In the wake of the murder of George Floyd and the COVID-19 pandemic, there has been a new public interest in health inequities research. With this new focus, there are also many researchers and institutions clamoring to receive lucrative funding and recognition in the field, but there are no official guidelines to distinguish a health equity expert.
In this episode, we sit down with Dr. Elle Lett who coined the term “health equity tourism” to describe when privileged and previously unengaged scholars enter the health equity field without developing the necessary expertise.
About Innate: How Science Invented the Myth of Race
“Interview with Dr. Elle Lett” is a bonus episode of Innate: How Science Invented the Myth of Race, a podcast and magazine project that explores the historical roots and persistent legacies of racism in American science and medicine. Published through Distillations, the Science History Institute’s highly acclaimed digital content platform, the project examines the scientific origins of support for racist theories, practices, and policies. Innate is made possible in part by the National Endowment for the Humanities: Democracy demands wisdom.
Hosts: Alexis Pedrick
Senior Producer: Mariel Carr
Producer: Rigoberto Hernandez
Associate Producers: Padmini Raghunath & Sarah Kaplan
Audio Engineer: Jonathan Pfeffer
“Innate Theme” composed by Jonathan Pfeffer. Additional music by Blue Dot Sessions
Health Equity Tourism: Ravaging the Justice Landscape, by Elle Lett, Dalí Adekunle, Patrick McMurray, Emmanuella Ngozi Asabor, Whitney Irie, Melissa A. Simon, Rachel Hardeman and Monica R. McLemore
Alexis Pedrick: Hey, listeners. It’s me, your host, Alexis Pedrick. This past spring, we published a 10-episode season called Innate: How Science Invented the Myth of Race. It explored everything from the origins of the myth of race to how a group of medical students have been trying to dismantle the practice of building race correction into medical instruments.
Now, obviously, we couldn’t fit all of our research into just 10 episodes, so today we’re sharing an interview we did with Elle Lett, a transdisciplinary scholar who studies and tries to mitigate the harm caused by systemic oppression. They coined the term health equity tourism to describe a phenomenon in which white scholars who don’t have any prior experience or a dedication to working in health equity research parachute into the field and siphon off funding and resources.
In this episode, they talk about the term and the harm that’s caused by it. This interview was done in the spring of 2022 by our producer, Rigoberto Hernandez.
Elle Lett: I’m Dr. Elle Lett. I am a Black trans woman, and I’m a statistician epidemiologist, and my PhD is in epidemiology. I am also a medical student at the University of Pennsylvania, and in general I consider myself a transdisciplinary scholar who studies and tries to mitigate the harms caused by systemic oppression.
Rigoberto Hernandez: We’ll just get started with the paper that you wrote recently. In it, you define the term health equity tourism. Could you tell us how you came about coining this term, and what does it mean?
Elle Lett: Yeah. So uh, that paper was published in the Journal of Medical Systems with the support of Dr. Jesse Ehrenfeld, the editor in chief there, and I want to briefly mention my co-authors, Dalí Adekunle, Emmanuella Asabor, Whitney Irie, Melissa Simon, Pat McMurray, Rachel Hardeman & Monica McLemore, and I believe that’s everyone.
And we wanted to talk about this phenomenon that we were seeing rapidly increase ever since the rest of society had to reckon with what Black people specifically and other people of color have always known – that we live in a fundamentally inequitable society that is subject to racism on all of its levels. People who have never had a commitment to, or practice surrounding, health equity have pivoted into trying to do a sort of diluted version of health equity research, because it has become, uh, lucrative in light of sort of the rest of society in the US, the NIH and funding agencies and journals saying, “Hey. We are in a racist society. We have to do something about it. We need to at least study it.” And now there are calls for, uh, funding agencies on, “Write a proposal about systemic racism.” Or JAMA will say, “We’re doing a special [inaudible 00:03:14] on race and racism.”
And so health equity tourism was the idea of these people without expertise or history of being committed to and studying the rigorous scientific discipline of health equity research trying to sort of parachute in to do work that they aren’t really qualified for.
Rigoberto Hernandez: So this is obviously a problem that goes beyond just some rogue scientists and rogue people. Could you tell us what conditions allow this to happen?
Elle Lett: So I hesitate to say the name of George Floyd, and I’ve even seen it written as the George Floyd effect. I don’t like that, because that man didn’t consent to being sort of this, like, time point after which everyone recognizes racism. It sort of became that his murder was that. And so with this George Floyd effect, which, again, a term I don’t l- like, I’d rather say something along the lines of eyes open for the rest of society.
But the whole country kinda just shook. And, well, talking about the US context. The whole country just shook. And a lot of people in power tried to do what little they could do from their places to seem responsive. And so what that looked like was allocating budgets or trying to do, uh, special editions about systemic racism. So the re- [inaudible 00:04:35] that came together was the whole world was shaking, um, in response to this sort of uprising, which catalyzed people who run the research infrastructure to incentivize publishing on this narrow aspect of oppression, which is racism.
