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American slavery began 400 years ago this month. This is referred to as the country’s original sin, but it is more than that: It is the country’s true origin.

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Ibram X. Kendi’s Antiracist Reading List (Published 2019)

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Ibram X. Kendi on books to help America transcend its racist heritage.

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We tend to think of prejudice as something that other people, particularly bad people, have in their hearts and minds.
The truth is, prejudice is inside us all. The good news is that psychology provides a powerful way to combat it.

Prejudice is due in part to cultural learning, from our parents, our schools and social messages and depictions in the media. But prejudice is also deeply embedded into our thought networks. Numerous studies have been done on implicit bias, the negative stereotyping and othering that we are not consciously aware of.

Whether we like it or not, prejudice easily digs into us. So if we're going to combat it, we need to change how our minds deal with it.

Since I was a young child, I've been pained by the brutality of prejudice and how it impacts us all. I've also learned how profoundly it shaped the lives of my Jewish ancestors, and I've witnessed it directed at my children who are multiracial.

Growing up, I did not know that my mother had been told by her father - who had become swept up by the fervor of Hitler-era Germany - never to tell anyone she had "tainted blood." My mother's name was not Ruth Eileen Dreyer, as she claimed, but Ruth Esther Dreyer. It was only later I learned that fact and that half of her maternal aunts and uncles died crowded into "shower rooms" meant not to cleanse them, but to cleanse the world of them.

I first encountered prejudice in my childhood friend Tom, who was white like me. He spewed venom about people of other races and ethnicities, calling them the n-word and other foul names. It bothered me, and I even got into a fistfight with him over it.

Regardless of my contempt for them, his slurs sank into my mind. One day, Tom and I - along with our friend Joe - rode our bikes to a bowling alley to play a game.

As we set up, Tom strangely commented, "It looks like rain." He and Joe giggled. I was confused. From where we were, we couldn't see the outside.

"It looks like raaaain," Tom repeated loudly as he and Joe tried to repress their laughter.

Finally, I noticed a Black man walking toward us - a dark cloud was rolling in. Get it?

I was horrified, and I felt sick to my stomach. But the thought also flittered into my mind that I was glad they weren't making fun of me.

Flash forward a couple of decades. My then-teenage daughter Camille was dressed up for a school dance, looking absolutely wonderful. She is Afro-Latina-American (my first wife was Latina, Camille was her child from a previous relationship, and I adopted her).

As I watched her approach, a voice bubbled up inside my head, unbidden and unwelcome. The auditory equivalent of a smirk, it was Tom's voice, saying very clearly, "It looks like raaaain."

Last year, I told the story of Tom's voice popping into my head to Camille.

Her response was sweet and pure. "I love you, Daddy," she said. "We all have burdens like that to carry."

Yes, we do.

Negative stereotypes pervade people's lives. Even if you hate them - or are the victim of them - they are in your cognitive network. That means they are available to do mischief, even when you're not conscious of it. If you go to the rigid, defended, frightened, angry, judgmental parts of your own heart, you will see that bias resides there.

But you can learn to use that recognition, and apply it to reduce the harmful impact of that part of you and the chance that your privilege and prejudice could be passed to others. By applying the practices of acceptance and commitment therapy - which focus on cultivating psychological flexibility rather than struggle and avoidance - to investigate your implicit biases, you become more aware of them and bring your actions in line with your conscious beliefs. This kind of mindful awareness allows prejudicial thoughts to become less dominant, and studies show it can even help us commit to positive actions to combat prejudice.

My lab researched this. We studied many forms of prejudice, including gender bias, weight bias, bias based on sexual orientation, ethnicity and more. We expected to find a common core, and we did.

We found that all forms of prejudice can be largely explained by what's called authoritarian distancing - the belief that we are different from some group of "others" and because they are different, they represent a threat that we need to control.

When my lab examined the psychological factors led some people to settle into authoritarian distancing, we found three key characteristics:

the relative inability to take the perspective of other people;

the inability to feel the pain of others when you do take their perspective;

the inability to be emotionally open to the pain of others when you do feel it.

Drawing on our findings, we developed interventions that have been found to significantly reduce prejudice.

In some ways, the most difficult to eradicate forms of bias are invisible and unconscious because they are based on privilege. For example, a white person can honestly say "I don't think about race", but she's not aware of how much that exudes privilege when her Black neighbor has no choice but to think about it - she sends her teenage son out into the world every day, knowing that he is more likely to be arrested or shot at because he is Black.

Similarly, a man can believe that he is without gender bias but still talk more than - and over - his women colleagues in meetings.

Because it's unfair and irresponsible to ask those who bear the costs of privilege to do all the heavy lifting to correct it, the first step is to look at your own behavior. Try to notice your indirect indicators of bias - the times in which your supposedly unbiased actions are actually rooted and shaped by your privilege.

As you're doing this, ask people who are close to you and who've experienced bias if they can help you. For example, when I start mansplaining, my wife gives me a look. Do not expect this to feel good, but it's a worthy journey.

Here are 3 steps that you can take to start recognizing and disarming your own prejudice:

1. Own your bias

Observe any tendencies to judge others or yourself or to enact bias based on privilege. Bring as much self-compassion and emotional openness to that awareness as you can. When do you notice prejudicial thoughts or biased actions popping up?

Let go of any tendency to buy into your judgement or make them more important by avoiding them or criticizing yourself for hosting them. These are thoughts, feelings, and invisible habits, and they are yours. You are responsible, but you are not to blame.

Just note their existence and increase your awareness of the negative cultural programming that we all carry.

2. Connect with other people's perspective

Deliberately take the perspective of those whom your mind judges, feeling what it's like to be subjected to stigma and bias, sometimes without conscious awareness by the person doing harm.

Don't run from the pain of seeing those costs, or allow it to slip into guilt or shame. The goal is connection and ownership.

Allow the pain of being judged or being hurt to penetrate you. As you do, bring your awareness to how causing anyone that kind of pain goes against your values.

3. Commit to change

Channel the discomfort of ownership and the pain of connection into a motivation to act. Commit to concrete steps that you can take to reduce the effect of prejudice and stigma on others.

This could mean learning to listen more; speaking out when another person makes light of prejudice; stepping back so others can step forward; joining an advocacy group; getting to know people who belong to groups that your mind judges.

Taking these actions is not meant to erase what you are carrying and experiencing but to channel those feelings toward expressing compassion.

You can practice these steps regularly. As you begin to loosen the grip of your implicit biases, you'll find that your enjoyment of being with people of all kinds increases, no matter how different they may have once seemed to you.

The sad fact is if we're not helping solve the problem of prejudice, we are helping to perpetuate it. And if we don't learn to acknowledge our privilege or catch the subtly prejudicial thoughts that go through our minds, we are supporting bias - and potentially passing it on.

It's hard to admit to ourselves that we've been complicit, and it's hard to diminish the impact of bias. But with work, we can do it.
Excerpted with permission from the new book Watch his TEDxUniversityofNevada Talk here: A Liberated Mind: How to Pivot Towards What Matters by Steven C. Hayes. Published by Avery, an imprint of Penguin Random House, LLC. © 2020 by Steven C. Hayes.

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Prejudiced thoughts run through all our minds - the key is what we do with them

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Harmful stereotypes pervade our thinking - even if you believe yourself to be completely unbiased. These 3 steps can help you notice and disarm your own prejudice, and psychologist Steven C. ...

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When editors of The New York Times for Kids put together a package about race, their driving priority was simple: Put kids' experiences first.

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This month's issue of The New York Times for Kids includes a group discussion on race with five children of different backgrounds, ages 9 to 14. Credit... The New York Times

Times Insider explains who we are and what we do, and delivers behind-the-scenes insights into how our journalism comes together.
On the last Sunday of each month, nestled within the pages of The New York Times's print edition, is a section off-limits to the paper's usual subscribers. A message printed across the top of its front page warns, "Editors' note: This section should not be read by grown-ups."

Although adults are not the intended audience, The New York Times for Kids does not shy away from grown-up topics, having covered issues like the coronavirus pandemic, school shootings, the opioid epidemic and the call to remove statues of controversial historical figures. With the deaths of George Floyd and Breonna Taylor setting off continued protests in recent months, and Black Lives Matter becoming what may be the largest movement in this country's history, it's no surprise this month's issue of NYT Kids features a package centered on race and racism. Both are concepts that adults have a hard time speaking about openly - but for kids, discussing and understanding race seems to come far more naturally, editors of The Times's Kids section said.

"There is more of a comfort in talking about identity and how we move through the world," Amber Williams, the editor of the Kids section, said. "And I think that's partly from social media and partly because they haven't been taught yet by society that race is a topic to be avoided."

In fact, August's issue in large part is made up of candid firsthand accounts from kids themselves. Within, a 14-year-old openly shares the story of a time a classmate called her an anti-Black slur. An 8-year-old relives her first experience at a Black Lives Matter march. A 16-year-old discusses the generational trauma inflicted upon Indigenous peoples in Canada and the United States. These kids and teens boldly drive the conversation, sharing their experiences with race and racism.

Alongside them, adult reporters define concepts like "microaggression" and "colorism" that might be new to the section's young readers (and, in some cases, their parents). Times reporters and contributors explain current issues in an attempt to create an atmosphere of empowerment through knowledge.

"It's just giving them tools to have those conversations on their own without us, because they're already talking about it, they're already thinking about it," Lovia Gyarkye, an editor for the Kids section, said. "I think they don't need us to explain or talk to them about race; what they need is a platform to be listened to."

To give children a springboard for dialogue, the editors also hosted a virtual round-table discussion about race with five children of different backgrounds, ages 9 to 14. Moderated by Jason Reynolds, the author of "Stamped: Racism, Antiracism, and You," the group did not avoid difficult topics. Their conversation, included in the section, touched on how race made them feel, their own experiences with racism and what they perceive adults' roles to be in this type of dialogue.

"We talk constantly about how to take kids seriously," Ms. Williams said. "This race package is letting kids guide the conversation. We, as adults, for The New York Times for Kids, should be thinking about how to include as many kids' voices as possible."

Both editors vehemently believe the section should not patronize young readers. Rather, the section is meant to serve as a space where kids feel as if they're in conversation both with one another and with informed journalists, no matter the topic.

"It's not really in the best interest of kids for adults to just tell them how to feel," Ms. Gyarkye said. "I think it's more about giving them the opportunity to tell us how they feel, and helping them understand how each other feels."

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Talking About Racism With The Times's Youngest Readers (Published 2020)

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When editors of The New York Times for Kids put together a package about race, their driving priority was simple: Put kids' experiences first. Send any friend a story As a subscriber, you have 10 gift articles to give each month. Anyone can read what you share.

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When the topic of racism comes up, I often think of a billboard in the small town of Harrison, Arkansas.

It was a sign promoting a white supremacist radio station called White Pride Radio. The sign's message, emblazoned next to the picture of a cute-looking white girl with a cute-looking dog, read "It's not racist to [heart] your people."

My takeaway: Even white supremacists don't want to be called racist.

Which might explain why, for people dedicated to fighting racism, simply saying you're "not racist" doesn't feel like quite enough. To effectively defeat systemic racism - racism embedded as normal practice in institutions like education and law enforcement - you've got to be continually working towards equality for all races, striving to undo racism in your mind, your personal environment and the wider world.

In other words, you've got to be anti-racist.

You may know me as NPR's TV critic. But I've also spent years exploring how systemic racism affects media and society. I've written a book about it, called Race-Baiter, and built a TEDx talk around how to talk about race across racial lines. As a Black man who speaks often on these subjects, I find race, racism and anti-racism to be things people think they know but often don't - at least, not as well as they think they do.

As the world continues to sort through a racial and civil rights reckoning kicked off by police killings of Black people like George Floyd and Breonna Taylor, now more than ever, people want to know how to be anti-racist.

After talking to a few experts, I and the good folks at Life Kit have come up with a few suggestions.

Tip #1: Accept that we've all been raised in a society that elevates white culture over others. Being anti-racist will mean first challenging those notions inside yourself.

This was one of the most important takeaways from my conversation with Anneliese A. Singh, who just joined Tulane University as its first Associate Provost for Diversity and Faculty Development. She's also written a workbook on these issues called The Racial Healing Handbook.

"Everyone who lives in the United States kind of learns some form of anti-Black racism," Singh says. "I think we have to ask ourselves that question...How does anti-Black racism live within us?"

Singh calls white supremacy "white body supremacy," a term used by therapist Resmaa Menakem, as a way to emphasize how racism has a visceral, physical impact; elevating white bodies, and bringing trauma to non-white ones.

She suggests some people may even go through a process similar to the stages of grief - especially those who have privilege because of their white or light skin - when they uncover their unconscious bias and realize how extensively systemic racism affects their perspectives.

"I'm going to be in denial if I'm white or have light skin about how white supremacy works," she says. "[We'll move] through that denial into some anger...And then when we go into acceptance, I think then we can really leverage our lives to make a difference."

Tip #2: Learn the history of racism and anti-racism, especially in America, to educate yourself about the complexities of the issues you'll be confronting.

A glance at the 2020 bestseller lists reveals lots of great books on anti-racism, from Ibram X. Kendi's How to Be an Antiracistto Layla Saad's Me and White Supremacy and Robin DiAngelo's White Fragility.

Most of them note that, for white folks, anti-racism involves learning to accept that white people have a racial culture, too. I've said white supremacy's greatest advantage is that white racial culture in America is often treated like it's invisible; not directly talked about among white people, some of whom joke that they have no culture.

Singh says people of color can benefit from similar study and introspection, with a particular focus on identifying and challenging any ideas that may breed colorism or contempt for other non-white groups. She calls this dynamic of elevating whiteness among non-white people, "internalized whiteness."

One important note for white people: When people of color share their experiences with white supremacy, believe them.

"I can't tell you how many people I've seen who claim to be anti-racist and care about building anti-racist organizations," Singh says. "But when people of color speak, they're like, 'Oh, well, they're doing it wrong.' Or 'That's one (person's experience).' You have an opportunity in that moment to believe what that person is saying."

Tip #3: Seek out films and TV shows which will challenge your notions of race and culture and dive in deeply, learning to see anti-racism in new ways.

I'm probably biased, but I've always felt TV shows and films teach us how to dream about what is possible in society and what ought to be. (For example: I insist Morgan Freeman's performance as a Black American president in Deep Impact and Dennis Haysbert's turn as President David Palmer on 24 made it easier for some voters to imagine a Black POTUS when Barack Obama came around.)

So I wasn't that surprised when Justin Simien, creator of the Netflix drama Dear White People, told me viewership for his series jumped 600 percent after George Floyd's death sparked an international dialogue on anti-racism.

Dear White People centers on a group of non-white students at a mostly white, Ivy League college as they negotiate issues of identity, classism, anti-racism vs racism, homophobia and more. One poignant storyline features a young Black student, Reggie Green, who is nearly shot by a campus security guard at a party. Reggie then finds himself haunted by flashbacks of the traumatic event as well-meaning acquaintances attempt to check in on him.

Simien says the scenes with Reggie show, without lecturing the audience, how attempts to ask a Black person about racial trauma can sometimes backfire.

"The whole goal of it is for you to care so deeply about these [characters] that you don't realize you're being taught anything," he adds. "When you see that he had a gun pulled on him and he had this near-death experience, and now for the rest of the school year, everyone's coming up to him asking him, "Are you OK? Is there anything I can do?" You understand how that's not enough."

Simien suggests viewers pass up "feel good" TV shows and films showing indisputably virtuous Black people overcoming racism, often in the Jim Crow South, with help from well-meaning white people (in other words, skip screenings of The Help or .)

Well-made TV shows and films about anti-racism should be messier and much more provocative.

"You should feel challenged in some way by the piece because it's so subversive," Simien says. "[Racism is] ubiquitous and it's systemic and we can't see it...Racism lives in our collective blindspots. That's why it's so pernicious. So, there has to be a moment in the piece where you go, 'Oh! I didn't think about it like that.'"

The goal: to expose yourself to art that cuts through prejudices and stereotypes, allowing you to finally, fully see people of color.

"I had a friend put it this way," Simien says. "'We're inviting people to see us for the first time and it should break your heart that you haven't seen us yet'...That I have to interact with you through a character version of myself because I think you can't handle my daily truth. [That] should break your heart."

Tip #4: Find local organizations involved in anti-racism efforts - preferably led by people of color - and help uplift their voices and ideas.

This tip comes courtesy of Arisha Hatch, the Vice President and Chief of Campaigns at Color of Change - a civil rights organization founded in 2005 following Hurricane Katrina.

She says learning to uplift non-white voices - even those who may disagree with you - is important for white people seeking to be anti-racist.

"Part of being an ally and part of letting go of privilege is, I think, putting yourselves in situations where you may be uncomfortable," Hatch adds. "You may have a different idea, but...you're actively working to support organizers and activists who have been thinking about these systemic problems for generations."

Also, Hatch says to be an effective anti-racist, you must assess your own power - where are the spheres where you can have the most influence?

Beyond the obvious strategy of confronting family and friends who may be racist, consider this: When you sit down at a PTA meeting at your child's school, which parents do you speak with and get to know?

At work, are you considering how procedures or strategies may advantage whiteness, and are you helping to challenge them?

Are you spending money with businesses that are owned by non-white people?

If you or a relative has a rental property, are you seriously considering applications from non-white people?

These are ways you can make a difference in your own environment, where you have power. Remember, anti-racism is about pushing past knowing better and instead actively doing better.

One thing is clear: Pulling all of this off takes a lot of energy and can feel overwhelming. And it doesn't help that one way people perpetuate systemic racism in America is by encouraging others to accept the status quo and reject many anti-racist ideas as too extreme.

But there is no better feeling than really making progress on working to build a better world. And these tips offer great ideas for starting on a long and rewarding road.

Above all, Color of Change's Hatch suggests keeping one, optimistic thing in mind.

"This is what winning looks like and feels like," she says of the current drive toward racial equity in law enforcement, politics, corporate America and elsewhere. "The moral arc of history is on our side and we are getting closer and closer every day to a culture that actually embraces the beauty and creativity of Black people in our lives."
This podcast portion of this story was produced by Audrey Nguyen. We'd love to hear from you. Leave us a voicemail at 202-216-9823 with a greeting, your name, your phone number and a random life tip. It might appear in an upcoming episode. Or send us an email at LifeKit@npr.org.

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'Not Racist' Is Not Enough: Putting In The Work To Be Anti-Racist : Life Kit

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Even white supremacists don't like to be called racist. That's why, NPR's Eric Deggans says, "not racist" doesn't feel like quite enough. In this episode, he walks us through steps to being anti-racist - in other words, ways you can continually strive to undo racism in your world and within yourself.

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The Social Justice Standards—organized into the domains Identity, Diversity, Justice and Action—provide a road map for anti-bias education at every grade level.

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Skip to main content

A Framework for Anti-Bias Education

The Social Justice Standards are a road map for anti-bias education at every stage of K-12 instruction. Comprised of anchor standards and age-appropriate learning outcomes, the standards provide a common language and organizational structure educators can use to guide curriculum development and make schools more just and equitable.

Divided into four domains-identity, diversity, justice and action (IDJA)-the standards recognize that, in today's diverse classrooms, students need knowledge and skills related to both prejudice-reduction and collective action. Together, these domains represent a continuum of engagement in anti-bias, multicultural and social justice education. The IDJA domains are based on Louise Derman-Sparks' four goals for anti-bias education in early childhood.

Each of the IDJA domains has learning outcomes and school-based scenarios organized by grades K-2, 3-5, 6-8 and 9-12.

Download the Standards

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The Social Justice Standards are a road map for anti-bias education at every stage of K-12 instruction, providing a common language and organizational structure educators can use to guide curriculum development and make schools more just and equitable.

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Teaching Anti-Racism: Digital Resources About Racism and Resistance

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There are many resources, accessible from home, to help in the critical work of educating young people.

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I am not Black; I am a Middle Eastern Muslim woman who wears hijab. Although Middle Eastern Muslims face bias and Islamophobia on a daily basis, the community I come from has not experienced the same abuse that the Black community has received.

But my emotions have been high since the death of George Floyd. I can identify with the fear of being pulled over by police while being alone or anger when I cannot attain opportunities because of the way I look. What Black and brown people have in common is that we all are fighting hate towards us in this country. Our communities must be co-conspirators that stand together with the Black Lives Matter movement.

Even though the non-Black communities of color face their own systemic barriers, displays of anti-Blackness flared within them this summer in response to the protests. It hasn't helped that much of our national conversation about racism-and most coverage of Black Lives Matter protests-tends to fall along lines of Black and white. Students who don't identify as Black or white may feel confused about the movement or feel like they don't have any voice in the dialogue.

In response, educators should be ready to lead diverse classrooms into conversations about the Black Lives Matter movement and guide non-Black students of color in understanding the history of anti-Blackness. They should encourage a co-conspirator classroom, where students learn about and conquer their own biases, reflect on structural inequities and support each other to push for change in their communities.

Classroom Conversations About the Movement

As protests against police brutality continue, students may need a place to process their feelings and have questions answered. The classroom-real or virtual-can provide that place. Teaching Tolerance's guide for facilitating critical conversations is a good tool to help teachers create a community and establish norms.

Educators facilitating conversations about protests and responses to them should be empathic and recognize that some students may feel fear, anxiety or trauma around police violence they've seen in the media or in their communities, while others may feel anxiety and fear about violence they have seen in the media or in their communities during the protests.

Educators should be ready for students to echo rhetoric they have heard online or in their own homes. Recentering the goals of the Black Lives Matter movement, which focus on ending systematic racism and police brutality towards all people of color, will help students in understanding that violence is not part of the movement. Tracing the historical context of how the movement began, along with the movement's mission is a good start.

If students share information about the movement that is incorrect, it is important to be ready to interrupt it. Teaching students about digital literacy before, during or alongside these conversations is especially helpful. Given the polarized response to Black Lives Matter, encouraging students to be critical consumers of information and giving them the tools they need to recognize and critique biased or fake sources are key. It will both help them understand the movement and provide a model for recognizing and interrupting racist responses to it.

Non-Black students of color can and should recognize that suffering from racism doesn't make one immune to anti-Blackness. Critical conversations can help them understand implicit bias -ultimately supporting them in self-reflection and taking action against the biases they hold.

Participating in discussions about race and anti-Black racism helps students recognize that their own silence against racism doesn't help the problem; it only makes it worse.

Teaching About Hard History

The success of co-conspiratorship in classrooms is reflected by students' ability to talk about the topic of race in a way that honors the identities of all participants. Being able to participate in critical conversations about race and racism is the first step to collaboration and changemaking.

But understanding history plays a role as well. Students must learn to examine the grueling roots of anti-Black racism in this country. This history can help students understand that anti-Black racism is structural, that it's tied to slavery, and that opportunities and access to resources have been and continue to be denied to Black communities.

Students should recognize that, while Black history is filled with joy and resistance, this history also includes racialized trauma. Students may need to be reminded that this history of anti-Blackness and this racial trauma continues to this day. Students need to understand this history-and the fact that white supremacy has both individual and structural impact-in order to process the damage of the past and to restructure communities in the future.

Having non-Black students of color draw parallels between their communities' histories and histories of Black communities can help them empathize, connect and begin to understand co-conspiracy. Students should remember that real solidarity is not about "not being racist"-it's about what Ibram Kendi calls "being an antiracist."

A Community of Co-Conspirators

Teaching students ways to advocate alongside peers and communities-and for themselves-is one way to cultivate skills for promoting anti-racism.

As your classroom community builds these skills, you will be able to identify learning opportunities within your content area that will allow students to advocate for Black and non-Black communities of color. Through their learning, their co-conspiratorship can help them self-identify as change makers who will do good through collective action.

Committing to supporting non-Black students of color as they process their feelings about the Black Lives Matter movement, understand its root causes, participate in critical conversations in safe spaces and cultivate co-conspirator attitudes is an important way educators can combat anti-Black racism in this country. Standing together as communities of color will assure that hate will not prevail.

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The Black Lives Matter Movement Goes Beyond Black and White

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I am not Black; I am a Middle Eastern Muslim woman who wears hijab. Although Middle Eastern Muslims face bias and Islamophobia on a daily basis, the community I come from has not experienced the same abuse that the Black community has received. But my emotions have been high since the death of George Floyd.

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Helping students understand and like their own identities without devaluing others; encouraging them as they find the ways we're all connected and deserving of respect; teaching them to recognize injustice and showing them how to act against it-this is the work that social justice educators choose to do.

To support educators in this work, Learning for Justice developed the Social Justice Standards, a road map for anti-bias education at every stage of K-12 instruction. This set of standards-a full framework-divides social justice teaching and learning into four key "anti-bias domains": Identity, Diversity, Justice and Action.

Taken as a whole, this framework is the cornerstone for all of Learning for Justice's anti-bias resources. It features anchor standards, descriptive scenarios and learning outcomes tailored for every grade band. The standards provide the foundation for the Learning Plan Builder, where educators use the age-appropriate learning outcomes to begin their backward-design process.

We've always offered online resources for self-guided professional development (including PD around the Social Justice Standards). But we know that in-person training and the opportunity to process information with colleagues is invaluable-especially when a staff is making a point of learning and growing together. With this in mind, we are pleased to share our new, free guide for facilitating PD around the standards: the Social Justice Standards Professional Development Facilitator Guide.

The guide empowers educators already familiar with the standards to share them with colleagues. If you like the standards but you don't yet feel ready to lead others through them, you can brush up on your own knowledge with our online PD. When you are ready, our PD facilitator guide provides all of the resources you'll need to train colleagues in using the standards and in taking the first steps toward integrating them in your department, school or district.

Here's some of what you'll find when you download the guide:

Activities to build familiarity with the Social Justice Standards.

Case studies describing creative ways other educators have integrated the standards into their teaching.

Handouts and activities to practice writing essential questions based on the standards.

Guided questions to explore the difference between prejudice reduction and collective action and why that distinction is especially important in today's classrooms.

You'll learn how to introduce the standards to colleagues, to explain their origins and to offer concrete ways of embedding them in lessons, classrooms and curricula across your school or district. The guide includes all the handouts, readings and presenter slides you'll need for a complete training. (We've even included the evaluation!)

The format is flexible; you can plan to share the standards with colleagues in one longer meeting, space the guide's six units over several weeks or share only the units that are most relevant to your PD and implementation goals.

We're excited to share this new resource with you, and we can't wait to hear how you use it. Download it and give it a try-and be sure to let us know how your training goes!

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Lead Your Own Training: The Social Justice Standards

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Helping students understand and like their own identities without devaluing others; encouraging them as they find the ways we're all connected and deserving of respect; teaching them to recognize injustice and showing them how to act against it-this is the work that social justice educators choose to do.

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This slide deck appeared in my inbox - and once again, I am so grateful for those who are telling this story well. (Credit goes to Jenae Butler, a PGM for Google Cloud). #BlackLivesMatter pic.twitter.com/zExAsIXR5G
- Ana Clara Blesso (@anaclarablesso) June 17, 2020

Credit: Jenae Butler, a PGM for Google Cloud. #BlackLivesMatter pic.twitter.com/8lWLQ3MLsm
- Ana Clara Blesso (@anaclarablesso) June 17, 2020

"Knowing that George Floyd's death and related protests would spark uncomfortable conversations at work, I wanted to use my communication and design experience to complement existing resources and provide the basis for productive dialogue with my own team," Butler told Colorlines. "I never expected the deck to resonate and be shared so widely, but I think it shows that seemingly small actions can have outsize impact, and that it's always important to be brave and authentic to yourself."

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Black Googler Creates Anti-Racism Resource Guide for All

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This slide deck appeared in my inbox - and once again, I am so grateful for those who are telling this story well. (Credit goes to Jenae Butler, a PGM for Google Cloud). #BlackLivesMatter pic.twitter.com/zExAsIXR5G - Ana Clara Blesso (@anaclarablesso) June 17, 2020 Credit: Jenae Butler, a PGM for Google Cloud.

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Surface-level Diversity

by Debbi Michiko Florence, Middle grade: The Only Black Girls in Town by Brandy Colbert, Jasmine Toguchi, Mochi Queen A Dash of Trouble by Anna Meriano

Ignoring Intersectionality

Three decades ago, legal scholar and civil rights activist Kimberlé Williams Crenshaw coined the term " intersectionality " as a way of examining how courts failed to account for the overlapping forms of discrimination faced by Black women. Today, the term is used more broadly to refer to the way race, class, gender, sexuality and other characteristics overlap and shape individuals' experiences. "We like to think about people being one thing or the other when you can be Asian and queer and an immigrant," said Martin, the University of Washington professor. While a decade ago it may have been hard to find books by and about people whose identities sit at those types of intersections, that's increasingly less true, Martin said. "You can find those books if you are looking."

Sidekick Syndrome

: Picture books Maybe Something Beautiful by F. Isabel Campoy and Theresa Howell, illustrated by Rafael López, The Patchwork Bike by Maxine Beneba Clarke and illustrated by Van T. Rudd, Niño Wrestles the World by Yuyi Morales

Middle grade: Sal and Gabi Break the Universe by Carlos Hernandez, Tristan Strong Punches a Hole in the Sky by Kwame Mbalia, Dactyl Hill Squad by Daniel José Older

Treating Groups as Monoliths

by Jewell Parker Rhodes, Young adult: Black Brother, Black Brother The Henna Wars by Adiba Jaigirdar, Black Enough: Stories of Being Young & Black in America edited by Ibi Zoboi

Excluding #OwnVoices

by Traci Sorell and illustrated by Frané Lessac, Picture books: by Matthew A. Cherry and illustrated by Vashti Harrison, We Are Grateful: Otsaliheliga Saturday by Oge Mora

Stopping at the Text

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Diversifying Your Classroom Book Collections? Avoid these 7 Pitfalls | KQED

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Keeping your book selection relevant means making sure it includes meaningful experiences of different kinds of people, especially from marginalized communities. Here are some strategies and book titles that can help students grow from what they read.

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new policies identifying solutions to this growing and deadly threat.

According to the statement:

The new policy approved by the AMA, representing physicians and medical students from every state and medical specialty, opposes all forms of racism as a threat to public health and calls on AMA to take prescribed steps to combat racism, including: (1) acknowledging the harm caused by racism and unconscious bias within medical research and health care; (2) identifying tactics to counter racism and mitigate its health effects; (3) encouraging medical education curricula to promote a greater understanding of the topic; (4) supporting external policy development and funding for researching racism's health risks and damages; and (5) working to prevent influences of racism and bias in health technology innovation.

"The AMA recognizes that racism negatively impacts and exacerbates health inequities among historically marginalized communities. Without systemic and structural-level change, health inequities will continue to exist, and the overall health of the nation will suffer," said AMA Board Member Willarda V. Edwards, M.D., M.B.A. "As physicians and leaders in medicine, we are committed to optimal health for all, and are working to ensure all people and communities reach their full health potential. Declaring racism as an urgent public health threat is a step in the right direction toward advancing equity in medicine and public health, while creating pathways for truth, healing, and reconciliation."

Building on our pledge this past summer to confront systemic racism and police brutality, #OurAMA has taken action to explicitly recognize racism as a public health threat and detailed a plan to mitigate its effects. https://t.co/Ra1X6jae3m
- AMA (@AmerMedicalAssn) November 17, 2020

Dr. Jessica Shepherd, a Black OB-GYN in Dallas, told Business Insider that AMA's declaration "is critical to address racial disparities in healthcare from the top down."

"We fail to realize that there are so many things that occur at the systemic part of healthcare that if we don't make changes such as the one we're discussing now, then we'll never really get to the heart of the problem," Shepherd said.

"over the last year, a number of county and state authorities have also labeled racism a public health threat," listing "county councils in San Bernardino, California, and Montgomery [County], Maryland, as well as authorities in Michigan, Nevada, Cleveland Denver and Indianapolis" joining in.

It's clear that from maternal mortality to HIV to COVID-19, racism has historically cut short the lives of too many Black, Indigenous, Latinx, and other people of color in the U.S. This statement and its policies, however late, are a step in the right direction.

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American Medical Association Declares Racism a Public Health Threat

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new policies identifying solutions to this growing and deadly threat.

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By: Jacqueline Dougé, MD, MPH, FAAP &Monique Jindal, MD, FAAP

In light of recent national events, more parents are wondering whether they should talk to their children about race and racism. And, if the answer is yes, how can they do this in a thoughtful and effective manner?

The truth is kids are impacted by race at a very early age. As early as 3 months, a baby's brain can notice racial differences in the people around them. By age 2, children soak up stereotypes about race and may express these with fear. By age 4, children can directly express bias regarding race by teasing. By age 8, children are aware of social norms and can express bias in more subtle forms. And, by age 12, many children become set in biased thoughts, actions and decisions.

This means that there is nearly a 10-year period where parents may be able to intervene! Parents are the primary sources for children to learn about race and racism. Whether parents choose to talk to their kids about this or not, children will learn from their environments and the other people in their life.

Reflecting on race: look to books

What if we told you that parents can use books to not only help start the conversation, but also keep the conversation going?

Books are powerful tools that can serve as " mirrors, windows, and maps," reflecting children's own identity. Reading allows children to take a few steps in someone else's shoes, showing children the range of possibilities for their place in the world.

Exposure to diversity: who benefits?

Which children are we talking about? The answer is: all children - Black children, white children, Latinx children, girls, boys, etc. Exposing children to diversity helps children of all backgrounds. It helps children in to form their own identity and shapes their attitudes and behaviors towards people who are different than them. And while racism is shown to have a significant impact on the health of children and families, children of all racial/ethnic backgrounds who are exposed to diversity have been shown to be more likely to enroll in college and have higher test scores, self-confidence and leadership skills.

Books can help ensure your child believes in themselves, becomes an ally to others, understands that racism and discrimination exist, recognizes the power of kindness, compassion and empathy for others, and ultimately celebrates both what's common and different among the people they meet.

Strategies to select diverse and inclusive books

Here are some strategies that can help parents select high quality diverse and inclusive books. We recommend choosing books that:

Include characters who share your child's race, ethnicity and your family's cultural and religious beliefs, as well as characters who do not.

Have a main character who is a person of color.

Provide a voice to those who rarely have one.

Tell stories that challenge myths or stereotypes ( Hair Love by Matthew A. Cherry, illustrated by Vashti Harrison, about a Black father doing his daughter's hair, for example).

Tell stories that normalize daily life among all racial identities ( Corduroy, written and illustrated by Don Freeman, about a Black mother and child going shopping, for example).

Help children develop social action skills (helping the elderly, having environmental awareness, or volunteering at a soup kitchen, for example).

Help children recognize inequities in social structure (consider books about gender and sports or differential treatment of holidays within the United States).

Are written or illustrated by racial/ethnic minorities.

Are age appropriate (picture books for children age 5 and under, and chapter books for elementary aged children).

Present characters facing real-life experiences.

Showcase experiences relevant to their own ( The Snowy Day by Ezra Jack Keats, about a Black boy enjoying walking through his neighborhood in the snow, for example).

We also recommend avoiding books that promote stereotypes. such as those that focus on any of the 5 F's (food, fashion, folklore, festivals and famous people). Stereotypes overgeneralize individuals or groups of people. If choosing books on these topics, it is important to reflect on if the book is reinforcing stereotypes and also to select other books that feature this racial or ethnic group in other settings.

How to use books to start conversations about race and racism with your children

The American Psychological Association's (APA) RES Project can help parents learn how to use books to guide conversations. We recommend parents listen and be open to answering their child's questions and use some of the questions on this site as conversation starters. Some examples, by age:

Preschoolers: "What is different and similar between your child and the characters in the book?"

Elementary aged children:"Who is your favorite character, and what did you like about them?"

Preteens and teens:"How did the book inspire you to think differently? How did the book challenge your understanding of race?"

Consider having a family "book club" with teens where parents and teens all read the book and share their reflections and what they learned.

Talking about race and racism is important. The conversations can start early and be ongoing. Parents are a child's first teacher and our nation's children need us now more than ever. By reading children diverse and inclusive books, we have the opportunity to affirm their own identity, help them learn about others, build empathy and encourage their kindness towards others, all in an effort to build a better and more just world.

More information

About Dr. Dougé

Jacqueline Dougé, MD, MPH, FAAP is the Child Health Medical Director at the Howard County Health Department. Her interests are health disparities, media, school health and the interaction of public health and pediatrics. Within the American Academy of Pediatrics, she co-chairs the Council on Community Pediatrics' Prevention and Public Health Special Interest Group. Her blog site is jackiedouge.com.

About Dr. Jindal

Monique Jindal, MD, FAAP, is a member of the American Academy of Pediatrics (AAP) Section on Minority Healthy, Equity and Inclusion and the Maryland Chapter of the AAP. She is an internal medicine-pediatrics physician at Johns Hopkins Medical Institution. Dr. Jindal's broad research interest is in understanding the impact of racism and discrimination on health equity for minority children and their caregivers.

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Using Books to Talk With Kids About Race and Racism

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Reading allows children to take a few steps in someone else's shoes, showing ​them the range of possibilities for their place in the world. In this article, learn how to use books as a powerful tool to help discuss racial identity, bias and racism they may encounter.

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ACLP Creates Diversity, Equity & Inclusion Task Force

Co-Chair: Rechelle Porter, CCLS

Co-Chair: Divna Wheelwright, MS, CCLS

Board Liaison: Jenaya Gordon, MA, CCLS, NCC

Staff Liaison: Jennifer Lipsey, CEO

This task force was formed to expand the dialogue about and elevate awareness of the importance of inclusion, equity, and diversity within ACLP and the field of child life.

ACLP Creates DEI-Focused Education
Child Life Annual Conference

ACLP Institutes International Membership
Eligible individuals who primarily reside out of the United States, Canada, and associated territories may receive a percentage off of the professional member rate based on the World Bank classification of their home country. This professional membership is only available by request to the ACLP Office.

Diversity & Inclusion Workshop for ACLP Staff, DEI Task Force Chairs and Board

Carrie Ellis, Principal Consultant, Celestial Consulting LLC, Workshop Facilitator

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ACLP Creates Diversity, Equity & Inclusion Task Force Co-Chair: Rechelle Porter, CCLS Co-Chair: Divna Wheelwright, MS, CCLS Board Liaison: Jenaya Gordon, MA, CCLS, NCC Staff Liaison: Jennifer Lipsey, CEO This task force was formed to expand the dialogue about and elevate awareness of the importance of inclusion, equity, and diversity within ACLP and the field of child life.

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Abstract

The American Academy of Pediatrics is committed to addressing the factors that affect child and adolescent health with a focus on issues that may leave some children more vulnerable than others. Racism is a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families. Although progress has been made toward racial equality and equity, the evidence to support the continued negative impact of racism on health and well-being through implicit and explicit biases, institutional structures, and interpersonal relationships is clear. The objective of this policy statement is to provide an evidence-based document focused on the role of racism in child and adolescent development and health outcomes. By acknowledging the role of racism in child and adolescent health, pediatricians and other pediatric health professionals will be able to proactively engage in strategies to optimize clinical care, workforce development, professional education, systems engagement, and research in a manner designed to reduce the health effects of structural, personally mediated, and internalized racism and improve the health and well-being of all children, adolescents, emerging adults, and their families.

Statement of the Problem

Racism is a "system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call 'race') that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources." Racism is a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families. ⁻ Although progress has been made toward racial equality and equity, the evidence to support the continued negative impact of racism on health and well-being through implicit and explicit biases, institutional structures, and interpersonal relationships is clear. Failure to address racism will continue to undermine health equity for all children, adolescents, emerging adults, and their families.

The social environment in which children are raised shapes child and adolescent development, and pediatricians are poised to prevent and respond to environmental circumstances that undermine child health. Pediatrics as a field has yet to systematically address the influence of racism on child health outcomes and to prepare pediatricians to identify, manage, mitigate, or prevent risks and harms. Recognizing that racism has significant adverse effects on the individual who receives, commits, and observes racism,, substantial investments in dismantling structural racism are required to facilitate the societal shifts necessary for optimal development of children in the United States. The American Academy of Pediatrics (AAP) is committed to reducing the ongoing costs and burden of racism to children, the health care system, and society.,

Today's children, adolescents, and emerging adults are increasingly diverse. Strategies to address health and developmental issues across the pediatric life span that incorporate ethnicity, culture, and circumstance are critical to achieving a reduction in health disparities. Accordingly, pediatrics should be at the forefront of addressing racism as a core social determinant. The inclusion of racism is in alignment with the health equity pillar of the AAP strategic plan. In a series of workshops in 2016 during national meetings of pediatricians, 3 strategic actions were identified: (1) development of a task force within the AAP to address racism and other forms of discrimination that impact the health status and outcomes of minority youth, (2) development of a policy statement on racism, and (3) integration of evidence-based anticipatory guidance about racism into Bright Futures.

The objective of this policy statement is to provide an evidence-based document focused on the role of racism in child and adolescent development and health outcomes. This policy statement will allow pediatricians to implement recommendations in practice that will better address the factors that make some children more vulnerable than others. The statement also builds on existing AAP policy recommendations associated with other social determinants of health, such as poverty, housing insecurity, child health equity, immigration status, and early childhood adversity.,⁻

Racism as a Core Determinant of Child Health

Racism is a core social determinant of health that is a driver of health inequities. ⁻ The World Health Organization defines social determinants of health as "the conditions in which people are born, grow, live, work, and age." These determinants are influenced by economic, political, and social factors linked to health inequities (avoidable inequalities in health between groups of people within populations and between countries). These health inequities are not the result of individual behavior choices or genetic predisposition but are caused by economic, political, and social conditions, including racism.

The impact of racism has been linked to birth disparities and mental health problems in children and adolescents.,⁻ The biological mechanism that emerges from chronic stress leads to increased and prolonged levels of exposure to stress hormones and oxidative stress at the cellular level. Prolonged exposure to stress hormones, such as cortisol, leads to inflammatory reactions that predispose individuals to chronic disease. As an example, racial disparities in the infant mortality rate remain, and the complications of low birth weight have been associated with perceived racial discrimination and maternal stress.,,

Investments in policies to address social determinants of health, such as poverty, have yielded improvements in the health of children. The Food Stamp Program, a War on Poverty initiative first developed in the 1930s during the Great Depression and later revived in the 1960s, is linked to improvements in birth outcomes. Efforts in education, housing, and child health insurance have also led to improved health outcomes for issues such as lead poisoning, injuries, asthma, cancer, neurotoxicity, cardiovascular disease, and mental health problems.,, Expansion of child health insurance has improved health care access for children, with significant gains for African American and Hispanic children in terms of access to well-child, doctor, and dental visits. Despite these improvements, it is important to recognize that children raised in African American, Hispanic, and American Indian populations continue to face higher risks of parental unemployment and to reside in families with significantly lower household net wealth relative to white children in the United States, posing barriers to equal opportunities and services that optimize health and vocational outcomes. ⁻

Juvenile justice involvement is also a critical social determinant of health. Because racial inequity continues to shape the juvenile justice system, this area is a modern example of race being an important determinant of short- and long-term outcomes. The AAP published a statement in 2011 focusing on key health issues of justice-involved youth, which was recently revised to include an in-depth discussion on racial and ethnic inequalities for this population. Although the overall rates of youth incarceration have decreased, African American, Hispanic, and American Indian youth continue to be disproportionately represented. While incarcerated, youth experience additional adverse experiences, such as solitary confinement and abuse, that have the potential to undermine socioemotional development and general developmental outcomes. ⁻ Differential treatment of youth offenders on the basis of race shapes an individual's participation and ultimate function in society. This type of modern racism must be recognized and addressed if the United States seeks to attain health equity.

