The 2021 Joseph St Geme, Jr, Leadership Award Address: The Role of Structural Racism in Injuries to Children and Adolescents

Most realize that injuries do not occur randomly. They are not acts of God nor chance or certainly not fate. This is one of the reasons why the term “accident” is no longer used to describe these events. In fact, injuries are predictable at the population level.

Injuries also do not affect the members of communities equally. Figure 1 shows the higher rate of injury deaths in Black youth, American Indian youth, and Hispanic youth compared with White or Asian American youth over the last 2 decades. Although there has been a decline in these death rates between 2000 and 2019, over the last decade this decline has flattened out and rates have actually increased for Black children and adolescents who, even in 2019, have injury death rates threefold higher than those of Asian American youth.

Investigators in the injury prevention and control field long ago rejected the idea of “accident prone” individuals and instead focus on the environment that places some youth at greater risk of injury and injury death than others. This is where structural racism comes in. It creates an environment that affects the risk of injury and death for children who are vulnerable by virtue of race, ethnicity, poverty, or where they live and, hence, if they die.

In the injury field, it is most appropriate not to limit interventions to just injury prevention but to broaden it to the concept of injury control, not only reducing the occurrence but limiting the effects of injury on health and function. Injury control (Fig 2) consists of the primary prevention of injuries from happening in the first place, the acute care of the injured person including being picked up by emergency medical services, taken to a hospital, and receiving appropriate trauma care, and then, finally, rehabilitation after the injury to return the individual to their optimal functioning. Structural racism and the environment can and does result in disparities at each of these 3 points: prevention, acute care, and rehabilitation. Although much of the article focuses on examples of structural racism and the primary cause of injuries, it also more briefly discusses the intersection of racism and the other two aspects of injury control.

One of the greatest racial disparities in mortality from any cause are the death rates from firearm assaults to youth in the United States (Fig 3). Young Black males have 12 times the risk of dying from a firearm injury than young White males do.¹  These are not deaths that occur in mass shootings, the kinds of shootings that make the evening news all too often in this country. Rather, they are the shootings that occur every day, especially in the nation’s cities and streets. This disparity is not limited to just in young Black males. In 2019, Black females this age died of firearm homicides at a rate nearly 6 times greater than White females did.¹ 

One common response to this data is that there are the estimated 400 million guns held privately in the US²  are too many and a substantial part of the problem. However, that is not the reason why there are so many more deaths in Black males than in any other group. Other underlying factors are at play. First is the concentration of poverty in neighborhoods that have been neglected for generations. One clear manifestation of this was the practices of mortgage companies across the country to purposely segregate housing. For example, the 1937 Home Owners’ Lending Corporation security map of Philadelphia separated areas of the city into 4 grades of “worthiness for government-backed investment and economic development.”³  The lowest grade was given to dilapidated areas with an “undesirable population of Blacks, immigrants and Jews.” It was colored red in these and similar maps in other cities, hence the term redlining.

Eighty years and 3 generations later, these are the same areas with the highest rates of firearm injuries and deaths, and they are mostly occurring to Black men living in these neighborhoods. It is a result of social and economic exclusion occurring year after year, decade after decade, and generation after generation in these neighborhoods. The underlying cause of the higher rate of firearm injuries and deaths is not due to the people living there but the environment that has been created for them and in which they were raised. For many youth living in those neighborhoods, carrying a firearm makes sense to them.

Much attention has been recently focused on the widening income gap in the United States as a whole and the effect it has on so many aspects of health and health care. The juxtaposition of low-income households and high-income households in the same community is also harmful, especially for Black members in those communities. In a recent study, researchers examined the relationship between rates of firearm homicide and income inequality, using the well-known Gini coefficient, which ranges between 0 for maximum equality and 100 for maximum inequality.⁴  In this study, the researchers found that for each 1% increase in the Gini coefficient in a county, which is a small change in income disparity, there was more than double that increase in firearm homicide among Black individuals in both 1990 and 2000 but no difference among White individuals. This difference persisted after adjusting for mean household income and for social capital. Income inequality, as a measure of relative deprivation, captures the effect of the individual’s relationship to the larger society, and it is one of the drivers of Black firearm homicide.

Another example of the impact of structural racism is on pedestrian injuries in youth. I began to look at pedestrian injuries starting while I was in Memphis and found that pedestrian injuries occur primarily to children living in the poor areas with predominantly Black residents.⁵  They do not occur in middle class suburbs. They occur in inner city areas where children have poor access to playgrounds and live on major arterial roads with high-speed traffic.

An instructive contrast is Sweden.⁶  Sweden has few pedestrian deaths each year and the reason is that they constructed their towns and neighborhoods so that children could go to school, the playfield, and the grocery store without ever having to cross a major arterial. It is not a matter of teaching children how to cross streets safely. The clear evidence indicates that children under 10 do not have the developmental means to do so safely every time. Instead, adults have to create environments where children can live and play without running the risk of being struck by a car and killed or severely injured.

Another example is childhood drowning. Swimming lessons do decrease the risk of drowning of young and school aged children by as much as 88%, but few Black children, immigrant children, or Hispanic children are ever taught how to swim. This just requires the will, not money, and not expensive indoor swimming pools. Bangladesh is one of the poorest countries in the world, with a gross domestic product per capita of $2000 compared with almost $70 000 in the United States. However, in Bangladesh, in 10 years, >480 000 children were taught basic swimming skills, by using local ponds and bamboo barriers.⁷  If it can be done in a poor country like Bangladesh, why can’t it be done in the richest country of the world?

