The Anesthesia & Analgesia Strategy for the “People and Health Advocacy” Section: Economic, Academic, and Healthcare Dividends of Diversity, Equity, and Inclusion

Although there is a moral and ethical obligation for organizations to foster diversity, equity, and inclusion (DEI), there are also federal and state laws in the United States and in other countries to ensure that organizations do not wittingly or unwittingly adopt practices that are discriminatory.1,2 To mitigate discriminatory practices, organizations typically develop DEI policies, which cover the representation and participation of people of different gender, race, ethnicity, religion, age, sexual orientation, and disability status.3 A clear and robust DEI policy should be viewed as protection for the organization—and in turn its assets or profits—from prosecution or lawsuits for breaching employment laws. In this way, it is not dissimilar to having a fire safety policy or a data security policy. For example, adopting a strong DEI policy might have prevented the US Internal Revenue Service from breaching the law, and consequentially protected the entire US government and federal system from a successful lawsuit by a plaintiff, Mr. Moritz, famously represented by Ruth Bader Ginsburg.4 Apart from adhering to existing laws and regulations, there are economic benefits to improving DEI.5 Companies can reach a more extensive talent pool, incorporating different perspectives, and so enhancing the firm’s agility and innovation.6–8 DEI has been shown to foster a sense of belonging for all employees, and thus reduce turnover, including addressing burnout.9 All this strengthens the firm’s competitive advantage over other stagnant or ossified competitors, and corporate responsibility like DEI strategies has been effective at improving the well-being of employees.10,11 WHY ANESTHESIA & ANALGESIA NEEDED A DEI STRATEGY Although DEI seems sensible for business firms, why did an academic journal like Anesthesia & Analgesia (A&A, herein referred to as the Journal) originally need a DEI strategy and a dedicated Section Editor? It might be argued (a) that science is a pure pursuit, uncontaminated by unpalatable issues of biases and discrimination, and (b) that scientists and academic leaders are driven only by the selfless search for truth, blind to gender, race, ethnicity, religion, sexual orientation of their teams or colleagues. Even if this were true—which we believe most readers will view as unlikely12—there are some unavoidable realities. The first reality is that the Journal is a business as well as academic concern, so if a strong DEI policy helps increase its competitive edge, then the Editor-in-Chief and Editorial Board will embrace it with vigor, unabashedly for the profit motive if for no other reason. A second reality is that the Journal operates in partnership and collaboration with numerous stakeholders, which include, most proximately, the publisher (Wolters Kluwer), the International Anesthesia Research Society (IARS), and the affiliated professional societies. Universities and hospitals (whose libraries purchase the journal), funding agencies, and industry (who place advertisements) also have a vested stake in the Journal. For the reasons cited above, all of these stakeholders have adopted robust DEI policies and expect from their partners similar standards and transparent commitments. Successful and sustainable relationships require common values. Raw economics aside, there are also good scientific reasons to articulate a clear DEI strategy, which have been outlined by the Council of Science Editors, another key stakeholder.13 Diversity across journal editors and peer reviewers ensures the widest range of thematic perspectives, and thus avoids groupthink or the unintentional promotion of narrow perspectives, which can disengage or reduce participation from others. This diversity creates a visible, globally welcoming appearance as the journal’s editorial board becomes representative of society: it does not look like “us” versus “them.” Encouraging DEI helps prevent one or a few paradigms or perspectives in science, or a limited number of like-minded authors, from dominating the content. In turn, this will increase innovation and foster publication policies that seek the widest range of themes and article types. Like newspapers, medical journals do not make the news—we just report it. In this regard, clinician scientists are increasingly studying and examining the roles not just of sex, race or ethnicity, but other less acknowledged sociodemographic factors (eg, racism, sexism, discrimination) as influencing health outcomes.14 Such work may challenge existing paradigms, but where the evidence is strong, medical journals have a duty to publish the work. Yet we need expert editors and peer reviewers, who have bona fide expertise, to assess the submissions. Consequently, success in publishing naturally assists the academic career promotions of those authors producing it; and in turn, over time, this will help reverse the currently unequal representation of women, people of color, and other heretofore underrepresented groups in academic medicine. For example, a recent analysis in the United Kingdom (UK) revealed that, despite women and people of color comprising 32% and 39% of consultant staff (ie, attending physicians), respectively, only 19% and 16% of UK professors are from these 2 groups, respectively.15 RECOGNIZING THE PUSHBACK TO DEI: TOWARD “PEOPLE AND HEALTH ADVOCACY” Although there is a need for A&A and other medical journals to have a DEI strategy, implementation is not without barriers. The principle of DEI has been sometimes controversial, because it can be misunderstood. It is often wrongly assumed that supporting a clear DEI policy inevitably means supporting specific initiatives like quotas, positive discrimination or affirmative action, or “tick box” training programs.16 Based on misunderstandings, restricting or abolishing organizational DEI policies can occur—however, this is misguided and potentially harmful, because this is akin to banning insurance. None of these prohibitions have been coupled with dismantling the underlying legislation protecting equal opportunity in the workplace, so the risk of the organization breaching the law remains, and if anything, is increased without having the insurance of a DEI policy. Moreover, given