Addressing Racial Bias in Pediatric Medicine with Drs. Nia Heard-Garris and Monique Jindal

[00:00:00] Erin Spain, MS: Welcome to Science in Translation, a podcast from NUCATS, Northwestern University Clinical and Translational Sciences Institute. I'm your host, Erin Spain. There are many benefits to be had when investigators from CTSA hubs collaborate on projects that aim to excel the translation of research into the clinic and the community. Today we're highlighting such a collaboration between two Chicagoland CTSA hubs, which led to research uncovering persisting racial disparities in children's healthcare. Here with details is Dr. Nia Heard-Garris, a member of NUCATS and an assistant professor of Pediatrics at Feinberg and an attending physician at Lurie Children's Hospital, as well as Dr. Monique Jindal, an assistant professor of Clinical Medicine at the University of Illinois Chicago School of Medicine and a member of the Center for Clinical and Translational Science at UIC. Welcome to the show, both of you.

[00:01:03] Dr. Nia Heard-Garris: Thank you so much for having us. Really delighted to be here.

[00:01:06] Dr. Monique Jindal: Yes. Thank you. Excited to have this conversation.

[00:01:09] Erin Spain, MS: Well, I'm excited to have you both on here as well, and I want to dig into your backgrounds a little bit. You are both very passionate about clinical practice and policy that supports children, their families, their communities. Tell me a little bit about your research backgrounds. Let's start with you, Dr. Heard-Garris.

[00:01:26] Dr. Nia Heard-Garris: So I fell into research, if I'm being honest. I grew up seeing lots of disparities. I didn't know that's what they were at the time. But just growing up as a child divorced parents, I lived in two different neighborhoods and they couldn't be more different. One neighborhood, we talked about college and the future and all of the things that people would expect. And then my other neighborhood, there was no talk about that. There was no grocery stores, there was no fresh fruit. And I always wondered why. And so that really launched me into this career because I was interested in policy, I was interested in advocacy. And when I did a fellowship and research, they said, oh, you can actually ask and answer these questions and try to figure out what solutions could be on a population level. And so that's really why I got into this work is trying to ask and answer questions that I thought were important to my community and things that could actually move the needle with respect to policy and medicine and just health overall.

[00:02:22] Erin Spain, MS: Is a personal tie here.

[00:02:24] Dr. Nia Heard-Garris: For sure, for sure. And it's important for me. We write all these papers and do all this work, but if my family doesn't understand what I'm doing, I'm doing something wrong.

[00:02:32] Erin Spain, MS: Dr. Jindal, I want to hear about your background. What led you to this type of work?

[00:02:36] Dr. Monique Jindal: Yeah, I mean, I think similarly I fell into it. During residency, the first time you're really getting to truly interact with patients and get to know them and get a little glimpse into their lives, outside of the clinic room as well, you start realizing all of the things that are impacting their health, so much of which is nothing that's in that clinic room and so many things outside of it. And you know, I was seeing this every day. I was seeing the patients that were struggling, I would see my peers getting frustrated with patients and their circumstances. And I think taking a step back and realizing how much was basically set up against our patients became like a big catalyst for me to decide I need to do something bigger than just being in the clinic. I need to think about this more broadly and maybe have an impact on the overall social settings that are impacting our patients' lives .

 [00:03:31] Erin Spain, MS: I'm not surprised that you two found each other as collaborators, but I'm curious: how did that happen?

[00:03:36] Dr. Monique Jindal: I've been following Nia's work, so I was fangirling for a while, I'm sure. The first time we officially met was when I had applied for a research fellowship at Lurie, and so Nia had interviewed me and we realized right away the similar passion.

[00:03:53] Dr. Nia Heard-Garris: Yeah, and we've since collaborated on a lot of different things, but this most recent collaboration has been a labor of love. And thankfully, Monique has the passion, the brilliance and perseverance to push through on this one

[00:04:06] Erin Spain, MS: We're talking about a paper recently published in The Lancet Child and Adolescent Health, and in the paper, you reviewed data from five years of recent studies and found that non-white children almost universally received worse quality care than white children. However, this discrepancy was much worse in emergency medicine. Let's talk about this. Why is that particular disparity so urgent?

