The AMA President Defends ‘Advancing Health Equity’

Robert Graboyes’ November 24 opinion article focusing on the American Medical Association’s “Advancing Health Equity: A Guide to Language, Narrative and Concepts” conveniently misses the point of why the guide was created and what it is trying to accomplish. Language has tremendous power in medicine and in the care we provide our patients.

The language guide is not intended to punish physicians for using the wrong language, as Graboyes suggests, but rather to give them a greater understanding of language’s power and to challenge the long-held narratives in medicine that have harmed historically marginalized people and communities. The guide promotes equity in medicine by helping my fellow physicians and me center the care we provide around our patients’ lived experiences, without reinforcing stigmatization or negative stereotypes. It is designed to stimulate awareness about language and concepts most of us didn’t learn in medical school, in the hope that it moves us closer to something we all want – healthier people and stronger communities. In short, it was created to help us become better healers.

The AMA’s work to advance racial justice and equity in medicine is rooted in the preponderance of science, evidence and data that conclusively demonstrates that racism—both explicit and implicit—results in poorer patient health within our health system and society at large. This has had and continues to have a detrimental effect on the health of far too many across this country. Achieving optimal health for all people is good for medicine and good for our nation, and we believe language plays an important role in reaching that goal.

— Gerald Harmon, M.D., president of the American Medical Association

A Response from Dr. Graboyes

I thank Gerald Harmon, president of the American Medical Association (AMA), for reading and commenting on my essay, “The Pall of Politics Descends Upon American Medicine,” which criticized “Advancing Health Equity: A Guide to Language, Narrative and Concepts” (AHE), produced by the AMA and the Association of American Medical Colleges.

Harmon says I miss “the point of why [AHE] was created and what it is trying to accomplish.” But my goal was not to describe what AHE’s authors tried to accomplish, but rather what they did accomplish—which was to undermine patient care and trust in at least five ways:

AHE implies that differences in health status constitute prima facie evidence of malevolence. In truth, a patient might be vulnerable to illness because of, say, alcohol consumption, genetic inheritance or excessive exposure to sunlight. But AHE banishes the word “vulnerable” and insists that such patients are “oppressed” or “disenfranchised,” thus diverting patients’ attention from important determinants of health.

AHE spurns the idea of individual responsibility for one’s own health. AHE rejects the question, “How can individuals protect themselves against health problems?” in favor of, “What kind of public collective action is necessary to confront health inequity across identifiable populations?” In other words, your health is the government’s responsibility, not your own. “Individualism” and “meritocracy” become, in AHE’s terminology, “dominant” or “malignant” narratives. This is a plea for helpless dependency.

AHE stokes racial and class divisions. Harmon says AHE “promotes equity in medicine . . . without reinforcing stigmatization or negative stereotypes.” But in fact, AHE cultivates its own brand of racial stereotyping and stigmatization—most prominently in its repeated focus on the ills of “whiteness.” AHE also demonizes whole professions. For example, it warns that doctors shouldn’t say, “Low-income people have the highest level of coronary artery disease in the United States.” Instead, they should say, “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 the United States.” A banker or realtor could respond, with considerable accuracy, that “People underpaid, forced into poverty and denied care by the AMA’s long history of racism, anti-competitive behavior and price-gouging have the highest level of coronary artery disease in the United States.” I don’t endorse such scapegoating, but AHE invites it.

AHE stymies communication by replacing normal speech with long, awkward circumlocutions. In the previous paragraph, AHE admonishes doctors to jettison a clear, natural-sounding 27-syllable declaration with a barely comprehensible 78-syllable stemwinder. Doctors already have too few minutes to spend with patients, who may struggle to understand what doctors say. But with AHE, short, clear and medical must give way to interminable, opaque and sociological.

AHE shifts doctors away from individual patient care and toward collective social goals. It seeks to “shift the narrative from an individualistic lens to an equity lens”—to move “from the traditional biomedical focus on the individual and their behavior to a health equity focus on the well-being of communities.” This is dangerous. A century ago, Dr. Harvey Jordan (later dean of the University of Virginia Medical School) enthusiastically said eugenics was steering medicine “from individualism to collectivism,” transforming “doctors of private diseases” into “guardians of the public health.” Jordan’s wish soon led to medical complicity in tens of thousands of forced sterilizations. Today, the same impulse yields race-based allocation of COVID medications—the danger of which is eloquently described by Brookings scholar Shadi Hamid (“Race-Based Rationing Is Real—And Dangerous”).

Finally, Harmon said the AMA’s “work to advance racial justice and equity in medicine is rooted in the preponderance of science, evidence and data that conclusively demonstrates that racism—both explicit and implicit—results in poorer patient health within our health system and society at large.” Indeed, racism has wreaked horrible damage on the health of whole communities, and science can help us understand how. But AHE’s curative prescriptions have much to do with subjective storytelling and little to do with science. AHE openly expresses its debt to critical race theory—a deconstructionist field that, in the words of co-founder Kimberlé Crenshaw, “rejects the prevailing orthodoxy that scholarship should be or could be ‘neutral’ and ‘objective.’”

— Robert Graboyes, contributor

We Can’t Classify Kant as Woke

I’m surprised that you would decide to publish a piece as poorly argued as Robert Tracinski’s “Was Kant the First ‘Woke’ Philosopher?”

The entire premise of the article is doomed to failure. Tracinski decides to defend Marc Thiessen’s recent opinion piece about “critical race theory.” Thiessen insists that CRT is a “subset” of critical theory (it’s not) and then contends critical theory “began with” Immanuel Kant. That shows a truly astonishing degree of ignorance, since critical theory didn’t “begin” with anyone. A quick Google search would show that “critical theory” is a term that applies to any number of disparate texts that offer new or different perspectives in approaching disciplines such as literature, sociology, history, etc.