its proven economic advantages, prohibiting or abandoning a DEI strategy in toto is like choosing to be poorer. There are cogent criticisms about lack of standards, consistency, and accountability across DEI policies, which we must all acknowledge have contributed to pushback. However, poor practice in some places should not justify dismantling the principle in its entirety. Although A&A has not encountered internal or external pressures to eliminate DEI efforts, there has been a considerable backlash in society more broadly, especially recently and mostly focused within the United States, to advancing DEI.16 The analysis of Shuman et al.17 suggests that DEI efforts are perceived as threatening, especially by those within majority groups in society. The threats come under status, merit, and moral. Status is perceived as threatened on the misunderstanding that if persons from racial and ethnic minority populations make gains, this can only be at the majority’s expense. The merit threat can be enhanced by affirmative action policies that imply that achievements result from group membership, rather than objective skills or qualities. The moral threat is a complex psychological feeling that DEI implies successful groups have benefitted from a fundamentally unfair system and so should feel guilt. It is important to be sensitive to these perceptions, why they arise, and to understand that resistance comes in the forms of denying (that inequities exist), defending (legitimizing or justifying the status quo), and distancing (the appreciation that inequity exists but that one personally has nothing to do with it). These reactions have already been translated into political restrictions on state funding for DEI initiatives18 and the US Supreme Court delivered a 2023 ruling against race-based affirmative action in college admissions.19 In their commentary describing the backlash to DEI efforts, Bajaj et al. suggest that instead of defending current DEI strategies, more effort should focus on acknowledging the failures of current approaches.16 Part of that is to appreciate that the brand of “DEI” as a phase may have become a trigger for division, whereas its core elements are largely uncontested. There are no legal or political drivers to dismantle fundamental equalities legislation. This itself creates a recognized dilemma for organizations. On the one hand, they still need to adhere to the law in respect of nondiscrimination and equity. Yet on the other hand, they find themselves increasingly constrained in how they can shape DEI policies.20 One important mitigation is to rebrand DEI in ways that restore focus on its core elements. At A&A we recognize that submitted articles to this section deal with issues like the representation of women and individuals from racial and ethnic minority populations in academia and careers; the unique challenges facing disadvantaged minorities in the workplace; and legal or institutional frameworks that might create implicit biases. To that end, we have taken the decision, not lightly, to rename this section “People & Health Advocacy.” CORE ELEMENTS OF THE A&A PEOPLE AND HEALTH ADVOCACY STRATEGY First, it is important to explain that the Journal has a strategy and not a policy (Table). Policies tend to be more rigid sets of rules to which an organization and its employees adhere. In contrast, a strategy is a dynamic roadmap to an organizational vision, making it more aligned with the work of an academic journal. Second, the core element of our strategy is driven by the appointment of a dedicated Section Editor for People & Health Advocacy (A.J.M.), who in turn will appoint a team of content expert associate and assistant editors and peer reviewers. This visibility should send a clear signal to the readership that this topic is a priority for which submissions are welcome. The inaugural Journal Executive Editor for DEI (Dr Paloma Toledo) laid these same foundations, especially through the themed issue published in October 2023.21 Table. - Summary of the Journal People and Health Justice Strategy 1. Legal framework and economic advantage Recognize the legal and economic benefits of a strong strategy in respect of diversity, equity, and inclusion, aligning with the policies of our funders, partners, and stakeholders. 2. Awareness & commitment Develop a culture among editors and reviewers to promote principles of diversity, equity, and inclusion in all journal activities. 3. Leadership in health equity Highlight the role of anesthesiologists in achieving health equity through a policy framework. 4. Perioperative disparities focus Make the Journal a leading platform for diverse perspectives on perioperative disparities. 5. DEI education Educate all Journal users on the principles of diversity, equity, and inclusion, through publications, lectures, and workshops. 6. Collaboration with healthcare disparities editor Partner with the Section Editor for Healthcare Disparities to solicit relevant papers and develop strategies for improving healthcare. 7. Global perspective on DEI Collaborate with the Section Editor for Global Health to integrate a global perspective on issues pertaining to diversity, equity, and inclusion. 8. DEI strategy development The People & Health Advocacy Section Editor will define and update the strategy including:(A) Internal promotion within the Journal.(B) External promotion in academic anesthesiology.(C) Development of metrics for success. 9. Additional development areas (A) Develop communication tools for People & Health Advocacy principles.(B) Collect data on People & Healthcare Justice opportunities for best practices.(C) Encourage publication of People & Health Advocacy Open Mind articles.(D) Actively identify and engage authors from underrepresented racial and ethnic minority populations worldwide.(E) Promote recruitment and retention of editors and reviewers internationally from underrepresented racial and ethnic minority populations.(F) Collaborate with EICs of other journals to develop People & Health Advocacy or DEI strategies in anesthesiology.