Medicine in the Age of Social Justice

Sally Satel, MD, is Senior fellow at the American Enterprise Institute and lecturer at the Yale School of Medicine Department. This is her speech at the recent Freedom of Intellectual Navigation Conference at the University of Chicago.

Today, I’m going to tell you about a relatively new, significant trend in medicine. In essence, it puts identity politics over patients. That’s something I’ve been very interested in and quite concerned about for a while, since 2001, exactly, when I wrote a book called PC MD – How Political Correctness is Corrupting Medicine. Twenty-four years later, the problem has become mainstream within my profession.

We can start in the ’70s, when a cadre of epidemiologists began to develop the concept of social determinants of health. There’s no denying that any of these categories—education, health care, community, economic stability—have significant effects on health, and they’re all very valid topics of research for clinicians, though they are mainly investigated in schools of public health.

So, here’s the question that will basically foreshadow the rest of the talk: How should doctors think about their professional relationship to the social factors? What are the pragmatics involved in that kind of interaction?

In the past decade, this question gained extra momentum and a lot more controversy when another determinant of health was added, namely, social oppression. That’s what takes us to the title of this talk: Medicine in the Age of Social Justice.

I’ll start with an example. During the George Floyd protests of June 2020, Jennifer Nuzzo, an epidemiologist at Johns Hopkins University, tweeted that “the public health risks of not protesting to demand an end to systemic racism greatly exceed the harms of the virus”.

I don’t doubt for a minute she was well-meaning, but the tweet really wasn’t coherent—I mean, how do you quantify the risks of not doing something? Also, many people pointed out the hypocrisy. Also, many people pointed out the hypocrisy. You wouldn’t hear most public experts saying: “Sure, go to a pro-life march, or religious services,” so the inconsistency was glaring.

A bigger problem to me, even beyond the hypocrisy, was the fact that so many health professionals endorsed her tweet—and, by extension, the contention that it was within the boundaries of their job as public health professionals not only to tell the public about the risks of a certain activity but to tell them which risks were worth taking. They were promoting their own moral commitments. Health professionals can have those commitments, of course, as individuals, but it’s different when you try to impose them on a population.

Another example of medicine in the age of social justice was the sentiment of the Association of American Medical Colleges informing medical schools that they had to employ anti-racist training. A year later, the AMA exhorted doctors to “confront inequities and dismantle white supremacy, racism, and other forms of exclusion and structured oppression.” Well, how can doctors do that? How can they do it in a way that serves the disadvantaged? That’s a big question.

One effort to dismantle racism was undertaken in late 2020 by the CDC’s Advisory Committee on Immunization Practices (ACIP). As you remember, at first, we had to ration the vaccine. It was clear that people over 65 were undeniably the highest-risk group for getting COVID morbidity and mortality. Almost every country gave them high priority. Yet ACIP told the CDC that it should not prioritize age. Why? Because, the 65-and-over cohort in America was whiter than the general population.

That is true: Whites are 60 percent of the population but 75 percent of the over-65 population. Blacks are 14 percent of the general population but are underrepresented in the over-65 group, at 9 percent. To compensate for this discrepancy in proportion, the committee decided to put essential workers ahead of seniors, figuring that minorities would be over-represented in that cohort. They called this an equity approach and specifically invoked it as a move to compensate for historical injustices that Black people in the US endured.

ACIP’s decision was anomalous. Racial politics is not an accepted method of rationing scarce treatment resources. Public health has used various other options, such as basing distribution on who has the best prognosis—that’s classic battlefield triage—or who is the sickest, or on a first-come, first-served basis. (That’s how kidneys are allocated when you need a transplant.)

Remarkably, ACIP did its own calculation and found that overall, more Americans would die, between 0.5 percent and 6.5 percent, if the equity approach were implemented. Older Black people would be among them. In the end, there was considerable public outcry, and ACIP reversed its plan and went along what most countries did, which was, basically, health care workers and older people in long-term facilities first, followed by those 75 and older and front-line essential workers, followed by those 65 and older, the immunocompromised, and other essential workers.

Take this next example, which figures prominently in a climate that is increasingly sensitized to allegations of racism in medicine. I am referring to the much-discussed neonate study that attracted a lot of attention around the time of the George Floyd incident. The 2020 paper published in the Proceedings of the National Academy of Sciences reported that the mortality rate of newborns was cut in half when Black infants were treated by Black doctors. According to CNN, it “laid bare how shocking racial disparities in health can affect even the first hours of life”.

