Residency · Residency · Pediatrics
Health Disparities and Antiracism in Pediatric Practice
Introduction
Health disparities are preventable differences in health outcomes and their determinants that are closely linked to social, economic, and environmental disadvantage. In pediatrics, these disparities are evident from birth and accumulate across the lifespan, affecting virtually every measurable health outcome. Race is a social construct, not a biological one, yet racial and ethnic minorities in the United States experience consistently worse health outcomes across the spectrum of child health. Addressing health disparities requires understanding the historical and structural roots of inequity and actively integrating antiracist principles into clinical practice, education, and policy. The AAP has declared racism a core determinant of health inequity and a public health crisis.
Scope of Pediatric Health Disparities
Birth Outcomes
The Black infant mortality rate is approximately 2.3 times that of White infants, a disparity that has persisted for decades. Black women have a 50% higher rate of preterm delivery compared to White women, regardless of income or education level. Low birth weight disproportionately affects Black infants and contributes to neonatal morbidity and downstream developmental outcomes. These disparities persist after adjusting for socioeconomic status, suggesting that racism itself, through chronic stress and structural barriers, is a direct contributor.
Childhood Chronic Disease
Black and Puerto Rican children have 2-3 times higher asthma prevalence and hospitalization rates, driven by environmental exposures (housing quality, air pollution) and differential access to specialty care. Hispanic and Black children have significantly higher obesity prevalence, linked to food deserts, marketing of unhealthy foods in minority communities, and limited safe spaces for physical activity. Racial disparities in type 2 diabetes incidence, HbA1c control, and complication rates are well documented, and type 1 diabetes management outcomes are worse in minority children even within the same healthcare system. Minority children have lower rates of mental health service utilization despite similar or higher rates of exposure to trauma and adverse experiences, with cultural stigma, language barriers, and provider shortages contributing to this gap.
Access to Care
Hispanic children are the most likely to be uninsured, with immigration status, language barriers, and enrollment complexity contributing to this disparity. Children on Medicaid have reduced access to specialists, longer wait times, and lower reimbursement that discourages provider participation. Geographic disparities affect rural communities and urban underserved areas, which have fewer pediatricians, subspecialists, and mental health providers per capita. Families with limited English proficiency receive lower quality care, less preventive care, and experience more medical errors, though professional interpreters improve outcomes when utilized.
<image>Infographic displaying key pediatric health disparities across racial and ethnic groups in the United States, including bar graphs comparing infant mortality rates, preterm birth rates, asthma hospitalization rates, obesity prevalence, and uninsured rates between White, Black, Hispanic, American Indian/Alaska Native, and Asian/Pacific Islander children, with structural determinants (residential segregation, environmental exposures, insurance access, provider availability) annotated as contributing factors</image>
Understanding Racism as a Health Determinant
Levels of Racism
Structural or institutional racism refers to policies and practices embedded in social, economic, and political systems that produce and maintain racial inequity, including redlining, school funding formulas tied to property tax, mass incarceration, and immigration enforcement. Interpersonal racism encompasses discriminatory interactions between individuals, including explicit bias (conscious prejudice) and implicit bias (unconscious associations that influence behavior and decision-making). Internalized racism involves the acceptance of negative societal messages about one's own racial group, contributing to decreased self-efficacy, psychological distress, and reduced healthcare seeking.
Racism in Medicine -- Historical Context
The medical profession has a documented history of complicity in racial oppression, including the Tuskegee syphilis study, forced sterilization programs, Henrietta Lacks and the HeLa cells, and exclusion of minorities from clinical trials. This history has produced medical mistrust that persists today and affects healthcare utilization, vaccine acceptance, clinical trial participation, and willingness to disclose information. Race-based medicine, the inappropriate use of race as a biological variable in clinical algorithms (such as race-adjusted eGFR, race corrections in pulmonary function testing, and UTI calculators with race as a variable), can perpetuate disparities by altering treatment thresholds. There is a growing movement to remove race from clinical algorithms or replace it with evidence-based biological variables, such as cystatin C-based eGFR.
Implicit Bias in Clinical Practice
Studies demonstrate that physicians hold implicit biases that affect clinical decision-making, including pain management (with minority children receiving less analgesia for equivalent conditions), referral patterns, communication style, and perceived treatment adherence. The Implicit Association Test (IAT) is a tool for measuring unconscious racial associations. Implicit bias can be mitigated through awareness, structured decision-making tools, standardized clinical protocols, and institutional accountability.
Antiracist Approach in Pediatric Practice
Defining Antiracism
Antiracism is not merely the absence of racist behavior but the active process of identifying, challenging, and changing the values, structures, and behaviors that perpetuate systemic racism. An antiracist approach recognizes that neutrality is insufficient, as inaction in the face of inequity reinforces existing disparities. The goal is equity (resources allocated proportional to need) rather than equality (the same resources for all regardless of baseline disadvantage).