(G) Support publication of articles from LMICs and authors from non-English-speaking cultures to foster diversity. Abbreviations: DEI, diversity, equity, and inclusion; EICs, Editors-in-Chief; LMICs, lower- and middle-income countries. This prioritization can be bolstered by commissioning articles in response to global events or policies that have either positive or adverse proven or potential impacts on topics related to diverse representation, equity, inclusion, and engagement. Global examples include the possible adoption of new assisted dying legislation in the UK, and how these might affect vulnerable groups;22 or the impacts of restricting access to abortion services in some states in the United States and other countries, and how these might impact the health of women.23 These are sensitive and controversial issues. Therefore, when delving into these, it is important the Journal does not take any political stance, but remains an open forum for constructive, evidence-based discussion from all perspectives, focused on improving healthcare outcomes. An important role of the Section Editor for People & Health Advocacy will be collecting and analyzing demographic data, to shape and inform future strategic initiatives. If as a journal, we are committed to publishing these issues, then we need to know how well we are doing—but especially what we are not doing well and what to do about it. It is important to know who is determining what gets published: the demographic characteristics of editors and peer reviewers, as well as who is seeking to publish: the demographic characteristics of authors.24 In turn, these analyses synergize with parallel work on studies pertaining to academic promotions and departmental representation of traditionally underrepresented groups (ie, women, racial and ethnic minority populations).25 This dimension of the strategy may not be easy. Whereas geographic location, institution, qualifications and academic rank are generally self-evident, details of factors like gender, age, race, ethnicity, sexual identity, disability status are not straightforward to collect and require acknowledgement of privacy and data protection issues. After gathering and analyzing data on the demographics of our editors, reviewers, and authors, we can implement strategies to address systemic challenges faced by underrepresented groups in publishing. Efforts to counter systemic racism and discrimination will include mentorship and education on conducting research in this field, reviewing the relevant studies, and statistical approaches for research in collaboration with other journals and medical societies, thereby creating a pathway for underrepresented investigators to gain the skills and expertise to conduct and publish research. We will also review all policies to ensure our policies are equitable and do not prevent groups of individuals or certain topics from being published. In this way, the refreshed title emphasizes the “people” and also their expectation—and indeed fundamental right—to justice in the field of healthcare. One exciting opportunity to advance this theme is the new Journal Editorial Fellowship program: see: https://journals.lww.com/anesthesia-analgesia/Pages/Announcement.aspx. This initiative was originally designed over a decade ago when the current A&A Editor-in-Chief (J.J.P) was editor of Anaesthesia. It was adopted and expanded later by the British Journal of Anaesthesia. The Editor-in-Chief has taken advantage of the size and reach of A&A in introducing the Fellowship to our Journal. Successful applicants will spend a year shadowing 2 Section Editors, learning the mechanics of journal and article management and processing, including experience in how to peer review. Dedicated mentorship and training will not only assist the individual Fellow’s own career development but also serve as a pathway and create a pool of talent from which future peer reviewers and editors can be drawn.15 We already have applicants who have come from each continent and across wide demographic groups. We are confident that this Editorial Fellowship will add diversity to our editorial board. The Section Editor for People & Health Advocacy will not work in a vacuum. The Journal is justly proud of its 2 closely connected sections: Healthcare Disparities (led by Dr Olubukola Nafiu) and Global Health (led by Dr as there is and (eg, where a or and (eg, in a of in these themes are in ways that to be are connected as (a) if DEI policies (the focus of of People & Health are then healthcare disparities should be and (b) if this positive is then global health should However, there are some factors specific to each of these themes and the new also the the at the of the US issues pertaining to staff as well as clear the theme is not just about but open to discussion about legal and fundamental The of people and health health and global The that there is people and health healthcare and global there are issues that can be specific to each of The that policies related to people and health can health disparities or the reverse is the Healthcare disparities and global health are through common The in examples of issues that can be specific to each not health is still a for a people and health is to have in people and health political or events may not healthcare disparities if all are are for the populations and countries are not for DEI that remains the United cultures are in at the for DEI strategies (eg, In countries where DEI is well it might be argued by some that there is no a diversity and one can on to other to the response This the reality that a robust DEI strategy helps the organization from like an insurance and this risk is In a more way, some countries with DEI policies and as the currently are in about these the DEI policies have all the the Journal authors a unique and opportunity to the which will impact on the well-being of our to the People & Health Advocacy section will to the same scientific that are to all other submissions. any research that does not standards be a threat to the Journal and to advancing the of DEI in and perioperative medicine. it is to ensure our People & Health Advocacy policy is transparent and is This will include at scientific (eg, and publishing data the journal’s initiatives with as increased diversity among or in health equity content. 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We look to partnership with authors, peer reviewers, the editors, and all our in the United States and where DEI remains at the of the of in perioperative and management of is the DEI Section Editor for Anesthesia & is the Editor-in-Chief of Anesthesia & Analgesia and was not in the of this This was