How Pediatric Care Providers Are Identifying and Addressing the Impacts of Racism on Children

Last year, in explaining why he quit a job he’d once loved, pediatrician Benjamin Danielson, M.D., described the torment of seeing a Black parent whose son was being treated for a lung condition being reported to child welfare authorities. Hospital staff told Danielson — now a clinical professor of pediatrics at the University of Washington School of Medicine — the boy’s mother wasn’t exhibiting the emotional response they expected, and they questioned whether she understood the severity of his illness and could adequately care for him. The mother confided in Danielson, a Black doctor she’d known for more than a decade, that she was troubled by their questioning and was terrified of showing any emotion for fear of being separated from her son.

As Danielson came to learn, she and her siblings had been placed in foster care as children after their own mother had become frustrated and angry with hospital staff caring for one of her siblings. Danielson, who knew his patient’s mother to be a loving and capable caregiver, saw not just the trauma the child welfare system inflicts, but also the exhaustion the woman was experiencing juggling her job, other child care obligations, and the hour-long bus ride to the hospital. Having to attend additional meetings and conform to the child welfare agency’s expectations only made matters worse: eventually, the mother lost her job, putting a family with few resources into an even more precarious position.  

Danielson published this account in a Health Affairs essay that appealed to pediatric providers to address racism in pediatric care. In it, Danielson pointed to disparate treatment in many forms, including subjecting Black families to greater scrutiny and punishment. Research has shown that Black patients and their visitors are more likely to have hospital security called on them. They are more likely to be labeled by health care providers in medical records as “aggressive” or “noncompliant.” And Black parents are more likely than white parents to be suspected of and reported for child abuse.

Dorothy Roberts, J.D., a professor of law and sociology at the University of Pennsylvania and author of Torn Apart: How the Child Welfare System Destroys Black Families — and How Abolition Can Build a Safer World, says hospitals can be a place of terror for poor families, given the tendency of staff to conflate poverty with neglect — and the ease with which a report to child welfare authorities can lead to a traumatizing investigation and a child’s placement in foster care. “Hospitals and other health care settings shouldn’t be places where people are afraid to get help for fear of triggering an investigation that might tear a family apart,” she says.

In this issue of Transforming Care, we consider the roles of implicit bias and structural racism in creating and perpetuating racial health disparities in pediatric care. Implicit bias refers to learned stereotypes and prejudices that operate automatically and unconsciously, while structural racism takes into account the many ways societies foster racial discrimination through housing, education, employment, media, health care, criminal justice, and other systems. We focus on these factors more than on interpersonal racism, or negative feelings or prejudices that play out between individuals, because while the latter is important, the former are more likely to be undetected or unacknowledged. Our goal is to shine a light on these problems and to point to concrete steps pediatric providers can take to address them.

Reviewing Security Practices in Children’s Hospitals

As part of efforts to use data to promote diversity, equity, and inclusion (DEI), Children’s National Hospital in Washington, D.C., has engaged both families and providers to identify and try to address inequities in care.

This process revealed that, in some instances, families felt staff weren’t properly addressing their child’s pain. If parents raised their voices or swore in a bid to have their concerns taken more seriously, some staff would call hospital security. “For Black and brown patients, that’s like throwing salt in the wound,” says Denice Cora-Bramble, M.D., M.B.A., chief diversity officer at Children’s National. “The last thing you want to see when you’re in crisis, when you’re in a hospital room, is the police.”

To avoid this, Children’s National created Social Work Intervention with Families and Teams (SWIFT), a program that dispatches pairs of social workers to medical units where bedside nurses or other staff report a conflict, either between parents themselves or between parents and staff. The social workers, who are trained in crisis intervention, de-escalation, and attentive listening techniques, meet separately with parents (or caregivers) and staff and then develop a plan for resolving the dispute. Among 216 instances when SWIFT teams were summoned, the majority (84%) were resolved without calling security.