Of course, there’s another obvious problem with Tracinski’s article: it’s a spectacular act of protection. Even as he decries the largely imaginary anti-empiricist orientation of the “woke,” he fails to recognize the American conservative movement’s rejection of the Enlightenment project. The most obvious example of that is the wholesale dismissal of COVID science. Similarly, there are almost no prominent conservatives who accept climate science. Large number of conservatives parrot the idiotic lie that the 2020 election was stolen.

And that’s the central point Tracinski studiously avoids: In its attempts to overturn the 2020 election and its efforts to install officials who can, if necessary, overturn the 2024 presidential election, the American conservative movement has wholeheartedly adopted the authoritarian politics Tracinski pretends to see among the “woke.” Tracinski attempts to provide intellectual cover for the authoritarian stupidity of the American conservative. He fails, obviously, inevitably and spectacularly.

— Bill Friend, N.J.

Mr. Tracinski’s Reply

Bill Friend’s objection to my case for Immanuel Kant as the first “woke” philosopher focuses overmuch on the semantics of the word “critical” (used in Kant’s Critiques and in critical race theory), which was not really central to my case. Rather, I point to Kant’s insistence that “objects must conform to our cognition”—in effect, that our preconceptions inexorably shape our perception of reality. This lays the foundation for the idea that we are all trapped inside a “socially constructed” reality that reflects our place in various racial and economic power structures—which is what the “woke” want us to be awakened to.

Mr. Friend goes on to assume that my motive in criticizing these anti-Enlightenment ideas on the left is to divert attention from an anti-Enlightenment backlash and the indulgence of conspiracy theories on today’s right. Yet I have written on those topics many times; I would encourage him to look me up a little more thoroughly.

We need to move beyond the assumption that anyone who criticizes the illiberal left must therefore support the illiberal right. Can’t we oppose both? The point of my new column for Discourse, “The Neo-Classical Liberal,” is precisely to draw people together in this common cause and in making the positive case for a liberal alternative.

— Robert Tracinski, contributor

Black America Is Not a Monolith

I cannot thank Erec Smith enough for his thoughtful and eloquent article, “What To Do When You’re the Wrong Kind of Black Person.” I am 85 years old, which is a long time to have been the wrong kind of Black person. Having been raised to value individual responsibility, education and sustained effort, I managed to achieve moderate success in life. Over the years, I have seen proponents of perpetual victimhood change their response to my views from a somewhat bemused “N——, please,” to outright hostility. The situation Mr. Smith describes is real and worsening. He is absolutely correct—we must speak up and speak out.

— James Morrison, Tucson, Ariz.

Walking on Eggshells

I’ve just found your publication and was impressed by the essay of Erec Smith. I’m an older lady who enjoys the company of plenty of people from different backgrounds. I travel a lot and grew up in the North, but I have lived south of the Mason-Dixon line for decades.

When BLM started, I went to the website to see where I might help but was put off by the Marxist bent. When asking my Black neighbor if we could still be friends if I was white, he rolled his eyes and said he was tired of people walking on eggshells with him.

But Mr. Smith’s final advice of love and laughter was the clincher. I love people based on behavior, not superficial attributes. My default attitude is that everyone is good until their behavior indicates otherwise. And even then, everyone deserves forgiveness. The attitude that everything is fixed and there can be no redemption for any failings, even if it’s not something you can change, makes being human impossible.

— Kathy Nerger, Huntsville, Ala.

Personal Fulfillment vs. Institutional Action

I am a recent arrival on the shores of Mr. Gurri’s writings, and I am pleased to have washed up here. He’s a very good writer with provocative ideas. However, it seems to me that one could falsify the thesis of “The Revolt of the Public” with four simple words: Norway, Sweden, Denmark, Finland. My friends from Norway don’t have to choose between personal fulfillment and institutional action. The institutions act to enhance personal fulfillment. People in Norway are more secure, freer and happier than we Americans are. And that’s due in large part to their government, which they largely support.

— Bill McClanahan, San Francisco, Calif.

Can India Also Learn From Switzerland? 

“What Can a Divided America Learn From Switzerland?“ is a good, thought-provoking article. In India, we too have to deal with polarization, which is based on religion, region and caste. Yes, our election system does allow citizen-voters to respond and vote out a political party. The problem is that many citizen-voters do not vote, and when they do, there is little assurance that their votes will count.

On the polarization issue, I find that the so-called national parties in India often overlook their regional leaders’ actions, which do not always support needed anti-polarization policies and programs. Also, many regional political parties, who have a say in sending representatives to national parliament, have a limited objective of securing power at any cost. Hence, these parties’ leaders are simply unconcerned about polarizing impacts of their political activities or campaigns. As a result, we in India are facing a challenge of dealing with political actions that, on one hand, assist pro-polarization scenarios, and on the other hand, divide people and threaten the country’s unity.

We are a big country, and although we have much to learn from democratic practices in Switzerland and the USA, I believe it is only the conscious efforts of Indian citizen-voters that can save our democracy.

— Narendra Apte, Pune, India

A New Perspective on the Old World

Thanks so much for this insightful and beautifully written article by Martin Gurri, “Europe’s Postcards From the Edge.”  I particularly enjoyed Gurri’s portrayal of the following:

• The EU not as a union, but as a grouping of tectonic plates constantly crashing against each other;
• Angela Merkel as the dowager empress of a new-model Holy Roman Empire;
• The contradiction of populist uprisings in France and Italy by populations that nevertheless worship their elites;
• And the horrifying prospect of the EU hanging on for a thousand years like Byzantium, trying to imitate something it is not.

Gurri’s article made my day, my week and my year so far!

— Susan Breidenbach, Reno, Nev.

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