The Development of Race as a Construct

Race as a social construct is rooted in history and remains a mechanism through which social class has been controlled over time. Flawed science was used to solidify the permanence of race, reinforce the notions of racial superiority, and justify differential treatment on the basis of phenotypic differences as people from different parts of the world came in contact with each other. Race emerged as a social classification used to assign dominance of some social classes over others. Scientific, anthropologic, and historical inquiry further solidified race as a social construct. Modern science, however, has demonstrated that there is only 1 biological race and that the clines (phenotypic differences in skin and eye color, hair texture, and bone structure) at the core of early anthropologic research were insufficient to establish different races among human beings. Dr Francis Collins, former director of the National Human Genome Project and presently the director of the National Institutes of Health, has affirmed that humans are 99.9% the same at the level of their genome. Despite this, efforts to collect, organize, and categorize individuals on the basis of the plausibility of the 0.01% human variation remain a force of scientific discovery, innovation, and medical-pharmaceutical collaborations. Rather than focusing on preventing the social conditions that have led to racial disparities, science and society continue to focus on the disparate outcomes that have resulted from them, often reinforcing the posited biological underpinnings of flawed racial categories. Although race used in these ways has been institutionalized, linked to health status, and impeded our ability to improve health and eliminate health disparities,, it remains a powerful measure that must be better measured, carefully used, and potentially replaced to mark progress in pediatric health disparities research.,

As such, it is important to examine the historical underpinnings of race used as a tool for subjugation. American racism was transported through European colonization. It began with the subjugation, displacement, and genocide of American Indian populations and was subsequently bolstered by the importation of African slaves to frame the economy of the United States. Although institutions such as slavery were abolished more than a century ago, discriminatory policies, such as Jim Crow laws, were developed to legalize subjugation. As the United States expanded west in North America and into Alaska and the Pacific Islands, the diversity of populations encompassing the United States also expanded. Native Hawaiian and Pacific Islander, Alaskan native, Asian American, and Latino American populations have experienced oppression and similar exclusions from society. ⁻ Although some racial and/or ethnic groups have received reparations and fared better than others over time, remnants of these policies remain in place today and continue to oppress the advancement of people from historically aggrieved groups. ⁻

Through these underpinnings, racism became a socially transmitted disease passed down through generations, leading to the inequities observed in our population today. Although the endemic nature of racism has powerful impacts on perceived and actual health outcomes, it is also important to note that other forms of discrimination (eg, sex, religion, sexual orientation, immigrant status, and disability status) are actively at play and have created a syndemic with the potential to undermine child and family health further. It is important to address racism's impact on the health and well-being of children, adolescents, and emerging adults to avoid perpetuating a health system that does not meet the needs of all patients. Pediatricians are uniquely positioned to both prevent and mitigate the consequences of racism as a key and trusted source of support for pediatric patients and their families.

Childhood Experiences of Racism

Children can distinguish the phenotypic differences associated with race during infancy ⁻; therefore, effective management of difference as normative is important in a diverse society. To identify, address, and manage the impacts of racism on child health, it is critical that pediatricians understand 3 key levels through which racism operates: (1) institutional, (2) personally mediated, and (3) internalized. The experience of race is also impacted by other identities that people have related to ethnicity, sex, religious affiliation, immigrant status, family composition, sexuality, disability, and others that must be navigated alongside race. Much of the discussion to date related to the historical underpinnings of race deals with institutionalized (or structural) racism, expressed through patterns of social institutions (eg, governmental organizations, schools, banks, and courts of law) that implicitly or explicitly discriminate against individuals from historically marginalized groups.,,, Children experience the outputs of structural racism through place (where they live), education (where they learn), economic means (what they have), and legal means (how their rights are executed). Research has identified the role of implicit and explicit personally mediated racism (racism characterized by assumptions about the abilities, motives, or intents of others on the basis of race) as a factor affecting health care delivery and general health outcomes. ⁻ The impacts of structural and personally mediated racism may result in internalized racism (internalizing racial stereotypes about one's racial group). A positive racial identity mediates experiences of discrimination and generates optimal youth development outcomes.,, The importance of a prosocial identity is critical during adolescence, when young people must navigate the impacts of social status and awareness of personally mediated discrimination based on race. ⁻

Although children and adolescents who are the targets of racism experience the most significant impact, bystanders are also adversely affected by racism. As an example, young adults who were bystanders to racism and other forms of victimization as youth experience profound physiologic and psychological effects when asked to recall the memory of a past anchoring event as a victim or bystander that are comparable to those experienced by first responders after a major disaster. Three core features that characterized the abusive event(s) were as follows: (1) an individual gets hurt psychologically or physically, (2) a power differential exists (eg, age, size and/or stature, or status) versus the target individual resulting in domination and erosion of the target's self-esteem, and (3) the abuse is repetitive, causing stress levels to increase because of anticipation of future events. Internalized negative stereotypes related to race can unconsciously erode self-perception and capacity and may later play out in the form of stereotype threat or the fear of confirming a negative stereotype of one's race. Stereotype threats can undermine academic and vocational attainment, key developmental milestones for the victim. Underachievement then reinforces the stereotype held by both the perpetrator and victim, further enhancing the vulnerability of the victim and the bystander to repeated acts of overt or covert victimization. These observations suggest that universal interventions to eliminate racism (experienced as a victim or bystander) from the lives of children and to engage in active societal antiracism bystander behavioral intervention may optimize well-being for all children and the adults who care for them. For individual intervention to occur, however, bystanders must identify critical situations, view them as an emergency, develop a sense of personal responsibility, have self-efficacy to succeed with the intervention, perceive the costs of nonintervention as high, and consciously decide to help., Research has demonstrated that racism has an effect on health across racial groups in communities reporting high levels of racism but that racially diverse environments, such as schools, can benefit all youth by improving cognitive skills such as critical thinking and problem-solving.

Racism at the Intersection of Education and Child and Adolescent Health

Educational and vocational attainment are key developmental outcomes that pediatricians monitor to assess for successful growth and development. After accounting for sleep and time spent at home, children spend a significant portion of their time in educational settings. ⁻ Educational achievement is an important predictor of long-term health and economic outcomes for children. Adults with a college degree live longer and have lower rates of chronic disease than those who did not graduate from college. It is critical for pediatricians to recognize the institutional, personally mediated, and internalized levels of racism that occur in the educational setting because education is a critical social determinant of health for children.

Disparities in educational access and attainment, along with racism experienced in the educational setting, affect the trajectory of academic achievement for children and adolescents and ultimately impact health. Chronic absenteeism, defined as missing ≥10% of school days in an academic year, is a strong predictor of educational achievement. Chronic absenteeism disproportionately affects children of color, children living in poverty, children with disabilities, and children with chronic diseases. In high school, 21.2% of Hispanic, 23.4% of African American, and 27.5% of American Indian children were chronically absent in 2013-2014 compared with 17.3% of white children. Immigration enforcement and the fear of apprehension by authorities can negatively affect school attendance for Hispanic and black immigrants, thereby perpetuating inequalities in attendance. According to the National Center for Education Statistics, the graduation rate for white students nationally in 2015-2016 was 88% compared with 76% for African American students, 72% for American Indian students, and 79% for Hispanic students. Disparities in chronic absenteeism and high school graduation rates prevent children from realizing the full benefits of educational attainment and can increase the development of chronic disease and reduce overall life expectancy.

Although the landmark US Supreme Court case Brown v Board of Education banned government-sponsored segregation and laid a foundation for equal access to a quality public education, the US Department of Education continues to report institutional or structural inequality in educational access and outcomes, even in the most diverse and well-resourced communities in the United States. Students from historically aggrieved groups have less access to experienced teachers, advanced coursework, and resources and are also more harshly punished for minor behavioral infractions occurring in the school setting. They are less likely to be identified for and receive special education services, and in some states, school districts with more nonwhite children receive lower funding at any given poverty level than districts with more white children.

Children may also experience personally mediated racism early in their schooling, which may be internalized and ultimately affect their interactions with others. Early teacher-child interactions are important for long-term academic outcomes. The relationship of teacher to student across ages and grade levels influences school adjustment, literacy, math skills, grade point average, and scholastic aptitude test scores. ⁻ Given the critical nature of the student-teacher relationship, it is important to explore how racism and implicit bias affect this dynamic. Student-teacher racial mismatch can impact academic performance, with studies showing that African American children are more likely to receive a worse assessment of their behavior when they have a non-Hispanic white teacher than when they have an African American teacher. This finding may result from racial bias in teachers' expectations of their students, with data demonstrating that white and other non-African American teachers are more likely than African American teachers to predict that African American students would not finish high school. Similarly, data indicate that teachers may underestimate the ability of African American and Latino students, which can lead to lower grade point averages and fewer years of schooling. African American students who have 1 African American teacher in elementary school are more likely to graduate from high school and enroll in college than their peers who do not have an African American teacher; the proposed mechanism for this improved long-term educational outcome is the exposure to a role model early in the educational experience. These findings indicate the importance of ensuring a diverse teacher workforce, particularly as the population of students in US schools continues to diversify. School racial climate, which refers to norms, curricula, and interactions around race and diversity within the school setting, also impacts educational outcomes for students. Students who had a positive perception of school racial climate had higher academic achievement and fewer disciplinary issues. Racial inequities in school discipline begin early, and school discipline has long-term consequences for children. Although federal civil rights laws prohibit discrimination in the administration of discipline in public schools, the US Government Accountability Office found that African American and American Indian students are overrepresented among students experiencing suspension. Data from the US Department of Education confirm that a disproportionate number of African American children receive more than 1 out-of-school suspension in preschool and overall in kindergarten through grade 12 are suspended 3 times more and expelled 1.9 times more than white students. To mediate the effects of institutional and personally mediated racism in the educational setting and prevent internalized racism, studies show that a positive, strong racial or ethnic identity and parental engagement in families is protective against the negative effects of racial discrimination on academic outcomes. ⁻

How Pediatricians Can Address and Ameliorate the Effects of Racism on Children and Adolescents

Pediatricians and other child health professionals must be prepared to discuss and counsel families of all races on the effects of exposure to racism as victims, bystanders, and perpetrators. ⁻ Pediatricians can implement systems in their practices that ensure that all patients and families know that they are welcome, that they will be treated with mutual respect, and that high-quality care will be delivered regardless of background using the tenets of family- and patient-centered care. To do this, it is critical for pediatricians to examine their own biases. Pediatricians can advocate for community initiatives and collaborate with government and community-based organizations to help redress biases and inequities in the health, justice, and educational systems. These strategies may optimize developmental outcomes and reduce exposure to adverse events that dramatically alter the lived experiences, health, and perceived self-value of youth.,,

Conclusions

Achieving decisive public policies, optimized clinical service delivery, and community change with an activated, engaged, and diverse pediatric workforce is critically important to begin untangling the thread of racism sewn through the fabric of society and affecting the health of pediatric populations. Pediatricians must examine and acknowledge their own biases and embrace and advocate for innovative policies and cross-sector partnerships designed to improve medical, economic, environmental, housing, judicial, and educational equity for optimal child, adolescent, and emerging adult developmental outcomes.

Section on Adolescent Health Executive Committee, 2018-2019

Maria E. Trent, MD, MPH, FAAP, Chairperson

Robert M. Cavanaugh Jr, MD, FAAP

Amy E. Lacroix, MD, FAAP

Jonathon Fanburg, MD, MPH, FAAP

Maria H. Rahmandar, MD, FAAP

Laurie L. Hornberger, MD, MPH, FAAP

Marcie B. Schneider, MD, FAAP

Sophia Yen, MD, MPH, FAAP

Council on Community Pediatrics Executive Committee, 2018-2019

Lance Alix Chilton, MD, FAAP, Chairperson

Andrea E. Green, MD, FAAP

Kimberley Jo Dilley, MD, MPH, FAAP

Juan Raul Gutierrez, MD, FAAP

James H. Duffee, MD, MPH, FAAP

Virginia A. Keane, MD, FAAP

Scott Daniel Krugman, MD, MS, FAAP

Carla Dawn McKelvey, MD, MPH, FAAP

Julie Michelle Linton, MD, FAAP

Jacqueline Lee Nelson, MD, FAAP

Gerri Mattson, MD, FAAP

Staff

Dana Bennett-Tejes, MA, MNM

Committee on Adolescence, 2018-2019

Cora C. Breuner, MD, MPH, FAAP, Chairperson

Elizabeth M. Alderman, MD, FSAHM, FAAP

Laura K. Grubb, MD, MPH, FAAP

Janet Lee, MD, FAAP

Makia E. Powers, MD, MPH, FAAP

Maria H. Rahmandar, MD, FAAP

Krishna K. Upadhya, MD, FAAP

Stephenie B. Wallace, MD, FAAP

Liaisons

Liwei L. Hua, MD, PhD - American Academy of Child and Adolescent Psychiatry

Geri D. Hewitt, MD - American College of Obstetricians and Gynecologists

Seema Menon, MD - North American Society of Pediatric and Adolescent Gynecology

Ellie E. Vyver, MD, FRCPC, FAAP - Canadian Pediatric Society

Lauren B. Zapata, PhD, MSPH - Centers for Disease Control and Prevention

Acknowledgments

We are grateful for internal review and critical feedback by Drs Benard Dreyer, Olanrewaju Falusi, Renee Jenkins, Judith Palfrey, Krishna Upadhya, Joseph Wright, Jonathan Klein, Janie Ward, Michael Lindsey, Lance Chilton, James Duffee, Andrea Green, Julie Linton, Virginia Keane, Jackie Nelson, Raul Gutierrez, Lase Ajayi, Lee Beers, Nathaniel Beers, Heidi Schumacher, and Tonya Vidal Kinlow.

Footnotes

Address correspondence to Maria Trent, MD. E-mail: mtrent2{at}jhmi.edu

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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The Impact of Racism on Child and Adolescent Health

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The American Academy of Pediatrics is committed to addressing the factors that affect child and adolescent health with a focus on issues that may leave some children more vulnerable than others. Racism is a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families.

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Description

Presentation slides (PDF): Camara Jones Part 1, Amani Allen, Camara Jones Part 2

Webinar transcript (PDF)

This kick-off webinar of APHA's Advancing Racial Equity series examined racism and its historic and present-day impact on health and well-being. Presenters:

identified the multiple levels on which racism operates;

described the physiological impacts of racism and discrimination on health; and

explored the principles for and barriers to achieving health equity.

Welcome/Opening Remarks

APHA Executive Director Georges Benjamin, MD
Introduction

APHA President-Elect José Ramón Fernández-Peña, MD, MPA, Director of Health Professions Advising, Northwestern University
Presenters

APHA Past President Camara Phyllis Jones, MD, MPH, PhD, 2019-2020 Evelyn Green Davis Fellow, Radcliffe Institute for Advanced Study, Harvard University

Amani Allen, PhD, MPH, Executive Associate Dean, UC Berkeley School of Public Health

Moderator

Tia Taylor Williams, Director, APHA Center for Public Health Policy and Center for School Health and Education

We encourage you to view webinars from the 2015 series The Impact of Racism on the Health and Well-Being of the Nation in advance of the 2020 webinar series.

Upcoming Webinar topics

Policing and Police Violence

Maternal Health

Strategies and Actions

Housing

Check out other APHA racism and health resources, including our popular book, Racism: Science & Tools for the Public Health Professional.

Questions? Contact Tia Taylor Williams.

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Racism: The Ultimate Underlying Condition

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Presentation slides (PDF): Camara Jones Part 1, Amani Allen, Camara Jones Part 2 Webinar transcript (PDF) This kick-off webinar of APHA's Advancing Racial Equity series examined racism and its historic and present-day impact on health and well-being.

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Centers for Disease Control and Prevention

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Presented on .

The first years of a child's life are some of the most important in terms of cognitive, social, and physical development. Early experiences occurring when a child's brain and behavior are being shaped affect a child's ability to learn, to get along with others, and to develop an overall state of well-being. Unfortunately, not all children have the same positive experiences or opportunities, which can lead to disparities. Social, economic, and environmental factors have been closely linked to health disparities.

Research suggests that many disparities in overall health and well-being are rooted in early childhood. For example, those who lived in poverty as young children are more at-risk for leading causes of illness and death, and are more likely to experience poor quality of life. This growing problem costs the United States billions of dollars annually. Our understanding of the lasting value of early experiences continues to grow. Interventions that support healthy development in early childhood reduce disparities, have lifelong positive impacts, and are prudent investments. Addressing these disparities effectively offers opportunities to help children, and benefits our society as a whole.

This session of Grand Rounds discusses how, together, we can address health disparities in early childhood through increased collaborations, public health partnerships, and early intervention.

In this session of Beyond the Data, Dr. Phoebe Thorpe and Dr. Ross Thompson discuss the positive impact of early childhood education and community intervention on young children's health and well-being. Tune in to see how some programs, like ZERO TO THREE, are making it easier for families of young children to receive the care that they need.

Ross A. Thompson, PhD

Distinguished Professor of Psychology
Board President, Zero to Three
University of California at Davis

Paul H. Dworkin, MD

Executive Vice President, Community Child Health;
Founding Director, Help Me Grow National Center,
Connecticut Children's Medical Center;
Professor of Pediatrics, University of Connecticut School of Medicine
Connecticut Children's Medical Center

Georgina Peacock, MD, MPH

Director, Division of Human Development and Disability
National Center on Birth Defects and Developmental Disabilities, CDC

Mary Ann McCabe, PhD, ABPP

Associate Clinical Professor of Pediatrics
George Washington University School of Medicine

John Iskander, MD, MPH

Scientific Director

Phoebe Thorpe, MD, MPH

Deputy Scientific Director

Susan Laird, MSN, RN

Communications Director

Get notified about the latest updates from Public Health Grand Rounds right in your inbox by setting up an alert today!

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Presentation Slide Deck pdf icon [5 MB, 90 Pages, HTML]

Help Me Grow National Centerexternal icon
Advancing Developmental Promotion, Early Detection and Linkage to Services

Caring for Children in a Disaster
Resources for planning and preparedness

Early Hearing Detection and Intervention (EHDI)
Resources for identifying and getting services for children with hearing loss

Essentials for Childhood
Framework for communities to create safe, stable, and nurturing relationships and environments for children

Healthy Stepsexternal icon
Pediatric-based program for extending services to vulnerable young children and their families

MMWR
Health Care, Family, and Community Factors Associated with Mental, Behavioral, and Developmental Disorders in Early Childhood - United States, 2011-2012

The Science of Early Childhood Development 15 Years After Neurons to Neighborhoods pdf icon [613 KB, 7 Pages]

August 2011, Maternal Health

More than 4 million newborns in the US are screened yearly for hearing loss and certain disorders. Learn how newborn screening provides an opportunity for reductions in morbidity and mortality while reducing health care costs associated with treatment of lifelong debilitating conditions.

November 2015, Maternal Health

Preterm birth is a challenge. Its causes are numerous and poorly understood. Modern technology and stronger public health strategies have made a significant impact in reducing preterm births and infant mortality. Find out how improvement efforts can reduce preterm births, especially among racial and ethnic minorities.

Page last reviewed:

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Addressing Health Disparities in Early Childhood

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Presented on . The first years of a child's life are some of the most important in terms of cognitive, social, and physical development. Early experiences occurring when a child's brain and behavior are being shaped affect a child's ability to learn, to get along with others, and to develop an overall state of well-being.

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Discolosure

Planners and speaker disclose they have no relevant financial relationships

Seattle Children's is accredited by the Washington State Medical Association CME Accreditation Committee to sponsor continuing medical education for physicians.

Seattle Children's designates this online educational activity for a maximum of 1 AMA PRA Category 1 Credit ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

This activity meets the criteria for up to 1 hour of Category I CME credit to satisfy the relicensure requirements of the Washington State Medical Quality Assurance Commission.

Videos are available for only one year after posting.

If you wish to receive Category I CME credit for viewing this Provider Grand Rounds session, please complete the evaluation form. Upon completion of the form you will receive an auto-reply email that will serve as the only confirmation of your CME credit. Please keep the email for your records.

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Addressing Racial Inequities in Our Own Community

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Discolosure Planners and speaker disclose they have no relevant financial relationships Seattle Children's is accredited by the Washington State Medical Association CME Accreditation Committee to sponsor continuing medical education for physicians. Seattle Children's designates this online educational activity for a maximum of 1 AMA PRA Category 1 Credit ™.

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The impact of racism on the health and wellbeing of children is significant and we must first examine our own implicit biases if we are to bring about change. We need to understand the differences between equity and equality and to advocate for our children, but in order to do so we have to educate ourselves and begin the change within. In this episode Dr. Lynn Smitherman, Vice Chair of pediatric education at Wayne State University School of Medicine walks us through definitions and constructs to better understand racism and antiracism. Dr. Smitherman is the AAP District V champion for equity, diversity and inclusion and has long been advocating for children's social wellbeing.

Let's dive right in and hear Dr. Smitherman's thoughts about the impact racism has on children and the need to change the narrative. Dr. Smitherman offers strategies for change at the institutional, practice and individual level and provides multiple resources to drive change.
[00:01 - 08:39] Opening Segment

Introducing today's guest, Dr. Lynn Smitherman

Dr. Smitherman path to pediatrics

Comfort in talking with children and parents

[08:40 - 26:09] Racism

Dr. Smitherman talks about restorative justice

She talks about some terms related to racism

Bias

Explicit

Implicit

Discrimination

Prejudice

Racism

Institutional/Structural

Interpersonal

Internalized

[26:10 - 40:01] People of Color

Dr. Smitherman talks about racism in the context of medicine

She talks about ways to handle racism

For children

For pediatricians

Having allies from different backgrounds is crucial

[40:02 - 52:07] Education

We talk about addressing racism in the medical field

Educate yourself

Reflect on your current values

Dr. Smitherman shares some relevant resources. Links below.

How to tackle racism in childhood and adolescence

Positive messaging

The root of the problems

[52:08 - 58:00] Closing Segment

Dr. Smitherman tells us why we should stand against racism

Children are vulnerable

Final Takeaways

Differences among bias, prejudice, and discrimination

Racism's impacts on children

Equity, diversity, and inclusion

Intentional effort to participate in change

Trust as a bridge to people of color

Personal change, practice change, and organizational change

Representation in the medical field

Tweetable Quotes:
"We all have biases because we are all human beings and we all have ideas and thoughts of things we like and don't like." - Dr. Lynn Smitherman

"...for racism to exist, there has to be not only that prejudice but also a feeling of superiority that one group is superior over another group." - Dr. Lynn Smitherman
Resources Mentioned: For Kids: Videos
If you'd like to connect with Dr. Smitherman, email lsmither@med.wayne.edu. Also, visit https://www.med.wayne.edu/ to learn more about her space.

If you'd like to connect with me, you can find me at LinkedIn, Facebook, and Twitter or email me at gagginol@yahoo.com. To learn more about me visit https://www.medicalbhs.com/

LOVE WHAT YOU HEARD? Leave us a 5-star review so we can continue to provide you with great content. Share this episode and help people know more about children's health and well-being.

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Pediatric Meltdown - Racism: Its Impact on Children's Wellbeing and Changing the Narrative with Dr. Lynn Smitherman

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The impact of racism on the health and wellbeing of children is significant and we must first examine our own implicit biases if we are to bring about change. We need to understand the differences between equity and equality and to advocate for our children, but in order to do so we have to educate ourselves and begin the change within.

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‎Life Kit: Parenting: Talking Race With Young Children on Apple Podcasts

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‎Even babies notice differences like skin color and hair texture. Here's how to handle conversations about race, racism, diversity and inclusion, even with very young children.

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Sign up to get tips for living a healthy lifestyle, with ways to fight inflammation and improve cognitive health, plus the latest advances in preventative medicine, diet and exercise, pain relief, blood pressure and cholesterol management, and more.

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How racism harms children - Harvard Health

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Thanks for visiting. Don't miss your FREE gift. The Best Diets for Cognitive Fitness, is yours absolutely FREE when you sign up to receive Health Alerts from Harvard Medical School Sign up to get tips for living a healthy lifestyle, with ways to fight inflammation and improve cognitive health, plus the latest advances in preventative medicine, diet and exercise, pain relief, blood pressure and cholesterol management, and more.

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In light of recent events, many caregivers may find themselves struggling to talk about the concepts of race, ethnicity and racism with kids. What is discussed depends on a family's make up and the community in which they live, but it is important for everyone to have the conversation. Remember: it is okay not to know all the answers. You can look them up and learn together!

Where Do I Start?

Educate yourself about race and racism. If caregivers feel uncomfortable or feel they lack knowledge about a topic, they are more likely to avoid it.

Read a few articles or books; watch a few documentaries or videos; or listen to podcasts about race and racism.

At What Age Should I Start Talking to My Kids About Race and Racism?

Caregivers should begin talking about race and racism early!

Kids are learning and hearing about race whether parents talk to them about it or not. As soon as 6 months of age kids are noticing skin color (just like they notice other physical differences) and by 2 to 4 years of age they are already internalizing racial bias!

Silence about race teaches children that they cannot talk about it and may reinforce racism later on.

Keep in mind their developmental level. Start by asking questions to understand what they are currently thinking, how they are feeling, and what they want to know.

Follow their lead. If they ask follow-up questions, they are showing you they are ready for more.

Caregivers can give more complex information as children mature.

Remember, conversations should be ongoing and should not be a one-time occurrence.

When I Talk About Race and Racism, What Should I Say?

The first step in talking about racism is to talk about race itself. Let kids know that there is nothing wrong with observing physical characteristics and differences. However, they want to be careful not to make negative judgements based on those differences.

Talk about the positive aspects of being different and the similarities in all groups (different is not weird or bad).

Teach them about stereotypes and remind them that not all people in one group are the same.

Talk about historical and institutional racism (e.g., slavery, Jim Crow, civil rights and the ongoing struggle for social justice). Understanding history can help explain why certain words or statements are hurtful and why current events may be happening. Remember to highlight that racism is not a thing of the past.

Discuss that people are sometimes treated unfairly because of the color of their skin (kids understand fairness really well). For older kids, you can have deeper discussions about the systems that help maintain these inequalities.

Use tools to help engage kids in the conversation. Books are a helpful tool in engaging and explaining concepts to kids.

Talk about how they can make change. Topics can include being kind to all people of all backgrounds, as well as and listening to and understanding the experiences or feelings of others who are different.

What Can I DO?

Set an example: Have a diverse network of friends, attend diverse community events, and consume diverse media such as books, shows, movies, and videogames in your home.

Highlight heroes of color.

Have discussions about how people are represented in what you watch and challenge stereotypes.

Let your children see you talk to others about race by having open discussions with other adults around them.

Pay attention to what is trending online and what teens are exposed to.

Other Resources:

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In light of recent events, many caregivers may find themselves struggling to talk about the concepts of race, ethnicity and racism with kids. It is okay not to know all the answers. You can look them up and learn together!

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Appointed head of the incoming administration's task force on health equity, the Yale University scientist "is not sitting in her ivory tower."

Dr. Marcella Nunez-Smith will run the Biden administration's task force on health equity. "The Biden-Harris team has been really clear on saying that our response and recovery needs to be equitable," she said. Credit... Yale University

Growing up in the United States Virgin Islands, Dr. Marcella Nunez-Smith saw firsthand what can happen in a community with limited access to health care. Her father, Moleto "Bishop" Smith Sr., was only in his 40s when he suffered a debilitating stroke that left him partly paralyzed and with slurred speech.

The cause was high blood pressure, which could have been treated but had never been diagnosed. Without prompt access to advanced treatments, "the stroke was allowed to run its course," Dr. Nunez-Smith, 45, recalled in a recent interview. Her father never fully recovered.

"He was a champion and a fighter," she said. "But my memories are of a father who had to live life with this daily reminder of how we had failed in terms of our health care. I don't want another little girl out there to have her father suffer a stroke that is debilitating and life-altering in that way."

Now, tapped by President-elect Joseph R. Biden Jr. to lead a new federal task force, Dr. Nunez-Smith, an associate professor of internal medicine, public health and management at Yale University, will address a terrible reality of American medicine: persistent racial and ethnic disparities in access and care, the sort that contributed to her father's disability.

Dr. Nunez-Smith has an expansive vision for the job, with plans to target medical resources and relief funds to vulnerable communities but also to tackle the underlying social and economic inequalities that put them at risk.

Her goals are ambitious, experts noted.

"For so long, we've been setting our sights on the more achievable goals and attempted to say, 'We probably can't have totally equitable care, so let's at least make sure minority patients get insurance, or at least make sure there's a health clinic in their community,'" said Dr. Utibe R. Essien, an assistant professor of medicine at the University of Pittsburgh School of Medicine who studies racial disparities in cardiovascular disease.

"This is a great opportunity to stretch and reach for what's been imagined for decades, if not centuries," he said.

Racial health disparities represent a vast, structural challenge in this country, made all the more stark by the raging pandemic. Black, Latino and Native Americans are infected with the coronavirus and hospitalized with Covid-19 at higher rates than white Americans, and they have died of the illness at nearly three times the rate, according to the Centers for Disease Control and Prevention.

"Making sure communities hardest hit by the pandemic have access to safe, effective vaccines remains a priority," Dr. Nunez-Smith said. But "what's needed to ensure equity in the recovery is not limited to health and health care. We have to have conversations about housing stability and food security and educational equity, and pathways to economic opportunities and promise."

Many factors have contributed to higher rates of infection and severe disease in minority communities. Black, Latino and Native Americans are more likely to live in crowded households than white people, and less likely to be able to work from home. Minority Americans have higher rates of underlying health problems that increase their risk for severe Covid-19, and they often have limited access to medical care. Asian-Americans have been infected at a lower rate than white Americans, yet have had a slightly higher rate of both hospitalizations and deaths.

While almost every American now knows someone who has been affected by Covid-19, in communities of color at least one third of people have lost someone close to them. "Think about the individual toll that takes," Dr. Nunez-Smith said. "These are people's parents, friends and loved ones. We cannot overstate the disproportionate impact."

Dr. Nunez-Smith currently serves as one of three co-chairs on an advisory board advising the Biden transition team on management of the pandemic. Colleagues describe her as a brilliant scientist with a gift for building consensus, a sharp contrast to the politically driven administration officials who guided the response during the Trump era.

"She is a national gem," said Dr. Harlan Krumholz, a professor of medicine at Yale School of Medicine. "This is a person who spends her days thinking about how we can make health care more equitable, and what interventions can address these disparities."

At Yale, Dr. Nunez-Smith wears many hats - practicing internist, scientist, teacher, mentor and the director of several research centers. She directs Yale's Equity Research and Innovation Center, which she founded, as well as a research collaborative funded by the National Institutes of Health to study chronic disease in Puerto Rico, Trinidad and Tobago, Barbados, and the United States Virgin Islands.

But she also is involved in community organizations like the Community Foundation for Greater New Haven and Connecticut Voices for Children. "She's not sitting in her ivory tower," said Christina Ciociola, senior vice president for grant-making and strategy at the foundation.

"She is out on the front lines," Ms. Ciociola said. "She sees patients, and she's seen friends and colleagues suffer with this illness. She's lost people to the pandemic."

Image

President-elect Biden speaking with Dr. Nunez-Smith, third row, second left, and other members of the transition's Covid-19 advisory council last month. Credit... Amr Alfiky/The New York Times

Dr. Nunez-Smith's early interest in medicine was encouraged by her mother, a retired nursing professor, who instilled her commitment to community or, as she puts it, "the village." Her grandmother played a pivotal role in her life, as did her godfather, a surgeon who still practices in St. Thomas.

Her mother filled the home with medical books. "She said I could read anything I could reach," Dr. Nunez-Smith recalled. "I started early on learning medicine and nursing texts, and became fascinated with the human body and biology."

Over time, she came to understand the importance of health policy and its repercussions in places like the U.S. territories, where lower federal payments for services affect access to care and high quality medical care is limited. (A recent study she co-wrote found that older women in the U.S. territories with breast cancer waited longer for surgery and radiation, and were less likely to get state-of-the-art care, than their counterparts in other regions of the United States.)

After graduating from high school at age 16, Dr. Nunez-Smith attended Swarthmore College in Pennsylvania, majoring in biological anthropology and psychology, and went on to earn a medical degree at Jefferson Medical College, now called the Sidney Kimmel Medical College.

She completed a residency and internship at Harvard's Brigham and Women's Hospital, and then a fellowship at the Robert Wood Johnson Foundation Clinical Scholars Program, where she also received a master's degree in health sciences.

Some of her research has been informed by her own experiences as a Black female physician, she said. She still encounters hospital patients who assume she has come into the room to collect their meal tray or empty their trash, even though she introduces herself as a doctor and has a stethoscope hanging around her neck.

In studies of attitudes toward the health care system among Black patients, she has found that distrust is rampant. A survey of 604 Black Americans, carried out in May jointly by Dr. Nunez-Smith's Equity and Research Innovation Center and the N.A.A.C.P., found that more than half believed Black people were less likely than white people to get access to coronavirus tests when testing was scarce, and that they were less likely to be admitted to the hospital when needed. More than half thought that hospitalized Black patients were less likely to "have everything done to save their lives."

The survey also found that over one-third of Black respondents had lost a job or seen their hours reduced. Nearly one-third said they did not have enough money to buy groceries and had trouble paying rent. Economic pressures keep them going to work even when they fall ill, Dr. Nunez-Smith said.

"People are very worried about surprise bills for seeking care, and this is very different from other countries, where cost is not a consideration," she said. "How do we make sure there are positive incentives for coming in and getting tested and getting care?"

All of these factors must shape the response to the pandemic, she said. Testing sites must be located in or near low-income communities, for example - they cannot be only drive-through sites used by people who have cars.

Hotel rooms should be provided to people who don't have space at home to quarantine or isolate after an exposure or positive test. Workplaces must take the steps necessary to keep essential workers safe.

"One size won't fit everyone - you can't just say, 'Everybody stay home and stay safe,'" she said. "There are people whose jobs require them to leave their homes, and if we don't have a message to them, that's our failure."
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Those hesitant to take a Covid vaccine must be reassured that the vaccines are safe and effective - and that they won't get a surprise bill later. They need to be told in advance about the predictable side effects.

Scientists who study health equity acknowledged the task force's goals will be difficult to accomplish, but welcomed the incoming administration's ambitious focus.

"Yes, it will be hard and we will need to take iterative steps," said Dr. Clyde W. Yancy, chief of cardiology at Northwestern University Feinberg School of Medicine. "But begin is exactly what we should do, and considering the link between poor health, poor education, poor housing and poverty, a case can be made to target economic development in the most vulnerable communities as an important first step."

Like many Americans, Dr. Nunez-Smith is juggling work and community responsibilities while raising school-aged children amid a pandemic. She knows the pressures are bound to increase as she takes up difficult new responsibilities.

"Everyone needs a village," she said. "I feel grateful to have a great supportive spouse, family members. I had a friend drop off several meals yesterday, and someone else is going shopping for us. It's our village we're trying to keep safe."

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Dr. Marcella Nunez-Smith Takes Aim at Racial Gaps in Health Care

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Appointed head of the incoming administration's task force on health equity, the Yale University scientist "is not sitting in her ivory tower." Growing up in the United States Virgin Islands, Dr. Marcella Nunez-Smith saw firsthand what can happen in a community with limited access to health care.

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In this issue, we focus on the topic of mistrust of health care providers or systems among Black Americans, who are much more likely than whites to get seriously ill and die from COVID-19 but less willing to take the coronavirus vaccine.To draw lessons on ways of building trust with Black patients, we looked at clinical encounters in which the stakes of not addressing mistrust are high, including childbirth, childhood vaccination, and the care of patients with HIV, cancer, and substance use disorder. Many of the programs we found have focused on improving communication, increasing transparency, creating welcoming environments, and attending to access barriers, among other approaches for engaging patients who have been poorly served by the health care system.

The medical establishment has a long history of mistreating Black Americans - from gruesome experiments on enslaved people to the forced sterilizations of Black women and the infamous Tuskegee syphilis study that withheld treatment from hundreds of Black men for decades to let doctors track the course of the disease. So it's not surprising that just 42 percent of Black Americans said in November they'd be willing to take a COVID-19 vaccine. As Michael Che, one of the stars of Saturday Night Live, quipped last month, "I've got mixed feelings about the vaccine. On the one hand, I'm Black, so naturally I don't trust it. But on the other hand, I'm on a white TV show, so I might actually get the real one."

Mistrust of the health care system persists even among some Black medical professionals such as Oni Blackstock, M.D., a primary care physician, researcher, and former assistant commissioner of New York City Health Department's Bureau of HIV. When Blackstock's seven-year-old son needed to go the emergency department (ED) for a skin abscess, she hesitated. The last time Blackstock had taken him to the ED - for a broken wrist - a white orthopedist reset the bone without giving him a painkiller. "I have never seen so much fear in my child's face," Blackstock recalls, "and I felt completely responsible." To avoid a similar experience, she phoned her twin sister, an ED physician, who called ahead to ensure that a trusted colleague would treat her nephew.

Studies have found Black Americans are consistently undertreated for pain relative to white patients; one revealed half of medical students and residents held one or more false beliefs about supposed biological differences between Black and white patients, like the former have higher pain tolerance than the latter. In addition to this kind of differential treatment, the health care system often gives short shrift to the physical and emotional tolls of exposure to police brutality; substandard housing and schools; polluted neighborhoods; or other parts of the daily experiences of some Black Americans. Our September 2018 issue of Transforming Care described how health systems are working to reduce health disparities by confronting racism head on. In this issue, we look at the problem of mistrust, which has risen to the fore during the pandemic amid concerns about its effects on Black Americans. As a group, they are much more likely than whites to get seriously ill and die from COVID-19 but less willing to take the coronavirus vaccine.

What Is Medical Mistrust?

A growing body of researchers is exploring the factors that fuel medical mistrust, particularly among Black and other patients of color. Laura Bogart, Ph.D., a social psychologist and senior behavioral scientist at the RAND Corporation whose research has documented the effects of medical mistrust on HIV prevention and treatment outcomes, defines medical mistrust as an absence of trust that health care providers and organizations genuinely care for patients' interests, are honest, practice confidentiality, and have the competence to produce the best possible results.

Bogart and other researchers have found that medical mistrust is not just related to past legacies of mistreatment, but also stems from people's contemporary experiences of discrimination in health care - from inequities in access to health insurance, health care facilities, and treatments to institutional practices that make it more difficult for Black Americans to obtain care. As she describes in a Q&A below, lack of trust can either be harmful (e.g., by causing people to avoid care) or empowering (e.g., by encouraging people to pursue health system reform and broader social change).

Often, patients who don't trust their health care providers are labeled as noncompliant and blamed for their failure to benefit from treatment. "Even the term mistrust is victim blaming," says Kimlin Tam Ashing, Ph.D., director of the Center of Community Alliance for Research and Education at the cancer center City of Hope in Los Angeles County, whose research assesses the biological, psychological, and cultural underpinnings of racial and ethnic disparities in cancer outcomes. "It puts it on the community when in fact the community has been let down by the medical system and by providers who continue to discriminate."

Improving Patient-Provider Relationships

Strengthening relationships between patients and their health care providers may be a means of building trust as some studies have found that people have more confidence in their providers than "the health care system" or "Big Pharma" writ large.

Treating Patients as the Experts

One such effort is part of the Merck for Mothers initiative, which aims to reduce maternal morality worldwide; in the U.S., Black women are three times more likely to die from pregnancy-related causes then white women. Among the explanations: providers spend less time with Black patients, ignore their symptoms and complaints, and lose contact with them during the postpartum period when women undergo major physiological changes that put them at risk of death.

In 2019, the Merck for Mothers initiative brought together Black women in New Orleans; doulas from Birthmark Doulas; OB-GYNs from Touro LCMC Health, a local community hospital; and other perinatal care professionals for "Equity Action Labs." During the labs, women described the problems they'd experienced during delivery and with prenatal and postpartum care with local providers and helped design solutions. Their accounts were troubling: one mother described her child's long-term health problems that resulted from having her concerns discounted, and many said they'd felt judged by providers or had procedures done to them (e.g., having internal fetal monitors inserted) without their permission.

The women offered suggestions to avoid these experiences, which Touro providers have begun to test, including having OB-GYNs and pregnant women take part in a trust-building visitmidway during a pregnancy to explore women's past experiences with the health care system, their goals for childbirth, and their safety concerns. "Our hope is that by having someone take the time to sit with them and ask these questions, women will feel enhanced trust between themselves and their providers," says Stephanie Visco, manager of Birthmark Doulas, a collective that is working to improve birth outcomes among low-income women.

Touro is also piloting a navigation program to offer women postpartum supports that are more comprehensive and longer than the typical six-week period. In addition, the hospital has begun to offer providers case-based training in structural and institutional racism and mandated implicit-bias training for all providers and staff.

Using Empathy, Not Arguments

In an effort to encourage Black patients to participate in COVID-19 vaccine trials, Pfizer partnered with clinical research sites in minority communities and worked with community organizations to have trusted leaders make appeals. Black representation in Pfizer's and other clinical trials reached 10 percent, an underrepresentation of the overall population of Blacks in the U.S. (13%). Black medical professionals had some success in recruitment by listening and responding to individuals' concerns, but public health authorities still face an uphill battle in convincing Black Americans to accept the new vaccines.

Pediatricians who've had success persuading skeptical parents to accept vaccinations for their children say effective approaches turn on empathy rather than information. At Kaiser Permanente in Northern California, providers who've undergone the health system's Effective Communication without Confrontation training program are encouraged to understand parents' challenges (e.g., by acknowledging there's a lot of information about vaccinations and mixed messaging to sift through) and recognize their shared goal, which is to protect children.

Jessica Jaiswal, Ph.D., assistant professor in the department of health sciences at the University of Alabama, says providers may feel compelled to try to dispel patients' conspiracy beliefs, but hearing and validating patients' concerns before offering new information may be a more helpful approach to building trust. "I don't know if it's useful to try to convince someone that the government did not create HIV to kill Black people," Jaiswal says, referring to the theory that the U.S. military deliberately created HIV. "However, I think it's worthwhile to acknowledge the hundreds of years of institutional racism that make someone think that."

