Federal action will be particularly damaging to health and medicine research

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LAST MONTH, President Trump issued an Executive Order on Combating Race and Sex Stereotyping to eliminate federal funding for initiatives that investigate how gender and racial biases consciously or unconsciously further inequality in America. Following a memorandum published weeks earlier by the Trump administration in response to the growth of diversity & inclusion (D&I) trainings in academic and corporate spaces, the executive order boasts a goal of furthering one of our nation’s founding ideals: “all men are created equal.” Rejecting assertions of structural racism in America that forge a privileged status for certain citizens, the order claims to draw inspiration from the strides of racial justice activists and the dream of Dr. Martin Luther King, Jr., a world imagined 57 years ago where children would “not be judged by the color of their skin but by the content of their character.”

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As physicians, researchers, and patient advocates, we are alarmed by this executive order. Not only does it exploit the words of Dr. King to demean ongoing anti-racism efforts, it also promises dangerous and long-range implications for federally-funded medical, scientific, legal, and other research on the social determinants of health.

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Amidst ongoing protests of police brutality by activists of the Movement for Black Lives, the executive order purports to combat stereotyping and foster equality by challenging a “pernicious and false belief that America is an irredeemably racist and sexist country.” The administration denounces such beliefs, which it claims “promote division and inefficiency,” and deems it “the policy of the United States not to promote race or sex-stereotyping or scapegoating in the Federal workforce or in the Uniformed Services, and not to allow grant funds to be used for these purposes.” As a result, the administration’s executive order can reasonably be understood to forbid governmental agencies from conducting D&I trainings that teach employees about the historical, social, and psychological dimensions of white supremacy in America.

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Yet, the potential consequences of the order extend far beyond D&I trainings. Buried within its lofty rhetoric lies a prohibition on using federal grant funds for any project deemed to promote so-called “Divisive concepts” (Sec. 5). Three such concepts are specifically forbidden:

1. That one race or sex is inherently superior to another race or sex; 2.
2. That an individual, by virtue of his or her race or sex, is inherently racist, sexist, or oppressive, whether consciously or unconsciously; and
3. That any individual should feel discomfort, guilt, anguish, or any other form of psychological distress on account of his or her race or sex.

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At face value, perhaps ironically, these concepts may seem defensible. Indeed, the very goal of D&I trainings in the boardroom, and the very aim of critical race theory discourse in the classroom, is to dismantle false conceptions of racial and gender superiority, expose conscious and unconscious gender and racial biases, and unearth silenced discomfort, guilt, and anguish from the clutches of America’s deep legacy of racial and gender oppression. However, this irony only exposes the way the executive order twists the language of anti-racism to silence its very mission.

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Scholars have long argued that social determinants of health are inextricably linked to the concept of systemic or structural racism, conscious or unconscious bias, and gender discrimination. Future research on social determinants of health in the US is now threatened by the executive order in two ways.  

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First, the concept of systemic or structural racism is, inherently, an uncomfortable topic, one that may make some feel “distress or anguish.” The language within the order indicates that funding for research on social determinants of health or effects of structural racism may be entirely withdrawn if any individuals experience these feelings.  

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Second, the goal of medical research in this area is to promote health equity by learning from uncomfortable truths. This involves defining, exploring and addressing all forms of racism, including the way conscious and unconscious biases in medical practice have historically created racial and gender inequalities in patient health and health care. Thus, while research on systemic and structural racism, and its many tendrils of influence, is designed to foster healing, not division, such work may be misconstrued as promoting “divisive concepts” in direct contradiction to the administration’s executive order.

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Beyond undermining research on social determinants of health, the new order threatens the medical system’s ability to delivery equitable care across four discrete domains:

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1. Scientific Funding Following the exploitation of black Americans by the Tuskegee Institute, racial justice advocates launched “National Negro Health Week” in 1915, to expose the immense health challenges of black Americans. It would take another 70 years for researchers to conduct a comprehensive evaluation of health disparities in the United States. In 1985, the landmark Heckler Report on Black and Minority Health provided an update on health disparities nationwide.  

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Since 1985, physicians, scientists, epidemiologists, and others have investigated the root causes of inequity in health delivery and outcomes with the goal of promoting justice in health care. However, health disparities remain across both race and class, with some metrics worsening. Over the past few months, amidst vast racial inequities in exposure to and mortality from the COVID-19 pandemic, there has been renewed interest in disentangling the root causes of health care disparities. By targeting federally-funded research projects that engage the historically “divisive concepts” of race and sex, the executive order threatens to strip scientists of critical tools that deepen our understanding of social determinants of health, a field of study already overlooked and underfunded in many academic institutions.

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2. Medical Curricula Medical schools depend on federal funding. Even more, medical school curricula have become better in recent years at acknowledging the complicated relationship between health outcomes and social determinants of health. As medical schools increasingly adopt innovative methodologies to teach these crucial insights, President Trump’s executive order promises to halt their progress. Moreover, a core tenet of the medical profession is to “First, do no harm.” Scholars have shown that “colorblindness” in medical practice shelters unconscious biases that harm patients of color. Medical curricula that ignore the impact of systemic racism on individual patients and populations at large inadequately prepare medical students to meet their patients’ needs.

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3. Trainee Funding All medical residents, medical fellows, and most medical PhDs are funded by federal grants. The executive order could prohibit trainees from participating in or developing research projects on structural racism in medical practice, or social determinants of health more generally, as described above.

