Minimizing Harm: Why We Published An Ad We Found Objectionable

Minimizing Harm: Why We Published An Ad We Found Objectionable
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This week, we published in the August 2022 print edition of Health Affairs an advertisement by an organization called Do No Harm. We did so with mixed feelings after considerable deliberation. Knowing that some readers will disagree with our decision, I am writing to explain our choice.

While I hesitate to expand the audience for the ad (more on that later), this Forefront piece will make little sense if the reader doesn’t know what the ad says. Here it is:

Problems With The Ad

Before I explain why we published the ad, let me offer the reasons we considered not publishing it.

First, in my view, the content of the ad is both argumentative and misleading. Argumentative in that it accuses unnamed people of adhering in unspecified ways to a “radical, divisive, and discriminatory ideology,” language which is designed more to inflame than to elucidate. Misleading in that it calls for resistance to a “destructive trend” without any statement of what that supposed trend is, much less evidence that a trend exists. I believe we would have been justified in rejecting the ad for this reason alone.

Second, the goals of Do No Harm run directly counter to our goals at Health Affairs. I have stated clearly and unambiguously our commitment to being anti-racist and dismantling systems that disadvantage certain populations. So far as I can tell, the goal of Do No Harm is to resist efforts to dismantle structural racism, but it’s actually unclear—their primary activity seems to be to demonize those who seek a more equitable society. Their website consists mostly of stories of what they view as bad actions by bad actors. What they stand for is left largely to the imagination. What is clear is that they reject the deep evidence base, some of which we have published at Health Affairsregarding the existence of, and the harms associated with, racism.

Third, we interpreted the request to run the ad as a “gotcha” move. A bit of research led us to a Twitter thread from Do No Harm about the same ad that begins: “A few weeks ago, we contacted three prominent medical journals to place this ad. It’s a straightforward item asking doctors to contact us if they’ve seen woke excesses harming medicine. You can probably guess what happened next.” It shows that shortly before reaching out to us they attempted to place their ad in a number of medical journals, without success. A later tweet states, “This wasn’t a gotcha game,” by which I assume they mean they were sincere in their desire to run the ad. But, of course, when they were turned away, they decided to promote this fact, which in my book pretty much defines “gotcha.” It was obvious to us that if we declined the ad, we too would be criticized for our decision. Their victimization narrative, which they promote so heavily on their website, would have one more entry. And the story would be theirs to tell.

Finally, the intellectual dishonesty of the organization is appealing. A few months ago, someone brought to my attention that Health Affairs was referenced negatively in an editorial in the wall street journal. The piece, written by the board chair of Do No Harm, Stanley Goldfarb, states that we are “bringing race and other nonacademic factors into the peer-review process, threatening the scientific analysis on which physician practice and patient health depend.”

That’s a pretty serious charge, so I sent an email to Dr. Goldfarb asking for the basis of it. He responded promptly with not a single word—just a link to my own Forefront article.

Dr. Goldfarb also wrote a blog post on his own website, in which he said this about my question to him: “It’s disturbing that Health Affairs‘ leadership has either forgotten what it’s doing or doesn’t want to admit it.” This is poppycock. I have been and will continue to be completely transparent about what we are doing.

What are we doing? Here is what I said in that Forefront article, in reference to collecting race and ethnicity data of our authors and reviewers:

Health Affairs will use collected information to measure and report aggregate statistics on the racial, ethnic, and gender composition of the journals’ authors and reviewers. We may also use individual-level data for specific purposes that include, but are not limited to, selecting peer reviewers for certain papers and ensuring diversity in specific activities, including commissioned writing, events, content planning, and fellowship opportunities.

Individual-level data will not be used as a factor in decision making on submitted manuscripts. Data will be held in strict confidence and will not be shared with any third parties—including peer reviewers (see our Data Use Privacy Policy.) [emphasis in original]

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Dr. Goldfarb left a lot to the imagination when he chose his words to describe what we are doing at Health Affairs. I think a reasonable reader would interpret him as saying that the race of an author is being considered when we judge the merits of a paper. And, given our commitment to anti-racism, I would say he is also implying that we favor papers by authors from historically underrepresented groups in the peer review process.

This is untrue.

But here is what is true. If we receive a paper describing the experience of American Indians in the United States health care system, we may want to be sure at least one of the reviewers of the paper identifies as American Indian. That reviewer will not know the identity of the author, and the author will not know the identity of the reviewer, even though we know.

I am prepared to have a substantive debate with someone who thinks we should not take this approach. There are arguments to be made either way, and I will happily defend my decision. But we can only have that debate if the people on the other side are willing to set aside their use of inflammatory and misleading insinuations and actually talk about what we are doing.

If you explore the website of Do No Harm you will find it filled with insinuations and associations that are designed to tap into base emotions of grievance. Their invocation of the movement to defund the police on the home page of a website purportedly focused on medicine is just one example.

Considering The Objections

I have provided four reasons for rejecting the ad. As I worked through them I found them compelling but not device.

If we reject the ad because it is argumentative and misleading, we will go down the rabbit hole of trying to edit the copy and negotiate over their word choice, something that seems neither productive nor likely to end with a satisfactory resolution to either party.

If we reject the ad because the organization’s views run counter to ours, we are placing ourselves as a health policy journal in a very awkward position. Health Affairs does not lobby and does not take policy positions. Our mission to improve health leads to some fairly obvious conclusions, like that more people having health insurance is a good thing. But our mission also includes serving as a forum for discussion. If a trade association wants to take out an ad, do we only run it if in our judgment they are supporting a policy that will improve health? That doesn’t seem like the right approach.

If we reject the ad because we view it as a gotcha move, well, then they got us.

And if we reject the ad because the organization’s board chair has attacked me personally then we are just being petty.

Putting It All Together

It’s easy to list the pros and cons for publishing the ad, and it is tempting to try to create a scale to balance them, but in the end I have a more visceral response. It is a response based on my personal beliefs.

I believe the work of Do No Harm is harmful. I believe the power this organization has and seeks and the message it carries is a form of racism, and I believe that racism kills. Reading the ad, with its anodyne language, makes me queasy. And I acknowledge that for some, particularly those who have directly experienced the effects of racism, the reaction will be much more intense. I have no desire to create or support this sort of harm.

I also believe that those who seek to eradicate racism must be aware of the case being made by those who see nothing wrong with the inequities that exist in our society and are exerting all of their effort to preserve and justify them. Again, I acknowledge that many who have suffered the consequences of racism will say they have heard enough. They are fully aware of racism denialism and need not be reminded yet again. You, reading this, may feel this to be the case.

But I do not believe this is the case for all of our readers. Myriad organizations have stated that they aspire to be anti-racist, with little pushback thus far. It is easy to surround yourself with people who share your own beliefs. It is important to acquaint yourself not just with the beliefs of others, but with the language they use to gather adherents.

I don’t hold out great hope, but I also believe that a larger circle of people scrutinizing their work may lead Dr. Goldfarb and his followers to open their eyes to the centuries of racism that undergird the practice of medicine in this country and the disparate outcomes we observe.

While I think publishing the ad to be the wiser course, I respect those who would have reached the opposite conclusion. I disagree with Do No Harm and I’m willing to take their advertising money and use it to publish scholarly material that shows just how wrong they are.

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