by Cameron Takmil, February 24, 2024

Millions of children visit the emergency room every year with cuts, bruises, and a myriad of other diagnoses. Many are turned away from necessary treatments for seemingly nothing except one thing – race. While seemingly trivial, disparities across racial and ethnic lines persist, underscoring a critical need for systemic reform. Recent research spearheaded by experts at Northwestern revealed that healthcare inequities are widespread, affecting non-white minorities profoundly in pediatric care. 

The most concerning disparity was in pain management. When comparing kids of color to their white counterparts, they were not given proper medication at the same rate (Godoy 2024). 

These disparities manifest in other ways, including but not limited to diagnostic imaging, surgical complications, emergency care wait times, and treatment for developmental disabilities. Children of color often get the short end of the stick in these circumstances, receiving less than optimal care. UCLA researchers determined that white pediatric patients were more likely to receive sepsis treatment, compared to their black counterparts who also were less likely to be given full diagnostic testing through automated sepsis-alert systems (Li et. al 2022).

Premature infants of color tend to have increased rates of morbidities with regard to bronchopulmonary dysplasia, intraventricular hemorrhage, and necrotizing enterocolitis (Fanta et. al 2021). Those same infants generally had a lower birth weight, were born more prematurely, and had a higher mortality rate compared to white infants.

Differences lie not only in physical health, as mental health has seen its fair share of disparities amongst pediatric patients. Post-diagnosis, Latino and Black children receive medication and treatment at a lesser rate than White children (Fanta et. al 2021). Underdiagnosed and undertreated, patients of color were less likely to be evaluated on evidence-based mental health care and be given the correct medication all in all.

These inequalities persist despite the families having insurance, pointing towards the idea that these disparities are caused by other factors (Godoy 2024). Nevertheless, Hispanic and Black populations were much less likely to be uninsured, which is another hindrance in access to ubiquitous healthcare (Zhang et. al 2019).

The source of these inequalities stems from decades-long structural racism. Race-based residential segregation, institutional racism, and concentrated poverty have led and in many cases today, continues to worsen quality of housing, safety, and healthcare access and quality. A Harvard study found that in nearly all of the largest urban areas in the United States, two-thirds of non-Hispanic Black children and more than half of Hispanic children lived in areas graded as low- or very low opportunity (Slopen, Heard-Garris 2021). On the other hand, fewer than 1 in 5 Asian or White children live in low- or very low opportunity neighborhoods, clearly more affluent than their minority counterparts.

Government programs that have kept many afloat are slowly falling to the wayside, exposing vulnerable populations to even worse conditions. The Special Supplemental Nutrition Program for Women, Infants and Children, or WIC, served nearly half of the U.S’s infant population, and over six million children overall (Center for Health Journalism 2024). WIC has been able to improve birth metrics such as birth weight, preterm birth, and infant mortality rates. Despite being seemingly essential, the refusal by Congress to adjust its budget has put close to a million Americans at risk of losing their benefits.

These disadvantages extend into overall health as “toxic stress” – a term used by researchers at the Dana-Farber Cancer Institute – leads to negative consequences in physical and psychological health. Their study discovered that adversity during childhood was associated with poorer neurocognitive, neonatal, and cardiovascular health (Umaretiya et. al 2022). Due to red-lining – residential segregation policy in the 20th century – environmental risk is increased in more impoverished areas, posing a risk of safety and exposure to its residents (Samuelson 2024). Pediatric patients of color who live in these areas with higher density of housing code violations are more likely to be admitted and return to the ED due to asthma and related complications  (Fanta et. al 2021). 

If that was not enough to overcome, this prejudice has been baked into society with false, harmful, and misleading stereotypes, which many internalize, whether consciously or subconsciously. Minority parents, especially Hispanic parents, frequently report that healthcare providers do not dedicate sufficient time to understand their child’s needs, respect their parenting expertise, or align with their child-rearing preferences (Flores 2005). These same populations also reported that topics such as community violence, household smoking, alcohol usage, issues paying for the child’s basic needs, and spouse/partner support were discussed more frequently than white parents.

