Last week, during a White House press briefing on COVID-19, CDC Director Rochelle Walensky urged Americans to get jabs for their kids. "We know that vaccination helps to decrease community transmission," she said, "and protect those who are most vulnerable."
Her message was succinct, accurate, and easy to understand. But it was at odds with new guidance from the American Medical Association and the Association of American Medical Colleges. In a document called Advancing Health Equity: A Guide to Language, Narrative and Concepts, the AMA and AAMC urge physicians and other health-care workers to replace many "commonly used" words, such as vulnerable, with "equity-focused" alternatives, such as oppressed.
The document is a classic example of how administrative bureaucracies of all sorts are thinking about social justice in 2021. Substantive disparities exist in health-care outcomes in the United States--across a variety of demographic and socioeconomic lines--alongside ongoing debates about their causes and how best to eliminate them. But in response, two leading medical organizations are proposing a lot of language policing that presumes far-left answers to a host of thorny questions.
In this instance, the guide explains:
Vulnerability is the result of socially created processes that determine what resources and power groups have to avoid, resist, cope with, or recover from threats to their well-being. Instead of stigmatizing individuals and communities for being vulnerable or labeling them as poor, we begin to name and question the power relations that create vulnerability and poverty.
People are not vulnerable; they are made vulnerable.
If adhering to the guidance, Walensky would have to say something like, "We know that vaccination helps to decrease community transmission and protect those who are most oppressed."
But that would be misleading. Medical vulnerability is not synonymous with oppression. Men are more vulnerable to COVID-19 than women, but not because men are more oppressed. My grandmother is far more vulnerable to the disease than a wrongfully incarcerated teenager, yet she is far less oppressed. Meanwhile, a warehouse worker whose boss fails to update workplace-safety protocols might indeed be vulnerable to COVID-19 because of lopsided power relations. But if exposed to a public-health message urging vaccination for "the most oppressed," he might think, That's not me, whereas a message informing him that "indoor workers are among the most vulnerable" is far more explicit about whom the advice is for.
A language guide can be worthwhile even if it gets a few things wrong. But Advancing Health Equity is rife with specious reasoning, questionable assumptions, and dubious judgments, all presented in an effort to get doctors talking like ideologues of the social-justice left.
"Dominant narratives ... must be named, disrupted and corrected," the guide declares. Among other things, it calls on doctors to reject individualism, to prefer equity to equality, to overturn "a dominant narrative" that "regards health as a personal responsibility," and to "expose the political roots underlying apparently 'natural' economic arrangements, such as property rights." No guidance is offered to doctors who agree with any of the dominant narratives in question, or who prefer to separate their clinical interventions from their politics or activism. One supposes, for example, that many AMA members believe that property rights are beneficial to the societies where they are protected, and that probing the political philosophy behind them is far beyond a doctor's professional expertise.
Worse still, the new guide is likelier to hinder equity than to advance it. The most vulnerable Americans suffer disproportionately insofar as the medical system adopts language to advance an ideology rather than to communicate clearly--especially if it leads doctors to use language that is most intelligible to people with degrees from fancy colleges and relatively inaccessible to almost everyone else. Fundamentally, doctors should talk in ways that listeners understand.
Founded in 1847, the American Medical Association is a professional organization of physicians and medical students, representing an estimated 270,000 members, or roughly a quarter of the doctors in the United States. It lobbies on their behalf and publishes a medical journal. Any student of its history should feel heartened that today it intends to fight against racism. For more than a century, many of its chapters blocked Black physicians from membership, a practice that persisted into the 1960s. The Association of American Medical Colleges was founded in 1876. Its membership includes 172 medical schools and more than 400 teaching hospitals, many of which have their own shameful histories of white-supremacist racism.
That history has almost certainly contributed to some racial disparities in health-care outcomes. And regardless, the AMA and AAMC ought to be applauded for, say, the attention now given to disparities such as the higher rates at which Black women die in childbirth or the importance of foreign-language interpreters who help patients and doctors understand one another.
In an article titled "Do No Harm: Critical Race Theory and Medicine" in the journal Liberties, Sally Satel, a practicing psychiatrist and a lecturer at the Yale University School of Medicine, chronicles and praises various attempts, past and present, to reduce or eliminate health disparities. But she worries that some recent initiatives ostensibly promoting equity are so lacking in rigor that, at best, they waste scarce resources.
For example, the AMA and AAMC both advocate for mandatory anti-racism training at member organizations, but "the data on effectiveness of such training initiatives are dismal," Satel writes, "with study after study showing that such efforts often backfire by reinforcing racial and ethnic stereotypes while failing to improve morale, collaboration, or diverse hiring within a workplace."
A new drug that performed as dismally in clinical trials would never reach the public--but the medical profession's normal standards of rigor seem not to apply to efforts branded as "anti-racism."
When I asked Satel what she thought of the Advancing Health Equity guide, she began by emphasizing that it is important for doctors to think about how to effectively communicate with patients from diverse backgrounds and to remember the extra obstacles that some patients face. For example, she told me, if prescribing a medicine that requires refrigeration, a doctor might stress the importance of keeping it cold and ask, "Is that going to be a problem?" If so, the doctor should connect a patient without a home or reliable electricity to a social worker to help address that obstacle.
In Satel's telling, however, the paucity of time that most doctors get to spend with each patient is the primary obstacle to providing sufficient care--not the "dominant narratives" that the guide seeks to upend with newspeak. "Most doctors don't have enough time to discharge the limited expertise that we do have, and [the AMA and AAMC] want us to become activists on matters where we don't have any expertise," she said. "And a lot of the particular language they recommend isn't natural speech. That's intimidating to the average person. Patients would look at you like, 'What is wrong with this doctor?' They want a doctor who treats them like this is a normal human interaction, not like they're going through a bureaucratic odyssey together. It's bizarre and alienating."