With COVID-19 vaccines, Kenneth Hempstead, M.D., a pediatrician who serves as vaccine communications lead for Kaiser Permanente in Northern California, says both empathy and information are important; because these are new vaccines, clinicians need to be extraordinarily transparent about what we do and don't know about long-term safety concerns. "I'm optimistic about the vaccines," he says. "But if we say we have 100 percent confidence in them, and there turns out to be a problem, we run the risk of ruining the public's trust in all vaccines."

Building Relationships Outside Exam Rooms

Some advocates say that engendering trust among patients and providers will require carving space outside of the exam room. That's the idea behind 3rd Conversation, a program led by X4 Health, a social impact design firm, and funded by the Andrew and Corey Morris-Singer Foundation. The program's designers recognized patients and providers were having separate conversations about their health care experiences and frustrations. 3rd Conversation provides a space where they can come together to share their experiences and strengthen their relationships, with an eye toward finding solutions together.

At 3rd Conversation events, pairs of clinicians and patients get together for facilitated conversations; each is asked to share a personal story about when a relationship with a health care provider or patient made a significant difference to them. The sessions have revealed that clinicians and patients often want similar things, like more time during visits to get to know each other and less time spent looking at screens. Clinicians have also expressed frustration at their inability to help patients with social and economic challenges. "It demoralizes them when a patient comes in and is sick from pneumonia and they can give them medication, but they know the patient is going to sleep in a homeless shelter where they are apt to become sick again," says Jennifer Sweeney, cofounder of X4 Health.

Sweeney says interest in 3rd Conversation remains high, even amid the pandemic, with requests coming in from large health systems and academic medical centers to private physician practices, and federally qualified health centers.

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Making Institutional Changes

Studies that rely on surveys such as the Medical Mistrust Index - which asks respondents how strongly they agree with statements such as "When healthcare organizations make mistakes they usually cover it up," and "Healthcare organizations are more concerned about making money than taking care of people" - have found that many people distrust the policies or motives of institutions, not the people who work there. Building trust will require coupling efforts to improve interpersonal relationships with broader efforts to change health care institutions, ones that involve clear-eyed examinations of how these institutions have and have not supported the communities they serve.

Uncovering Instances of Institutional Racism

At Boston's Brigham and Women's Hospital, staff have deliberately sought to uncover instances of institutional racism - that is, differential access to goods, services, or opportunities by race - as part of the work of the Department of Medicine's Health Equity Committee. The goal is to find concrete examples of how racism affects care within the walls of their institution and use critical race theory and quality improvement methodologies to change the status quo. "After much conversation and debate, the concept of institutional racism was no longer distant, abstract, or someone else's problem," says Michelle Morse, M.D., M.P.H., former co-chair of the committee and a hospitalist at Brigham and Women's.

One project grew out of an analysis showing that, from 2008 to 2017, Black and Latino heart failure patients admitted to Brigham and Women's were significantly more likely to be admitted to the general medical service than the specialty cardiology service. Rates of comorbidities and insurance status didn't explain the differences. Nationally, heart failure complications are one of the most common reasons people are admitted to hospitals, and several studies (for example, here and here) have shown that patients who receive care from cardiologists have better outcomes than those who don't receive this specialty support. At Brigham and Women's, heart failure patients who were admitted to the general medicine floor were more likely to have unplanned hospital readmissions within 30 days. Unlike those discharged from the cardiology service, patients discharged from general medicine aren't given extra supports, such as home monitoring and check-in calls.

Leaders have taken immediate and longer-term steps to try to reduce this inequity, including surveying physicians to elucidate what influences their decisions about where to admit patients. In preliminary results, providers said they perceived white patients to advocate more often and more vigorously for access to specialty cardiology services, and that this impacted their decision-making - a phenomenon that hasn't previously been well described in the literature. They're also trying to improve the quality of heart failure care on the general medicine service, including by offering follow-ups after discharge. "We've already seen shifts in practice, we think in large part because of the ripple effects of the discussion that came about after finding this example of institutional racism within our walls," Morse says. The next step is an effort to give hospitalized Black and Latino patients preferential access to the subspecialty cardiology service to redress this longstanding injustice.

Attending to Affordability, Access Barriers

Some patients say they are treated with less respect by health care providers because of their income, type of insurance coverage, and/or race, and some fear they may have care withheld or may not receive the best-quality care. To try to engage Black, Latino, and other people of color, the cancer center City of Hope is taking several steps to engage patients and dismantle emotional, financial, and other barriers to accessing and engaging in care.

All patients are invited to complete a survey, SupportScreen, which asks if they are experiencing social, emotional, or financial problems that may affect their ability to follow treatment. The automated system then directs social workers, financial services staff, chaplains, and other supportive care medicine staff to offer help.

Leaders are also trying to make it easier for Black patients and others to take part in clinical trials. Nationally, minority patients are less likely to do so due to restrictive inclusion criteria and patient-level factors, ranging from lack of transportation to concern about lost income from missing work and other costs associated with participation. Communities and potential participants also need assurance that therapeutical clinical trials provide the standard of care at a minimum (i.e., treatments known to be effective won't be withheld, as happened during the Tuskegee study). To make it easier to take part in trials, City of Hope has partnered with community hospitals and built or acquired community practices, some in parts of suburban Southern California that lack oncologists or oncology subspecialty services. In a trial funded by the Patient-Centered Outcomes Research Institute and led by City of Hope researcher Ashing, the cancer center is training community ambassadors and research navigators to increase awareness and acceptability of biomedical studies, including clinical trials, among underrepresented populations.

Ultimately, it will be important to encourage more people to receive timely cancer screenings, Ashing says. Nationally, Black people have worse outcomes for many types of cancer, including lung, colon, cervical, breast, and blood cancers, due in part to the fact that they are often diagnosed at later stages.

Creating Safe, Welcoming Environments

While reviewing historical practices, health systems can take immediate steps to make patients who've been marginalized feel more welcome. UnityPoint Health system, a network of hospitals, clinics, and home care services in Iowa, Illinois, and Wisconsin, sought to redesign care for its LGBTQ patients after hearing about the challenges Kyle Christiason, M.D., one of UnityPoint Health's physicians, faced finding appropriate medical options for his son after he identified as transgender.

Together, Christiason and UnityPoint Health created the system's first LGBTQ clinic in Cedar Falls, Iowa, in 2018. In developing it, Christiason and his colleagues proceeded with an attitude of cultural humility: acknowledging what they didn't know and getting input from LGBTQ community members by holding town hall meetings and focus groups and fielding surveys. One of the clinic's first patients told Christiason he hadn't felt comfortable telling his primary care physician of 20 years that he was gay because he hadn't wanted to disappoint him. Nationally, many LGBTQ people say they don't trust their providers enough to divulge information about their gender identity or sexual orientation; more than half say they've experienced some type of discrimination in health care, including having providers refuse to treat them.

All of the clinic's staff take part in regular Safe Zone training on LGBTQ identities and how to serve as allies. Christiason says having consistent routines, like asking people about their pronouns, makes a difference. "If I know your behavior is going to happen this way every time, that starts to create trust," he says. The clinic, held two evenings each month, provides routine primary care as well as pre-exposure prophylaxis to help prevent HIV transmission, gender-affirming hormone therapy, and postsurgical care following gender-affirming procedures.

Staff end each clinic with a huddle to review what did and didn't go well, discuss ways to improve, and share examples of what brought them joy in their work. "Sometimes they're tiny, like 'I got someone to smile,'" Christiason says. "Sometimes they're quite profound. Once, someone came out of an exam room and said, 'I just want you all to know that because you chose to let me be my most authentic self, I decided not to kill myself after my last visit. I've been thinking about how I can end my life for 10 years, and now for the first time, I think I can take care of myself because you showed that I matter.'''

After receiving positive feedback on the first clinic, the health system established a second LGBTQ clinic in Des Moines.

Signaling Commitment to Improving Patients' Experiences

Geisinger Health System's Proven Experience program encourages patients who have had a poor experience to apply for no-questions-asked refunds of copayments, coinsurance, and deductibles as a way of building trust. Applicants are told, "You placed your trust in us, and we place our trust in you."

The idea for the refund, which came from an incoming CEO, initially met with resistance from other health system leaders who worried about financial losses, the legalities of such a program, and the possibility of specious complaints, says Greg Burke, M.D., chief patient experience officer. Burke says these problems haven't materialized since the program's inception in 2015; instead, it has helped leaders spotlight and correct problems and sends a signal to patients "that the system wants to hear how we are doing," he says. Complaints related to perceived lapses in quality or differences of opinion about the course of treatment are excluded from the refund program and are referred to Geisinger's internal safety division instead.

Most complaints (70%) relate to communication failures, such as providers saying something hurtful or not following up as promised. Geisinger gives all new physicians and advanced practitioners a four-hour training course on effective communication, with a focus on making eye contact, introducing yourself, informing patients of what you are doing and asking permission, being personable, and ending on an upbeat note. Providers who have persistent problems are offered individual coaching sessions.

Involving Patients in Research

Involving patients in research aimed at improving care, known as participatory research, is another mode of building trust. Starting in 2015 at Yale School of Medicine's Department of Psychiatry, researchers engaged in a participatory research training exercise with members of the local community who were in recovery from substance use disorder and other behavioral health conditions. One of their goals was to make behavioral health research more responsive to the concerns of community stakeholders, particularly for people of color.

Over the course of two years, people in recovery met with clinicians, researchers, policymakers, and community advocates to explore ways they could work together to conduct participatory research. Participants were given opportunities to share their stories and offer suggestions. One finding was that researchers and patients may have different priorities, with the latter often focused on practical changes that help them achieve their goals rather than on clinical diagnoses or effects, says Miraj Desai, Ph.D., an instructor at Yale's Program for Recovery and Community Health and the project director. "People overwhelmingly focused on seeing concrete meaningful changes in their communities and lives and wanted to know how research can be more closely aligned with these goals," he says.

Participants also suggested researchers should create opportunities for trial investigators and community partners to get to know each other, such as by sharing meals; address the challenges patients may face in joining projects (e.g., finding transportation or missing work); and create opportunities to discuss racism, poverty, and other social problems that affect health.

Moving Forward

These and other efforts suggest that some health care professionals and systems had begun taking the problem of medical mistrust seriously well before the need to vaccinate most Americans made it urgent. Some of the work was driven by professional societies, including the American Board of Internal Medicine, which has worked to rebuild trust in the medical profession since 2018, in part by building a compendium of trust-building practices. The Journal of the American Medical Association, Behavioral Medicine, and other journals have also devoted commentaries and/or issues to the subject.

Not all of the initiatives we've featured are focused on the particular experiences of Black Americans. To move forward, efforts are needed to document and understand the many reasons fueling medical mistrust of health care providers and institutions among Black patients by documenting the problem and learning from patients about what may help. The Institute for Healthcare Improvement recently launched its second round of the Pursuing Equity Learning and Action Network, in which teams of community health centers, free clinics, and large health systems are examining the impacts of racism within their organizations and communities and deploying improvement strategies to close specific equity gaps.

Changing facts on the ground will be important, including reviewing not just hiring, promotion, and procurement practices at health care organizations but also where they have chosen to locate and upgrade facilities. Including more Black people in clinical and leadership roles will also be necessary but not sufficient. Efforts are needed to expand the health care workforce to include peers and navigators in supporting patients, make the history of racism in medicine a required part of health professionals' training, and create systems to identify and address instances of disparate care.

Ultimately to earn Black patients' trust, policy changes are needed to make it easier to access and afford care. When asked if seeing President Obama receive the COVID-19 vaccine on camera would persuade them to get vaccinated, two Black men pointed out to a Washington Post reporter that should the former president experience serious side effects he'd have access to the best doctors and receive care that is unimaginable in their own or other low-income communities.

Q&A: Broaching Conversations About Medical Mistrust

Laura Bogart, Ph.D., is a social psychologist and senior behavioral scientist at the RAND Corporation whose research has documented the effects of medical mistrust on HIV prevention and treatment outcomes. Transforming Care spoke to Bogart about how clinicians and health systems can broach conversations about mistrust and ameliorate its effects.

Transforming Care: You've described medical mistrust as a form of resilience and a healthy survival mechanism that arises in response to oppression. How does framing mistrust in positive terms change how we go about addressing it?

Bogart: If we recognize that mistrust isn't necessarily harmful, it changes how we frame our response. It's very natural that people would want to put their guard up and ready themselves for the possibility of discrimination after experiencing so much systemic racism. If channeled effectively, mistrust can empower people to protect themselves and pursue changes at the institutional and societal levels. Mistrust becomes problematic when it stops people from engaging in healthy behaviors or when it leads to avoidance of the health care system.

Transforming Care: What advice would you give to providers who are interested in talking about mistrust with their patients?

Bogart: I think it has to start with education to raise provider awareness about the levels of mistrust in communities, the origins of it, and its impact on engagement, adherence, and treatment outcomes. In the case of HIV, in a national survey of Black Americans in 2016, we found that a high percentage of Black Americans believe that the virus is manmade (31%), that a cure is being withheld (40%), and that antiretroviral treatment is poison (33%). We also know medical mistrust is correlated with not adhering to medical advice, filling prescriptions, and delaying cancer screenings and other preventive health measures. It's also higher among patients who have experienced discrimination.

Transforming Care: What are some of the signs of it in an exam room?

Bogart: It could be a lack of engagement during the health care interaction. A patient may not ask questions. They may not make eye contact or may seem uncomfortable. Some patients won't verbally agree with providers. They may just take the prescription and leave. These behaviors can be indicative of mistrust. Some patients may be more direct and say they don't like medication or don't trust the medication.

Transforming Care: What sort of techniques do you suggest providers use to broach a conversation about mistrust?

Bogart: There are lot of different techniques and strategies. First and foremost, it's important to validate mistrust by acknowledging and affirming experiences of discrimination and conveying that patients' thoughts, behaviors, and emotions are well grounded, justifiable, relevant, and meaningful. Their mistrust may stem from recent negative experiences or be a response to historical injustices including unethical experimentation in health care. When exploring mistrust, it's important to ask open-ended questions in a nonconfrontational, nonjudgmental way while also providing accurate information. A provider might say, "It's totally understandable that you might be apprehensive about getting vaccinated given what's happened in the past and even now with inequality and mistreatment in health care. What have you heard about the vaccine?" A provider could then offer further information if needed by saying, "It sounds like you have been hearing a variety of things. Would it be okay if I told you a little about what I know about the vaccine?"

Transforming Care: You created the HIV Conspiracy Belief Scale to assess the prevalence of beliefs that HIV is manmade and a cure is being withheld. What have you learned about what drives conspiracy beliefs?

Bogart: I define the term conspiracy more neutrally than others do - as an effort to explain the cause of an event, practice, or circumstance by referencing the actions of powerful people who attempt to conceal their role. They may be true or untrue. It's important to avoid putting a value judgment on them. They can serve several psychological needs by helping to explain why one group isn't doing as well as another. They can also provide a sense of control and security for people who are feeling threatened or powerless, such as in the face of discrimination, or have an expectation of future mistreatment.

Transforming Care: You've also distinguished mistrust that is based on suspicion of malicious intent, such as genocidal beliefs, and mistrust based on concern about benign neglect - more of a carelessness or indifference that may lead to bad things happening. Are there differences in the characteristics of people who hold one view or the other?

Bogart: In terms of sociodemographic characteristics, we have found that people with lower levels of education and income may be more likely to have mistrust-related beliefs, but these are not strong effects, and we don't find either education or income accounts for a lot of the variance in how much people hold these beliefs. There may be a social norm around medical mistrust, which means that it may be acceptable and common in communities, families, and social networks, to have such beliefs - which is why it is important to tackle mistrust at the community level.

Transforming Care: What are some strategies health care organizations can use to address mistrust within the communities they serve?

Bogart: It requires genuine partnership. There are a lot of organizations - churches and community groups among them - that can help elucidate reasons for mistrust, where the mistrust is coming from, and what specific kinds of mistrust-related beliefs are common in communities. The key is that health care organizations need to act on the feedback they receive and not just pay lip service to it.

Transforming Care: What about when it comes to providers having conversations with patients? Someproviders may have less empathy or difficulty restraining their desire to correct the patient, what you call the "righting" reflex? Do you think everyone can be trained to be responsive to patients' concerns?

Bogart: I do think people can be trained on very basic skills. Some people are going to take it further than others. Some people are going to be better at it. But as for the basic skills-providers can learn them. People who do try actually may find that it's gratifying, because it doesn't take that much or any more time, but you see better adherence among patients and better patient satisfaction and outcomes.

Publications of Note
Medicaid Work Requirements in Arkansas Led to Delayed Care, Medical Debt
Arkansas was the first state in the nation to impose work requirements to qualify for Medicaid coverage, compelling most adults between the ages of 30 to 49 to work 20 hours a week or participate in "community engagement" activities. Before a federal judge put the policy on hold in April 2019, 18,000 adults had lost coverage. A survey of low-income adults in the state found more than half of those who lost access to Medicaid after the work requirements were imposed delayed care (56%) and/or postponed taking medication (64%) because of concerns about costs, while half reported serious problems paying off medical debt. These rates were significantly higher than those among Arkansans who did not lose Medicaid coverage. The survey also found that the work requirement did not increase employment over 18 months and that awareness of the policy remained poor, with more than 70 percent of Arkansans reporting they were unsure whether the policy was in effect. Most of the coverage losses were reversed after the court order. Benjamin D. Sommers et al., " Medicaid Work Requirements in Arkansas: Two-Year Impacts on Coverage, Employment, and Affordability of Care," Health Affairs 39, no. 9 (Sept. 2020):1522-30.
Access to Midwifery and Birth Centers Under Medicaid
Interviews and focus groups with Medicaid officials and staff at birth centers in states that participated in the Strong Start for Mothers and Newborns II initiative - an effort to test different models of prenatal care for Medicaid beneficiaries, including comprehensive team-based care at birth centers - revealed that Medicaid beneficiaries chose birth centers because they preferred midwifery care, wanted a natural childbirth, or wanted other services that may be not available in hospitals. However, the key informants also said that beneficiaries have less access to birth centers than do privately insured patients because of lower Medicaid reimbursement rates, as well as the challenges of contracting with managed care organizations and participating in value-based delivery system reforms. The authors say addressing these barriers could improve birth outcomes for mothers and newborns while yielding savings for Medicaid programs. Brigette Courtot et al., " Midwifery and Birth Centers Under State Medicaid Programs: Current Limits to Beneficiary Access to a High‐Value Model of Care," Milbank Quarterly September 15, 2020.
Indiana's Medicaid Waiver and Interagency Coordination Increased Enrollment for Justice-Involved Adults
After Indiana's 2015 Medicaid waiver expanded eligibility for low-income adults, the state sought to increase the number of justice-involved adults covered by the program by increasing coordination between the state's corrections agency and its Medicaid program. As part of the effort, the Indiana Department of Correction began initiating Medicaid applications for inmates who lacked coverage and suspended rather than discontinued coverage for others while they were incarcerated. The Medicaid expansion increased the percentage of justice-involved adults who received Medicaid coverage within 120 days of release by nine percentage points. With coordination between agencies, the state saw an additional 29-percentage-point increase in coverage. The study also found a 14-percentage-point increase in the number of inmates who had coverage that was effective within seven days of their release. Justin Blackburn et al., " Indiana's Section 1115 Medicaid Waiver and Interagency Coordination Improve Enrollment for Justice-Involved Adults," Health Affairs 39, no. 11 (Nov. 2020):1891-99.
Early in the Pandemic Older Adults with Low Health Literacy Were Unable to Accurately Identify Ways to Prevent COVID-19 Infection
Researchers found older adults at higher risk for COVID-19 lacked critical knowledge about prevention in the early weeks of the pandemic. The surveys of adults with one or more chronic conditions, conducted at the outset of the U.S. outbreak (March 13-20, 2020) and during the acceleration phase (March 27-April 7, 2020), found that while participants increasingly perceived COVID-19 to be a serious public health threat and reported more changes to their routines, there was no significant change in the proportion who could accurately identify ways to prevent infection. Black adults and those with lower health literacy were more likely than whites and those with higher health literacy to report feeling less susceptible to becoming sick with COVID-19. In addition, individuals with low health literacy remained more likely to feel unprepared for the outbreak and to express confidence in the federal government response. The authors conclude that public health messaging to date may not be effectively reaching vulnerable communities. Stacy Cooper Bailey et al., " Changes in COVID-19 Knowledge, Beliefs, Behaviors, and Preparedness Among High-Risk Adults from the Onset to the Acceleration Phase of the US Outbreak," Journal of General Internal Medicine 35, no. 11 (Nov. 2020):3285-92.
Reproductive Health Issues May Foreshadow Cardiovascular Disease in Later Life
A review of studies that have investigated the association between reproductive risk factors in women and subsequent risk of cardiovascular disease found a variety of risk factors - from early menarche and contraceptive use to gestational diabetes and preterm birth - were associated with cardiovascular disease. The researchers found associations for composite cardiovascular disease were twofold for pre-eclampsia, stillbirth, and preterm birth; 1.5- to 1.9-fold for gestational hypertension, placental abruption, gestational diabetes, and premature ovarian insufficiency; and less than 1.5-fold for early menarche, polycystic ovary syndrome, and early menopause. The associations varied for ischemic heart disease, stroke outcomes, and heart failure. A longer length of breastfeeding was associated with a reduced risk of cardiovascular disease. The authors say policymakers should consider incorporating reproductive risk factors into clinical guidelines for cardiovascular risk assessment since the risk of cardiovascular disease may be modifiable. Kelvin Okoth et al., " Association Between the Reproductive Health of Young Women and Cardiovascular Disease in Later Life: Umbrella Review," BMJ 371, no. 8263 (Oct. 2020):m3502.
Declines in Non-COVID-19 Hospital Admissions Vary by Diagnosis, Patient Population
Researchers studying differences in hospital admission patterns among patient groups since the onset of the pandemic found that declines in non-COVID-19 admissions between February and April 2020 were generally similar across demographic subgroups and exceeded 20 percent among all primary admission diagnoses. By late June and early July 2020, non-COVID-19 admissions were 16 percent below pre-pandemic levels, but admissions were substantially lower for patients residing in majority-Latino neighborhoods (32% below baseline) and remained well below baseline for patients with pneumonia (down 44%), COPD and asthma (down 40%), sepsis (down 25%), urinary tract infection (down 24%), and acute ST-elevation myocardial infarction (down 22%). John D. Birkmeyer et al., " The Impact of the COVID-19 Pandemic on Hospital Admissions in The United States," Health Affairs 39, no. 11 (Nov. 2020):2010-17.
Complex Patient Bonus Unlikely to Mitigate Regressive Effects of MIPS
A review of the first round of performance data from the Merit-based Incentive Payment System (MIPS) found that compared with clinicians with the lowest socially at-risk caseloads, those with the highest had 13.4 points lower performance scores, were 99 percent more likely to receive a negative payment adjustment, and were 52 percent less likely to receive an exceptional performance bonus payment. The authors note the lower scores were partly explained by lower clinician reporting of and performance on technology-dependent measures, which may reflect lack of technological capability at the practice level. They also found that having a complex patient bonus in place would have increased performance scores and the likelihood of receiving an exceptional performance bonus for clinicians with the highest socially at-risk caseloads by 4.7 percent and 2.8 percent, respectively. However, the proportion receiving negative payment adjustments would have remained unchanged. The study included data on more than 500,000 clinicians. Kenton J. Johnston et al., " Clinicians with High Socially At-Risk Caseloads Received Reduced Merit-Based Incentive Payment System Scores," Health Affairs 39, no. 9 (Sept. 2020):1504-12.
Policy Changes to Improve Pandemic Response, Increase Health Equity
In a commentary in the New England Journal of Medicine, three health disparities researchers call for major policy changes to advance health equity and improve the pandemic response, including greater investment in hospitals and clinics that serve marginalized communities, the creation of a universal food income benefit, and reforms to unemployment insurance to increase income and broaden eligibility. They also recommend greater investment in community development, expanding affordable housing, and increasing economic opportunity to reduce income disparities. Seth A. Berkowitz, Crystal Wiley Cené, and Avik Chatterjee, " COVID-19 and Health Equity - Time to Think Big," New England Journal of Medicine 383, no. 12 (September 2020):e76.
Employment May Explain Disparities in COVID-19 Outcomes Among Minorities
Blacks and Latinos are more than three times as likely as whites to be hospitalized with COVID-19 and experience higher death rates from the disease. Using data from the Medical Expenditure Panel Survey, researchers found these disparities are not fully explained by health risks, such as diabetes or obesity. They found Blacks were substantially more likely than whites to work in health, public safety, and public utility jobs while Latinos were more likely than whites to work in food-related jobs, suggesting employment may be a factor in transmission within households. Blacks at high risk for severe COVID-19 illness were 1.6 times as likely as whites to live in households with health-sector workers. Among Latino adults at high risk for severe illness, 64.5 percent lived in households with at least one worker who was unable to work from home versus 56.5 percent among Black adults and 46.6 percent among white adults. Thomas M. Selden and Terceira A. Berdahl, " COVID-19 and Racial/Ethnic Disparities in Health Risk, Employment, and Household Composition," Health Affairs 39, no. 9 (Sept. 2020):1624-32.
Geography, Employment, Incarceration, and Other Factors May Explain Differences in COVID-19 Cases Among Minority Groups
Reviewing data from 351 cities and towns in Massachusetts, researchers found communities with a higher proportion of Black and Latino residents had higher rates of COVID-19 cases. A 10-percentage point increase in the Black population was associated with an increase of 312.3 COVID-19 cases per 100,000 residents, whereas a 10-percentage point increase in the Latino population was associated with an increase of 258.2 cases per 100,000 residents. For the Latino population, independent predictors of higher COVID-19 rates included the proportion of foreign-born noncitizens living in a community, mean household size, and share of workers employed in the food service sector. Higher COVID-19 cases among Blacks were not explained by these and other demographic, economic, and occupational variables studied. The researchers suggest higher COVID-19 cases among Blacks may be explained by other factors, including disproportionate incarceration rates, residence in multi-unit buildings, and segregation, which may produce variation in access to care and exposure to environmental hazards. Jose F. Figueroa et al., " Community-Level Factors Associated with Racial and Ethnic Disparities In COVID-19 Rates in Massachusetts," Health Affairs 39, no. 11 (Nov. 2020):1984-92.
Mental Health Disorders Linked to Grief May Increase with More COVID-19 Deaths
In a commentary in the Journal of the American Medical Association, three psychiatrists call for greater investment in mental health funding to address the psychological problems experienced by Americans who have lost loved ones to COVID-19, including grief, depression, and substance abuse. They also call for widespread screening to identify individuals at highest risk for prolonged grief, post-traumatic stress, and suicide and recommend training for primary care clinicians and mental health providers conducting screening and offering support to the bereaved who cannot participate in traditional mourning practices. Naomi M. Simon, Glenn N. Saxe, and Charles R. Marmar, " Mental Health Disorders Related to COVID-19-Related Deaths," Journal of the American Medical Association 324, no. 15 (Oct. 2020):1493-4.
Minnesota's Payment Policy for Medicaid Births
In 2009, Minnesota's Medicaid agency established a single payment rate for uncomplicated vaginal and cesarean births, a change from the prior payment that had given providers higher reimbursements for cesarean births. Researchers seeking to determine if the policy had differential effects on cesarean birth rates and maternal morbidity among Black and white women in Minnesota, as compared to six other states, found cesareans decreased among both Black and white women in Minnesota compared to the control states and this decline was greater among Black women (a decline of 2.88 percent from a pre-policy rate of 22.2 percent) than among white women (a decline of 1.32 percent from a pre-policy rate of 19.3 percent). Rates of postpartum hemorrhages increased, with larger increases among Black women. Jonathan M. Snowden et al., " Cesarean Birth and Maternal Morbidity Among Black Women and White Women After Implementation of a Blended Payment Policy," Health Services Research 55, no. 5 (October 2020):729-40.

Editorial Advisory Board
Special thanks to Editorial Advisory Board member Don Goldmann for his help with this issue.
Jean Accius, Ph.D., senior vice president, AARP

Anne-Marie J. Audet, M.D., M.Sc., senior medical officer, The Quality Institute, United Hospital Fund

Eric Coleman, M.D., M.P.H., professor of medicine, University of Colorado

Marshall Chin, M.D., M.P.H., professor of healthcare ethics, University of Chicago

Timothy Ferris, M.D., M.P.H., CEO of Massachusetts General Physician Organization and professor of medicine at Harvard Medical School

Don Goldmann, M.D., chief medical and scientific officer, Institute for Healthcare Improvement

Laura Gottlieb, M.D., M.P.H., assistant professor of family and community medicine, University of California, San Francisco, School of Medicine

Carole Roan Gresenz, Ph.D., senior economist, RAND Corp.

Allison Hamblin, M.S.P.H., vice president for strategic planning, Center for Health Care Strategies

Thomas Hartman, vice president, IPRO

Clemens Hong, M.D., M.P.H., medical director of community health improvement, Los Angeles County Department of Health Services

Kathleen Nolan, M.P.H., regional vice president, Health Management Associates

J. Nwando Olayiwola, M.D., M.P.H., chair and professor, Department of Family and Community Medicine at The Ohio State University

Harold Pincus, M.D., professor of psychiatry, Columbia University

Chris Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality

Sara Rosenbaum, J.D., professor of health policy, George Washington University

Michael Rothman, Dr.P.H., executive director, Center for Care Innovations

Mark A. Zezza, Ph.D., director of policy and research, New York State Health Foundation

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Understanding and Ameliorating Medical Mistrust Among Black Americans

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In this issue, we focus on the topic of mistrust of health care providers or systems among Black Americans, who are much more likely than whites to get seriously ill and die from COVID-19 but less willing to take the coronavirus vaccine.To draw lessons on ways of building trust with Black patients, we looked at clinical encounters in which the stakes of not addressing mistrust are high, including childbirth, childhood vaccination, and the care of patients with HIV, cancer, and substance use disorder.

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The Commonwealth Fund Fellowship in Minority Health Policy at Harvard University

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Abstract:

Assess the extent of substance use, specifically by minorities in the Department of Youth Services (DYS) in the State of Massachusetts, and aid in the redevelopment of policies that improve interventions and treatment in the DYS Day Reporting Centers.

Background:

In the United States, illegal drug and alcohol use by adolescents have been a serious problem for nearly four decades. Based on self-reporting, the rates of illicit drug use by American adolescents peaked in the early eighties at 66%, declined until the early nineties, then after a steady rise has leveled at approximately 54%. Over the past 26 years, the drug of choice for teenagers has been marijuana. Although other more addictive and lethal drugs have entered the market during this time period, the perceived lower health risks of marijuana continue to make it more widely used. Alarmingly 80% of today's teens have consumed alcohol and 51% have done so before the age of 13.

When surveyed, minority adolescents (particularly African American youth), report substantially lower rates of alcohol use when compared to Caucasians. Hispanic youth have rates of alcohol use which are closer to those of Caucasians. The rate of marijuana use among all youths is essentially the same (25-29%) but African American youth are much less likely than Caucasians and Hispanics to use drugs other than Marijuana.

With persistent drug use at earlier and earlier ages, many adolescents become involved with criminal activities, crimes of drug possession or crimes related to drug use. In fact, data reveals that there is a direct correlation between substance abuse, delinquency, violent behavior and arrest. Despite lower rates of substance use, minority adolescents are processed through all levels of the criminal justice system in numbers greater than their white counterparts. This trend continues into adulthood where the number of drug offense admissions to U.S. prisons has increased disproportionately for African American men.

Methods:

This project was designed to assist the Department of Youth Services (DYS), the juvenile justice system in the State of Massachusetts, in re-developing its substance abuse policy. An extensive review of the literature centered on substance use among adolescents, substance use among minority adolescents, and substance use in the juvenile justice system. The review also covered multiple substance abuse policy recommendations including those made by the Office of Juvenile Justice and Delinquency Prevention, and compared successful existing juvenile intervention programs.

Secondary analysis was performed on the quantitative data of an anonymous survey done March 2000 of 1470 youths in DYS detentions centers and Day Reporting Centers. The data was examined to determine the rates of substance abuse among minority adolescents and to identify differences in their substance abuse preferences. Quarterly data from the Day Reporting Centers was analyzed to determine actual urine drug test results by site.

The existing substance abuse policy was reviewed. It was determined that given the numerous sites in Massachusetts, the Dorchester DRC- the Dorchester Community Network Center, would be the principle focus of this project. This site was comprised predominantly of African American and Latino youth. Personal interviews were conducted with the Director of Substance Abuse Services, the Metro Area Substance Abuse Policy specialist, the Program Director and Assistant Director for the Dorchester DRC and the Substance Abuse clinician for the Dorchester DRC. The interviews concentrated on the implementation of the current policy and the adequacy of the substance abuse interventions and treatments.

Results:

The anonymous survey done in March of 2000 revealed that the primary drug of choice for all adolescents in the Department of Youth Services was marijuana at almost equal rates between Blacks (49.8%), Hispanics (53.3%) and Caucasian (46.9%) youth with significantly less use by Asians (26%). However, the use of alcohol as a primary drug was the greatest amongst Asians (21.9%) and then Caucasian (11.9%) and Hispanic (10.3%) youth and least amongst Black youth (7.1%). However Black youth were least likely to report that their drug or alcohol use was a problem when compared to the other youth.

The analysis of the quarterly random drug testing data revealed that marijuana was the drug detected most frequently. One of the limitations of the urine test is its inability to detect alcohol use in all but those who were intoxicated at the time of the test. The types of drugs used by adolescents of different races and ethnicities at each site could not be analyzed since it was not specified when the actual tests were obtained.

The personal interviews revealed much of the challenges faced when attempting to treat adolescents who do not view substance use as a problem.

Recommendations:

Given the unique issues faced in treating the adolescent substance abusers and the different etiologies for substance use amongst minorities when compared to non-minorities, the following recommendations were proposed for the Department of Youth Services:

Place race/ethnicity identifiers on the drug tests to track the trends of use between groups at each site

Establish a database for the tracking of interventions, treatment and follow-up for all adolescents with positive drug tests

Require cultural competency and diversity training for the staff and clinicians

Develop curriculums focused specifically on marijuana and alcohol for those adolescents who do not wish to abstain

Mandate the separation and accessibility of substance abuse histories from the sealed criminal records at the time of a youth's release from DYS.

Develop written policies with community outpatient substance abuse treatment centers

Increase formal communication between case managers and community treatment centers

Cultivate faith based collaboration within the communities

Faculty Preceptor:

Boyles, Director of Substance Abuse Services, Department of Youth Services, Boston, MA

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executive level state government experience

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juvenile justice - health/mental health care

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Dr. Shairi Turner is an Internist and a Pediatrician. Her career focus is to make Florida a national leader in Trauma Informed Practices. She has presented extensively on the neurobiological impact of trauma with the National Association of State Mental Health Program Directors and the National Center for Trauma Informed Care.

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Introduction

Adverse childhood experiences (ACEs) are common and associated with negative health and social outcomes.1 Nearly half of children in the U.S. have experienced at least one childhood adversity prior to age 18 with a much higher prevalence among children of color and socioeconomically vulnerable children.2 Early life adversity can undermine learning and is linked to a range of school-related problems,3 and can jeopardize psychological health and well-being.4 According to resilience science, identifying factors and processes that influence development represents an important step in the promotion of individual and family resilience.5 The role of family-level variables is central to promoting child flourishing and counteracting adversity across the life course. Using a nationally representative data set, this study examines the relationship between cumulative ACEs and flourishing outcomes mediated by family resilience and moderated by race/ethnicity and family poverty level (FPL) in children ages 6-17 years.

Adverse childhood experiences

ACEs, often chronic and intergenerational, are broadly characterized as abuse, neglect, and household dysfunction prior to age 18 years.6 In recent years, the ACEs framework has expanded beyond the household-level to encompass community-level stressors such as economic hardship, discrimination, witnessing neighborhood violence, and bullying.7 Experiencing mistreatment of any kind and growing up in an unpredictable environment in which safety, stability, and trusting and nourishing relationships are disrupted can impact neurobiological, cognitive, and social-emotional development.8 Cumulative ACEs are predictive of cascading life course problems such as academic failure, problems with socio-emotional maladjustment, and poor health outcomes.1,9 Evidence continues to mount that cumulative ACEs exposures, rather than individual ACE experiences, yield the most negative impacts on overall well-being.7 Research suggests that the cumulative effect of stressors in families may lead to deteriorating family resilience as well as worsening of child and adolescent outcomes.10,11

ACEs and child flourishing

Flourishing relates to well-being and for this study is a parent-reported measure based on indicators of whether children show interest and curiosity in learning new things, can focus and persist to achieve goals and are able to regulate emotions and behaviors in challenging situations.12 Children who have experienced at least one ACE are significantly less likely to flourish compared to those with no ACEs.13 Children exposed to adversity are more susceptible to toxic stress and may have an increased vulnerability to stress reactivity.8 Chronic stress has negative effects on the brain and body, which can lead to concomitant difficulties with learning and memory, executive functioning, and emotional regulation in the absence of protective factors and processes. Innate abilities to engage with others, process information, learn new lessons, and maintain flexibility or resilience diminish as the survival response takes over from these secondary social processes.14 Yet children somehow manage to flourish despite the challenge of having experienced ACEs and can learn healthier ways of responding to adverse events. For example, children who demonstrate resilience or the ability to stay calm and in control when faced with a challenge have higher rates of school engagement.15

Resilience and protective factors

Evidence suggests that, despite adverse conditions, the ability to demonstrate resilience persists.16 The difference between those who adapt and do well and those who do not maintain or re-establish baseline functioning after experiencing adversity is the presence of protective factors such as strong social support from friends, family, and community.17 Research on resilience indicates that healthy relationships protect against adversity and strengthen the ability to effectively manage stress and cope with adversity.5 Protective factors operate at the community, family, and individual levels and can contribute to well-being in children as measured by school engagement and achievement, social adjustment and behavior, and mental and physical health.18,19,20 For the current study, analyses include family-level factors as potential mechanisms that contribute to child resilience.

Importance of family relationships

The importance of safe, stable, nurturing relationships across development contributes to the health and well-being of individuals across the lifespan.7 Family resilience refers to the ability of a family to withstand and rebound from disruptive life events. Family processes can support and protect the biological, psychological, and social functioning of children, whose development is most vulnerable to adversity.21 Moreover, supportive relationships and positive family functioning can buffer the impact of stress. The capacity to process, integrate and make sense of traumatic experiences happens through healthy relationships that provide emotional support.22 Good caregivers have the capacity to offer safety, protection, and reassurance under conditions of stress, which provide an important basis for emotional regulation and healthy attachments when repeated over time.

Racial/ethnic and socioeconomic disparities

Although ACEs affect people across racial/ethnic and socioeconomic divides, patterns of adversity are differentially distributed across race/ethnicity and income with some communities facing a disproportionate burden of trauma as compared to others.4 These inequities are most evident in families of color, those living in poverty, and in community contexts with vastly different resources.23,24 Researchers have explored the interconnected and sometimes overlapping system of disadvantage that commonly occurs within the context of adverse community environments.25,26,27 Certain groups are at higher risk for ACE exposure including those who are poor, reside in unsafe neighborhoods, lack access to health care, or are enrolled in public insurance programs.15 Concentrated disadvantage exists among Black and Hispanic youth living in urban areas, who are exposed at a higher rate to traumatic events than their white peers.28,29 As a result, children and families of color residing in low-income neighborhoods are particularly vulnerable to the impact of ACEs on their mental and physical health and socio-emotional learning.24

Present study objectives

While extant literature has focused strongly on the long-term, negative health consequences of ACEs, less is known about the factors and processes that may offer protection against the corrosive health effects of early life trauma and socioeconomic disadvantage. Building on previous population-based studies, the current study estimates the direct effect relationships of cumulative ACEs and family resilience on three child flourishing indicators using the 2016-2017 NSCH combined data set for children ages 6-17 years in the United States.30 This study also examines the mediating role of family resilience, a new measurement featured in the 2016 and 2017 NSCH, and the moderating influence of race/ethnicity and family poverty level (FPL) on the ACEs-flourishing link within an integrated moderated-mediation model. We hypothesized that family resilience mediates the relationship between ACEs and child flourishing and that these pathways vary by race/ethnicity and FPL.

Study data and methods

Population and data

Data from the 2016-2017 NSCH was used, a cross-sectional survey conducted annually by the US Census Bureau, which provides national and state-level data on the physical and mental health of non-institutionalized children, ages 0-17, from all 50 states in the United States and the District of Columbia. The NSCH was funded and directed by the Health Resources and Services Administration's (HRSA) Maternal and Child Health Bureau (MCHB). Households with one or more children under 18 years old residing in the home were randomly surveyed. The survey was administered via web and paper-based instruments that were delivered by mail to either a parent or guardian of one child who was randomly selected as the subject of the survey. A total of 71,811 surveys were completed for the 2016 and 2017 NSCH combined data set. There was an overall weighted response rate of 40.7% for 2016 and 37.4% for 2017. The final analytic sample included 44,686 respondents reporting on children ages 6-17 years.30

Key measures

Child-level household data provided demographic information (i.e., age, sex, race/ethnicity, and family poverty level), ACE summary counts, and questions about family resilience and child flourishing that were obtained via self-report from parents and guardians at the time of the interview. All variables used in this study have been documented previously, and their properties and coding are presented in publicly available NSCH variable codebooks.30

Adverse childhood experiences (ACE) assessment

The nine ACE items measured by the NSCH included parent or guardian divorced or separated; parent or guardian died; parent or guardian served time in jail; witnessed or heard parents or adults slap, hit, kick, punch one another in the home; a victim of violence or witnessed violence in the neighborhood; lived with anyone who was mentally ill, suicidal, or severely depressed; lived with anyone who had a problem with alcohol or drugs; treated or judged unfairly because of his or her race or ethnic group; and economic hardship (e.g., hard to cover basics like food or housing). The NSCH did not include questions about emotional, physical, and sexual abuse or emotional and physical neglect that are found in the original ACE study questionnaire6 and state-by-state Behavioral Risk Factor Surveillance Survey (BRFSS).31 ACE survey items were coded as dichotomous variables that featured "yes or no" response options with the exception of economic hardship. The question, "How often has it been very hard to get by on your family's income?", was coded as a "yes" for "somewhat often" or "very often" responses and as a "no" for "rarely" or "never" responses. An ACE summary score was created by summing the nine dichotomous ACE variables and used as a continuous variable in the model analyses. Dichotomous ACE variables, including 0, 1, 2, 3, 4, 5, or ≥6 ACEs, were generated to determine prevalence.