In addition to addressing problems as they happen, leaders have sought to learn from them by having monthly reviews of all SWIFT interventions. “We want to make sure parents’ and other caregivers’ concerns are heard and that they can stay at children’s bedside. We also want staff to know we support them,” says Brenda Shepherd-Vernon, M.S.W., LICSW, LCSW-C, director of the Department of Family Services at Children’s National, who helped develop SWIFT.

The monthly reviews allow the team to assess how and when the SWIFT team is used and try to make systemic changes to avoid future issues. For example, early results show that nearly two-thirds of the calls involved “high-stress” units in the hospital, including critical and acute care units and emergency departments, where there is often greater uncertainty about a patient’s diagnosis or course of treatment. With most calls (73%) occurring in the evenings, leaders theorize that having fewer staff — including consulting doctors — on hand to answer family members’ questions may also be a factor. Leaders are budgeting to have more social workers on staff during overnight shifts to offer families support.

The SWIFT program is part of broader DEI efforts at Children’s National to foster, nurture, and sustain a culture where patients, families, and employees feel welcomed and respected. This includes a confidential online system where employees can report instances they witness or experience of biased, racist, or other discriminatory behavior. “It’s been one of the most meaningful ways of keeping a finger on the pulse of what’s happening in the hospital,” Cora-Bramble says.

Undoing Judgments and Promoting Health Equity

As the chief resident and then as an assistant professor of internal medicine–pediatrics at Wayne State University School of Medicine, Ijeoma Nnodim Opara, M.D., was struck by the disparaging ways in which colleagues as well as medical students and residents referred to Black patients — from suggesting that they were less knowledgeable or capable to expressing disapproval of parents’ choices regarding their children. “The dishonor and the disrespect were rampant,” she says.

Opara also noticed that some trainees seemed to have little awareness of the economic and cultural contributions Black families had made in the city of Detroit or the ways in which policies like redlining had disadvantaged Black neighborhoods. To counter this, she created the Health Equity and Justice in Medicine training program for internal medicine, internal medicine–pediatrics, and pediatrics residents in 2013.

The mandatory, four-year program — a mix of critical discussion, community engagement, scholarship, and advocacy — seeks to break down walls between the medical residents and the patients they serve. It does so by helping residents understand how a history of disinvestment in the neighborhoods surrounding the hospital affects their patients, and by sending trainees to volunteer at food banks, reentry programs, and other nonprofits that are working to strengthen their community.

Opara hopes that the course will empower residents to speak up when they hear or see racist or other discriminatory behaviors and will embolden them to advocate for policy changes. “We have children dealing with poverty, with the aftereffects of a family member being incarcerated, with neighborhood safety concerns, and a public school system that is struggling,” says Opara. “As doctors, you can’t fix all of these problems. But if you understand how patients’ life experience informs their clinical presentation, you are a better doctor for it and you can advocate more effectively on their behalf.”

Opara says the program has been a draw for residency candidates, who sometimes question their ability to effect change: “I say, ‘What are you talking about? The civil rights movement was populated by young people. You have incredible power because academic health centers cannot exist without you.’”

Listening to What Communities Say They Need

In June 2022, just as the team fielding the Community Health Needs Assessment for Akron Children’s Hospital, in Akron, Ohio, was wrapping up its surveys and conversations with community members, Jayland Walker, a young Black man, was shot and killed by Akron police. Families were shaken, especially parents of Black boys who worried about their sons’ safety, but respondents also noted that the shooting was just the latest incident fueling longstanding concerns about policing, gun violence, and safety. Overall, more than 18 percent of parents and caregivers said their children didn’t feel safe in their neighborhoods, with significantly higher rates of low-income Black families reporting this as an issue.

The assessment revealed that children’s mental health was also a top concern. Surveys of Ohio high school students found startlingly high rates of suicidal ideation among Hispanic and Black children, mirroring the national trends that spurred the Congressional Black Caucus to form the Emergency Task Force on Black Youth Suicide and Mental Health. Parents in Akron’s 12-county service region said they struggled when they sought to get help for their children’s stress, anxiety, or other mental health concerns. In Northeast Ohio and nationally, there are shortages of behavioral health providers, and many psychiatrists don’t accept Medicaid, which is the source of coverage for 60 percent of Black youth.