Turning to the problem of trauma care, why are there poorer outcomes among Black patients? High quality trauma center care is effective in decreasing the risk of death in adults under the age of 55 by 45% compared with care at local community hospitals.⁸  Fortunately, Black children, poor children, and non-English speaking children are more likely to be transferred to and treated at these level I trauma centers than White children are, but the reasons are only partly due to selecting the best place for their care. It is also due to transfer of uninsured or underinsured patients by referring hospitals.

However, the care received by individuals once they arrive at our trauma centers, even the nation’s best academic trauma centers, does depend on their race and ethnicity, reflecting structural racism in our health care system. In a recent study of one major trauma center, researchers found that children who were Black, Hispanic, or other non-White race and ethnicity were half as likely to receive care in the PICU than White children with the same severity of injury were.⁹ 

Those who care for critically ill and injured patients know that at some point, optimal care, the best care, means end-of-life care. The attending physician discusses with families and writes do-not-attempt-resuscitation orders and withdrawal-of-care orders. For example, Cooper et al¹⁰  showed that Black and Hispanic patients were much less likely to receive a do-not-attempt-resuscitation order or a withdrawal-of-care order (Fig 4). The reasons for this are complex and reflect both physician practices and family desires. However, the roots of this lie in generations of structural racism within our health care system and distrust of health care providers by minority families. This distrust is now reflected in the lower rates of coronavirus disease 2019 immunization in minority communities. It is not due to the Tuskegee study begun 90 years ago but the care received in our hospitals last month and last year.

The third part of injury control in which disparities also occur for injured youth is rehabilitation. In a study of children hospitalized for traumatic brain injury in 2001–2010, uninsured children after a brain injury were less likely to be transferred to inpatient rehabilitation care in 17 of the 18 states examined.¹¹  Even among those who are sent to inpatient rehabilitation, American Indian and Alaskan Native children at discharge have less improvement and worse outcomes than non-Native children do.¹²  Why is that? What is the structural racism within our health care systems that allow such disparities to occur? How can this be changed?

I want to offer some ideas that I think can change these structural differences in the incidence and treatment of injuries to children and adolescents.

First, we must commit ourselves to viewing these differences as unacceptable and a national disgrace. We have to start with the belief that injuries are preventable and the disparities in health care are changeable. There has been a 95% reduction in deaths from motor vehicle crashes per mile driven in the 20th century because of safer cars, safer roads, more use of seat belts and air bags, and less drunk driving. Why have we not seen a 95% reduction in firearm deaths? How much of the efforts right now in state legislatures and Congress to block legislation that would lessen the toll of firearms is really about racism couched in the rights of individuals to own guns to protect their families? In a national survey conducted during the pandemic, the most common reason people gave for buying a firearm was self-protection against other people.¹³  Pediatricians have long been activists in advocating for policy changes and legislation that reduce injuries. Pediatricians through their professional organizations, particularly at the local and state level, should advocate for effective legislation on reducing the incidence of firearm injuries and deaths. Counseling on substance abuse should be routine in all pediatric offices and for all adolescents regardless of perceived risk.

Second is our infrastructure. There is much in the news about President Biden’s proposal to revitalize and invest in our infrastructure, broadly defined. We must advocate that this effort both makes children a priority and that it be used to eliminate the structural racism that has been responsible for the toll of injuries in vulnerable communities. Pediatricians must lead efforts to make the child tax credit permanent because it has now been shown to reduce poverty substantially during the pandemic.

Third is addressing some of the underlying issues of violence. Reduction of deaths from violence is hard but let me offer two actions that we as pediatricians can do. We need to ensure that all children receive quality education, starting with early childhood education. Multiple studies have shown that interventions to provide this to children have made large differences in the lives of children and have been extremely cost-effective. However, the children of color we see in our practices every day also need quality education but are the least likely to receive it. Counseling parents to enroll their children in quality early educational programs is key. Pediatricians should routinely query if their patients are succeeding in school and must play a proactive role in identifying problems and seeking evaluations and intervention if they are not.

Fourth, we must advocate for keeping youth out of jail. We all know of the disproportionate arrest and incarceration of youth from vulnerable populations, whether they be people of color or are just poor. There is overwhelming evidence that shows putting youth together in a prison teaches them one thing: how to be better criminals. In Seattle, the public health department is working with the county toward a goal of 0 youth detention. Other communities should follow suit. Pediatricians have the important role of identifying behavior and substance abuse problems early and intervening to prevent youth from entering the pathways to violence.

Finally, each of us needs to honestly look at our hospitals and clinical programs and identify the structural racism that is there and work to eliminate it. This will take more than statements on our Web pages and attendance at equity, diversity, and inclusion classes. It takes real commitment to identify the problems and make structural changes throughout the health care enterprise.

Consider a thought experiment. What if Black and American Indian and Alaskan Native children had the same rates of injury deaths as White children did over the last 20 years? There would be >24 000 more Black individuals and 2400 more American Indian and Alaskan Natives alive today. But also consider the reverse. What if White children had grown up in the same neighborhoods as Black children and received the same trauma care as Black children? What if White children and adolescents had the same death rates as Black youth over the last two decades? A total of 108 622 more White children would have died. If these rates of death would not be acceptable for White children, why have they been tolerated for Black children?

I am hopeful for the future because of the commitment and energy of our students, residents and younger faculty in bringing about change for a more equitable society and health care system. I am also hopeful because there have been dramatic reductions overall in deaths from injuries to children and adolescents in the United States over the last 40 years. We know how to do it. However, we have been able to accomplish this more in White children then in children of color, more in wealthy children then in poor children, and more in suburban areas than in inner cities. Admitting that these disparities lie in structural racism is the first step in changing these risk factors and improving outcomes. We can and must do better.