Crystal W. Cené, M.D., M.P.H. / n engl j med 392;24 nejm.org June 26, 2025
川普政府目前以行政命令和行政行動的形式對多元化、公平和包容性 (DEI) 舉措的攻擊揭示了對 DEI 與健康公平之間關係的嚴重誤解。 DEI 措施是經由組織內部的結構化努力，旨在創建包容性的教育和工作環境、糾正歧視性政策並減輕系統性不平等的影響。在醫學領域，這些措施影響了提供照護、創造知識和將證據轉化為實踐之勞動力的招募、留任和支持。醫療保健領域的 DEI 舉措包括針對第一代學生的途徑計劃、針對教師和受訓人員的指導和研究培訓計劃、薪酬平等和育嬰假政策以及無障礙計劃。
如今，DEI 被誤解為一種分裂、排斥或灌輸的形式破壞了任人唯賢的管理制度。這種錯誤的描述加劇了有害的「零和」敘事。事實上，DEI 舉措挑戰了公平競爭環境的神話，並推行了有助於實現真正的用人唯賢的管理政策。天賦資質在人群中是均勻分佈，但機會卻並非如此。 DEI 的努力旨在擴大機會管道，以便所有具才華的人都能為社會做出貢獻。
反 DEI 行動將逆轉數十年來在建立更具包容性的衛生勞動力和改善患者治療結果方面上所取得的進展——這兩個目標雖然不同但相互關聯。研究顯示，提高種族和族裔勞動力的多樣性可以增強溝通、滿意度、信任度和治療依從性，從而改善患者的健康狀況；增加具文化和語言敏感性之照護；擴大醫療服務不足和病情較嚴重的社區之醫療服務覆蓋面，且在這些的社區中非白人之臨床醫生相較於其白人同行，更有可能實踐能涵括種族和族裔少數群體之患者參與臨床和生物醫學研究，進而拓寬研究問題和方法。
然而，僅有多樣性是不夠的。要實現其效益，需要包容性的政策、公平的做法、勇敢的領導和責任感。
健康公平是一個理想的目標：確保每個人都能有公平、公正的機會獲得健康。實現健康公平需要消除結構性和社會上的障礙，例如在獲得照護、教育、就業、住房和安全環境的上的歧視以及限制。健康公平倡議旨在透過增加醫療服務的機會和質量，消除因種族、民族、年齡、語言、性別、性取向、能力、保險狀況或地理位置等定義，從而產生的群體間之醫療保健差距。確保健康公平的責任需要使用依社會和人口學變項所分析的數據來追蹤差異，透過品質改進（QI）的努力工作，以執行循證之實踐。
自 1985 年美國衛生與公眾服務部發布《赫克勒報告》( Heckler Report ) 以來，幾十年來健康差距一直得到充分記錄，而且這種差距仍然存在且代價高昂。光是 2022 年，健康差距就給美國造成了 3,200 億美元的醫療支出過剩和生產力損失。由於人口結構變化和人均成本上升，預計到 2040 年將增加至 1 兆美元。健康差距並不是隨機的；它們是關於社會在何處、如何以及向誰投資資源的政策、實踐和決策等的可預測結果。當部分人口無法享受醫療保健的三重目標（更好的體驗、更好的健康和更低的成本）時，整個人口的健康就會受到影響。例如，在新冠疫情期間，美國農村地區的醫療專業人員和醫療設施較少，疫苗接種率遠低於非農村地區。這些獲取機會的差異導致疫苗接種覆蓋率較低、新冠肺炎傳播率較高，進而導致整體死亡率較高。
最終，在醫療保健領域中，其目標是健康上的公平； DEI 是實現該目標的策略。聯邦政府最近的行動混淆了 DEI 和健康上的公平，使兩者都處於危險之中。例如，刪除追蹤人口健康差異的公共衛生網站和資料集；取消有關臨床試驗多樣性的指導；解散關鍵的健康公平諮詢委員會；撤出對低收入國家的資助；終止數百萬美元的研究經費，包括那些專注於環境正義中的健康差異和少數族裔群體的經費，以及那些專注於培訓科學工作者中代表性不足的群體的經費；以及在與健康相關的聯邦機構中大規模的裁員。這些席捲的措施正在拆除消除健康差距和改善患者治療效果所需的基礎設施。
公平不僅是美國國家醫學院定義的醫療保健品質六個領域之一，也是跨領域項目中支持所有其他領域者。以公平為重點的品質提升 ( QI ) 通常涉及針對遭受不平等待遇的邊緣群體制定介入措施。例如，針對黑人產婦的客製化的介入措施，旨在減少產婦死亡率方面長期存在的種族差異。然而，如果在所有人當中此類舉措被視為「偏袒」某個受保護群體（例如種族、性別或原屬國籍），則可能被視為非法。
另一種方法是設計一般性的品質提升介入措施，希望它們能為高風險群體帶來不成比例的利益，然這種方法或許可以避免法律審查，但往往無法消除差異，甚至可能加劇差異。
對 DEI 和健康公平的攻擊對臨床醫生和科學家造成了未被充分重視的心理傷害。反 DEI 指示導致研究經費突然終止、聯邦研究基礎設施瓦解、自我審查以避免在研究提案和論文中標記有「目標詞」，以及對學術組織和其他非營利組織的資金損失。由於用於支付學術機構內部關鍵基礎設施的研究資金的流失，加大了醫療服務系統透過增加臨床收入來彌補預算缺口的壓力。為了彌補這一缺陷，醫療系統正在裁減員工，增加利潤豐厚的臨床服務，同時限制對無保險和保險不足的患者的照護和服務。科學家，特別是那些進行健康公平研究的科學家，面臨著壓力，需要調整他們的研究議程，申請更多的資助，增加臨床工作量以維持薪資支持——在許多科學家努力建立自己的職業生涯並在學術界取得進步的時期，這些要求增加了不穩定性。
這些變化和速度之瘋狂的節奏以及大學紛紛採取措施降低財務風險，加劇了恐懼、倦怠和不確定性，尤其是在職業生涯早期的臨床醫生和科學家。要隨著政治任務的不斷變化重新制定研究計畫以符合規定，需要的不僅僅是更換標記的術語包括「差異」、「公平」或「女性」。它需要時間來重新反思和重新概念化研究問題和方法。
致力於實現健康公平的臨床醫生和研究人員必須清楚地傳達 DEI 的目標和證據，作為促進健康公平的策略，讓每個人都受益
對於那些認同自己所進行研究或提供臨床照護的社區之臨床醫師-科學家來說，這種傷害會被放大。他們中的許多人正遭受深深的道德傷害和悲痛。他們循環地經歷否認、憤怒、討價還價和沮喪——試圖拒絕接受，卻感到無力去應對。接受現任政府倒退的意識形態和做法，則感覺就像是背叛了他們所致力於提升的社區。
醫療衛生界和科學界該如何因應？致力於實現健康公平的臨床醫生和研究人員必須清楚地傳達 DEI 的目標和證據，作為促進健康公平的策略，讓每個人受益。 DEI 計畫應有意地去設計以對結果影響產生有意義的變化，而不僅僅是滿足過程指標（例如參與率或培訓次數）。應該衡量和追蹤這些變化，並調整策略以確保問責。我們必須強調，停止資助和對健康公平和 DEI 研究、計畫和辦公室的撤資對國家健康的危害。
