Damning Research Reveals Extent of Pediatrics Care Gap: Children of Color Receive Worse Treatment

Mark Masselli(00:04)
We know our healthcare system has disparities in how adults from minority backgrounds are treated. But the
gap between how children of color and white children are treated is perhaps an unknown, enormous tragedy.
Our guest is the top expert in the problem.

Dr. Nia Heard-Garris (00:19)
I think patients, you know, patients and families that understand or hear about this work, knowing this right, can
help to advocate more effectively for their children, for their sibling, for their nephew, you know, for their
grandkid. And understanding like these disparities exist, whether, you know, people are intentional about it or
not, that if you, if your child has a disability, then maybe that's some point that we need to fight for.

Margaret Flinter (00:48)
Dr. Nia Heard-Garris is a pediatrician and a researcher at the Feinberg School of Medicine at Northwestern
University, and a leader in the American Academy of Pediatrics in addressing childhood inequities.

Dr. Heard-Garris (01:00)
How do we think about disparities in a way that we can work with our policy makers and our legislators to help
make sure that care is more equitable? because we know that policy actually does change things and save lives.
If you think about, even just, you know, the integration of hospitals, hospitals didn't just integrate because they
wanted to. It's because there was legislative action and legislative changes that said, well, we are gonna stop
reimbursing you unless you, integrate your floors. And, and hospitals did it overnight.

Margaret (01:32)
And this is Conversations on Healthcare.

Mark (01:44)
Well, Dr. Nia, Heard-Garris, welcome to Conversations on Healthcare.

Dr. Heard-Garris (01:48)
Thank you so much for having me. I'm so delighted that you chose to take on this topic and excited to connect
with your listeners.

Mark (01:56)
Well, it was your Lancet Child and Adolescent Health piece that was just published. your research review. You
and your co-authors examined dozens of studies from 2017 to 2022. I wonder if we could start though by asking
you what motivated you to undertake this review?

Dr. Heard-Garris (02:16)
You know, Mark, that's a really good question because I don't think a few years ago we would've decided to
take this on had we not been asked. the Lancet emailed me one day and said, Hey, can we jump on a call? we
had this conversation and said, you know, we know that disparities exist for this group and that group, and this
sub-specialty and that sub-specialty, but has there ever been, an article that have, has put it all together so we
can see the whole landscape of pediatrics? Like everybody is in their little silos and have their little niches, but
what about the whole field? What can we say at large? And I said, you know, I've never seen that. I've never
seen a full, like, comprehensive view of pediatrics as we know it. And so really it's because they asked and said,
we, we need somebody to do this. Can you do this? And it felt like a massive undertaking at the time. but I'm
really happy we were able to pull together almost a one-stop shop of what it looks like, what the field of
pediatric looks like. And how does it impact the health and well-being of kids when disparities exist?

Margaret (03:22)
Well, there are so many important findings, and we of course would like to ask you about each of them. I dunno
if we'll have time for each of them, but, but let, let, let's try, first, the strongest disparities between, white
children and children of color involve pain management, which I think is particularly heartbreaking when we
think about children finding that, children of color were less likely than their white peers to get painkillers for a
broken arm or a broken leg for appendicitis, for migraines. And of course, we, we, we ask, is there some worry
here? The children from diverse backgrounds are more likely to get addicted to pain killers. That pain tolerance
is different. What's going on there?