Child flourishing indicators

Child flourishing questions were formulated based on a review of positive health indicators by a Technical Expert Panel.32 A validated scale for measuring indicators of child flourishing does not exist. For ages 6-17, the three child flourishing questions asked, "How true are each of the following statements about this child": a) Shows interest and curiosity in learning new things, b) Works to finish tasks he or she starts, and c) Stays calm and in control when faced with a challenge. Response options were collapsed and dichotomized for each question to reflect that "definitely true" met flourishing criteria and "somewhat true" or "not true" indicated that the child did not meet flourishing criteria. The flourishing indicators represent three overlapping, yet distinct constructs of learning, resilience, and regulation. Each flourishing question was assessed individually as a separate outcome and coded as a binary variable (yes or no). The degree to which the individual constructs are impacted by cumulative ACEs can be best understood by retaining the specificity of the individual flourishing items.

Family resilience mediator

Family resilience, a new measurement in the 2016-2017 NSCH data set, is a composite measure composed of four items including: "When your family faces problems, how often are you likely to do each of the following?" (a) Talk together about what to do, (b) Work together to solve our problems, (c) Know we have strengths to draw on, and (d) Stay hopeful even in difficult times. Response options were "none of the time", "some of the time", "most of the time", or "all of the time". A response of either "most of the time" or "all of the time" was required to meet each individual indicator. The latent variable of family resilience was reverse coded to show that larger values indicated higher levels of resilience.

Race/ethnicity moderator

The moderating role of race/ethnicity was examined on the impact of cumulative ACEs on flourishing outcomes. The race and ethnicity distribution of the population was measured with the question, "What is this child's race/ethnicity?". Racial/ethnic status was coded as a trichotomous variable: 0 = "Hispanic"; 1 = "White, non-Hispanic"; 2 = "Black, non-Hispanic". The category of "Other, Non-Hispanic", children with more than one race category, were not included in this analysis due to insufficient numbers in the 2016-17 NSCH sample to provide reliable estimates.

Family poverty level (FPL) moderator

The moderating role of FPL on the impact of cumulative ACEs on flourishing outcomes was examined. Household family poverty level was measured with the question, "What is the income level (federal poverty level, FPL) of the household that this child lives in?". Response options derived from the Census Bureau included "0-99% FPL"; "100-199% FPL"; "200-399% FPL"; "400% FPL or more". The first three categories were collapsed into one category and, subsequently, the measure was coded as a dichotomous variable: "below 400% FPL" and "400% FPL or above". FPL uses an absolute threshold to measure poverty based on household income and size, whereas economic hardship is the perception of poverty and one's ability to cover basic necessities. These variables measure different things and are not completely collinear.33

Analytic strategy

For this cross-sectional study, we used the 2016-17 NSCH data to examine associations between ACEs, flourishing, and family resilience, in addition to examining the mediating role of family resilience and moderating influences of race/ethnicity and FPL. Descriptive statistics were used to describe the characteristics of each variable in the sample using frequencies and proportions. The distribution of ACEs was cross-tabulated for race/ethnicity by gender and FPL for 0, 1, and ≥2 ACEs. Sample weighted correlations between the endogenous measures were obtained to evaluate the strength of the associations between flourishing items. Several correlation tests and sensitivity analyses were conducted to determine if any confounding was present between the ACE item that was asking about economic hardship and the FPL measure. Specifically, Cramer's V was used to calculate the association between the ACE poverty item and the total ACE score, and a point-biserial correlation test was used to calculate the association between the ACE poverty item and FPL measure. In addition, a sensitivity analysis was performed to assess specifics involved with the overall latent measure. Survey sampling weights provided by the NSCH were used to account for gender, race, and ethnicity distributions for non-institutionalized children who live in the United States, as well as to adjust for nonresponses. A moderated-mediation probit model, shown in Fig. 1, was used to examine a composite measure of family resilience as mediating changes in ACEs on three specific indicators of flourishing for all moderating conditions.34 There is precedence for using structural equation modeling for simple mediational analysis. The inclusion of moderating conditions that reflect the disparities evident among diverse racial/ethnic groups and income levels require a more complex model. Since we were interested in multiple interactions within a system, we built a stacked model using categorical moderators to examine how those interactions would occur across the entire system. A stacked group approach using a probit link function with weighted least square parameter estimates was implemented to assess moderator effects. Mplus was utilized to estimate the direct, indirect and total effects of the model.35 This study also explored the adjustment of age and sex in the models, which were found to provide minimal effect and were subsequently dropped from the models.

A probit model was used to examine a composite measure of family resilience (RESIL) as mediating changes in ACEs on specific indicators of flourishing for all moderating conditions (i.e., White versus Black vs Hispanic and above vs below family poverty level). The mediating structure was constructed on three binary outcome measures of flourishing: a) child shows interest and curiosity in learning new things (CUR), b) child works to finish tasks he or she starts (FIN), c) and child stays calm and in control when faced with a challenge (RES).

Results

Measurement correlations

The sample weighted inter-item correlation matrix showed that the flourishing scale items were correlated (Supplementary Table 1). Additional modeling demonstrated that the direction of the effects was similar between the flourishing index and the multiple items that comprise child flourishing. Since there were magnitudinal differences between flourishing indicators, disaggregating the effects of flourishing into individual components could yield further insight into how family resilience can help children realize positive outcomes in learning, regulation, and resilience across contexts of race/ethnicity and poverty.

The association between the ACE poverty item and the FPL measure was not strong (Cramer's V = 0.3806). Similarly, the association between the ACE poverty item and the total ACE score was not strong (point-biserial correlation = −0.26). The ACE poverty item comprised approximately 7.47% of the total ACE score. A sensitivity analysis indicated that removal of the ACE poverty item from the total ACE score produced a nonconsequential impact on the estimates with minimal effect on the model results. These results provided justification for maintaining the ACE poverty item in the total ACE score and suggested that there should be little, if any, confounding of the ACE poverty item with the FPL moderator.

Sample characteristics

Table 1 displays the sample characteristics for n  = 44,686 children age 6-17 years. Nearly equal proportions of male and female children are represented by this sample, which includes Non-Hispanic White (80.13%), Black (7.07%), and Hispanic (12.8%) race/ethnicities. Slightly more than half of the children are from families living below the poverty level (56.5%).

Table 1 National Survey Children's Health (NSCH) sample characteristics for children age 6-17 years, n = 44,686.

Prevalence and distribution of adverse childhood experiences (ACEs)

Just over half of respondents (53.82%) reported their children having no ACEs, whereas (45%) of children experienced at least one ACE from the 9 ACE items presented in the NSCH, which is the equivalent of 20,039 children. More than one-fifth of our sample, 22% (9,765) of children experienced ≥2 ACEs. Furthermore, 30.16% of children living below FPL experienced ≥2 ACEs compared to 11.07% of children living above FPL. Proportionally, 33.38% Black, 26.81% Hispanic, and 20.05% White children experienced ≥2 ACEs. Table 2 shows the distribution of ACEs by race/ethnicity with gender and FPL. Black male (34.61%) and female (32.07%) children had the highest proportion of ≥2 ACEs compared to Hispanic male (26.99%) and female (26.63%) children and White male (19.48%) and female (20.65%) children. Similarly, Black children living below FPL (38.61%) had the highest proportion of ≥2 ACEs compared to Hispanic (31.52%) and White (29.49%) children living below FPL.

Table 2 Crosstabulation of adverse childhood experiences by race/ethnicity with gender and family poverty level for children age 6-17 years, n = 44,686.

Proportion of child flourishing

The proportion of child flourishing outcomes reported by a parent or guardian as definitely true include showing interest and curiosity in learning (83.4%), working to finish tasks (63.9%), and staying calm and in control when faced with a challenge (49.5%).

Proportion of family resilience

Regarding family resilience, families were likely to either most of the time or all of the time talking together about what to do (85.0%), work together to solve problems (85.1%), know that they have strengths to draw on (87.3%), and stay hopeful (91.7%) in difficult times.

Direct, total, and indirect effects by race/ethnicity

Table 3a displays parameter estimates for direct, indirect, and total effects by race/ethnicity. As ACEs increased, flourishing indicators significantly decreased across race/ethnicity with the exception of interest and curiosity in learning for Black children, which decreased, however non-significantly. As family resilience increased, flourishing indicators significantly increased, and as ACEs increased, family resilience significantly decreased across race/ethnicity. Indirect effects demonstrated an average partial mediation of family resilience on the relationship between ACEs and flourishing for Black (37.5%) and Hispanic (30.6%) children.

Table 3 (a) Probit estimates with sampling adjusted weighting for the direct, total, and indirect effects of ACEs on flourishing outcomes by race/ethnicity of children ages 6-17 years. (b) Moderation effect parameter estimates differences with sampling adjusted weighting for direct, total, and indirect effects of ACEs on flourishing outcomes by race/ethnicity of children ages 6-17 years.

Moderation effects by race/ethnicity

Table 3b displays the moderation effect parameter estimate differences for direct, indirect, and total effects across race/ethnicity groups. As ACEs increased, Black and Hispanic children experienced a steeper decline in family resilience compared to White children. However, White children experienced significantly greater decrements in flourishing compared to Black and Hispanic children as ACEs increased. For example, specific flourishing outcomes showed that White children experienced a steeper decline in interest and curiosity in learning compared to Black and Hispanic children. White children also showed a decline in working to finish tasks compared to Black children. The moderated-mediation effect of family resilience on the relationship between ACEs and curiosity in learning was statistically significantly greater for Black than for White children.

Direct, total, and indirect effects by FPL

Table 4 displays parameter estimates for direct, indirect, and total effects by FPL, including moderation effect differences across levels of FPL. All direct, indirect, and total effect parameter estimates were statistically significant. As ACEs increased, flourishing and family resilience significantly decreased across FPL. As family resilience increased, flourishing indicators significantly increased across FPL. Indirect effects demonstrated an average partial mediation of family resilience on the relationship between ACEs and flourishing for children who were living below (27.7%) and above (21.0%) FPL.

Table 4 Probit estimates and moderation effect parameter estimate differences with sampling adjusted weighting for direct, total, and indirect effects of ACEs on flourishing outcomes by FPL of children age 6-17 years.

Moderation effects by FPL

As ACEs increased, flourishing decreased slightly more quickly for above versus below FPL children, however this finding was non-significant. Statistically significant moderation effect differences for direct effect pathways demonstrated that compared to below FPL children, above FPL children were more likely to improve in their ability to stay calm and in control as family resilience increased. There were no statistically significant moderated-mediation effects of family resilience on the relationship between ACEs and flourishing in FPL groups.

Discussion

The goal of this study was to examine the mediating effect of family resilience on the relationship between ACEs and child flourishing across varying race/ethnicity and FPL groups in a national sample of children ages 6-17 years. This study contributes to the existing literature by enhancing understanding of ACEs impact on child flourishing indicators of learning, resilience, and regulation and the protective familial factors and processes that can intervene on the ACEs-flourishing association, including the potential disparities inherent in these relationships across racial/ethnic and income groups.

Data indicate that the main variables were related in the expected directions. As adversity increased, families were less likely to demonstrate qualities of resilience and children were less likely to flourish across race/ethnicity and FPL. Although the association between ACEs and child flourishing may be best explained through several mediating variables, the partial mediating results highlight that family resilience is useful in understanding how ACEs are related to child flourishing. For example, White families were more likely to maintain family resilience in the face of adversity, although their children functioned more poorly at high-risk levels relative to Black and Hispanic children. Although family resilience reduced the negative impact of ACEs on flourishing in both races, there was a greater reduction for Black than White children. A more consistent income gradient for cumulative ACEs influence on flourishing by FPL could suggest that higher income is not necessarily a protective factor for ACEs impact on flourishing.

Prevalence and distribution of adverse childhood experiences

Concordant with previously reported NSCH data,15,33 nearly half of U.S. children age 6-17 years nationally and in most states have experienced at least one ACE. Our findings show that ACEs are widespread, yet ACEs prevalence persists in being the highest among Black and Hispanic children and low-income families. Although race/ethnicity and income are not psychosocial adversities in and of themselves, they can confer the risk of exposure to ACEs and other traumas. Numerous social and health inequities create a concentrated disadvantage among Black and Hispanic children and those living below FPL, which leave them disproportionately vulnerable. It is highly likely that the actual adversities faced by U.S. children are underestimated by the NSCH ACEs measure, which excludes questions about abuse and neglect.

Direct effects of ACEs, flourishing, and family resilience

As ACEs increased, the estimated probability of all indicators of flourishing outcomes and family resilience decreased across race/ethnicity and FPL, reinforcing the notion that ACEs are consequential for all children regardless of their background. Direct effect results in this study also indicated that family resilience increased child flourishing. As a result, increasing family resilience in the face of ACEs may also increase child flourishing. This hypothesis is further supported by reported findings from the 2011-12 NSCH data that showed children with two or more ACEs who were described as resilient were significantly more engaged in school and better able to maintain calm and control.15,36 In the 2016-2017 NSCH data, 50% of children did not meet flourishing criteria for staying calm and in control when faced with a challenge and, therefore, increasing self-regulation for children with ACEs is a priority area for focusing resilience efforts. We can gain a more nuanced understanding of enhancing and tailoring prevention and intervention efforts to effectively address ACEs impact on learning, resilience, and regulation for diverse racial/ethnic and family poverty level groups by analyzing the distinct pathways of flourishing indicators.

Mediating influences of family resilience on ACEs and flourishing

Family resilience was found to be a partial mediator, suggesting that resilience is a multi-factorial process and that there are additional potential mediating influences that can also explain the association between ACEs and child flourishing outcomes. Previous studies using NSCH data have identified a number of partially mediating factors of adversity and flourishing such as residing in a safe neighborhood, attending a safe school, and parental monitoring of friends and activities.20 Several studies among resilient Black and Hispanic children point to strong values of family cohesion and cooperation and greater intergenerational interdependence and social supports outside the immediate family as determinants of resilience that can contribute to lessening the impact of adversity.37 A combination of child, family, and community-level factors can serve as protective processes in promoting resilience for vulnerable children.38

Moderating effects by race/ethnicity and FPL

Moderator findings underscore the disproportionality of cumulative adversities affecting Black and Hispanic children and families and those living in socioeconomically disadvantaged communities. The partial mediating effect of family resilience in the relation between ACEs and child flourishing varied across different race/ethnicity and FPL groups. Findings revealed that family resilience may be more difficult to muster for Black and Hispanic children, although children in these families tend to function slightly better at high levels of adversity relative to their White counterparts. A similar trend was observed between above and below FPL, however, there was less variance between groups indicating that ACEs are distributed more evenly across income levels and not just concentrated in socioeconomically disadvantaged families. One possible explanation may be that previous exposure to some or moderate amounts of stress can result in a steeling or hardening effect that can promote resilience to later stress and may operate at high levels of ACEs for some people and groups of people.39 These findings warrant further attention as they are consistent with prior research that emphasizes the differential effects of ACEs by race/ethnicity and income in U.S. children.25,28

Limitations

Several limitations should be noted. In the absence of longitudinal population-based data that includes ACEs exposures, the indirect pathways were analyzed using cross-sectional data. A correlational study design. precludes interpretations of causality and insights based on temporal precedence. Although the NSCH ACEs measure excluded indicators of child abuse and neglect, research suggests that the assessed ACE items often co-occur with abuse and neglect.7 Consequently, results derived from measuring cumulative risk likely include children with such experiences, though not all. Still, understanding the actual distribution of ACEs is key to developing effective interventions and prevention efforts. Moreover, self-report data by a parent or guardian may be subject to respondent bias due to hesitancy of sharing openly about their family and the associated stigma, which in turn can contribute to underestimates of adversity exposure and overestimates of family resilience. Finally, this data excluded children who are doucumented in research as having high levels of disadvantage and ACEs, such as children who have been institutionalized and are without an address, in addition to under-sampling racial and ethnic minorities. The absence of these children limits our understanding of the impact of ACEs on vulnerable and marginalized groups. Overall, these limitations point to the need to develop more sensitive and accurate ways to measure exposure to ACEs that include household and community-level stressors and their effects across the life course.

Future directions

Despite these limitations, findings from this study offer preliminary evidence that can guide future research. Examining an ACEs dose-response effect within the context of risk and protective factors and processes using national, population-based data can inform a public health response that can result in a larger impact for future prevention efforts. Studies based on national samples provide credible data to support the role of federal agencies in directing financial support and resources to ACEs prevention and intervention efforts. Supportive policies for early intervention can promote long-term psychological health and well-being. Considering this study's findings along with other literature, it is important that future research explore an interrelated system of an individual, family, social, and other community-level protective factors that may play a role in lessening ACEs impact on child flourishing; in addition to understanding how race/ethnicity and FPL, in combination, influence outcomes and effects particularly in longitudinal studies.

ACEs are a result of modifiable and preventable disparities,29 and are identifiable root causes of medical problems.24 Sociocultural factors such as race/ethnicity and socioeconomic status are among the most influential determinants of health and disease in the population.40 The inequities intrinsic to these factors play a stronger role in influencing health and determining outcomes than either health care or individual health behaviors.41 Since ACEs are distributed widely across race/ethnicity and FPL and not just concentrated in children from Black and Hispanic and socioeconomically disadvantaged families, both universal prevention and targeted intervention efforts are needed.25,28 ACEs conversations should be routinely incorporated into well-child visits to provide foundational knowledge of toxic stress and health and to share resilience-promoting resources with children and parents as early as possible.42 Addressing ACEs within a social determinant of health and trauma framework using a two-generational approach can improve the ability to reduce health and achievement inequities while strengthening resilience for children and families facing many risks.43 ACEs education and resources are valuable to children and families whether or not a child has been exposed to ACEs, since learning how to recognize and manage stress and learn resilience is fundamental to development and child flourishing.

Conclusion

ACEs are detrimentally impactful regardless of one's status, and high ACEs, in particular, are nearly insurmountable across race/ethnicity and FPL. At the same time, it is important to recognize the vulnerability of racial/ethnic minorities and low-income family resilience to ACEs exposures and effects. The prevention of ACEs should be the number one charge of public policy, programs, and health care. Among sectors providing services to children and families who have been exposed to ACEs, we can increase our predictive powers of adversity-related risk and resilience by assessing protective and social factors in addition to the dose-response relationships to various negative outcomes. ACEs resources should be made available in every setting that serves the needs and touches the lives of children and families.

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Acknowledgements

E.G. was a postdoctoral fellow at UW DFMCH, supported by Health Resources and Services Administration (HRSA), research training grant T32HP10010 when this manuscript was written.

Author information

Affiliations

1. Madison Department of Family Medicine and Community Health, University of Wisconsin, Madison, WI, USA

Ellen Goldstein

2. Milwaukee Helen Bader School of Social Welfare and Institute for Child and Family Well-Being, University of Wisconsin, Madison, WI, USA

James Topitzes

3. Anne and Henry Zarrow School of Social Work, University of Oklahoma-Tulsa, Tulsa, OK, USA

Julie Miller-Cribbs

4. Design and Statistics Unit, Madison Schools of Nursing and School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA

Roger L. Brown

Contributions

E.G., J.T., and J.M.-C. conceptualized and designed the study. R.B. analyzed the data. All authors contributed to the interpretation of the data and writing of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Ellen Goldstein.

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Competing interests

The authors declare no competing interests.

Patient consent

Since this is a national data set that was made available to the public, no patient consent was required.

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# data[].attributes.attachment_link.title
Influence of race/ethnicity and income on the link between adverse childhood experiences and child flourishing

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The impact of early adversity increases the risk of poor outcomes across the life course. Identifying factors that protect against or contribute to deleterious life outcomes represents an important step in resilience promotion among children exposed to adversity.

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EmbraceRace supports parents to raise children who are brave, informed and thoughtful about race. Join the movement!

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Parents and other caregivers are seeking resources to help them hold children through the current, terrible wave of racialized violence, which is exacerbated by the tensions and vulnerabilities exposed by the COVID-19 pandemic. As scholars, writers, and parents who use books to connect with our children and spark conversations with them, we've developed this book list to help engage the broad range of emotions and needs of diverse children in our multiracial society. In some cases, we've highlighted worthy, albeit lesser-known titles. Some are older books, some are newer, and a few will publish later this year but are available for pre-order now. This list skews heavily towards #ownvoices books and is arranged alphabetically by title.

Please use these books to help you do the work of making the world a safer, more equitable place for all children.

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20 Picture Books for 2020: Readings to Embrace Race, Provide Solace &...

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As scholars, writers, and parents who use books to connect with our children and spark conversations with them, we've developed this book list to help engage the broad range of emotions and needs of diverse children in our multiracial society.

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Expertise

Dr. Alfiee built a mental health disparities research enterprise over 20 years in academic medicine at institutions like Duke and Georgetown Medical Centers. Invite her innovative, evidence-based insights to enhance your organization.

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Dr. AlfieePsychologist. Scientist. Media Personality. FEATURED MEDIA:DR. ALFIEE ON CNN TOWN HALL RECENT LINKS Dear Dr. Alfiee: Back to School Tips for Parents Sunshine is the Best Disinfectant and the Key to Helping You Rise...

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The Commonwealth Fund Fellowship in Minority Health Policy at Harvard University

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Abstract:

Assess the extent of substance use, specifically by minorities in the Department of Youth Services (DYS) in the State of Massachusetts, and aid in the redevelopment of policies that improve interventions and treatment in the DYS Day Reporting Centers.

Background:

In the United States, illegal drug and alcohol use by adolescents have been a serious problem for nearly four decades. Based on self-reporting, the rates of illicit drug use by American adolescents peaked in the early eighties at 66%, declined until the early nineties, then after a steady rise has leveled at approximately 54%. Over the past 26 years, the drug of choice for teenagers has been marijuana. Although other more addictive and lethal drugs have entered the market during this time period, the perceived lower health risks of marijuana continue to make it more widely used. Alarmingly 80% of today's teens have consumed alcohol and 51% have done so before the age of 13.

When surveyed, minority adolescents (particularly African American youth), report substantially lower rates of alcohol use when compared to Caucasians. Hispanic youth have rates of alcohol use which are closer to those of Caucasians. The rate of marijuana use among all youths is essentially the same (25-29%) but African American youth are much less likely than Caucasians and Hispanics to use drugs other than Marijuana.

With persistent drug use at earlier and earlier ages, many adolescents become involved with criminal activities, crimes of drug possession or crimes related to drug use. In fact, data reveals that there is a direct correlation between substance abuse, delinquency, violent behavior and arrest. Despite lower rates of substance use, minority adolescents are processed through all levels of the criminal justice system in numbers greater than their white counterparts. This trend continues into adulthood where the number of drug offense admissions to U.S. prisons has increased disproportionately for African American men.

Methods:

This project was designed to assist the Department of Youth Services (DYS), the juvenile justice system in the State of Massachusetts, in re-developing its substance abuse policy. An extensive review of the literature centered on substance use among adolescents, substance use among minority adolescents, and substance use in the juvenile justice system. The review also covered multiple substance abuse policy recommendations including those made by the Office of Juvenile Justice and Delinquency Prevention, and compared successful existing juvenile intervention programs.

Secondary analysis was performed on the quantitative data of an anonymous survey done March 2000 of 1470 youths in DYS detentions centers and Day Reporting Centers. The data was examined to determine the rates of substance abuse among minority adolescents and to identify differences in their substance abuse preferences. Quarterly data from the Day Reporting Centers was analyzed to determine actual urine drug test results by site.

The existing substance abuse policy was reviewed. It was determined that given the numerous sites in Massachusetts, the Dorchester DRC- the Dorchester Community Network Center, would be the principle focus of this project. This site was comprised predominantly of African American and Latino youth. Personal interviews were conducted with the Director of Substance Abuse Services, the Metro Area Substance Abuse Policy specialist, the Program Director and Assistant Director for the Dorchester DRC and the Substance Abuse clinician for the Dorchester DRC. The interviews concentrated on the implementation of the current policy and the adequacy of the substance abuse interventions and treatments.

Results:

The anonymous survey done in March of 2000 revealed that the primary drug of choice for all adolescents in the Department of Youth Services was marijuana at almost equal rates between Blacks (49.8%), Hispanics (53.3%) and Caucasian (46.9%) youth with significantly less use by Asians (26%). However, the use of alcohol as a primary drug was the greatest amongst Asians (21.9%) and then Caucasian (11.9%) and Hispanic (10.3%) youth and least amongst Black youth (7.1%). However Black youth were least likely to report that their drug or alcohol use was a problem when compared to the other youth.

The analysis of the quarterly random drug testing data revealed that marijuana was the drug detected most frequently. One of the limitations of the urine test is its inability to detect alcohol use in all but those who were intoxicated at the time of the test. The types of drugs used by adolescents of different races and ethnicities at each site could not be analyzed since it was not specified when the actual tests were obtained.

The personal interviews revealed much of the challenges faced when attempting to treat adolescents who do not view substance use as a problem.

Recommendations:

Given the unique issues faced in treating the adolescent substance abusers and the different etiologies for substance use amongst minorities when compared to non-minorities, the following recommendations were proposed for the Department of Youth Services:

Place race/ethnicity identifiers on the drug tests to track the trends of use between groups at each site

Establish a database for the tracking of interventions, treatment and follow-up for all adolescents with positive drug tests

Require cultural competency and diversity training for the staff and clinicians

Develop curriculums focused specifically on marijuana and alcohol for those adolescents who do not wish to abstain

Mandate the separation and accessibility of substance abuse histories from the sealed criminal records at the time of a youth's release from DYS.

Develop written policies with community outpatient substance abuse treatment centers

Increase formal communication between case managers and community treatment centers

Cultivate faith based collaboration within the communities

Faculty Preceptor:

Boyles, Director of Substance Abuse Services, Department of Youth Services, Boston, MA

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executive level state government experience

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juvenile justice - health/mental health care

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Dr. Shairi Turner is an Internist and a Pediatrician. Her career focus is to make Florida a national leader in Trauma Informed Practices. She has presented extensively on the neurobiological impact of trauma with the National Association of State Mental Health Program Directors and the National Center for Trauma Informed Care.

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Dr. Bernice King: The US needs a radical revolution of values

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To cultivate a society grounded in equity and love, we must uproot systems of oppression and violence towards Black communities, says Dr. Bernice Albertine King, community builder and daughter of Dr. Martin Luther King Jr. In a time of mourning and protest, King calls for a revolution of values, allies that engage and a world where anger is channeled into social and economic change.

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By: Jacqueline Dougé, MD, MPH, FAAP &Monique Jindal, MD, FAAP

In light of recent national events, more parents are wondering whether they should talk to their children about race and racism. And, if the answer is yes, how can they do this in a thoughtful and effective manner?

The truth is kids are impacted by race at a very early age. As early as 3 months, a baby's brain can notice racial differences in the people around them. By age 2, children soak up stereotypes about race and may express these with fear. By age 4, children can directly express bias regarding race by teasing. By age 8, children are aware of social norms and can express bias in more subtle forms. And, by age 12, many children become set in biased thoughts, actions and decisions.

This means that there is nearly a 10-year period where parents may be able to intervene! Parents are the primary sources for children to learn about race and racism. Whether parents choose to talk to their kids about this or not, children will learn from their environments and the other people in their life.

Reflecting on race: look to books

What if we told you that parents can use books to not only help start the conversation, but also keep the conversation going?

Books are powerful tools that can serve as " mirrors, windows, and maps," reflecting children's own identity. Reading allows children to take a few steps in someone else's shoes, showing children the range of possibilities for their place in the world.

Exposure to diversity: who benefits?

Which children are we talking about? The answer is: all children - Black children, white children, Latinx children, girls, boys, etc. Exposing children to diversity helps children of all backgrounds. It helps children in to form their own identity and shapes their attitudes and behaviors towards people who are different than them. And while racism is shown to have a significant impact on the health of children and families, children of all racial/ethnic backgrounds who are exposed to diversity have been shown to be more likely to enroll in college and have higher test scores, self-confidence and leadership skills.

Books can help ensure your child believes in themselves, becomes an ally to others, understands that racism and discrimination exist, recognizes the power of kindness, compassion and empathy for others, and ultimately celebrates both what's common and different among the people they meet.

Strategies to select diverse and inclusive books

Here are some strategies that can help parents select high quality diverse and inclusive books. We recommend choosing books that:

Include characters who share your child's race, ethnicity and your family's cultural and religious beliefs, as well as characters who do not.

Have a main character who is a person of color.

Provide a voice to those who rarely have one.

Tell stories that challenge myths or stereotypes ( Hair Love by Matthew A. Cherry, illustrated by Vashti Harrison, about a Black father doing his daughter's hair, for example).

Tell stories that normalize daily life among all racial identities ( Corduroy, written and illustrated by Don Freeman, about a Black mother and child going shopping, for example).

Help children develop social action skills (helping the elderly, having environmental awareness, or volunteering at a soup kitchen, for example).

Help children recognize inequities in social structure (consider books about gender and sports or differential treatment of holidays within the United States).

Are written or illustrated by racial/ethnic minorities.

Are age appropriate (picture books for children age 5 and under, and chapter books for elementary aged children).

Present characters facing real-life experiences.

Showcase experiences relevant to their own ( The Snowy Day by Ezra Jack Keats, about a Black boy enjoying walking through his neighborhood in the snow, for example).

We also recommend avoiding books that promote stereotypes. such as those that focus on any of the 5 F's (food, fashion, folklore, festivals and famous people). Stereotypes overgeneralize individuals or groups of people. If choosing books on these topics, it is important to reflect on if the book is reinforcing stereotypes and also to select other books that feature this racial or ethnic group in other settings.

How to use books to start conversations about race and racism with your children

The American Psychological Association's (APA) RES Project can help parents learn how to use books to guide conversations. We recommend parents listen and be open to answering their child's questions and use some of the questions on this site as conversation starters. Some examples, by age:

Preschoolers: "What is different and similar between your child and the characters in the book?"

Elementary aged children:"Who is your favorite character, and what did you like about them?"

Preteens and teens:"How did the book inspire you to think differently? How did the book challenge your understanding of race?"

Consider having a family "book club" with teens where parents and teens all read the book and share their reflections and what they learned.

Talking about race and racism is important. The conversations can start early and be ongoing. Parents are a child's first teacher and our nation's children need us now more than ever. By reading children diverse and inclusive books, we have the opportunity to affirm their own identity, help them learn about others, build empathy and encourage their kindness towards others, all in an effort to build a better and more just world.

More information

About Dr. Dougé

Jacqueline Dougé, MD, MPH, FAAP is the Child Health Medical Director at the Howard County Health Department. Her interests are health disparities, media, school health and the interaction of public health and pediatrics. Within the American Academy of Pediatrics, she co-chairs the Council on Community Pediatrics' Prevention and Public Health Special Interest Group. Her blog site is jackiedouge.com.

About Dr. Jindal

Monique Jindal, MD, FAAP, is a member of the American Academy of Pediatrics (AAP) Section on Minority Healthy, Equity and Inclusion and the Maryland Chapter of the AAP. She is an internal medicine-pediatrics physician at Johns Hopkins Medical Institution. Dr. Jindal's broad research interest is in understanding the impact of racism and discrimination on health equity for minority children and their caregivers.

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Using Books to Talk With Kids About Race and Racism

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Reading allows children to take a few steps in someone else's shoes, showing ​them the range of possibilities for their place in the world. In this article, learn how to use books as a powerful tool to help discuss racial identity, bias and racism they may encounter.

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Columbia University Irving Medical Center

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The COVID-19 pandemic has exacerbated the deep fissures in our nation's health care system, accentuating tragic disparities largely along racial and ethnic lines and highlighting the need for an immediate exploration of the underlying structural racism so that health care can become more inclusive and equitable, according to Maya Sabatello, LLB, PhD, associate professor of medical sciences in the Division of Ethics in the Department of Medical Humanities and Ethics and in the Department of Medicine at Columbia University Vagelos College of Physicians and Surgeons.

Maya Sabatello

Sabatello, an expert on human rights and the ethical, legal, and social implications of genetics, proposes a COVID-19 Truth and Reconciliation Commission. "These commissions began as a way to help authoritarian governments recover from their abusive pasts and transition toward democracy without being punitive," Sabatello says. "The United States may not be a fragile democracy, but our health care system-who controls it, who benefits from it-resembles an autocratic regime."

In a paper published in the American Journal of Bioethics, Sabatello and colleagues outline a forward-looking path to break the cycle of disparity and create a nationally equitable health care system.

Why do you think a Truth and Reconciliation Commission could help address the inequities exposed by the pandemic?

Truth and Reconciliation Commissions are an attempt to establish and publicly record the experiences and scale of the physical and emotional harm caused by past injustices. They help us think about the experiences of victims and perpetrators so we can develop ways to address and overcome systemic issues. A Truth and Reconciliation Commission is aimed at acknowledging wrongdoing and learning from injustices in order to move forward.

A Truth and Reconciliation Commission would allow racial and ethnic communities that have been targets of structural racism and have been disproportionately impacted by the COVID-19 pandemic to speak up and share their experiences in a forum that aims to lead to real change. This would include Black/African American, Latinx, and Indigenous communities but should also be inclusive of other groups experiencing structural discrimination. It would also give clinicians a forum to have conversations around the systemic issues they face in providing equal care so that they can help reconstruct the system. Additionally, it's a constructive way for administrators of health care systems and politicians to hear the perspectives and the pain that's caused by their decisions in order to promote systemic and structural changes.

What are the most important ethical issues raised by the pandemic?

In addition to the need to assure equal access to quality care for everyone, we need to think about medical research that can significantly impact care.

We conduct a lot of research in this country, and we need a lot of participants to do that research, but we do not have an equitable process in place to assure that participants can benefit from this research. Many of these participants may not have access to COVID-19 treatments or vaccines because they don't have health insurance, or have only limited health benefits. It's time to fix this and make sure that everyone-particularly marginalized communities who have paid such a high price because of previous wrongdoing-can benefit from the scientific knowledge that comes out of research.

We need to have more extensive consideration of cultural diversity in research. Community engagement in research-obtaining the views of different communities, seeing them as partners, discussing the pros and cons of research, and finding ways to address concerns-is essential for us as we move forward.

We also need to reconstruct the health care system so that it is completely inclusive and allows everyone to have equal access to quality care. The United States is the only developed country that does not offer a national health care plan, and although the Affordable Care Act has increased access to care for some, there are still very significant gaps and disparities.

Creating a new health care system requires us to deal with the structural racism that exists in all aspects of society and has a significant health impact on racial and ethnic minorities. This means looking at racial and ethnic bias in medicine, understanding the health needs of racial and ethnic minorities, giving proper attention to these health needs, and increasing the diversity of health care providers to better understand patients' backgrounds and the cultural nuances that affect health.

Are there any other communities we need to consider when addressing inequities due to the pandemic?

The disability community frequently gets left behind in these discussions, yet about 26% of the U.S. population and 20% of the pediatric population has a disability. We still don't have data about how many people with disabilities were sick or died of COVID-19. An array of factors prevents people with disabilities from getting good care, yet the prevalence of the underlying conditions that increase COVID-19 morbidity and mortality is far higher among people with disabilities.

People with disabilities are often wrongly presumed to lack capacity and to have a lower quality of life than what they actually experience. That is another 'ism' we have to deal with as we address ethical issues related to our health care system, medical research, and the pandemic more specifically. COVID-19 will likely increase the number of individuals with disabilities, since the disease has lingering physical, cognitive, and psychological effects.

We are seeing more conversations about vaccine distribution in nursing homes, where many younger people with disabilities live alongside elderly residents. We have to ensure that people with disabilities are included in clinical trials and have access to the vaccines.

Is there a risk, given COVID-19 disparities, that communities of color will be blamed for the pandemic?

It's easy to blame the individuals who are already discriminated against-we tend to scapegoat those who are less powerful. It happened during the 1918 pandemic, and it's obviously a risk now. It's harder for us, as a society, to take responsibility for environmental factors and sociopolitical structures that caused the disproportionate COVID-19 harm to communities of color. But this is exactly what needs to be done-and a Truth and Reconciliation Commission can facilitate that.

Viruses do not discriminate on the basis of race, ethnicity, or skin color. They have more power among people living and working in more dense environments, among those who don't have the opportunity to isolate.

I think we need to be extremely careful when we start looking for genetic differences to explain risk for certain diseases in research. I think that funding bodies have a huge responsibility to ensure that research is being done in the right way, so that they don't fund research projects that raise the risk of further stigmatizing historically marginalized communities.

We know that our genetic makeup is more than 99.9% similar across racial and ethnic groups and that there is greater diversity within, rather than across, these racial and ethnic groups. We need to work harder to change the structures that put racial and ethnic minorities at risk.

How would a COVID-19 Truth and Reconciliation Commission get started?

Ideally, the federal government would initiate a post-COVID-19 Truth and Reconciliation Commission, but it may not be feasible since our political system has become so polarized. Instead, we may need to rely on state-level decisions and allies across economic sectors, academic institutions, and state governments that are standing up now and saying enough is enough. We need to take advantage of the momentum, engage with anyone who's willing to be part of that conversation, and, importantly, start acting on it.

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Racial Injustice in U.S. Health Care Calls for a Truth and Reconciliation Commission, Bioethicist Says

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The COVID-19 pandemic has exacerbated the deep fissures in our nation's health care system, accentuating tragic disparities largely along racial and ethnic lines and highlighting the need for an immediate exploration of the underlying structural racism so that health care can become more inclusive and equitable, according to Maya Sabatello, LLB, PhD, associate professor of medical sciences in the Division of Ethics in the Department of Medical Humanities and Ethics and in the Department of Medicine at Columbia University Vagelos College of Physicians and Surgeons.

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A Guide of Anti-Racist Books for Children

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An annotated list of anti-racist children's literature that meets the criteria of having a BIPOC protagonist, the experience of self discovery, self-advocacy, and realizations on the part of the main character and/or a joy or celebration of one's cultural or ethnic identity.

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This is just a sampling of the work we are doing as an organization. In addition, SRA has several scheduled events Spring 2021, including a virtual conference in March that may be helpful for our members interested in antiracism and work around youth participatory action research.

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S1 - (Yosso) Whose culture has capital A critical race theory 

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I recently had a conversation with a younger friend of mine - a Black man in his 30s here in Atlanta - about whether I was going to get the Covid-19 vaccine when it becomes available to me and whether I should.

My answer was clear: Absolutely.

So was his: Absolutely not. At least not yet, not until he was able to see over a longer period of time how others responded to it. In fact, he was somewhat astonished that I was eager to be vaccinated, treating it as a gullibility or naïveté on my part.

It wasn't necessarily that he didn't trust vaccines, it was that he didn't trust the government that was pushing it. This mistrust, I believe, is an underappreciated part of vaccine hesitancy, particularly among younger Black people.

It is now a well-established fact that Black people are getting the vaccine less than their white counterparts and also express more doubt about it. But those numbers are more complicated than the top-line takeaways might suggest.

A survey released Thursday by the National Foundation for Infectious Diseases found some interesting age variations. As CNN reported:

"The survey, which was conducted in December 2020, also revealed that older Black adults and men are more willing to get the Covid-19 vaccine. For example, 68 percent of adults age 60 and older said they planned to get the vaccine while only 38 percent of Black adults age 18-44 planned to get it. Many of the younger respondents expressed distrust in the health care system, saying it treats people unfairly based on race and ethnic background, according to the survey findings."

The "distrust in the health care system" is real in the Black community. I have written about the effect of the full history of the United States' failures and abuses in the medical field, relative to Black people.

Perhaps most notably, at least in the last century, was the Tuskegee experiments in which hundreds of Black men were told they were being treated for syphilis when in fact they were not. They were being observed to see how the disease would progress. Those men suffered under this experiment for 40 years. The Associated Press exposed the program in 1972.

But the Black people in the age group most resistant to the vaccine today were not alive when that experiment was conducted. Indeed, older men, those who might have been alive during that time -those whose peers were targeted by the Tuskegee experiment - are more likely to want the vaccine.

It occurs to me that something bigger might be contributing to those numbers: an overall mistrust of a government that has repeatedly disappointed, disrespected and dehumanized Black people. This is a phenomenon that may be most acutely felt by young people.

These young people have come of age in an era in which mass incarceration has sucked whole neighborhoods dry of brothers and cousins, fathers and uncles. They have come of age where the rapacious war on drugs ground up Black bodies and wasted human capital.

They have come of age in an age of a rash of killings of unarmed Black people by the police, and those officers and the systems that animated them have rarely been held accountable.

They have come of age watching the government cover up poor treatment of Black people. They've watched the government allow - indeed cause - the Flint water crisis, and drag its feet as the people of New Orleans suffered after Hurricane Katrina and the people of Puerto Rico suffered after Hurricane Maria.

They have watched four years of nonstop corruption by Donald Trump, a man who lied incessantly and whose government failed to constrain the virus in the first place.

From the perspective of Black people, particularly many young ones, the government has demonstrated by deed that it is not to be trusted, that the health and welfare of Black people and Black bodies is not its concern. Indeed, the opposite may well be true.

I went back and forth with my 30-something friend, arguing the science of the vaccine, discussing the disproportionate impact the virus was having on the Black community and how it was imperative that as many Black people get vaccinated as possible.

As a 2018 Pew Research Center poll found:

"On this scale, the share of whites who show high levels of trust (27 percent) is twice as high as the share of Black (13 percent) and Hispanic adults (12 percent). The older a person is, the more likely they are to tilt toward more trustful answers."

But I could see in his eyes that his vision was clouded by the darkness of distrust. How could the same government that destroys so many Black lives be trusted in its intentions to save his?

To him, the vaccine wasn't simply a product of medical research and science, it was also part of a governmental campaign and an imposition of the system. In an America where Black people have too often seen tools used as weapons, hesitancy will be a high hurdle.
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Opinion | A Holistic View of Vaccine Hesitancy

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I recently had a conversation with a younger friend of mine - a Black man in his 30s here in Atlanta - about whether I was going to get the Covid-19 vaccine when it becomes available to me and whether I should. My answer was clear: Absolutely. So was his: Absolutely not.

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Amidst the intertwined pandemics of COVID-19 and racism, something unprecedented should be happening in research on poverty and children's development. Scholars should be looking in the mirror and starting to see their blind spots regarding race and racism. Scholars of color (who are in the minority) have been aware of this for years. Others are only just starting to see how their own training hinged on certain models that are White and WEIRD (Western, educated, industrial, rich, Democratic). They are starting to see how their own mentors reinforced privilege by allowing access to pipelines of opportunities that looked like their own. They are beginning to understand how their own research about "others" (i.e., people from places, experiences, and histories unlike their own) hinges on theories, methods, and importantly, assumptions that excluded the realities, experiences, and expertise of the very people being studied, particularly with respect to race and racism.

Blind spots are hard to see; by definition, they are about omission. Yet blind spots - such as clinical color blindness, overlooking issues of race and racism, or consigning race to a static variable - contribute to the creation of future scholarship and science, and to the fostering of explanations that can be terribly misguided. Such blind spots are harder still to address. Training and education - our typical responses - are only as effective as accepting what is reflecting back from the mirror and our efforts to continually shift and re-shift those reflections.

