As pediatricians, we champion the need to address social determinants of health, such as poverty and food insecurity, in an effort to achieve health equity. We emphasize screening for toxic stress. In our conversations about equity, we include data about racial and ethnic disparities.
Because of our commitment to work for the health and well-being of all children, pediatricians are uniquely positioned to consider and address the needs and concerns of the at-risk communities for whom we care. Whether they cope with financial insecurity and deprivation, racism, religious discrimination, or language barriers and immigration status, our attention and support makes a difference for our patient families.
As members of the AAP Public Health Special Interest Group (SIG) and the Immigrant Health SIG, we realize that racism and intolerance continue to obstruct health equity for children of color.
Witnessing the toll
According to the most recent census report, the majority of children under 5 are children of color. As pediatricians, we witness firsthand the physical and psychological toll of racism and intolerance on our patients of color. We see children who experience post-traumatic stress because they witnessed their brother or sister killed by gun violence. We see Central American children who escaped threats of death and persecution because they didn’t want to join a gang. We see children anxious and frightened of losing a parent to deportation. We see mothers who fear for the safety of their black sons on the streets, at the hands of one another or at the hands of police who could protect them. We see children feeling they must hide their Muslim religion and identity to avoid being bullied or ostracized. And we try to alleviate symptoms of children and families whose chronic stress takes the form of asthma, obesity and a lifelong risk of poor health.
Children are exposed to media reports of politicians who demonize groups of people based on their country of origin or their faith, of people criticized for advocating for equal rights for people of color, and of violence against black and brown people and police officers. This is the world in which our children live, and we as pediatricians can choose to stay silent, essentially complicit in racism’s effects, or we can take a stand.
Conscious vs. unconscious bias
As Camara Jones, M.D., M.P.H., Ph.D., wrote 16 years ago, institutional, personally mediated and internal racism harmfully impact black children. Since then, a rich scientific literature has shown that the prevalence of consciously expressed racism (roughly equivalent to Dr. Jones’ concept of personally mediated racism) has decreased over the past decades. Conversely, unconscious, implicit bias persists unabated (AAP News, March 2016, http://www.aappublications.org/news/2016/03/25/Racism031616).
Even within our own profession, unconscious racial bias likely underlies such otherwise incomprehensible outcomes as strikingly disparate provision of analgesia for abdominal pain in black and white children with appendicitis (Goyal MK, et al. JAMA Pediatr. 2015;169:996-1002, 10.1001/jamapediatrics.2015.1915). Pediatricians do not intentionally withhold pain medications from their black patients. But such studies speak to the need for all of us to become more aware of our unconscious biases.
Unconscious biases are not moral flaws, but unavoidable effects on our unconscious minds of the environment in which we all live. There is an effective way to address unconscious biases: becoming aware of and consciously counteracting them.
Institutional racism (the third pillar of racism described by Dr. Jones) may have the most powerful effect on the lives of our black and brown patients. From profoundly unequal schools, to discrimination in homeowner lending, to workplace discrimination and wage theft, written and unwritten rules that govern our educational system, workplaces and neighborhoods continue to lead to starkly disparate outcomes in education, home ownership, employment and income between families of different races. These rules may be public, like laws, or unspoken, like hiring practices. They may be secret, like banks’ lending policies, and they may consist of systemic non-enforcement of laws, as in the case of wage theft. And they may have the utmost consequences, such as law enforcement practices that threaten the safety of children of color.
What may be the role of each pediatrician in the quest to mitigate racism and intolerance and seek health equity?
It may emerge from the clinic. Consider the role of Alan J. Shapiro, M.D., FAAP, in building Terra Firma to facilitate access to integrated medical care, mental health care and legal services for immigrant children seeking safe haven (AAP News, July 2015, http://bit.ly/2fEoIUd).
It may take the form of education, as Ashaunta T. Anderson, M.D., M.P.H., M.S.H.S., FAAP, and Angela M. Ellison, M.D., M.Sc., FAAP, enlighten colleagues about racial socialization (AAP News, July 2015, http://bit.ly/2fXB3Gz).
It may arise through public health, such as the patient-inspired, data-driven activism of Mona Hanna-Attisha, M.D., M.P.H., FAAP, to mitigate the seeping of contamination into the water supply of poor, largely minority children (AAP News, December 2015, http://bit.ly/1RimyI7; March 2016, http://bit.ly/2fCvqfz).
Or it may involve finding our own voice in the call to action by AAP CEO/Executive Vice President Karen Remley, M.D., M.B.A., M.P.H., FAAP, and AAP President Benard P. Dreyer, M.D., FAAP, to address violence and intolerance (AAP News, July 8, 2016, http://bit.ly/2fXmoeL) and engage in difficult conversations (AAP News, October, 2016, http://bit.ly/2f0bvUp).
Many of us can understand the issues faced by our patients either from personal experiences or witnessing firsthand the effects of racism and intolerance. We can stand up for our patients where individual or systemic racism denies them their chance to grow into healthy members of our communities. We can also stand up for our patients who are denied resources, opportunities and attention in our nation’s underserved rural communities. We have a responsibility to provide direct support of children, both protecting those at risk and creating a future generation of those who help be part of the solution rather than the problem. Within our own local, regional, national and global communities, each of us has a role to play in supporting every child — black, brown, white and every hue — to achieve a safe, hopeful future.
Dr.Dougé is co-chair of the AAP Public Health Special Interest Group. Dr. Linton is co-chair of the Immigrant Health Special Interest Group (SIG). Dr. Köhler is a member of the Immigrant Health SIG National Steering Committee.