Dr. Heard-Garris (04:02)
It, that is a question that we continue to, to struggle with. And I think some of this is rooted in hundreds of
centuries of racialized thinking and racialized medicine back in the days, and actually it wasn't that long ago, but
when med students still believed and were taught that black, black children, black adults have thicker skin, so
they don't feel pain in the same way, or, they have stronger lungs. And so they can handle more, you know,
infections and harder work. these, these are ideologies that were held in, in times of enslavement, right? To
justify how, black people, especially children were treated. If they're not, if you believe they're not feeling as
much pain, you can inflict more pain, more work, more burden. And those ideologies, those thoughts, those
ideas continue to get passed on into medicine. So much so that you can look at studies from, from maybe even
just 10 years ago where medical students said, yes, I think there's something different about black skin versus
white skin. So you don't need as much pain medicine. You don't need as much attention to, pain. 'cause the the
pain is not there. Or we don't believe that people are in such pain when we think about, children that really deal
with pain crises. So, sickle cell. Sickle cell and how, yeah, how those children and, and also those adults are
seen as we were, you know, we called them drug seekers, right? Like, they're not really in that much pain.
They're just looking for drugs. They're just looking for pain medicine when really they don't need it. And it, and
it's that sort of teaching from medical students, and then they grow up to be, you know, attendings and residents
and trainees, and that keeps it going. And so that's really our thought. This study didn't parse out like why these
disparities exist within pain, but just that they exist. But we do know from years and decades of, of the studies
about the, the beliefs that physicians hold specifically. But with that being said, it, it's, it's unacceptable. You
know, if a kid breaks their arm, if they have appendicitis, if they're having migraines, and in some cases what we
studied was, having a digit replaced. So having a finger or toe replaced, you can imagine, incredibly painful. So
they need adequate pain medicine no matter what race or ethnicity they are.

Mark (06:17)
Absolutely. And you, you found that children of color face longer wait times, for care at the emergency room.
Maybe a couple of questions. How much longer of a wait time are we talking about? And I'm wondering, do
you, know if this is unconscious bias at play?

Dr. Heard-Garris (06:35)
These are all, I mean, you guys are asking the questions that we need. The next study is the next steps to try to
figure out what is happening here. Just in my other work, I know that there are extensive structural barriers to
care for many marginalized groups and many racialized groups. meaning, you know, they might have to access
care that's further away. They don't have as many physicians. their insurance isn't taken everywhere at every
different healthcare facility. and so that could be leading to overcrowding and longer wait times or delays in
care. You don't go, you are like, oh, it's not that bad. Like, I don't wanna wait four hours, five hours in the
emergency room. Or you have waited for four or five hours in the emergency room and you've got your second
shift job. You can't, you can't continue to wait. So we've also found that, racial and ethnic minority, families are
more likely to leave without being seen at all in the emergency room. So they did seek care, they tried and then
for whatever reason had to leave. But to your question and to your point, we need to do more work to try to
figure out what, what is that? What, what are the reasons for that? Is it, you know, accessibility to care? There's
literally not enough places where they can get care, or there's not enough places that will accept insurance, or
there's not enough providers. Like, what, what is the issue here? And how do we rectify it? And again, some of
the stuff I think is ideology and implicit bias and beliefs. If you feel like someone is coming in and you're
triaging, you know, who gets to be seen first versus who is seen less if they're in pain. And again, you have these
beliefs that the pain isn't that bad, they're acting, maybe you're gonna bump them lower on the priority list. But
all of this stuff, we need to continue the, to test and do more research and do more studies and really understand
why and create solutions for these problems.

Margaret (08:22)
Well, Dr. Heard-Garris, your, your systematically going through and, and removing the things that I might start
guessing at as what is, is responsible here. but one of the, one of the ones that really, jumped out at us, was that
providers were less likely to order diagnostic imaging, for children. and, and that not being tied to insurance just
seem to be less likely to order diagnostic imaging. That that seems like one that would be separate from a lot of
other potential issues, pain tolerance and, and the like. any insights into that one on your part?

Dr. Heard-Garris (09:01)
Yeah, so what's interesting about, imaging and treatment in general, so, and we didn't say this earlier, so I'm
glad, I'm really glad you brought this up about insurance because a lot of the studies before, it's difficult, you
know, if, a patient doesn't have insurance, you can definitely explain disparities in care because they don't have
insurance, which is the kind of the first step in healthcare in this country. And so, one of the reasons why we