And then the reason why tourism is so easy is because the people who are resourced enough to respond to the sort of reactionary call and rush of resources are the people who are already positioned at the top of these hierarchies. So these are the people at predominantly white institutions who already have huge budgets, who can then [inaudible 00:05:13] their exa- staff and their resources to applying to new, uh, this new pool of resources.
What I mean by that is that there are studies that demonstrate that Black and Latine p- people have more difficulty finding research mentors, and they are less likely to, um, get funding, and they’re less likely to get tenure. They’re less likely to be sort of at the top of the pyramid here. And so when you have this reactionary response to racism that creates a limited but sort of immediate pool of resources, the people who are already resource-rich are able to, uh, take advantage of it. ’cause you know-
Rigoberto Hernandez: [inaudible 00:05:46]-
Elle Lett: … [inaudible 00:05:46] have to spend money to make money, so to speak.
Rigoberto Hernandez: Just to kinda take a step back to people who might not understand how academia works, getting published in high-profile journals is kinda the coin, the currency, of academia in science, specifically.
Elle Lett: So academia is this, like, sort of microcosm of capitalism, except instead of money, our p- our coin is publications and grants. And so you do research, and you publish it in these journals y-… And particularly in high-impact journals. And then you use that to make a case for writing grants, where you get millions of dollars to continue to do more research, to continue to publish, to continue to get grants. And it’s this sort of, like, cyclical thing that sort of runs on its own. Kinda made-up currency, because there’s no guarantee that those publications actually lead to anything, as far as changing health for people.
But it is a huge budget, and it is one of the dominant aspects of es-… Especially health-related sciences. Like, the NIH and their funding pretty much runs the game. Shouldn’t sh- it shouldn’t, but it does.
And so what I’m talking about is when people who come in from different fields are sort of rebranding their work, or trying to take their skills in, like, health economics, or their skills in, like, surgery, or their skills in all these other fields and saying, “Okay. Let’s just do a health equity project with these skills.” And they don’t recognize that health equity, e- specifically in the academic world, ha-… It’s actually a specific science that requires of… Appreciation and implementation of its own theories, and even its way of doing things.
You’ll see a lot of my work… I have large teams. I purposely listed all of those people at the beginning to set up what I’m about to say now, and on that list you have nurses. You have social workers. You have people whose PhDs are in epidemiology. You have peesh- peoples whose PhDs are in other social sciences. You have people who have backgrounds in history of science in there, and anthropology. And there’s a reason why I use such interdisciplinary teams, is so that… Inter meaning different disciplines, is so that our work can be transdisciplinary, which means fusing those disciplines.
Because if you think about society, it’s inequitable in every level, and so you really have to address it from many perspectives, and health equity research isn’t stuff [inaudible 00:08:01] that I think can be done quickly or reactionary. And I talk about this in the paper. Has to be done at the slow and steady perspective, with the, um, sense of sustainability. And so that’s why something like that, with a team that, like, the ones that I build, would have never gotten through the cracks. Not to say all my work is perfect, but it’s because I make sure I have enough perspectives and enough history, um, of people who engage in health equity work so that we really can capture some of those nuances in a way that tourists would miss.
Rigoberto Hernandez: You point out the fact that there is a sense of urgency in kinda the work that health equity’s doing, and it’s kinda, like, rushing the work, which leads to more sloppy work. Could you talk about this sense of urgency, and how th- fundamentally, like, goes against that kind of work that’s already been done?
Elle Lett: Yeah. I think honestly, the sense of urgency almost angers me, if I’m honest. Because let’s the pandemic, an example. Yes, it’s a urgent situation, and [inaudible 00:09:02], um, dif- differential mortality burden for Black and Latino people in America is extraordinary, and it’s painful to see. But it’s also wholly predictable, because COVID was just an acute shock to an already fundamentally inequitable system. Old Black people in my family who aren’t scientists, who aren’t scholars of any type, can tell me that that’s how it was going to be, because it is not new. It is just something that was always here, and whenever there’s something that quickly burns up our resources or leads to a rush of negative health outcomes, it’s differentially manifesting as to people who are marginalized the most.
And so that’s what I mean by these things have been here. And they’re, and Black people and Latino people and disabled people and trans people have been working at these things their entire lives, because it’s more than just science to them. It’s their livelihoods.
And so for you to just wake up and say, “Oh, hey, I see this problem. Oh my goodness, I’ve never… I d- I’m realizing that there’s this urgent Black maternal mortality burden, or that there’s this huge disparity in [inaudible 00:10:12] for Black people.” We’ve already known that. We’ve already been here. So for you to come in and not do your due diligence and learn our methodologies, our Black feminist methodologies, and learn our approach to things, and think that you will bring s- your skills and immediately be able to provide value is arrogant, and it’s also demonstrably false.
