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Both the protests in the summer of 2020 for racial justice and the news that non-White Americans are disproportionately affected by COVID-19 have highlighted the urgent need to address racism everywhere, including in pediatric practice.
Since the inception of the United States, social, economic, political, and scientific institutions have been built on a foundation emphasizing the inferiority of individuals related to phenotypic differences.1 This hierarchy ensconced white individuals as superior to all other groups with Native Americans and Blacks on the bottom. Centuries of flawed scientific theory supporting racial inferiority/superiority remained until it was definitively disproved with the sequencing of the human genome at the cusp of the 21st century. Some fifty years after the discovery of the genetic code, at a White House ceremony in 2000 to announce the discovery, Craig Venter, a pioneer of DNA sequencing, observed, “The concept of race has no genetic or scientific basis.”2 We can now definitively declare that genes play little to no role in the health inequities disproportionally experienced by people of color (POC). Racism, not race or genes, has a profound impact on the health of children of color.3
Racism is defined as prejudice, discrimination, or antagonism directed against someone of a different race (social construct defined by phenotypic features and assigned a social value) based on the belief that one’s own race is superior. It is the belief that all members of each race possess characteristics or abilities specific to that race, especially to distinguish it as substantially inferior or superior to another race or races.4 In order to exist, racism must include 2 components, racial prejudice and social power. Racial prejudice is a set of discriminatory or derogatory attitudes based on assumptions deriving from perceptions about race or skin color. Social power is the historically social, political, and economic privilege bestowed upon some groups. Higher parental unemployment affecting health care access, infant mortality rates, and inequities in the juvenile justice system are disparities we all know; the root of these inequities is more than just poverty or zip code: It is based on how the US social structure was established.5 Given this definition and the current evidence, racism is a social determinant of health (SDOH).5
Levels of racism
Structural or institutional racism occurs on the macro level and is described as access to goods, services, and opportunities for society based on race. It cannot be attributed to an individual or group of individuals, but rather is based on laws, precedents, policies, and interventions that disadvantage people based on race. As suggested by the “racial iceberg,” structural racism is usually below the surface and often difficult to identify since over time it has become the status quo.6 As documented by several scholars, one way this type of racism can manifest is by access to power. It has been well established that segregation is a major contributor to structural racism. By limiting where individuals can live and access community resources such as transportation and grocery stores, the overall well-being of those in under-resourced communities is lower than that of those in well-resourced communities. This also leads to inequities in access to appropriate medical care, education, and a clean environment. Individuals who live in under-resourced communities tend to be POC. As of 2019, 17% of children in the United States were living in poverty; of all Black children this equates to 31%, American Indian 30%, Hispanic 23%, and White children 10%.7 In addition, structural racism also impacts access to power as can be seen with voter suppression; lack of racial representation in positions of power, such as elected officials; and control of the media.8
Interpersonal or personally mediated racism, on the other hand, is more easily identified. It is where prejudicial thoughts are acted out between individuals in the form of discrimination based on race. It can be as subtle as microaggressions or as obvious as violent acts, racial slurs, or exclusionary practices. This form of racism may be unintentional or unconscious, as seen with implicit bias, or intentional, as seen with discriminatory hiring practices or subjective grading.7 Interestingly, this type of racism can be easily taught to young children. The social experiments that Jane Elliott did with her third-grade students the day after Martin Luther King Jr was shot are a prime example of how quickly prejudice and discriminatory practices can be taught, embraced, and internalized within a few hours. Her White students, who had been separated into blue-eyed groups and brown-eyed groups, and told the blue-eyed group were smarter because of their eye color, quickly learned who was superior and inferior in the world of their classroom.9
Finally, internalized racism occurs when individuals accept the negative stereotypes and messages about themselves and their race. This is best demonstrated in the Black doll/White doll experiments of Drs. Kenneth and Mamie Clark in the 1940s and has since been replicated several times.10,11 These experiments demonstrate that preschool children assign positive attributes to White dolls and negative attributes to Black dolls. For children of color, internalizing negative traits, especially when reinforced by adults around them, can lead to self-loathing and a desire to change their appearance by straightening hair, using bleaching creams for their skin, etc.