made sure all of the, the children here, all the children in these studies had insurance is 'cause we wanted to take
that piece away and said, okay, everybody has insurance. We're not saying they all have the same insurance. So
we know there's differences, right? If you have a top tier Cadillac private insurance, right? Versus you have
public insurance that doesn't cover much and you're not allowed to see many providers. There obviously are
inherent differences in there, but at least we can take away the insurance piece and just leave it there. But what
was really interesting about the study and like, help me to even think about how racism, how racialized
medicine, how all these things impact everyone, not just racial and ethnic minorities, is because we white
children were being over-treated. And so, for example, if you're coming in for a cough or a viral illness and
you're a white child, you're more likely to get imaging, you're more likely to get x-rays, and you're more likely
to get, treatments that are not evidence-based, right? Versus if you're a black child, you may be less likely to get
those things. And there's been a big push, against giving treatment and providing more medical, intervention
when it's not needed, especially from a radiological standpoint. We don't wanna expose children to, x-rays if we
don't need to, right? We don't wanna increase their risk, even if it's small, the more x-rays that they get, it's a
higher risk for cancer. And so it, this, this problem, these disparities, this difference in treatment actually
impacts white children too, and it's a problem. And that they're getting more imaging, they're getting more
things that they don't need, probably, again, based on how they look. And the other children are not getting that
same level of care or, care that is unnecessary. And so, yeah, I, I am am hoping that people, when they read this,
this work, they take that away there too. That it's not just black, Latinx, Hispanic, Asian American Indian
children affected. It's really all children. It's all children. And we should be demanding that all children get the
care that they need and the care that they deserve.

Mark (11:33)
Well, well, that's true. All children should be treated equally. But I think our listeners are gonna find these next
findings really heartbreaking. black and Hispanic and Asian American children who receive palliative care are
more likely to die in the hospital compared to white children. And Hispanic children also are more likely to
receive medically intense care during their last days of life. I'm wondering, as you sort of, people hear this, what
kind of reaction have you received from the medical community?

Dr. Heard-Garris (12:05)
Yeah. I'm, I, you know, feel like this one, because it's one of our last findings. It's not when people have picked
up as much, but I think it's actually one of the most important ones. and so I'm, I'm delighted that I just, I love
this, this program because we're del we're delving into these more nuanced, sort of problems. The reason why I
think the most important ones is that palliative care, you know, a lot of these children, there's no more treatment,
either that they want or that they can get. And so really, the, the premise to palliative care is to provide the best
wishes for the child and their family. And for most people, that's not to die in a hospital. And that's not
everybody, but it's a large majority of people don't wanna be at home with their family. They wanna spend their
last hours, or last days, or last weeks or last month in the settings that are familiar. Not a, you know, a heart rate
monitor going off constantly. Not people coming in and outta their room measuring their temperature. They
wanna be at home, right? And so that is extremely heartbreaking. we know that, that this is true as well for
adults that, older or older adults that are black, and Hispanic are more likely to not have those wishes of dying at
home. met. And again, I think we need more research to figure out why that is. I would say one of the reasons
that we found in this study is that they're less likely to get consultants from a palliative care team. That means an
expert that has experience with dying, terminal illness, palliative care people are less likely to think like, let me
consult the palliative care experts for this family. and so as a result, maybe more, maybe less likely to get that,
have the, their wishes met. 'cause as you might imagine, you know, providers, nurses, doctors, respiratory
therapists are there doing their job, right? Their job is to keep that patient alive by any means necessary. And
then the palliative care professionals come in and say, okay, yeah, we know that's what you want, right? But
what does this family want? What does this kid want? How do they wanna spend out their life? Right? And it
may not be in the hospital hearing beeping, going off every five seconds, unable to sleep, unable to have, you
know, all the visitors and all the people around them. and so I'm really happy you brought this up, because from
cradle, really to grave, we're seeing disparities throughout pediatrics and the littlest ones and the ones that are, at
the end of their lives. it just, it's really heartbreaking.

Margaret (14:42)
Yeah, Absolutely. Yeah. Well, we've talked about from, cradle to grave. Let's talk about from sea to shining, sea
shining. I, I think your, your study was national in its focus. Am am I correct on that? You Are absolutely
correct. And, and that would of course lead to the question any differences, urban, rural, northern, southern,
densely populated frontier. Did you see any, anything that you thought, aha, this is, this is a piece we can dig
further and see why the differences, anything like that emerge for you?

