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      Racial Justice and Academic Pediatrics: A Call for Editorial Action and Our Plan to Move Forward

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          Supported by an undeniable evidence base and highly publicized atrocities documenting the alarming and pervasive impacts of racism on communities of color, policy makers and public health officials are increasingly declaring racism a public health crisis – albeit one that has unfolded over more than 400 years. 1 , 2 These designations are intended to ignite seismic changes across all sectors of government, health care, and education in order to eliminate the permeating effects of racism - internalized, interpersonal, and institutional - throughout society. 3 Racism has historically served as an undercurrent behind many of the social determinants of health such as education, housing, employment, and the built environment that, in turn, drive inequities in health and health care. 4 During the global pandemic, these inequities have been exacerbated and amplified as communities of color are disproportionately decimated by COVID-19. 5 , 6 Brutal and reprehensible killings of African-Americans as well as stigmatization of immigrants under discriminatory immigration policies have further illustrated the scope of racial inequities. 7 , 8 Within epidemiologic and health services research, evidence is emerging to document the deplorable and cumulative effects of racism on children over the life course.9, 10, 11 These experiences produce intergenerational transfer of trauma and compound adverse consequences of social determinants of health. Indeed, racism permeates nearly every aspect of American life, beginning with lives of children. The professional world of pediatrics and the world of academic medicine are not immune to internalized, interpersonal, and institutional racism as they mirror broader society. 12 While the 1910 Flexner Report is sometimes credited with establishing the biomedical model as the gold standard for medical training, it substantially eroded diversity in medicine as it recommended the closure of five out of seven predominantly black medical schools. 13 , 14 One legacy of the Flexner Report is that people of color are still vastly underrepresented among medical students, physicians, and medical school faculty. Progress in workforce diversity and inclusion has been marginal at best, demonstrating that promotion of diversity as a key strategy to mitigate against racism is, by itself, insufficient. 15 In 2019, only 3.6% of full-time faculty were Black or African-American, 5.6% were Hispanic, and 0.3% were Native American, Alaskan, Hawaiian, or Pacific Islander. 16 Most medical schools and pediatric residencies have far fewer underrepresented in medicine (UIM) trainees than they should. The number of African-American males in medical school is currently lower than it was in 1978. 17 Further, UIMs continue to bear the disproportionate burden of achieving diversity and inclusion while simultaneously combatting racism and microaggressions on a regular basis. 18 As many sectors and industries increasingly deem racism a public health crisis, scientific journals must also reflect on their mission, structure, and content in order to reshape the discourse on racism and hold themselves accountable as leaders in the scientific community. 19 Historically, scientific journals have functioned to further the progress of science by publishing and disseminating new research, allowing investigators to keep up to date with developments in their fields and direct new scientific inquiry. The mission of Academic Pediatrics is to strengthen the research and educational base of academic general pediatrics through scholarship in pediatric education, health services, patient care and advocacy. Our journal's content areas include pediatric education, child health services, holistic medicine, health policy, and the social, family, community, and physical environment- among many others. In light of our longstanding commitment to vulnerable children and families, diversity, and our desire to be effective stewards of scientific inquiry, we have re-examined our journal structure, policies, and procedures as they relate to accelerating diversity, inclusion, and equity. In determining a new standard for publishing, we have reviewed our journal's internal structure and the content of articles we publish. While our commitment to diversity and inclusion is strong, the composition of our Editorial Board and Editors has not aligned with our strategic values. Of the 24 members of our Editorial Board, only 2 are UIM. Of our 15 Editors, only 2 are UIM. While these findings are partly attributable to low turnover, they fundamentally bring into question how members are recruited and selected for such positions. In addition, in examining the content of our publications, we find that although Academic Pediatrics serves as a welcoming journal for articles on diversity, inclusion, and equity, our journal has not systematically invested in initiatives to advance the science in these critical fields. With the responsibility to be a leader in the scientific community, Academic Pediatrics has developed a set of comprehensive strategies to improve our internal policies, procedures, and composition and establish a more intentional approach for our publications. Academic Pediatrics will take a number of steps to address the diversity of our Editorial Board and Editors. First, we will utilize forthcoming turnover in our Editorial Board to increase the Board's diversity. We will be substantially more proactive in recruiting from a very highly qualified and talented pool of UIM that clearly already exists. Recognizing the need to develop and nurture future Editors from diverse backgrounds, the journal will also establish a mentoring program to foster the development of junior UIM faculty interested in journal leadership. The journal will partner with the Academic Pediatric Association to develop a competitive application process for those interested. The intended benefit of this program for participants is that it will position UIM junior faculty for future roles as Editors, both with Academic Pediatrics and other journals, and provide them with networking and mentoring opportunities with senior leaders in the field of academic pediatrics. For Academic Pediatrics, this program will bring diversity to our leadership and impactful perspectives to our strategic vision and operation as a journal. Our ultimate goal is that our leadership reflects the diversity of the children our readership serves. To address journal content, Academic Pediatrics will implement both short-term and long-term strategies. In the next year, the journal will utilize at least six article types – Commentaries, Perspectives, Policy Commentaries, Narrative Reviews, In the Moment, and traditional research articles – to provide a broad lens on how the social construct of race and racism affect children, families, the health care workforce who serve them, and academic medicine. Long-term, the journal will implement a bolder approach to advance the science on racism, unconscious bias, and diversity. We will continue to publish descriptive studies because it is essential to continue to monitor and highlight disparities, but we will prioritize evidence-based interventions and educational programs to address diversity and inclusion, equity, and racism. Although necessary to elucidate inequities, descriptive and exploratory studies alone are insufficient to dismantle ingrained structural forces that perpetuate societal inequities which ultimately impact health. These studies may foster incrementalism, but paradigm shifting, multi-disciplinary, multi-sector science is needed. Academic Pediatrics will push the boundaries towards solutions-oriented scholarship. This will include a Call for Papers on these topics encouraging prospective authors to submit manuscripts of all journal article types. We will also explore publishing a Supplement on Racism or part of an issue on Racism that will include our standard articles plus methodology pieces examining how to apply varying definitions of race/ethnicity, disparities, and equity to studies of racism and its effect on children and the lifespan. We will endeavor to amplify the impact of such articles by disseminating them through our social media channels. The Editorial Board and Editors will also partake in continuing education on the most advanced theoretical frameworks, methodologies, and statistical approaches informing high quality research and scholarship on race and racism. We will consider modifications to editorial, publication, and reviewer guidelines to advance the rigor and impact of studies addressing these topics. As our society grapples with the implications of what it means to declare racism a public health crisis, scientific journals have the opportunity to join a growing number of industries taking leadership in translating an aspirational agenda into meaningful action. For scientific journals, it starts with recognizing there is a corresponding scientific gap that merits attention and investment to foster more impactful studies on racism. At its core, Academic Pediatrics is committed to improving the health and well-being of children and developing the futures of academic pediatricians and leaders through rigorous and innovative research. With these foundational principles, Academic Pediatrics will elevate our accountability as a journal to bolster our intellectual investment in the science and scholars with the potential to bring forth a more just and equitable society for all children and families. While we have no illusion that we hold all the right answers, our reflection is empowering us to start asking the right questions.