"The lived experience of families in poverty intersects with experiences of race, immigration status, and the structures and systems that perpetuate injustice."

Historically, the neglect of race and racism in research on poverty and child development has been shaped by denial and fear of race - as immutable - carrying the burden of explaining poverty. This neglect is shaped by over-application of models that reinforce notions that being poor is less a condition of society and more a condition of being a member of a lesser-than-non-White group, whether Black, Latino, or indigenous in the U.S. context. And scholars with good intentions unintentionally began practicing "assimilationist" racism, preferring to ignore the issue rather than face it head on. The recent publication of Lawrence Mead's "Poverty and Culture" in a peer-reviewed journal showed that, 50 years after Senator Daniel Moynihan's report, The Negro Family: The Case for National Action, all these blind spots are surprisingly alive and well in poverty research.

How can family and child development scholars build a dynamic and resilient world view and a professional architecture to directly address race and racism in their research? How can scholars disrupt the perpetuation of inaccurate ideologies, and recalibrate power imbalances to optimize discourse and guide policy?

First, scholarship of and for children and families should stay grounded in lived experience. Data, whether in the form of numbers or words, do not emerge free of history and context; history and context should be the starting point. The lived experience of families in poverty intersects with experiences of race, immigration status, and the structures and systems that perpetuate exclusion and racism. At the same time, lived experience is the daily routines, survival strategies and resistance to oppression that parents, caregivers, workers, educators, and children and youth engage in every day. Research on poverty should be enriched by greater integration of quantitative, qualitative and mixed-methods literatures on intersectionality; racial socialization and identity; experiences of and responses to discrimination; representation, racial composition, and intergroup relations in the contexts of work, schools, and media, and funds of knowledge and traditions of socialization in racially, linguistically, and culturally diverse communities. This list can go on. These areas of research are robust and growing, each typically with both basic developmental and applied/intervention studies. Research on mainstream poverty needs to change and view these emerging areas as core, not neglected.

Second, as scholars, we can surround ourselves in authentic ways with others who are outside our inner disciplinary circles, ask for and be open to accepting authentic critiques, and strive toward richer research questions that may generate more powerful implications. Poverty scholarship can go deeper than controls for race, considering it a fixed and context-free characteristic. How can experiences of racism at household, neighborhood, structural, or policy levels be integrated into policy research on poverty and child development? Would our proposals for anti-poverty policy be more effective if they integrated attention to racial segregation and other disparities by race in opportunity and social mobility? We can be much bolder in straying from conventional silos and daring to cross disciplines and levels of analysis. Race and racism are inherent at all layers of Bronfenbrenner's ecological model, from macro-level structures to micro-level interactions. But because poverty researchers and race researchers largely do not overlap or collaborate, a number of novel questions are neglected. What would it mean to address structural sources of racism in tandem with other areas of anti-poverty policy? Can social movements change the linked and mutually reinforcing narratives around race and poverty?

Third, scholarship can and should start with understanding and questioning existing assumptions and pushing toward changing these defaults. Are we assuming that every child is born on a level playing field even though Black-White racial differences in household wealth are large and constrain the ability of Black families to respond to economic shocks? Are we naïve in assuming that enhancing income - the conventional realm of safety net policies - is enough to address intergenerational disparities of wealth, without concurrent efforts to adjust the many tax and transfer policies that disproportionately benefit the wealthy?

Fourth, we can diversify the poverty policy and scholarship research "workforce." At any established public policy and social science, population, and developmental science research conference where poverty scholars convene, you witness a sea of White people, sometimes predominantly White male people. Contrast this with convenings focused on race, ethnicity, or immigration and child development: You see scholars who are closer to representing the diversity of the United States. A much more robustly diverse pipeline of scholars across disciplines is required. Fellowship programs recently initiated by the Russell Sage Foundation, and those set up years ago by the Foundation for Child Development, the American Psychological Association, and the National Institutes of Health, are important first steps toward diversifying the pipeline of scholars, but are only a start (and will fail as a singular source of interventions). If admissions to graduate training programs; hiring processes in research institutions and universities; and the topics of research valued in curricula, departments, and peer review do not change priorities, we will continue to see the artificial and ultimately harmful divide between research on poverty and race among both scholars and scholarship.

"Are we naïve in assuming that enhancing income - the conventional realm of safety net policies - is enough to address intergenerational disparities of wealth, without concurrent efforts to adjust the many tax and transfer policies that disproportionately benefit the wealthy?"

Fifth, we can be louder and more active in our universities as we pursue or engage in external funding, in our roles as peer reviewers and editors, and as participants and leaders of professional organizations. Scholars who have profited from existing systems can and should demand more change toward inclusion. This opportunity to lead brings together the substance, messages, and models, explicit and implicit, conveyed by our research. This is an opportunity to step away from privilege and question how the public profile and output of your work is framed through an anti-racist lens. This is also an opportunity to create mechanisms - publishing avenues, grants, forums for speaking engagements - that were previously closed.

Addressing race and racism in research on poverty and children's development is going to be hard. However, the rewards will be full and rich, and will ultimately increase the impact of developmentally informed anti-poverty policies and practices. Our work will otherwise stagnate if we continue with siloed and segregated approaches, dipping into the same tools and perspectives that have shaped poverty research to date. That is, if we do not actively strive for change now, anti-racist poverty policy will not make progress. With such progress, we will be better positioned to overcome inequality in race and income, instead of chaotically reacting to public health and economic shocks like those triggered by COVID-19.
Header photo: Miki Jourdan. Creative Commons.

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Blind spot on poverty in child development research

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Amidst the intertwined pandemics of COVID-19 and racism, something unprecedented should be happening in research on poverty and children's development. Scholars should be looking in the mirror and starting to see their blind spots regarding race and racism. Scholars of color (who are in the minority) have been aware of this for years.

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A lingering mistrust of the medical system makes some Black Americans more hesitant to sign up for COVID-19 vaccines. It has played out in early data that show a stark disparity in whom is getting shots in this country - more than 60% going to white people, and less than 6% to African Americans. The mistrust is rooted in history, including the infamous U.S. study of syphilis that left Black men in Tuskegee, Ala., to suffer from the disease.

In Tuskegee today, that 20 th century tragedy is still very relevant, according to nurse Cheryl Owens, who grew up in the town. She's been talking with friends and elderly relatives who say they're afraid to get the COVID-19 vaccine.

"So, I asked why?" she says. "And it was like, 'well, you remember that Tuskegee syphilis study. That's why.' "

Officially named the " Study of Untreated Syphilis in the Negro Male," the U.S. Public Health Service, working with the Tuskegee Institute recruited hundreds of rural Black men in 1932. The study offered free meals and checkups, but never explained that participants would be human subjects in a study designed to withhold medical treatment.

"They had local leaders, church leaders, medical people to convince them to become involved with the study," says Owens, a nurse at the Central Alabama Veterans Health Care System.

Tuskegee, now a city of about 8000 people, has a storied African American history as home to the Tuskegee Airmen. Booker T. Washington and George Washington Carver were educators here.

But the syphilis study also looms large in Tuskegee's collective memory. Owens, who is 59, says she remembers hearing about it in elementary school, so she understands why people in this nearly all-Black community are skeptical when the government says take a shot.

"They felt that the government really wanted to inject something in their bodies and they were going to eventually die from that," Owens explains.

To help dispel that notion, Owens penned an op-ed, published in the local newspaper The Tuskegee News, including a photo of her getting a shot of the COVID-19 vaccine.
Ramping up vaccine rollout
Heath officials are up against a powerful sentiment as they try to ramp up vaccinations.

"I think a part of the challenge is that there's still a lot of anxiety about the vaccine," says Amir Farooqi, director of the Central Alabama VA. "It's unfortunate because it's a really great tool to help people protect their personal health as well as the public health."

The VA's Tuskegee campus has repurposed a large auditorium into a vaccine clinic, to allow for social distancing. Shots are given at one of four stations, partitioned off with privacy curtains.

Vietnam veteran Douglas Terry, 78, is relieved to be in the queue.

"With this there is hope," he says.

Terry doesn't even feel the stick when nurse Pamela Bell gives him his first jab.

"That's what we want to hear," she says, warning him that his arm might be a little sore for a while.

Terry says he intends to spread the word that he and his wife got the shot.

"To give them courage to do it also," he says.

That's what VA officials want to hear. They've set up a selfie station at the clinic, and hand out stickers that proclaim, "I got vaccinated at the Central Alabama Veterans HCS to protect our Veterans and Community."
'Word of mouth will be key'
The VA's infectious disease physician, Dr. April Truett, says that kind of word of mouth will be key to overcoming reservations about the shot.

"The more people hear about the vaccine, the more they know someone else who's received the vaccine, the more they see how well they did, the more comfortable they become with the vaccine," she says.

In the broader community, elected officials in Tuskegee have also posted videos getting shots, and some residents say they've gotten letters from the presidents of historically Black universities encouraging inoculation.

"It's the biggest PR project to get Black people to take that vaccine," says Lucenia Williams Dunn, a former mayor of Tuskegee who now runs a local community development organization. She's 77-years-old and has high blood pressure, but she's not convinced to get the vaccine.

Even though she's been watching the pandemic's devastating and disproportionate impact on African Americans, she still questions the rapid development of the vaccine. And then, there's the history.

"You cannot separate the experience of the past with what we believe in the present," Dunn says. "People say, 'well, you know, y'all ought not be worried about that that syphilis study.' Yeah, we do, because it's part of our experience."
Descendants of men involved in Tuskegee Study react
The vaccine rollout has sparked a conversation among descendants of the men involved in the syphilis study. Among them is Theilene Williams of Tuskegee. Her grandfather Willie Fitzpatrick died before knowing the truth about the study.

"We called him Papa," Williams says. "He was he was a good man, family man, a farmer."

Williams says there's a difference between what's happening now and what the government did to her grandfather and the other men.

"They didn't know what they were getting into," she says.

Williams, who is 72, says she was able to talk with her doctor about the vaccine.

"I went on and got it - the first shot," Williams says. "We know about it. We've been hearing, talking about it. It's not like 'come on, we're going to do this' without knowing anything about it like they did."

Her grandfather is among those now memorialized at the Tuskegee History Center on a large tile circle in the middle of the museum.

"Around here in alphabetical order, you have the names of all 623 men," says Tuskegee civil rights attorney Fred Gray, on a tour of an exhibit on the syphilis study.

Gray represented the men when the truth about the study came out in 1972. The men were not injected with syphilis, but those who already had it were left untreated, even once penicillin was available.

"Not only did they withhold treatment," Gray says. "But they sent these men's names to the various doctors in the area and told them if they came to their office, not to treat them for syphilis."

Gray won a $10 million settlement for the men, and their families, and pressured Congress to prevent such unethical science.

"And the federal government passed laws which would prohibit now anyone, the government or anyone else from having a study like they did," he says.
Issue with people using syphilis study to refuse vaccine
Later, he got President Clinton to apologize to the men and their descendants.

"What the United States government did was shameful," Clinton said in 1997. "And I am sorry."

Gray, now 90 years old, has had his first dose of COVID-19 vaccine. He takes issue with people citing the syphilis study as a reason not to get vaccinated. He says individuals must make their own decisions whether or not take the vaccine.

"But they shouldn't put it is because of what the government did to the men in the Tuskegee syphilis study, because they are altogether different situations," Gray says.

A January poll from Kaiser Family Foundation found that more than half of Black adults surveyed said they did not have immediate plans to get vaccinated. Forty-three percent said they were going to wait and see how it's working.

The mistrust of the healthcare system among African Americans is two-fold, says Rueben Warren, director of the National Center for Bioethics in Research and Health Care at Tuskegee University - established and funded by the federal government as a result of the syphilis study.

"It's both historical and current," he says. "And not either/or but both/and."

Warren says the "use and abuse of Black bodies" dates to slavery, and continued for hundreds of years. He cites the Eugenics movement, for example.

Now, he says, the coronavirus pandemic and its disparate impact on people of color, have exposed the shortcomings of the U.S. healthcare delivery system. For instance, there's no hospital serving the general public in Tuskegee and COVID-19 testing was hard to come by early on.

So it's not just historical but it's current," he says. "The combination of that makes folks pause."

Warren says seeing the mayor or a community leader get a shot isn't the kind of assurance that people need. He says that's neglecting to consider that some people might not have health insurance that could help then manage any future complications.

"What about next year?" he asks. "Next year, if something comes up and I don't have health insurance, I'm out in the cold."

He advocates providing health coverage to the uninsured who get the vaccine.

That, Warren says, is a way of assuring people that the healthcare system will deliver for them in the future, despite the history.

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In Tuskegee, Painful History Shadows Efforts To Vaccinate African Americans

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A lingering mistrust of the medical system makes some Black Americans more hesitant to sign up for COVID-19 vaccines. It has played out in early data that show a stark disparity in whom is getting shots in this country - more than 60% going to white people, and less than 6% to African Americans.

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Before Ibram X. Kendi wrote "How to Be an Anti-Racist" and the term "anti-racism" swept into the cultural lexicon, political activist and scholar Angela Davis said that "in a racist society, it is not enough to be non-racist. One must be anti-racist." But in a world where many people have been taught that being "not racist" is a behavior that should be applauded, suddenly being told that it isn't enough has elicited confusion. Isn't being non-racist a good thing? Shouldn't we treat everyone equally, regardless of their race, because everyone has the same opportunities? Well ... no. Because the simple truth is that everyone doesn't have the same opportunities.

The election of President Obama in 2008 caused many political pundits to speculate that America had entered into a "post-racial" age. These pundits took the election of a Black man as evidence that racism had ended. Because, surely, if a Black man could make it to the highest office in the country, anyone could, right? But the myth of the post-racial age only obscures the fact that systemic racism still permeates every institution in this country. From the health care industry to K-12 education to the office C suite, racism is endemic in America. And for many white people, the successive murders of Ahmaud Arbery, Breonna Taylor and George Floyd in the spring and summer of 2020 (as well as the global protests for racial justice) brought them face-to-face with the understanding that systemic racism is alive and well in America.

In our society, systemic racism still creates dramatically different life experiences and outcomes for communities of color. Yvonne Davenport-Perkins and Ruka Curate of Lens Diversity write, "One of the reasons why white people haven't understood (the phrase 'anti-racism') before the summer of 2020 is because privilege acts as a barrier and a shield. Many white people have not had to confront these issues because they weren't happening in their backyard. But with the start of the COVID-19 pandemic and the shutdown orders, in conjunction with police brutality and an already fraught election process, white people began to see that what POC had been speaking on for many years were not just isolated incidents." To provide some examples of this systemic racism, the average Black family has roughly 1/10 of the net worth of the average white family. Black and Latinx people make up 32% of the US population but a full 56% of the incarcerated population in the U.S. Only 19% of 18-24-year-old Native American students enroll in college, compared to 41% of the rest of the U.S. population. Latinx workers are statistically more likely to be injured on the job and they face the highest rates of fatal work injuries, but they are also 2.5x more likely to lack health insurance than their white counterparts. All of these statistics show examples where systemic racism intersects with economic, educational, health and life outcomes.

For many folks (especially white folks) this sudden understanding about the myth of a post-racial age, as well as the subsequent realization that systemic racism makes up the fabric of American society, also came with an understanding that being neutrally "not-racist" is impossible.

We live in a world shaped by race, and we've therefore been conditioned to have racist worldviews. As Kendi puts it, "A racist idea is any idea that suggests one racial group is inferior or superior to another racial group in any way. Racist ideas argue that the inferiorities and superiorities of racial groups explain racial inequities in society."

Claiming to be "not racist" gives people a pass from interrupting racism when they witness it. And if one doesn't intentionally confront racism (both on an individual and a systemic level) and instead pretends to not see it, racism continues to thrive. Or, as Desmond Tutu said, "If you are neutral in situations of injustice, you have chosen the side of the oppressor."

So instead, the imperative is for each of us to be anti-racist. The leaders of Lens Diversity, which was created to help corporations, academic institutions and non-profit organizations in response to the many difficult events in 2020, describe anti-racism as "any effort or action designed in direct opposition to racism, bias, oppression, marginalization and brutalization of any group of POC." In practical terms, this means that we have to show up to interrupt, confront and call out racism whenever we see it. It could be in line at a grocery store, in an office staff meeting, in a classroom space or it could be the crucial introspective act of noticing and interrogating our own racist thoughts when they emerge.

Beyond a commitment to interrupting racism, both internally and in the world, how else do people become anti-racist? First, we have to dispel the notion that being anti-racist is an end goal or a destination to arrive at. We can't rid ourselves of our racist conditioning, and we will continue to make mistakes (especially white people, whose privilege has specifically allowed them to not "see" racism for much of their lives). So, being anti-racist means showing up, over and over, to fight against racist policies, ideas and actions. "It is possible to become anti-racist, but it is not easy work nor is it a one-shot deal," the leaders of Lens Diversity write. "It doesn't start and end with posting a black square to show that you're 'down' or having friends from a different ethnic group. It starts with ignoring your ego and looking in the mirror. Asking yourself, 'How am I biased? How am I racist?'"

A key piece of anti-racism is educating oneself in a way that interrogates the racialized frameworks we grew up in. For many people, that means unlearning a whitewashed history of our country and seeking out the histories of communities of color. It means educating ourselves on how systemic racism dictates different life outcomes for people of different races.

There are numerous resources for beginning one's anti-racist education: For starters, the Solidarity Library, Your Black Friends Are Busy and The Institute for Anti-Racist Education have fantastic reading lists. But self-education also has to be paired with action and activism. It's critical that once people become aware of how systemic racism operates in this country that they actively seek to disrupt those systems. One resource, the Anti-Racist Roadmap, pairs education with activism. It prompts users to identify actions they can take within five different impact areas to reappropriate resources to communities of color and disrupt racism within their own circles. This pairs anti-racist learning with concrete and specific actions. What is clear is that anti-racism requires us to show up again and again, even after we've made mistakes.

As the leaders of Lens Diversity state, "All people are operating on a racist ideology, but they can also look to dismantle that and replace it with something better. Anti-racism is a necessary rung in the ladder to equity for all because we all have so much to unlearn. But it starts with self and has a ripple effect."

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How to be an anti-racist and what new steps you should take

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Before Ibram X. Kendi wrote "How to Be an Anti-Racist" and the term "anti-racism" swept into the cultural lexicon, political activist and scholar Angela Davis said that "in a racist society, it is not enough to be non-racist. One must be anti-racist."

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Center on Culture, Race & Equity

Bank Street believes Black Lives Matter and is committed to creating spaces of dialogue and learning that help build equitable environments for Black children across the country. The Center on Culture, Race & Equity (CCRE) encourages all educators, caregivers, and families to learn more about the anti-racist practices and interventions that help disrupt racism in schools and communities and, ultimately, help transform the structures and systems that devalue the lives of people of color.

CCRE has compiled the following resources on equity and culturally responsive practices, including information on the foundations of anti-racist education and age- and grade-specific resources, which can help both adults and children construct knowledge around building relationships, naming injustice, and working together to change the world. In addition, as systemic racism is also responsible for the disproportionate burden COVID-19 has thrust upon Black communities and other communities of color, CCRE has included pandemic-specific resources on race, equity, self care, and distance learning.

We encourage you to explore and share these resources with your community. For questions or further information regarding this resources list, contact us at ccre@bankstreet.edu or follow us on Twitter @ccre_bsc.

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Equity & Culturally Responsive Resources

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Skip to content Center on Culture, Race & Equity Bank Street believes Black Lives Matter and is committed to creating spaces of dialogue and learning that help build equitable environments for Black children across the country.

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Child Life Specialists as Advocates for Social Justice, Equality and Equity in Health Care

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The U.S. Department of Health and Human Services (HHS) response to the COVID-19 pandemic has included initiatives and efforts to address the impact of the pandemic on racial and ethnic minority communities. According to the CDC, COVID-19 has had a disproportionate impact among American Indian and Alaska Natives, African American and Hispanics in cases, hospitalizations and deaths. The HHS offices of minority health are a key part of the overall HHS response, helping to lead efforts around safety guidelines, partner engagement, minority representation in research and other areas.

The Offices of Minority Health are established within six agencies at HHS:

These offices, in conjunction with the HHS Office of Minority Health and NIH National Institute on Minority Health and Health Disparities, lead and coordinate activities that improve the health of racial and ethnic minority populations and reduce health disparities. Click on each logo below to see their work to reduce address the COVID-19 pandemic.

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HHS Offices of Minority Health COVID-19 Initiatives and Resources - The Office of Minority Health

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The U.S. Department of Health and Human Services (HHS) response to the COVID-19 pandemic has included initiatives and efforts to address the impact of the pandemic on racial and ethnic minority communities. According to the CDC, COVID-19 has had a disproportionate impact among American Indian and Alaska Natives, African American and Hispanics in cases, hospitalizations and deaths.

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In this moment in the nation, when anti-Blackness is so widespread, it is especially important for Black children to know that they are precious and brilliant. And one powerful way to affirm Blackness and Black identities is through reading.

Educator and multicultural scholar Rudine Sims Bishop provides a powerful metaphor for reading. She says that, sometimes, books can serve as mirrors, windows, and sliding-glass doors. Books can help us to see ourselves, look out into the world and learn about the experiences of others, and use our imaginations to become part of the world an author captures or creates.

An essential part of that metaphor is the way books can serve as mirrors that reflect the racial and cultural identities of the reader. Yet historically and presently, there have been too few books that mirror Black identities - too fewbooks that center Black joy. This was a particular frustration for me, as a Black parent, when seeking out books for my daughter that were a reflection of her lived-experiences and a celebration of Blackness.

As parents and caregivers, we understand how important it is for children to read. And we also understand how important it is that Black children feel seen, valued, and loved in their reading lives. As Director of Diversity and Equity at the Teachers College Reading and Writing Project at Columbia University, my work in advancing antiracism in education begins by centering and honoring the lived experiences of students of color. So I specifically want to share the kind of books that affirm and celebrate Black identities. These are books that not only belong on bookshelves in our homes, classrooms, and school libraries. They should be an integral part of the curriculum.

Echoed across the research is that there are two things Black children need to further their emotional and academic development. First, is to develop strong racial and cultural identities. Second is opportunities to develop their critical consciousness. When inclusive, culturally responsive books are kept out of or are limited in the curriculum and on library shelves, the message becomes clear to all students about whose lives matter and whose don't. Books offer powerful mirrors for Black children that are joyful to read in school and at home. Here's what to consider.
Choose books that reinforce Black is beautiful.
Because racism is real, it's possible your child has already experienced anti-Blackness directly. When my daughter was 4, she came home from nursery school as asked, "Why am I brown all over?" She asked this question in a way that absolutely let me know that something problematic happened in her pre-K classroom that day. And sure enough, I learned that she was told by a white peer that she could not play with her because she was "brown all over."

Books can help us counter negative messages and provide empowering ones. For young children ages 4-7, reading aloud " Skin Again" by bell hooks, "The Skin You Live In" by Michael Tyler, and " Sulwe" by Lupita N'yongo help young Black children to recognize the beauty of their Black skin.

Similarly, Black hair is beautiful. And yet, the world often tries to tell us otherwise. " Hair Love" by Matthew Cherry, " Crown: An Ode To The Fresh Cut" by Derrick Barnes, and " Bippity Bop Barbershop" by Natasha Anastasia Tarpley are each powerful odes that affirm Black hair.

Reading books like these at home are important. They can help open up opportunities for children to talk to caregivers about any negative messages they're wrestling with. They can give caregivers and parents opportunities to combat those messages with messages of love, affirmation, and joy. And they help to provide Black children with the protective armor they need to develop strong racial and cultural identities.
Find stories that feature dynamic characters.
When selecting books that increase the visibility of Black identities, choose books that present Black characters and people in dynamic ways, experiencing a range of emotions, and taking part in a variety of experiences. Avoid books that lean into stereotypes and, instead, select those that demonstrate the full humanity of Black people. Books that celebrate Blackness and help Black children feel seen include "All Because You Matter" and "Freedom Soup" both by Tami Charles, "I Am Every Good Thing," another incredible book by Derrick Barnes, and "Saturday" by Oge Mora.

Books that feature Black characters riding skateboards, honoring their cultural identities, spending time with a parent enjoying their special bond, and more, validate the various experiences of Black children.

Tips for selecting books centered on Black joy:

Selecting books that center Black joy can help you and your child experience a celebration of Blackness as you read together. Think about:

1. Characters - Look for books that present Black characters in a variety of ways so that Black children can imagine their past, present, and future. As previously mentioned, one thing that's frustrating is the way society often presents Black identity as a singular thing. Select books that recognize the richness and diversity of Black identities.

2. Family Structures - Look for books that are inclusive of many families, such asadoptive families, multiracial families, intergenerational family units, single-parents, and same-sex parents and caregivers.

3. Communities - Select books that represent communities positively; that show the richness of communities, their strength and resilience. It's important that stories do not limit a community's past and present histories to oppression, but instead demonstrate the care and wisdom that exists within communities.

4. Racial/Cultural Identities - Look for books where Black identities and cultures are presented powerfully and authentically. Select books that show the authentic ways Black people speak, where languages and traditions are presented accurately and respectfully.

Keep these resources in mind.
Black authors and illustrators understand the importance of celebrating Black identities. And they bring this nuanced, authentic understanding to the page. There are several ways to locate their work. Check with local libraries and bookstores. The following two websites are also helpful resources. The Brown Bookshelf focuses on raising awareness of the myriad Black voices writing for young readers. AALBC, is the oldest and largest online bookstore "dedicated to African American and Black literature from around the world."

Books about Black characters and Black people are for ALL readers. And they are especially for Black children who deserve to feel seen and valued in the world.
Dr. Sonja Cherry-Paul is an author, consultant, and Director of Diversity and Equity at Teachers College Reading and Writing Project. She is also the co-founder and co-facilitator of the Institute for Racial Equity in Literacy.

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In this moment in the nation, when anti-Blackness is so widespread, it is especially important for Black children to know that they are precious and brilliant. And one powerful way to affirm Blackness and Black identities is through reading. Educator and multicultural scholar Rudine Sims Bishop provides a powerful metaphor for reading.

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"'Are we going to be guinea pigs for the vaccine?'"

For months, Dr. James Hildreth's sister had been asking questions like this.

While public health officials were urging Americans to take measures to help stop the coronavirus, high rates of infection within Black communities fueled his sister's mistrust, said Hildreth, the president of Meharry Medical College, an historically Black institution in Nashville. She had no desire to be vaccinated, and thought officials wanted people like her - Black people - "to prove the vaccine is safe so others will take it."

Those concerns have been echoing from communities across the U.S., according to Hildreth, a member of the Biden administration's COVID-19 Health Equity Task Force. He also has worked as a Food and Drug Administration adviser on the veting of the COVID-19 vaccines' safety and effectiveness for their emergency use authorization. He knows whose lives are at stake if he doesn't take these roles seriously.

The coronavirus pandemic repeats a truth that communities of color in the United States have been saying for generations: They suffer worse health outcomes compared to white communities, and systemic racism drives those disparities.

At each turn during America's COVID-19 response, Black, Latino and Indigenous people have endured higher rates of infection, lack of access to and insurance coverage for testing and treatment and death. Despite greater vulnerability to the virus, disproportionately fewer people of color have been vaccinated across the U.S. compared to white people as the nation's immunization campaign ramps up.

Memories of historical atrocities run long and suspicions high when it comes to medical care. Black Americans are more likely than white Americans to say they do not trust their health care provider, rooted in both contemporary experiences - like that of Dr. Susan Moore, a Black physician who died of COVID-19 after posting on social media that her pain and calls for help were not taken seriously - and other painfully recent history.

From 1932 to 1972, federal researchers examined the effects of syphilis on Black men when left untreated. None of the 623 participants in the United States Public Health Service Syphilis Study were told what was happening, and, in one of the worst examples of unethical medical research in modern U.S. history, researchers secured no one's consent. They were told they had "bad blood," but researchers withheld actual treatment from them, even after penicillin was discovered as an effective, affordable and readily available therapy for the disease.

Freddie Lee Tyson was one of the men in the study. A carpenter, loving husband and father of nine children in Tuskegee, Alabama, Tyson worked throughout his adult life to build a better world for himself and his family. Tyson served as a deacon in his church and a firefighter. With his hands, he built his children's Catholic school and the barracks at present-day Moton Field Municipal Airport, where the Tuskegee Airmen excelled as the first Black pilots in the U.S. military during World War II and became national heroes.

But with all of his accomplishments, he didn't deserve to be "treated as though he didn't have any worth," said his daughter, Joyce Christian.

He was never told him he had contracted congenital syphilis from his mother or that he was enrolled in the study, and since he never developed symptoms, he wouldn't have guessed it either. When the Associated Press leaked reports that the men had been denied needed medical care for decades, one of Tyson's sons, who was enlisted in the Air Force, called his family with the news. Researchers ended the study, and later a phone call came for Tyson confirming he had been a test subject. Shortly thereafter, he independently found his name on a list of participants. Tyson's family was first shocked and then angry - "all the things you have when you find out a loved one has been in a study so inhumane," said Christian, 72, a retired nurse who told her family's story to the PBS NewsHour.

Christian said that after a few days, her father had advice for one of her sisters: "'I can't do anything about it now, but you can. You all can do something about it and never let this happen again to anyone."

"Targets for bad experiments"

Growing up, Alanna Nichols was warned about the hazards of the U.S. health care system for Black patients. Nichols' mother, a nurse for more than two decades in Ohio, told her about the horrors in Tuskegee, and that Black mothers and newborns suffered worse outcomes during childbirth than white mothers and infants. Be careful about taking new prescription drugs, her mother would caution.

"Underrepresented groups are always targets for bad experiments," said Nichols, 44, an entrepreneur and social worker by training, who added she keeps up with new peer-reviewed research on health

When the coronavirus emerged, her family - including her husband, a military veteran and U.S. Postal Service worker who has been in remission from prostate cancer - took health precautions seriously and began to avoid travel. Nichols said she obsessively washed her hands and wore face masks.

In December, the Food and Drug Administration began authorizing vaccines to prevent COVID-19 infections for emergency use, the first time the agency had done so to stop a viral pandemic.

"Underrepresented groups are always targets for bad experiments."

The only people Nichols knows personally who have gotten vaccinated are teachers at her son's school, but she said her husband will be "first in line" when it's his turn to get vaccinated.

Nichols, though, still has too many questions about the vaccine candidates. What group saw the weakest results? What are the side effects? Everything about the pandemic remains "so new and confusing," Nichols said, who craves more transparency about what is happening.

"It makes you a little paranoid to jump so fast without knowing the actual [vaccine] data points that's driving urgency," she said. The only trusted messenger she said she would believe is a retired health care professional "who don't have skin in the game" and who "understand what the paranoia or needs are as it relates to underrepresented communities."

"I need them in the conversation right now," she said.

"It made me not trust white people"

After the birth of her first child, Gabriela Momen endured dark feelings she eventually realized were symptoms of postpartum depression. A married Mexican-American mother of five in Round Rock, Texas, Momen raised concerns about her welfare during a check-up. But "My doctor just dismissed them" and chalked everything up to the "stress of being a homemaker and just my culture," she said. Momen never received mental health care, and it had another lasting effect.

"It made me not trust white people to be in charge of my well-being," she said.

Nearly a decade later, the coronavirus pandemic and calls for racial justice following the death of George Floyd opened Momen's eyes to other forms of insidious, casual racism. In her predominantly white neighborhood, Momen, 34,says it wouldn't matter if her family drove better cars or had more money to throw around than their neighbors. They would always be viewed as different because of the color of their skin, their religious beliefs as Muslims and their last name (her husband is Palestinian American).

Momen said she feels "like the vaccine was not created for us," and resents calls from public officials to get vaccinated for COVID-19.

"It makes it feel like rich, white men made a vaccine that worked for them and now we're going to have to take it to protect them," Momen said as she nursed her 1-year-old child, the sound of her four older children participating in virtual classes humming in the background.

A self-described middle-class supporter of "Medicare for All," Momen said she feels like national calls for more expansive health care coverage are ignored, "but when they have a vaccine, they shove it down our throats."

Even if her family decides to eventually get the vaccine, she is discouraged by the current lack of shots near her home in suburban Austin. Members of her household (who include her in-laws) are also concerned about data that suggest some vaccines may be somewhat less effective at preventing infections from certain COVID-19 variants.

Momen said she needs more people who look like her and her family to advocate for vaccines and play a greater role in developing them. Only then, Momen said, will she gain enough confidence to accept any vaccine used against the coronavirus.

"A blessing in disguise"

Kymberly Hartfield, 45, began following headlines about COVID-19 when it was still just a blip in the American news cycle. When China started to construct pop-up hospitals in Wuhan to treat patients of a mysterious pneumonia-like illness, Hartfield said she sensed catastrophe and "really started paying attention to what was going on with the virus."

Hartfield, a Black mother of three and a community activist in Marietta, Georgia, has avoided vaccines for years; she has never gotten a flu shot. When the Trump administration appeared to inject politics into public health campaigns, such as promising that a vaccine would be ready ahead of Election Day, "I was a firm 'hell no,'" Hartfield said.

"Most people recognize there's systemic, structural changes that need to be made and the appetite to do so is greater than ever."

Yet Hartfield kept a close eye on the vaccine effort. From her perspective, Operation Warp Speed "eliminated red tape," and the technology used to develop the two first vaccines had been advanced over several years, not rushed overnight. That gave Hartfield "valid reasons to trust the speed of it all," she said.

It wasn't until Christmas during a phone call with her Great Aunt Lois when she made up her mind to get vaccinated. Her 79-year-old aunt lives nearly 400 miles away in Moss Point, Mississippi, and has been a fixture throughout Hartfield's life.

Being unable to see her aunt for months on end has been one of the hardest things for Hartfield to accept about the pandemic, she said. Her aunt isn't comfortable using computers or even smartphones ("she's just super old school"), so Hartfield can't text her aunt photos or see her facial expressions when they do catch up on the phone. When her aunt asked Hartfield if she planned to get vaccinated for COVID-19, Hartfield said no.

"'If you're not going to get vaccinated, how are we going to see each other?'" Hartfield said her aunt asked.

That struck Hartfield. And then she heard a doctor quoted in a news report say, "Whatever the side effects are, we can treat that easily. It's COVID we can't treat easily."

"That made sense to me," Hartfield said. And together with missing Great Aunt Lois, Hartfield's misgivings eased.

"It's overwhelming to the point where people give up and say, 'If it happens, it happens. I've got other things to deal with. I don't need another hard thing to deal with.'"

The coronavirus and George Floyd's death exposed rampant inequalities in the U.S. with such force that "there's no turning back," Hartfield said. "Most people recognize there's systemic, structural changes that need to be made and the appetite to do so is greater than ever. That's why I call it a blessing in disguise."

But if public health officials think they can convince skeptical people in Black communities to get vaccinated, they won't, Hartfield added. Instead, she said, experts should offer transparent information to these communities and empower them to decide for themselves - as she did. To get there, she thinks that policymakers and public health officials must be more creative in reaching out to communities of color and people who are discouraged and struggling to pay the rent and feed their families: "It's overwhelming to the point where people give up and say, 'If it happens, it happens. I've got other things to deal with. I don't need another hard thing to deal with.'"

"With COVID, we know what's happening"

Over time, Dr. James Hildreth's sister began to change her mind about getting vaccinated for COVID-19, he said. It took several weeks of seeing friends and colleagues in her community get their shots to make her more comfortable. Now she is asking him which of the approved COVID-19 vaccines she should get.

More than simply "hearing information that you need to hear," Hildreth said, it is important for his sister and others to be "hearing it from someone that you trust."

Stories like Hildreth's may soon be more abundant as more and more people get vaccinated and trust grows. But monitoring just how equitably federal, state and local governments handle distribution may still present challenges. In a recent report from the Centers for Disease Control and Prevention, there was no race or ethnicity data for roughly half of all vaccine doses distributed from mid-December to mid-January. That's problematic, Hildreth said, because until the U.S. keeps better records, "we can't truly know what the real disparity is. We need to collect the data to know where all our resources need to be."

Freddie Lee Tyson's experience, and the larger history of atrocities weigh on his daughter every day. To ensure no family suffers in the same way, Christian, her siblings and the descendants of those 623 men established the Voices For Our Fathers Foundation to honor their legacy and hold the U.S. government accountable to history.

"The men had no idea," Christian said. "With COVID, we know what's happening. We know about the facts."

The virus is real and has killed more than 500,000 in the U.S. The vaccines, developed by "the best minds in the world," are the best way to end this pandemic, Christian said. So she, too, has decided to get vaccinated because the only way out is to "rely on science. We have to believe in science."

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For Americans of color considering the COVID-19 vaccine, here's why trust is so important

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"'Are we going to be guinea pigs for the vaccine?'" For months, Dr. James Hildreth's sister had been asking questions like this. While public health officials were urging Americans to take measures to help stop the coronavirus, high rates of infection within Black communities fueled his sister's mistrust, said Hildreth, the president of Meharry Medical College, an historically Black institution in Nashville.

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In American epidemics, race is a preexisting condition.

Whether it's the influenza pandemic of 1918 or COVID-19 over a century later, race and ethnicity have been, and continue to be, enormous factors in determining whether people will receive medical attention when they become ill, and the sort of attention they will receive.

In " The 1919 Influenza Blues," Essie Jenkins documented the toll the flu took on the country, noting that viruses don't discriminate when it comes to their victims. She sang:

According to the Centers for Disease Control and Prevention estimates, the 1918 flu infected 500 million people worldwide and resulted in 50 million deaths around the globe, 675,000 of which were American. But while viruses don't discriminate, people do. In cities across the nation, black people struck by the flu were often left to fend for themselves. They received substandard care in segregated hospitals, where they could be relegated to close quarters in basements, or they were only allowed admittance to black-only hospitals. Even in death, black bodies were neglected by white public infrastructure. In Baltimore that year, white sanitation department employees refused to dig graves for black flu victims after the city's only black cemetery, Mount Auburn, could not accommodate any more graves.

"The mayor then had to appeal to the War Department, which is now called the Defense Department," said Marian Moser Jones, a social historian and ethicist of public health at the University of Maryland. "The War Department sent 342 black soldiers, black American soldiers to do the task, which is very much in keeping with the way black soldiers were treated by the Army in the war. They were detailed to the worst duties, the most grueling labor details were the ones who were most often sent out to clean out the trenches after a battle and even exhume and rebury dead soldiers' remains.

"It's sort of a continuity from the war. The resources that were there, that were limited, the resources to address African American health and even death were overwhelmed in cities like Baltimore."

The flu epidemic is inextricably linked to World War I. The first cases in the U.S. were identified in soldiers living in close quarters in Army barracks before heading to Europe to join the war, which the United States entered in April 1917. Even the name that we use to identify the disease, the "Spanish flu," is inaccurate, according to historian Kenneth C. Davis, author of More Deadly Than War: The Hidden History of the Spanish Flu and the First World War.

"Fear driven by propaganda, censorship and lies were so much a powerful part of the spread of the Spanish flu. People were misled, often deliberately, by officials," Davis said. "Newspapers were censored. The reason it is the Spanish flu is because of censorship. [During the war] Spain was a neutral country. It didn't censor its news reports as rigorously as some of the warring countries did, so the first report of a massive epidemic comes out of Madrid in the spring of 1918 and that's the reason it was reported by Reuters in London that Madrid was under a mass epidemic. That's the reason it was called the Spanish flu. It certainly didn't originate there."

Today, in the age of COVID-19, it's worth examining the social dynamics of 1918 and how their legacy continues to shape modern public health.

"A lot of my historian friends have a cottage industry now talking about the lessons learned. I'm a bit more cautious," said Vanessa Northington Gamble, a medical doctor and professor of medical humanities and American studies at George Washington University. "Who you are - and I mean in terms of your race, your gender, where you live - will have a major role in how you experience COVID-19. It also will play a major role in the services that you get. ... If there's anything we can learn from the 1918 influenza epidemic, is that we really have to look at issues around race and class and racial and social inequities."

Race and patient care

When the flu epidemic of 1918 came to Chicago, black people were blamed, and that blame came directly from John Dill Robertson, the city's commissioner of public health. It wasn't just white medical officials who engaged in this sort of blame. Robertson had a tremendous influence on the way the Chicago Tribune covered migration, and there, the prejudice was plain. Even before the pandemic reached Chicago, the Tribune 's coverage of migration was alarmist.

A March 5, 1917, headline from the Chicago Daily Tribune, as it was known at the time, blared, Rush of Negroes to City Starts Health Inquiry.

The flu simply heightened those existing prejudices.

Half a Million Darkies from Dixie Swarm to the North to Better Themselves, the paper proclaimed July 8, 1918. In the corresponding article, reporter Henry M. Hyde laid out a series of pathologies: Black people moving to Chicago from the South, he wrote, "are compelled to live crowded in dark and insanitary rooms; they are surrounded by constant temptations in the way of wide-open saloons and other worse resorts."

The reason for such ills wasn't any innate inferiority that could be attributed to blackness. In an academic paper about Jim Crow and public health, Betsy Schroeder Schlabach, a professor of history and African American studies at Earlham College in Richmond, Indiana, explained how discriminatory housing policies created ghettos. Black people were relegated to limited parts of the city. Housing was overcrowded, and white landowners became slumlords, charging rents that were 15% to 25% higher for black tenants, and then refused to make needed repairs when asked.

"The way that the Tribune, especially, talks about disease is the same way they talk about the Great Migration: swarms of migrants coming to the city and bringing with them all sorts of disease," Schroeder Schlabach said. "There's similar ways that today we talk about the border or the way definitely [President Donald] Trump talks about immigration crisis and disease."

Interestingly, the Nov. 2, 1918, edition of the Cleveland Advocate bore the headline: Flu Shuns Us, Says Health Doctor, referring to black people. The idea that black people were not getting the flu, or dying from it the way white people were, was a widely held belief at the time, Gamble said. Getting a clear picture of what black people experienced nationally during the flu pandemic is difficult. Gamble thinks that segregated black neighborhoods may have functioned as a makeshift quarantine. But it's also likely that instances of black illness were underreported.

"The only year in the 20th century when black people in the USA had lower influenza mortality than white people was 1918," researchers Helene Økland and Svenn-Erik Mamelund wrote in the International Journal of Environmental Research and Public Health. "One hypothesis is that black people, who mainly lived in the South and under miserable living and working conditions, cramped conditions, white racism and violence, and poor medical care, were less susceptible to the 1918 influenza pandemic autumn wave due to higher exposure to the less virulent spring and summer waves. However, this hypothesis, the mechanisms for the crossover in the role of race in 1918 pandemic mortality, and the subsequent return to the 'normal' pattern of higher black than white mortality in 1919, have received little attention in the literature, nor has this [or other] hypothesis been theoretically or empirically substantiated."

