Good day, everyone. My name is Louis Danpierre. I'm a pediatric intensivist practicing in Brooklyn, New York. I have been practicing in the area of New York for over 20 years. Today, I'm really excited to share some thoughts around the topic of diversity, equity, and inclusion. What I'd really like to address with you are the challenges for pediatric patients of a specific racial background and culture. But before I get into it, it is a pleasure for me to have been chosen by the ESCCM to share my thoughts, my experiences, and perhaps some of my readings around this topic. It's really an honor. Well, when it comes to diversity, equity, and inclusion, it is certain that our personal experiences will taint or will affect how we react to those issues. So let me begin by introducing myself as far as my personal experiences taint or color my opinions about this topic. I was born in Haiti, an island in the Caribbean that is mostly African American. But there, I wonder if we are really diverse, if we are really equitable, and whether or not everyone is included. It's a land of multiple contrasts, and at times, one may feel that it's not equal on every level. Certainly, there are times that I've felt that perhaps I have not been included, in spite of the fact that we're mostly African American and people of a different skin color might feel actually in a minority. After living there for 20 years, I migrated to Mexico, where I did my medical studies. There, I was certainly a minority. There were not many African Americans in the campus, in the area where we lived. However, imagine a posse of skinny, and some of them were tall, black men walking around the town of Montemorelos in the city of Monterrey, Mexico. This was in the era of Michael Jackson. We certainly felt as we were a minority, but always felt included. As a matter of fact, we were treated almost like celebrities there. So picture that. Fast forward, we migrated later to New York. That is often called the mosaic of cultures. So this is the background and the backdrop that I'd like to leave with you as we discuss this topic of diversity, equity, and inclusion. And I will furthermore share my personal experiences with you in that way. Well, as I shared with you earlier, the issue of inequity remains a problem in all societies, regardless of how homogeneous we might think they may be. It happens in many workplaces, and disparity also happens in homogeneous racial and or ethnic situation, whether it be economical, social, from an issue of language, from issues of religion, ideology, or even politics. It seems that human beings find many different ways to make it inequitable. Scholars have found that there is a difference between equality and inequity. And perhaps inequity is when it is just an issue of inequality that becomes unfair. So therefore, one needs to be quite cognizant of all these issues and have some introspection to be able to deal with them in the right way. In a broad sense, I find that after one has educated itself on issues of diversity, equity, and inclusion, the word that comes to mind is an issue of advocacy. Once one becomes an advocate, you're able to influence decisions and perhaps change conditions that are unfair, like I said before. So there are different platforms where one can become an advocate. One can become an advocate on the social issues, on institutional issues, and even on political issues. But as we know it now, the health of individuals become another platform where we must be advocates. We must not only be advocates in terms of how we deal with the science of health, but also on the social, the cultural aspects of the health of individuals. One can advocate both ways, either on an individual basis as to create social, cultural, and language connections, listening to patients, empathizing with them. And yes, I will say it, just love your patients. And also one can advocate in a collective way. But I have this question. Does it mean that minority patients benefit from minority doctors? Do patients benefit from the fact that the relationship or the concordance with a doctor or a patient of the same race, racial background, or ethnicity bring about some benefit or better connection? Let us explore that. As we explore these difficult questions, let us remind ourselves that changing public policy require quite a bit of work. One can change public policy by involving oneself into the media, by education, by changing the way laws are written, by changing the way that budgets are distributed, how individuals see one thing or the other. Lobbying is another way of changing public policy and also research and showing results of this research. Might also be other avenues or tools to change public policy and therefore creating a messaging that will compel people to change. However, my professional bias is to say to you that there is no greater way or situation where one must be an advocate because pediatric patients must be given a voice. We must involve their hearers, inform the public about situations that involve children because many of them cannot do it on their own. We must engage institutions, perhaps hospitals and pharmaceutical companies and on and on and on to hear us pediatricians and advocate for pediatric patients because they are the future of any society. And indeed, there's a plethora of tools that one can utilize for advocacy for children. Their bill of rights, their inherent rights, their ability or availability or their access to health care to make them safe, to make sure that there's quality of care for them. Education, creating networks and contacts for them, giving them emotional support, making sure that they have access to health care insurance. Children's hospitals do not exist without child life specialists. There are professional groups that