Dr. Nia Heard-Garris was startled when her 4-year-old son came home from preschool one day and declared, “Mommy, sometimes I’m white.”
As a pediatrician who studies the impact of racism on children’s health and the mother of a Black boy with caramel skin, she carefully inquired further. He told her one of his friends said he only played with white kids.
“He just told the boy, ‘OK, I’m white today then.’ This kid was fine with that answer and let him play,” Heard-Garris, a pediatrics researcher at the Feinberg School of Medicine at Northwestern University in Chicago, told TODAY.
“My No. 1 job as his parent is to keep him safe and try to help protect him from some of those things. However, the world is the world and I wasn’t expecting at 4, he would have to start to navigate these experiences.”
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As kids get older, these experiences get more intense, said Heard-Garris, who wrote about the incident in JAMA Pediatrics. They may also do real damage.
Racism is a core social determinant of health that has a profound impact on the health of children, adolescents, young adults and their families, the American Academy of Pediatrics said in its first policy statement on the subject, issued in 2019 and citing 180 studies and papers.
“Racism harms children’s health, starting from before they are born," said Dr. Sally Goza, the AAP’s president, in June.
Toxic stress
Researchers studying the impact said it affects kids’ physical health, mental health and development.
When children are targets of racism, they experience chronic stress and are flooded with stress hormones like cortisol, leading to inflammatory reactions, noted Dr. Maria Trent, coauthor of AAP’s policy statement and a pediatrics professor at the Johns Hopkins University School of Medicine in Baltimore.
This can harm kids’ health in the short term, “but also may create long-term problems like heart disease, diabetes and depression,” Trent wrote in an essay for Children’s Rights.
The mental health aspects of racism on children’s health may be better known, Heard-Garris said. That includes the impact of bias kids experience directly or second-hand — perhaps witnessing their parents being the targets — and the effects of both are similar, she noted.
Children’s exposure to discrimination was linked with higher rates of attention deficit hyperactivity disorder, anxiety and depression, and decreased general health in a 2017 study.
It could lead to behavioral issues such as aggression and hostility, but also being withdrawn and feeling socially isolated, Heard-Garris said.
“The self-esteem is a part of it, and feelings of hopelessness and helplessness. Those tend to come out especially around events like we’re seeing now — feeling like the weight of the world is on your shoulders,” she noted.
Kids tell her, “Sometimes it feels like nothing will change. Sometimes it feels so big.”
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Mistrust of health care system
There’s also the issue of unconscious bias in the health care system, which often unknowingly interacts with people of color differently than with other patients, said Dr. Ray Bignall, a pediatric nephrologist at Nationwide Children's Hospital in Columbus, Ohio.
He’s particularly concerned about how doctors and other health professionals interface with children in ways that are overtly or covertly racist, which leads to mistrust and delay in treatment. That, in turn, can lead to worse health outcomes for minority kids.
“There are many families who are very hesitant and skeptical of accessing pediatric care,” Bignall said.
“Every African-American person in the U.S., I would venture to guess, so many of us have a story about how the medical system didn’t listen to us or our family member.”
He recalled getting involved in the case of a Black boy with kidney disease whose chart contained complaints about his family not following through on doctors’ recommendations. Bignall’s white colleague had initially provided care, and when Bignall talked to the boy’s mother during a follow-up visit, she told him she almost didn’t come because the other doctor essentially threatened to call child protective services if she didn’t follow the care recommendations more consistently.
When Bignall asked his colleague about it, “the comment he made to me was, ‘I know that I can talk with them this way because we have such a good rapport that I feel like I could kind of light a fire underneath her to look after her kid better,’” Bignall recalled.
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“It was such a striking dichotomy from the experience she had shared with me. It really underscores the challenge that a lot of Black patients have.”
Bignall didn’t know whether the other doctor would have said the same thing to a white family, but in his experience, there’s a different threshold for being proscriptive and less collaborative when dealing with ethnic minority families and those who come from a background of social disadvantage, he said.
When Bignall took over the boy’s care, he found out his father had recently died and the family didn’t have heat in their home in the middle of winter. The label “difficult family” in a child’s chart is sometimes a code word for a family that’s stressed out and struggling even before it has to deal with a sick kid, he said.
