

      It is one of the tools supported by the AMA to help render visible that which is otherwise hidden; in this case, narratives that sustain race and class oppression and shape harmful assumptions and stereotypes present in our language. The Guide opens space for exploration of core equity concepts in medical education and practice and, as such, serves to support the AAMC's efforts to develop new competencies in diversity, equity, and inclusion. The terms explored in the Guide are not commonly present in medical literature and include ableism, anti-racism, cissexism, colorblind racism, cultural safety, exploitation, intersectionality, meritocracy, patriarchy, racial capitalism, white supremacy, and whiteness.

      Moving Forward

      The AMA Strategic Plan and the AMA/AAMC Center for Health Justice Narrative Guide generated controversy when released. Their challenge to the status quo is consistent with the calls in this journal for “an anti-racist reimagining” of medicine to address “unhealed wounds and unmet needs.”
      • deShazo RD
      • Hoesley CJ
      • Vickers SM
      Ending racial bias in American medicine: a call for help from the AMA, NMA, AAMC, and the rest of us.
      Some critics of these documents have based their criticism on denial of structural racism and systemic exclusion in the United States, and in medicine in particular. Others have expressed skepticism of the AMA's sincerity and wondered whether the commitments in the plan will be fulfilled and if racial justice and health equity work will be supported by the organization in the long run. They ask, “Why should we trust the AMA?” Their skepticism over the AMA's efforts exists for good reasons. For more than 100 years, the AMA reinforced or passively tolerated the marginalization and exclusion of Black physicians. Only in 2008 did the AMA apologize and pledge to “do everything in our power to right the wrongs that were done by our organization to African-American physicians and their families and patients.”

      American Medical Association. The history of African Americans and organized medicine. Available at:https://www.ama-assn.org/about/ama-history/history-african-americans-and-organized-medicine. Accessed December 16, 2021.

      In sum, the harmful effects of historical and contemporary AMA policies affecting inclusion and equity are beginning to be acknowledged, as evidenced in the strategic plan. With humility, we understand the skepticism over the AMA's commitments, knowing that trust can only be gained over time by purposeful action. We also celebrate this time of profound change in medicine and society as a window of opportunity for transformation and healing.

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        • Acosta DA
        • Skorton DJ
        Making `good trouble': time for organized medicine to call for racial justice in medical education and health care.
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