‘Structural racism’ in the US affecting healthcare of black and hispanic children says Lancet report

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The medical journal, the Lancet, has released two papers called Lancet Child & Adolescent Health in which it shows that paediatric care for non-white children is worse than white children across the USA.

The series finds that policy reform is urgently needed to address disparities.

The papers state that: ‘A review of recent evidence reveals widespread patterns of inequitable care across paediatric specialties, including neonatal care, emergency medicine, surgery, developmental disabilities, mental health care, and palliative care, regardless of health insurance status.

The authors call for policies to counteract ‘structural racism embedded in society including housing, employment, health insurance, immigration, and the criminal justice system’, that could help address health inequities and thereby improve the health of children from racial and minority ethnic groups in the USA.

From neonatal and primary care to emergency medicine and surgery, the quality of healthcare received by minority ethnic children in the USA is almost universally worse compared to their white peers.

Overcoming these pervasive healthcare inequities – borne of structural racism – requires policy changes in multiple sectors of wider society, including housing, health insurance, and the criminal justice system.

Series author Dr Monique Jindal, of University of Illinois Chicago School of Medicine, said: ‘There are deeply entrenched racial disparities that span broad sectors of US society and transcend generations.

‘These lead to, among other disadvantages, stark inequities in healthcare for children from minoritised racial and ethnic groups.

‘There is a critical need for far-reaching policy changes that directly address deep-rooted structural racism at its core.’

The series reveals extensive inequities in care across paediatric specialties, including neonatal care, emergency medicine, and palliative care.’

By limiting the review to studies that controlled for health insurance status, the authors identified differences in care quality that are not due to a lack of access to health services.

Evidence from the past five years indicates infants from minoritised racial and ethnic groups, particularly black and Hispanic children, consistently receive lower-quality neonatal care than White infants.

In primary care, there is poorer quality communication between healthcare providers and children, youth and families from minoritised racial and ethnic groups, contributing to persistent inequalities.

Disparities also exist in end-of-life care, the study found.

Black, Hispanic, and Asian American children who receive palliative care are more likely to die in the hospital compared to White children. Hispanic children are also more likely to receive medically-intense care during their last days of life.

Differences in wait times, triage assessment, and the evaluation of suspected child abuse for children from minoritised racial and ethnic groups were also found for emergency medicine.

The strongest evidence of disparities was in pain management with children from minoritised racial and ethnic groups being less likely than their white peers to receive painkillers for a broken arm or leg, appendicitis, or migraine.

White patients were given more painkillers, antibiotics, IV fluids, and diagnostic imaging – even when not justified on medical grounds.

Disparities exist in the diagnosis of developmental disabilities, with black and Asian children less likely to be diagnosed before preschool or kindergarten as compared to white children, while Latino children with special health care needs receive fewer specialist services than their white peers.

There are also inequities in mental health care services, with lower rates of adequate care for major depressive disorder and ADHD among black, Hispanic, and other children from minoritised racial and ethnic groups compared with white children.

Dr Natalie Slopen, of Harvard University, who led the research review, said: ‘Existing policies and practices at the local, state, and federal levels in the USA create and perpetuate structural racism, leading to paediatric health disparities among minoritised racial and ethnic groups.

These pose significant obstacles to achieving child health equity and highlight the need for policy solutions that directly address entrenched structural racism.

Housing and neighbourhood policies play a major role in health disparities, as housing instability, poor quality, unaffordability, and neighbourhood characteristics significantly influence children’s health outcomes.

Racial disparities in housing – which are deeply rooted in historical policies – persist and impact health outcomes, indicating a need for comprehensive strategies to improve social and economic conditions in segregated neighbourhoods.

Economic and employment policies underscore the impact of low socioeconomic status on children’s health, with racial income gaps persisting and anti-poverty programs needing an anti-racist approach.

Disparities in health insurance access persist, especially for children from minoritised racial and ethnic groups, highlighting the importance of expanding Medicaid and Children’s Health Insurance Program (CHIP) coverage to achieve equity in paediatric health.

The criminal justice system’s disproportionate impact on Black people is linked to numerous ill health effects, emphasising the need for policies that prevent young people from going to prison and mitigating the effects on children with parents in prison.

Immigration policies also have a significant effect on children’s health by determining access to public benefits, with policies enhancing eligibility linked to better paediatric health outcomes.

Series lead, Dr Nia Heard-Garris, of the Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University, said: ‘We now have more evidence than ever that paediatric care in the USA is not only disparate, but inequitable for a large group of children.

‘Policies that advance health justice and reach across institutions, communities, and populations are urgently needed.’

Slopen added: ‘We must fundamentally rethink and redesign systems and policies, not only in healthcare but across the societal spectrum, to promote equitable, excellent health for all children.

The authors point to numerous changes that could be implemented in broad sectors of society, including measures to improve the social and economic conditions of segregated neighbourhoods, which can benefit child health.

The reports also state that: ‘Investments in communities can improve access to resources and opportunities, and has been linked to reduced depression and obesity and increased physical activity. Other measures – such as eviction prevention policies – could also ultimately benefit the health of children from racial and minority ethnic backgrounds.

‘Universal access to health insurance and standardising administrative policies would ultimately deliver greater paediatric health equity.’

They also highlight that policy changes to end racial segregation of paediatric care and enhance the diversity of the medical workforce are needed.

The authors also say further research is needed to better characterise the experiences of Asian American and Native American paediatric patients.