And tha- and one thing I’ll say is, that is not to say that people who don’t share those identities can’t do work. Equity is everyone’s job. But it does mean that if you don’t share that identity, then you have to learn somewhere, and that learning comes from humility, dedication and investment in community.
Rigoberto Hernandez: So I think that’s a key point that we need to address, is like… S- it’s not a surprise, or, that the tourists tend to be white people, and the people who have done equity work are predominantly people of color who are part of those communities. Could we talk about how background informs research that communities of color’s already been doing, and how their background of the white equity tourist informs the kind of wher- how they’re approaching their work?
Elle Lett: Yeah. I’m gonna center it on me, and so I can talk about it from that perspective, and then maybe we’ll step back and talk about communities. But I’m a Black trans person, and I study issues that affect Black trans people. And I do that recognizing that liberation for Black trans people is connected to liberation for disabled people and other disenfranchised groups. But I know that my core lens comes from that, and I have enriched that with the scholarship of my scholarly ancestors, so I read Black feminism. I read Patricia Hill Collins. I read, um, Chicana feminism. I read these early intersectionality scholars to help frame how I do my work.
And so I take my identity… Because identity isn’t sufficient, right? But I take the inheritance of m- as it comes with my identity, the work that people who have come before me, and I use that to enrich my scholarly pursuits. And so I think that what comes with my Blackness is that marrying those two together, and with the perspective of actually navigating this world as a Black trans woman, I see science differently. I see my intersectional position, and I see how things manifest.
I mean, there’s a reason why there’s a literature that speaks to how people from different backgrounds can produce more unique scholarship, and that’s because who you are informs your work. And if you’re a white person, you’ve always benefited from white supremacy, and if you’re trying to address inequities built on white supremacy, your lens defaults to biasing you away from that. Your lens defaults to you not being able to see the solutions, because you benefit from the problem.
And so it doesn’t make it impossible for you to do health equity work and a anti-racist praxis, but it does make it harder, and it does mean your investment into building a community with Black people and learning from our methodology, learning from our theoretical frameworks, has to be even deeper than a Black person’s would be, because you don’t get the experiential, um, sort of immediate buy-in that we get. If anything, it’s the reverse.
And there’s other people who talk about it it. There’s a paper called the Coin Model of Privilege that I think is a really good introduction to how we all lay at, uh, sit at different intersections of privilege and of unearned advantage and unearned disadvantage, so to speak.
Rigoberto Hernandez: So in your paper, you say that health equity touris- is that it runs a r- risk of polluting and diluting, which are very pointed works.
Elle Lett: I use the metaphor of a landscape in that paper very purposefully, ’cause I’m, I’m a visual thinker, and I think of it as, like… We’re building this landscape where we get to dream a reality where health is equitably distributed. And what tourists do is they bring in things that don’t necessarily fit the landscape. They’ll just dump something that they came up with, or they won’t do the hard work of learning how to build in this landscape, and so they’ll build something that only kinda fits. And so the pollution is when they just dump something. They don’t have a health equity sort of praxis, and they don’t have an approach to it. They’re just generalizing their own skills.
And so some of the examples from COVID would be the couple of studies that came out of high-impact journals that tried to, with very poor rationale that has been debunked time and time again, show that the difference of mortality for COVID might be due to m- a genetic difference between Black and white people that was just like really poorly done study that found one genetic variant that is potentially higher in some Black people, and then they, like, extrapolated to saying this huge mortality difference might be related to this very insignificant gene, which just makes absolutely no sense. And then also ones about how, like, hygiene in Black people might be less hygienic. All these things that are just demonstrably false and lead to biological essentialism, where you think race is genetic when it’s not, or cultural inferiority, when you’re saying there’s something intrinsic to Black people. Now, that’s polluting.
Diluting is like when you haven’t been around long enough to really stake your claim on it, so you use euphemism. You don’t say racism. You say race. You don’t recognize that economic disparities are the product of, like, class oppression. And so you say these sort of diluted, imprecise, perhaps not really useful studies that don’t really make an actionable claim, but sort of demonstrate disparities and disparities over and over again.
And disparities and inequities are different things. Disparities are just, like, numerical differences. 10% here, 20% there. But inequities are differences that are due to a lack of justice, and so that distinction alone tells you what, like, dilution is.
Rigoberto Hernandez: And [inaudible 00:16:07] t- g- going back to that thing you said about the fact that they’re linking genetics with a higher mortality for t- COVID-19. That’s kind of taking science back a few decades, because that’s kind of like saying there’s a biological difference and there’s nothing we can do about it that puts it on the individual. “Hey, it’s your fault. It’s not society’s fault.” And when you localize the problem, that kind of absolves society from thinking about it.
Elle Lett: You are right on the money. It’s all about where the locus of intervention, right? And I think… Actually, I’m not convinced that all the people who use these biological and s- essentialist arguments believe them. I think they’re just more comfortable. Because when you take a biological essentialist argument, the locus is, like, in Blackness, and so “It’s their fault for being Black. There’s nothing we an do about it. It’s just a fact of who they are.”
