Medical researchers Vanessa Selak, Professor Rod Jackson, and Associate Professor Matire Harwood are among the authors of an editorial in the New Zealand Medical Journal pointing to the racism in its editorial process. Here they explain why.

 

“The values and the positioning of the researcher are never absent”. (Professor Helen Moewaka Barnes, 2008)

“We recognise that Nature is one of the white institutions that is responsible for bias in research and scholarship. The enterprise of science has been — and remains — complicit in systemic racism, and it must strive harder to correct those injustices and amplify marginalised voices” (Nature Editorial June 9, 2020)

We are Māori (Matire Harwood) and Pākehā (Vanessa Selak and Rod Jackson) medical researchers who investigate how heart disease and stroke (collectively referred to as cardiovascular disease) affect different ethnic groups across Aotearoa New Zealand. 

We submitted an article to the New Zealand Medical Journal (NZMJ) earlier this year based on our analyses of ethnic differences in cardiovascular risk profiles using data from nearly half a million people in New Zealand. 

While the NZMJ published our article last week, along with an invited editorial that we wrote about racism in the health sector (including recommendations for the NZMJ), we believe that the NZMJ has more to do to ensure that it can meet its claim of being “the principal scientific journal for the profession in New Zealand” by addressing racism in its editorial process. 

We consistently find, as with other experts in this field, that if you are Māori or Pacific, you’re more likely to have a heart attack or stroke than if you’re European, and if you have one of these events, you’re also more likely than Europeans to have them at a younger age, be disabled by them, and to die prematurely because of them. 

This increased risk of cardiovascular disease and its complications is one of the main reasons why, if you are Māori or Pacific, your life expectancy is 6-7 years less than if you are European. 

This finding would be sad enough if there was nothing that we could do about it, but is made more tragic, and our health system and successive governments clearly culpable, because these differences are avoidable, unfair and unjust (that is, they are inequities, not simply differences or inequalities). 

These inequities are caused by complex and multiple factors, but there are two major underlying reasons. 

The first is that the opportunities and privileges provided by income, housing, and education are unevenly distributed by ethnicity in New Zealand. 

And the second is that institutional (or structural/systemic) racism within our health system can adversely affect access to, and through, excellent and timely healthcare. 

These reasons are well accepted and understood by those with expertise in the field of health equity due to decades of work internationally, predominately by black, Indigenous, and other systematically disenfranchised (including Māori and Pacific) academics and clinicians.

As with other researchers, an important way in which we share the findings of our work is by writing articles. We submit these articles to the editors of scientific journals, who then seek the opinions of other experts through the process of peer review before deciding whether or not the articles should be published in their journal. 

The purpose of peer review is to help to ensure that published research is ethically and methodologically robust. But who gets to decide what is ethically and methodologically robust — and, therefore, what is published? 

There is no doubt that certain voices are privileged by the editorial process of health and medical journals, whereas others are systematically screened out.  

For Indigenous-led research, as noted by Professor Helen Moewaka Barnes,

“approaches, and methods from outside the western epistemological frame are regarded with scepticism and hostility and are regulated, undermined, and marginalised”. 

While much of our research is published in international journals, we are regular contributors to the NZMJ, to help ensure that our findings are available to New Zealand clinicians, policy makers and researchers, so that they can be acted on to improve the cardiovascular health of people in New Zealand. 

Several weeks after submitting our article, the NZMJ provided us with feedback on our article from three reviewers, all of whom are anonymous. We were shocked as the feedback from two of the reviewers contained racist comments including: 

“It may be appropriate to also describe the immigration of all the ethnicities, from when there were no people in NZ, or none”

“What is the relevance of indigeneity in the specific context of this paper?”

“The penultimate paragraph is poorly served by phrases such as “. . . the effects of colonisation . . .” when “. . . the effects of NZ development . . .” may be more appropriate”

“Smoking is an important risk factor which is dependent on personal choice — the report demonstrates that Maori smoke more than other ethnicities — what comment should be made in Discussion?”

“the phrase ‘Institutional racism’ is not a fact, but an opinion” 

“What of the ‘other side of the coin’ [to institutional racism] ie that the unique Maori and Pacific world views result in these groups tending to opt for non-participation in non-Maori and non-Pacific (ie ‘Western’) approaches to health care? Either of these two views can be described as potentially inflammatory and attributing blame — a dangerous thing to do without evidence (and even with evidence).”

While the NZMJ provided us with the opportunity to address these comments through the peer review process and in the editorial that they asked us to write, we believe that the editorial process followed by the NZMJ is an example of systemic racism for a number of reasons. 