Dr. Heard-Garris (15:18)
Yeah, I think those are next step studies, Margaret. I think we really need to think about the way our country is
sliced and divided and how people live and where people live. delving a little bit deeper beyond insurance,
right? Right. Thinking about geography, I think is incredibly important. A lot of, racial and ethnic minorities
actually live in rural areas. And we know that, there's not a hospital, there's not an urgent care or a clinic every
block in a lot of those rural communities. Like a lot of communities are really struggling when it comes to
access to healthcare. So I think those are the next sort of studies. This study re this big study really focused on
racial and ethnic minority children because of what we know about structural racism. But additionally, there are
multiple intersections. So being a racial ethnic minority that lives in a ver you know, like a rural area versus
where I am in Chicago, it it, the, the issues are different. They're not always the same. Being a racial ethnic
minority that has great insurance and has, you know, lots of resources, still experiences significant structural
racism, but again, might be the disparities might be different. and what we, where we see the problems might be
different. and so I think, as we understand more and more about pediatrics and as we understand implicit bias,
structural racism, and how these factors work together, I think those are natural progressions and thinking about
geography and thinking about gender, right? How are, how are girls treated, boys, you know, the whole
spectrum of gender and what that means. How to, you know, if you are a sexual and gender minority. so all of
these different intersections are important. And if we don't start looking and asking the question, we'll never find
the answers. Yeah. And more importantly, we'll never fix it. most people again, go into healthcare 'cause they
really do wanna help people. and so if we don't know how help and what, where parts are broken, it's gonna be
hard to really fix it.

Mark (17:17)
You know, I wanna pick up on that thought about how we fix it. And you know, we've been following other
research that has shown that children who are black Asian spoke our primary language other than English, and
had no health insurance, were less likely to be diagnosed with developmental delays despite accounting for
cognitive ability. And black and Hispanic children were less likely to receive services. you know, all of this is, is
just tragic news. And, and I think you have been really sounding the alarm. I'd like to ask you how we fix this. I
know there needs to do more studies, but, you know, what are, what are some initial observations that you have
of steps that we can take to improve this? And then obviously we wanna see the research about what's effective.
and, so what, what are your initial thoughts as you think about strategies for, to fix all of these disparities?

Dr. Heard-Garris (18:13)
Yeah, Mark, these, disparities didn't come in overnight. And so I think, you know, again, a, a lot of us in
healthcare are doers and want it to be fixed like tomorrow. and I do think for us, there are multiple levels,
multiple tiers, multiple points of intervention. and so while most healthcare people, researchers, academics,
people who like to read, healthcare journals will read this, I really think about all of the solutions being at
different sort of nodes of intersection. So, for example, I think patients, you know, patients and families that
understand or hear about this work, knowing this right, can help to advocate more effectively for their children,
for their sibling, for their nephew, you know, for their grandkid. And understanding like these disparities exist,
whether, you know, people are intentional about it or not, that if you, if your child has a disability, then maybe
that's some point that we need to fight for. Like, we need to push a little bit harder. Like, okay, they're not
talking and they're three years old, they're not walking and they're fine. You know, like, we need to do more
than just talking about it. Like, we need services and escalating, if you're not being heard. So I do want patients
to feel some empowerment. I don't think all of the ownership belongs on them, but there's some empowerment
in having this information that, oh, maybe I'm not gonna get the services right away if I don't ask. Right. And
push, you know, my, my, healthcare provider on it. So I think there are some things, patients can do, but
certainly physicians like understanding that these dynamics are happening and making sure in some ways you
can protocolize things like for all patients at uc that are delayed. There, there are checks like you're gonna send
them to a developmental specialist, or they're gonna receive occupational therapy or speech therapy, whatever it
calls for. Like, trying to be as systematic as you can, not just only, okay, this patient, I think they need this, or
maybe they don't need that. And working with the parents as partners to help, make those decisions. And then
finally, like from institution institutional level, I think they can help providers. I think they can help healthcare
providers to do this in a more systematic way, pulling their data and sharing that back to them. I think, again,
you don't know what, you know, you don't know what needs to be fixed if you don't look. and so asking, you
know, the, institutions to look at their data, how many patients have you referred that had this exact same
diagnosis, the exact same de developmental delays, the exact same, you know, treatment had the exact same
diagnosis, but different totally different treatment plans. And, you know, medicine is personal, and so not
everyone's gonna have exactly the same thing. But, you know, if you're seeing a lot of differences in how you're
treating one group versus another group, it begs the question why. and having discussions with providers as
groups, as individuals, as practices on how we wanna take care of kids in an equitable way. So I think there's

multiple, kind of nodes of intervention. And then finally, I guess I didn't mention like society, there's a lot of
patient advocacy groups, especially for kids that have developmental disabilities and rally rallying around those
groups and getting support and providing them with this discu, you know, this Lancet article so that they're able
to know like, these things exist and how can we put research money behind it? How can we put patient
advocacy, knowledge or training or anything behind it so that, we can narrow these gaps.