The guide is also politically naive. The AMA and AAMC imagine that if doctors and other health-care professionals adopt the suggested language, they will bring about progressive change by way of the credibility that their words carry. More likely, they will squander that credibility. The medical profession won't remain more broadly trusted than left-wing activists if the two become indistinguishable. And that's what will happen if doctors follow the guide's advice. Instead of saying, "Low-income people have the highest level of coronary artery disease," it urges health professionals to substitute this doctrinaire sentence: "People underpaid and forced into poverty as a result of banking policies, real estate developers gentrifying neighborhoods, and corporations weakening the power of labor movements, among others, have the highest level of coronary artery disease."
In a section attacking "the narrative of individualism," the guide posits that health promotion "typically means educating people as individuals," and urges "shifting this narrative, from the individual to the structural, in order to more fully understand the root causes of health inequities in our society." It's already hard enough to get my conservative grandfather to heed his doctors about how best to care for a bad back worn down from decades in construction. A new narrative meant to problematize real-estate developers or individualism would not improve his medical condition, but it would inflame his temper. One wonders if the AMA and the AAMC grasp how many patients of all races and socioeconomic groups (never mind doctors) strongly disagree with the agenda that the two organizations are pushing. Either way, patients will feel put off by doctors who sound like ideologues from a different political tribe.
In another passage, the guide introduces a hypothetical 44-year-old Puerto Rican man who "has diabetes and hypertension" and "expresses a mistrust of institutions because of negative experiences with the criminal justice system." The language guidance includes the claim that "the use of 'free clinic' puts a pejorative narrative that undermines equity and exposes the reality of a two-tier, segregated health care system." It fails to note the useful information that free conveys to people without money. What should an equitable health-care system value more highly--succinctly providing relevant facts to the poor or stigmatizing familiar language in hopes of shifting narratives? Open more free clinics, I say, and don't rename them something like health-equity communes, because few poor people will know that they can get care there without having to pay.
"Dominant narratives absolve people and institutions of responsibility for social injustice," another passage states. "Economic crises are said to be caused by markets, mistakes, unfortunate events, rather than decisions and choices made by institutions and networks of power." In today's economy, some observers blame high inflation on the bad luck of the coronavirus pandemic, while others point to excessive or misdirected spending by politicians. Other explanations are possible too. AMA and AAMC members are surely internally divided on these complicated questions. The fact that the authors of this guide feel qualified to assert their view--as general guidance across economic crises, no less--suggests that they have no sense of the limits of their expertise or the proper bounds of professional associations for physicians and medical schools.
The guide posits that instead of doctors asking the conventional question, "How can we promote healthy behavior?" they should ask, "How can we democratize land use policies through greater public participation to ensure healthy living conditions?" Though a staunch proponent of land-use reforms, I would still urge doctors to focus on promoting healthy behavior, as surely as I'd urge YIMBY activists to eschew inquiries into treating cancer.
While lamenting the turgid, stilted political prose of the 1940s, George Orwell wrote, "It becomes ugly and inaccurate because our thoughts are foolish, but the slovenliness of our language makes it easier for us to have foolish thoughts. The point is that the process is reversible." In their guide, the AMA and AAMC put forth dozens of foolish thoughts that warrant pushback. A reversal would include emphasis on the importance of simplicity, economy, and accuracy in health communications--and a commitment to pluralism rather than doctrinaire leftism in professional organizations. As Matt Bai recently argued in The Washington Post, "These medical groups ... may believe they're bringing history and language more in line with the goal of social justice. What they're actually doing is trying to control what their members are allowed to think and say."
It is unethical, I would argue, for a professional organization to put its weight behind recommendations that many of its dues-paying members would quibble with or actively oppose. But the leaders of the AMA and AAMC don't appear to be having second thoughts.
"The AAMC Board of Directors is strongly supportive of the association's work on health equity, which is a key theme throughout our recent strategic plan," J. Larry Jameson, its immediate past chair, told me via email. "We agree that it is important to convey accuracy in medicine and science. However, we also recognize that the words and phrases used can also cause unintended harm by reinforcing stereotypes or unconscious bias. In our commitment to health equity, it is important to review and adapt our terminology as we better understand its interpretations."
AMA President Gerald Harmon explicitly endorses the new guidance too. Dominant narratives can be "wielded as a weapon to oppress others," he wrote as part of an article extolling its release. "That is the case, for example, with the use of adjectives that dehumanize individuals by reducing them to their diagnosis--simply referring to a patient living with diabetes as a 'diabetic'--or that unfairly labels groups of people as 'vulnerable' to chronic disease while ignoring the entrenched power structures, such as racism, that have put them at higher risk."
Come on. Merriam-Webster defines the noun diabetic as "a person affected with diabetes." The claim that calling someone that term is "dehumanizing" is speculative catastrophizing, not established fact.
AMA members who disagree with the new guidance should speak up. Much as measures taken in the name of "counterterrorism" are prone to excess because many critics are afraid to object, many professionals fear pushing back against even ridiculous measures undertaken in the name of equity. False or overbroad accusations that dissenters are soft on racism, or worse, abound--and dissenting at the AMA specifically can jeopardize your position. But eliminating health disparities is too important a cause to let counterproductive language policing go unchallenged, especially by the doctors whose dues are promulgating nonsense.
I welcome your thoughts on language and health care. Please email firstname.lastname@example.org.