Gamble was also circumspect about fully trusting black infection statistics. "I do not say it's definitive. There's some indications [that black people were less affected]," she said. "And black physicians believed it too. But even if the incidence was lower, the number of black people who got influenza in 1918 overwhelmed the health care and social services institutions that were available to black people. So black hospitals were overwhelmed. Black nurses were overwhelmed. Things such as the National Urban League, they had volunteers to go into homes to try and take care of people. They were overwhelmed, and especially because the black community, for the most part, was left on its own."

Shroeder Schlabach found that Robertson's public health edicts functioned as another layer of Jim Crow laws, limiting the movement of black Americans, and effectively quarantining them to ghettos on the city's South Side. Public health officials became a de facto police force. Beginning in 1917, Robertson's health department passed 75 regulations, regulating where people could drink water to where children could play. It also implemented mandatory reporting of flu cases.

"If you caught influenza, you were obligated to self-quarantine and then report that you had caught it to the Department of Public Health, and then they would come to your house and placard your house, like put a big red sign up on your house," Schroeder Schlabach said. "That served to stigmatize disease. The Public Health Department sent visiting nurses on expeditions to find people who were sick. They would visit homes, and that resulted in about 40,000 visits [across the city] during the pandemic where nurses and public health officials could come into your house without your permission and ask if you were infected.

"What that does, especially for black households during the pandemic, is it takes away the sanctity of the home, giving the Public Health Department, who also had the power of the police, entering into your home. For the black family in early 20th-century Chicago, that's a direct threat to their safety. These ordinances about mandated reporting of disease were the ones that functioned similarly to Jim Crow laws that regulated all facets of black life."

Black people who were wealthy enough could visit a doctor in his office. Dr. Roscoe Giles, for example, placed ads in The Chicago Defender announcing his services. But for those who were less fortunate, Provident Hospital, the nation's first black-owned and -operated hospital, was one of the few places where black people could be seen and treated. While black medical schools, such as Howard University Medical School, which grew out of the Freedmen's Hospital in Washington, and Meharry Medical College in Nashville, Tennessee, were instrumental in turning out black physicians, Provident was crucial in training black nurses.

The Defender also ran columns by Dr. Wilberforce A. Williams advising black readers how to avoid the flu.

"He combines really practical advice about washing your hands, covering your mouth when you cough, but also, 'If you want to be a good black citizen, donate to these things,' or, 'Live hygienically, and that means you can be a good person,' " Schroeder Schlabach said. "I found that to be a really interesting mix in his articles. In one article, he chastises a young mother who didn't want to report that her child had contracted the disease because she feared social isolation. He just rakes her over the coals like, 'This is foolish. You can't put your pride before the well-being of the community.' "

Even as they were relegated to inadequate medical facilities, with black doctors and nurses facing shabby treatment and disrespect, black people still found ways to make the best of horrible situations.

"Black Chicagoans responded with innovation and tremendous grit and determination," Schroeder Schlabach said. "At one point, the Public Health Department mandated that people needed to wear a mask. And what a group of black Chicago ladies do is that they start innovating with the masks and making them out of delicate lace and exquisite jewels. So even in the face of the pandemic, they were looking fabulous in these diamond-studded flu veils. Doctors and nurses just refused to accept any form of segregation. They're more like icons. I see that as remarkable determination."

Race, professionalism and modern inequality

The effects of America's doctrine of separate and unequal life permeated everything during the 1918 flu epidemic. It not only shaped who received treatment and where, but also which people were deemed qualified to provide medical care.

In the midst of the first World War and the flu epidemic, there was a hope that black people could prove themselves as full Americans by serving their country, both in the medical field and in the military. The occupations, they hoped, would function as a " citizenship machine."

"It was W.E.B. Du Bois who really motivated African Americans to enlist and join the Army," Davis said. "He thought this would really prove how they were loyal Americans who could make a great contribution to the war effort and to fighting. And some of the first American troops to go to France were African American troops, including the very famous group known as the Harlem Hellfighters."

Yet white institutions like the American Red Cross (ARC) were loath to accept black nurses into their ranks to help with the war effort until the situation was so dire that they had no choice.

"Many African American women were rebuffed by ARC chapters when they sought to participate, and had to create their own alternatives for wartime voluntarism," Moser Jones wrote in a case study of the American Red Cross's response to the flu pandemic. "Similarly, black women seeking to enroll as ARC nurses met with frustration. During the war, the ARC served as the official recruiter of nurses for the U.S. Armed Forces. The nursing division, which required every ARC nurse to have completed three years of training in an accredited nursing school, enrolled 24,000 trained nurses. Trained black nurses, however, were rejected for service abroad, and were only enrolled as reserve members of the home defense program."

"They were finally allowed to come in and treat white soldiers, but they were still of course living in segregated facilities," Davis said. "So, even the angels of mercy taking care of these dying soldiers still had to confront the racism of the day."

A job listing in the December 1918 Monthly Bulletin of the Department of Public Health and Charities of the City of Philadelphia was openly discriminatory:

There are four vacancies for assistant physicians at the Philadelphia Hospital for the Insane. Thirty-fourth and Pine Streets, two at a salary of $900 per annum and two at $720 per annum, including board, lodging, and laundry. Applicants must be white, twenty-one years of age, residents of Philadelphia, and licensed to practice in the State of Pennsylvania. These positions are open to both sexes. Successful candidates must reside at the hospital.

The Nov. 2, 1918, edition of The Chicago Defender reported that a black nurse named Olive Walker in Ohio was "denied the privilege of helping the Red Cross nurse committee to down the influenza epidemic at Hiram College. The dean of the college refused to allow her to serve when he became aware of her racial identity." Lincoln Hospital in New York would hire black nurses, but not black physicians, Gamble said. And even the famous Dr. Giles of The Chicago Defender was asked to leave a new job at a tuberculosis sanitarium after six hours on the job. White patients didn't want him to treat them.

Public health historians say that prejudice in American health care is once again at the forefront with the emergence of COVID-19. This time, Asians are the target of racialized scapegoating, from the Trump administration labeling COVID-19 the " Chinese virus" to Asian Americans being blamed for the pandemic's presence in America.

"I called my mother, who works at a hospital in Northern California," wrote Frank Shyong, a columnist for the Los Angeles Times. "I asked her to stay home, but her boss told her if she didn't show up, she would lose her job. At work, patients sometimes refuse to be seen by her, because suddenly an Asian woman in a face mask is a threat."

In November 1918, the Rev. Francis J. Grimke preached a sermon about the flu epidemic and what lessons could be gleaned from it. His words, delivered to the 15th Street Presbyterian Church in Washington, still hold tremendous relevance:

Jesus said, "The first and great commandment is, 'Thou shalt love the Lord thy God with all thy heart, and with all thy soul, and with all thy mind, and with all thy strength.' And the second is like unto it, 'Thou shalt love thy neighbor as thyself.' Upon these two commandments hang all the law and the prophets." Race prejudice, colorphobia, runs directly counter to both of these great commandments. And, therefore, never mind what the white man may think of it, we see clearly what God thinks of it, and it is the estimate that He puts upon it that is to determine its character. Let us hope, therefore, not only for the sake of people of color, but also for the sake of the white people themselves that the great lesson as to the folly of race prejudice - of assuming that a white skin entitles one to better treatment than a dark skin, which this epidemic has so strikingly taught, may not be lost upon them. It is a lesson which for their own sake it is well for them to learn. It will be better for them here, and it will be better for them hereafter, if they learn it, and learn it well. And, of course, it will be better for us as a race in this country. It will remove out of the way some very serious obstacles to our progress, and will relieve us of many of the disagreeable things that we are at present forced to endure, though not without protest.

COVID-19 has not only brought interpersonal racism to the fore, but heightened the degree to which structural racism affects treatment and care.

Public defender Scott Hechinger and defense attorney Rebecca Kavanagh have pleaded with officials to release inmates as COVID-19 has spread through the close quarters of Rikers Island, New York City's main jail complex. Similar situations exist in U.S. Immigration and Customs Enforcement detention facilities, where detainees are facing shortages of soap. Both places disproportionately house black and brown people.

"My worry is that there will be two standards of care, that incarcerated patients with one set of symptoms may be denied access to hospitals, even though in the community people with the same sets of symptoms do go to the hospital," Dr. Homer Venters, the former chief medical officer for New York jails, told The Guardian. "And then that will lead to different rates of deaths and certainly to different rates of preventable deaths among people who are behind bars."

As with the 1918 flu, responses, or lack thereof, to COVID-19 have become tied up with patriotism and xenophobia in ways that exacerbate the spread of disease. In the midst of the 1918 pandemic, Philadelphia hosted a massive parade to sell war bonds to pay for the American war effort.

"There was enormous pressure," Davis said. "If you didn't buy the war bonds, you weren't doing your part. You were a slacker. So 200,000 people go out, even though the health department knows that the virus is in and around Philadelphia, on the Navy bases, and they were going to have this parade and soldiers and sailors were going to be marching in the parade. Two days after that parade, every hospital bed in Philadelphia was filled and it was a complete disaster and it was a disaster because the authorities ignored the advice not to cancel this parade."

In a live chat with constituents on Facebook, Tate Reeves, the governor of Mississippi, explained his opposition to giving official orders to the public to implement COVID-19 quarantines. "Eric Worth [a constituent] says 'China did a lockdown and it was good for them. Why can't Mississippi?' Well, Eric, I'm going to tell you that Mississippi is never going to be China," Reeves said. He has since given a shelter-in-place order to one county in the eastern part of the state, but insisted that a statewide shelter-in-place order was "not sustainable."

In 1918, "things like the war effort and paying for the war and patriotism and support for the war, really outdid the concern for public health," Davis said. "They were so interested to keep the troops going to Europe that they kept filling these ships up with sick men and these ships became what were called floating coffins. So, that's a really important lesson as well. Misplaced priorities. When you place things like the economy over the public health, you do so at grave peril to many, many people."

Soraya Nadia McDonald is the culture critic for The Undefeated. She writes about pop culture, fashion, the arts, and literature. She is the 2020 winner of the George Jean Nathan prize for dramatic criticism, a 2020 finalist for the Pulitzer Prize in criticism, and the runner-up for the 2019 Vernon Jarrett Medal for outstanding reporting on black life.

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In 1918 and 2020, race colors America's response to epidemics

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In American epidemics, race is a preexisting condition. Whether it's the influenza pandemic of 1918 or COVID-19 over a century later, race and ethnicity have been, and continue to be, enormous factors in determining whether people will receive medical attention when they become ill, and the sort of attention they will receive.

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As the novel coronavirus 2019 (COVID-19) pandemic sweeps across the world, troubling associations between race and disease have gone viral. On social media, theories of Black people's immunity to the novel coronavirus spread rapidly and widely, with the initially small number of cases in Africa often cited as evidence. Since then, the virus has spread to the continent and will surely exacerbate already compromised health systems. The virus was also erroneously labelled as the "Kung Fu Flu" and the "China Virus," among other epithets, by members of the United States Presidential administration-including the President himself. While these labels may have the air of jest, white supremacists have sought to use the novel coronavirus for bioterrorism, targeting racial minorities specifically. Claims of immunity falsely suggest that Black people across the entire Diaspora cannot contract the disease. Meanwhile, labels that construct the disease as Chinese obscure the vital pathways the contagion has taken irrespective of racial categories. These claims are more than just racist and xenophobic-they are dangerous to everyone's health.

It is times like these, amid existential fear and anxiety, where we must be most attuned to the ways in which race is deployed, to the historical origins from which these ideas emerge, and to how these ideas undergird social fear and political inaction. Race has no biological basis. Rather, it is historically, politically, culturally, and affectively produced not only by systems and structures, but by moments, just like the one we are presently in. The embedded effects of oppression, marginalization, and racism have very real biological consequences. We must consistently ask ourselves: (1) What does the racialization of disease reveal and what does it occlude? (2) What meanings do we attach to a condition and create in these processes of racialization? (3) How do these meanings impact people's day-to-day lives both now and in the future?

COVID-19 is an infectious disease caused by the novel coronavirus, SARS-CoV-2. The disease causes respiratory illness (like influenza) with symptoms such as cough, fever, and in more severe cases, difficulty breathing. This virus disproportionately impacts the elderly and people with "preexisting conditions." We know that 50 to 129 million non-elderly Americans have such conditions. This figure increases substantially when you consider individuals over the age of 55. Black, Brown, and Indigenous communities bear a disparate burden of these conditions. We know that COVID-19 will disproportionately impact communities of color. The racialized experience of COVID-19 will be further exacerbated at the intersections of class, gender, and age.

These racialized associations, new and old, have historical roots and have been the subjects of scholarly critical analysis for decades. Claims of "Black immunity" and the "Chinese" or "Wuhan" virus, are not wholly distinct. Rather, they are, two sides of the same coin. These claims have erased the suffering of marginalized people and continue to do so. As these individuals succumb to disease, they are inevitably blamed, if not entirely feared and demonized as vectors of disease. These pervasive ideas of racialized disease are dangerous for our health.

Assertions of Black immunity to COVID-19 represent the persistent afterlife of slavery and the pervasive power of white supremacist thought. As historian Rana Hogarth argues, these theories emerged in the era of enslavement, as the system itself made such observations of racial difference possible in the Atlantic world. According to Hogarth, "Slavery apologists would, of course, eventually use this claim to suggest that Black people's peculiarities were a sign of their fitness for servitude." While a pandemic of this size and scope is unprecedented in our generation, the world bore witness to major outbreaks of the past. Black immunity theories emerged, perhaps most prominently, in Philadelphia in the late eighteenth century in the face of successive Yellow Fever outbreaks. Prominent Declaration of Independence signatory and abolitionist, Dr. Benjamin Rush, ardently believed that African Americans were immune to the disease as a result of their purportedly acclimatized bodies. In Philadelphia, Rush worked with African Methodist Episcopal ministers Absalom Jones and Richard Allen to recruit the city's free Black community to care for dying white citizens. When African Americans themselves succumbed to disease, their suffering was ultimately erased, unexplained by immunity.

Even today medical students are taught to quickly associate disease with racial and ethnic identity. Sickle Cell Anemia is associated with African Americans, Cystic Fibrosis with European descendants, and Tay-Sachs disease with Ashkenazi Jews. While these shorthand associations facilitate consultation speed and efficiency, they are dangerous and sometimes fatal. A classic case of the consequences of associating race and disease has been shared widely by legal scholar and critical race theorist, Dorothy Roberts. Roberts recounts a Pediatrics journal article on the misuses of racialized diagnosis when a young Black girl repeatedly returned to the emergency room for pneumonia or respiratory concerns over a six year period. At a subsequent ER visit, the 8-year-old's x-rays were examined by a radiologist, who exclaimed, "Who's the kid with cystic fibrosis?" Her medical records illuminate a narrative of racialized assumptions that rendered her invisible to the myriad clinicians who treated her over the years-because of her skin color. Instead of getting a treatment-targeting diagnosis, she went untreated for years.

Diseases without clear etiologies-like ALS, which has been dubbed a "white" disease-often accrue false, racialized narratives as well. Scholars have discovered that Western medicine's beliefs that particular races cannot contract certain disease does not just impact patient diagnosis or misdiagnosis but impacts the entire care system. While some scientists and physicians rely heavily on associations between race and disease, less attention is devoted to serious analysis of the social determinants of health, i.e. the structural forces that often lead to disparate disease burden in racial minorities. A preliminary paper by a group of epidemiologists in Wuhan, China drew on myths about minority immunity based on blood type, claiming, "#COVID19 deaths likely higher in Europe but less so in Asia/India (more B) or Latin Americans (more O)." Yet, who was the first person to die of COVID-19 in Brazil? A Black female domestic worker. The first person to die of COVID-19 in St. Louis, Missouri, a hyper-segregated city and home of "Ferguson," was an older Black woman who worked as a nurse. Beyond social media arguments, we have not attended to the real reasons that Black people are showing up around the globe with lower rates of COVID-19.

Those that are the most invisible, most marginalized, and who lead the most precarious lives will be the ones most affected by COVID-19. They certainly are not always the first individuals diagnosed, but they are usually the first to die. COVID-19 spread globally for two chief reasons: (1) a particularly high R0, the "reproduction number" indicating how contagious an infectious disease is, and (2) individuals who had access to resources which allowed them to travel. Thus, in locations like St. Louis, the first case of COVID-19 emerged in a white-majority county suburb- a white student was infected in Italy before returning to St. Louis. Early on, it was easy to "joke" that the virus was a "white disease." And then a Black woman succumbed first. In Brazil, most people cannot get a COVID-19 test, leaving those without money or sick-time undiagnosed and ultimately invisible to public health workers.

When we consider the afterlife of slavery, ongoing medical racism, global histories of medical mutilation and experimentation, and Black invisibility within white supremacist medical systems-asking why Black people would joke about our own susceptibility is warranted. Theories of Black immunity sound like the perfect reward for generations of racialized violence, amid a dystopian global nightmare. The reality is, regardless of diagnosis, we are particularly susceptible and arguably among the most vulnerable.

As we attempt to identify who COVID-19 most severely impacts, we must resist the rapid, yet uncritical, definition of certain risk populations. Currently the disease is propagandized as a "Chinese" virus. Elderly populations are considered most vulnerable. And yet, there is powerful anecdotal evidence that such conclusions are flawed: take the example of Dez-Ann Romain, a 38-year-old New York City School Principal who succumbed to the disease, or Judy Wilson-Griffin, a Black nurse beloved by coworkers and family members who became St. Louis's first COVID-19-related death.

In an effort to find control in chaos, racialized claims like Black immunity ultimately represent a scrambling for power and a desire to make sense of uncertainty. We deploy these ideas which ultimately play into our own oppression and the oppression of others, however. Although the history of race and the cultural innovations created in response to oppression, do give communities of color resilience in the time of great anxiety, racialized rhetoric about diseases can be dangerous for your health. This language is as dangerous when Black people co-opt it. COVID-19 has no demonstrated biological association with any racial or ethnic group-viruses do not discriminate. Popular Black British actor, Idris Elba, himself impacted by COVID-19, responded directly to the "conspiracy theory" of Black immunity. In fact, the virus has the ability to infect us all, and will inevitably indirectly touch each and every human life in the world. Its most severe impact will be on those who are most socially vulnerable-the incarcerated, the unemployed, the unhoused, the uninsured-groups in which Black and brown individuals are disproportionally represented. Racializing disease on those grounds alone has no impact other than to promulgate dangerous assumptions. Seemingly banal claims of "Black immunity" may bring some semblance of humorous communal bonding, but they are not funny. These claims are not Black people's invention-instead they are White people's invention, driven by white supremacy, and they ultimately leave us biologically disadvantaged. We must uproot the myth of Black immunity and the related myth labeling the virus as a Chinese pathogen. The stakes are entirely too high!

Copyright © AAIHS. May not be reprinted without permission.

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The Myth of Black Immunity: Racialized Disease during the COVID-19 Pandemic

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As the novel coronavirus 2019 (COVID-19) pandemic sweeps across the world, troubling associations between race and disease have gone viral. On social media, theories of Black people's immunity to the novel coronavirus spread rapidly and widely, with the initially small number of cases in Africa ofte

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The Deadliest Flu: The Complete Story of the Discovery and Reconstruction of the 1918 Pandemic Virus

The 1918 H1N1 flu virus caused the deadliest pandemic of the 20th century. To better understand this deadly virus, an expert group of researchers and virus hunters set out to search for the lost 1918 virus, sequence its genome, recreate the virus in a highly safe and regulated laboratory setting at CDC, and ultimately study its secrets to better prepare for future pandemics.

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The Deadliest Flu: The Complete Story of the Discovery and Reconstruction of the 1918 Pandemic Virus The 1918 H1N1 flu virus caused the deadliest pandemic of the 20th century.

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The concept of the "yellow peril" is centuries old, and although today it brings to mind racist fears of East Asia, some of its first uses refer to West and South Asia. As John Kuo Wei Tchen and Dylan Yeats lay out in their rich documentary survey of the persistence of anti-Asian paranoia in literature, art, pop culture, and everyday life, "yellow is part of a visual imaginary that varies in relation to the extension of European colonization into 'the Orient.'" The object of blame-the "other"-is always shifting. In the 19th century, the concept took on a new life in the US with the expansion westward. The white protestant promise that pioneers would find new beginnings in the west turned out to be an empty one, and the Chinese in America, then working the railroads along the Pacific, became the ones to blame. Class conflict turned racial. Below is a gallery of images from the book and three short excerpts from Yellow Peril! that describe how yellow perilist scapegoating of immigrants in the US arose, a Chinese view of the Statue of Liberty, and the legacies of "yellow peril" in immigration law that are with us today. To read an interview with the authors of Yellow Peril!, check out "From Coolie to Googlebot" on CultureStrike.
The Enemy Within

Throughout U.S. history, politicians and pundits have reshaped the meaning of "America" amid moral panics and national dilemmas. Depicting Chinese immigrants as potential threats to national security in the 1880s secured Congress's exclusive Constitutional right to regulate immigration as a function of its war powers, internal and external. This became the policy precedent for subsequent immigration exclusion laws and culture wars. Rooting the institutional origins and political logic of the idea of "unassimilable" foreigners (be they racially and/or ideologically unfit for participation in American democracy) in this earlier history helps us carry analysis of the role of yellow perilism forward through the subsequent mid-century variations of the "Red Scare" and more recent calls for excluding "undesirable" and "un-American" groups. Maintaining a narrow notion of proper Americanism, in the face of these supposed threats, has profoundly shaped U.S. political culture.

Over the nineteenth century, the extension of popular democracy and the development of industries provoked a fear of "the mob." Elite Americans looked on anxiously at what they considered to be the excesses of the French Revolution and its disregard for life and property. At home, the boisterous parades that typified the Revolutionary period morphed into more formalized political parties holding orderly conventions. Immigration complicated this already fraught situation. Samuel Morse saw unregulated immigration as a "conspiracy," for Catholic emigrants were "but obedient instruments in the hands of their more knowing leaders, to accomplish the Indispensable Enemies designs of their foreign masters." Critics also regularly compared Mormons to Oriental fanatics, or a "tribe of locusts" whose "swarm of emigrants from their pestilent hive" threatened the free American experiment. Carroll Wright considered French Canadian millworkers in New England "the Chinese of the Eastern States ... a horde of industrial invaders, not a stream of stable settlers."

This racial civilizational logic led to Chinese Exclusion in 1882 and set the stage for a broader culture of political scapegoating. Eugenicists, for example, claimed inferior races infused with "primitive" African and "semi-civilized" Mongol blood degraded workplaces and neighborhoods, and threatened the stability of the entire social system. Reformers sought to assimilate new European immigrants into "American" standards of living, blaming poor living conditions and crime on Old World cultures, not the poverty of the industrializing machine. Japanese, Korean, Indian, Italian, Russian, and Jewish hordes joined the Chinese as the targets of exclusion in the early twentieth century. When Attorney General Michael Palmer described the "lopsided faces, sloping brows, and misshapen features" of supposedly dangerous radicals in 1919, he linked the American eugenics movement, which dismissed social problems and political opposition as rooted in cultural and biological depravity, to American anti-Communism.

This institutional exclusion of dangerous and intermingling Oriental peoples and ideas provided a framework for understanding the challenges ahead. Under the banner of anti-Communism, the federal government waged war against homosexuality, labor-organizing, civil rights, and antiwar activists. Today, U.S. political parties compete over who is tougher on terrorism and China. A tight-knit network of think tanks mobilize disaffected Americans around the newly fabricated "heathen" threat of Sharia Law and Muslim American "radicalization." FBI informants pressure angry youth on the margins of society to plot "terrorist" acts so they can arrest them. Government operatives infiltrate mosques and antiwar groups to observe and disrupt lawful assemblies. Though ultimately fanciful, these fearmongering techniques have real effects. They silence opposition from the most vulnerable communities, and they focus the anxieties of millions of Americans away from the problems haunting liberalism and onto easy-tohate scapegoats.

Arab "control" of oil prices, Japanese "unfair" competition, and the Chinese "manipulation" of currency help politicians and pundits protect Americans from understanding the glaring domestic policy failures underpinning their economic woes. This civilizational-clash framework, built over generations of misinformation, justifies the request for Americans to give up the promise once again. It is no longer the "Asiatic mode of production" or Asian Communism but Asian Capitalism that threatens "the American way of life." U.S. deficit spending, once necessary to fight Communism, now imperils the nation. The only constant amid these shifting and contradictory threats to the American Dream, is that Oriental enemies, not U.S. government actions nor corporate practices, are always to blame.

Yellow perilist scapegoating obscures the effective analysis of U.S. political debates, but also ostracizes, silences, and sometimes sacrifices individuals and communities on the altar of American fantasy. State repression and vigilante violence has suppressed myriad efforts by communities of color to organize for their survival and success. At the same time, the politics of resentment and suspicion provoke some, desperate to hold on to what they imagine to be theirs, to harass, discriminate, and attack their "un-American" neighbors.

*

Saum Song Bo, "A Chinese View of the Statue of Liberty" (1885)
This letter, written by a Chinese American shortly after the passage of the 1882 Chinese Exclusion Act, condemns the hypocrisy of an exclusionary theory of liberty. Ironically, Emma Lazarus had famously celebrated the promise of the "huddled masses yearning to breathe free" in America in Joseph Pulitzer's (also an immigrant) New York World that same year as part of the campaign to finance the construction of the Statue of Liberty pedestal. Saum Song Bo (n.d.) connects his own exclusion from American citizenship with French imperialism in Southeast Asia.
Sir:

A paper was presented to me yesterday for inspection, and I found it to be specially drawn up for subscription among my countrymen toward the Pedestal Fund of the Bartholdi Statue of Liberty. Seeing that the heading is an appeal to American citizens, to their love of country and liberty, I feel that my countrymen and myself are honored in being thus appealed to as citizens in the cause of liberty. But the word liberty makes me think of the fact that this country is the land of liberty for men of all nations except the Chinese. I consider it an insult to us Chinese to call on us to contribute toward building in this land a pedestal for a statue of Liberty. That statue represents Liberty holding a torch which lights the passage of those of all nations who come into this country. But are the Chinese allowed to come? As for the Chinese who are here, are they allowed to enjoy liberty as men of all other nationalities enjoy it? Are they allowed to go about everywhere free from the insults, abuse, assaults, wrongs, and injuries from which men of other nationalities are free?

If there be a Chinaman who came to this country when a lad, who has passed through an American institution of learning of the highest grade, who has so fallen in love with American manners and ideas that he desires to make his home in this land, and who, seeing that his countrymen demand one of their own number to be their legal adviser, representative, advocate, and protector, desires to study law, can he be a lawyer? By the law of this nation, he, being a Chinaman, cannot become a citizen, and consequently cannot be a lawyer.

And this statue of Liberty is a gift to a people from another people who do not love or value liberty for the Chinese. Are not the Annamese and Tonquinese Chinese, to whom liberty is as dear as to the French? What right have the French to deprive them of their liberty?

Whether this statute against the Chinese or the statue to Liberty will be the more lasting monument to tell future ages of the liberty and greatness of this country, will be known only to future generations.

Liberty, we Chinese do love and adore thee; but let not those who deny thee to us, make of thee a graven image and invite us to bow down to it.

"The Chinese Exclusion Case" (1889)
Americans have always defended themselves against discriminatory legislation and fought for equal protection under the Constitution. The Chinese Exclusion Act never really worked, for immigrant laborers found ways to circumvent the law that rendered them illegal. As a result, Congress sought to tighten the law such that no Chinese could reenter the U.S. even if they had entered prior to the enactment of Exclusion. Chae Chan Ping (n.d.) traveled to China to attend to his father's death before the Exclusion Act was tightened and left his family in California. Immigration authorities would not let him return under the newly expanded act. Ping challenged that Congress could not deport a Chinese citizen entitled to reside in the U.S. under the Burlingame Treaty of 1868. The resulting decision, excerpted below, justified legislative oversight over immigration irrespective of treaty obligations as an extension of Congressional war powers. This decision serves as the basis of all immigration law in the U.S. to this day.
That the government of the United States, through the action of the legislative department, can exclude aliens from its territory is a proposition which we do not think open to controversy. Jurisdiction over its own territory to that extent is an incident of every independent nation. It is a part of its independence ...

To preserve its independence, and give security against foreign aggression and encroachment, is the highest duty of every nation, and to attain these ends nearly all other considerations are to be subordinated. It matters not in what form such aggression and encroachment come, whether from the foreign nation acting in its national character, or from vast hordes of its people crowding in upon us. The government, possessing the powers which are to be exercised for protection and security, is clothed with authority to determine the occasion on which the powers shall be called forth, and its determinations, so far as the subjects affected are concerned, are necessarily conclusive upon all its departments and officers. If, therefore, the government of the United States, through its legislative department, considers the presence of foreigners of a different race in this country, who will not assimilate with us, to be dangerous to its peace and security, their exclusion is not to be stayed because at the time there are no actual hostilities with the nation of which the foreigners are subjects. The existence of war would render the necessity of the proceeding only more obvious and pressing. The same necessity, in a less pressing degree, may arise when war does not exist, and the same authority which adjudges the necessity in one case must also determine it in the other ...

The exclusion of paupers, criminals, and persons afflicted with incurable diseases, for which statutes have been passed, is only an application of the same power to particular classes of persons, whose presence is deemed injurious or a source of danger to the country. As applied to them, there has never been any question as to the power to exclude them. The power is constantly exercised; its existence is involved in the right of selfpreservation ...

Excerpted from YELLOW PERIL! by John Kuo Wei Tchen and Dylan Yeats by arrangement with Verso Books, Copyright © 2014

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Join the authors along with guest performers and speakers this Friday, March 7, at NYU's A/P/A Institute to celebrate the publication of Yellow Peril!

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The concept of the "yellow peril" is centuries old, and although today it brings to mind racist fears of East Asia, some of its first uses refer to West and South Asia.

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American slavery began 400 years ago this month. This is referred to as the country's original sin, but it is more than that: It is the country's true origin.

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We're trying to have more meaningful conversations about racism as a country. Part of that means talking about implicit bias - assumptions and stereotypes that may influence our decisions and actions without us even realizing it. Implicit bias can have many harmful consequences: The customer who's accused of stealing; the grad student being told they're in the wrong room; the driver being pulled over for no reason. And in some cases, these biases can lead to violence.

On this episode, we explore what implicit bias means - what it is, how we can test for it, and what we can do about it. We hear stories about whether or not anti-bias training actually works, the origins - and criticisms - of Harvard's Implicit Association Test, and where our biases actually come from.
Also heard on this week's episode:

Stanford University social psychologist Jennifer Eberhardt talks about the ways implicit biases have affected her own life, and how she tries to educate people about them in her work. Her book is "Biased: Uncovering the Hidden Prejudice That Shapes What We See, Think, and Do."

Evolutionary psychologist Corey Cook from Pacific Lutheran University discusses the evolutionary origins of biases. He argues that they likely developed as a way to assess threats.

We hear from Harvard psychologist Mahzarin Banaji, one of the researchers who helped develop the Implicit Association Test, about the humbling experience of confronting her own biases. Her book is "Blind Spot - Hidden Biases of Good People."

White people aren't the only ones with implicit biases - that's what Brennan Center for Justice fellow Ted Johnson discovered when he took Harvard's Implicit Association Test a few years ago. In this story, we hear what the test taught Johnson about himself, and about the nature of racism. Johnson's Atlantic essay is called "Black-on-Black Racism: The Hazards of Implicit Bias."

Despite its popularity, the Implicit Association Test has drawn criticism over the years. Is it really an accurate way of measuring biases? Olivia Goldhill, a science reporter for Quartz, helps us dive into the history of the IAT, and its critiques.

Neurologists Anjan Chatterjee and Roy Hamilton of the University of Pennsylvania discuss an app they've used to try and change people's biases.

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We're trying to have more meaningful conversations about racism as a country. Part of that means talking about implicit bias - assumptions and stereotypes that may influence our decisions and actions without us even realizing it.

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follow this link to find all code switch podcasts

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the history of attacks against asian americans is complicated. addressing it will be

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The history of attacks against Asian Americans is complicated. Addressing it will be, too

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Wider recognition of the racism Asian Americans have been facing since the start of the pandemic is a critical step, advocates and experts say. But this moment has also prompted some to consider another question: What is the best path forward?

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Footnotes

[1] Rothstein, R. (2017) The color of law: A forgotten history of how our government segregated America. Liveright Publishing.

[3] Alexander, M. (2010). The new Jim Crow: Mass incarceration in the age of colorblindness. The New Press.

[4] Drake, S. C. & Cayton, H. R. (1945). Black metropolis: A study of negro life in a northern city. University of Chicago Press.

[5] Franklin, D. L. & James, A. D. (1997). Ensuring inequality: The structural transformation of the African-American family. Oxford University Press.

[6] Tucker, M. B. & Mitchell-Kernan, C. (Eds.). (1995). The decline in marriage among African Americans: Causes, consequences, and policy implications. Russell Sage Foundation.

[7] Edin, K. & Kefalas, M. (2011). Promises I can keep: Why poor women put motherhood before marriage. University of California Press.

[8] Wilson, W. J. (1987). The truly disadvantaged: The inner city, the underclass, and public policy. The University of Chicago Press.

[9] Darity, W. A. & Myers, S. L. (1995). Family structure and the marginalization of Black men: Policy implications. In Tucker, B. M. & Mitchell-Kernan, C. (Eds.), The decline of marriage among African Americans: Causes, consequences, and policy implications (pp. 263-308). Russell Sage Foundation.

[10] Coles, R., & Green, C. (Eds.). (2010). The myth of the missing Black father. New York: Columbia University Press. doi:10.7312/cole14370

[11] Boyd-Franklin, N. (2006). Black families in therapy: Understanding the African American experience. Guilford Press.

[12] Pinderhughes, E. B. (2002). African American marriage in the 20 th century. Family Process, 41(2), 269-282.

[13] Jones, J. & Mosher, W. D. (2013). Fathers' involvement with their children: United States, 2006-2010. National Center for Health Statistics. https://www.cdc.gov
/nchs/data/
nhsr/nhsr071.pdf

[14] Taylor, R.J., Hernandez E., Nicklett, E.J., Taylor, H.O., & Chatters, L.M. (2014). Informal social support networks of African American, Latino, Asian American, and Native American older adults. In Whitfield, K.E., Baker, T.A. (Eds). Handbook of minority aging (pp.417-434). Springer.

[16] Shonkoff, J. P. & Phillips, D. A. (Eds.). (2000). From neurons to neighborhoods: The science of early childhood development. National Academies Press.

[17] Hart, B., & T.R. Risley (1995). Meaningful differences in the everyday experience of young American children. Paul H Brookes Publishing.

[18] Kaushal, N., Magnuson, K., Waldfogel, J. (2011). How is family income related to investments in children's learning? In Duncan, M.R., & Duncan G. (Eds.) Whither opportunity: Rising inequality, schools, and children's life chances (pp. 187-206). Russell Sage Foundation.

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Family, Economic, and Geographic Characteristics of Black Families with Children - Child Trends

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1] Rothstein, R. (2017) The color of law: A forgotten history of how our government segregated America. Liveright Publishing. [3] Alexander, M. (2010). The new Jim Crow: Mass incarceration in the age of colorblindness. The New Press. [4] Drake, S. C. & Cayton, H. R. (1945).

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It would be more than just a symbolic gesture.

Mr. Shihipar is a public health researcher who leads Narrative Projects and Policy Impact Initiatives at the People, Place and Health Collective - a research laboratory in the Department of Epidemiology at the Brown University School of Public Health.

Romelia Navarro is comforted by a nurse as she wept at the bedside of her dying husband, Antonio Navarro, in St. Jude Medical Center's Covid-19 unit in Fullerton, Calif. Credit... Jae C. Hong/Associated Press

While Black and Latinx people make up only 13 and 18 percent of the U.S. population respectively, as of November they represent more than 50 percent of the country's Covid-19 hospitalizations. In Los Angeles County, deaths among Latinx people have increased more than 1,000 percent since November, nearly triple the rate for white residents. Native Americans have been nearly twice as likely as white people to die from Covid-19.The virus has killed a disproportionate number of Filipino nurses. To bring desperately needed relief to the communities of color that have been ravaged by the pandemic because of the effects of structural racism, the Department of Health and Human Services should declare racism a public health emergency.

There is momentum behind this idea. Across the country, cities and states have declared racism a public health crisis. The American Academy of Family Physicians has also called for the declaration of a public health emergency. Last year, Senator Elizabeth Warren and Representatives Ayanna Pressley and Barbara Lee proposed a bill that would instruct the Centers for Disease Control and Prevention (C.D.C.) to create a center addressing the impact of racism on public health. The White House has created a Covid-19 health equity task force that will make recommendations to improve the federal government's data on racial disparities and its response to them.

Studies and recommendations are good, but communities of color need action now, and a declaration by H.H.S. that racism is a public health emergency would have immediate impact. Under the Public Health Service Act, the declaration would allow HHS to allocate resources and personnel to tackle the issue, much like it has for the pandemic as a whole and for the opioid crisis. For instance, the it could allow workers from hard hit communities of color who lost their jobs because they had to take time off after becoming illto use National Health Emergency Demonstration Grants to find employment.

It's true that and policies designed for individuals of particular races may face legal challenges. But the programs that flow from a declaration that racism is a public health crisis could avoid this by targeting communities rather than individuals. A study published in August by amfAR, the Foundation for AIDS Research, found that predominately white counties had the lowest levels of coronavirus infection. This is no surprise, given that high rates of illnesses among Black and Latinx people can be attributed in part to racist housing policies.

Central Falls, R.I., whose population is 66 percent Latinx and 13 percent Black, provides an example of how this could work. The tiny town of only 1.2 square miles had the highest positivity rate in the state - around 20 percent. In December, the state offered vaccinations to all adults who lived there. They were offered in December in two public housing buildings, and since then the state has held vaccination clinics at the local high school and elsewhere. As of late February, weekly number of new Covid cases has dropped 80 percent compared to 65 percent state wide. About 33 percent of residents have received one dose, and 21 percent have been fully vaccinated.

"While there is a higher concentration of people of color in the city, the community-based nature of the effort has also helped to address issues around accessibility and vaccine hesitancy," said Dr. Philip Chan, the consultant medical director for the Rhode Island Department of Health.

Still, Rhode Island, like every other state, lags in its effort to vaccinate nonwhite people, emphasizing the need to expand such programs. A declaration of a public health emergency would allow the federal government to deploy members of volunteer medical corps and the public health commissioned corps to other communities similar to Central Falls to establish vaccination clinics, engage in door-to-door outreach, and offer free testing. It would also allow governors to request the reassignment of health department staff funded by the federal government to assist with these local operations. Through the Public Health Emergency Fund, funding could be used to procure hotel rooms to serve as quarantine housing for people who test positive.

In recent months, one criticized study published in the journal JAMA speculated that Black people have higher rates of Covid-19 because they have a higher expression of enzymes in the nose that allow viruses to enter the body to cause disease. Other scientists suggested that physical separations be stratified by, among other factors, "ethnicity'"- erroneously treating Covid-19 risk as innate rather than structurally constructed. The declaration would provide an important balance to such messages by formalizing for the public that it's racism, not race, that causes Covid disparities.

The emergency powers provided by a public health emergency declaration are limited, but they are meant to lead to further action. In 2017, the Commission on Combating Drug Addiction and the Opioid Crisis advised Donald Trump to declare the opioid crisis a national emergency, in part to raise awareness about the issue among Americans and " force Congress to focus on funding." A declaration here would provide a similar impetus for legislative action. Since the declaration would need to renewed every 90 days, it would serve to draw regular attention to the government's progress.

It's well known that structural racism is behind the massive disparities in Covid-19 infection, death and vaccination. A declaration on this issue would be the first step toward fixing the problem.

Abdullah Shihipar (@ashihipar) is a public health researcher who leads Narrative Projects and Policy Impact Initiatives at the People, Place and Health Collective - a research laboratory in the Department of Epidemiology at the Brown University School of Public Health.
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Opinion | Declare Racism a Public Health Emergency

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It would be more than just a symbolic gesture. Mr. Shihipar is a public health researcher who leads Narrative Projects and Policy Impact Initiatives at the People, Place and Health Collective - a research laboratory in the Department of Epidemiology at the Brown University School of Public Health.

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When I was growing up in the 1980s, we were taught that the way to be a good person was to swear that race didn't matter, at least not anymore.
We had all learned the lessons of the civil rights movement - that everybody is equal, and according to the morals of the sitcoms we watched after school ( Diff'rent Strokes, Webster, Saved by the Bell), what was racist was pretending that people were any different from one another. Furthermore, the most un-racist people didn't even see race at all; they were color blind.

We now know that color blindness is a form of racial denial that took one of the aspirations of the civil rights movement - that individuals would one day "not be judged by the color of their skin but by the content of their character" - and stripped it from any consideration of power, hierarchy or structure. The moral logic and social appeal of color blindness is clear, and many well-meaning people have embraced it. But when it's put into practice in a still-racist world, the result is more racism.

The sociologist Eduardo Bonilla-Silva, author of the groundbreaking book Racism Without Racists: Color-Blind Racism and the Persistence of Racial Inequality in America, describes how once we stop seeing racism as a factor and treat equality as a reality rather than an aspiration, our minds naturally seek other explanations for the disparities all around us.

In a way, color blindness makes the civil rights movement a victim of its own success: Legal segregation is over, so now it must be up to people of color to finish the work themselves. As Bonilla-Silva puts it, if racism is no longer actively limiting the lives of people of color, then their failure to achieve parity with whites in wealth, education, employment, and other areas must mean there is something wrong with them, not with the social systems that somehow always benefit white people the most.

Social scientists look to this question - whether you believe that racism is to blame for disparities or that Black people just need to work harder - to help them determine what they call racial resentment. And racial resentment, in turn, is a predictor of opposition to policies that would improve the economic security of millions.

Instead of being blind to race, color blindness makes people blind to racism, unwilling to acknowledge where its effects have shaped opportunity or to use race-conscious solutions to address it. Denial that racism still exists; denial that, even if it does exist, it's to blame for the situation at hand; denial that the problem is as bad as people of color say it is - these denials are the easy outs that the dominant white narrative offers to people. Wellesley College professor Jennifer Chudy's research finds that only one in five white Americans consistently expresses high levels of sympathy about anti-Black discrimination.

Color blindness has become a powerful weapon against progress for people of color, but as a denial mindset, it doesn't do white people any favors, either. A person who avoids the realities of racism doesn't build the crucial muscles for navigating cross-cultural tensions or recovering with grace from missteps. That person is less likely to listen deeply to unexpected ideas expressed by people from other cultures or to do the research on her own to learn about her blind spots.