These sentiments extend far beyond healthcare, as anti-minority beliefs have come to the forefront in the past years. According to a recent national survey, “51% of whites think that blacks are prone to violence, whereas only 16% of whites think that whites are prone to violence” (Flores 2005). In the doctor’s office, we see much of the same, as the prevalence in which community violence was discussed quadrupled and tripled for Hispanic and Black patients respectively. Similar trends were found with regard to substance use, even in families where average income exceeded $75,000 (Flores 2005). 

This gap in communication and understanding only exacerbates the feeling of marginalization and can lead to decreased satisfaction with care and impaired patient-provider communication. These same minority populations have been reported to have higher levels of distrust of their provider, mainly due to implicit and explicit discrimination (Umaretiya et. al 2022). Such interactions might not only perpetuate discrimination but also detract from providers’ ability to educate, inform, and aid these patients.

It is not all hopeless, though, as there is a pathway for solutions to reduce the gap between patients of color and white patients. Addressing and solving disparities in pediatric healthcare is a multifaceted challenge that demands an in-depth and multidisciplinary approach. The strategies to promote health equity in pediatrics can be categorized into three levels: individual, institutional, and structural as demonstrated in research (Fanta et. al 2021). 

At the individual level, healthcare professionals can make up ground by engaging in continuous professional development focused on understanding and mitigating the impact of interpersonal racism, discrimination, and bias on pediatric health inequities (Fanta et. al 2021). It is crucial to educate providers on not only their explicit biases, but more importantly their implicit biases that they might not be aware of. Through this, a mindset of cultural humility and openness, being other-oriented, and recognizing the impact of power dynamics on building trusting relationships with patients and their families can be cultivated. 

These shortcomings of healthcare are not only the responsibility of the providers to ameliorate, as the onus is on institutions to invoke change themselves. Diversifying the workforce can enhance the relatability and effectiveness of the patient-provider relationship (Fanta et. al 2021). This could help patients feel more comfortable with providers who might be more apt to understand their plight. 

In a broader sense, addressing structural disparities requires moving outside of the healthcare system and advocating for policy reform aimed at eliminating inequities in critical social determinants of health. These determinants include healthcare access and quality, economic stability, education, neighborhood and built environment, and social and community context (Fanta et. al 2021). A study from Dana-Farber notes that adopting universal and systematic social determinants of health – coined as SDOH in their paper – screening within pediatric care can identify key areas where interventions can be most effective (Umaretiya et. al 2022). Identifying the specific root causes on a patient-to-patient basis will allow for much more optimized solutions.

Something as simple as integrating SDOH screens into each visit, within national pediatric protocols, can help identify mechanisms driving disparities and opportunities for intervention (Jindal et. al 2024). Developing multilevel health equity interventions that address identified pathways, such as access to care, patient-health-care-system interaction, and the impact of toxic stress, is crucial (Umaretiya et. al 2022).

It will be imperative to focus on improving the various systems that lead to poorer healthcare outcomes for pediatric patients of color. Efforts to dismantle the underlying racism that perpetuates pediatric racial and ethnic health inequities must focus on policies within multiple interdependent systems. This includes challenging housing policies that sustain poor housing, limiting access to resources like high-quality education and healthcare, and increasing exposure to environmental risk factors (Jindal et. al 2024). Enhancing family resilience through evidence-based psychosocial interventions can also play a role in mitigating the effects of toxic stress (Umaretiya et. al 2022).

To effectively reduce and solve disparities in pediatric healthcare, a concerted effort from all stakeholders—healthcare providers, institutions, policymakers, and communities—is required. This involves addressing not only the immediate healthcare needs of children but also the broader structural and social determinants of health that contribute to disparities. By implementing these strategies at the individual, institutional, and structural levels, we can move closer to achieving health equity in pediatrics, ensuring that all children have the opportunity to thrive and reach their full health potential.

Bibliography

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