I am hopeful that our nation’s current attention to racism will evolve into a sustained campaign to reverse racist policies and their effects. We tend to avert our eyes from uncomfortable subjects. Maybe this time will be different. I hope so.
We are renewing and elevating our efforts to address racism and promote equity at Health Affairs. In this blog post I introduce our perspective and agenda.
Where there is racism, only anti-racist systems can generate equitable results. Dismantling institutional racism and building equitable systems takes time, effort, and courage. Leaders must combine urgency with the long-view so that institutional change can take hold, take root, and be sustained.
In a Health Affairs Blog post last year, I spoke of the relationship between racism and power and called upon the health sector to use some of its accumulated power to fight racism. Health Affairs isn’t included in the $3.8 trillion of U.S. health care spending tabulated in the National Health Expenditure Accounts, but we certainly view ourselves as part of the sector. What, then, is our role in fighting racism?
When Steven Pearlstein, a Washington Post columnist, called Health Affairs “the bible of health policy,” he was not making a theological statement. He was making a statement about power. Papers we publish garner attention—among elected officials, health system leaders, professional and trade associations, and journalists. Publishing in Health Affairs helps people advance professionally, something of great value. Audience research tells us our readers look to us to set the health policy agenda. Our budget may be modest, but Health Affairs is a powerful institution. How do we use this power to make progress?
As editor-in-chief, I offer early answers to these questions, with the knowledge that our understanding and approach will evolve as we proceed. Our agenda has three elements: equitable participation, new voices, and introspection.
We are examining all aspects of our work to determine where we fall short of an equitable ideal.
As a journal, equity begins with authors, reviewers, and editors. We have begun to document the gap between who is involved in these processes and who would be involved in a world without racism. This raises a number of measurement challenges, but our efforts in this area are underway. We will report our findings publicly and hold ourselves accountable for closing that gap.
Even as we gather data, we are digging into the question of why the vast majority of our submissions come from a small set of elite institutions, and we are setting out to change this.
We are querying the role that the methods and data sources underlying most of the work we publish plays in creating exclusion. Quantitative methods applied to large datasets inherently diminish the voices of numerical minorities. Complex methods and databases disadvantage analysts with fewer resources. We need to be more open to other methods while also considering how to create a more equitable environment for those using these methods.
In addition, readily analyzable data, whether survey, clinical, claims, or otherwise, provide limited insight into critical lines of inquiry related to equity, race, and racism. We need to expand our horizons to embrace methods and data appropriate to the questions that need to be answered.
We acknowledge our part in the long tradition of treating race and ethnicity as explanatory variables in quantitative analysis without situating those results in the context of racism and white supremacy. We will do our part to dismantle that tradition and be honest about the reasons health disparities exist and persist. We invite and encourage discourse on how best to measure and ameliorate the harms of racism.
We, like others, have built an ecosystem that defines, invites, and rewards some types of merit, while it shuns, devalues, and ignores others. If the evolution of the health care quality enterprise has taught us anything, it is that quality is multidimensional and perceived differently by those inside the system and those outside of it. It is time for academic publishing to undergo a similar evolution, and we hope to lead it.
We acknowledge that the dominant voices in our work are those with power and privilege. Even as we have dramatically increased the volume of our content focused on equity, the narrative has primarily been written by those in power. We vow to change this.
We believe those who have been harmed by the burdens of racism are the voices that need to be elevated as the nation seeks a better path forward. We intend to amplify those voices.
We embrace the greater diversity of younger generations and will expand our efforts to include their work, thoughts, ideas, and perspectives in everything we do.
We acknowledge the power of art as a form of expression, a mechanism for healing, and a shared element of our humanity. We will seek ways to bring the power of art into our work.
We are aware that our own staff and leadership are overwhelmingly white and economically privileged. We have a traditional work culture which professes that there is a wall separating the personal and the professional. We zealously guard our political neutrality for good reasons and with good intentions but at the risk of reinforcing existing power structures. We know that even speaking of these issues causes discomfort and even anxiety for some. We will do so, nonetheless.
We are aware that racism is a systemic phenomenon and that eliminating individual prejudices and biases, even if it were possible, would not be enough to dismantle racist structures. We will combine work to uncover and address our biases with work to interrogate our systems for ways they reinforce inequitable outcomes, even if those outcomes are not by design.
We will seek to do our part to promote candid discourse on the subject of racism.
Where Do We Go From Here?
We have been working quietly on our equity agenda at Health Affairs for a few years. But we have made less progress in this time than I had hoped.
With all that has happened in the intervening period, it is time to be public. Public about our goals and aspirations, about our perspective and our language. Public so we can be held accountable for outcomes. Public so we can enlist the help of our community. Public so we can be challenged to do better.
We have plans in place to address each element of our agenda. In September 2020, Dr. Vabren Watts joined us as our equity project director, and his full-time commitment has been essential in accelerating our progress. Over the coming months he, I, and others at Health Affairs will have more to say about each element of this plan.
Through additional posts we will describe in more detail our action plans, our goals, our progress, and our shortcomings. We will be more definitive about some of the concepts described here and the ways we will measure and report our results. We hope you will soon see changes that reflect our progress.
As we publicly launch our efforts directed at equity, we hope you will join us in this journey to a place we should have arrived at long ago.