In late February, the Journal of the American Medical Association published an episode of its JAMA Clinical Reviews podcast titled, “Structural Racism for Doctors—What Is It?” In an accompanying tweet, the journal offered this eye-popping teaser: “No physician is racist, so how can there be structural racism in health care?” The answer, they promised, was in JAMA’s “user-friendly podcast,” a 15-minute conversation between two (white) physicians, host Ed Livingston and guest Mitchell Katz, editors in the JAMA network of journals.

It didn’t go as planned. The podcast and tweet soon came under fire—even from the journal’s parent organization, the American Medical Association. By March 4, the tweet had been deleted, the guest who tried to explain structural racism issued a statement distancing himself from the host’s remarks, and JAMA’s editor-in-chief Howard Bauchner issued an apology. The podcast was later taken down, and on March 16, Bauchner live-streamed a video conversation with three Black colleagues meant to set the record straight. It was too little, too late. On March 25, AMA announced that Bauchner had been placed on administrative leave.

What makes this story worth telling is not the drama of an editorial shakeup at one of the world’s top medical journals. Rather, it’s the content of the podcast itself. Now, don’t get me wrong. If your goal is to understand what structural racism is and how it harms health, look elsewhere. The podcast’s errors are so naive or absurd—No physician is racist? No Black or Hispanic people experience discrimination because that would be illegal?—that it doesn’t merit a rebuttal. And if you know from experience the toll that racism takes, you may have decided early on not to listen. At best, it is a distraction, a theft of energy and time; at worst, a form of gaslighting.

Yet the podcast does serve a purpose—just not the one JAMA intended: it illustrates rather than illuminates the problem of structural racism in medicine. And not just in medicine: The conversation between Livingston and Katz succinctly presents some of the most common ways well-meaning white people (an oxymoron, if we understand whiteness properly) uphold white supremacy when talking about race. Moreover, because the podcast carried the imprimatur of the American Medical Association, it shows how white supremacy remains embedded in powerful institutions—even ones that profess liberal values of equal opportunity and health for all.

The structure of white ignorance

Many white people struggle to understand structural racism. This difficulty is no accident. As a system of domination, white supremacy requires tacit agreement among people who think they are white not to see the world as it is. Philosopher Charles Mills calls this agreement an “epistemology of ignorance,” by which he means the structured ways of not knowing that allow whites to claim innocence. 

This peculiar blindness, Mills writes, is something “people of color, for their own survival, have to learn to become familiar with.” W.E.B. Du Bois wrote about “the deliberately educated ignorance of white schools.” Ralph Ellison implicated white non-seeing in Invisible Man. James Baldwin described the “liberal innocence” of white people as integral to white power and domination. The “crime of which I accuse my country and my countrymen,” Baldwin wrote, is “that they have destroyed and are destroying hundreds of thousands of lives and do not know it and do not want to know it.”

This insight is key to understanding the JAMA podcast. It helps us make sense of why Livingston, the host, spends most of the first minute professing ignorance. “Going into this interview,” he says, “I didn’t understand the concept” of structural racism. Some 20 seconds later, he doubles down: “Given that racism is illegal, how can it be so embedded in society that it’s considered structural? As a child of the sixties,” he reiterates, “I didn’t get it.” During this introductory segment, Livingston also mystifies racism, sneering at the idea that it “somehow” influences people’s possibilities, and introduces the conversation as “structural racism for skeptics.” 

These professions of ignorance, limited understanding, and skepticism are not virtuous. They are made possible by reigning white supremacy. As Mills foretold regarding such claims of ignorance, Livingston’s “nonknowing is not the innocent unawareness of truths to which there is no access.” Instead, it is “a self- and social shielding from racial realities that is underwritten by the official social epistemology.” Or, in this case, by the official journal of the American Medical Association.

To appreciate what is remarkable about Livingston’s self-avowed ignorance, just imagine if the podcast had been about anything else. Could Livingston possibly have begun other episodes by expressing his skepticism about osteoarthritis, admitting that he “didn’t understand the concept” of glaucoma, or confessing that he “didn’t get” the pharmacologic management of tobacco cessation (all recent topics on the podcast)? Of course not. It would have instantly undermined his credibility. Yet bearing only the credential of whiteness, Livingston can safely claim ignorance about racism, casting doubt on its reality, because his (implicitly white) audience will do the same.

The most insidious part is that the podcast distorts, deflects, and ultimately denies the harm of structural racism—even while imploring us to acknowledge it. It tells people who have suffered because of racism that they haven’t. It re-assures white listeners that they are good people if they have good intentions. Livingston is not subtle about this form of denial as self-preservation:

I think using the term racism invokes feelings amongst people—as I just said, my own feelings earlier on, that make it—that are negative, and that people do have this response that we’ve said repeatedly, I’m not a racist. So why are you calling me a racist? And because they respond that way, they’re turned off by the whole structural racism phenomenon. Are there better terms we can use? Is there a better word than racism?

There may be. How about “white supremacy?”

The refusals of white supremacy

Mills emphasizes that white ignorance is neither passive nor accidental but integral to a system of white power and domination. It involves the active refusal to know. Building on this idea, geographer Andrea Gibbons identified five refusals of white supremacy, all of which are evident in the JAMA podcast.

