Historical Racism In Medicine: How The AMA Is Charting A New Course

In 2021, the American Medical Association (AMA) released a report titled, “Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity," detailing their five strategic approaches and ambitious roadmap towards eliminating health inequities rooted in historical and contemporary injustices and discrimination. As the largest association representing American physicians and medical students, this effort, along with more recent and groundbreaking policies, are part of the AMA's acknowledgement of its role in racial injustice and health inequities.

The AMA: Power, policy, and proactive change

With over 240K physician-members and more than 190 state and specialty medical societies, the AMA has become one of the most influential medical organizations since it began in 1847. It has political power and policy influence through Congressional testimony by its leaders and through lobbying efforts. The organization's house of delegates (HOD) represents state medical associations and national medical specialty organizations like the National Medical Association (NMA), the largest and oldest association of Black physicians in the U.S. Representation also includes federal services like public health.

Recent AMA activities towards ending racism in medicine

2021 - Issued the aforementioned 83-page report revealing that the organization has been "rooted in white patriarchy and affluent supremacy."

2020 – Published policy document entitled “Elimination of Race as a Proxy for Ancestry, Genetics, and Biology in Medical Education, Research and Clinical Practice," and “Racial Essentialism in Medicine." These documents confirm race as a social construct, not associated with biology.

2019 - AMA Center for Health Equity was established upon the historic appointment of the AMA's first Chief Health Equity Officer, Dr. Aletha Maybank.

2018 - AMA's Annual House of Delegates meeting presented the “Plan for Continued Progress Toward Health Equity."

Medical Racism: Then and now

This encouraging timeline, however, is against a backdrop requiring seismic shifts within the field and practice of medicine. Racism in medicine, and the underlying beliefs and prejudices, run deep.

Now: Health disparities reflect systemic racism

• Infant mortality of Black Americans is twice that of Whites.
• Babies born to Black mothers living in more racially segregated cities have higher rates of mortality.
• Life expectancy of Black Americans is as much as six years less than that of Whites.
• 71% of Black women diagnosed with breast cancer are alive five years later compared to 86% of White women.
• A Black woman is 2.2 times as likely to die of breast cancer as a White woman.
• Black, Hispanic, and AIAN people fare worse than White people across the majority of examined measures.
• Review interactive disparity data: Healthy People 2020 Overview of Health Disparities.

Then: Harmful beliefs about biology and the value of life for people of color embedded racism

1998 - Black boys were involuntarily infused with the cardiotoxic drug fenfluramine in New York City.

1970s-1996 – The Tuskegee Syphilis Study jailed Black mothers who were unwitting research subjects in South Carolina.

1875 - Surgeries were conducted upon Black female slaves in the 1840s without their permission nor anesthesia.

Physicians of color, including Black, LatinX, and Native Americans, were historically excluded from jobs in their chosen field. Black physicians couldn't work for a hospital without exclusive membership in an AMA medical affiliate. Numerous Black medical schools were closed based on exclusionary tactics.

AMA panel highlights professional stories of medical racism

During an AMA panel discussion in Sept. 2022, Harriet A. Washington, MA, a fellow in ethics at Harvard Medical School and author of the 2007 book, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present, shared her personal experience with racism in medicine when she presented at a history of medicine conference in 2001.

“There were 20 people there, most from Germany and also a few from the U.S. and Russia. Each person she spoke with at the conference said that the U.S. Public Health Service Syphilis Study at Tuskegee was the singular example of medical mistreatment of Black Americans."

The same AMA panel featured Abigail Echo-Hawk, a member of the Pawnee Nation, executive vice president of the Seattle Indian Health Board, and the director of the Urban Indian Health Institute, a tribal epidemiology center. She shared a discussion she had with a Native American woman who was forced into an acclimation school and subjected to forced sterilization as many of her peers were in the 1960s and 1970s.

"And that's when I discovered she had been sterilized against her will, unknowingly, as a young, Native woman in that boarding school, along with thousands of other Native women, who were taken. They either brought physicians to them or they took them into hospitals and they forcibly sterilized generations of Native women."

Rupa Marya, MD, author and associate professor of medicine at the University of California, San Francisco, also participated in the AMA panel, relaying current failures in medical education and practice.

“It's shocking to me in medicine that up to 40% of dermatologists, certified dermatologists, cannot diagnose common skin problems in Black skin."

Ms. Washington reinforced the lack of knowledge.

“...it's no accident that in 2016, University of Virginia found that half of all medical students thought that African Americans don't feel pain the way whites do."

The AMA's new direction and renewed commitment to fighting medical racism

In 1909, George Barnard Shaw wrote in The Doctor's Dilemma, “The tragedy of illness at present is that it delivers you helplessly into the hands of a profession which you deeply mistrust."

During a 2020 Special Meeting, the AMA HOD took critical steps to change this mistrust by adopting guidelines to address systemic racism in medicine, including discrimination, bias, and abuse, which includes demonstrations of prejudice known as microaggressions.

This historic suite of policies outlined its history and the structural, systemic, and interpersonal forms of racism and bias that exist across the discipline and profession of medicine – from social determinants of health to medical research, physician practices, academic medical centers, and all levels of medical education.

These policies extend far, acknowledging racism as a public health threat, calling on all to remove race as a proxy for biology, and challenging the profession to eliminate racial essentialism. Finally, the policies call on technology developers and innovators to be proactive and transparent around the implications of racial bias within medical algorithms and other technologies.

AMA Board Member Willarda V. Edwards, MD, was instrumental to development of these policies and called for transformation, stating, “The AMA recognizes that racism negatively impacts and exacerbates health inequities among historically marginalized communities. Without systemic and structural-level change, health inequities will continue to exist, and the overall health of the nation will suffer."

AMA's five strategic approaches to advance equity

The AMA's Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity highlights five approaches central to transforming medicine in the U.S..

Embed racial and social justice throughout the 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 when developing and implementing policies and practices.
• Assess organizational change – culture, policy, 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 and minoritized physicians.
• Establish a coalition of multidisciplinary, multisectoral equity experts in health care and public health to collectively advocate for justice in health.

Push upstream to address all determinants of health and the root causes of inequities

• Strengthen physicians' knowledge of public health and the structural and 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, partnership and payment models that advance public health and health equity.
• Measure the AMA's effectiveness—and ensure accountability.

Ensure equitable structures and opportunities in innovation

• Embed racial justice and health equity within existing AMA healthcare innovation efforts.
• Equip the healthcare innovation sector to advance equity and justice
• Center, integrate and amplify historically marginalized and Black, Indigenous, LatinX and people of color who are healthcare investors and innovators.
• Engage in cross-sector collaboration and advocacy efforts.

Foster pathways for truth, racial healing, reconciliation and transformation for the AMA's past

• Amplify and integrate often “invisible-ized" narratives of historically marginalized physicians and patients.
• Quantify the effects of AMA policy and process decisions that excluded, discriminated and harmed.
• Repair and cultivate a healing journey for those harms.

AMA efforts toward the strategic plan

Through advocacy efforts, formal support for legislation, and programs through their Center for Health Equity, the AMA has initiated partnerships and investments to improve health equity at the organization and in the broader community. Three of these initiatives include:

• The Release the Pressure campaign provides knowledge and tools to encourage Black women to focus on heart health.
• Medical Justice in Advocacy fellowship program is a partnership with Morehouse School of Medicine's Satcher Leadership Institute empowers physician advocacy and advance health equity for marginalized communities.
• The West Side United partnership is AMA's $3 million multi-year investment in its own west side neighborhoods in Chicago.

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