When that person then faces the inevitable uncomfortable racial reality - an offended coworker, a presentation about racial disparity at a PTA meeting, her inadvertent use of a stereotype - she's caught flatfooted. Denial leaves people ill-prepared to function or thrive in a diverse society. It makes people less effective at collaborating with colleagues, coaching kids' sports teams, advocating for their neighborhoods, even chatting with acquaintances at social events. Nor is denial easy to sustain.

To uphold the illusion of effortless white advantage actually requires unrelenting psychological exertion. Sociologist Dr. Jennifer Mueller explains that color blindness is a key step in "a process of knowing designed to produce not knowing surrounding white privilege, culpability and structural white supremacy."

But it was a white poet, novelist and farmer named Wendell Berry whose words brought home to me most poignantly the moral consequences of denial. In August 2017, I traveled to Northern Kentucky to meet with a multiracial grassroots organization called Kentuckians for the Commonwealth.

After a day of workshops, one of the members gave me a dog-eared copy of a book by Berry, a local hero who had grown up in rural Kentucky during the Jim Crow era. The book was called The Hidden Wound - Berry wrote it in 1968, in the midst of widespread protest and unrest - and that night in my hotel room, I read it from cover to cover.

By denying the reality of racism and their own role in it, Berry explained, white Americans have denied themselves critical self-knowledge and created a prettified and falsified version of American history for themselves to believe in, one built on the "wishful insinuation that we have done no harm." Of course, he understood the impulse of white people - himself included - to protect themselves from "the anguish implicit in their racism."

A few years before Berry published The Hidden Wound, James Baldwin, as keen an observer of human behavior as there's ever been, wrote his own account of what happens when white people open their eyes to racism.

"What they see is a disastrous, continuing, present condition which menaces them, and for which they bear an inescapable responsibility. But since, in the main, they seem to lack the energy to change this condition, they would rather not be reminded of it." Baldwin went on to observe that white Americans "are dimly, or vividly, aware that the history they have fed themselves is mainly a lie, but they do not know how to release themselves from it, and they suffer enormously from the resulting personal incoherence."

Wendell Berry calls this suffering "the hidden wound." He counsels that when "you begin to awaken to the realities of what you know, you are subject to staggering recognitions of your complicity in history and in the events of your own life." Of this wound - this psychic and emotional damage that racism does to white people - he writes, "I have borne it all my life . . . always with the most delicate consideration for the pain I would feel if I were somehow forced to
acknowledge it."

As I closed Berry's book in that Kentucky hotel room, I thought about what it must it be like to be part of the dominant group in an unfair "meritocracy" that denies its oppressions and pathologizes the oppressed.

"I think white folks are terribly invested in our own innocence," says the scholar Catherine Orr. The belief that the United States is a meritocracy, in which anyone can succeed if only they try hard enough, also supports the notion that anyone who is financially successful is so because they've worked harder or are somehow more innately gifted than others.

Both ideas operate as a justification for maintaining our profoundly unjust economic system. Recent research from social psychologists at Yale and Northwestern finds that "Americans, on average, systematically overestimate the extent to which society has progressed toward racial economic equality, driven largely by overestimates of current racial equality."

Wealthy white Americans, they find, have the most unrealistic assessment of how much progress the United States has made in terms of economic equality (and thus how fair the competition has been that they seem to have won). In a 2019 public opinion survey, majorities of both Black and white people said that being Black makes it more difficult to get ahead in America. Yet only 56 percent of white respondents believed the corollary - that being white helps you get ahead.

And of those who recognized the obstacles Black people face in terms of economic mobility, Black respondents attributed this to systemic discrimination, such as having less access to good schools and high-paying jobs. White people, on the other hand, were more likely to blame problems such as the lack of good role models and family instability - pathologies, in other words, that ultimately lay blame at the feet of Black people themselves.

Morally defending your position in a racially unequal society requires the fierce protection of your self-image as a person who earns everything you receive. From the tradition that trade unions make a place for members' sons and legacy admissions at colleges to college students who can choose career-building but unpaid or low-paying internships because families can support them and employers who seek "a good fit" by hiring younger versions of themselves, the deck is stacked on behalf of white people in ways that are so pervasive we rarely notice them.

Within this context, many white people both resent affirmative action and imagine that it is vastly more widespread than it really is. The share of Black and brown students at selective colleges has actually declined over 35 years despite stated affirmative action policies, and the overwhelmingly white categories of children of alumni, faculty, donors or athletes made up 43 percent, for example, of students admitted to Harvard from 2010 to 2015.

Meanwhile, according to a 2016 study by Harvard Business School professor Katherine DeCelles, Black job applicants who removed any indications of their race from their résumés were significantly more likely to advance to an interview. Many other studies bear out similar findings, including an economic research paper that traced improved job prospects to whether applicants had names like "Greg" or "Emily" as opposed to "Lakisha" or "Jamal," and a sociological study in New York City that found that "Black applicants were half as likely as equally qualified whites to receive a callback or job offer."

Still, the idea that people of color are taking jobs from white people is another zero-sum belief that lumbers on from era to era. As Ronald, a middle-aged white man from Buffalo, New York, told the Whiteness Project, "I think affirmative action was nice. It had its time, but I think that time is over with. Are we going to keep this up another one hundred fifty years? 'Oh, we gotta have so many Asians in the fire department, we gotta have so many Blacks in the fire department.' . . . The white guys will never have a chance to be a fireman or a cop anymore." Although using such numerical quotas to achieve affirmative action in employment was outlawed in 1978 by the Supreme Court, Ronald's grievance is evergreen, as is his certainty that white guys getting all the public service jobs was the natural order of things, not its own form of white affirmative action.
Excerpted from the new book Watch her TEDWomen Talk now: The Sum of Us: What Racism Costs Everyone and How We Can Prosper Together by Heather McGhee. Copyright © 2021 by Heather McGhee. Reprinted by arrangement with One World, an imprint of Random House, a division of Penguin Random House LLC. All rights reserved.

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Why saying "I don't see race at all" just makes racism worse

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When writer Heather McGhee was growing up in the 1980s, she and other Americans were taught the way to be a good person was to swear that race no longer mattered. Today we're paying a price for that mindset: blame, racial resentment and the denial by many that racism still exists.

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Contributing Voices: Examining Essays from "The 1619 Project" with Nikole Hannah-Jones

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The National Institute of Health (NIH) has announced a new initiative to address structural racism - the UNITE Initiative.

"With representation from across the NIH Institutes and Centers, UNITE aims to establish an equitable and civil culture within the biomedical research enterprise and reduce barriers to racial equity in the biomedical research workforce," according to the NIH website.

NIH hopes that this initiative will help address racism and discrimination that has impacted healthcare throughout history.

"Historical racism has led to the marginalization and oppression of Indigenous peoples, African Americans, Latinos, and other communities of color. ... Structural racism has resulted in persistent health disparities, poor health status, and premature mortality as demonstrated by the current disproportionate burden of morbidity and mortality from COVID-19. Within the biomedical research enterprise, structural and institutional racism has resulted in inequitable access to funding, training, and workforce opportunities," according to the NIH website.

The UNITE initiative will help Latinos and other people of color in multiple ways, such as providing more research on minority health and health disparities and improving workforce diversity so that Latino healthcare workers can thrive at NIH.

What is the UNITE Initiative?

The UNITE initiative comprises five committees focused on addressing structural racism and promoting racial equity.

The five committees are the following:

U - Understanding stakeholder experiences through listening and learning

N - New research on health disparities, minority health, and health equity

I - Improving the NIH culture and structure for equity, inclusion, and excellence

T - Transparency, communication, and accountability with our internal and external stakeholders

E - Extramural research ecosystem: changing policy, culture, and structure to promote workforce diversity

Each committee has about 15 members, all of which are experts who work across the 27 different institutes and centers at NIH.

These committees will work individually and together to advise NIH leadership on how to create an equitable culture.

"To reach this goal, UNITE is facilitating research to identify opportunities, make recommendations, and develop and implement strategies to increase inclusivity and diversity in science. These efforts will bolster the NIH's effort to continue to strive for diversity within the scientific workforce and racial equity on the NIH campus and within the extramural community," according to the NIH website.

As NIH is a federal institution, the UNITE initiative is in line with the Biden administration's commitment to addressing racial equity.

"NIH's efforts are consistent with President Joe Biden's Executive Order on Advancing Racial Equity and Support for Underserved Communities and is part of an overall effort by the Department of Health and Human Services to respond to the EO to improve equity, diversity, and inclusion in the federal workplace," according to the NIH website.

How Systemic Racism in Healthcare Impacts Latinos

Because NIH is one of the largest biomedical research centers in the world, the UNITE Initiative will have a large impact on Latinos and other people of color living in the U.S., including the thousands of doctors and patients at the institute.

The initiative is working to address systemic racism in healthcare, which unfortunately affects many Latinos.

For example, racism and bias in the doctor's office can affect Latinos.

Many studies have shown that physicians have implicit, subconscious preferences for white patients over patients of color.

Some ways that Latinos experience implicit bias are:

Not only do Latino patients experience racism and bias, but so do Latino doctors.

More than 40% of Latino and Black resident physicians experience racial discrimination and bias from the patients they serve, according to a study published in JAMA Network Open.

The study also found that 84% of resident physicians do not report these biased and discriminatory instances, indicating a lack of resources or trust from doctors of color in their institutional leadership.

Another instance of systemic racism in healthcare is the lack of diversity and representation of Latinos and other people of color in clinical trials and research.

Although Latinos represent 18.5% of the U.S. population, they make up less than 10% of participants in federal cancer clinical trials and fewer than 4% of FDA drug trials. This is one of the aspects of the UNITE initiative - to increase research on health equity and minority health.

Thankfully, with the help of Genentech, Salud America! is working on bringing more Latinos into cancer and Alzheimer's research.

How Else Can We Help Latinos?

Systemic racism and bias continue to hurt Latinos in healthcare. But we can help make a difference.

One way is through examining our own biases.

Download the free Salud America! " Find Out If You Have Implicit Bias and What to Do Next " Action Pack. This will guide you to see if you have implicit bias, reflect and learn from others who have overcome their own implicit bias, and encourage others to learn about implicit bias, too.

Another way we can address system racism is by asking our city to declare racism a public health crisis.

Download the free Salud America! "Get Your City to Declare Racism a Public Health Crisis Action Pack"!

The Action Pack will help you gain feedback from local social justice groups and advocates of color. It will also help you start a conversation with city leaders for a resolution to declare racism a public health issue along with a commitment to take action to change policies and practices. It will also help build local support.
GET THE ACTION PACK!

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National Institute of Health Establishes UNITE Initiative to Combat Structural Racism | Salud America

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The National Institute of Health (NIH) has announced a new initiative to address structural racism - the UNITE Initiative. "With representation from across the NIH Institutes and Centers, UNITE aims to establish an equitable and civil culture within the biomedical research enterprise and reduce barriers to racial equity in the biomedical research workforce," according to ...

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She+ Geeks Out's Felicia Jadczak, Co-CEO and Head of Training and Fatima Dainkeh, Learning and Development Manager, discuss the recent increase in anti-Asian hate crimes happening in the US. They also discuss what it means to support BIPOC people overall, Asian Americans and Asians as a specific group, and how that all connects when we're talking about the complexity of allyship among BIPOC. View the full video transcript below.
Felicia: I just wanted to take a couple minutes to chat about something that's been really prevalent, especially in the last few weeks and couple months, where we've been seeing a dramatic- I don't know if it's dramatic necessarily, but definitely a marked increase, in how many incidents of violence and anti-asian hate are happening here in the US.

A lot of the time that we at SGO, and myself personally, spent over the course of 2020 and into 2021 around thinking on topics like anti-racism, hate, and how do we support marginalized groups, was quite frankly and and meaningfully, focused on the Black population and African American population. And so as we're sitting here, it's February. It's Black History Month. I also wanted to just talk a little bit about, what does it mean to support BIPOC people overall, Asian Americans and Asians as a specific group, and how does that all connect when we're talking about relations between different marginalized groups?

When we're talking about the fact that in the Asian community, there can still be quite a lot of anti-Blackness and we're layering all this with the idea of Asians as the model minority, and I think you can tell that even from those couple points alone, it's really complicated. I've been wrestling with this myself personally because, of course, I absolutely denounce any kind of violence against any group. I am half-Asian myself and so I have a personal connection from that standpoint, but I also struggle in the sense of how does this fit into the work that I'm doing, in the anti-racist work? I want to make sure that I'm not focusing efforts on just one group, but on the flip side, I think this is a common problem that not just facilitators or activists encounter, but everyday people encounter, is how do we support the entire world when everything is burning around us? So these are just a few thoughts that I've been wrestling with, and Fatima. I'd love you to maybe jump in and share anything that you'd like to add into that, because I know this is a topic we ourselves have been discussing quite a bit over the last couple months, if not few years, around how do we support each other in terms of marginalized groups? How do we act as allies? How do we practice what we preach? And how do we be anti-racist when it's not just one person or one group?

Fatima: Thanks so much for sharing that. There's so much that you said that we can unpack, and as you were talking I was just thinking about the idea of race in how racism has been created. And when we think about the work of being anti-racist, we have to really be intentional about what that means, to your point, but also recognizing the hierarchy that was created to think about who's part of dominant groups and who is part of subordinate groups. And yes, people of Asian backgrounds are not considered white. I think there's that there's a tension around that because there are conversations within communities of color where we might feel like, okay, this person has more privilege than me and so therefore they have it better. And so therefore I need to focus on the issues that are happening to me because if I don't do it then who else will?

And a lot of times when we're thinking about racial allyship, to your point, we are focusing on Black and sometimes Indigenous folks in these conversations, but a lot of it is based off of the history of this country in the US. I think if we are talking about race and racism, or even tribalism and different communities and cultures, that conversation will look different.

But what I've been thinking about is how do we talk about allyship without centering pain or centering horror that's happening in the black community. To say, "hey, Black people- you all know how it feels so like why aren't we doing X, Y, and Z?" And instead saying well regardless, or in honor, of whatever we're going through, how do we just show support and solidarity without doing this oppression Olympics? But I also think what helps us have these conversations is to be honest about the nuances and I think you mentioned it earlier when we were talking about anti-Blackness within other communities of color and what that messaging is.

And then like what's the history around Asian people? Specifically Asian Americans and Black Americans or Black people in the diaspora. What's that relationship? And oftentimes we talk about how we're butting heads or the tension that exists, but we don't always always talk about how we've come together many times and done a lot of social activism together and created a lot of language and work to think about. Honestly a lot of our communities, even if it might not be the same exact experiences, are going through similar things because the very foundation of racism is based on making you and I feel like we're not important or we're not centered. Sometimes there's not enough conversations to be had. Or when the hurt is there, it's harder to hear someone else's story, because emotionally we're sort of tied up with whatever is happening within our communities and a lot of us are segregated.

When we think about, even me growing up thinking about Asian Americans who were in my Black- mostly Black community, the only time I was interacting with Asian Americans was through shops and stores and even though it was the community that I lived in, no one who looked like me owned any of the shops in the community. And so I didn't know what that history was about because my parents are recent immigrants from West Africa. When I started learning about that tension that existed in some communities, not all, a lot of it had to do with historical aspects around Black people's businesses no longer being there and how a lot of white people who were in power were sort of strategizing, "well who? Which immigrant gets the best opportunity?" Which then makes us feel like, "oh, well, there's something going on here."

I do think there's opportunity for more conversations to see more similarities than differences and to also name those differences and be okay with saying, okay, how do we help each other out? What do you need from me? What do I need from you? And recognizing that there is some privilege that's still happening within some of these communities. I know, Felicia, you and I at some point talked about even the gender pay gap. As we talked about women of color who aren't paid as much, and when you look at that break down, a lot of times people argue and they say "hey, well, actually Asian women are making more money, so they're more privileged, and so we shouldn't care." But a lot of the research shows that that doesn't mean that people of Asian descent are absolved from discrimination or prejudices or stereotypes. So it's almost like a game where if you don't really take your time to get into the work or understand even the Asian American experience within this country, if you just look at it from a surface level, it might be very individualistic. We just say okay, that's just one case. That's just two cases. Those are just two cases, but what we know through history and even in the research is that people of Asian American descent are being discriminated against and these ideologies are coming out through hate crimes, are coming out through, unfortunately, some of the events that recently happened.

So yeah, I've been trying to think about what it is that we can do within the black community while also hearing some of those narratives of hurt. And saying, okay, how do we hold both of these truths to say, "Yes, I hear you and that doesn't make it okay with what's happening to our Asian family." Right, we say family, cousins, whatever you might say. To really think about what's our role in this. And part of activism, or part of anti-racist work, is being able to look at someone else and hear them out and say, "Okay. Here's what I can do. Here is my role and in dismantling racism."

Felicia: Yeah, I think as you were talking, I was just thinking how deep the roots of white supremacy go because this is what we see. Like the fact that we're even talking like this right now is because we had been taught and conditioned and have fit ourselves into trying to like, please this this wider thing, right? And that has been what pitted these groups against each other. And then, of course, you know, we're not even talking about other groups that are also experiencing hate crimes, and violence, and oppression. I think it's just so telling how difficult it still is to be able to say no one should be killed because of who they are. I'm not excusing anything or not saying that one group is better, or one group is worse, or that even one group is more deserving of our attention. But like you said, it's really about saying, "yes, and-" which I know is that it is a phrase you love to go back to. I agree with that, but it's saying yes, we can acknowledge painful histories and centuries of oppression and horrible things that have happened and we can still be there to support our family in this fight.

In terms of what's happening right now, one thing that really was just very much in my mind as you were talking, Fatima, was how it can be so tiring sometimes to do the work. Some of us might have been thinking like, "oh, I like I did it already," right? Like, I already marched, I already protested. I already did something on social media or shared the voice or did whatever and so, I'm not saying that's how I feel or how you feel. But that's a thing that I think is very common. This is that moment where you have to decide. Do you say I'm too tired and not do anything further? Or do you say I'm really tired and a lot of people are even more tired than I am. And this is when I tighten up the shoe laces on my running shoes. From my standpoint, the work is never done and we have to just keep doing this, because until we can get to that point, where this is not a topic of conversation the work isn't done.
Never miss a video. Catch all our diversity, equity, and inclusion webinars, Geek Out talks, AskSGO clips, and more when you subscribe to our YouTube channel.

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She+ Geeks Out's Felicia Jadczak, Co-CEO and Head of Training and Fatima Dainkeh, Learning and Development Manager, discuss the recent increase in anti-Asian hate crimes happening in the US. They also discuss what it means to support BIPOC people overall, Asian Americans and Asians as a specific group, and how that all connects when we're talking about the complexity of allyship among BIPOC.

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Missing Daddy by Mariame Kaba addresses the youngest victims of the prison industrial system-children with loved ones who are incarcerated. Alongside beautiful illustrations by bria royal, Kaba renders in detail the experience of children who may not fully understand their loved ones' extended absence. The story's description of ridicule at school, domestic stress when caretakers manage households alone and enforced separation from a beloved father may help young readers feel less alone as they manage the impact of long-term and long-distance incarceration on their families and themselves.

ELEMENTARY SCHOOL

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Missing Daddy by Mariame Kaba addresses the youngest victims of the prison industrial system-children with loved ones who are incarcerated. Alongside beautiful illustrations by bria royal, Kaba renders in detail the experience of children who may not fully understand their loved ones' extended absence.

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Webinar: Achieving Health Equity for All Kids

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US News is a recognized leader in college, grad school, hospital, mutual fund, and car rankings. Track elected officials, research health conditions, and find news you can use in politics, business, health, and education.

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As COVID-19 infections increase, so too does racism and xenophobia. Use our "Speak Up" strategies to let people know you're not OK with racist or xenophobic comments about coronavirus or anything else.

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Amid the pandemic, Asian American people continue to experience racism, violence and harassment. These resources can help you teach the historical precedents for this moment, introduce ways for students to recognize and speak up against coronavirus racism, and start conversations with even the youngest learners about recognizing and acting to address injustice.

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Since the beginning of the COVID-19 pandemic, there's been a significant uptick in violence against Asians and Asian Americans. The organization Stop AAPI Hate collected more than 2,800 reports of verbal abuse, harassment, and physical assaults against Asians in the United States from March to December 2020. These reports depict a disturbing reality, especially for Asian women, who experienced violence nearly 2.5 times more than their male counterparts. However, the numbers do not tell the full story: They don't include many of the unreported and increasingly normalized incidents of violence that started as soon as the Trump administration began to unapologetically characterize the global pandemic as the "Chinese virus." Since then, Asians and Asian Americans have shared countless accounts with one another, privately describing the challenges of everyday life in the U.S.

As an example, early last March, my aunt came home from the grocery store visibly upset. She explained that she had been chased out of a local Bay Area supermarket by another shopper because he insisted that she was carrying the virus. My uncle then suggested that perhaps dying his hair blonde could save him from the anti-Asian harassment.

These stories are painful, but they are also part of a larger, and often dismissed, history of violence. In addition to the Chinese Exclusion Act of 1882, the assaults against Filipino farmworkers in the 1930s by white mobs, and the Japanese internment camps of the 1940s, there's a longstanding history of racialized colonial wars that shaped our communities' histories before we even arrived to the United States.

As a Vietnamese woman born in Oakland, California, I was never taught about the effects of the Viet Nam War or how, in the aftermath, refugees and immigrants spent indefinite amounts of time in various camps across the globe. I didn't know about the estimated two million civilians and more than one million Vietnamese soldiers who were killed. I did not understand the enduring impacts of the chemical Agent Orange, which U.S. troops used during the war, until I visited my mother's homeland in the early 2000s. And it wasn't until later that I learned about the massacres or the racist characterizations of Vietnamese people used to legitimize millions of deaths. It was then that I also learned about the anti-war protests across the globe, including those led by Black civil rights leaders, like Dr. Martin Luther King Jr., Dr. Angela Davis, and Muhammad Ali. These leaders also fought hard for our rights as new immigrants and children of immigrants in the United States.

Fortunately, I've been able to seek out knowledge and learn directly from Asian American leaders, including Yuri Kochiyama, a Japanese internment camp survivor who was friends with civil rights leader Malcolm X. She spent much of her life highlighting the issues impacting Asians and Asian Americans and in racial solidarity to end police violence and systemic racism against Black, Indigenous, and other communities of color.

The myth that we have not been impacted by white supremacy also ignores our diverse communities' experiences with Islamophobia and anti-South Asian violence, especially post-9/11. It dismisses the lived realities of and and Asian Americans, as well as our . And it often fails to account for the experiences of our Native Hawaiian and Pacific Islander counterparts, whose stories are often conflated with that of Asians in the category of API, Asian Pacific Islanders. Yet, with all of these ongoing needs, less than one percent of philanthropicfunding goes to our communities.

But instead of this support, Asian communities are being scapegoated for the virus.

I've asked community ambassadors and organizers in Oakland, who know our neighborhoods intimately, what they think about the recent incidents of assault and harassment. They shared that the violence is much more systemic than what's on the news: It's about poverty, the impacts of gentrification, including displacement and houselessness, racial profiling, mental health needs, limited health care, and other social services. But instead of this support, Asian communities are being scapegoated for the virus.

We've been hurting for a long time, and we've been working to create solutions for just as long. Now, finally, our stories are getting some attention. Hopefully, resources will come next.

Regardless, this moment is a reminder to build together, to continue to share our stories, to provide resources, to help one another address immediate needs and create long-lasting change. Our lives depend on it-and each other.

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Ignoring the History of Anti-Asian Racism Is Another Form of Violence

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Since the beginning of the COVID-19 pandemic, there's been a significant uptick in violence against Asians and Asian Americans. The organization Stop AAPI Hate collected more than 2,800 reports of verbal abuse, harassment, and physical assaults against Asians in the United States from March to December 2020.

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Responding to Anti-Asian Violence and Georgia Shootings

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After a shooting spree in Georgia took the lives of eight people—including six Asian American women—it’s important to pause, check in and prioritize care.

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‘Model Minority’ Myth Again Used As A Racial Wedge Between Asians And Blacks

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The perception of universal success among Asian-Americans is being wielded to downplay racism’s role in the persistent struggles of other minority groups — especially black Americans.

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When I was halfway through the 11th grade, my pre-calculus teacher pulled me out into the hallway. He wanted to talk about my latest test. "You can do better than this," he said. "I'm so surprised by grades like this from someone like you."

Someone like you? I'd never done particularly well in his class, so the implication of his words churned in my stomach. In that moment, I felt acutely the weight of the dark braid trailing down my back and the glasses slipping down my nose.

I knew my performance was being evaluated not against my own earlier work but against the image of the perfect, straight-A, Asian student who lived in my teacher's mind: the myth of the "model minority."

What Is the Model Minority Myth?

The myth of the model minority is based in stereotypes. It perpetuates a narrative in which Asian American children are whiz kids or musical geniuses. Within the myth of the model minority, Tiger Moms force children to work harder and be better than everyone else, while nerdy, effeminate dads hold prestigious-but not leadership -positions in STEM industries like medicine and accounting.

This myth characterizes Asian Americans as a polite, law-abiding group who have achieved a higher level of success than the general population through some combination of innate talent and pull-yourselves-up-by-your-bootstraps immigrant striving.

What's So Bad About the Model Minority Myth?

While most people agree that negative stereotypes of Asian Americans are harmful, some still question the harm of the model minority myth. What could be so bad about being part of a group that's seen as being successful?

Like all stereotypes, the model minority myth erases the differences among individuals.

My own 11th-grade experience offers one example. My mother is Malaysian Chinese; my dad is white. I am usually perceived as Asian. So, because of the model minority myth, my failure to reach an expected level of achievement in math was attributed to some kind of deficiency or lack of effort on my part.

Instead of differentiating for me like I saw him do with others in the class, my teacher let me continue to slip. I was not offered extra help or any other support, and I did not know how to live up to the image of the model minority student. I stopped trying.

While I was eventually able to overcome this negative self-image, many others are not. Asian American college students have higher rates of attempting suicide than those in other groups. The model minority myth hides the pressures and paradoxes inherent within an Asian American identity. If you don't fit into the myth, it is hard to find your place at all.

The model minority myth ignores the diversity of Asian American cultures.

Data about Asian American achievement typically lumps this diverse population together into a singular group. Taken as a whole, it shows that Asian Americans tend to hold higher degrees and earn larger incomes than the general population. These successes are often attributed to differences in family attitudes toward education. From these metrics and attributions, the stereotype emerges that Asians are winning in their pursuit of the American Dream. But when we break these numbers down, the myth begins to crack.

Take pay disparities, for example. For every dollar the average white man makes in the United States, an Asian Indian woman makes $1.21 and a Taiwanese woman makes $1.16. A Samoan woman makes $0.62. A Burmese woman makes 50 cents. The experiences of these groups are not the same.

The model minority myth operates alongside the myth of Asian Americans as perpetual foreigners.

The model minority myth is just one of a collection of stereotypes about Asian American people. Popular television and films exoticize Asian culture and peoples. If you're a man, you're a kung fu master. If you're a woman, you're a submissive sex object. If you're gender non-binary or transgender, you don't exist at all. Mickey Rooney's racist portrayal in Breakfast at Tiffany's lives in our collective imagination alongside every East or South Asian actor who has played a bit part as a humorless doctor or IT guy.

Buried under these stereotypes, the message is clear: Asian Americans are all the same-and all different from other Americans. On one hand, Asian Americans are often perceived as having assimilated better than other minority groups. On the other hand, Asian Americans are seen as having some foreign quality that renders them perpetual outsiders.

It's a paradox familiar to every Asian American who regularly faces the question, "But where are you from, originally?"

The model minority myth erases racism against Asian Americans.

Positioning Asian Americans as beneficiaries of the bounty of the American Dream, the myth of the model minority ignores the Chinese Exclusion Act of 1882 and Japanese internment in the 1940s. It suggests that the U.S. has always been a welcoming place for people of Asian descent, in spite of the mass lynchings of Asian Americans in the 19th century and the murder of Vincent Chin in 1982.

The myth persists in spite of the fact that 1 in 7 Asian immigrants in America today is undocumented and facing potential deportation, a fact that is repeatedly overlooked in our national conversation about immigration. The model minority myth says Asian Americans are doing well today and must therefore have benefitted from an elevated status among people of color, in spite of centuries of systematic discrimination.

The model minority myth is harmful to the struggle for racial justice.

The myth says that Asian Americans have played within the rules of the American system to their own group benefit. The success of some groups of Asian American immigrants is often held as an example toward which other groups should strive. It suggests that Asian Americans are doing well and that if other groups would only work harder, have stronger family bonds and get over their histories of oppression, they too would succeed.

When paired with racist myths about other ethnic or racial groups, the model minority myth is used as evidence to deny or downplay the impact of racism and discrimination on people of color in the United States. Given the history of that impact on Black Americans particularly, the myth is ultimately a means to perpetuate anti-Blackness.

The model minority myth pits people of color against one another and creates a hierarchy in which Asian people are often represented at the top. By putting people of color in competition with one another, the myth distracts us from striving together toward liberation for all.

Dismantling the Myth

Understand that the collective is important while individual differences still exist.

The term Asian American was coined in the late 1960s as a means of harnessing the collective power of people of Asian origin, much in the same way the term was first used. Asian American political identity was strongly inspired by the Black Liberation Movement. Today, more inclusive terms like Asian-Pacific American (APA) or Asian American Pacific Islander (AAPI) signal the continued need for collective striving against similar experiences of racism and imperialism within our various ethnic subgroups. This collective political identity remains important.

At the same time, focusing solely on collective identity can perpetuate the model minority myth: The experiences of the most visible Asian American ethnic groups can hide the experiences of other groups.

Some studies of educational achievement have shown that certain Asian ethnic groups, particularly those from parts of East and South Asia, indeed score very well in some subject areas. When students from these groups consistently do better than even white students, it is easy for educators to take inherently biased actions based on a belief that all Asian students are innately intelligent and hardworking. Those same studies, however, reveal that other Asian ethnic groups have vastly different results. For example, Southeast Asian and Pacific Islander students in particular often underperform when compared with all other racial and ethnic groups.

As an educator, it is important to understand the different histories and experiences of Asian American and Pacific Islander students and communities. Some of these communities arrived in America as refugees escaping war or genocide, and some were imported as sharecroppers to replace enslaved people of African descent after the Civil War. Still other communities, particularly those native to various Pacific Islands, were here long before white settler colonialism. As educators, we must unlearn the biased, simplistic beliefs that we might hold about what it means to be Asian American or Pacific Islander in order to better attend to the real needs of our students and communities.

Feature Asian American figures and texts in your classroom.

One of the commonly felt experiences of Asian Americans is that of being invisible or erased. The model minority myth means that neither our historical struggles nor activism tend to be covered in schools and classrooms. The significant underrepresentation of Asian American educators furthers this problem.

Asian American and Pacific Islander history has been a part of American history for centuries. May is AAPI Heritage Month. Use this as a starting point, but do not limit your conscious inclusion of AAPI people and experiences to a single month. Asian Americans and Pacific Islanders comprise the fastest-growing ethnic group in the United States. We must make a conscious effort to represent these stories and people in our classrooms, regardless of our own identities and those of our students.

Raise awareness in yourself and others.

There may be names and examples in this piece with which you were unfamiliar. Learn about activists like Grace Lee Boggs, Larry Itliong and Yuri Kochiyama. Say the name of Vincent Chin. Teach your students about Ela Bhatt. Research Supreme Court cases like U.S. v. Bhagat Singh Thind and .

Dive into data to help understand the collective and individual experiences of various AAPI groups. Check your own biases and assumptions. Do not let a student like me slip through the cracks because you expect her to be smarter or more studious than her classmates.

As you raise your own awareness, you'll help those around you to understand and dismantle the model minority myth as well.
Blackburn is a professional development trainer for Teaching Tolerance.

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The myth of the "model minority" is pervasive. It does real damage. And Asian American students aren't the only ones it harms.

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There's white folks, there's Black folks, and we really have failed to talk about anyone who is not in one of those two groups.

What we're seeing now is, Asian Americans are a surprise in terms of the racial discourse of this country. And it's because of that failure. It's because we have really only had the conversation in this one way, where it's a racial binary.

I'm really hopeful that this moment means that we will have a continued conversation about what it's like to be an Asian American, as a racialized community in America.

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Asian American community battles surge in hate crimes stirred from COVID-19

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As the U.S. continues its battle against COVID-19, it is also battling a rise in hate crimes against Asian Americans. A recent report found that hate crimes against Asian Americans in major U.S. cities surged by nearly 150 percent in 2020 -even as the number of overall hate crimes fell.

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A Toolkit for Addressing Anti-Asian Bias, Discrimination, and Hate

During the course of the COVID-19 pandemic, New York City saw a sharp increase in harassment and violence against Asian people and communities, especially Asian elders. Discrimination and harassment on the basis of race, national origin, age, and disability (including having or being perceived to be exposed to COVID-19) is illegal under the New York City Human Rights Law. Since the start of COVID-19, we have seen a sharp increase in instances of hostility and harassment directed at Chinese and other Asian communities related to COVID-19 stigma and misinformation. The NYC Commission on Human Rights, the Mayor's Office for the Prevention of Hate Crimes, the Mayor's Community Affairs Unit (CAU), and the Mayor's Office of Immigrant Affairs are coordinating closely to educate the public about their rights and protections in light of COVID-19-related stigma and hate crimes.

There has been a significant, troubling increase in anti-Asian hate crimes and bias incidents since the start of the pandemic. Beginning in February of 2020, the Commission received a sevenfold increase in reports of anti-Asian harassment, discrimination, and violence. It is crucial to note that hate crimes and bias incidents have been found to be vastly under-reported so these numbers only reflect reported incidents.

If you have faced harassment or discrimination in housing, at work, or in any public place, contact the NYC Commission on Human Rights by filling out our online form or by calling 212-416-0197. If you are a victim of or witness a hate crime, call 911. There is language support if you need interpretation services.
See tweet from Mayor's Community Affairs Unit.
In this toolkit you can find the following

Campaigns

Additional Resources

Remarks from Mayor Eric Adams

Campaigns

I Still Believe in Our City

"I Still Believe in Our City" is a public awareness campaign by multidisciplinary artist Amanda Phingbodhipakkiya. The public awareness campaign was developed with the NYC Commission on Human Rights to combat anti-Asian discrimination, harassment, and bias as a result of COVID-19, and launched with the support of the NYC Department of Cultural Affairs. The art featured here is from an upcoming Art Display Case exhibition presented in partnership with the NYC Department of Transportation's Temporary Art Program.

The "I Still Believe in Our City" campaign has graphics available to address anti-Asian racism and harassment.

Suggested posting text

As #COVID19 hit NYC, Asian and Pacific Islanders faced an added threat: racism and hate.
You have a right to live free of discrimination. If you have seen anti-Asian harassment, speak up and report it to us by calling 212-416-0197.

Since the beginning of the #COVID-19 pandemic, NYC has seen a startling increase in harassment and discrimination against Asian communities.
Know this: Our city is unified in its fight against stigma and hate. Learn more at http://nyc.gov/stopcovidhate

Asian New Yorkers: You have the right to be free from harassment and discrimination under the New York City Human Rights Law. If you have been discriminated against or harassed, report it here: http://nyc.gov/reportdiscrimination

Foreign language graphics and posting text available in Traditional Chinese, Korean, Japanese, Tagalog, and Vietnamese.

Download printable posters
13" x 19" (with bleed) 13" x 19" (no bleed) 8-1/2" x 11" (with bleed) 8-1/2" x 11" (no bleed) Download posters in Korean, Traditional Chinese, Tagalog, Vietnamese, and Japanese
We Are More

"We Are More" is an art series that celebrates the resilience and range of Asian American and Pacific Islander communities. The series seeks to break down tired worn out cliches and stereotypes of Asian Americans and Pacific Islanders, and forge in its stead a brilliant, multidimensional identity that encompasses the resilience and range of the communities.

Featuring dynamic visuals, bold typography, and human stories, "We Are More" is on view in Times Square in partnership with Times Square Arts, with subsequent installations appearing in Boston and other cities around the United States.

Learn more and download all the images at morethan.art.

We Are One New York
Download the graphics
Suggested posting text

Coronavirus-related discrimination and harassment is not acceptable. You deserve to be treated with dignity and respect no matter what. If you have been discriminated against or harassed, report it here: http://nyc.gov/reportdiscrimination

There is a lot of anxiety and fear around COVID-19, but one thing is clear: people and places shouldn't be stigmatized for the spread of viruses. If you have been discriminated against or harassed because of COVID-19 fears, report it here: http://nyc.gov/reportdiscrimination

Fight Fear with Facts

Download the graphics
View translated posting text available

Suggested posting text

Discrimination for having a serious illness like #COVID19, or facing harassment because of the belief that you have been exposed to it, is illegal under the NYC Human Rights Law. Report discrimination and harassment to @NYCCHR at 212-416-0197 or online at http://nyc.gov/reportdiscrimination.

No matter who you are, your city will fight for you. Report bias, discrimination, or harassment to @NYCCHR at 212-416-0197 or report it online at http://nyc.gov/reportdiscrimination.

If you or someone you know has faced discrimination or harassment because of your race, religion, immigration status, or disability, contact the @NYCCHR at 212-416-0197 or report is online at http://nyc.gov/reportdiscrimination.

Graphic Available in 21 Languages

Are you or someone you know the victim of harassment? Call 311. If you are the victim of a crime or witness a crime, call 911. NYPD officers are not allowed to ask about your immigration status. Learn more at nyc.gov/stopcovidhate.

Arabic: Square
‫يجهل تقع أنت أو أي شخص تعرفه ضحية للمضايقة؟ اتصل بالرقم 311 .إذا كنت ضحية جريمة أو شاهدت وقوع جريمة، فاتصل بالرقم 911 .ال يسمح لضباط إدارة شرطة مدينة نيويورك بالسؤال عن حالة الهجرة الخاصة بك. تع رف على المزيد من خالل الموقع اإللكتروني nyc.gov/stopcovidhate

Farsi: Square
آیا شما قربانی آزار و اذیت هستید، یا از آشنایان کسی را می شناسید که باشد؟ با 311 تماس بگیرید. اگر قربانی جرم یا شاهد وقوع جرم هستید، با 911 تماس بگیرید. مأموران اداره پلیس نیویورک اجازه ندارند در مورد وضعیت مهاجرتی شما سؤال کنند .
nyc.gov/stopcovidhate

האם אתם או מישהו שאתם מכירים קרבנות של הטרדה? התקשרו אל 311 .אם אתם קרבנות פשע או צופים בפשע , התקשרו אל 911 .קציני משטרת ניו יורק אינם מורשים לשאול אתכם אודות סטטוס ההגירה שלכם. מידע נוסף בכתובת Hebrew: Square

nyc.gov/stopcovidhate

Japanese: Square
あなた、またはあなたの知っている人がハラスメントの被害に遭ってはいません か。311 にご連絡ください。犯罪の被害者、または目撃者の場合は、911 にご連 絡ください。ニューヨーク市警察の職員があなたの滞在資格を尋ねることはあり ません。詳細は nyc.gov/stopcovidhate

Korean: Square
본인이나 아는 사람이 괴롭힘을 받고 있습니까? 311 에 전화하세요. 범죄의 피해자이거나 목격자인 경우, 911 로 전화하세요. NYPD 경찰은 이민 신분에 대해 질문할 수 없습니다. nyc.gov/stopcovidhate 에서 자세히 알아보세요.

Portuguese: Square
Você ou alguém que você conhece é vítima de assédio? Ligue para 311. Se você for vítima de um crime ou testemunhar um crime, ligue para 911. A Polícia de Nova York não pode fazer perguntas sobre seu status de imigração. Saiba mais em nyc.gov/stopcovidhate

Russian: Square
Вы или ваши знакомые стали жертвой притеснения? Позвоните по номеру 311. Если вы стали жертвой или свидетелем преступления, позвоните по телефону 911. Сотрудники Департамента полиции Нью-Йорка (NYPD) не имеют права задавать вопросы о вашем иммиграционном статусе.

‫‫کیا آپ یا آپ کے جاننے والوں میں سے کوئی ہراساں کیے جانے کا شکار ہے؟ 311 پر کال کریں۔ اگر آپسے کوئی فرق کسی جرم کا شکار ہوئے ہیں یا کسی جرم کے گواہ ہیں، تو 911 پر کال کریں ۔ NYPD افسران کو آپ کیتر ک وطن کی حیثیت کے متعلق سوال پوچھنے کی اجازت نہیں ہے ۔ Urdu: Square

nyc.gov/stopcovidhate

Resources for Victims of Hate Crimes

Download the resource graphics series, available in multiple sizes.

Additional Resources

Bystander Intervention Trainings

Bystander intervention is built on the idea that we all play a role in creating safe public spaces for each other when we see our neighbors and community members facing bias, discrimination, or harassment. The NYC Commission on Human Rights and community partners regularly co-host bystander intervention trainings to provide New Yorkers with the tools and strategies to safely respond when they witness bias incidents and discrimination.

Hate and Bias Incidents Related to COVID-19 Fact Sheet

Fact Sheet on Hate and Bias Incidents Related to COVID 19 | Español (Spanish) | عربى (Arabic) | اردو (Urdu) | Kreyòl Ayisyen (Haitian Creole) | 한국어 (Korean) | বাংলা (Bengali) | русский (Russian) | Français (French) | Polskie (Polish) | יידיש (Yiddish) | Tiếng Việt (Vietnamese) | 日本語 (Japanese) | 简体中文 (Chinese -Simplified) | 繁體中文 (Chinese - Traditional)

What is a Hate Crime Fact Sheet

What is a Hate Crime Fact Sheet | Español (Spanish) | عربى (Arabic) | اردو (Urdu) | Kreyòl Ayisyen (Haitian Creole) | 한국어 (Korean) | বাংলা (Bengali) | русский (Russian) | Français (French) | Polskie (Polish) | 简体中文 (Chinese -Simplified) | 繁體中文 (Chinese - Traditional)

Guide for Victims of Hate Crimes

Download the guide to share about resources & services available to victims of hate crimes

Educational Resources

The New York City Department of Education and OPHC have developed for educators across the City a resource guide to materials to prevent anti-Asian and anti-COVID related discrimination that can be incorporated into lesson plans.
COVID-19-Related Anti-Bias Education Resource Guide
Community Resources

Asian American Federation (AAF)

"Stay Safe from Hate: How to Protect Yourself in Threatening Situations" booklet is available in five Asian languages (Chinese, Korean, Japanese, Tagalog, and Vietnamese) and includes verbal de-escalation strategies, bystander techniques, non-violent communication strategies, and physical defense techniques.
Download for free and check it out
Stop AAPI Hate

Do you have a hate incident to report? Help document the recent rise in hate crimes against Asian American elders by going to https://stopaapihate.org/.

