For the first time in more than 110 years of publishing, Canada’s leading medical journal has partnered with Black researchers to produce two special issues on health care in Black populations – a project that has the publication taking a hard look at its role in perpetuating anti-Black racism in Canadian health care.
The Canadian Medical Association Journal (CMAJ) released the special issues in October. The journals spotlight Black authors on topics ranging from anti-Black racism in Canadian medical schools to revising prostate cancer screening processes for Black men, who are disproportionately affected by the disease. While putting together the issues, editorial staff at CMAJ had the chance to reflect on its own biases, said editor-in-chief Kirsten Patrick.
“It’s taken these special issues and the process that led to them for us to have better insights into how our structures have been racist and how they have excluded people who have been historically oppressed from publishing in the journal,” said Dr. Patrick.
That process began almost two years ago following advocacy work by the Black Health Education Collaborative (BHEC), a community of scholars and practitioners seeking to improve Black health through education and research. The collaborative’s co-leads, Onye Nnorom and OmiSoore Dryden, pitched the idea of a series of articles on Black health and anti-Black racism in Canadian health care after being invited by the journal to write on the topic following the death of George Floyd in the summer of 2020.
“It took months of meetings but eventually they came around,” said Dr. Nnorom, who is a family physician as well as the Black theme lead for the faculty of medicine and equity, diversity and inclusion lead within the department of family and community medicine at the University of Toronto. “They had a couple of ‘aha’ moments of understanding what had led to a significant underrepresentation of Black research authors and topics of health equity in the journal’s history.”
Those meetings also resulted in the formation of a special editorial committee of Black health, anti-Black racism and health equity experts who would help shape the two special issues, which were slated for publication in the spring of 2022. When the submissions began pouring in, CMAJ decided to double its output from one issue to two. “I realized very quickly that this is a problem that people have been experiencing for years – we just haven’t been talking about it [at CMAJ],” said Dr. Patrick.
Underrepresentation of racialized authors
CMAJ has not historically collected race-based data on its submission authors, making the breadth of underrepresentation of Black and other racialized researchers nearly impossible to quantify in absolute terms. However, the journal recently started inviting authors to self-identify their race on manuscripts, which Dr. Patrick said will allow CMAJ to measure its efforts to improve diversity beginning early next year.
That decision was influenced by the pandemic, said Dr. Patrick. As public health agencies worked to flatten the curve of infection, experts successfully convinced many of these units to start collecting race-based data. That data confirmed what those experts had already suspected: COVID-19 infection rates and the risk for more severe outcomes were both higher in racialized communities. This has helped shift perceptions in the Canadian medical community that collecting race-based data helps to better serve racialized communities.
Dr. Patrick also noted that in the early days of consultation with the BHEC, the Black leaders at the table pointed to an overall lack of diversity within the journal’s staff (its editors, associate editors, publishers, reviewers and others) as a problem. “We noticed that there was not a lot of representation at the decision-making table,” said Dr. Nnorom.
Although the CMAJ does not have data on the racial make-up of its staff, Dr. Patrick admits that it does not – and has not – had a very diverse workforce. “They pointed this out to us and said, ‘Here is your lack of diversity,’” she said. They also told her that Black colleagues had not felt welcomed in the pages of CMAJ – “and you need to look at that,” she recalled them saying.
In its original call for papers for the two special issues, CMAJ acknowledged its need to “increase spaces that welcome research” led by Black scholars and that it had been part of “systemic racism that has undermined the publication of that work.” Dr. Patrick said that she was not surprised by the high level of submissions after the journal made that acknowledgement. “We are giving folks an outlet to talk about anti-Black racism in the health-care system and in medicine in Canada – obviously, we’re going to get stuff that hasn’t had an outlet before.” Moving forward, CMAJ has committed to reporting annually on its progress covering Black health topics and on the race of its authors, when that information becomes available.
It is also working to increase diversity among its staff. The journal hired its first Black associate editor, among other racialized hires, and has tapped the Toronto-based consultancy firm Inclusive Leaders to help map its path forward with equitable hiring processes. The firm’s work is “rooted in anti-oppression,” which Dr. Patrick said is a necessary lens through which to look at CMAJ. “They look at things not just through an anti-Black racism lens, but through the lens of Islamophobia, anti-Indigenous oppression et cetera,” she said. “It was really important that we did special issues on anti-Black racism, but the CMAJ is perpetuating a lot of oppression and we need a broad focus on our equity work.”
“Representation is important, but it is not enough”
While Black and other racialized hires and improved equity processes are positive steps forward, Dr. Nnorom said that CMAJ needs to go further by hiring experts in anti-Black racism. “Representation is important, but it’s not enough,” said Dr. Nnorom. “You need people who have expertise in understanding racism itself, and how it manifests in society.”
Dr. Patrick agrees. For a start, she said CMAJ is assembling a permanent advisory panel of Black physicians and scholars. She has also committed to recruiting staff with substantial experience in anti-racism and equity work. “When we are hiring people, and when I’m making connections with people, I am doing so in a very deliberate way,” she said. “We can’t just have token people, because that has been a criticism of universities: we’re putting token people in without giving them resources or power and saying you’re our diversity token – and I am very conscious about not doing that.”