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          Most cited references 13

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          The state of diversity in the health professions a century after Flexner.

          Although the 1910 Flexner Report recommended the closure of a large number of operating medical schools, its impact was disproportionately felt on minority schools. The report's recommendations resulted in the closure of five out of seven predominantly black medical schools. Also noteworthy about the report was Flexner's utilitarian argument that black physicians should serve as sanitarians and hygienists for black communities in villages and plantations. A century later, despite decades of targeted programs and advocacy, minorities are still vastly underrepresented among medical students, physicians, and medical school faculty of all ranks. Today's arguments about the need for diversity in medicine in many ways echo Flexner's words. They continue to focus on benefits to minority populations, service in underserved areas, and minorities' role in the primary care workforce. These are valid, in fact laudable aspirations, but when made in isolation, they circumscribe the value of minority medical professionals. Minorities in the medical sciences provide immeasurable services to the entire nation, enhancing educational outcomes, expanding and improving the quality of health care provided, and contributing to the breadth and depth of medical research. This article presents how the Flexner Report shaped medical education and created a culture of medical research leading to narrow performance standards that fail to properly reward teaching activities, patient care, and health promotion. Efforts to achieve diversity in medical education should not end at graduation but should be extended to provide minorities opportunities to excel and to lead.
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            Minority Faculty Development Programs and Underrepresented Minority Faculty Representation at US Medical Schools

            Diversity initiatives have increased at US medical schools to address underrepresentation of minority faculty.
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              Racism, the public health crisis we can no longer ignore