Mark (21:48)
Great. Thank you.

Margaret (21:49)
Well, I know that you're calling for policy changes, including that senior managers of healthcare systems and
providers have to take steps to eliminate race-based pediatric care. We are focused as a, as a organization on the
primary care system. much of your work is focused on the hospital system, but I think the, the issues are
somewhat the same. And I'm struck as I, as I, hear your thoughts on this, that we tend to focus on the differences
between people and then the outcomes, but not so much the processes that go out to the outcomes. And we chalk
it up to disparities, but we don't consider that it might have been our disparities that were delivered unto the
patient. So I think you've, you're just doing such an incredible service here. But I, I'd like to ask you, do you see
any, a call already based on your research for any particular policy changes at the state level or even, you know,
those who regulate all of us through the Joint commission or through CMS? Do you, do you have a sense yet of
what some of the policy changes you might call for based on the research would be?

Dr. Heard-Garris (22:58)
Yeah. I think some of this work is gonna need to happen at the institutional level. I absolutely believe in policy
and making, legislative changes so that health and progress happens at a society or a population level. Like I
think that absolutely needs to happen. Some of the problems though, before we get to the legislative changes
are, for example, just even, how people's race, ethnicity, language are documented Within the electronic health
records, right? So like, if you are trying to make legislative changes and you are trying to recommend certain
things, if we're not even able to trust, you know, what these electronic health records have in them, it's difficult
to do that. So I do think a first step is making sure that people are able to self-identify. So for example, and I see
this, I've heard this a lot anecdotally with biracial children, right? Depending on what parent brings them in, if
somebody is, looking at them, they mark down their race. So let's say it's a, a biracial child whose mom is white
and dad is black, let's say. And so the mom brings them in, they're like, okay, they're white. And then the dad
brings them in their race changes for the same visit of the same for a different visit of the same kid. They're
black. And so then how do you analyze that, right? If we can't even really trust what race and what ethnicity that
we are marking on, the electronic health record, I'm happy to say I, I do know of from a children's hospital
standpoint, I'm not sure what's happening in the adult hospitals. There is a conscientious push to change this to
ask people to self-identify, self-disclose if they would like to, how they identify from a race, ethnicity, and even
language preference, right? Like if a family says that, they prefer, you know, they want to speak Spanish and it's
on their chart English, they're not gonna have the interpreter services, they're not gonna have the things that they
need at the ready for them and for their visit. So you will continue to see disparities. If everybody thinks they
speak English, they understand it well enough, right? and so I think that needs to happen as a kind of a first step,
but you're right, as a larger population level, how do we think about disparities in a way that we can work with
our policy makers in our legislators to help make sure that care is more equitable? because we know that policy
actually does change things and save lives. If you think about, even just, you know, the integration of hospitals,
hospitals didn't just integrate because they wanted to, it's because there was legislative action and legislative
changes said, well, we are gonna stop reimbursing you unless you, integrate your floors. And, and hospitals did
it overnight. So we do know that policy has such power to help to mitigate some of these disparities. And I
wanna, invite policy makers to partner with researchers and partner with physicians to help doing it in ways that
are thoughtful because physicians are on the front lines and it is difficult to practice medicine today. and so
people feel very strongly about, you know, legislators coming in and telling them how to practice medicine, but
I do think working with them on thoughtful policy changes that will help to make the society healthier as a
whole. Make a lot of sense.

Mark (26:17)
Dr. I wonder, you know, policy doesn't come about without people and I'm wondering if you could just share
with our audience a little bit about your back background, what you're working on now, and maybe, what's the
next research project underway as you think about this opportunity? But I, I, I know people would be interested
to know about the, the person as well.