First, the peer reviewers did not appear to have expertise in the field of health equity, which was necessary to be able to adequately evaluate the merits of the article. 

Second, the NZMJ treated all reviewer comments equally, at least initially, whether or not they were racist, in terms of their dissemination of those comments to us as authors who had to respond to those comments. 

Third, by treating these comments equally and not filtering out the racist comments through the editorial process, our Māori and Pacific co-authors were unnecessarily exposed to racist comments. 

Fourth, when we raised concerns with the NZMJ that some of the peer review comments were racist, we were still required to respond to those comments. 

Finally, our responses to the racist comments were sent back to the reviewers who had made those comments (along with our responses to their other comments), which led to further racist comments to which our team were again unnecessarily exposed and to which we again had to respond. 

The article was eventually published in the NZMJ only because one of us (Rod Jackson) insisted that we keep trying, but we were left bruised, exhausted and wondering whether we should have just published our findings in an international journal. 

We wrote our editorial in order to constructively advance and support progress on racism. We drew on an extensive body of literature and the personal experience of recognising one’s own racist beliefs (Vanessa Selak) to address the racist comments of the reviewers:

“I grew up believing that New Zealand was a country with limitless opportunities. Success was there for those who worked hard, and was therefore deserved by those who achieved it. And if certain groups in New Zealand weren’t achieving, it was most likely because they weren’t working hard enough. After all, my parents had achieved financial success in my lifetime despite arriving in New Zealand without any money or the ability to speak or write English. 

This belief persisted and was reinforced as I succeeded academically at school before earning and, I thought, deserving, a place in medical school. Once I got to medical school, this belief extended to health. After all, so many of the conditions I was learning about were caused, and/or significantly exacerbated, by modifiable ‘lifestyle factors’. Throughout this time, I believed myself to be a good person. My aim in medicine was to ‘help people’ and I considered myself to be ‘colour blind’: I would treat everyone the same, irrespective of their ethnicity. But if they chose not to attend or follow my instructions, that was their choice and outside of my responsibility as a clinician. 

It wasn’t until I embarked upon training in public health medicine that I began to realise (and am continuing to realise) how mistaken I have been about many of my core beliefs, and about how, through my ignorance, I have contributed to racism in New Zealand.” — Vanessa Selak.

In addition to recommendations for Pākehā health professionals and researchers, we provided recommendations to the NZMJ to help address systemic racism within the editorial process: (1) assign a Maori co-editor, (2) develop a code of practice on racism in their peer review process, and (3) to commit to an open peer review process so that peer reviewers are no longer anonymous.

We’re grateful that the NZMJ published our editorial on racism in the health sector and we have now paid to make both the editorial and our paper on ethnic differences in cardiovascular disease risk factors in Aotearoa New Zealand freely available to the public. 

We now invite the NZMJ to formally consider our recommendations on how to address racism in its editorial process.

 

Vanessa Selak is a senior lecturer in Epidemiology and Biostatistics at the University of Auckland. Rod Jackson is a professor of Epidemiology and Biostatistics, University of Auckland. Matire Harwood is an associate professor, General Practice and Primary Healthcare, University of Auckland. 

The NZMJ editorial can be found here.

Below is a reply from Frank Frizelle, the editor of the NZMJ, and Vanessa Selak’s response to that.

Frank Frizelle:

Public health doctors, epidemiologists and clinicians (even journal editors) are all trying to help patients as best they can. Public health physicians and epidemiologists interpret data and publish articles, that can be important and may at times influence government health and social policy. The manuscript that was submitted on cardiovascular disease might have some sort of impact on policy and so was considered worth publishing.   

All manuscripts that are published in quality medical journals undergo peer review and although this is not a perfect system it is the best we have and is the most internationally accepted standard at present.

Peer review is aimed to ensure that the quality of the manuscript is as good as possible, and may also close jumps in reasoning, where the connections between ideas are obvious to authors but not necessarily the readers. As this manuscript is written by well-known public health doctors and epidemiologists, it was important to get the clinicians perspective on the issues that they raised. If I had asked other public health doctors, it is not likely to have challenged the authors to consider their manuscript from a clinical perspective, and clinicians are at the end of the day the ones seeing the patients, and can influence what happens to individual patients.

The academic clinicians who review such journal articles are very experienced doing so (that is why we ask them). What was very interesting here is the difference in the interpretation of the findings between the clinicians and the authors.

The authors were dismayed at having to explain their interpretations of the findings, despite this being a standard part of any academic process — to be able to explain your interpretation of the results to people who have a very different interpretation to yours. The reason for not doing this was that the authors thought that the reviewers’ comments were racist, and the authors as a result have criticised both the reviewers and the Journal on the issue of institutional racism.