But then if you really take… It… Really, any [laughs] of the theoretical frameworks that I list in that paper… You can go critical race theory, you can go intersectionality. You can go… a lot of those things are under attack right now. But anything that acknowledges social structural components, and that locus leaves the individual and it becomes society.
And when you, as a white scholar, identify society as the issue, and then you see that the issue is impacting Black people differentially, then the question is, “How am I impacted by that?” And then you have to face unearned privilege and recognize that your, uh, privilege results in their oppression.
And so that’s where people, I think, get frustrated. I think that’s why people are more wedded to a biological essentialist argument, because it absolves them from the responsibility to critically evaluate their own positionality and recognize that their, um, advancement is at the expense of people of color.
White supremacy is a system that systemically improves the life, uh, the outcomes of white people at the expense of people of color. Specifically, Black people, Indigenous people, Latine people and other people who are racialized as not being white.
Rigoberto Hernandez: You talk about being in a moment. This moment of, like, interest in health equity tourism by, like, NIH and, uh, and, like, just generally in society, there’s a moment to, like, want to study this. And you say there’s a hope that it will become a movement. We’re not there yet, but what happens if this does… If this moment doesn’t become a movement?
Elle Lett: So this is a conversation that I am having with a lot of the co-authors from that study, and other health equity scholars, my mentors, my mentees… And the short answer is that we will persist. Like, that won’t change what we do. But for me… And I’m just gonna speak for me. I would rather people who are tourists instead of community members in this health equity landscape, to just stay out of it. If that’s who you are, I’d rather you recognize it and then just, just, just not try to take up arms right now.
Because if this moment sh- is just a moment, if it’s just a blip of, like, a momentary increase in resources, I’d rather those of us committed to this as our primary sort of discipline, and our commitment as far as scholars, to be able to capitalize on it and, and build it into our work as we move forward, and so that we can advance our missions as much as we can in this moment. And then before we go back to a resource-sparse, uh, scenario, which is really just the norm, and have to sort of trudge along slowly.
Because if, uh, if not, the alternative is that all these tourists will pollute and dilute our landscape and then leave, because this isn’t their home. Continue with this metaphor. This is just where they’re visiting. And we’ll be here. Because of how things are set up for especially junior scholars, or scholars at, like, HBCUs or predominantly Latino-serving institutions, they aren’t set up to out-compete these tourists from other institutions right now, and so they’re not going to be able to… In a tourist-rich scenario, they’re going to lose out on things from this moment. And so then when everyone else goes home, we weren’t advanced. If any way- they, way, we were further marginalized, and then we have to play clean-up.
And so it could, potentially, set us further back. And what I mean set us further back is that right now, we’re see- we could either see a proliferation of race-based science as opposed to sc- science that studies, that en- tries to mitigate racism, we could see a proliferation of these cultural inferiority and biological essentialist works. Or we could see a proliferation of just the same old demonstration of disparities over and over again that we already know about.
And what I mean by that is that these grants? Like, one of the major s- NIH grants is, like, the R01. That’s, like, little under a million dollars over five years. That’s over five million dollars. That’s a lot of money, and if your work isn’t really going to do anything, if it’s not really going to advance any sort of health equity mission, that’s five million dollars that could’ve gone elsewhere. And that was, there was a special call for a study on systemic racism from the NIH. And how many more special calls are we gonna get? We don’t know. Just, it’s the whole moment versus a movement question.
Rigoberto Hernandez: One of the things that I find interesting about health equity research is that it’s very much like, as you pointed out some examples, it’s like, y- you take from the whole community. It’s very collaborative. So like, what happens to the trust of these communities if somebody comes in and does sloppy work?
Elle Lett: Yeah, and research is, like, a fundamentally extractive process, right? And that’s why I really… There was this post on Twitter, um, about this white woman who had four R01s, all of them on studying Black fat people, basically. That’s what they were about.
I don’t use fat as a pejorative. I think of it as a descriptor, and there’s no fatphobia here. But they were all… And she was bragging about how she was able to secure these funds, and nowhere in her bragging 12-thread post was acknowledgement of the fact that her entire career is built off of the plight of Black people that she presumes are suffering from chronic illnesses. There was no, um, discussion of how she was redistributing… ‘Cause they were each… There were four, and they were all 700,000 ea-… That wasn’t, that was just for one year, so that’s, like, $2.8 million over five years. That’s, like, what? 15 million? Don’t quote me, but yeah. $15 million, right?
And she’s not talking about how she’s re- uh, distributing that, how she’s reimbursing her study participants, how diverse her team is, until she… She was prodded a little bit. But her co-… She doesn’t have a co-investigator who’s Black. She doesn’t mention partnering with community organizations. She doesn’t talk about any of those things.
