I’m deepening my efforts to be an anti-racist health care provider, following the syllabus outlined by Adiaha Spinks-Franklin. You can go here for an overview of the historical intersection in the U.S. of racism and health. And you can go here to explore implicit biases.

Today, the articles I’m reviewing focus on the present and on my specialty: pediatrics. Each article is linked below and available to the public - no paywall.

Racism and Child Health: A Review of the Literature and Future Directions (2009) by Pachter and Garcia Coll.

The Impact of Racism on Child and Adolescent Health (2019) by Trent et al, Policy Statement from the American Academy of Pediatrics (AAP).

These studies were published 10 years apart. Much changed from 2009 to 2019; some changes are embedded in the texts themselves. For example, the first study (2009) mainly addressed impacts of individual-level racism, with only one sentence in the discussion section indicating a need to consider ‘nested effects’ in future work; the authors were not considering systemic racism. Compare this to the 2019 policy statement, which acknowledged institutional racism within its abstract and repeatedly discussed both ‘structures’ and individuals when considering the roots and impacts of racism. The 2019 paper also suggests structural and policy-level interventions.

Related and striking: In 2009, Pachter and Garcia Coll found only 40 articles ‘reporting empirical research on racism and child health.’ FORTY!! EVER!! This is utterly gobsmacking. Now, I do have some quibbles with the search methodology - notably, they searched only medical databases and assumed social science literature would be well-represented - but regardless the number of studies is shockingly low. Everywhere researchers looked, racism negatively impacted child health…but scientists hadn’t looked very far or hard. Pachter and Garcia Coll therefore limited their call for next steps to Get More Data about racism- define the constructs, develop better instruments of measurements, figure out the theoretical models, and for pete’s sake ASK THE QUESTIONS across a broad range of populations, ages, and health outcomes.

This work has begun. And because of this work, the 2019 paper could reach beyond calls for more research and instead promoted evidence-based interventions. It is not often that I feel emotional reading scientific papers. But I felt empowered and PROUD to be a pediatrician when I read this call to action. It’s so dang good that I’m going to reproduce the whole list of recommendations (with some editing for length). tl;dr: I’ll provide my own context again at the end, scroll down.

AAP 2019 Recommendations for ‘How Pediatricians Can Address and Ameliorate the Effects of Racism on Children and Adolescents’

Examine your own biases

Optimizing Clinical Practice

• Create a culturally safe medical home, including family-centered communication strategies and valid measures of perceived and experienced racism

• Use strategies such as the ‘Raising Resisters’ approach to provide support for youth and families to 1) recognize racism in all its forms, 2) differentiate racism from other forms of unfair treatment or stressors, 3) safely oppose negative messages or behaviors, and 4) counter or replace messages/behaviors with something positive.

• Train clinical and office staff in culturally competent care

• Assess all patients for stressors and social determinants of health and connect families to resources

• When patients report experiencing racism, assess for mental health conditions

• Identify patient and family strengths and assets

• Infuse cultural diversity into Reach Out and Read and other early literacy programs

• Consider engaging in quality improvement evaluation around office-based approaches

• Consider developing medicolegal partnerships to provide resources for families with civil rights concerns

Optimize Workplace Development and Professional Education

• Pediatric training competencies should relate to effective communication across differences

• Encourage the creation of interactive learning communities that promote cultural humility

• Integrate active learning strategies, such as simulation and language immersion

• Diversify the pediatric workforce

• Provide ongoing professional education to reduce implicit biases

Optimize Systems Through Community Engagement, Advocacy, and Public Policy

• Acknowledge that health equity is unachievable unless racism is addressed

• Engage community leaders to create safe playgrounds and health fuood markets

• Advocate for improvements in the quality of education in segregated communities

• Support local educational systems

• Advocate for implicit bias training in schools and for robust training of educators in culturally competent classroom management

• Advocate for increased access to mental health services in school

• Advocate for curricula that are multicultural, multilingual, and reflective of the communities children live in

• Diversify the teacher workforce

• Advocate for alternative strategies to incarceration for nonviolent youth behavior

• Collaborate with first responders and community police by sharing expertise on child and adolescent development, mental health, cultural differences

• Advocate for fair housing practices

‘Acknowledge that health equity is unachievable unless racism is addressed.’ The AAP is not mincing words regarding the stakes here. I am both convinced and convicted. I practice medicine as a developmental behavioral pediatrician, seeing kids with significant behavior and mental health problems. There is so much I can and will add to my practice.

First, I already ask an extensive list of psychosocial questions. But I don’t directly address racism (good grief, Lauren!!). I will look into clinically relevant measures to ask. I want to think of a way to frame the question so that it is meaningful to ask every patient, both to normalize the conversation and so that I am not in the position of determining someone’s race. So I will mull that over and then add it to my ‘social history’ for every patient.

Next, it will be fun to intentionally evaluate the clinic’s books for Reach Out and Read, as well as the toys and books we use in our parent empowerment program. I love finding books written by and centering stories of people of color. I had never thought to bring this passion to work - what a great opportunity!!

I am also excited to look into the ‘Raising Resisters’ strategy outlined above. It sounds like it is based in solid nonviolent communication and resistance theories. Many of my patients are bullied, and I could see connecting these strategies regarding racism to broader strategies around resisting bullying and being an ally instead of a bystander. I sense a future essay…

I am deeply involved in medical education at the institutional and professional level. Incorporating implicit bias education for trainees and beyond is a no-brainer to me. I will look into what the current practices are in my institution and other professional homes. Where I have direct curricular control, I will add this training.

Lastly, I will continue my professional involvement with the schools my patients attend, advocating for culturally competent classroom management and curricula. I will also continue my volunteer work around incarceration.

There is so much work needed to build an anti-racist health care system, and each individual has a different role to play. If you are a parent, please ask your pediatrician what they or their practice is doing to address racism. If you are a pediatrician, please consider the above actions and commit to one in each category - perhaps leave a comment below! Other health care practitioners and indeed all professionals, I would love to hear how your specialty or professional organization is addressing racism. And each and every one of us can advocate to change the unjust policies in our communities around food, housing, education, and incarceration.

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Further Reading:

Racism and its Effects on Pediatric Health - a collection of articles and resources put together by the AAP and the editorial board of Pediatrics