Now, that’s pretty striking. The data came from Florida—a retrospective database that ranged from 1992 to 2015. Thankfully, the deaths—the actual absolute numbers of deaths—were under 1 percent of all the babies born in those years.

But the message was chilling nonetheless. As the authors of that original article wrote, “We posit that these differences may be ameliorated by racial concordance between the physician and newborn patient”—implicating that Black babies (most? all?) should be treated by Black doctors.

The study received even greater exposure in 2023 when Supreme Court Justice Ketanji Brown Jackson included it in her dissenting opinion in Students for Fair Admissions v. Harvard and UNC. She cited this study as an argument for maintaining affirmative action in medical schools. Indeed, affirmative action was a feature of admission to medical school as work by economist Mark Perry, using data from the AAMC, has shown. Black students with middling grades and MCAT scores are up to four times more likely to be admitted than their white and Asian counterparts with comparable scores. As of 2022, the National Board of Medical Examiners altered the reporting of the seven-hour Step 1 exam results from a numeric score to pass-fail. According to the physician-led planning committee that made this change, it not only hoped to reduce the stress of a single high-stakes exam; it also wanted to account for the fact that numeric scoring “negatively impacts diversity based on known group differences in performance.”

Questioning racial preferences can be fraught. Consider, for instance, a 2020 incident involving Norman C. Wang, a cardiologist with the University of Pittsburgh School of Medicine. After publishing a peer-reviewed critique of affirmative action in the Journal of the American Heart Association, Wang’s colleagues denounced him on social media for his “racist thinking” and condemned his paper as scientifically invalid and “racist.” The journal retracted his article and the school removed him as director of the electrophysiology program and limited his contact with trainees. Litigation brought by Dr. Wang is ongoing.

So now, let’s go back to the baby study. According to reanalysis conducted in 2024, the picture was far less troubling than originally reported. It turns out that the authors of the original study controlled for many variables including type of insurance coverage, delivery by cesarean section, length of hospital stay, and 65 other conditions affecting the newborn, such as neonatal hypoglycemia. The one thing they left out—which is kind of surprising because it’s regarded as the biggest risk factor for newborn health—is birth weight. Low birth weight is defined as under 1,500 grams, and it turned out that the Black newborns were much more likely to be in the lower birth weight category than the white newborns.

When you’re a 1,500-gram baby, you don’t go in the regular nursery—you go to the NICU, the newborn ICU, and you are taken care of by a neonatologist. And most of the neonatologists in this country are white—about 3.8 percent are Black. Of course, these little Black babies who are more likely to be in the NICU are going to be taken care of by white doctors. The bottom line is the doctor’s race was irrelevant—it was the gravity of the infant’s illness that led to these tragic outcomes. That’s an important corrective.

Justice Jackson’s claim, recall, that we need more minority physicians in order to treat minority patients—or race concordance—is a topic of great interest in medicine.

To me, it’s plausible that individuals who are highly distrustful of the medical system, especially immigrants who may not be sufficiently acculturated or who don’t speak English, might well respond better to medical professionals who share their background. Whether it needs to be the doctor per se is up for debate. I’ve been in clinics where—and I’m in one now—I’m the only white doctor, and most of the staff are Black, and we effectively share the patients. I know that they make connections sometimes that I can’t, and that’s fine, because you have a nurse who will say something like, “Oh yes, Dr. Satel is really good—you should trust her.” That can help a lot.

What do the data say? Do minority patients do better with minority doctors? Existing evidence on that question tends to suffer methodological limitations, such as using only proxy measures for health, mining retrospective data, or including small sample sizes.

We also need to ask “what are the preferences of minority patients?” A 2020 Kaiser Family Foundation survey on race and health asked 1,500 adults, “Given the choice, would you prefer to see a doctor who [is of your race or ethnicity], or does it not make much difference to you?” 76 percent of Black patients responded that “it did not make much of a difference,” as did 86 percent of Hispanics. The remaining respondents said they “preferred” a race-matched doctor, but the strength of preference was not assessed.

Along these lines, a 2024 U.S. News & World Report surveyed 2,000 adults about health care issues. It found that 13 percent look for a primary-care physician who is the same sex, gender, or race as them. I wonder if women are pulling that up, because often, women like to see women doctors. In all, satisfaction with care does not appear to differ much by race. Neither do most Americans care about the race of their doctor. One cancer expert attributes the differences in outcome to socio-economic factors, not race.