advocate for children and their well-being and their health care. There are many networks that are available that we can tap into to help us advocate for our children. There are non-profit organizations galore that are ready to support, whether they are in children's hospitals or community hospitals with pediatric wards. There's a number of ways that one can tap to advocate for children. When it comes to issues of race and culture, there are some who believe and strongly believe that minority patients benefit from having a minority physician or a minority doctor. But they certainly say that this would be a tall order. And Dr. Huerto and Lindo wrote in this article trying to find the link between doctors that are minority and patients that are minority having significant benefits. And we shall explore some of their thoughts here. They try to advance that when a patient and a provider are from the same race. And there's a specific term that I have been introduced to that is the ethnic concordance, meaning that there's an increasing likelihood of matching a patient with a provider, the provider's race or ethnicity. And by doing so, one can improve communication. It sounds intuitive. And there are some articles that are promoting the fact that when there's concordance, there's improved communication. When there is concordance, there's better compliance with medications, especially when it relates to adult patients with cardiovascular health. The doctor-patient relationship might improve in adult patients when there's concordance. And it seems also that there's a quicker acceptance of the treatment, perhaps because communication has improved, then the acceptance to the treatment might be better. Let's be cautious here because we're talking about adult patients. Well, let us take a closer look at this here. This pie shows that the majority of physicians in the US are of the Caucasian race, the white race, at 56.2%. The next largest pie here is at 17% Asian. And some of the minorities are barely represented here. So how do you provide concordance for the majority of patients? That is a tall order, especially in the United States. Furthermore, in an article published in Pediatric Critical Care Medicine, looking at the practice patterns in Pediatric Critical Care Medicine, we see what happens here in the workforce in their surveys. 64% were male. Hispanics form only 7.1%. Caucasians, 81.6%. And look at the African-American representation, 2.6%. How can I match and be concordant with patients of the race that I am pertaining to? That is quite impossible. And the sad thing here is quotes from this article. They're a slight gain since 1977. Look, the percentage of African-American increase from 2.2% to 2.6% only. That is very dismal. And what is sad, again, is that the increase is so meager that we'll never get to that order, if that were the case. The good news for me as a pediatrician is that there are some articles that have looked at this issue of concordance, and they speak much differently than the articles that are relative to adult patients. And this article written by George D. Stevens and Barry Zuckerman and Neil Houghton, look into the parent-provider relationship and ask the same question, does race, ethnicity, concordance, or discordance influence patient reports on the report of high quality basic pediatric preventive services? Does it? And the result of this study here is very different. Whether a patient lives in a urban or non-urban environment, white, black, or Latino, when patients and their providers were concordant or discordant, as you compare them, there was no statistical significance in the basic preventative care that they had received, which means whether a patient is of the same race and or ethnic background living in an urban or non-urban environment, it doesn't matter what the race of the provider and or the patient is in terms of providing good care for pediatric patients. I believe this is good news. Therefore, just to reiterate the point in broader, bigger letters, when it comes to pediatric patients, when there is a non-concordant provider, in spite of or despite the racial and or ethnic difference, there is no statistical significance. There is no disparity in basic preventative services, and there is no disparity in family-centered care, meaning basic preventative care is fair for all patients, regardless of ethnic or racial background, and family-centered care the same. However, when there was no regular provider continuity of care, we found that there was differences in family-centered care because of the non-regularity in all the groups. So, I submit to you that the efforts should be focused on all the factors instead of racial and or ethnic background. They should be focused on understanding the social contexts, cultural contexts perhaps, and maybe linguistic differences. However, there's work to be done because it is not all fair when it comes to enrollment and recruitment for pediatric patients, especially when it relates to asthma, out-of-hospital cardiac arrest, trauma sepsis, issues of oncology, and even perception of care. Patients that are in the minority, or minority patients, do not get the fair treatment. The treatment is with disparity, which means there is inequality that is unfair or inequality that can be changed, inequality that doesn't need to exist, disparity that exists for a reason that is not right. So, let us think about this a little bit more profoundly. And look, even in major clinical trials, there are unfair advantages. Restore has found that Black and Hispanic patients were less likely to be approached to even receive a consent to be part of a study that perhaps doesn't really involve a risk, per se. And it seems that they declined the consent even more frequently. So, some conclusions that