學術領導者也必須敏感地意識到，在當前環境下教師、員工、臨床醫生和受訓人員所遭受的心理壓力——其中許多人正經歷著深深的失落感—並應尋求創造性的方式來支持他們。
致力於科學、自由和正義的機構和個人必須對審查科學研究、修改歷史以及設置健康和機會障礙的行為堅決抵制上的努力。科學、醫學和國家健康所面臨的賭注實在太高，我們不能袖手旁觀，看著這一切遭到破壞。
作者所提供的揭露表格可在 NEJM.org 上找到。
本文於 2025 年 6 月 21 日發表在 NEJM.org 上。
The Health Equity, Medical, and Scientific Costs of Dismantling DEI
Crystal W. Cené, M.D., M.P.H. / n engl j med 392;24 nejm.org June 26, 2025
Current attacks by the Trump administration on diversity, equity, and inclusion (DEI) initiatives — in the form of executive orders and administrative actions— reveal a critical misunderstanding of the relationship between DEI and health equity. DEI initiatives are structured efforts within organizations designed to create inclusive educational and work environments, redress discriminatory policies, and mitigate the effects of systemic inequities. In medicine, these initiatives influence the recruitment, retention, and support of the workforce that delivers care, generates knowledge, and translates evidence into practice. DEI initiatives in health care include pathway programs for first-generation students, mentorship and research training programs for faculty and trainees, pay-equity and parental leave policies, and accessibility programs.
Today, DEI is being misrepresented as divisive, exclusionary, or a form of indoctrination that undermines meritocracy. Such mis characterizations fuel a harmful “zero sum” narrative. In reality, DEI initiatives challenge the myth of a level playing field and pro mote policies that help make true meritocracy possible. Talent is evenly distributed across populations, but opportunity is not. DEI efforts aim to expand access to opportunity so that all talented people can contribute to society.
Anti-DEI actions will reverse decades of progress toward building a more inclusive health work force and improving patient outcomes — distinct but related goals. Greater racial and ethnic workforce diversity has been shown to improve patient health by enhancing communication, satisfaction, trust, and treatment adherence; increasing culturally and linguistically sensitive care; expanding access to care in underserved and sicker communities, where non-White clinicians are more likely to practice than their White counter parts; and broadening research questions and methods, including participation of patients from racially and ethnically minoritized groups in clinical and biomedical studies.
However, diversity alone is not enough. Realizing its benefits requires inclusive policies, equitable practices, courageous leadership, and accountability.
