A growing body of research has documented the role of racism in pediatric healthcare and its contribution to adverse outcomes. From the likelihood of receiving pain medication in the emergency room to the risk of dying in surgery, race can have a severe impact on the health and wellbeing of the country’s youngest patients.
The roots of discrimination begin well before a child enters the exam room with social determinants of health, or the environment and forces that shape where children live, play, and study. Bias also emerges in research that can guide children’s healthcare decisions as well as predictive technologies. On an individual level, implicit bias among pediatric providers can influence clinical decision making and health outcomes for these young patients.
Call to action underscores urgency
Last year, the American Academy of Pediatrics issued a Call to Action, urging providers to acknowledge the long-standing inequities in healthcare and their roots in societal racism. From the way diseases are managed to how medicine is taught, the effects of racism are interwoven in the healthcare system. Eliminating race-based medicine is necessary, challenging, and long overdue, leaders said.
Studies demonstrate far-reaching impact
Numerous academic studies demonstrate the far-ranging health inequities that begin early and persist throughout a child’s lifetime. For example:
The rate of preterm birth among African American women in 2021 was 14.8%, or about 50% higher than the rate among White (9.5%) or Hispanic women (10.2%) in 2021, according to the Centers for Disease Control and Prevention. Low birth rate not only increases the risk of infant death but can also lead to health conditions, such as cerebral palsy and developmental delays.
Being African American is strongly associated with a higher risk of complications following surgery and increased mortality, even among apparently healthy children, as discussed in the August 2020 issue of Pediatrics.
Black children are 18% less likely to receive imaging tests during an emergency department visit, and Hispanic children are 13% less likely. These findings, which persisted even after controlling for factors, such as health insurance and income, can impact the care they receive, authors of the study published in a 2021 issue of JAMA Network Open noted.
Implicit bias in the exam room
Researchers are increasingly looking at the role of implicit bias in children’s healthcare. This refers to attitudes or stereotypes that might impact a provider’s decision and care judgments in an unconscious way. These attitudes can create racial differences in young patients’ access to healthcare and exacerbate already existing inequities. Stressful conditions—such as the COVID-19 pandemic—can increase a pediatric provider's implicit bias, explain authors of a 2021 article in the Journal of Pediatric Psychology.
Previous accounts and studies have noted that unconscious preference for White patients may be exacerbated in emergency department settings, where providers face a stressful environment, competing demands, high acuity, overcrowding, and fatigue.
Structural racism impacts children, too
Pediatric patients are also impacted by discrimination on a system level, which is known as structural racism. This refers to all of the ways that society creates bias, from housing and education to criminal justice and healthcare. These practices reinforce discriminatory beliefs and the way resources are distributed, according to the American Medical Association.
Last year, researchers examined “neighborhood hot spots,” or areas that experienced a higher level of social vulnerability. This refers to external factors, such as socioeconomic status and housing type, that can stress human health. In these areas, researchers found increased pediatric intensive care use for acute respiratory failure that was so severe the children required mechanical ventilation. Differences among neighborhoods linked to social determinants of health point out the findings published in 2022 in Pediatric Critical Care Medicine. Similar research has linked childhood asthma to social determinants of health.
Technology can exacerbate inequities
Pediatric racism isn’t limited to human interactions. Some researchers have looked into machine learning and its predictive tools. Even though machine learning has the potential to improve racial health inequities, human biases can seep into the program’s data.
For example, researchers described how racial inequities are encoded into the design of a tool used to predict severe sepsis, according to findings published in 2022 in the Journal of Pediatrics. Those predictions, in turn, have the potential to further deepen care gaps. Removing these deeply entrenched biases requires a dedication to anti-racism principles throughout the process of designing, developing, and implementing machine learning, the authors wrote.
Changing mindsets and systems
In a recent policy brief, the American Academy of Pediatrics described several important steps to address racism in pediatric care. The group urged professional organizations and medical specialties to critically examine policies and guidelines that incorporate race or ethnicity. The organization also called on medical schools, academic health systems, and accrediting bodies to promote health equity in their curricular content.
Culturally humble care can help
On an individual level, providers should strive to provide culturally humble care that acknowledges and addresses implicit bias, advises the author of the 2022 Health Affairs article urging pediatricians to confront racism.
On a broader scale, health equity training should be provided for all levels of healthcare organizations. While training can be an effective way to identify and address bias for providers and clinical teams, it can also support culturally concordant hiring practices and bolster improved operational policy development.
This equity emphasis needs to go beyond the examination room to the patient experience throughout the entire healthcare setting, which includes looking to solutions, such as hospital security policies with an eye toward anti-racism.
More robust research is necessary
Acknowledging the broad-ranging pediatric care inequities that can persist throughout the course of a child’s life is key to addressing them. Robust evidence is critical in bringing the awareness of structural racism to the forefront and informing efforts to address its burden, write authors of a 2022 JAMA Pediatrics piece.
This work is essential to create environments that support children and parents alike.
RTI Health Advance can help address care inequities
From implicit bias to machine learning gaps, RTI Health Advance helps clients understand and address the root causes of healthcare inequities. Our health equity consulting services can help you improve care and outcomes for historically marginalized populations. Contact us today.