Stop AAPI Hate is the nation's leading coalition documenting and addressing anti-Asian hate and discrimination amid the COVID-19 pandemic.

Other

If you would like to connect with other community-based organizations in your area, please visit the Mayor's Office of Criminal Justice's Victim Services Finder, which is currently available in English, Arabic, Bengali, Chinese, French, Haitian Creole, Korean, Russian, Spanish, and Urdu.

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During the course of the COVID-19 pandemic, New York City saw a sharp increase in harassment and violence against Asian people and communities, especially Asian elders. Discrimination and harassment on the basis of race, national origin, age, and disability (including having or being perceived to be exposed to COVID-19) is illegal under the New York City Human Rights Law.

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​Horrific events like the killing of George Floyd and the protests and civil unrest that followed graphically illustrate how racism and discrimination harms everyone in our communities.

The American Academy of Pediatrics condemns racism in all forms. And pediatricians are deeply concerned about the effects of racism on children. Even vicarious racism - secondhand racism witnessed through social media, conversations with friends or family, or media images - harms children's health. ​

Children are listening

As a parent, you must assume children of almost any age are hearing about what is happening in our nation today. They may overhear adult conversations, see a video on YouTube, or watch news coverage of violent protests. They may feel afraid for their own safety or their family's safety. They might have questions about what the protests mean, why people have been killed by police, and if they are safe. ​

How to help your children understand

Ideally you can talk with them first, in ways they can understand, before they hear about it from other sources. When talking to your children, keep the following tips in mind:

Check in with your child. Ask what they know, what they've seen, and how they are feeling. Tell them you understand their feelings and reassure them it's normal to feel these emotions. You know your child best and what information they can handle. For younger children, tell them what you are doing to keep your family safe. For pre-teens and older children, ask if they've ever experienced mistreatment or racism, or seen it happening to others.

Watch for changes in your child's behavior. Some children may become more aggressive, while others will become withdrawn or scared. If you are concerned that your child may be struggling with anxiety, fear or distress, call your pediatrician or mental health provider for additional support.

Limit what your child sees in the media. Do not leave the TV on in the background. With older children and teens, watch with them and talk together about what you're seeing. Listen to their observations and share your own. Use commercial breaks, or pause the video, to have brief discussions. With younger children, limit TV, smartphone, or tablet use, especially when the news is on. Make sure the media they do see occurs in a common area where you can check in.

Be aware of your own emotions. As an adult, tune into how you are feeling and check that you are ok. If you are not, ask for help to deal with the trauma and emotional impact of these events and images. Make a list of your own coping strategies, and when you need to use them, tap into that list.

Use this teachable moment. For all families, this is an opportunity to discuss the history of racism and discrimination in the US and help your children discover ways to make change. ​

Resources can help. If you struggle to find the "right" words, try using books or other resources to share with your child. The tips in this article can also help. Remind your children that no one is perfect, talk about what you are doing to be anti-racist, what you have learned, and how you as a family can step up.

Talk and act

It's ok to acknowledge that people are treated differently based on the color of their skin and where they live and share examples of this happening. But this is also an opportunity to show your children how to make a positive difference. For example, perhaps your family can call your city council person or superintendent to advocate for issues faced by communities of color. Think about how you might confront your own biases and show how you want your children to respond to others who may be different than them.​

Remember

These are conversations that many Black American families have had for years. But if this is not something your family has discussed yet, what is happening right now is a teachable moment. If we are to progress in this country, it's going to be because we help our children, adolescents and young adults learn not just that racism exists, but that it is something all of us can work together to dismantle. ​

Additional Information:

About Dr. Heard-Garris:

Dr. Nia Heard-Garris, MD, MSc, FAAP is a pediatrician and a physician-investigator at the Ann & Robert H. Lurie Children's Hospital of Chicago and in the Department of Pediatrics at Northwestern University Feinberg School of Medicine. She believes in using research to better inform clinical practice and policy that supports children, their families, and their communities. Within the Academy, she serves as the Chair and founding member of the AAP Section of Minority Health, Equity, and Inclusion. Dr. Heard-Garris, her husband, and beautiful 7-year old son live in Chicago.​

About Dr. Dougé​:

Jacqueline Dougé, MD, MPH, FAAP is a pediatrician, public health advocate, writer and creator of What is Black, a blog and podcast that helps parents raising Black children and teens navigate race, racism and parenting. She's the co-author of the AAP Policy Statement, The Impact of Racism on Child and Adolescent Health and member of the AAP Section on Minority Health, Equity & Inclusion. Her interests are health disparities, impact of racism on health, media, school health and the interaction of public health and pediatrics. ​

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Talking to Children about Racism: The Time is Now

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​Horrific events like the killing of George Floyd and the protests and civil unrest that followed graphically illustrate how racism and discrimination harms everyone in our communities. The American Academy of Pediatrics condemns racism in all forms. And pediatricians are deeply concerned about the effects of racism on children.

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Why does race matter so profoundly for health? David R. Williams developed a scale to measure the impact of discrimination on well-being, going beyond traditional measures like income and education to reveal how factors like implicit bias, residential segregation and negative stereotypes create and sustain inequality. In this eye-opening talk, Williams presents evidence for how racism is producing a rigged system -- and offers hopeful examples of programs across the US that are working to dismantle discrimination.

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Social justice advocate and law scholar Dorothy Roberts has a precise and powerful message: Race-based medicine is bad medicine. Even today, many doctors still use race as a medical shortcut; they make important decisions about things like pain tolerance based on a patient’s skin color instead of medical observation and measurement. In this searing talk, Roberts lays out the lingering traces of race-based medicine -- and invites us to be a part of ending it. “It is more urgent than ever to finally abandon this backward legacy,” she says, “and to affirm our common humanity by ending the social inequalities that truly divide us.”

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Abstract

The American Academy of Pediatrics is committed to addressing the factors that affect child and adolescent health with a focus on issues that may leave some children more vulnerable than others. Racism is a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families. Although progress has been made toward racial equality and equity, the evidence to support the continued negative impact of racism on health and well-being through implicit and explicit biases, institutional structures, and interpersonal relationships is clear. The objective of this policy statement is to provide an evidence-based document focused on the role of racism in child and adolescent development and health outcomes. By acknowledging the role of racism in child and adolescent health, pediatricians and other pediatric health professionals will be able to proactively engage in strategies to optimize clinical care, workforce development, professional education, systems engagement, and research in a manner designed to reduce the health effects of structural, personally mediated, and internalized racism and improve the health and well-being of all children, adolescents, emerging adults, and their families.

Statement of the Problem

Racism is a "system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call 'race') that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources." Racism is a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families. ⁻ Although progress has been made toward racial equality and equity, the evidence to support the continued negative impact of racism on health and well-being through implicit and explicit biases, institutional structures, and interpersonal relationships is clear. Failure to address racism will continue to undermine health equity for all children, adolescents, emerging adults, and their families.

The social environment in which children are raised shapes child and adolescent development, and pediatricians are poised to prevent and respond to environmental circumstances that undermine child health. Pediatrics as a field has yet to systematically address the influence of racism on child health outcomes and to prepare pediatricians to identify, manage, mitigate, or prevent risks and harms. Recognizing that racism has significant adverse effects on the individual who receives, commits, and observes racism,, substantial investments in dismantling structural racism are required to facilitate the societal shifts necessary for optimal development of children in the United States. The American Academy of Pediatrics (AAP) is committed to reducing the ongoing costs and burden of racism to children, the health care system, and society.,

Today's children, adolescents, and emerging adults are increasingly diverse. Strategies to address health and developmental issues across the pediatric life span that incorporate ethnicity, culture, and circumstance are critical to achieving a reduction in health disparities. Accordingly, pediatrics should be at the forefront of addressing racism as a core social determinant. The inclusion of racism is in alignment with the health equity pillar of the AAP strategic plan. In a series of workshops in 2016 during national meetings of pediatricians, 3 strategic actions were identified: (1) development of a task force within the AAP to address racism and other forms of discrimination that impact the health status and outcomes of minority youth, (2) development of a policy statement on racism, and (3) integration of evidence-based anticipatory guidance about racism into Bright Futures.

The objective of this policy statement is to provide an evidence-based document focused on the role of racism in child and adolescent development and health outcomes. This policy statement will allow pediatricians to implement recommendations in practice that will better address the factors that make some children more vulnerable than others. The statement also builds on existing AAP policy recommendations associated with other social determinants of health, such as poverty, housing insecurity, child health equity, immigration status, and early childhood adversity.,⁻

Racism as a Core Determinant of Child Health

Racism is a core social determinant of health that is a driver of health inequities. ⁻ The World Health Organization defines social determinants of health as "the conditions in which people are born, grow, live, work, and age." These determinants are influenced by economic, political, and social factors linked to health inequities (avoidable inequalities in health between groups of people within populations and between countries). These health inequities are not the result of individual behavior choices or genetic predisposition but are caused by economic, political, and social conditions, including racism.

The impact of racism has been linked to birth disparities and mental health problems in children and adolescents.,⁻ The biological mechanism that emerges from chronic stress leads to increased and prolonged levels of exposure to stress hormones and oxidative stress at the cellular level. Prolonged exposure to stress hormones, such as cortisol, leads to inflammatory reactions that predispose individuals to chronic disease. As an example, racial disparities in the infant mortality rate remain, and the complications of low birth weight have been associated with perceived racial discrimination and maternal stress.,,

Investments in policies to address social determinants of health, such as poverty, have yielded improvements in the health of children. The Food Stamp Program, a War on Poverty initiative first developed in the 1930s during the Great Depression and later revived in the 1960s, is linked to improvements in birth outcomes. Efforts in education, housing, and child health insurance have also led to improved health outcomes for issues such as lead poisoning, injuries, asthma, cancer, neurotoxicity, cardiovascular disease, and mental health problems.,, Expansion of child health insurance has improved health care access for children, with significant gains for African American and Hispanic children in terms of access to well-child, doctor, and dental visits. Despite these improvements, it is important to recognize that children raised in African American, Hispanic, and American Indian populations continue to face higher risks of parental unemployment and to reside in families with significantly lower household net wealth relative to white children in the United States, posing barriers to equal opportunities and services that optimize health and vocational outcomes. ⁻

Juvenile justice involvement is also a critical social determinant of health. Because racial inequity continues to shape the juvenile justice system, this area is a modern example of race being an important determinant of short- and long-term outcomes. The AAP published a statement in 2011 focusing on key health issues of justice-involved youth, which was recently revised to include an in-depth discussion on racial and ethnic inequalities for this population. Although the overall rates of youth incarceration have decreased, African American, Hispanic, and American Indian youth continue to be disproportionately represented. While incarcerated, youth experience additional adverse experiences, such as solitary confinement and abuse, that have the potential to undermine socioemotional development and general developmental outcomes. ⁻ Differential treatment of youth offenders on the basis of race shapes an individual's participation and ultimate function in society. This type of modern racism must be recognized and addressed if the United States seeks to attain health equity.

The Development of Race as a Construct

Race as a social construct is rooted in history and remains a mechanism through which social class has been controlled over time. Flawed science was used to solidify the permanence of race, reinforce the notions of racial superiority, and justify differential treatment on the basis of phenotypic differences as people from different parts of the world came in contact with each other. Race emerged as a social classification used to assign dominance of some social classes over others. Scientific, anthropologic, and historical inquiry further solidified race as a social construct. Modern science, however, has demonstrated that there is only 1 biological race and that the clines (phenotypic differences in skin and eye color, hair texture, and bone structure) at the core of early anthropologic research were insufficient to establish different races among human beings. Dr Francis Collins, former director of the National Human Genome Project and presently the director of the National Institutes of Health, has affirmed that humans are 99.9% the same at the level of their genome. Despite this, efforts to collect, organize, and categorize individuals on the basis of the plausibility of the 0.01% human variation remain a force of scientific discovery, innovation, and medical-pharmaceutical collaborations. Rather than focusing on preventing the social conditions that have led to racial disparities, science and society continue to focus on the disparate outcomes that have resulted from them, often reinforcing the posited biological underpinnings of flawed racial categories. Although race used in these ways has been institutionalized, linked to health status, and impeded our ability to improve health and eliminate health disparities,, it remains a powerful measure that must be better measured, carefully used, and potentially replaced to mark progress in pediatric health disparities research.,

As such, it is important to examine the historical underpinnings of race used as a tool for subjugation. American racism was transported through European colonization. It began with the subjugation, displacement, and genocide of American Indian populations and was subsequently bolstered by the importation of African slaves to frame the economy of the United States. Although institutions such as slavery were abolished more than a century ago, discriminatory policies, such as Jim Crow laws, were developed to legalize subjugation. As the United States expanded west in North America and into Alaska and the Pacific Islands, the diversity of populations encompassing the United States also expanded. Native Hawaiian and Pacific Islander, Alaskan native, Asian American, and Latino American populations have experienced oppression and similar exclusions from society. ⁻ Although some racial and/or ethnic groups have received reparations and fared better than others over time, remnants of these policies remain in place today and continue to oppress the advancement of people from historically aggrieved groups. ⁻

Through these underpinnings, racism became a socially transmitted disease passed down through generations, leading to the inequities observed in our population today. Although the endemic nature of racism has powerful impacts on perceived and actual health outcomes, it is also important to note that other forms of discrimination (eg, sex, religion, sexual orientation, immigrant status, and disability status) are actively at play and have created a syndemic with the potential to undermine child and family health further. It is important to address racism's impact on the health and well-being of children, adolescents, and emerging adults to avoid perpetuating a health system that does not meet the needs of all patients. Pediatricians are uniquely positioned to both prevent and mitigate the consequences of racism as a key and trusted source of support for pediatric patients and their families.

Childhood Experiences of Racism

Children can distinguish the phenotypic differences associated with race during infancy ⁻; therefore, effective management of difference as normative is important in a diverse society. To identify, address, and manage the impacts of racism on child health, it is critical that pediatricians understand 3 key levels through which racism operates: (1) institutional, (2) personally mediated, and (3) internalized. The experience of race is also impacted by other identities that people have related to ethnicity, sex, religious affiliation, immigrant status, family composition, sexuality, disability, and others that must be navigated alongside race. Much of the discussion to date related to the historical underpinnings of race deals with institutionalized (or structural) racism, expressed through patterns of social institutions (eg, governmental organizations, schools, banks, and courts of law) that implicitly or explicitly discriminate against individuals from historically marginalized groups.,,, Children experience the outputs of structural racism through place (where they live), education (where they learn), economic means (what they have), and legal means (how their rights are executed). Research has identified the role of implicit and explicit personally mediated racism (racism characterized by assumptions about the abilities, motives, or intents of others on the basis of race) as a factor affecting health care delivery and general health outcomes. ⁻ The impacts of structural and personally mediated racism may result in internalized racism (internalizing racial stereotypes about one's racial group). A positive racial identity mediates experiences of discrimination and generates optimal youth development outcomes.,, The importance of a prosocial identity is critical during adolescence, when young people must navigate the impacts of social status and awareness of personally mediated discrimination based on race. ⁻

Although children and adolescents who are the targets of racism experience the most significant impact, bystanders are also adversely affected by racism. As an example, young adults who were bystanders to racism and other forms of victimization as youth experience profound physiologic and psychological effects when asked to recall the memory of a past anchoring event as a victim or bystander that are comparable to those experienced by first responders after a major disaster. Three core features that characterized the abusive event(s) were as follows: (1) an individual gets hurt psychologically or physically, (2) a power differential exists (eg, age, size and/or stature, or status) versus the target individual resulting in domination and erosion of the target's self-esteem, and (3) the abuse is repetitive, causing stress levels to increase because of anticipation of future events. Internalized negative stereotypes related to race can unconsciously erode self-perception and capacity and may later play out in the form of stereotype threat or the fear of confirming a negative stereotype of one's race. Stereotype threats can undermine academic and vocational attainment, key developmental milestones for the victim. Underachievement then reinforces the stereotype held by both the perpetrator and victim, further enhancing the vulnerability of the victim and the bystander to repeated acts of overt or covert victimization. These observations suggest that universal interventions to eliminate racism (experienced as a victim or bystander) from the lives of children and to engage in active societal antiracism bystander behavioral intervention may optimize well-being for all children and the adults who care for them. For individual intervention to occur, however, bystanders must identify critical situations, view them as an emergency, develop a sense of personal responsibility, have self-efficacy to succeed with the intervention, perceive the costs of nonintervention as high, and consciously decide to help., Research has demonstrated that racism has an effect on health across racial groups in communities reporting high levels of racism but that racially diverse environments, such as schools, can benefit all youth by improving cognitive skills such as critical thinking and problem-solving.

Racism at the Intersection of Education and Child and Adolescent Health

Educational and vocational attainment are key developmental outcomes that pediatricians monitor to assess for successful growth and development. After accounting for sleep and time spent at home, children spend a significant portion of their time in educational settings. ⁻ Educational achievement is an important predictor of long-term health and economic outcomes for children. Adults with a college degree live longer and have lower rates of chronic disease than those who did not graduate from college. It is critical for pediatricians to recognize the institutional, personally mediated, and internalized levels of racism that occur in the educational setting because education is a critical social determinant of health for children.

Disparities in educational access and attainment, along with racism experienced in the educational setting, affect the trajectory of academic achievement for children and adolescents and ultimately impact health. Chronic absenteeism, defined as missing ≥10% of school days in an academic year, is a strong predictor of educational achievement. Chronic absenteeism disproportionately affects children of color, children living in poverty, children with disabilities, and children with chronic diseases. In high school, 21.2% of Hispanic, 23.4% of African American, and 27.5% of American Indian children were chronically absent in 2013-2014 compared with 17.3% of white children. Immigration enforcement and the fear of apprehension by authorities can negatively affect school attendance for Hispanic and black immigrants, thereby perpetuating inequalities in attendance. According to the National Center for Education Statistics, the graduation rate for white students nationally in 2015-2016 was 88% compared with 76% for African American students, 72% for American Indian students, and 79% for Hispanic students. Disparities in chronic absenteeism and high school graduation rates prevent children from realizing the full benefits of educational attainment and can increase the development of chronic disease and reduce overall life expectancy.

Although the landmark US Supreme Court case Brown v Board of Education banned government-sponsored segregation and laid a foundation for equal access to a quality public education, the US Department of Education continues to report institutional or structural inequality in educational access and outcomes, even in the most diverse and well-resourced communities in the United States. Students from historically aggrieved groups have less access to experienced teachers, advanced coursework, and resources and are also more harshly punished for minor behavioral infractions occurring in the school setting. They are less likely to be identified for and receive special education services, and in some states, school districts with more nonwhite children receive lower funding at any given poverty level than districts with more white children.

Children may also experience personally mediated racism early in their schooling, which may be internalized and ultimately affect their interactions with others. Early teacher-child interactions are important for long-term academic outcomes. The relationship of teacher to student across ages and grade levels influences school adjustment, literacy, math skills, grade point average, and scholastic aptitude test scores. ⁻ Given the critical nature of the student-teacher relationship, it is important to explore how racism and implicit bias affect this dynamic. Student-teacher racial mismatch can impact academic performance, with studies showing that African American children are more likely to receive a worse assessment of their behavior when they have a non-Hispanic white teacher than when they have an African American teacher. This finding may result from racial bias in teachers' expectations of their students, with data demonstrating that white and other non-African American teachers are more likely than African American teachers to predict that African American students would not finish high school. Similarly, data indicate that teachers may underestimate the ability of African American and Latino students, which can lead to lower grade point averages and fewer years of schooling. African American students who have 1 African American teacher in elementary school are more likely to graduate from high school and enroll in college than their peers who do not have an African American teacher; the proposed mechanism for this improved long-term educational outcome is the exposure to a role model early in the educational experience. These findings indicate the importance of ensuring a diverse teacher workforce, particularly as the population of students in US schools continues to diversify. School racial climate, which refers to norms, curricula, and interactions around race and diversity within the school setting, also impacts educational outcomes for students. Students who had a positive perception of school racial climate had higher academic achievement and fewer disciplinary issues. Racial inequities in school discipline begin early, and school discipline has long-term consequences for children. Although federal civil rights laws prohibit discrimination in the administration of discipline in public schools, the US Government Accountability Office found that African American and American Indian students are overrepresented among students experiencing suspension. Data from the US Department of Education confirm that a disproportionate number of African American children receive more than 1 out-of-school suspension in preschool and overall in kindergarten through grade 12 are suspended 3 times more and expelled 1.9 times more than white students. To mediate the effects of institutional and personally mediated racism in the educational setting and prevent internalized racism, studies show that a positive, strong racial or ethnic identity and parental engagement in families is protective against the negative effects of racial discrimination on academic outcomes. ⁻

How Pediatricians Can Address and Ameliorate the Effects of Racism on Children and Adolescents

Pediatricians and other child health professionals must be prepared to discuss and counsel families of all races on the effects of exposure to racism as victims, bystanders, and perpetrators. ⁻ Pediatricians can implement systems in their practices that ensure that all patients and families know that they are welcome, that they will be treated with mutual respect, and that high-quality care will be delivered regardless of background using the tenets of family- and patient-centered care. To do this, it is critical for pediatricians to examine their own biases. Pediatricians can advocate for community initiatives and collaborate with government and community-based organizations to help redress biases and inequities in the health, justice, and educational systems. These strategies may optimize developmental outcomes and reduce exposure to adverse events that dramatically alter the lived experiences, health, and perceived self-value of youth.,,

Conclusions

Achieving decisive public policies, optimized clinical service delivery, and community change with an activated, engaged, and diverse pediatric workforce is critically important to begin untangling the thread of racism sewn through the fabric of society and affecting the health of pediatric populations. Pediatricians must examine and acknowledge their own biases and embrace and advocate for innovative policies and cross-sector partnerships designed to improve medical, economic, environmental, housing, judicial, and educational equity for optimal child, adolescent, and emerging adult developmental outcomes.

Section on Adolescent Health Executive Committee, 2018-2019

Maria E. Trent, MD, MPH, FAAP, Chairperson

Robert M. Cavanaugh Jr, MD, FAAP

Amy E. Lacroix, MD, FAAP

Jonathon Fanburg, MD, MPH, FAAP

Maria H. Rahmandar, MD, FAAP

Laurie L. Hornberger, MD, MPH, FAAP

Marcie B. Schneider, MD, FAAP

Sophia Yen, MD, MPH, FAAP

Council on Community Pediatrics Executive Committee, 2018-2019

Lance Alix Chilton, MD, FAAP, Chairperson

Andrea E. Green, MD, FAAP

Kimberley Jo Dilley, MD, MPH, FAAP

Juan Raul Gutierrez, MD, FAAP

James H. Duffee, MD, MPH, FAAP

Virginia A. Keane, MD, FAAP

Scott Daniel Krugman, MD, MS, FAAP

Carla Dawn McKelvey, MD, MPH, FAAP

Julie Michelle Linton, MD, FAAP

Jacqueline Lee Nelson, MD, FAAP

Gerri Mattson, MD, FAAP

Staff

Dana Bennett-Tejes, MA, MNM

Committee on Adolescence, 2018-2019

Cora C. Breuner, MD, MPH, FAAP, Chairperson

Elizabeth M. Alderman, MD, FSAHM, FAAP

Laura K. Grubb, MD, MPH, FAAP

Janet Lee, MD, FAAP

Makia E. Powers, MD, MPH, FAAP

Maria H. Rahmandar, MD, FAAP

Krishna K. Upadhya, MD, FAAP

Stephenie B. Wallace, MD, FAAP

Liaisons

Liwei L. Hua, MD, PhD - American Academy of Child and Adolescent Psychiatry

Geri D. Hewitt, MD - American College of Obstetricians and Gynecologists

Seema Menon, MD - North American Society of Pediatric and Adolescent Gynecology

Ellie E. Vyver, MD, FRCPC, FAAP - Canadian Pediatric Society

Lauren B. Zapata, PhD, MSPH - Centers for Disease Control and Prevention

Acknowledgments

We are grateful for internal review and critical feedback by Drs Benard Dreyer, Olanrewaju Falusi, Renee Jenkins, Judith Palfrey, Krishna Upadhya, Joseph Wright, Jonathan Klein, Janie Ward, Michael Lindsey, Lance Chilton, James Duffee, Andrea Green, Julie Linton, Virginia Keane, Jackie Nelson, Raul Gutierrez, Lase Ajayi, Lee Beers, Nathaniel Beers, Heidi Schumacher, and Tonya Vidal Kinlow.

Footnotes

Address correspondence to Maria Trent, MD. E-mail: mtrent2{at}jhmi.edu

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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The Impact of Racism on Child and Adolescent Health

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The American Academy of Pediatrics is committed to addressing the factors that affect child and adolescent health with a focus on issues that may leave some children more vulnerable than others. Racism is a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families.

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Inspired by its children's book A Is for All the Things You Are: A Joyful ABC Book, the Smithsonian's National Museum of African American History and Culture recently launched a new activity booklet series designed for infants, toddlers and early learners.

The Joyful ABC Activity Booklet series provides caregivers and educators with guides to support children's positive identity development while also growing their language and literacy skills using interactive learning activities, museum objects and vocabulary based on characteristics featured in the book.

The booklet series centers Black joy in childhood as an act of resistance and strength in the face of this past year's unprecedented challenges. It includes two editions: one for infants and toddlers (ages birth to 3) and one for early learners (ages 3 to 5). Each Joyful ABC Activity Booklet provides early childhood caregivers and educators with:

Insight into children's developmental stages

Age-appropriate play and art activities

Literacy- and language-development experiences

Opportunities to look closely at museum objects

Suggested books, videos, articles and other resources

Through July, four additional booklets will be made available for free download the first Monday of every month. Activity booklets for letters A-I are currently available to download for free on the Joyful ABC Activity Booklets webpage.

"Created through an anti-bias/anti-racist lens, these booklets support children's growth into confident, compassionate, socially aware and inclusive individuals who embrace their uniqueness," said Anna Forgerson Hindley, director of early childhood education at the museum. "The new booklets focus on empowering children to see themselves as multifaceted individuals, but use accessible and age-appropriate activities and museum-related objects to help kids develop their own sense of justice and understanding of others."

In addition, the new interactive activity booklet series will be explored during the museum's free weekly children's art program, Joyful Fridays.

Designed for children ages 4-8, Joyful Fridays ' museum educators will discuss featured museum objects and lead an art project inspired by the booklet themes released for the month while celebrating black joy, history and culture.

The program takes place every Friday through July at 11 am ET. Registered participants receive a list of simple supplies needed, recommended books and links to related online resources.

This information can also be found in the museum's Joyful Fridays Learning Lab collection the first Monday each month. Participants can register for the free program at https://nmaahc.si.edu/events/upcoming. Past programs can be found on the museum's UStream page.

NMAAHC's Early Childhood Education Initiative works to support children's joy in human diversity and inclusion and develop a child's sense of justice and racial identity. The initiative educates children from birth to 8 years old by providing age-appropriate materials and resources for caregivers and educators to support children's growth. The Early Childhood Education Initiative web page has more education and child development resources.

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National Museum of African American History and Culture Announces Children's Booklet Series and Weekly Children's Programs

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Inspired by its children's book A Is for All the Things You Are: A Joyful ABC Book , the Smithsonian's National Museum of African American History and Culture recently launched a new activity booklet series designed for infants, toddlers and early learners.

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Anti-racism - Government of British Columbia

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Hua Foundation
Hua Foundation is a youth empowerment non-profit working on racial equity and civic engagement issues on unceded Musqueam, Squamish, and Tsleil-Waututh territory known as Vancouver, Canada.

Challenging Racist "British Columbia": 150 Years and Counting
This multi-media resource documents how the recent cycle of anti-racist activism is part of a broader history of Indigenous, Black and other racialized communities challenging white supremacy for over 150 years.

Be Anti-racist
BC's Office of the Human Rights Commissioner examines what stands between us and an anti-racist province.

CBC Unmasking Racism
Unmasking Racism is a virtual town-hall segment on systemic racism that explores solutions to build safer, more inclusive communities.

Stratagem, Equity and Inclusion
By Cicely Blain Consulting, this 60-page printed workbook is an immersive, deep-dive resource about equity, inclusion and social justice.

Decolonize First
By Ta7talíya Michelle Nahanee, this is a liberating guide and workbook for peeling back the layers of neocolonialism. It features 16 pages of process, prompts and links to resources to support your decolonizing journey.

I Dream Library
This website offers educational tools promoting 2SLGBTQQIA+ IBPOC representation in classrooms and libraries. It features readings lists for kids in pre-kindergarten and Grades 8+, including social justice and sexual orientation and gender identity (SOGI) booklists.

The Skin We're In
Puncturing the bubble of Canadian smugness and naive assumptions of a post-racial nation, Desmond Cole chronicles one year - 2017 - in the struggle against racism in this country. It is a vital text for anti-racist and social justice movements in Canada.

Hogan's Alley Society
This organization provides a collection of anti-racism resources specific to the Canadian context. The site also provides a way to get involved in their Metro Vancouver Regional District Black Experience Project, which maps out the experiences, contributions, and challenges of people of African descent in the city.

Call It Out
This 30-minute interactive e-course by the Ontario Human Rights Commission allows you to learn about the history and impact of racism in Canada. It helps you unpack terms like "race," "racial discrimination," and "white privilege," and guides you as to how you can prevent and address racism and hate.

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We all have a part to play when it comes to anti-racism.

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Hua Foundation Hua Foundation is a youth empowerment non-profit working on racial equity and civic engagement issues on unceded Musqueam, Squamish, and Tsleil-Waututh territory known as Vancouver, Canada. Challenging Racist "British Columbia": 150 Years and Counting This multi-media resource documents how the recent cycle of anti-racist activism is part of a broader history of Indigenous, Black and other racialized communities challenging white supremacy for over 150 years.

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"I'm not sure Asian-American families can avoid 'the talk' any longer," one expert said.

Credit... Kim Ryu

My daughter was the only kid who didn't have a separate Korean name when we signed her up for Korean classes three years ago. The blank space on the registration form looked at me, as if to say we'd forgotten something as parents.

When she was born in the United States in 2012, my spouse and I, who are both Asian-American, never thought to give her a name like Seohyun or Haeun. Though Korean was the language I spoke growing up in New York with my immigrant parents, I've forgotten many of the words I used to know. Yet hearing it spoken still conjures the sense of home.

I had no ambition to teach my daughter Korean, but when she turned 5, she insisted she wanted to learn so she could talk to her halmoni - her grandmother. So I conceded.

On Seollal, the Korean New Year, she and the other girls in her class sported traditional silk outfits. The floor-length skirts flapped to show their patterned leggings underneath, in a church basement that smelled of steamed rice and sesame oil.

It was familiar and reassuring.

Still, I kept asking my daughter when she would try soccer, which seemed to me the "American thing" to do on a Saturday morning. It was held at the same time as Korean School. I kept thinking about the parents on the sidelines and wondered what we were missing.

In March 2020, my daughter was in first grade, eager to talk about a school assignment that asked her to write about a problem and how to be a part of solving it. Her response was that women should be paid the same as men. I felt proud.

But then she continued. A classmate had written that coronavirus was a problem and that keeping Chinese people out of the country was the solution.

Later the other kids asked: "Are you Chinese?"

In the summer of 2020, the Stop A.A.P.I. Hate Youth Campaign interviewed 990 Asian-American young adults across the United States about their experiences during the pandemic, and found that one in four had reported experiencing racism in some way.

Kids said that they had been bullied, physically harassed and had racial slurs shouted at them. Dr. Juliana Chen, a child and adolescent psychiatrist at Mass General Brigham, said that kids who experience this kind of racism may stop going to school or speaking up in class. They might start acting out, feel unwell, have trouble sleeping or struggle with depression.

Tiffany Yip, a developmental psychologist at Fordham University, said that a child who hears a racist remark hears this: "You don't belong. You're other. You're different."

We are one of only a handful of Asian-American families in our school, which prides itself on teaching about inclusion. Earlier in the year, our daughter came home talking about Malala Yousafzai and Ruby Bridges, asking where we would have been sitting on the bus in times of segregation. Now I questioned what racial biases our progressive community might have held.

When schools closed and our country locked down, my family took daily walks, chalked the sidewalks, looked for teddy bears in windows, and tried to smile from behind our masks. But when a girl in our neighborhood pointed to my daughter and said they could not play together because of the "China virus," I wept.

During lockdown, we devoured books with Asian-American heroines by authors like Grace Lin and Min Jin Lee. I marveled: "That's my family's story." While my 7-year-old jumped from the couch, she said of one of the characters: "She likes to eat dduk guk" - Korean rice cake soup - "like me!"

Next we read about Li Keng Wong, a 7-year-old who was detained at the Angel Island immigration station in San Francisco in 1933. We admired the poems carved into the barracks there, wrote poems of our own, and taped them to our bedroom walls. But I struggled to find the words to explain to my daughter why Chinese-Americans were forced to live in these barracks; why they were separated from their families.

She doesn't yet know about the 84-year old man who died two days after being shoved to the sidewalk in Chinatown in San Francisco last month, or about the six Asian-American women killed by a shooter in Atlanta this week. While attacks on Asian people aren't always charged as hate crimes, many Asians feel an increasing sense of vulnerability.

And I found the answer to my daughter's question about where we would sit on the bus. Asian-Americans have our own, less well-known place in the civil rights story. Asians also lived in the South in the 1950s, and we, too, would have been told to move to the back of the bus. In the 1860s, there were segregated schools for Chinese-American children, for families that looked like ours.

I am finding the language to share this with my daughter. I will tell her about these injustices and I will remind her of Fred Korematsu, an American civil rights activist who objected to the internment of Japanese-Americans during World War II, and others who in their bravery spoke their minds when they disagreed with what our systems condoned.

Kids begin to develop a sense of racial identity by age 3 or 4, Dr. Yip said. Once they enter grade school, they hear about race and racism from peers and the media they consume.

"By not talking about race" and what they're hearing, Dr. Yip said, "you run the risk of intensifying stereotypes" which can then lead to racism.

As parents we fear these hard conversations, but Dr. Chen said that it's important to ask certain questions: What have you heard? What do you worry about? What's school like for you and your friends? Has anything like this ever happened to you or someone you know?

"We think we're protecting our kids, by not talking about racist incidents" Dr. Chen added. "But actually not talking about it is not helping." Building their racial identity is what helps them feel safe.

When a racist incident happens to your child, Dr. Chen said, don't jump into solving the problem. First ask how they feel and listen. Tell them you don't know all the answers, but you can find solutions together.

Dr. Yip also suggested telling teachers and school leaders about the incident. Parents can help start a conversation with all the kids involved. Ask: "Can you help me understand why you did this? How do you think it makes others feel?"

Make sure that the children who were targeted know it wasn't their fault, Dr. Chen added. Role play what you will do if it happens again and tell them, Mom or Dad or your caregivers will keep you safe.

"Black families always have the racial talk," Dr. Yip said. But many Asian-American families in past generations did not. They emphasized assimilating to what they thought was a post-racial state. Now with the surge in harassment and hate incidents, she said: "I'm not sure Asian-American families can avoid 'the talk' any longer." It's a talk that must include listening to, and coming to understand, all groups who face racial bias.

In hindsight, I now see that Korean School has done more for my family than soccer ever could. It's a place where my daughter sees she isn't alone. There are families who look like ours and wrestle with the same questions, about what we will forget, and what we will keep from our immigrant families' pasts. Being in a community equips us to be resilient in the face of the racism that we will inevitably encounter. I resolved to teach my daughter about the parts of myself that I, for too long, believed were meant to be forgotten. This will anchor her in who she is becoming, as an American.

It's been a year since the pandemic began. Ideas around race and identity have shifted in a seismic way. My daughter has gone from sewing masks for her bears, to carrying Black Lives Matter posters and voting with me in a presidential election. Her memories of these historic events will take shape over time.

But for now, she is 8. She is learning to do cartwheels and is making dioramas and writing short stories. When she grows up, she says she wants to be a writer. She's decided already on a character for her first book. Her name will be Minjee.

Read books, watch movies and consume media with racially diverse characters. Read with your children or talk with them about what they're reading.

Be proactive in bringing up conversations about race with your kids. Ask them what they are hearing and experiencing.

Kids will hear what's happening in the news. Discuss it with them in an age-appropriate way.

Role play what to do when you see a racist incident. Talk to your kids if a racist incident happens to your child or to someone in your community.

Read this parenting guide for parents of Asian-American teens: How are you and your children talking about racism?

Share these resources from the M.G.H. Center for Cross-Cultural Student Emotional Wellness with your kids.

Explore additional resources for talking about race with younger children such as Embrace Race and PBS Kids for Parents.

Sources: Juliana Chen, child and adolescent psychiatrist, Mass General Brigham; Josephine Kim, faculty, Harvard Graduate School of Education; Tiffany Yip, developmental psychologist, Fordham University

Heidi Shin is a journalist and a public radio and podcast producer. Follow her on Twitter @byheidishin and Instagram @shinherrie3

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I'm Helping My Korean-American Daughter Embrace Her Identity to Counter Racism

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"I'm not sure Asian-American families can avoid 'the talk' any longer," one expert said. My daughter was the only kid who didn't have a separate Korean name when we signed her up for Korean classes three years ago. The blank space on the registration form looked at me, as if to say we'd forgotten something as parents.

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​​​By: Ashaunta Anderson, MD, MPH, MSHS, FAAP & Jacqueline Dougé, MD, MPH, FAAP

Given the tragic and racially-charged current events, many parents are wrestling with their own feelings, the hopes they have for their children, and the difficulty of helping those children thrive in a world full of racial bias.

Parents may better face today's challenges with an understanding of how racial bias works in children, as well as strategies to help them deal with and react to racial differences.

How Do Children Learn Racial Bias?

Children learn about racial differences and racial bias from an early age and learn from their first teachers-their parents-how to deal with and react to these differences.

The process of learning racial bias is a lot like learning a new language (e.g., a child raised bilingual vs. a child who starts learning Spanish in junior high). Biology determines a critical early learning period as well as a later window where learning is much harder.

As early as 6 months, a baby's brain can notice race-based differences.

By ages 2 to 4, children can internalize racial bias.

By age 12, many children become set in their beliefs-giving parents a decade to mold the learning process, so that it decreases racial bias and improves cultural understanding.

But like language immersion, children exposed to society will gain fluency in racial bias even if their parents do nothing.

Strategies to Help Children Deal with Racial Bias

There are three strategies that parents can use to help their children deal with racial bias:

Talk to your children and acknowledge that racial differences and bias exist.

Confront your own bias and model how you want your children to respond to others who may be different than them.

Encourage your children to challenge racial stereotypes and racial bias by being kind and compassionate when interacting with people of all racial, ethnic, and cultural groups.

How Parents Can Confront Their Own Racial Bias

Parents must first confront their own biases, so that their example is consistent with messages of racial and ethnic tolerance.

Be a role model. Identify and correct your own racially biased thoughts, feelings, and actions. If you want your children to believe what you preach, you have to exhibit those behaviors as well. Your everyday comments and actions will say more than anything else.

Travel and expose your children to other communities. This can help them understand that there is diversity in the world that might not be represented in the community that you live in.

Do not reverse stereotype police officers and other groups or talk about law enforcement in a negative way.

Get involved in your child's school, your place of worship, and politics. Parents who are involved in this way are better able to advocate for fair treatment of racially marginalized groups and raise awareness of race issues in other groups.

Tips for Talking About Racial Differences & Racism

For preschoolers: At this age, your child may begin to notice and point out differences in the people around you (i.e., at the grocery store, at the park, etc.). If your child asks about someone's skin tone, you might say, "Isn't it wonderful that we are all so different!" You can even hold your arm against theirs to show the differences in skin tones in your family.

For gradeschoolers: This is the age that is important to have open talks with your child about race, diversity, and racism. Discussing these topics will help your child see you as a trusted source of information on the topic, and he or she can come to you with any questions. Point out stereotypes and racial bias in media and books such as villains or "bad guys" in movies.

I f your child makes comments or asks you questions about race based on school incidents or something they read or watched: Further the discussion with questions such as,"How do you feel about that?" and "Why do you think that?" This is also helpful if your child heard something insensitive or if your child experienced racial bias themselves. Before responding to his or her statement or question, figure out where it came from and what it means from his or her perspective. See Talking to Children About Tragedies & Other News Events for more information.

Talking about race is not racist. It's OK-and important. From a young age, children may have questions about racial differences and parents must be prepared to answer them. But, it's important to keep your child's developmental readiness in mind.

These conversations begin to lay the groundwork for your child to accept and respect everyone's differences and similarities. As children mature, the answers to questions will become more complex. These are moments to learn what your child understands or is struggling to understand about racial bias.

Remember:

To create a culture of inclusiveness, we all must look at and acknowledge our biases, so we can do something about the ones that are unfair or cause harm to others-like racial bias. Understanding the way people feel about and behave toward those outside their own group can help communities heal after a tragedy, as well as prevent future ones.

Additional Resources to Help Parents Address Racism & Discrimination:

About Dr. Anderson:

Ashaunta Anderson, MD, MPH, MSHS, FAAP is an assistant professor at the University of California, Riverside School of Medicine and a health policy researcher at RAND Corporation. Her research focuses on the impact of race and racism on child health. She is also a pediatrician and a published author of 50 Studies Every Pediatrician Should Know, a guide to the scientific evidence underlying everyday pediatric practice.

About Dr. Dougé:

Jacqueline Dougé, MD, MPH, FAAP is the Child Health Medical Director at the Howard County Health Department. Her interests are health disparities, media, school health and the interaction of public health and pediatrics. Within the American Academy of Pediatrics, she co-chairs the Council on Community Pediatrics' Prevention and Public Health Special Interest Group. Her blog site is drjacquelinedouge.com.

Ashaunta Anderson, MD, MPH, MSHS, FAAP & Jacqueline Dougé, MD, MPH, FAAP

American Academy of Pediatrics (Copyright © 2019)

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racial bias~ biases~ racism~ crime~ violence~ black~ police officer~ law enforcement~ racial issues~ skin color~ resiliency~ peace~ gun violence~ guns~ news~ tragedies~ current events~ violence in the media~ violence in movies~ explaining race~ difference

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​​​By: Ashaunta Anderson, MD, MPH, MSHS, FAAP & Jacqueline Dougé, MD, MPH, FAAP Given the tragic and racially-charged current events, many parents are wrestling with their own feelings, the hopes they have for their children, and the difficulty of helping those children thrive in a world full of racial bias.

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Over the last year, Priya Vulchi and Winona Guo traveled to all 50 US states, collecting personal stories about race and intersectionality. Now they’re on a mission to equip every American with the tools to understand, navigate and improve a world structured by racial division. In a dynamic talk, Vulchi and Guo pair the personal stories they’ve collected with research and statistics to reveal two fundamental gaps in our racial literacy -- and how we can overcome them.