30 Scientific American, December 2021 Illustration by Fatinha Ramos
THE SCIENCE
OF HEALTH
Claudia Wallis is an award-winning science journalist
whose work has appeared in the New York Times, Time,
Fortune and the New Republic. She was science editor
at Time and managing editor of Scientific American Mind.A pandemic is a stress test for society, revealing not only hidden
cracks in health systems but also broader social failings. A deep
fissure further exposed by COVID is the long-standing inequity in
the health and medical care of racial and ethnic minorities. The
outbreak has shown that Black, brown and Indigenous adults in
the U.S. are more medically vulnerable than other people because
of factors such as a heavier burden of chronic diseases, limited
access to care and the cumulative effects of racism. The care gap
is so bad even minority children who are relatively healthy and
have not experienced decades of discrimination fare worse than
their white peers during common, straightforward operations. The
questions for all of us are: Why—and what can be done about it?
First the facts. An abundance of studies has shown that Black
children do worse than white children in surgery. More compli-
cations and higher death rates have been documented in abdom-
inal, cardiac, oncological and other types of procedures in Black
children, and it isn’t just because they routinely start off sicker.
A 2020 study in the journal Pediatrics by researchers at Nation-
wide Children’s Hospital in Columbus, Ohio, looked at the rate
of surgical complications and deaths in the 30 days after inpa-
tient procedures for 172,549 Black and white children who were
judged—by a standard medical rating system—to be in general
good health. Problems were rare overall, but Black children were
18 percent more likely than white children to have complications
and more than three times as likely to die.
“We were surprised,” says Christian Mpody, a pediatric epide-
miologist and co-author of the paper. “We know that the sicker
you are at presentation, the more likely you are to have compli-
cations. When we see a relatively healthy population, we should
not see the disparity.”
To investigate further, Mpody and his colleagues zoomed in on
one of the most common surgeries for children: appendectomy.
They compared the rates of complications between Black and white
children, examining the records of 100,639 procedures between
2001 and 2018. In a paper published this October, they reported
that the overall rate of complications declined through the years,
but the race gap scarcely narrowed. Black children always were
more likely to have complications, and the disparity held true
whether kids had an intact appendix or a burst one—a likely indi-
cator that the child was delayed in reaching the hospital or receiv-
ing care. The difference remained when researchers adjusted for
factors such as socioeconomic status and insurance coverage.
The two studies suggest that “there are some within-hospital
factors that play a role,” Mpody says. Earlier studies hint that
facilities may not be treating all children equally. A 2020 analy-
sis of emergency department records found that Black children
with appendicitis were less likely to be promptly diagnosed and
to get timely diagnostic imaging than white children. A 2015
study showed they were also less likely to receive any medication
for their abdominal pain. Such inequities may reflect implicit and
explicit racial bias on the part of staff, as well as structural rac-
ism embedded in practices at the facilities, says Monika Goyal,
lead author of both studies and an emergency medicine special-
ist at Children’s National Hospital in Washington, D.C.
Mpody’s appendicitis study did more than size up racial inequal-
ity; it put a price on it. The study found that hospitals incurred
higher costs from dealing with complications in Black patients—a
median of $629 more per child than for white kids. That means
hospitals could potentially save money by improving health care
for minorities. “While the cost argument feels sort of icky, we oper-
ate in a health-care system built on capitalism, so it matters,” says
Rachel Hardeman of the University of Minnesota School of Public
Health, who studies racial equity and reproductive health. She
points out that hospitals routinely engage in “continuous quality
improvement” efforts, but they don’t often prioritize health ineq-
uities as part of them. Hardeman says the economic argument
made by studies such as Mpody’s could begin to change that.
Hardeman’s own work suggests that training doctors and staff
to reduce unconscious bias could help close the race gap in out-
comes. Increasing the racial diversity of the medical workforce
could also help. Her research—and that of others—shows the out-
come gap narrows dramatically when Black doctors care for Black
patients. Black people make up 13 percent of the U.S. population
but only 5 percent of doctors, a number that has barely budged
despite diversity recruitment programs at medical schools. By hir-
ing more diverse staff, among other efforts, hospitals could be -
come places where all children have equal rights to get well.Unequal Surgery
Black children suffer more complications
after operations than white kids
By Claudia Wallis