AAP Voices Blog

*Editors’ note: This is one of a series of “AAP Voices” blog posts highlighting how racism impacts the health and well-being of children, adolescents, young adults and their families. To learn more, see the newly released American Academy of Pediatrics' policy statement, "The Impact of Racism on Child and Adolescent Health."

It’s been more than two decades since the landmark Adverse Childhood Experiences (ACEs) study first identified early traumas that have potentially lasting impact on health. Today, when we think about ACEs, what usually comes to mind is the three original categories described in that study: abuse, neglect and household dysfunction.

Since then, the concept of ACEs has expanded. It now includes a variety of other traumas children may be exposed to, including bullying, being placed in foster care, witnessing community violence, and experiencing racism.

I argue that racism is not only an Adverse Childhood Experience. Racism is an Adverse Life Experience that contributes to poor health outcomes, shorter life expectancies, and economic disparities among children, adolescents and adults. It’s a significant health risk that pediatricians, beginning with the American Academy of Pediatrics’ new policy statement on racism and child health, need to confront head-on.

Racism’s 1-2-3- punch

Racism can affect people on three different levels. Institutionalized or “structural” racism includes both material conditions (access to quality education, housing, healthcare, employment, etc.) and access to power (access to information, resources, and political voice); personally mediated racism is discriminatory behaviors or prejudicial attitudes based on race; internalized racism is the acceptance by members of stigmatized races of negative messages about their own abilities and intrinsic worth.

Like other ACEs, racism has been linked to poor health outcomes in children, adolescents and adults. Lifelong, accumulated experiences of racial discrimination by African American women, for example, has been identified as an independent risk factor for preterm delivery. Several other studies reinforce the correlation between experienced or perceived racism and risk of preterm birth and poor birth outcomes.

Research also links exposure to racism with insulin resistance in children and increased BMI, waist circumference, and cardiovascular disease in adults. A population-based study found direct effects of racism on academic outcomes of 8th graders, independent of socioeconomic disadvantage. School performance has been linked to long-term health outcomes.

How racism affects the brain & body

The bulk of evidence in the growing body of research reveals racism’s potential effects on mental health outcomes, such as increased depression, anxiety, and impaired self-esteem. A study of African American boys and girls 10-11 years of age found direct and mediated effects of perceived racism on later suicide and suicidal ideation. Two population-based studies show associations between bias-based harassment and compromised health in adolescents, including increased risk of substance use, and being threatened with a weapon.

Researchers believe chronic exposure to racism may lead to hypothalamic-pituitary-adrenal axis dysregulation. Racial discrimination seems to converge on the anterior cingulate cortex, with connections to both cognition and emotion, and may impair the function of the prefrontal cortex. Physiological responses there and in other regions of the brain can contribute to anxiety, depression and psychosis. It is the effect of the chronically primed allostatic load that contributes to poor physical and mental health.

“Based on what we now know about the ways racism harms children, mentally and physically, I contend that all pediatricians should work to become anti-racists.”

What is an anti-racist?

Since 2018, I have led a team of multi-disciplinary, multi-ethnic pediatric professionals to conduct anti-racism workshops across the country. The workshops focus on racism as an ACE, training healthcare professionals to become what we call “anti-racists,” and addressing the effects of racism during clinical encounters with patients. Based on what we now know about the ways racism harms children, mentally and physically, I contend that all pediatricians should work to become ant-racists.

An anti-racist is someone who actively interrupts the effects of racism by challenging all forms of racial bias and discrimination in communities and institutions. An anti-racist does not simply state, “I am not a racist” because they’ve never used a racial slur or intentionally mistreated someone based upon race. That passive attitude that does not cause the individual to examine his or her own racial attitudes. An anti-racist is keenly aware of his or her own implicit biases, prejudicial attitudes, and negative racial stereotypes held while actively working to overcome those thoughts and attitudes.

Becoming an anti-racist begins with acknowledging your own status within the current racial structure of US society. If the anti-racist self-identifies as a White American, that person has to acknowledge their own societal privilege, and how being White has benefitted them. White privilege is not earned or deserved. A person who wants to become an anti-racist will become comfortable with feeling uncomfortable during discussions about race and will work to conquer their own fragility.

In addition, someone seeking to become an anti-racist will develop healthy, interpersonal relationships with people of color who do not share their background and beliefs. This is beyond superficial, casual, work relationships; I’m talking about a true friendship. Anti-racists use these relationships to grow and learn more about how those friends are affected by racism.

An anti-racist will diligently acknowledge, change and adjust their own thinking and behaviors when they recognize their own negative biases or prejudicial thoughts. When a person becomes an anti-racist, they become a better doctor and better healthcare provider. They actively work to eliminate racial disparities in healthcare, advocate for disempowered families, and sponsor those who otherwise may not have opportunities to advance in an organization.

When we as pediatric providers decide to become anti-racists, we can collectively improve child health outcomes and extend the lives of Americans of every background.