And I’m like, you need to approach this with way more humility. Me, as a Black researcher, I recognize that, like, I have academic privilege, and I’m relatively, um, financially stable, and I have to be careful to not let my goal become extracting career advancement from the communities I’m supposed to be serving. Health equity research, if done right, is in service to the populations subject to inequitable health.
Rigoberto Hernandez: One thing that I also found really interesting about health equity, uh, studies that I have not seen elsewhere, and something that, actually, is something I learned recently is, like, it is very solutions-driven. So uh, I was hoping you can kinda talk about that. ‘Cause in, in your paper you actually give some, uh, kind of tips if you’re a health equity tourist. Maybe you, you could do this. Could you talk about that?
Elle Lett: Yeah. I did the whole from tourist to community member, uh, guide. Um, not like the little, uh, sorta [inaudible 00:24:09] title, but there was actually meat under there. Basically, it’s almost like harm mitigation. Like, how do you minimize how much harm you can do?
And so first part of it… We already talked about some of them, which is, like, framing things from sustainability rather than urgency. So don’t try to, like, immediately, like… Just because, just because you are new to a problem does not mean that a problem is new.
I think the recent potential, uh, rollback of Roe v Wade is an example. ‘Cause a lot of people are up in arms, but if you pay attention to a lot of Black reproductive justice organizations, they’ve been preparing for this for years to decades. And so a tourist would just sort of parachute in and try to solve this. But someone who is committed to health equity would actually go into the communities that are most impacted by something like this and ask them, “What have y’all already been doing, and how can we amplify? What are your solutions?”
Because key to this is that… And this is, again, going back to theory, but a lot of the theoretical principles that I try to think about in my work actually centers knowledge around the marginalized. That the keys to people’s liberation is with those communities. So we as researches, scholars, interventionalists… We aren’t actually saviors. We’re facilitators of people seeking their own liberation.
And so, uh, consistent with that, we would go into these communities, build rich relationships, and ask them, “How can we support you? What are your efforts? How can we consolidate? How can we advance them? How can we build something with you so that if and when we leave, it’ll be bigger and more effective than it was before, and it’ll be self-sustaining? As, in you will be able to maintain it?”
So that’s the sustainability over urgency thing. Unless it just works out, like, one of those things for… Like, diabetes, which is, like, one of the most studied but least solved problems in America, we’ve shown that community health navigators work. We’ve shown that bringing in people from local communities, paying them to support people who have diabetes in their community with medication adherence and helping shopping and all those things actually reduces the [inaudible 00:26:23] of the illness. That’s sustainable. You create jobs, you create a program… That’s self-sustainability. That’s sustainability over urgency, just rushing in.
Another is thinking about who is represented in your study, and who is not represented, and who can it harm? I think that… I won’t go through all of the [inaudible 00:26:44] for these two, but I think that researches are res- not just responsible for their work, but how their work can be used.
Rigoberto Hernandez: Mm-hmm.
Elle Lett: And so when we write a study that says “This genetic variant is whatever, related for this population,” we’re responsible for how people use that. And so that isn’t to suppress research, but it is to say that when we put something out there, we have to anticipate the ways it can be weaponized to harm people who are already harmed by systems of inequity, and we have to, uh, mitigate that.
So if we were to find stuff like that, I often write that I’m demonstrating a racial inequity in a paper, and I make sure to make it clear that this is because of systemic racism, not because of the identities or those people who happen to be racialized as Black. And so those are two examples where you’re building sustainable practices, and you’re taking responsibility for how your work might be weaponized.
Rigoberto Hernandez: That’s so interesting, because that sounds completely the opposite of wh- this kind of stuff that I read for other episodes, in which a lot of scientists, a lot of geneticists, they go in and they’re like, “I’m an objective scientist. I am, I am actually an anti-racist, so I just go in and I just do the work. All the other stuff, like, who cares?” But they never say, “If a white supremacist uses that work to kind of further their goals, then hey. How is that my fault? I’m just the scientist.”
Elle Lett: This is something I get on my high horse about. Science is not objective, because people are not objective. There are norms in science, and those norms are created by people who are in power. So the norms in science are white supremacist. Like, I’m a statistician. I love statistics. Like, I am a math nerd. Like, I really bri- it brings me joy. And I fell in love with statistics through studying genetics. I studied a molecular biology undergrad. I found population genetics super interesting.
All of genetics and statistics, those are, like, sister fields. They kinda came up together, was birthed out of eugenics. That tool is poison from the start. And it’s not to be said it can’t be used for pursuit of equity, but you have to have a understanding of its limitations.
Scientists have always tried to portray themselves as objective. However, if that was true, we wouldn’t have had scientific papers published c- on drapetomania by Samuel Cartwright, where he was saying that d- slaves wanted to run away because they were diseased. We wouldn’t have had Black women experimented on. If science was objective, there wouldn’t be commonly-held beliefs in present day that Black people have, um, thicker skin and therefore need less pain medication. Those perceptions of recently trained medical residents. That’s not your great-grandfather. That isn’t the old white-haired physician. Those are people who were in training in, like, 2018, 2019.