Clinical Practice Changes
Clinical algorithms should be examined for inappropriate use of race, questioning whether race corrections change management and whether they are based on biology or assumption. Standardized clinical protocols should be implemented to reduce bias-dependent variability in care across pain assessment, antibiotic prescribing, referral patterns, and diagnostic testing thresholds. Professional interpreters should be provided for all families with limited English proficiency, and children or untrained staff should never be used as interpreters due to the risk of medical errors, inappropriate burden on the child, and confidentiality concerns. Disaggregated data on health outcomes by race, ethnicity, language, and insurance status should be collected and analyzed within each practice or institution to identify disparities. Diversifying the healthcare workforce is essential, as minority physicians are more likely to practice in underserved communities, and concordant patient-physician race or ethnicity is associated with improved communication, trust, and preventive care utilization.
Training and Education
Implicit bias training should be incorporated into residency curricula, recognizing that single sessions are insufficient and that ongoing reflection and structural change are needed. Cultural humility, preferred over cultural competence, represents a lifelong commitment to self-evaluation, addressing power imbalances, and institutional accountability. Medical education should teach the social construction of race and ensure trainees understand that racial health disparities are driven by racism, not by inherent biological differences between racial groups. Medical education leadership and curricula should be diversified to include the contributions and perspectives of underrepresented groups and to critically examine how race is discussed in teaching materials.
<image>Framework diagram illustrating the multilevel approach to antiracism in pediatric practice, with concentric circles showing individual-level actions (implicit bias awareness, clinical decision-making, communication), practice-level actions (data collection, standardized protocols, interpreter services, diverse hiring), institutional-level actions (diversity pipeline programs, policy review, equity committees), and systemic-level actions (advocacy for health policy, Medicaid expansion, environmental justice, equitable school funding), with bidirectional arrows showing how changes at each level reinforce the others</image>
Community Engagement and Advocacy
Authentic partnerships should be built with communities affected by disparities rather than imposing solutions from outside. Support for community-based organizations that address root causes -- housing advocacy, education equity, environmental justice, and food access -- is essential. Policy advocacy should include efforts for Medicaid expansion, paid family and medical leave, minimum wage increases, affordable housing, environmental regulations, and immigration reform. Environmental racism, including the proximity of polluting industries and waste facilities to minority communities, lead remediation in housing, and clean water access, must be addressed. Pediatric offices can also serve as sites for voter registration and civic engagement.
Institutional Accountability
Healthcare institutions should establish equity committees or diversity, equity, and inclusion infrastructure. Health outcome data stratified by race, ethnicity, language, and socioeconomic status should be tracked and publicly reported. Measurable equity goals with timelines and accountability mechanisms should be set. Recruitment and retention of underrepresented minority physicians, nurses, and staff at all levels, including leadership, is critical. Institutional policies should be reviewed for disparate impact across hiring practices, promotion criteria, vendor contracts, and community investment.
The Pediatrician as Advocate
The AAP has issued policy statements recognizing racism as a public health crisis and calling on pediatricians to take active roles in addressing health disparities. Individual advocacy means ensuring each patient receives equitable care regardless of race, ethnicity, language, or insurance status. Community advocacy involves partnering with schools, faith communities, and local organizations to address social determinants. Policy advocacy includes engaging with legislators on issues affecting child health equity and supporting research funding for disparities reduction. Self-reflection requires regularly examining one's own biases, assumptions, and areas for growth, and creating psychologically safe spaces for colleagues to do the same.
Clinical Pearls
Race is a social construct, not a biological one, and racial health disparities are caused by racism and its downstream effects, not by inherent biological differences. Black infant mortality is 2.3 times that of White infants, a disparity that persists even after controlling for socioeconomic status, implicating structural racism as a direct contributor. Implicit bias affects clinical decision-making in measurable ways, including pain management, referral patterns, and communication, and standardized protocols and awareness can mitigate these effects. Antiracism requires active identification and dismantling of inequitable structures, not just the absence of individual prejudice. Clinical algorithms that use race as a variable (eGFR, pulmonary function tests) should be critically examined and replaced with evidence-based biological markers when possible. Collecting and analyzing health outcome data disaggregated by race, ethnicity, and language within one's own practice is essential to identifying and addressing local disparities.
References
- Trent M, Dooley DG, Douge J, et al. The impact of racism on child and adolescent health. Pediatrics. 2019;144(2):e20191765.
- Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight — reconsidering the use of race correction in clinical algorithms. New England Journal of Medicine. 2020;383(9):874-882.
- Johnson TJ, Winger DG, Hickey RW, et al. Comparison of physician implicit racial bias toward adults versus children. Academic Pediatrics. 2017;17(2):120-126.
- Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annual Review of Public Health. 2019;40:105-125.