There is the refusal of the other’s humanity and a tolerance for perpetual violence and exploitation. This refusal manifests in Livingston’s callous suggestion that we simply stop talking about racism and in the lack of empathy expressed for the lives cut short by structural racism. One senses no real urgency to correct injustices or ameliorate suffering; protecting white people’s feelings takes precedence. “I feel like I’m being told I’m a racist,” Livingston protests. “You are not a racist,” Katz offers reassuringly. This refusal shows up, too, in the refusal to admit physicians’ racist biases and race-based medical algorithms that deny care to people who deserve it.

There is the refusal to listen to or acknowledge the experience of the other. This refusal is most obvious in the fact that anyone at JAMA thought the way to teach about structural racism was to publish a conversation between two powerful, senior, white men with no relevant training, scholarly expertise, or firsthand experience with racism. It also leads Livingston and Katz, in the podcast, to center their own families’ experiences of anti-Semitism and to provide more vivid detail about gender discrimination in health care settings than they do about racial discrimination. It’s “not just along racial grounds,” Katz insisted. This form of deflection erases the specificity of anti-Black racism as experienced in U.S. medical institutions and in society at large.

There is the refusal to confront the history of racial oppression and the ways it continues to shape the present. This refusal appears in the way Livingston and Katz reduce racism to slavery or anti-Chinese prejudice in the 19th century and suggest that racism ended with “dramatic legislation that was passed in the 1960s.” They also ignore the extensively documented history of racism in medicine and neglect how medical schools continue to reinforce and legitimate racist ideas and practices.

There is the refusal to share space, which takes for granted segregated residential and occupational spaces that foster white ignorance. We see this refusal in the omission of AMA’s role in segregating U.S. medicine—as described in JAMA, no less—and in neglect of current legal challenges to discriminatory practices that segregate medical training. We see it, too, in Katz’s description of segregated neighborhoods without naming the racist policies that created and maintain them, and in Livingston’s acknowledgment that “hard-working people” in poor neighborhoods “have a hard time getting out of their place.”

There is the refusal to face structural causes, particularly the political-economic structures of white supremacy. This refusal takes shape in the way Livingston and Katz subtly but decisively substitute class for race, suggesting, “what you’re talking about isn’t so much racism” but “more of a socioeconomic phenomenon.” It also underlies Livingston’s colorblind racism, which misrepresents racism as hate and falsely equates anti-racism with being taught that you “just never ever even think about a person’s race or ethnicity when you’re evaluating them.” And it leads Katz, depressingly, to envision a twisted future without structural racism as one in which oppressive structures—poverty, mass incarceration, substandard housing—still exist, but the oppressed “wouldn’t be disproportionately minority.” 

These refusals amount to an utter failure to comprehend racism as structural—the supposed point of the podcast. Yet Mills, Gibbons, and others teach us that such failures serve a purpose. The structured ignorance of whiteness produces “the ironic outcome,” Mills concludes, “that whites will in general be unable to understand the world they themselves have made.” And the inability to understand that world allows it to persist.

Seeing the world as it is

One step toward unmaking the world of white domination is to challenge white ignorance. For that, the JAMA podcast provides a clarifying example. Its failure becomes its redeeming value. Seeing the structure of white ignorance laid bare invites all of us who are constructed as white to consider whether we, too, refuse to see the world as it is. 

A potential trap is that we might misdiagnose Livingston and Katz as the problem. After all, it was just a couple of doctors talking, right? On the contrary, locating white supremacy in individuals, rather than in structures, is how the shared commitment to white ignorance preserves one’s sense of self while allowing oppressive structures to persist. The podcast was the product of powerful systems, not just powerful men. That means the systems must change. 

Note: systems, plural. What makes racism structural is the way it is interwoven in a series of linked, mutually reinforcing systems—education, policing, banking, housing, employment, immigration, land use, elections, health care, and more. Denying this reality, as the JAMA podcast does, preserves the status quo. Changing it demands an honest account of how structural racism works.

The good news is that, because of its errors, the JAMA podcast catalyzed change. Black and Brown physicians and scholar-activists in medical institutions called on researchers not to submit their work to JAMA until it delivers more than another podcast, and thousands have signed a petition calling for broader changes. The pressure is working. On March 10, the AMA announced that Livingston had resigned, the journal will hire a new associate editor with expertise in racism, and AMA will solicit external review of editorial practices across the JAMA Network. That review is what led, two weeks later, to the editor-in-chief being placed on leave.

Meanwhile, broader change is afoot. After decades of critique, some U.S. hospitals and medical schools have begun to turn away from race-based algorithms. Medical journals are adopting new standards that encourage authors to think critically about race and take seriously the harms of racism. Physicians and medical educators are developing anti-racist institutional initiatives, seeking reparations and transformative justice. These moves inspire hope; they are also likely to inspire opposition. Listen closely for the refusals of white supremacy.

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Clarence (Lance) Gravlee is Associate Professor in the Department of Anthropology at the University of Florida. His research aims to explain and address the health effects of racism, with a focus on hypertension in the African Diaspora. His work has appeared in in a wide range of scholarly journals, including American Anthropologist, American Journal of Public Health, Annual Review of Anthropology, American Journal of Human Biology, Culture, Medicine & Psychiatry, Field Methods, Medical Anthropology Quarterly, and more. Recent work challenges false assumptions about race, genes, and COVID-19 and outlines how systemic racism drives COVID-19 inequities among racialized groups in the U.S.