Science is not objective. You are given the privilege of having the, uh, illusion of being objective because you’re white and you are coming from the dominant perspective. But dominance and objectivity are not the same.
And I’ll say this. Black scholars studying race have to have a much higher level of rigor in their work than white scholars studying race. And that also is a statement on how non-objective science is, because I’ve heard so many times, “Because they’re white, they’re more likely to be objective about race.” White people are the primary beneficiaries of racism. In what world does that make them the most objective?
Rigoberto Hernandez: Yeah. It’s interesting, because we’re actually doing a story about population genetics and kind of the origins of the Human Genome Diversity Project, which was started by Luigi Cavalli-Sforza in Stanford, and he’s, like… Famously, he said, like, “This project is gonna put the, the final nail in the coffin of s- of race science.” So like, uh, these anti-racists created the Human Genome Diversity Project, and they’re population geneticists. And population geneticist is kind of like another way of saying, like, race, without actually saying the word race.
Elle Lett: Mm-hmm.
Rigoberto Hernandez: It’s just basically the same thing.
Elle Lett: Yeah. And I mean, like, Francis Galton… Uh, like, all of these early geneticists and statisticians who created our field were all eugenicists. Like, that was the reason why they developed these tools, and that’s why, if anything, that speaks to one, how science is not objective, and two, how important it is to consider your positionality.
As somebody who studies health equity, as somebody who’s trained, or who has learned from social theory, I am trained to critically evaluate how my position, who I am, informs my work. White people get the privilege of not doing that, which dilutes the quality of their work. It’s not that… I’m not saying that I am more objective. I’m saying that a true objectivity doesn’t exist. But that doesn’t mean rigor does not, because if I am trained to recognize that I have biases, and what those biases may be leading me to conclude, then I can appraise my work more tr- realistically and try to lead to a more approximate truth.
I don’t think quantitative science is actually… That’s a whole different study, but I don’t think we can take complex phenomena like race and racism and really distill them down to basic statistics. I think those are a tool of simplifying, um, complex social phenomena to make them, uh, sorta easier to digest and to, like, sort of transmit to different people across different fields for different purposes.
Rigoberto Hernandez: So JAMA had one one of these, uh, theme issues.
Elle Lett: Talking about that paper, aren’t you? [inaudible 00:32:31].
Rigoberto Hernandez: Yeah, yeah. They had this, like, uh, call for papers.
Elle Lett: Mm-hmm.
Rigoberto Hernandez: And only one of their papers was by a Latino person. The rest were written by white people. And one of those papers was similar to something you had already done. Could you talk about that? Well, first, did you submit to that issue?
Elle Lett: [laughs] Um, so this is something that I’ve written about at length online, but I’m happy to… And that’s not to say I’m not happy to talk about it here, but it’s a longer story.
So I… One of the things that I study is the physician workforce, and how it has or has not changed over time, and back in 2019, 2020, I was workshopping two papers – one on the physician workforce, and one on medical trainees.
Prior to my work, the norm had been to report numerical or percent changes of Black people and l- Hispanic people in medical school or as physicians in, uh, medical schools. So you had medical students and then physicians in medical schools. And, and it would be like, “Oh, we had a .1% increase in the m- percent of Hispanic faculty. We’re getting better. Very slowly, but better.” But this would ignore how the population under it was changing, so how the US was changing.
So le- for, hypothetically, let’s say over 10 years the Hispanic faculty on average, of medical schools, improved by 30%. You would think that we were making progress, right? But what if the Hispanic population in the US has grown by 20% in that same time? Does that… That doesn’t mean that medical schools were becoming more permissive to him- Hispanic people. That just means that there were more Hispanic people vying for spots. And so what I did was I developed metrics that accounted for the underlying changes in the population distribution when we assessed, uh, physician workforce changes.
And so what I showed, that relative to the US population, the academic workforce for physicians was not improving. It was actually declining. So it was declining representation across pretty much every field, with the exception of Black women, one specific field at one specific level, the assistant professor level.
So I had shown pretty globally, across 16 specialties, that we actually were getting further from be- ha- having adequate representation. So like, we were getting further from a situation where the people who ran medical schools, who were academic physicians in all these, um, different specialties, looked like the people who they were treating. We were getting further from that truth. And I did the same thing for medical students.
So if you show that for medical students and for academic physicians, that means at the beginning of the pipeline when they’re first getting trained and at the end of the pipeline, we don’t have representation. Which also means it’s going to be at least 20 years before we have representation, because that’s how long it takes to train physicians all the way up to being full professors.
That’s huge finding, right? Make it 10 years. 20 is kind of overestimation, but that’s a huge finding. I shopped those papers around to JAMA. I shopped them to NEJM. Nobody was interested. Fine. I got one of them published in PLOS One, the one on physicians, which is a, a public, uh, open access journal, and I got the other one published in a new open access journal f- by JAMA. So it was in the JAMA network, but this is the medical student one. But it wasn’t, like, the main JAMA journal. I was happy with that. They’re highly cited. They get talked about in conferences. Great work.
