I am absolutely delighted and honored to be the recipient of the American Pediatric Society's 2024 David G. Nichols Health Equity Award.My presentation objectives are to (1) demonstrate how equity is hardwired into the human psyche at an early age; (2) highlight how we have not yet achieved equity in child health and the academic workforce; (3) address why it's the pediatrician's imperative to relentlessly pursue equity; and (4) propose a roadmap for the 7 steps that pediatricians can take to eliminate disparities and achieve equity.A seminal study documented that 15-month-old toddlers possess a sense of equity, expecting equal allocation of resources (in this case, crackers and milk).1 Toddlers in this experiment spent significantly longer looking at unfair versus fair resource allocation. Those toddlers altruistically sharing resources (their preferred toys) with a stranger in a second experiment paid more attention to the prior unfair outcome versus selfish sharers (who shared their nonpreferred toy with a stranger) and nonsharers. The study authors hypothesized that equity is key in fostering large-scale cooperation, which is considered a key driving force behind humans' evolutionary success.Adult neuroimaging research shows a preference for equity is hardwired into the human brain.2,3 Receiving fair (versus unfair) offers in bargaining games causes greater activation in the brain reward regions and significantly higher self-happiness ratings. Aversion to unfair offers in this work was strongly related to amygdala activity, indicating an automatic negative emotional response to inequities.But we still have a long way to go to achieve equity in child health and health care.In a 1966 Chicago press conference, Martin Luther King, Jr., called for massive direct action to raise the nation's awareness of the segregated, inferior medical care received by Black people in Chicago and across the United States, specifically citing Black infant mortality rates in the city's poverty-stricken Woodlawn area, rivaling those of Mississippi.4 He concluded:"Of all the forms of inequality, injustice in health is the most shocking and inhuman."Racial and ethnic minority children have outnumbered white children in the United States since 2020 (now 53% versus 47%, respectively), and 41% of American children are members of under-represented minority (URM) groups.5 In our nation's public schools, racial and ethnic minority students surpassed white students in 2014, and now comprise 55% of US public-school students (versus 45% white); 45% of all US public-school students are URM.6In 2010, I had the privilege of leading the American Academy of Pediatrics team that conducted a systematic review that found that racial and ethnic disparities in children's health and health care are extensive, pervasive, persistent, and occur across the spectrum of health and health care.7 Unfortunately, little has changed over past 14 years, with disparities still as pervasive as ever. Here are just a few:Fifty-six large US cities have dramatic life-expectancy gaps: a child born in one neighborhood has a life expectancy that is 20 to 30 years shorter than a child born a few miles away in another neighborhood.8 Large life-expectancy gaps occur most frequently in cities with higher levels of racial and ethnic segregation. In highly segregated New York City, for example, a child born in East Harlem (which is 86% racial and ethnic minority) has a mean life expectancy of 71 years, versus 90 years for a child born just few blocks away in the Upper East Side (which is 75% white).8Compared with white infants, Black infants are 2.4 times more likely to die, and Native American infants are 1.8 times more likely to die (Fig 1).9Latino children are over 2 times more likely to be uninsured versus white children, at 8.6% versus 4.1%.10 Black children are also more likely to be uninsured than white children, at 5% versus 4%.10Compared with white children with asthma, Black children with asthma are 2.2 times more likely to make emergency-department (ED) or urgent-care visits for asthma, 4.5 times more likely to be hospitalized for asthma, and 8 times more likely to die of asthma (Fig 2).11,12 Latino children with asthma are 1.6 times more likely to make ED or urgent-care visits for asthma, 2 times more likely to be hospitalized for asthma, and 1.4 times more likely to die of asthma, compared with white children with asthma (Fig 2).13,14A study of 1.4 million children who had inpatient surgery in US hospitals showed that postoperative mortality rates decreased as the income quartile increased.15 But the adjusted odds of mortality were significantly higher (by 30% to 40%) for Black versus white children in all income quartiles. Indeed, the adjusted incidence of inpatient death for Black children in the highest income quartile (1.3) was comparable to white children in the lowest income quartile (1.2).Between the 1991 peak and 2020, the overall US teen birth rate (for females 15–19 years old) fell from 61.8 to 15.4 births per 1000 females 15 to 19 years old, declining in all racial and ethnic groups.16 But major racial and ethnic disparities continue in teen birth rates. Compared with the teen birth rate for white females of 10.4 per 1000, the teen birth rates for other racial and ethnic groups of teen females was 25.7 per 1000 for American