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4. Privatization Restriction of federal funding for research on social determinants of health and racism in the medical profession also shifts such research from the public to the private sphere. Although private research is critical to sustaining the infrastructure of our medical system, it is important to maintain balance between public and private research endeavors to ensure matters of public interest are prioritized. For example, the 2001 Bush Stem Cell Policy Ban and 2007 executive order targeting stem cell research has had a profound impact on how, where, and what research has been undertaken. These actions, by restricting use of federal funding, significantly impacted the stem cell field limiting the work of smaller laboratories, concentrating the bulk of stem cell research work into private hands, and temporarily stymying US scientists until the executive order was revoked in 2009. Unlike stem cell research, the geography of health inequity within the context of America’s history of racial injustice is unique and, accordingly, the international research community is unlikely to do the work for us. As a result, in a world defined by this executive order, such work will simply go undone.  

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This Trump administration action comes at a critical time for America. Only recently have the fields of medicine and science begun to grapple with the full implications of systemic racism in medicine. As COVID-19 continues to devastate black and brown communities across the country, this new policy risks stymying important research on issues of race and gender in medicine before it has truly begun. Not only will the executive order negatively impact trust in the medical community — something that has been rendered fragile over generations of racism in medicine — it will also impair efforts to learn how to contain the long-term effects of the novel coronavirus. Ultimately, the executive order makes three harmful errors.

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First, it implies that simply naming, let alone studying, systemic racism is specifically designed to divide groups by assigning fault or blame. It does so by rejecting the possibility that “our most venerable institutions are inherently sexist and racist.” However, the true goal of studying systemic racism is to understand how racist ideas have invaded everyday systems in ways that subordinate the needs of some for the benefit of others. Empowered with this information, researchers, institutions, and policy makers can then redesign systems to be equitable and welcoming to all. While guilt and shame may be natural responses to discomforting truths, they are never the end goal.

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Historically, the health care community has avoided exploring connections between systemic racism and health outcomes. This failure has contributed to the lack of progress towards health equity and has worsened the impact of COVID-19 in predominantly black and brown communities. If disparities in health care and health outcomes are not acknowledged and studied, the implications will loom far beyond black America; many other underrepresented communities, including religious minorities, women, and LBGTQ people will suffer.

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Second, the executive order mischaracterizes the fundamental premise of diversity and inclusion work. The specific language evokes a presumption that D&I curricula exist because their proponents believe “America is an irredeemably racist and sexist country.” On the contrary, the philosophy of D&I training is rooted in the belief that Americans are capable of having awareness and sensitivity to the needs and differences of others. D&I work strives to emphasize our “common status as human beings and Americans,” as emphasized by Trump’s executive order, while recognizing that to achieve equity, we must embrace the totality of who we are, including the legacy of our forefathers.

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Simply put, systemic racism is real. Denying the existence of racism in America turns a blind eye to its proven physiological effects on people of color. Requiring education on systemic racism and its implications for Americans today can be discomforting, causing some to lash out against it, claim it as unfair, deny its truth, or even refuse to engage with its meaning. However, we believe a more responsible and promising approach is to look inward, explore our discomfort, name it, and strive for an ideology of personal and collective growth. Our hope is that the study of structural racism in America will not be viewed as a tool for accusation, but as an opportunity for justice.

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Finally, one of the most alarming facets of the order is its desire to protect Americans from discomfort. Trump names a “divisive concept” as that which makes “any individual feel discomfort, guilt, anguish, or any other form of psychological distress on account of his or her race or sex.” However, as physicians, researchers, and patient advocates, we understand intimately the ability to grow from pain and rebuild from destruction. Indeed, sometimes it is necessary to open a wound to excise the source of pain before healing can begin. Discomfort from learning about systemic racism should not be viewed as punishment for America’s sordid past. Instead, it should be embraced as an opportunity to grow as individuals and better our nation.  

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This recent executive order is misguided, dangerous, and will erode scientific progress toward better understanding the impact of systemic racism on the lives of people of color in America.

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Repercussions of the executive order are already being felt, as universities across the US halt or temporarily cease D&I trainings, diversity programs, and other cultural events for review. Unfortunately, other universities may soon follow suit.  

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Limiting study about the history of American racism ignores a famous warning: “Those who don’t learn history are doomed to repeat it.” It also ignores the rich legacy of the very man exploited to inspire this misguided policy. In a posthumously published essay, titled “A Testament of Hope,” Dr. Martin Luther King declared of the black rebellions exploding across the country, “It is exposing the evils that are rooted deeply in the whole structure of our society. It reveals systemic rather than superficial flaws and suggests that radical reconstruction of society itself is the real issue to be faced.”

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Yamicia Connor is an obstetrics and gynecology physician and Commonwealth Fund Fellow in Minority Health Policy at the Harvard T.H. Chan School of Public Health. Lydia Flier is a primary care physician at Mount Auburn Hospital in Cambridge and an instructor in medicine at Harvard Medical School. Etienne Toussaint is an associate professor of law at the University of the District of Columbia David A. Clarke School of Law. Yonatan Tekleab is a PhD candidate in the Department of Aeronautics and Astronautics at the Massachusetts Institute of Technology. Wesley Harris is a professor of aeronautics and astronautics at Massachusetts Institute of Technology. Connor, Flier, and Tekleab are members of Race to Better Health, an organization that seeks to reduce health care disparities through interprofessional coalition building. Harris serves on the Race to Better Health advisory board.

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