This man, Christopher Bennett, a white first author with, uh, someone who appears Asian as the se- uh, as the, as the second author, publishes in the special edition a s- very similar version to my paper that looked just at Black faculty at the academic physicians.
Mind you, I looked across all specialties, Black, Hispanic, white and Asian at all levels. So mine was, was more comprehensive, and it methodologically was more sound, because I also adjusted for population changes. His gets published in the special edition in JAMA. And the language is imprecise, it’s clearly not as methodologically sound, and it’s a subset of the work that I’ve done.
It’s health equity tourism at its finest. It’s this white person who… Intent be damned. I don’t care what his intent was. Who did a lower quality, a diluted version, of my work, but got in published in a high-impact journal. Were it not for… I would argue the quality of my work, his would erase mine, but mine is still being heavily cited, but it was published in this special edition of arguably one of the highest-impact journals in our field.
That frustrates me, because he was aware of my work. So the way he reached out to me was very disingenuous. At some point, New York Times had reached out [inaudible 00:37:21]… He reached out to me and said, “Can the New York Times reach out to you to discuss your article?” I was like, “Sure.” Then I looked up and found out this article. So he didn’t want them to re- me to dem- discuss my article. He wanted me to comment on his. He wanted me to [inaudible 00:37:32] it, so that’s what I deduced. Because why would the New York Times reach out to me on a story about your article if it wasn’t to talk about your article? That makes no sense.
So long to short is, that was as example. And my ego aside, the reason why that’s a problem, because it misrepresented the results. It showed a small increase in Black faculty, but if you had adjusted for the population like I did, you would show that it was no change or declining. And so it was inaccurate, and he also used disparities language instead of inequity, so he wasn’t tying it to the aspect of, “This is a justice issue.” He was talking about diversity or representat-…
He, he just did not have the expertise. He didn’t have the range. He didn’t know what he was talking about. And had he been someone who had spent more time in studying this sort of suspect of equity, which is diversity, equity and inclusion, the sort of more academic… Really talking about, like, physician workforce aspect. If he had just, honestly, even did a closer read of my paper, he would have realized the flaws of his own work.
Rigoberto Hernandez: R- literally a case study of, like, everything we just discussed, right?
Elle Lett: Mm-hmm.
Rigoberto Hernandez: Like, first off, the fact that JAMA has this urgency.
Elle Lett: Mm-hmm.
Rigoberto Hernandez: JAMA’s like, “Hey.” Whereas you had been posting this for years, and then now it’s like this instant version. “Hey, we need this. Uh, ah, scrambling… You!” [laughs] That’s-
Elle Lett: Exactly. And I’m just like, I’m… One, I have a version for the medical students that’s literally in their open access journal already from years before. Two, I’ve already published, and the data has only changed… There’s only one more year of additional data. And three, this is this white man who just has all of these… I mean, all of these privi-… He’s a little more senior than me. I’m a postdoc, where I have my PhD. He’s a physician.
And the fallout from it… ‘Cause I, I confronted the situation, and the fallout from it was also consistent with one of the challenges, too, was that he did not… Prior to this, he had reached out. We had a amicable relationship, and he even offered some degree of mentorship. And over the course of discussing this, he sort of just, like, ghosted me.
And so that is another thing that I talk about in that paper where if you’re really committed to health equity, feed back… I say this all the time, and to be clear, I f- I [inaudible 00:39:43] apply this to myself for communities that I’m trying to be in community with that I don’t, that I actually don’t exist in. So like, when I’m talking about trans health, one of the blind sides that I’ve had historically has been how that intersects with disability rights. And so when I’m criticized by people from that community, that is a gift. Because that is emotional labor they’re expending on me, under the assumption that we are committed to their, to justice for them, as- to jointly committed. And so they’re giving me the opportunity to rise to the occasion.
And so having to… Being humble enough and tough enough to suppress my ego and take that criticism is part of what it means to be someone who’s truly a champion for health equity. And his response was to cut off all communication to me. Which is fine. That’s his own opinion for having me be mentored. That’s not a issue.
But I’m saying, that’s demonstrative of this issue of ho- what really was white fragility, when white people come into health equity spaces, they see themselves as our deliverance, as our gift. And so when we criticize them for not doing it right, they are offended, and then they retract their commitment.
So that’s why it’s hard to place our trust into them. Because if you’re really committed to this, it’s not a… You, you recognize that you are not a gift, but you are a collaborator, co-conspirator, someone working with us, and you are no less subject to criticism than I am. We are equals. And if you can’t take my criticism, if you can’t be educated by me, that means you don’t see me as your equal.