Indian/Alaska Native females, 24.4 per 1000 for Black females, 23.5 per 1000 for Latina females, 22.6 per 1000 for Native Hawaiian females, and 2.3 per 1000 for Asian females.16Compared with a suicide-attempt rate in US white students of 9%, American Indian/Alaska Native youth lead the nation, at 16%.17 The Blackyouth rate is 14%, a major increase from 8% in 2011, whereas the Latino youth rate is 11%, unchanged from 2011. Multiracial (12%) and Native Hawaiian/Pacific Islander (10%) youth rates are higher, and the rate for lesbian, gay, bisexual, transexual, or queer youth is especially high, at 22%, versus 6% among heterosexual youth.I had the privilege of collaborating with colleagues on a recent study of patient-safety events in 5.2 million pediatric discharges from US hospitals.18 Compared with white patients, Black and Latino patients had significantly greater odds for 5 of 7 pediatric safety indicators. The largest disparities occurred in postoperative sepsis (adjusted odds ratio, 1.55 [95% confidence interval, 1.38–1.73]) for Black patients and postoperative respiratory failure (adjusted odds ratio, 1.34 [95% confidence interval, 1.21–1.49]) for Latino patients. Stratified analyses (by payer) demonstrated persistent disparities, even among privately insured children.As noted above, racial and ethnic minority children have outnumbered white children in the United States since 2020, and now account for 53% of children versus 47% who are white; 41% of America's children are URM.5 In contrast, the proportion of racial and ethnic minority medical-school faculty has changed little since 2010, and is still about one-third. The proportion of URM medical-school faculty has also changed little since 2010, and is even worse, at about 7%. This results in an alarming disparity ratio of URM children (40.5%) to URM medical-school faculty (6.9%) of 5.9 (Fig 3).19–22Pediatricians dedicate their careers to promoting the optimal health and well-being of all children. For example: the American Academy of Pediatrics mission is: "To attain optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults."23As noted earlier, studies document equity is hardwired into the human psyche and brain at an early age,1–3 so patients, families, and pediatricians are inherently equitable. Thus, the pediatrician's imperative is the relentless pursuit of equity for all children.What follows is a proposed roadmap for how to achieve equity in pediatrics. The roadmap consists of 7 steps to eliminate disparities and achieve equity.Race and ethnicity data (as self-identified by parent) routinely should be collected on all children by practices, health systems, Medicaid/Children's Health Insurance Program (CHIP), managed-care organizations, and private insurers, so disparities can be identified, monitored, and targeted as part of quality-improvement efforts. This is critical, given the lack of significant change over time in the total number of disparities, together with the appearance of many new disparities.24 This recommendation also is consistent with National Academy of Medicine reports,25,26 proposals by disparities experts,27 and the Affordable Care Act.28 Disparities monitoring and public disclosure, at least annually, should be considered by practices, hospitals, health plans, Medicaid, CHIP, counties, and states.Ensure that every child has health insurance and medical and dental homes. Racial and ethnic minority children comprise 64% of uninsured children,29 although constituting only 52% of US children,5 and multiple disparities exist and have persisted in lack of a personal doctor or nurse and in unmet dental needs. These facts underscore the urgent need to ensure every child has health insurance and medical and dental homes.Racial and ethnic disparities must be framed and addressed as quality-of-care issues, given the substantial prevalence and persistence of children's disparities, as pointed out by experts27 and a National Academy of Medicine report,26 and so disparities can be eliminated via rapid-cycle quality improvement and practice coaching.Ensure and advocate for all children to have access to needed subspecialty care. Children who need and receive care from a subspecialist have significantly fewer ED visits and hospitalizations and a greater likelihood of health care consistent with national practice guidelines than children not receiving needed subspecialty care.30 But racial and ethnic minority children are significantly more likely than white children to have problems getting subspecialty care.30Aim to attain the highest level of cultural competency and antiracism. Research documents bias and racism in pediatric care. For example, in young children hospitalized for skull or long-bone fractures, racial and ethnic minority children are 9 times more likely than white children to have skeletal surveys done and 4 times more likely to be reported to child protective services for suspected abuse.31 But a study of the predictors of asthma-care quality for Medicaid-insured children found that patients in practices with the highest cultural competence scores were less likely to underuse preventive asthma medications (odds ratio = 0.15) and had significantly better parent ratings of the quality of asthma care.32Pursue workforce diversity: it can be achieved. The Academic Pediatric Association's Research