[00:04:29] Dr. Nia Heard-Garris: I appreciate that question because I think it gives us an opportunity to really flesh out the nuance. So we saw that in emergency department, a lot of the research was persistent in showing disparities, but I actually am not convinced that it's worse in the emergency department. I actually think there is more research happening in that space, that more researchers are committed to uncovering disparities and thinking about health equity much more than other disciplines. And so we had a lot of findings with respect to what's happening in the emergency room or the emergency department, but that's because people are looking. I'm not convinced that there are more disparities in the emergency room as compared to, let's say, surgery or palliative care or other fields, but it's just we've got more committed people really looking for those.

[00:05:13] Dr. Monique Jindal: And I think that there is a component of our fast thinking when we're making clinical decisions. And so, in an emergency department setting, you think about all of the pieces that are happening, whether it's a busy environment, you have many patients at once, you have to think quickly. And so when we think about racial bias or some of the attitudes that we have and the quick thinking that we can do to make a decision that often is led by our biases when we are stressed by other things around us, there might be some interesting work to be done there to understand how that might look different in an emergency department setting versus primary care or something else. But I agree that we just don't have enough research in all these different settings to say where it might be worse.

[00:05:57] Dr. Nia Heard-Garris: If I can just add on to what Dr. Jindal said, because I think she made such a great point in thinking about how care changes or is led by bias . When you're stressed and you're hungry and you're tired and you're managing so many patients. And I would say Dr. Tiffani Johnson, who is a co-author on this work, has done a lot of research in this space and saying how implicit biases, so these are biases we're not really conscious of, can lead to worse outcomes and that is very clear in the emergency room but also in the ICU and also in surgery and also in primary care. And so I think what Dr. Jindal's saying is being able to test these differences would be really important for future work. Like, is it only in the emergency room? I doubt it. But is it more prevalent? Maybe.

[00:06:38] Erin Spain, MS: Dr. Heard-Garris, there's still more work to be done in this area, but you have recommendations in the paper that you've outlined for health researchers and providers that they can start implementing right away or in the near future. Can you tell me about those?

[00:06:52] Dr. Nia Heard-Garris: I think we really require a radical change in our thinking, in our structures and our building of structures and thinking about the healthcare system, healthcare delivery, as well as many, many other systems, which I will let Dr. Jindal talk about. In our paper we looked at studies where insurance was less of a factor, so we know there's differences between public insurance and private insurance. Absolutely. But we focus really on those papers to say, insurance is not the driver here necessarily, so what are these other things that we need to be thinking about? And so, of course, implicit bias that I mentioned earlier is one of the things we need to think about in changing practice and also changing policy and very explicit biases for certain patients and certain populations. From a perspective in healthcare systems, three main domains I would say are research, policy and practice. We need to think about how do we desegregate pediatric care. So that includes financing at a local, state and national level, to reduce residential segregation and also make sure access is actually equitable for people. And then of course, the diversity of the medical workforce. We need to think about ways to ensure that people are able to actually enter healthcare professions that would like to from all different walks of life. From a practice standpoint, I think it's really important that hospitals and healthcare systems review their own trends and what's happening with their own patients locally. And if there are disparities that exist within vaccines or surgical outcomes or palliative care consults, that they investigate those and work on what are the reasons why and try to find solutions to fix those things, as well as thinking about metrics, like how do we make sure that we're incorporating equity within our metrics? There's a lot of push from different hospitals to do quality improvement studies and quality improvement work. So how do we make sure that there's an equity lens when we do that work? And then the last domain really is my space in research. Researchers have a lot to do. Like I mentioned earlier, the emergency room and emergency department, there's a lot of researchers that are focused on disparities. We need other researchers and other specialties to pick up the mantle and really think about disparities, equity, racism within their own specialties, so that we can not only uncover these health inequities but also think about solutions and interventions to fix them and address them. So developing evidence-based literature and scholarship around this work is important because if we don't know that disparities exist, we can't then address them.

[00:09:24] Erin Spain, MS: Dr. Jindal, you actually led the follow-up paper to this that laid out policy recommendations for systems beyond the hospital, ranging from health insurance to housing and criminal justice. Would you explain what you've called the "layered impacts" of these systems on children, and what's an example of these impacts here in Chicago?

