At the societal level, important contributors to health outcomes include attitudes and prejudices of group identification, exposure to or threat of violence, racism and discrimination.
At the healthcare system level, factors related to health outcomes include access to pediatric rheumatologic care, coordination or lack of coordination of complex care, the presence or absence of a diverse workforce that reflects the patient population, and systemic and implicit bias in medical training and practice.
At the community level, factors related to health outcomes may include environmental toxins, lack of access to healthy food, the quality of the school system and the physical environment.
Family factors of note include income, food security, parents’ level of education and social capital. At the level of the individual child, important factors affecting health outcomes include mental health, sense of self-efficacy, relationships with healthcare providers and the ability to participate in shared decision making with pediatric rheumatologists.
Ashira Blazer, MD, MSCI, assistant professor, Division of Rheumatology, New York University School of Medicine, discussed diversity in rheumatology and the road to equitable care.
Inclusiveness, according to Dr. Blazer, is the process of including people who may otherwise be excluded, such as individuals with physical or mental disabilities, or members of minority groups. Inclusiveness, she argued, is an important concept that applies to physicians, patients, support staff and community partners. In an era in which precision medicine is aspirational and, hopefully, an increasingly frequent part of routine care, changing the concept of the average American and using inclusiveness to bring together all members of the population will help us better understand disease pathogenesis and provide equitable and personalized care.
Understanding the history of race-based prejudices is indispensable to our understanding of biases that still exist today, said Dr. Blazer. She described the history of the American caste system, in which individuals of African descent were designated the least social capital, individuals of European descent were allotted the most social capital and Native Americans were placed somewhere in between.
Dr. Blazer provided a startling comparison between the writings of Samuel Cartwright, MD, a physician in the antebellum South who, in 1851, published a treatise on biological differences thought, at the time, to separate Black people from other racial groups, and a 2016 survey of medical residents in the U.S. that demonstrated racial bias in pain assessment and treatment, as well as false beliefs about biological differences between Blacks and whites.4 In essence, many myths about racial differences popularized centuries ago persist in the minds of physicians (and the public) today.