I asked the authors for an editorial to explore this gap between what their interpretation of the data was and that of the clinicians. What they chose to do however was to provide some useful guidance for authors and reviewers in their editorial, and some suggestions made about the journal, though most of their suggestions were already in place eg: the suggestion for a Māori associate editor. The NZMJ has had a Māori/Pasifika associate editor for the past 10 years. (Editor’s note: The NZMJ does not currently have a Māori associate editor. Dr Kiki Maoate, who occupies that role, is Pasifika — Cook Islands.)

The issue about open review is one that is still evolving and is not a common format, largely due to concerns that reviewers will not be honest if authors know who they are, this might especially be the case in a small country with a small pool of reviewers.

The difference in how public health doctors, epidemiologists and clinicians interpret results is important and while this case is framed as an issue of institutional racism, the issue is far wider than that and has significant implications for the translation of policy into action. 

Vanessa Selak:

We don’t dispute the intentions of anyone involved in this process. However, as I tried to point out in my personal reflection, harm can be caused despite the best of intentions in the face of continuing ignorance.

This is not about a disagreement between public health doctors/epidemiologists and clinicians. This is about racist comments and how they are dealt with as part of the peer review process.

Matire is a GP at Papakura marae. She teaches medical students, and has had multiple clinical leadership roles, including currently advising the government on their Covid response, and is frequently in the media talking about clinical issues such as Covid. She has a breadth of experience in clinical and governance roles. Further info about Matire’s achievements are here, here, here and here. I could go on and on but will stop!

Rod and I are public health physicians. While some people may not consider us to be clinicians (which I can understand because we don’t directly treat patients anymore) we are registered medical practitioners and according to the Medical Council, are clinicians. Most of our work is directly relevant to clinical practice (our sub-specialty is in the field of clinical epidemiology) so while we don’t directly treat patients anymore, much of our work is of direct clinical relevance and we work very closely with clinicians who continue to directly treat patients, such as Matire, and a frequent cardiologist collaborator of ours, Andrew Kerr, who was one of our co-authors on the paper we originally submitted to the NZMJ.

As experienced academics who have published collectively hundreds of research articles, and who have ourselves peer reviewed similar numbers of articles, we are very well acquainted with the role and value of the peer review process as well as the importance of being able to justify one’s position. We simply couldn’t have gotten this far in our academic careers without being comfortable with this process (and, to be honest, without being good at it).   

While I have not always agreed with peer reviewer comments, I have never before encountered racist peer reviewer comments, despite much of my research having a focus on differences by ethnicity.

Our concern is not about disagreement and scientific debate, which we wholeheartedly welcome, but about a process that seems to be unaware of how to identify or appropriately address racist comments, and the harms caused by this lack of awareness.

We absolutely accept that no process is perfect. However, it is not perfection that is being sought, but a desire to continuously improve the quality of the process by considering constructive and legitimate feedback such as that which we believe we have provided. We would be very happy to help support the NZMJ in this process.

While we do agree that the perspective of clinicians who directly treat patients is crucial (and hence why we always work with such clinicians), such clinicians can also be wrong (as can public health physicians and epidemiologists).

Medical practitioners are required by the Medical Council of New Zealand to operate in a culturally safe manner. In my view, the racist peer review comments were not only incorrect but did not meet the clinical standard of cultural safety.

I would personally be very concerned about being treated by a doctor who, for example, believed that smoking was wholly dependent on personal choice. As noted in our editorial: “A lack of understanding of the effect of social determinants of health on health behaviours may lead to healthcare professionals inappropriately blaming individuals for their health behaviours, rather than seeing that behaviour as the consequence of their wider social context and therefore considering what strategies might genuinely assist and support that individual to address the behaviour.”

We did not explore the gap between our interpretation and that of the peer reviewers in our editorial because we felt that the more important issue was the false beliefs underlying the racist comments. We felt that a more constructive approach, both to the NZMJ, its peer reviewers, and the wider readership of the NZMJ, would be to unpack those false beliefs.

Our recommendation of a Māori co-editor is different to what is currently in place. What we are proposing is a partnership model between a Māori and Pākehā editor. We agree that Pacific people (as well as women) should be included in the editorial board, but Māori are not interchangeable with Pacific people and co-editorship is different to associate editorship.

We acknowledge that some reviewers may not feel comfortable publicly standing by their comments, but consider that accountability and transparency are more important for the advancement of science, and can be better served by an open rather than an anonymous peer review process. The BMJ (British Medical Journal) have written about why they’ve moved to an open peer review approach here.

© E-Tangata, 2020