Internalized racism coupled with a distrust of the health care system may cause certain POC to not seek out preventive health care or wait too long to seek care for an acute problem.
Racism and its effect on pediatric health
Racism, as it applies to health care, has been shown to contribute to the overall health disparities that we see in communities of color. With structural or institutional racism, there is decreased access to health care and resources for education, leading to lower health literacy and fewer health care providers of color.12,13 Over time, this has led to a distrust of the health care system as a whole by POC due to widely publicized historical events such as the Tuskegee Syphilis Study and the Marion tuberculosis outbreak. It is well chronicled that poor neighborhoods have higher incidences of behavioral problems, poor mental and physical health, delinquency, crime, and risky sexual behavior.14 Asthma and coronavirus disease 2019 (COVID-19) are examples of pediatric chronic health disease where racism has demonstrated a negative impact.
One of the most common chronic illnesses among children in the United States is asthma, accounting for a considerable number of inpatient and outpatient visits and affecting school attendance.15 When sociodemographic characteristics, health behaviors, and the child’s health at birth were controlled, the interaction between race and ethnicity and income is statistically significant. In fact, non-Hispanic Blacks have a higher prevalence of recurrent asthma exacerbations and hospitalizations than Whites after adjusting for demographic and socioeconomic factors.16 One study revealed that with non-Black children, poor children were 45% more likely than children who were not poor to have asthma. However, there was no statistically significant difference found between income groups with Black children.15
The COVID-19 pandemic highlights how SDOH shaped by institutional racism impact a new disease. Researchers at a children’s hospital found that infection rates differed significantly among racial and ethnic groups. Only 7% of non-Hispanic White children tested positive for COVID-19, compared with 30% of non-Hispanic Black and 46% of Hispanic children.17 The study found that children who lived in households with lower incomes also tested positive at higher rates than wealthier children, though the study states the racial and ethnic disparities in infection rates “only slightly attenuated after adjustment for socioeconomic status.”17
With regards to personally mediated racism, implicit bias has surfaced as a strong driver for health care disparities between White and minority children. This can be seen in pain management. One study in pediatric emergency departments demonstrated racial differences in analgesic administration for children presenting with acute abdominal pain and appendicitis.18 For those children who receive a diagnosis of appendicitis, Blacks in moderate pain were less likely to receive any pain medication than Whites, and Blacks in severe pain were less likely to receive opioid medication than Whites.18 Another study showed that when looking at optimal pain reduction, minority children were more likely to be discharged home in significant pain than their White counterparts.19 Even after adjusting for injury severity and pain intensity, minority children were less likely to receive opioids for the treatment of fracture pain than non-Hispanic White children with similar injury severity and pain scores.19
In sickle cell disease (SCD), a genetic disease found predominately in individuals of African and Mediterranean descent, personally mediated racism is clearly evident. This has been documented in one study, where 20 individuals with SCD aged 13 to 21 years were interviewed using the Perception of Racism in Children and Youth (PRaCY).20 Participants reported having racial bias experiences, with a total of 104 racial bias events, including community experiences such as being closely watched or insulted by someone else, and medical experiences such as being treated inappropriately in an office visit or emergency room visit.20 About half of the participants reported racist events caused by authority figures, 23.7% described events triggered by people of similar age, and about half of the events perceived by participants were explicit by the perpetrator. “The number of events of racial bias perpetrated by authority figures is concerning and has considerable school and community implications,” the researchers said.20 Not surprisingly, these experiences were associated with several negative emotions, including generalized dissatisfaction with life in 27.9% of participants, anger in 20.9%, inferiority in 16.3%, and anxiety in 9.3%.20 This finding suggests that these racist events can severely impact young patients’ lives and affect their health outcomes.