In response to community feedback, Akron Children’s has focused first on the areas over which it has most control. For example, leaders are working to make it easier for families to access mental health services, including by integrating behavioral health services into more of its primary care clinics (they’re now available at 33 of 35 clinics) and by training primary care providers to screen for behavioral health concerns such as anxiety and depression. To support primary care and behavioral health providers, Akron Children’s offers them the opportunity to have e-consults with specialists through Project ECHO. Patients can also access counseling and psychiatric services through telehealth.

With grant funding, the hospital has trained close to 500 employees and volunteers, as well as 60 members of the community, on how to recognize and respond to signs of suicidal ideation. Staff have also distributed lockboxes and/or gun locks as part of Zero Suicide, an approach that enlists health care providers in preventing suicide. In addition, the health system created a webinar, viewed by 1,000 staff and members of the community, on how to serve as an ally to LGBTQ+ youth, who are nearly five times more likely to attempt suicide than their heterosexual peers.

Akron Children’s also heard from some families that want more time to discuss their concerns with providers. In response, the health system has extended the length of visits by 15 minutes when a mental health concern is raised. “We want to give providers time to dig a little bit deeper and ask more questions and be able to listen with more purpose,” says Bernett Williams, M.P.A., chief diversity, equity and inclusion officer and vice president for community initiatives at Akron Children’s Hospital.

Identifying and Countering the Health Effects of Racism

Nia Heard-Garris, M.D., a pediatrician and researcher in the Department of Pediatrics at Feinberg School of Medicine at Northwestern University and the Ann & Robert H. Lurie Children’s Hospital, in Chicago, grew up shuttling between her divorced parents’ homes. Even though their homes were in adjacent neighborhoods of Cincinnati, one was much wealthier than the other and Heard-Garris was struck by the differences. “They were worlds apart,” she says. “One group of friends always talked about college and the future. And the other group was just trying to get through the day-to-day.”

These and other experiences fueled Heard-Garris’s interest in how adverse childhood experiences (ACEs) affect health and what might help youth cope with adversity. In an ongoing study, Heard-Garris and her colleagues are asking teens about their experiences. In addition to asking about their experiences of abuse, neglect, whether they live with someone who uses substances, and other traditional ACE questions, they are asking teens about their experiences of discrimination, racism, and the COVID-19 pandemic. Then, without identifying particular respondents, researchers pair that information with data from electronic medical records to explore how these experiences affect teens’ blood pressure, risk factors for diabetes, and other factors related to cardiovascular health. The study relies on a waiver that lets researchers ask teens directly about their experiences, instead of relying on parents’ reports; 200 teens have participated so far.

Teens who are interested in further research are invited to take part in an eight-week program that adapts an approach developed by Northwestern social psychologist Judith Moskowitz, Ph.D., to improve psychological and physical well-being. In addition to teaching teens skills to cope with stress and anxiety, the study is exploring whether engaging Black and Hispanic teens in advocating for an issue they care about — be it criminal justice reform, reducing gun violence, or something else — can be healing. “We’re trying to understand activism as a way to cope with racism-related stressors and life in general,” says Heard-Garris. “We're giving teens coping skills, but also teaching them how to change their environment in ways that lessen adversity either for themselves or others.”

Building Wealth and Housing Security to Promote Health   

In 2021, Boston Medical Center (BMC) established a Health Equity Accelerator to improve health outcomes for Black, Hispanic, and/or Latino/Latina patients, who make up roughly two-thirds of the health system’s patients. Part of its strategy is to undo the damage of redlining and racial segregation, which denied many families of color access to jobs and generational wealth.

One effort focuses on jobs: the health system has hired over 700 people from seven zip codes in Boston that were subject to redlining and other historical disinvestments and where residents have higher rates of chronic health conditions. People were hired to positions that have growth prospects, such as pharmacy technicians and medical laboratory technicians. “We know there are health benefits to economic mobility. For us, economic mobility equals health equity,” says Petrina Martin Cherry, M.B.A., BMC’s vice president of community engagement and external affairs.