in Academic Pediatrics Initiative on Diversity (RAPID) is the first research-educational program targeting faculty diversity in academic pediatrics.33 Launched in 2012 with ongoing National Institute of Diabetes and Digestive and Kidney Diseases funding, RAPID's goals are the successful recruitment, retention, and academic advancement of URM junior pediatric faculty. RAPID provides: (1) small research grants; (2) pairing RAPID Scholars with accomplished senior national mentors; (3) in-person mentoring and networking at an annual Pediatric Academic Societies breakfast; (4) an annual career-development and leadership conference; and (5) monthly Scholar conference calls.RAPID works.33 Successes include:A significant increase in the diversity of the Academic Pediatric Association's membership (by 86%, from 7% in 2011 to 13% in 2021; P < .0001)The first 6 RAPID Scholars obtained 4 career-development awards, a National Institutes of Health R01, and a multimillion-dollar Food and Drug Administration grantScholars generated multiple publications and national conference presentationsA highly rated annual conference of URM investigators from across the United States spanning spectrum, from residents to facultyPartnerships with the American Pediatrics Society, Pediatric Infectious Diseases Society, American Board of Pediatrics, and Mead Johnson have more than tripled the number of RAPID slots per yearOur program resulted in national legislation (which I had the privilege of drafting).36 Based on this research, federal CHIP reauthorization legislation was signed into law by the President and Congress in 2018 that made organizations that use PMs eligible for $120 million in grants for CHIP outreach and enrollment.36 PM programs now exist in 11 states and the Cherokee Nation.37,38Equity is hardwired into the human psyche and our brains at an early age. But we still have a long way to go to achieve equity in child health and the pediatric academic workforce. It's the pediatrician's imperative to relentlessly pursue equity because pediatricians dedicate their careers to the optimal health and well-being of all children. By following the proposed 7-step roadmap, pediatricians can eliminate disparities and achieve equity in child health and the pediatric academic workforce.Jackie Robinson (1919–1972), the famed social-justice pioneer and the first African American inducted into the Baseball Hall of Fame, said: "A life is not important except in the impact it has on other lives." Legendary Pittsburgh Pirate Hall of Famer, activist, and Puerto Rican humanitarian Roberto Clemente (1934–1972) said: "Any time you have an opportunity to make a difference in this world and you don't, then you are wasting your time on Earth."Let's join together as pediatricians to make a difference in this world by achieving equity in child health now and for all future generations.
We describe a bidirectional version of the grammar-based MedSLT medical speech system. The system supports simple medical examination dialogues about throat pain between an English-speaking physician and a Spanish-speaking patient. The physician's side of the dialogue is assumed to consist mostly of WH-questions, and the patient's of elliptical answers. The paper focusses on the grammar-based speech processing architecture, the ellipsis resolution mechanism, and the online help system.
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Objective The objective of this study was to determine whether parental preferences regarding primary care weight-management strategies differ by child age, gender, overweight severity, race/ethnicity or parental agreement that their child is overweight. Methods A survey was administered to parents of 2- to 18-year-old children who are overweight at an academic primary-care clinic regarding perception of child overweight, helpful/harmfulness of having the child present during weight discussions, and dietary-advice preferences. Multivariable analyses examined factors associated with preferred weight-management strategies, after adjustment for parent/child characteristics. Results Eighty-three per cent of parents agreed that a child's presence during weight discussions is helpful/very helpful, 74% that paediatricians should prescribe specific diets, and 55% preferred specific vs. general dietary advice only (N = 219). In multivariable analyses, characteristics associated with helpfulness of child presence included older child age (vs. 2–5 year olds, 6–11 year olds: odds ratio [OR], 4.6; 95% CI, 1.3–16; 12- to 18-year-olds: OR, 23; 95% CI, 4–136), male gender (OR, 5.0; 95% CI, 1.7–10) and obesity (vs. overweight: OR, 2.8; 95% CI, 1.7–12). Characteristics associated with preferring specific diets included Latino race/ethnicity (OR, 5.3; 95% CI, 3–12), older age (vs. 2–5 year olds, 6–11 year olds: OR, 2.8; 95% CI, 1.1–7; 12–18 year olds: OR, 3.7; 95% CI, 1.5–10) and agreement that the child is overweight (OR, 2.3; 95% CI, 1.1–5) and, for specific dietary advice, older age (vs. 2–5 year olds: OR, 2.3; 95% CI, 1.1–5) and agreement that the child is overweight (OR, 2.1; 95% CI, 1.2–4). Conclusions Findings suggest that weight-management strategies tailored to child age, gender, overweight severity, race/ethnicity and parental agreement that their child is overweight may prove useful in improving child weight status.
