Editor’s Note: Dr. Tasia Isbell (she/her/hers) is a third-year pediatric resident physician in the Leadership in Equity and Advocacy Track at the Boston Combined Residency Program at Boston Children's Hospital and Boston Medical Center. She is passionate about medical education, social determinants of health, and community engagement. She is pursuing a career in general pediatrics post-residency. -Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics
American Indian and Alaska Native (AI/AN) communities face significant health disparities that start in childhood and span the entire life course. These inequities manifest in adverse health effects that increase morbidity and mortality. Compared with non-AI/AN groups, AI/AN youth experience higher rates of:
- Adverse childhood experiences (ACEs)
- Chronic stress
- Mental health concerns
- Obesity
- Substance use disorders
- Violence
- Environmental hazards
Further, AI/AN youth experience significant barriers to healthcare access, including:
- Transportation limitations
- Socioeconomic obstacles
- Mistrust of the healthcare system rooted in generational trauma, discrimination, and systemic racism
In a Feature being early released this week in Pediatrics, Dr. Alessandra Angelino from the University of North Carolina-Chapel Hill and colleagues at Texas Children’s Hospital, the University of Washington, and Oregon Health & Science University explore the current state of ACEs among AI/AN communities (10.1542/peds.2023-062207). The authors begin their article with a story of an 18-year-old American Indian man with a new diagnosis of Ewing sarcoma who is consistently late for his scheduled admissions, a relatable experience for many pediatricians. As the narrative unravels, it is revealed that his tardiness is the culmination of multiple ACEs, including poverty, systemic racism, foster care, unstable guardianship, insurance woes, and transportation difficulties.
This narrative underscores the profound impact that ACEs and social determinants have on the way our patients navigate and experience the healthcare system. The authors then delve into the historical factors contributing to the disproportionate burden of ACEs among the AI/AN community, tracing these disparities back to colonization and legislative actions that persist today. This framework seamlessly guides readers to reflect on the way historical barriers are impacting the present-day challenges of the patient mentioned at the start of the article. Despite these challenges, he displays resilience and strength in showing up to his appointments, even if that means showing up alone and late.
The authors propose the following action steps for improving care for AI/AN communities:
- Education: Develop educational initiatives on health inequities, the burden, culture, and history of ACEs specific to AI/AN communities into primary, secondary, and medical school curricula.
- Trauma-Informed Care: Adopt a trauma-informed care approach, which is defined as medical care that centers on the identification, assessment, response, and prevention of traumatic stress on children, and uses culturally sensitive screening tools, such as the Child Traumatic Stress tool developed by the Department of Pediatrics at the University of Utah and the Center for Safe and Healthy Families at Intermountain Healthcare’s Primary Children’s Hospital.
- Gender-Affirming Care: Offer gender-affirming care that incorporates traditional indigenous understandings of identity including Two Spirit, an umbrella term across indigenous nations to describe individuals that transcend dichotomous frameworks of gender and sexuality.
- Community Partnerships: Foster community alliances with AI/AN communities and become familiar with resources and programs that can be offered to AI/AN youth.
- Strengths-Based Approach: Identify and nurture the strengths and protective factors of AI/AN youth to foster resilience, confidence, and self-esteem.
After reading this article, I plan to implement a moment of reflection when patients are late to hospital or clinic appointments. During this reflection, I will consider the barriers and social determinants at play, as well as the resilience it takes to show up.
I encourage each of you to read this article and consider taking a pause in your own practice to consider why your patients might be late (again!) too.
