Failure to address all drivers of health inequalities in childhood, including structural racism, means failing another generation of children, say Ian Sinha and colleagues
Racial health inequalities are a topic of intense political and media interest in the UK, in part because of differences in covid-19 mortality risk and vaccination delivery between White British people and other groups.
However, a recent review into racial disparities in the UK at a societal level concluded that although “disparities do exist, they are varied, and ironically very few of them are directly to do with racism.” That review, which was carried out by the Commission on Race and Ethnic Disparities (CRED) and commissioned by the UK government, has generated a lot of commentary and criticism. But we want to consider the conclusions of that review in the specific context of child health in the UK.
Although health inequalities in children in the UK are well described, these were not considered in the review. Children have been hit hard by the covid-19 pandemic—educationally, socially, and economically. This is especially important when considering ethnicity because pre-covid rates of child poverty were higher in Pakistani (47%), Bangladeshi (41%), Mixed race (33%), Chinese (31%), and Black (30%) children than White British children (17%).
Many of the inequalities in child health are driven by socioeconomic factors, as the CRED review states, but strategies to address social and racial problems are not mutually exclusive, and they should be considered together.
In the UK, racial health inequalities begin at, or even before, birth and continue through childhood. In 4.6 million singleton live births in England and Wales, the risk of neonatal and infant mortality was twice as high in Black African and Pakistani babies as White British babies. In 5131 paediatric heart operations, Asian infants were 52% more likely to die than White infants. In children with renal failure, national registry data demonstrate that South Asian and Black children were less likely to receive a pre-emptive renal transplant than White children. Our analysis of National Child Measurement Program data show that between the time periods 2009-2013 and 2014-2019 there was a relative increase in prevalence of obesity or severe obesity among White children of 1.7%, but this was higher in Black (6.6%) and Asian (7.4%) children.
Some differences in clinical outcomes may relate to interventions: in type 1 diabetes mellitus, insulin pump therapy is more likely to be used in White children (38.7%) than Asian (28.6) or Black (23.1%) children; continuous glucose monitoring was used by 13.5% of White children, but only 6.7% of Asian children and 6.5% of Black children.
It’s important to note that in none of these examples can the differences be solely attributed to socioeconomic factors—indeed, with regards to adverse birth outcomes, they explain only a quarter of the disparities in outcomes across infants from different ethnic groups. Clearly, more empirical data are needed to identify and understand racial inequalities, but there are known faults within the system.
We will only find these problems if we look for them, yet consideration for ethnicity and racial factors is not integrated into clinical pathways and education. For example, traditional diagnostic pathways for cystic fibrosis, previously considered a “Caucasian disease,” do not account for varying pathophysiology between ethnic groups, and genetic mutations more common in Black and Asian people are not incorporated into all regional newborn screening protocols in the UK.
Systemic problems mean that people from certain groups are at risk of being left behind as healthcare progresses. The term “BAME” does not help as it reduces children to being “white or non-white”—this impairs our development of the best services according to particular needs.
Even inanimate technologies and interventions can exacerbate racial inequality. Transcutaneous oxygen saturation monitors, for example, miss occult hypoxaemia three times as frequently in Black people than White people. Spirometers have been programmed to correct their values for race, a practice that has its roots in eugenic theories which claimed the lungs of Black slaves were inherently inferior to those of White people. This means that when we tell Black children their lung function is good, systemic errors are limiting their lung growth potential based on their race—this, surely, is the very definition of systemic racism.
Artificial intelligence, considered the next bastion of technology for health, can also perpetuate inequalities if due care is not taken to prevent human societal biases from creeping into algorithms. It is essential that racism, bias, and discrimination are considered when we develop new technologies or, once again, certain groups may be left behind.
Whenever racial inequalities in health are found, the default is to look towards biological and socioeconomic factors for an explanation. In doing so we risk falsely biologizing racial inequalities, explaining them away based on racial stereotypes, stigmatising people from different ethnic groups, and justifying cuts to resources for the very people who need them most.
Saying that the NHS has elements of structural racism may feel inherently uncomfortable, but no more so than suggesting that healthcare workers should undergo inherent bias training to identify their individual subconscious prejudices. By failing to address all the drivers of health inequalities in childhood—including deep rooted structural racism—we are failing another generation of children.
Ian Sinha is a consultant respiratory paediatrician at Alder Hey Children’s Hospital and a professor within the Division of Child Health at the University of Liverpool. Twitter @wheezylikesund1
Hammad Khan is a consultant neonatologist at Evelina London Children’s Hospital. Twitter @Drhammadkhan
Shrouk Messahel is a paediatric emergency medicine consultant at Alder Hey Children’s Hospital. Twitter @shroukmessahel
Partha Kar is a consultant in diabetes and endocrinology at Portsmouth Hospitals NHS Trust. Twitter @parthaskar
Competing interests: No authors have any conflicts of interest to declare.