Dr. Heard-Garris (26:38)
Wow. I'm on the spot. I, you know, I'll just say quickly 'cause I think this is important to understand about what
I do and what I'm interested in is that, when I grew up, my growing up, my mom and dad were divorced. And so
they, I lived in two separate neighborhoods and the neighborhoods were very different, right? And so one was
much more well off and the other one was not. It was lower resourced. And so I felt like I was straddling both of
these different worlds. So I got to see my friends who were in the well off community and talk about high
school and college and like their future and their plans and my other friends. We didn't have those same
conversations and literally the neighborhoods were touching, but they couldn't be more different. And so I think
I got this like, front row view of how, like, just circumstance, really can shape your, your trajectory in life, your
trajectory in health, your opportunities. And so that's always, that's always really stuck with me. So as a
researcher, even as a physician, I've always been really interested in how do we like level that playing field,
right? Like, I was lucky, just happened to be lucky and born to this family, right? That lives in this
neighborhood goes to this school, but how can we actually make opportunities more equitable so that, 'cause we
know talent is equitably distributed within our society, but not everybody gets access to go to great schools and
have great physicians and go on to do the things that they're meant to do. So a lot of my work thinks about how
do we make society more equitable? How do we give, opportunities and how do we make sure that things exist,
that children can really thrive? So a lot of our work is about that and systems around that. So, things that we're
working on now. So many things with respect to, healthcare disparities. I think our next step is doing some of
the things that Margaret was suggesting. Like, okay, well if we parse this down even more right from geography
or from a gender standpoint, are we seeing even more differences? Or were we seeing even more disparities?
Are there ways in which that we can examine how to fix the systems? 'cause I really believe it's a systems issue,
how to fix these systems that allow disparities to continue or even exacerbate them. So that's one thing. And
then the other things that I've ki I work on are incarceration and how the incarceration of a parent or major
caregiver impacts the health of children for similar reasons. You know, racism, structural racism, black children,
rural children, children that are impoverished or grow up in families with lower resources are disproportionately
impacted. So again, how do we make sure even those children have had families that are parents that have gone
to jail or prison, how do we make sure that their lives are not impacted in the same way? We need to work on
incarceration in and of itself. And that's a policy issue. That's things that we can work on. And from a health
issue, how do we make sure that children because their mom went to prison or their their dad went to jail, are
not, relegated right to a certain path just because how they were born. It, it's, it's not fair. It doesn't make sense.
It's unjust. And then the last thing is, how do we empower parents? How do we empower patients and families
and communities to not only like sit back and wait for change to happen? 'cause again, we want this change to
happen, like as physicians who are in the systems as policy makers, we all want the changes to happen, but it
can be slow. and so some of the work we are working on in my lab is how do we empower youth to say we see
these as problems. How can we directly write letters to our policy makers? How can we directly call out issues
where we see them? So we just finished a study where there was an intervention we created about activism, and
they worked on the teams that were in our study, worked on the school to prison pipeline and why there're more
police in their schools than counselors when there's a mental health crisis and there's been a mental health crisis.
So I'm veering a little off from, this bigger issue, but that's kind of the global work of, what we're doing trying to
make, health more equitable within our seas to shining sea.

Margaret (30:50)
Well, Dr. Nia Heard-Garris. We could keep you, here for a long time, but I think we'll try and bring you back
again, for lots more discussion. We wanna thank you for this important work and for joining us to explain it.
And we wanna thank our audience for joining us, being here today. Be sure to subscribe to our videos on
YouTube. Find us on Facebook and X with our account names, CHC Radio. As always, you can go online to
chcradio.com, sign up for email updates, and please share your thoughts and comments about this program and
this important conversation. Thank you so much.

Dr. Heard-Garris (31:25)
Thank you for having me. I would love to come back. This was the most thoughtful conversation I have had on
this issue. Thank you so much for even bringing this to your viewers, and I'm happy to engage further.

Margaret (31:36)
Perfect.

Mark (31:37)
Well, thank you for shining a light on this. So important. Thank you.

Dr. Heard-Garris (31:40)
Thank You.

Margaret (31:45)
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