Rigoberto Hernandez: Yeah. And, uh, and going back to JAMA, like the fact that you were workshopping with them and they didn’t accept it at the time. It kind of speaks about, like, the fact that health equity researchers are just kind of… “We tried. Uh, they don’t want it, so we’ll just go where we can.” So it’s, it’s kind of points to this, like, systemic thing.
Elle Lett: And let’s, to be clear, why JAMA did their special issue. The reason why JAMA did their special issue was not the George Floyd effect. The reason why JAMA did a special issue is because they were recovering from an embarrassment. I’m not sure if you’re aware of this, but they had a podcast where one of their editors had denied the existence of systemic racism. And so in response… First of all, many of my health equity mentors have been, and are still, boycotting JAMA because of that.
Secondly, in response, they pulled together this po- ham-fisted special edition wh- on race and racism. Also, I wanna note that I actually sent a Lettr to the editor about this article and they didn’t respond to it.
Those papers… And there f- There were five articles in the special edition, where four of the five were almost all of them were all by white people. Only one was by a Latino auth- author. All of those were just disparities articles, demonstrating health inequi- heal- health disparities by race. Where it was just like, we see this outcome. We see Black people do worse, Hispanic people do worse. White people do better. That’s it.
Whereas Health Affairs did a special edition on racism, and theirs was totally different. It was about, “How do we measure not race, but racism? What are some new innovations in this field?” And that is, like… To me, like, demonstrates sort of the difference between a tourist and a community member of health equity on a, like, journal level. It’s like, we’re reacting to something, our own mistake, and we just want to show the bare minimum to show commitment. Whereas we’re like, “This is something we’re about. We’re trying to advance it. What do we do next?”
Rigoberto Hernandez: Uh, one more thing is like… Kind of insult to injury is, he wanted you to comment on his paper to advance, further advance, his career [laughs]. And it’s just kind of like, uh, it wasn’t enough that this happened. It’s also…
Elle Lett: I was like, “What do you want from me?” [laughs] Yeah, I was insulted. And one thing, I’m, in some ways, very junior. I think hierarchy… The only hierarchy that is really useful to me is, like, who’s teaching, who’s learning, really. Like, I didn’t like shirk from the reality that this person’s a fellow and I’m a medical student, technically.
Um, because I think that is what holds us back. We are deferential to people because of their status, and not because of the work they’ve done. And so his work didn’t feel senior to me, so I didn’t address it as such.
Rigoberto Hernandez: Like, at first we were like, “This is very inside baseball.” But actually, if you look at it, it has implications for, like, the whole field.
Elle Lett: Mm-hmm.
Rigoberto Hernandez: Right? I wonder how you, you, uh, how you would say to people who say, like “Inside baseball. No one cares.”
Elle Lett: So wh- there are many aspects, uh, that I think generalize it to it. Like, one aspect of the sort of tourism issue is how and why Black people aren’t represented in the sciences, why Latine people aren’t represented in the sciences. We’re forced out. We’re, uh, not given the same opportunities, and this tourism is just sort of a more narrow, uh, representation of that. But there’s a reason why Black people are underrepresented across most sciences.
And two, I’d argue that there is a justice aspect to all science, right? Like, all of it pertains to our everyday life, whether it be about the planet we’re [laughs] slowly destroying, or about the services we should be or neglect to provide, as far as health. I think all of it relates to equity. It’s not inside baseball if you look close enough.
Rigoberto Hernandez: Yeah. And I think my biggest takeaway is that, like, we hear you talk about, like, the way that health equity research approaches things. It’s just night and day to the stuff that we’ve been reading about, like race science in America. [inaudible 00:45:02]. It’s completely opposite.
Elle Lett: I mean, me, whenever I have a new idea, y- I call up people. I’m like, “What do you think about this?” I’m like… I was doing a project that was about, [laughs], racial inequities, and it was impacting not just Black people but, uh, Latine and Hispanic people. I called our researchers from those identities who also studied those groups, and I was like, “What do you think about this? This is very much like a… We built a team.
I tried to not be, uh, so wedded to the capitalist promotion, publish or perish narrative as I am to how do we make health more equitable? And we are oriented around that primary question. You build teams. You build collaborations. You build an army of people trying to move the needle forward. And so it looks different because the goals aren’t the same. The goals aren’t to move up. I mean, that’d be nice, but the goals are to make the world better.
Alexis Pedrick: Innate: How Science invented the Myth of Race was made possible by a major grant form the National Endowment for the Humanities. Democracy demands wisdom. This episode was produced and reported by Rigoberto Hernandez. It was edited by Padmini Rabinat. It was mixed by Jonathan Pfeffer, who also composed our Innate theme music.
Distillations is more than a podcast. We’re also a multimedia magazine. You can find our videos, stories and every single podcast episode at Distillations.org, and you’ll also find podcast transcripts and show notes. Check out ScienceHistory.org/Innate for more information about the project. For Distillations, I’m Alexis Pedrick. Thanks for listening.