Mental health is also affected by personally mediated racism. Young children who experience discrimination are at an increased risk for mental health and behavior problems, but less so if they have a strong sense of racial and ethnic identity.21 Investigators studied more than 170 children, with more than half of the children Latinx, about 20% Black, and the rest mixed race. Children who reported discrimination and had low ethnic-racial identity scores were at high risk for anxiety, depression, oppositional behavior, and other mental health and behavior problems.21 However, the effects of discrimination were muted among children with a strong sense of ethnic-racial identity, according to the report.21
As children are raised in a climate embedded with institutionalized racism, then exposed to prejudice and discrimination (ie, personally mediated racism), certain values may be instilled, resulting in the development of internalized racism. This is concerning as it relates to pediatric health. Schmeer and Tarrance expanded the concept of “weathering” to childhood (how adverse societal hardships influence negative health effects), via a study where children’s c-reactive protein (CRP) levels were measured for low-grade inflammation (considered for levels between 1-10 mg/L).22 Among children born to parents born in the United States, low-grade inflammation was found in 17% of White children, compared with 22% and 26% for Black and Hispanic children, respectively, and 19% for children of other races. Low-grade inflammation was higher in children of foreign-born parents: 31% for Hispanic, 26% for Black, and 22% for children of other races.22
In the study by Coker and colleagues on perceived racial/ethnic discrimination among fifth-graders, 15% of children answered yes that they were treated poorly because of their race, ethnicity, or color of their skin (wording based on child’s understanding of the question). Also, 80% of those who answered yes also stated that they were treated poorly in school.23 In addition, those children who reported perceived discrimination had symptoms of depression, attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder.23 Specifically, Black, Hispanic, and children of other races had an association between perceived racial/ethnic discrimination and depressive symptoms, while White children did not.23
Over the past few decades there has been a concerning trend in the suicide rate in school-aged children, specifically among Black children. One study highlighted the increase of the suicide rate in Black children younger than 12 years of age.24 Robinson and colleagues demonstrated that Black girls reported increased suicidal ideation compared with White girls, and Black girls were more likely to report suicidal ideation at lower levels of depressive symptoms.25 Suicides in Black girls were 1.2 per 100,000 in 2007 and increased to 4.0 per 100,000 in 2017.26
It is time to acknowledge the factor of racism in this trend in order to establish appropriate treatment and prevention efforts.
How to talk to children and families about racism
Illustrating the adverse effects of racism on pediatric health and how to combat this disparity is part of the mission of the Pediatric Section of the National Medical Association (NMA), in addition to providing comprehensive updates on recent advances in pediatrics and addressing issues of national importance. Pediatricians are the first line in providing anticipatory guidance on the promotion of child health and development, including the impact of racism and how children can be resilient despite the effects of racism. The first step to address racism with families and patients is for pediatricians to first address their own bias and prejudice. Evidence has shown that awareness of bias and taking conscious action to mitigate bias can have a significant impact on how the message is received.27 Exploring one’s biases through assessments such as Harvard’s Project Implicit28 can be effective in understanding how biases may unconsciously impact everyday interactions. This can be the start toward understanding the actions, policies, and institutions that contribute to racism. Ibram Kendi, in his New York Times best-selling book How to Be an Antiracist, defines being an anti-racist as “one who is supporting an antiracist policy through their actions or expressing an antiracist idea.”29 Pediatricians taking an antiracist approach can have beneficial effects in addressing racism with patients and families.
In terms of creating an environment in the clinical setting that reduces bias, pediatricians should take action to improve the practice environment. Diversifying the pediatric workforce is an integral part of the NMA’s mission as the oldest and largest organization of physicians of African descent. Additionally, bias and antiracism training for all clinical staff and professionals is vital.3 Furthermore, we must not be afraid to ask the necessary questions to understand how patients and families may have been impacted by racism and bias in the clinical setting. This can be done by adjusting patient satisfaction surveys to include questions that allow patients to fully describe their clinical interaction and having a comprehensive system for addressing such grievances when they are reported.