[00:09:43] Dr. Monique Jindal: The reality is that you can't really talk about child health without talking about the many other systems that influence health and often, at times, over determine one's well being. So when we talk about the layered impact, sometimes people think about health and healthcare as if it's in this vacuum, but the reality is what their access to education, quality of their housing, access to, employment opportunities, access to healthy food, even access to the quality of healthcare that they're getting is dependent upon where you live. The list goes on and on. All of these things are upstream factors that impact one's health, and they're often interrelated. Maybe an easy one for people to wrap their head around is when we think about residential segregation. So oftentimes people call for redlining policies that happened in the 1930s up into the '70s. But they're not just historical policies. The impact of redlining is being felt still today. And there are many practices that basically continue to perpetuate residential segregation. that gets into the policy piece, right? So you think about the fact that those neighborhoods that were created still persist today. We still have poor investment in these neighborhoods. And so what that looks like is lack of job opportunities, lack of transportation, lack of healthy food, all of these things that I had already mentioned. And so, if we don't change those policies, the downstream impact on all of these other factors, that we often call social determinants of health, won't be changed.

[00:11:16] Erin Spain, MS: Tell me about the reaction that you both received from these papers. There was a lot of headlines in the media. Tell me about that experience and what came from it.

[00:11:25] Dr. Monique Jindal: Well, I think it's interesting,in some ways, the first paper of highlighting disparities. I think for all of us who do this work, it wasn't anything earth shattering, right? Like we know that Black children receive worse care than white children. We know that Black children have worse health outcomes than white children. And so it was interesting to see the shock value that some of the headlines had for people when to those of us who are really steeped in this work, this has been known for many, many years, and this was almost a re-upping of what we know to bring everyone to the current state.

[00:11:58] Dr. Nia Heard-Garris: I agree. I think what this series really added was putting them all together in one place, right? Making it easy to access what's happening in neonatology, what's happening in emergency rooms, what is happening in surgery. But I think Dr. Jindal's right in that we knew what we were going to find. We were dismayed still to find it, but we kind of anticipated what the results were going to be. When people saw all of the overwhelming evidence in every specialty – it wasn't just one hospital, it's not just one specialty, it's all of them – I think that's what really, really shocked people that it was so overwhelming. And so, different news outlets, even businesses, reached out and said, what can we do? Like, why is there disparities in pain for children? We found that appendicitis, digit replacement, which is a finger or a toe is removed and needs to be amputated, those things are painful. Why are kids not getting care for that? And so I was happy to see that there was such a response. We always, in this space, want to see not just the reaction but people working together on solutions to help make this problem better. We never want to see kids in pain. We don't want to see kids die in the hospital. We don't want to see kids born too early, or low birth rate. So how can we really use a multidisciplinary approach, a multi-sector approach, business, philanthropy, medicine, all of these players to make healthcare better for kids?

[00:13:23] Erin Spain, MS: You're both part of NIH Clinical and Translational Science Awards or CTSA programs, which aim to accelerate the translation of research into the clinic and community. Can you elaborate on this cross-institutional collaboration between NUCATS and CCTS and the possibilities that it opened for this study and other work?

[00:13:44] Dr. Nia Heard-Garris: I'll just say that Lancet reached out and said, Is there a space for work like this? Does this already exist? Should we work on it? What do you think? asking me. And I remember having lunch actually with Dr. Jindal and being like, I don't know about this. I don't know if I should say yes to this. It seems like a really big ask. Disparities are present, we know that. And she is like, Yes, we absolutely have to do that. I will write it. I will do it. So if she had not said yes, and we had lunch and we had built this collaboration already, this series would not have happened without her and her encouragement and, again, persistence and perseverance because it took a really, really long time and a lot of hard work. And so I will just say without that colleague encouraging, promoting, pushing the field forward with this collaboration, this wouldn't have existed.

[00:14:32] Dr. Monique Jindal: Dr. Heard-Garris, you have been such an amazing sponsor in my career, and I wouldn't have had this opportunity without you. so I think that just speaks to the necessity in this work to collaborate with people who understand you, who have similar passions, who will stay up late working on things even when they don't want to and will lean on each other for that support.

[00:14:55] Erin Spain, MS: What message would you like to give to other researchers at each of your institutions about creating these bridges and connecting with your colleagues at other Chicagoland CTSAs? Why is it important to make these connections?