Health equity is an aspirational goal: ensuring that everyone has a fair and just opportunity to be healthy. Achieving health equity requires removing structural and social barriers, such as dis crimination and limitations on access to care, education, employment, housing, and safe environments. Health equity initiatives target health care disparities affecting groups defined by race, ethnicity, age, language, gender, sexual orientation, ability, insurance status, or geography, by increasing access to and quality of care. Ensuring accountability for health equity requires tracking disparities using data disaggregated by social and demographic variables, engaging in quality-improvement (QI) efforts, and implementing evidence-based practices.
Health disparities have been well documented for decades, since the “Heckler Report” was issued by the U.S. Department of Health and Human Services in 1985, and they remain persistent and costly. In 2022 alone, health disparities cost the United States $320 billion in excess medical spending and lost productivity. The figure is projected to increase to $1 trillion by 2040 because of demographic shifts and rising per capita costs.2 Health disparities are not random; they are predictable outcomes of policies, practices, and decisions about where, how, and in whom society invests resources. When segments of the population are excluded from the benefits of health care’s triple aim — better experience, improved health, and lower costs — the health of the entire population suffers. For example, during the Covid-19 pandemic, rural areas of the United States with fewer medical professionals and health care facilities had substantially lower vaccination rates than nonrural areas. These access disparities led to lower vaccination coverage and higher Covid-19 transmission rates, resulting in higher overall mortality.
Ultimately, within health care, health equity is the goal; DEI is a strategy for achieving that goal. Recent federal actions conflate DEI and health equity, placing both at risk. Examples include the remov al of public health websites and data sets that track population health disparities; removal of guid ance on diversity in clinical trials; disbanding of critical health equity advisory committees; withdrawal of funding from low-income countries; termination of millions of dollars in research grants, including those focused on environmental justice health disparities and minoritized populations and those focused on training of groups that are underrepresented in the science workforce; and massive layoffs at health-related federal agencies. These sweeping actions are dismantling the infrastructure needed to eliminate health disparities and improve patient outcomes. Equity is not only one of the six domains of health care quality, as defined by the National Academy of Medicine — it is also a cross-cutting domain that bolsters all the others. Equity-focused QI often involves tailoring interventions to marginalized groups that experience disparities. For exam ple, tailored interventions for Black birthing people aim to reduce long-standing racial disparities in maternal mortality. Yet such initiatives may now be deemed unlaw ful if they’re perceived as “prefer encing” a protected group, as defined by race, sex, or national origin, among others.
An alternative approach — designing general QI interventions in hopes that they disproportion ately benefit at-risk groups — may avert legal scrutiny but often fails to eliminate disparities and may even exacerbate them.
The assault on DEI and health equity has caused underrecognized psychological harm to clinicians and scientists. Anti-DEI directives have led to abrupt termination of research grants, dis mantling of the federal research infrastructure, self-censorship to avoid flagging of “target words” in research proposals and papers, and loss of funding to academic and other nonprofit organizations. The loss of research funding, which pays for critical infrastructure within academic institutions, has heightened pressure on care delivery systems to cover budget shortfalls with increased clinical revenue. To compensate, health systems are reducing staff and growing lucrative clinical services while limiting care and services for uninsured and underinsured patients. Scientists, particularly those conducing health equity research, are being pressured to pivot their research agendas, write more grants, and increase clinical work to maintain salary support — demands that increase instability during a time when many are working to build their careers and progress through the academic ranks.
The frenetic pace of these changes and the speed at which universities have scrambled to mitigate financial risks are fueling fear, burnout, and uncertainty, especially among early-career clinicians and scientists. Reframing a research program to comply with shifting political mandates requires more than replacing flagged terms such as “disparities,” “equity,” or “women.” It requires time to reflect and reconceptualize research questions and approaches.
Clinicians and researchers working to achieve health equity must clearly communicate the goals and evidence for DEI as a strategy to advance health equity, which benefits everyone
For clinician–scientists who may themselves identify with the communities in which they con duct research or provide clinical care, the harm is amplified. Many of them are experiencing a profound sense of moral injury and grief. They cycle through denial, anger, bargaining, and depression — trying to resist acceptance, yet feeling powerless to do so. Accepting the regressive ideologies and practices of the current administration feels like a betrayal of the very communities their work aims to uplift.
How should the health care and scientific community respond? Clinicians and researchers working to achieve health equity must clearly communicate the goals and evidence for DEI as a strategy to advance health equity, which benefits everyone. DEI initiatives should be intentionally designed to effect meaningful changes in outcomes, not just meet process metrics (e.g., participation rates or numbers of trainings). These changes should be measured and tracked, and strategies should be adjusted to ensure accountability. We must highlight the danger to the health of the nation of defund ing and divesting from health equity and DEI research, programs, and offices. Academic leaders must also be sensitive to the psychological toll on faculty, staff, clinicians, and trainees navigating the current environment — many of whom are experiencing a profound sense of loss — and seek creative ways to support them. Institutions and individuals committed to science, freedom, and justice must vehemently resist efforts to censor scientific inquiry, revise history, and erect barriers to health and opportunity. The stakes for science, medicine, and the nation’s health are simply too high for us to stand by and watch the destruction.
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This article was published on June 21, 2025, at NEJM.org.