In clinical interactions, pediatricians have the unique opportunity to directly impact the understanding of racism by patients and families. For example, in well-child visits, pediatricians can provide anticipatory guidance for parents on what to look for regarding a child’s development of racial awareness/identity. Pediatricians can provide advice on how to approach discussions about race in a developmentally appropriate manner.30 Additionally, providing resources that promote the development of a diverse cultural outlook, such as information about diverse community events, or providing books with diverse protagonists through https://www.reachoutandread.org, can be an effective way that pediatric offices support patients and families working to understand and address racism. When approaching your pediatric patient, it is important to note that children do become racially aware developmentally as with all other domains (Table 1). There are resources in addressing racism for yourself, your patients, and your practice (Table 2).30
Discussions with patients and families around racism can be difficult, especially when there is racial discordance between providers and families. Become comfortable being uncomfortable in order to truly help families understand and address racism. Pediatricians should approach these conversations with honesty: it is our role to help every child achieve their best while understanding the truths in society.
The authors would like to thank the Race and Children Education Collaborative of Anti-Racist Developmental Behavioral Professionals (RACE CARD) for their contribution to Table 1.
1. Something Happened in Our Town: A Child's Story About Racial Injustice by Marianne Celano, PhD, ABPP, Marietta Collins, PhD, and Ann Hazzard, PhD, ABPP
2. Beyond the Golden Rule: A Parent’s Guide to Preventing and Responding to Prejudice by Dana Williams
1. Embrace Race: Books, resources, and blogs to education and support families wishing to know more about race, culture, bias and racism. www.embracerace.org
2. Healthy Children: The American Academy of Pediatrics’ parenting website. www.healthychildren.org
1. Siegel E. Six steps anyone can take to become an ally in White, Male-Dominated Workplaces. Forbes. Octboer 25, 2019. https://www.forbes.com/sites/startswithabang/2019/10/25/6-steps-everyone-can-take-to-become-an-ally-in-white-male-dominated-workplaces/?sh=1997e47949fd
2. Hanna-Attisha M. I’m Sick of Asking Children to be Resilient. New York Times. May 12, 2020. https://www.nytimes.com/2020/05/12/opinion/sunday/flint-inequality-race-coronavirus.html
1. Sussman RW. The Myth of Race: The Troubling Persistence of an Unscientific Idea. Harvard University Press; 2014.
2. National Human Genome Research Institute. June 2000 White House Event. Accessed December 12, 2020. https://www.genome.gov/10001356/june-2000-white-house-event/
3. Trent M, Dooley DG, Dougé J, AAP Section on Adolescent Health, AAP Council on Community Pediatrics, AAP Committee on Adolescence. The impact of racism on child and adolescent health. Pediatrics. 2019;144(2):e20191765
4. Jones CP. Confronting institutionalized racism. 2002. Phylon (1960-), 50(1/2), 7-22. Accessed November 19, 2020. doi:10.2307/4149999
5. Johnson T. Intersection of bias, structural racism and social determinants with health care inequities. Pediatrics. 2020;146(2):e2020003657.
6. Gee GC, Ro A, Shariff-Marco S, Chae D. Racial discrimination and health among Asian Americans: evidence, assessment, and directions for future research. Epidemiologic Reviews. 2009;31(1):130-151.
7. Children in poverty by race and ethnicity in the United States. The Annie E. Casey Foundation Kids Data Count Center. September 2020. Accessed December 19, 2020. https://datacenter.kidscount.org/data/tables/44-children-in-poverty-by-race-and-ethnicity#detailed/1/any/false/1729,37,871,870,573,869,36,868,867,133/10,11,9,12,1,185,13/324,323
8. Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000;90(8):1212-1215.
9. Peters W. A class divided. Frontline. March 26, 1985. Accessed November 30, 2020. https://www.pbs.org/wgbh/frontline/film/class-divided/
10. Clark KB, Clark MP. The development of consciousness of self and the emergence of racial identification in Negro preschool children. Journal of Social Psychology. 1939;10:591-599.
