Cardiology Journals Look Inward to Undo Structural Racism

Effective immediately, research submitted to Circulation: Cardiovascular Quality and Outcomes should follow “best practices” for study design and data analysis when it comes to intentionally addressing structural racism. The news was announced in an editorial written by that journal’s editors.

The catalyst for their move was a July 2020 article in Health Affairs that, in the midst of the United States’ tumultuous reckoning with racism, advocated for researchers, journals, and peer reviewers to adopt “rigorous standards for publishing on health inequities.”

“This is an important piece, and it led us to self-reflection,” Khadijah Breathett, MD (University of Arizona, Tucson), and colleagues note in their paper, which calls out the long history of racism in the health sciences and healthcare.

Together they developed five key messages that encourage researchers to form diverse and inclusive teams, take a critical eye toward how racism shapes the world when designing their studies, explicitly outline how and why they categorize various racial/ethnic populations, provide context when describing their results, and avoid relying on broad-strokes genetic explanations for disparities.

This is just a starting point, and we certainly don’t have all the answers. Khadijah Breathett

Breathett stressed to TCTMD that beyond their editorial, the journal is changing its instructions for authors submitting manuscripts. “We have the full support of the American Heart Association,” she said, which released its own call to dismantle structural racism late last year. The organization’s 11 other journals are currently reviewing their standards—the Journal of the American Heart Association, for instance, announced they’ve adopted the same instructions for manuscript submission.

“This is just a starting point, and we certainly don’t have all the answers,” said Breathett. “[What] we’re hoping is that these [fuel] the momentum to change and let people know we’re changing things today: ‘We expect this of you and we know that you’ll rise to the challenge and we’re going to work with each other to get there.’”

Key Ingredients

From the outset, research should be informed by a broader understanding, or “conceptual framework,” that digs into the “underlying structures and processes that lead to disparities,” the authors advise. For example, they suggest the National Institute of Minority Health and Health Disparities Research Framework can be used to develop study questions.

When examining health inequities, “don’t blame it consistently on the individual [person] and say they need to change their behavior. No, that’s not working—that’s a Band-Aid,” Breathett elaborated. “We have to consider where the behavior came from in the first place and we have to address the policies, the structures, that are [and have been] supporting one population over another for most of the history of this country and throughout the world.”

In terms of design, studies should enable participants to self-report their race/ethnicity and, when reporting data, specify how populations are divvied up for analysis. If there are limitations to the data set, these too should be specified. Also important, the editorial stresses that “Black, Indigenous, and People of Color should not be categorized as non-White,” advising against blanket categories like other or minority, because these “can perpetuate White race as the standard.”

Breathett acknowledged that she expects there to be some “inertia;” that’s typical for anything new. Even in research specifically on racial/ethnic disparities, the systemic aspect of racism hasn’t often been discussed and these conversations were sometimes even discouraged. “This area was not thought to be significant or relevant, and there are still some that don’t think it exists, some that don’t believe racism is real.” The events of the past year, she added, “have I think clearly shown otherwise to many.”

People are “thirsting for change,” Breathett said, describing their shift as a small but meaningful part of the process. “We hope that this encourages scientists to push beyond the current boundaries that are in place, to change the future of care and outcomes for patients of all races and ethnicities.”

Though much work lies ahead. “I think these instructions help show you how to do that,” Breathett noted.