The medical center has also zeroed in on housing. “Having a stable home you can afford becomes an easy way to talk about how economic policy decisions in the past translate to differences in health today,” says Megan Sandel, M.D., M.P.H., codirector of BMC’s Grow Clinic for Children, which treats children who are failing to thrive, sometimes because their families must choose between paying rent and buying food. Most come from neighborhoods of Boston where a majority of residents live in poverty.

Families with children who have chronic health conditions or other special health care needs are at great risk of living in poverty and of experiencing homelessness. From 2016 to 2020, Sandel and her colleagues tested whether helping such families to find more stable housing improved their physical and mental health. The majority of the 78 families they recruited for a randomized, controlled trial of their Housing Prescriptions as Health Care intervention were experiencing homelessness; others had to move frequently, often fell behind on rent, and/or put more than half of their income toward rent.

Participants — of whom more than 90 percent identified as Black, Hispanic, and/or Latino/Latina — were randomized into two groups. The intervention group received priority placements in affordable housing and case management services to help with their health as well as financial and legal needs, while the other group received the usual hospital-based social work services and referrals to housing supports.

After six months, the percentage of children in the intervention group with fair or poor health fell by 32 points. Average scores on measures of anxiety and depression also fell among parents in the intervention group, as compared to controls. "Some families were still waiting for better housing after six months, but they felt like there was someone in their corner, and that seemed to help,” says Allison Bovell-Ammon, M.Div., former director of policy and communications at BMC’s Children’s HealthWatch and a coauthor of the study. The team is now assessing the impact of the intervention on health care spending. Meanwhile, Massachusetts has used the pilot data to develop pools of housing vouchers reserved for families with significant medical needs.

Moving Forward

Seattle Children’s, the health system from which Danielson resigned in protest in 2020, has had a Center for Diversity and Health Equity for 17 years. But Danielson’s resignation and the ensuing external assessment of Seattle Children’s efforts to combat racism and promote equity — conducted by former U.S. Attorney General Eric Holder and his law firm, Covington & Burling — prompted the health system to invest more heavily in advancing health equity.

Seattle Children’s has developed an equity dashboard tracking 28 quality measures used by children’s hospitals across the U.S. to benchmark performance. The measures are now reported by patients’ race, ethnicity, and language, and the results are shared with all employees. “There’s an expectation that every single measure on that dashboard will have an equity initiative that is going to improve a disparity, wherever it may be,” says Alicia Tieder, M.S.W., Seattle Children’s chief diversity officer.

The center has also hired eight additional staff with expertise in public health, social work, and social justice, among other subjects, to support health system staff in achieving a wide range of goals, including diversifying the workforce so that it reflects the patients Seattle Children’s serves. Its executive leadership team has evolved from having no one who identifies as racially or ethnically diverse in 2017 to 45.5 percent who do so in 2022.

Tieder’s team also led work to change Seattle Children’s security response system, resulting in an approach similar to that of Children’s National, after Holder’s report recommended that the health system institute new practices to eliminate racial disparities in policing practices that Holder said had been known since 2013, but not acted upon. A team of physicians and social workers is also working with the hospital’s risk managers and legal team to standardize practices regarding child welfare reporting. “We have to be really thoughtful about when, why, and how we’re going to make a referral to Child Protective Services,” Tieder says.

As children’s hospitals and other pediatric providers undertake similar efforts to identify and undo racist practices, including listening to and learning from families and staff, it remains to be seen whether these nascent efforts will move the needle on longstanding racial health disparities. Heard-Garris of Northwestern and her colleagues have called for much more research to understand the links between children’s experiences of racism and racial health disparities. But, she says, at least many people in the field have begun naming the problems: “When I started this work, no one was talking about racism explicitly, I'd get pushback when I brought it up,” she says. “I don’t have to do that as much anymore.”