The New England Journal of Medicine, the world’s oldest continuously published medical journal, is looking for historical roots of injustice in medicine by identifying examples of discrimination published in its own pages. One key goal of the project, according to editors, is to find ways to alleviate the harm that continues to arise from those past injustices.
NEJM launched the series “Recognizing Historical Injustices in Medicine and the Journal” with an introductory essay by members of the journal’s editorial staff in December 2023. To date, seven of eight planned articles have been published.
This special series was edited by David Jones, the A. Bernard Ackerman Professor of the Culture of Medicine at Harvard Medical School, and Scott Podolsky, director of the Center for the History of Medicine at the Francis A. Countway Library of Medicine and HMS professor of global health and social medicine. Aside from the preamble by the journal’s editors, the articles are written and edited by independent scholars with no editorial control by the journal.
“We need to do all we can to recognize these past injustices so that they’re not repeated,” said NEJM Deputy Editor Winfred Williams, HMS associate professor of medicine at Massachusetts General Hospital, on May 15 at the first in a series of symposia hosted by HMS to highlight the research findings.
The work that NEJM and the authors of the articles are doing on this project echoes calls by the American Medical Association, the Centers for Disease Control and Prevention, and other leading institutions to address racism and other forms of discrimination that contribute to health disparities, including higher rates of chronic disease and early death for many Black Americans.
In the introductory essay, Williams and his colleagues said they recognize that statements the journal published and endorsed in the past have contributed to the propagation and perpetuation of systems of social injustice and inequality based on race and other grounds. They are using this article series as a platform to share these lessons and promote health equity and social justice in the future.
Community learning
The symposium series is another example of such lesson-sharing, in a form that Joan Reede, HMS dean for diversity and community partnership, calls community learning: gatherings and publications designed to engage HMS faculty, staff, students, postdocs, and trainees in conversations that deepen their understanding and empower them to seek solutions that reduce health disparities, increase inclusion and equity, and enable better health and well-being for all.
“This is the core of who we are as a community,” Reede said. “We do the difficult work of discovering new ways to heal and share that knowledge within our community and worldwide. Together, we improve health care, education, science, and medicine for everyone.”
Initiatives like the series of articles and the accompanying symposia complement many other activities at HMS designed to reduce the harm caused by racism and discrimination, Reede said. These include programs that help bring people with diverse backgrounds and perspectives to biomedical research, cultural and curricular changes that focus on making medicine more welcoming for all kinds of people, and leadership in efforts to create better systems of providing care to those in greatest need.
The symposia are sponsored by NEJM, the HMS Office of Diversity Inclusion and Community Partnership, and the Center for the History of Medicine in Countway Library.
The first symposium focused on racism, medicine, and NEJM since 1812 and featured authors of the first four articles in the series. These articles covered historical justifications for health disparities as well as the journal’s relationship to slavery in the United States, response to the challenges of the Civil Rights movement, and medical representations of Indigenous Americans.
A second symposium, scheduled for Oct. 16, will feature authors of the articles on eugenics and Nazism.
On June 1, NEJM published an article focused on the role of women in medical theory and practice. An article analyzing the journal’s historical publications on sexual and gender minority individuals and communities is scheduled to appear in the coming months. The authors of these two articles will speak at a third symposium on Nov. 20.
Deep dive into the archives
The original concept for the article series was developed by Jones, who said that he had come across many disturbing articles in the pages of various medical journals while conducting his research and working with students and colleagues in history of medicine courses at HMS and Harvard. In addition to early material about the health and biology of enslaved Africans in America, Jones found troubling writings about Indigenous Americans, eugenics, and early Nazi medicine.
Another impetus for the series was the Presidential Initiative on Harvard & the Legacy of Slavery. The first phase of the initiative was a research project, completed in 2022, which documented Harvard’s ties to slavery. The second phase is an ongoing process of reckoning and repair.
“I started to imagine a series of articles that would use the Journal as a resource to look at different topics and try to first understand what had happened and why these kinds of articles were published, and then, equally importantly, to explore the influence of these kinds of past publications on the institutions, theories, and practices of medicine today,” Jones said.
The series could continue after the initial eight planned articles. Jones noted that there is still a vast supply of rich historical material to explore and much to be learned.
“This should be seen as just the start of a conversation,” Jones said.
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Truth-telling as an antidote to racism
Medicine and myth-making in America
Image: Spirit of Eagles, by Chholing Taha, 2010. Courtesy of National Library of MedicineThe historians on the May 15 panel noted that much of the early writing from NEJM should be understood in the context of conscious and unconscious efforts by intellectual leaders of the 19th and early 20th centuries to create a shared American identity, one that was focused on white Americans.
A common element of this work was an attempt to justify enslaving Africans and appropriating the land of Indigenous North American peoples.
“As I think about the national story that we must tell, it’s premised on the foundations of stolen African labor and stolen Indian land,” said psychologist Joseph Gone, co-author of the NEJM series’ article on Indigenous Americans, professor of global health and social medicine in the Blavatnik Institute at HMS, and professor of anthropology at Harvard University.
The panelists noted that early NEJM articles about the health of people of African descent in the U.S. tended to focus on efforts to improve the productivity of enslaved people and to provide pseudo-scientific evidence for supposed white supremacy, including arguments that being enslaved by white people had benefits for the mental health of Black people.
Indigenous Americans were often depicted as a fragile, imperiled race that was in the process of going extinct due to—early NEJM authors claimed—the forces of natural selection and evolution. Indigenous people were characterized as savage and barbaric, as well as susceptible to epidemics and alcohol. Reservations were even described as palliative care for a dying race.
Gone said that one antidote to these ills is to shine a light on the resilience and power of historically deprecated people. This might take the form of studying the benefits of incorporating traditional Indigenous cultural practices into contemporary mental health programs or profiling Indigenous historical leaders in American health care whose accomplishments have remained hidden in the shadows.
Finding ways forward
Modern medicine has evolved beyond specious assertions about race-based differences in human biology and disease susceptibility offered in the early pages of the Journal, the panelists said. But they added that beyond the harm done at the time, those statements continue to have repercussions on medicine today.
The authors noted that many racial constructs advocated in the early pages of NEJM are still ingrained in clinical practice and medical research. These include race-based algorithms for kidney function that put Black patients at a disadvantage and the ongoing need for systemic change to ensure health equity, such as increasing diversity in study cohorts so biomedical science and health care can better meet the needs of the world’s people.
A challenge for today involves replacing incorrect notions of race-based biological vulnerability with an understanding of how social status and structural inequities can drive health disparities, panelists emphasized.
Self-identified race can be an important indicator of social determinants of health. However, in many studies, it masquerades as a biological category, obscuring the health consequences of socioeconomic status or stress related to discrimination, they pointed out. This error results from paradigms of racial difference propagated in the early pages of NEJM and other early medical journals, panelists said.
Merlin Chowkwanyun of Columbia University’s Mailman School of Public Health, author of the NEJM series’ article on civil rights, said that proponents of social change should work across society to develop consensus about the importance of change while also advocating for institutions like NEJM to take a more active role in driving that change.
Reede, who moderated the symposium, reiterated the importance of continuing to engage the whole community in conversations about difficult topics related to diversity and social justice.
“Keep pushing, keep challenging, keep asking questions, because that’s the only way we’re going to get real change,” she said.