Other trends in Bignall’s medical field concern him as well. Black kids are disproportionately more likely to be born premature, which predisposes them to kidney disease, he said. A gene variant found in African-Americans may also play a role.
But if Black kids need specialist care or a kidney transplant, they’re referred for it later in the course of illness than other kids, he noted. “Is this because of physician bias? Or (patient) distrust of the medical system? We need to learn more,” Bignall noted. The delay means kids need dialysis sooner, exposing them to the increased morbidity associated with it.
Black children also wait longer to get a donor kidney and then when they do get it, it fails sooner, he said.
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Long-lasting effects
Racism is a “socially transmitted disease,” the AAP policy statement noted. Teachers treating minority children differently and guidance counselors telling them they shouldn’t think about college — "all of those things are still happening," which leads to those kids not feeling like they’re smart enough, Heard-Garris said.
The health impacts of racism in childhood are extremely long-lasting, added Dr. Monique Jindal, an internal medicine-pediatrics physician at Johns Hopkins Medical Institution.
“When we talk to adults about their experiences of racism, the number of times an adult will bring up an experience from childhood is so common, which just shows you how these experiences stick with you,” Jindal said.
She recalled watching Black kids wait in the emergency room of a hospital and be treated as if they don’t belong there. She said children tell her about hearing disparaging names and comments at school.
“(When) you’re constantly being told you’re not good enough and not valued, there’s this constant internalized racism where you start to believe these things that people say about you. It affects how a child develops their own identity,” Jindal said.
Every African-American person in the U.S., I would venture to guess, so many of us have a story about how the medical system didn’t listen to us or our family member.
Dr. Ray Bignall, pediatric nephrologist at Nationwide Children
“They can internalize it. But then also we’ve seen it can affect what a kid believes they’re capable of doing.”
She recalled treating a 13-year old Black boy who had been assaulted in his neighborhood. After a week in the hospital, he returned because he wasn’t feeling well. Jindal thought it was related to his initial injury, but it turned out he had so much anxiety about what had happened to him that he developed chest pain.
“I asked him, ‘Do you feel safe? How are you feeling?’ And he said, ‘Nobody in the hospital ever asked me that,’” she recalled. “Nobody asked him if he was OK, what his plans were, if he was going to be safe when he went home.”
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What can be done:
All of the experts were hopeful this moment in time was an opportunity for change since people are paying attention to the issue.
There are ways for parents and pediatricians to play an important role. Babies as young as 3 months old can notice the difference in skin color; at age 5, children start to know what’s fair and unfair; and by 12, some children even become set in their beliefs, Jindal said. That’s why it’s important to talk about race with kids.
“Kids are soaking up everything that’s around them and that includes these experiences of racism,” she noted. “Ask them questions, what they do and don’t notice, what they think about that. Kids are very honest creatures, they’ll tell you almost anything.”
“It’s important to talk about differences in race, skin color and all those things because kids are seeing them,” added Heard-Garris.
Meanwhile, pediatricians should be sensitive to the racism children experience and create a medical practice where all families feel welcomed, the AAP noted in its recommendations. When kids report experiencing racism, pediatricians should evaluate their mental health, including signs of post-traumatic stress, anxiety, grief and depression.
The health care field should be more diverse, Bignall said. Black people make up about 13% of the U.S. population, but 5% of doctors, according to the Association of American Medical Colleges. Latinos make up about 18% of the U.S. population, but less than 6% of physicians.
It means that during training in medical school, residencies and fellowships, there’s a lack of diverse perspectives that allow physicians of other backgrounds to better understand how to take care of minority children, Bignall noted.
“Non-white patients should not require a race-matched provider to receive a standard of care that is equitable and dignified,” wrote Dr. Rhea Boyd, a pediatrician in the San Francisco Bay Area, in The Lancet in 2019.
Bignall and Heard-Garris also supported policy changes addressing everything from inclusion to food and housing insecurity.
“If we put a Band-Aid on a really big problem… then this problem is just going to keep coming up,” Heard-Garris said. “Kids unfortunately will bear the brunt of it.”