[00:15:08] Dr. Monique Jindal: I think in our own institutions, we all have many resources and many opportunities, but at the same time, we work and live in silos. And so, oftentimes, we may not see the whole picture. We might not have the bandwidth to tackle the issues that we want to. And I mean, Hey, we're talking about structural racism, so certainly one person, one researcher, one institution, it's not going to cut it. When we think about the end goal of all of this work, which is improving pediatric care and pediatric wellbeing for all children, but especially minoritized children, we need each other. And if we don't collaborate across institutions, across cities, across the country, this will continue to be a universal problem.

[00:15:52] Dr. Nia Heard-Garris: Research is a team sport and it can be really lonely depending on what you're studying, where you are. A lot of people that do health equity work, anti-racism work are one of the few or only in their institutions. And I think it makes so much sense to build bridges across institutions with people that, Dr. Jindal said, understand you, understand the work, understand your research questions. I remember early on people giving me a lot of pushback. You're a physician, why are you studying that? That doesn't have anything to do with health. And you know, not having to explain yourself, having people that get you, it provides solidarity and community in a space that sometimes is really lonely and isolating. So it's absolutely necessary in my mind.

[00:16:32] Erin Spain, MS: I know that the CTSA programs have made a push in recent years to provide investigators with information about addressing racial disparities. Can you talk a little bit about some of the resources maybe available through both of your institutions, and how can investigators who are wanting to know more and wanting to know how to do this work or incorporate anti-racism into their work, how can they get started?

 [00:16:55] Dr. Nia Heard-Garris: I would say for Northwestern specifically, they've been very instrumental. I teach a course in the summer with Dr. Susanna McColley about anti-racism in research specifically. So we talk about methods, we talk about design, recruitment. How do we partner, truly partner with communities to build studies and research that really matters to them, to communities. Like I was telling you earlier, if my community, if my family, if they don't understand why I'm doing it and the importance of it, then I'm doing something wrong. So trying to convince other researchers to not only incorporate communities but really put them at the center of their design and their questions and making sure they're collaborators and partners and leaders of the work. Our CTSA has been very instrumental in doing that and allowing us the space, so much so that for one of the masters at Northwestern, it's a required course. And I was concerned. Before it was a selective group of people that wanted to learn this work. And now everybody must take this class. And honestly, the response has been amazing. People are asking new questions and thinking about their research in a lot of different ways. It's principal investigators, it's the research assistants, it's the medical students that are changing their study design, thinking about anti-racism, thinking about health equity in different ways. So I'm really grateful for their support in pushing us to push our next generation of researchers.

[00:18:17] Dr. Monique Jindal: I think we can, as researchers, at times underestimate the real community connections that our programs have. I think when we see patients every day, we think, Well, yeah, we're with the people, we know what their needs are, what their experiences are. But the reality is that we don't go home with them. We're not in their neighborhoods. I reached out to our CCTS to get some advice on community engagement and areas where we maybe already had connections and to learn about where they had already had built community connections and had already fostered trusting, meaningful relationships, and then even learning from them with their encouragement to, you know, say,Don't just tap into this community when you're ready for your research project. If this is something that you want to do, start talking to them now. Recently I talked to them about going into one of the communities and just being there to answer health questions at one of their community center meetings. And that's not something that necessarily I would've known to say, Oh, the community wants this. But the community asked CCTS for this. They asked the Community Engagement Corps. within the CCTS to provide this. So then that starts building connections, right? And that starts creating these trusted relationships that have to happen in order to do really meaningful community engaged research.

 [00:19:33] Erin Spain, MS: Thank you both today for talking about your collaboration and your research, and I can see that you are an amazing team and I hope to see more from you in the future.

[00:19:44] Dr. Nia Heard-Garris: Thanks so much for having us and highlighting the work and our collaboration and our love for each other. It's important to do things that you care about and you're passionate about, but also with people that you care about and that support you and support the work every step of the way.

[00:19:59] Dr. Monique Jindal: It's a really good reminder for us, how lucky we are to have some of these connections and collaborations. So thank you so much for having us.

[00:20:07] Erin Spain, MS: Subscribe to Science in Translation wherever you listen to your podcasts. To find out more about NUCATS, check out our website.