11. Jordan P, Hernandez-Reif M. Reexamination of young children’s racial attitudes and skin tone preferences. J Black Psychol. 2009;35(3):388-403. doi:10.1177/0095798409333621
12. Wallis C. Why racism, not race, is a risk factor for dying of COVID-19. Scientific American. Jun 12, 2020.
13. Phelan JC, Link BG. Is racism a fundamental cause of inequalities in health? Ann Rev Psychol. 2015;41(1):311-330.
14. Leventhal T, Dupéré V, Shuey AE. Children in Neighborhoods. In: Lerner RM, ed. Handbook of Child Psychology and Developmental Science. doi:10.1002/9781118963418.childpsy413
15. Miller JE. The effects of race/ethnicity and income on early childhood asthma prevalence and health care use. Am J Public Health. 2000;90(3):428-430. doi:10.2105/ajph.90.3.428
16. McDaniel M, Paxson C, Waldfogel J. Racial disparities in childhood asthma in the United States: evidence from the National Health Interview Survey, 1997 to 2003. Pediatrics. 2006;117(5):e868-e877.
17. Goyal MK, Simpson JN, Boyle MD, et al. Racial and/or ethnic and socioeconomic disparities of SARS-CoV-2 infection among children. Pediatrics. 2020;146(4):e2020009951. doi:10.1542/peds.2020-009951
18. Goyal MK, Kuppermann N, Cleary SD, et al. Racial disparities in pain management of children with appendicitis in emergency departments. JAMA Pediatr. 2015;169(11):996-1002. doi:10.1001/jamapediatrics.2015.1915
19. Goyal M, Johnson T, Chamberlain J, et al. Racial and ethnic differences in the management of pain among children diagnosed with long bone fractures in pediatric emergency departments. Pediatrics. 2019;144 (2 MeetingAbstract) 413. doi:10.1542/peds.2019-3370
20. Wakefield EO, Pantaleao A, Popp JM, et al. Describing perceived racial bias among youth with sickle cell disease. J Pediatr Psychol. 2018;43(7):779-788. doi:10.1093/jpepsy/jsy015
21. Marcelo AK.; Yates TM. Young children’s ethnic-racial identity moderates the impact of early discrimination experiences on child behavior problems. Cultur Divers Ethnic Minor Psychol. 2019;25(2):253-265. doi:10.1037/cdp0000220
22. Schmeer KK, Tarrence J. Racial-ethnic disparities in inflammation: evidence of weathering in childhood? J Health Soc Behav. 2018;59(3):411-428. doi:10.1177/0022146518784592
23. Coker T, Elliott M, Kanouse D, et al. Perceived racial/ethnic discrimination among fifth-grade students and its association with mental health. Am J Public Health. 2009;99(5):878-884. doi:10.2105/AJPH.2008.144329 PMID:19299673
24. Bridge JA, Asti L, Horowitz LM, et al. Suicide trends among elementary school–aged children in the United States from 1993 to 2012. JAMA Pediatr. 2015;169(7):673-677. doi:10.1001/jamapediatrics.2015.0465
25. Robinson WL, Droege JR, Hipwell AE, et al. Brief report: Suicidal ideation in adolescent girls: impact of race. J Adolesc. 2016;53:16-20. doi:10.1016/j.adolescence.2016.08.013
26. Shain BN. Increases in rates of suicide and suicide attempts among black adolescents. Pediatrics. 2019;144(5):e20191912
27. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19. doi:10.1186/s12910-017-0179-8
28. Project Implicit. Accessed November 24, 2020. https://implicit.harvard.edu/
29. Kendi I. How to Be an Antiracist. One World; 2019.
30. Literacy promotion: an essential component of primary care pediatric practice. American Academy of Pediatrics Council on Early Childhood policy statement. Pediatrics. 2014;134(2):404-409. doi:10.1542/peds.2014-1384
31. Fesperman MG. What we teach our children: a content analysis of racism in second grade textbooks. Master’s thesis. Smith College; 2013. https://scholarworks.smith.edu/theses/579/
32. Maroney T and Zuckerman B. “The Talk,” physician version: special considerations for African American, male adolescents. Pediatrics. 2018;141(2);e20171462.