one might take home is that perhaps if there was a concordance between the provider or the consent taker, and the parent, could that have made a difference? Or perhaps since there was a lack of consenting of minority patients in this study, can we generalize the findings? How about the benefit of underrepresented populations? But again, there's no point in belaboring it, because it is quite evident that ethnic concordance does not make a difference in the primary care in terms of racial and ethnic disparities for pediatric patients. However, pediatricians and pediatric intensivists at large should advocate for family-centered care. Invite parents on rounds. Include the patient as much as possible, especially when they are of a minority origin. Include child life in the consultation. Find language interpretation to break the barriers. Inclusion in clinical trials is something that we should practice significantly. Our involvement should not stop in the Pediatric Intensive Care Unit. We must find community partnerships and have connections from the Medical League of Canada. Be concerned with behavioral health. Immerse ourselves in finding resources that can help us advocate for our pediatric patients. Finding data on the community statistics, national features of well-being, and you can see here the links that one can use. Colleges, universities, national features of well-being, and you can see here the links that one can use. Community health rankings to know about the communities where our patients live. There are stats on health facts that one can know and find. There are cultural competency toolkits that are available. There is an AAP cultural effective care toolkit that is very helpful. The National Centre for Cultural Competence and Self-Assessment so that one can do self-assessments in terms of finding where you are in the spectrum. There is also the Implicit Association Test that is promoted by many, specifically here at the Harvard University, where one can test and find out where your own implicit biases reside. Well, look, we have all trained in major medical centres and children's hospitals, but we must also recognize that the access to critical care to these centres is not always available readily. The majority of pediatric patients are cared for in community hospitals, so therefore there needs to be a concerted effort to have critical care also close to home. This is not to say that the need for referral is not to be taken seriously. Networking with hospitals of a higher level of care is also essential, and we do recognize that, but we must form coalitions of pediatric care professionals who are also willing to work in community hospitals and maintain health and critical care accessible to all. And I submit to you that the majority of minorities live in inner cities and rural areas where critical care, as we know it in major medical centres, may not be available. So training like the PFCCS course and other life support training courses is also essential. Forming professional practice groups to cater to those inner city community hospitals is something that I definitely embrace. We must recognize the underserved areas and encourage underrepresented pediatric trainees into the practice of critical care. And as we saw before, there's not enough of us. We should all be mindful to mentor minority intensivists into the profession. The SCCM does have a diversity equity and inclusion committee, which I am part of, and there's a subsection on mentorship. Inclusion of the intensivists that are from the international communities, and specifically those that are from resource-limited areas, is also something that we must do. We must recognize worldwide disparities and encourage participation in global health as well. This perhaps will trickle down to all patients that are of the pediatric age range and help mitigate the disparities and the inequalities in unfair treatment that exists therein. My recommendations for pediatric patients that are of a specific racial background and culture is to, first of all, create social connections. Appreciate the diversity that exists in different cultures. Learn them, immerse yourselves in them before engaging patients and their parents. One must always mitigate the barriers that are created by different languages. Have a translator. Always look for a translator or perhaps a person that speaks the same language, and that can help a lot. We must advocate for all pediatric patients, whether it's in the PICU or beyond the Pediatric Intensive Care Unit. And lastly, I'd like to submit to you that there's no script, protocol, or guidelines in how to make social connections. And of course, diversity is good business, and we're hearing the buzz all around us these days. Educate yourselves about all the inequities that may exist around you. Mentor your patients. Ask them about their aspirations. Help minorities identify with Concordia providers, if possible. Create social and psychological interactions with adolescents, especially when they are from your race. And according to some experts, this promotes healthy development in them. And perhaps help them to envision a future self that may relate with you. Foster racial and ethnic pride in them. And I do recommend that one needs to make a diagnosis in the disparities that exist perhaps in yourself or in your environment. And lastly, effective social connections are more relevant than any racial or ethnic concordance that may exist. I thank you. I leave you with this. There may exist inequalities in health care outcomes from different populations. However, inequities are inequalities that are unjust, unfair, and certainly avoidable. So let us fight to change that and make it fair for all.

diversity

equity

inclusion

healthcare

ethnic concordance

family-centered care