In this issue of Pediatrics, Murosko et al1  explore the impact of residential racial segregation (RRS) on risk for intraventricular hemorrhage (IVH) in preterm infants. Using propensity score matching to reduce bias from confounding, they found a modest increase in the risk ratio for any grade of IVH among infants whose mothers lived in areas with high levels compared with low levels of racial segregation. In a stratified analysis, the effect of segregation was only significant for African American infants and not for white infants.

This methodologically rigorous study was motivated by the observation that African American infants have higher rates of IVH compared with their white peers, and African American women have higher rates of pregnancy-related complications associated with neonatal IVH compared with white women. The authors note that “…RRS accounts for some of the residual disparities between African American and white infants in infant mortality, preterm birth rates, and low birth weight” and aimed to interrogate the role of segregation as a driver of racial disparities in neonatal morbidities. It has long been clear that social forces act in determining population patterns of health and disease. Philosophers, physicians, and public health practitioners have long understood that the places people live impact their health and well-being. Only recently such considerations have made their way into the mainstream medical literature as more than factors to be controlled away.

Growing attention to the interaction between society and health in the wider biomedical literature is encouraging. Any discussion of the role of social determinants starts with a clear identification of the scientific question. Here, the role of residential segregation in driving disparate rates of neonatal morbidities is clearly defined. At the same time, it is important to remember that embarking on such analyses requires specificity of language, contextual grounding, and above all, transparent intention.

Racial segregation has a long, dark history in America, leading to “dramatic, persistent inequalities in social, economic, and educational opportunities.”2  Racial segregation and attendant neighborhood deprivation are associated with poor health outcomes for women, infants, and children.3,4  This is the result of both explicit policies and implicit social norms in American political history.5  Although focusing on particular perinatal morbidities may be of interest to clinicians, it is not clear how measuring such associations in isolation can lead to improved outcomes to the public health. Applying epidemiology theory can lend the needed context and framing for exploring causal relationships in disease distribution and informing interventions to reduce known disparities in outcomes.

For example, Nancy Krieger’s6  ecosocial theory incorporates constructs describing the relationship between physical bodies and their environments (embodiment) and the mechanisms by which they interact (pathways to embodiment); cumulative interplay between exposure, resistance, and susceptibility; and agency and accountability. It is ecologic, positing that population distributions of health and disease are determined at individual, group, and societal levels. Moreover, the theory encourages historical, political, economic, and spatial considerations.6  Murosko et al1  interpret their findings using concepts from social ecology (health influences at multiple levels), life course epidemiology (allostasis, vulnerability and resilience, heritability), and toxic stress (the embodiment of sustained environmental stressors). Synthesizing these ideas into a cohesive explanatory model can be helpful for identifying the upstream forces ultimately responsible for observed disparities.

Understandably, pediatricians often look for smaller-scale solutions to these broad, multilevel problems within their unique, clinically oriented skill sets. In recent studies, authors have highlighted the adverse impact of racial segregation in birth hospitals and NICUs on the quality of care infants and families receive.7,8  These observations may underscore the importance of performing local quality improvement assessments through racial and social lenses, both because signals for opportunities for improvement may be missed when looking at total populations and because deviations from standard care may have greater implications for specific populations.

We must also remember to view any discussion of the social determinants of health with an ethical frame. According to Margaret Whitehead,9  inequalities in health are considered inequitable if they are avoidable, unnecessary, and unfair. RRS did not result from an unfortunate accident of nature but was rather codified by specific policies (both de jure and de facto) that unfairly disadvantaged an entire class of people. Naming those regulations, laws, and normative practices responsible for the perpetuation of RRS in the United States can help us identify effective solutions to the detrimental effect of RRS on health. Bioethicist Norman Daniels10  has extended political philosopher John Rawls’ conceptualization of justice as fairness to the social determinants of health, positing that policies that create and sustain poverty are by definition unjust. No treatment of racial disparities in health is complete without a consideration of justice, equity, or racism. Applying a health equity frame forces us to give our scientific questions appropriate context and focus transdisciplinary efforts on developing theory-guided, evidence-based, and ethically sound solutions to improve outcomes for all children.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-1508.

FUNDING: Dr Fraiman receives grant support from the Harvard-wide Pediatric Health Services Research Fellowship Program (T32HS000063); the other authors have indicated they have received no external funding.

     
  • IVH

    intraventricular hemorrhage

  •  
  • RRS

    residential racial segregation

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.