The last development I’m going to talk about is physician activism. I should first say that I believe doctors can have an advocacy role. For example, right now we’re in a climate where I think there’s a lot of room for doctors to be advocates, because Medicaid is probably going to be cut and the tax subsidies for the people who have Obamacare are in peril. We have the head of a major government agency who still thinks autism is caused by vaccines and is telling people to avoid Tylenol. There’s enough to talk about, and I think those are subjects for doctors to take on and to talk to politicians about.

So, yes, there’s a role for advocacy for doctors as doctors. But we’re not seeing that much of it lately in terms of—again—this medicine in the age of social justice.

A colleague and I—Tom Huddle, who’s an internist at the University of Alabama—enumerated three guidelines for doctors who wish to responsibly leverage their professional standing to effect political change. We propose three guidelines. They should advocate policies that (1) directly help patients and (2) are rooted in professional expertise while (3) ensuring that their advocacy does not interfere with their relationships with their colleagues, students, and patients.

First, the reform they promote must have a high likelihood of directly improving patient health. “Dismantling white patriarchy and other systems of oppression” is not an actionable goal. Our primary job is to diagnose and treat, and to do no harm in the process. We have no expertise in redistributing power and wealth. Even seasoned policy analysts cannot readily tease out strong causal links between health and economic and social factors that lie upstream.

Indeed, with so many variables at play, manipulating policy in the service of health may not have the intended effect—and can easily create unwanted repercussions elsewhere in the system. The costs and benefits would be almost impossible to assess ahead of time. Moreover, patients suffering today have no time to wait for fundamental societal reorganization.

We do not deny that much of the health disadvantage suffered by minority groups is the cumulative product of legal, political, and social institutions that historically discriminated against them. But past discrimination is not necessarily a factor sustaining those problems now. We must address the discrete causes that operate today.

Second, physicians’ actions or their advice to policymakers should be rooted in expertise that is unique to their profession. Opining and advocating on behalf of general social issues exploits their moral authority, turns medicine into a vehicle for politics, and risks the trust of the public. Medical professionals will, of course, have their own views of the public good. They are free to take to the barricades as citizens—but not while wearing their white coats.

Third, doctors must not lose sight of the impact of advocacy on patients and students. While advocating for one’s own patients is a basic obligation of being a doctor, advocating on behalf of societal change can work against those patients, drawing time and attention away from their care. Why are tens of thousands of doctors registering patients to vote?

The faculty must also protect medical students’ education, an imperative complicated by advocacy, which seeks change rather than knowledge. Taking strong political stands at work also risks alienating trainees and colleagues with whom faculty members must collaborate in caring for patients. In 2024, The New York Times wrote about physicians chanting “Intifada, intifada” on the hospital campus; their cries could be heard in patients’ rooms! Trainees who hold different political views may withhold their opinions out of concern for their career prospects.

Overall, physician activism on social issues takes time away from patients, risks abusing the moral authority of the profession, erodes the already declining public trust.

It also alienates politicians, especially on the right.

Our health care system has many problems, including high costs, limited access, and plummeting trust following the COVID-19 pandemic. As America’s poor and marginalized bear these and other burdens most acutely, it is natural that some physicians will want to go beyond the day-to-day care of individual patients.

One meaningful action that young doctors—who are among the most left-leaning, politically active in medicine, and most apt to assume leadership roles—could take is to work in underserved areas. According to a 2020 analysis led by Adam Bonica of Stanford University, young physicians in the prior decade had been moving so “sharply to the left” and flocking so densely to urban areas—“ideological sorting,” the authors called it—that rural areas were suffering from shortages of physicians.

A new report in the Journal of the American Medical Association found that newly licensed clinicians from top-ranked medical institutions were half as likely to initially practice in socioeconomically deprived areas as graduates from other medical institutions. Specialists were also less likely to practice in deprived areas compared with primary-care clinicians.

Our profession appears to confront a growing paradox. Young physicians trained at elite schools are least likely to care for patients in the places they are most needed and could do the most good. At the same time, they are the most apt to promote vague goals of social justice as a professional duty. In so doing, they are helping neither patients nor the profession.

How far will this worrisome experiment in ideological capture go? And when will see compromised patient care? Will it? It is hard to imagine that lowering standards of excellence through racial preferences in medical school admission will not trickle down to patient management. Already the medical profession is under pressure to become a vehicle for social justice; doctors are encouraged to identify as activists first and healers second. This cultural shift in medicine has been well documented, but it needs to be brought more fully into public awareness.