              Extraordinary times call for extraordinary measures. We are facing a global pandemic, a climate catastrophe, an imminent recession, and possibly depression. The health of the most vulnerable and all of humanity is at stake. Yet there is nothing new, extraordinary, or unprecedented about racism, xenophobia, and discrimination. The killing of Mr George Floyd, on the back of numerous other deaths of Black Americans at the hands of the police, 1 and the two–four times increased mortality risk from COVID-19 for minority ethnic groups 2 have brought to light social and structural injustices that have existed for centuries and are derived from the same intersecting systems of oppression. When a single act of violence is captured and amplified on social media, much like the televised US civil rights protests of the 1960s, it brings police brutality into the consciousness of people across the world. It elicits a visceral response, and humanity joins together in condemning racism. However, police homicides are a daily occurrence in parts of the world, 3 and the people who die are usually poor, young men from othered groups. When it comes to violence, race and gender intersect. This means that Black and minoritised women are at higher risk of sexual and intimate partner violence, 4 and Black trans women are over-represented in hate crime murders. 5 Society is built on racial hierarchies, established through colonisation, that pervade structures, histories, politics, and, ultimately, minds. Overt acts of violence are surface-level symptoms of structural and cultural forms of racism that extend far deeper. Under this lies a pyramid of abuse, marginalisation, and injustice that exists in every society. The forms of discrimination and the targets might vary: in some societies they are based on race or ethnicity; in others, colour, caste, religious beliefs, Indigeneity or someone's migratory status. However, the underlying oppression that caused these injustices to occur are largely similar. Racism and xenophobia are about division and control, and ultimately power. Together they constitute a structural form of violence that results, at the extreme, in innocent people being murdered. The COVID-19 outbreak has uncovered a crisis in our social and political fabric extending beyond the outbreak itself: an uncomfortable propensity towards racism, xenophobia, and intolerance exacerbated by transnational health challenges and national politics. Internationally, we have witnessed the vilification of particular nationalities, with overt forms of sinophobia. 6 Politically, xenophobia has been weaponised to enforce border controls against particular nationalities and undermine migrant rights. 7 In the UK, minoritised ethnic groups are more likely to contract a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and, subsequently, face a higher risk of a severe form of illness. Why is this? People from minoritised ethnic groups are more likely to work as key workers in frontline jobs that expose them to SARS-CoV-2, and are more likely to live in overcrowded accommodation, meaning social distancing is not an option. 8 They are then more likely to have barriers to accessing health services, meaning that they present late in a worse condition, and with a higher probability of underlying illnesses that put them at greater risk of death. In some cases, the existence of these comorbidities lowers the chances for intubation and ventilation, resulting in a double burden of being more prone to be severely unwell and less likely to receive intensive care. 9 Beyond these proximal causes of ill health lie racism and structural forms of discrimination. Marginalised groups are disadvantaged in all the social determinants of health. However, racism is more than this, it is a fundamental cause of ill health. 10 At all socioeconomic levels, people of colour have poorer health outcomes. 11 Racism cumulates over the lifecourse, leading to activation of stress responses and hormonal adaptations, increasing the risk of non-communicable diseases and biological ageing. 12 This trauma is also transmitted intergenerationally and affects the offspring of those initially affected through complex biopsychosocial pathways. 13 The root of these so-called biological causes is racism, not race itself. Society is unwell. The symptoms—racialised violence, and excess morbidity and mortality in minority ethnic populations—reflect the cause: an unjust and unequal society. Scientists and doctors, by remaining technocratic and apolitical, are complicit in perpetuating discrimination. As a health community, we must do more than simply describing inequities in silos, we must act to dismantle systems that perpetuate the multiple intersecting and compounding systems of oppression that give rise to such inequities and injustices. To this end, we are producing a series of academic papers to centre the complex challenges of racism and xenophobia in the health discourse. We are working with a diverse team of academics and activists globally to highlight injustices, identify solutions, and enact change. Alongside this, we are launching the Race & Health movement, a multi-disciplinary community of practice that will continue beyond the social media. Our vision is to provide a catalyst in tackling the adverse health effects of racism, xenophobia, and discrimination. Academic outputs on their own are irrelevant. We must use the evidence to advocate for change and improvements in health. In this spirit, we are launching a global consultation, asking: what should we do, and how should we do it? Racism kills, and this is a public health crisis we can no longer ignore. As a health community, where were we? As the hashtags disappear and we start to emerge from the pandemic, even in ordinary times, we need extraordinary measures.

                Author and article information

                Acad Pediatr
                Acad Pediatr
                Academic Pediatrics
                Published by Elsevier Inc. on behalf of Academic Pediatric Association
                11 August 2020
                11 August 2020
                [1 ]Center for Child Health Policy and Advocacy, Baylor College of Medicine, Houston, TX
                [2 ]Section of Academic General Pediatrics, Baylor College of Medicine, Houston, TX
                [3 ]SRB Consulting, Newton, MA
                [4 ]Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
                [5 ]Division of General Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
                [6 ]Department of Pediatric and Adolescent Medicine and Department of Health Sciences Research, Mayo Clinic, Rochester, MN
                [7 ]Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
                [8 ]Division of General and Community Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH
                [9 ]Division of Pediatric Hospital Medicine, Department of Pediatrics, University of California Davis, Sacramento, CA
                [10 ]Department of Society, Human Development and Health, Harvard School of Public Health, Boston, MA
                [11 ]Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
                [12 ]Departments of Pediatrics and Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
                [13 ]Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine of USC, Los Angeles, CA
                [14 ]Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, MA
                [15 ]Department of Pediatrics, University of Utah, Salt Lake City, UT
                [16 ]Department of Pediatrics, UCLA Mattel Children's Hospital, University of California at Los Angeles, Los Angeles, CA
                Author notes
                [* ]Address correspondence to: Jean L. Raphael, MD, MPH, Suite 1540.00, Texas Children's Hospital, 6701 Fannin Street, Houston, TX 77030, 832-822-1791 raphael@ 123456bcm.edu
                © 2020 Published by Elsevier Inc. on behalf of Academic Pediatric Association.

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