How racial inequality affects health and healthcare

September 25, 2019

Although progress has been made, racial and ethnic inequalities remain in medical care, but pediatricians can help to change this, as well as mitigate the damage that has already been done.

Pediatricians may not be able to fix racial inequality, but they certainly can and should play a role in advocating for changes, according to a recent policy statement from the American Academy of Pediatrics.

The policy statement, published in Pediatrics, addresses the impact of racism on the health of children and teenagers, noting that pediatricians should always be watching for opportunities to talk to parents and patients about the effects that exposure to racism could have. Although there have been improvements in racism, as the policy statement notes, clinicians have to realize the extent to which the problem still exists.

“I have been working in this area for some time so the content doesn't surprise me, however, I think the depth of the existing data across medical, psychological, educational, and judicial and general historical literature already exists,” says Maria Trent, MD, MPH, professor of pediatrics in adolescent/young adult medicine at Johns Hopkins Medicine in Baltimore, Maryland, and co-author of the policy statement.

The goal of the policy statement was to provide evidence-based guidance on the role of racism in child and adolescent development as well as health outcomes, and to help pediatricians understand their role in employing strategies that can optimize care and improve the health and well-being of the affected children and their families. This also means examining one’s own biases, the statement notes.

“We hope that pediatricians will examine their own biases; begin to help families unpack the impact that racism is having on the health of children; and provide effective support and anticipatory guidance that results in optimal patient-centered, family engaged care, that the overall quality of care for patients and families improves, and that patients will have optimal outcomes,” Trent says. “This will require partnership with community agencies and effective advocacy not only in the office but in our local communities and beyond.”

Some suggested interventions that pediatricians can use to help patients who experience racism include the creation of a culturally safe medical home that is sensitive to racism, using strategies like Raising Resisters to provide support for children and their families to recognize and resist racism, training clinical staff to provide culturally competent care, assessing patients for stressors and connecting them and their families to community support organizations, watching for other mental health conditions-such as posttraumatic stress, anxiety, and depression-in victims of racism, and encouraging cultural diversity and community involvement in the practice.

Trent simplifies these interventions, suggesting that providers adopt the approach recommended by Janie Ward, PhD, a leading scholar in education-Read It, Name It, Oppose It, Replace It.

Acts of racism affect all children, teenagers, and families, and in all of the places they spend their time-including schools, Trent notes. Clinicians have to understand the impact to help, and are being tasked to proactively address racism as care providers, community leaders, and child advocates.

“The emotional and physical health impacts are both in the present and in the future,” Trent says. “The Academy is committed to facilitating strategies to optimize our workforce to be prepared to assist patients and families struggling with the short- and long-term impacts of racism in its multiple forms through its policies, publications, and programming. Most importantly, we are committed to listening to children, adolescents, and families using a culturally competent, patient-centered, family engaged approach to begin the process of healing and change.”

A study out of Stanford on racial and ethnic disparities in neonatal intensive care units (NICU) accompanied the policy statement, and reveals that minority infants-particularly African-American infants-were often disadvantaged when it came to care and outcome measures in NICUs. The study reviewed 41 articles which revealed widespread and complex disparities in the structure, process, and outcome measures faced by disadvantaged infants in NICUs. Its authors hope the study provides motivation to create a new normal for these children.

“This review should be seen as an invitation for providers, NICUs, hospitals, and health systems to do quality improvement through a racial/ethnic equity lens,” says Krista Sigurdson, PhD, assistant adjunct professor of social and behavioral sciences at the University of California, San Francisco and lead author of the report.

At the same time, studies are geographically/historically contextual, she notes.

“Each area of care and healthcare system merits its own analysis. One area that stands out from the systematic review is that NICUs with higher volume black infants may provide worse quality of care,” Sigurdson says. “This suggests that health systems used by black communities deserve particular quality improvement and the same may apply to pediatric services in general.”

Sigurdson says she hopes the report will result in reflection by health systems, but also action from pediatricians.

“Pediatricians can educate themselves on systemic and interpersonal racism and how preterm birth and healthcare systems-including neonatal care-exist within these larger historical and contemporary forces,” she says.

She also suggests pediatricians take a role in helping to develop quality improvement projects that partner with affected communities of color to help define problems and develop solutions tailored to addressing racial and ethnic inequalities in neonatal care. As a frontline provider to patients affected by these disparities, pediatricians can play a vital role in helping to mitigate early exposure to racism.

“In their day-to-day work, pediatricians can advocate for families of color in the NICU and outside to help ensure that they have the supports and services needed,” Sigurdson says. “Pediatricians can make sure that families know what is available to them, particularly in terms of fostering their involvement in the care of their hospitalized infant. They can trust families of color when they voice problems or have complaints about healthcare systems or providers and help address problems that arise.”

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