Protecting children from racism: urgent health system actions
Authors: Sonora English, Thilagawathi Abi Deivanayagam, Tracey Bignall, Leandra Box, Jabeer Butt, Delan Devakumar
Journal: The Lancet (2024)

According to the United Nations Convention on the Rights of the Child, all children have the right to the highest attainable standard of health "without discrimination of any kind".1UNICEFConvention on the Rights of the Child.https://www.unicef.org.uk/wp-content/uploads/2016/08/unicef-convention-rights-child-uncrc.pdfDate accessed: December 15, 2023Google Scholar The UK has committed to upholding this right. However, not all children in the UK are equally protected. Racism is a known risk factor for health in children, ranging from preterm birth and low birthweight, to major depression and asthma, and childhood is a vital period that can shape health throughout the life course.2Selvarajah S Maioli SC Deivanayagam TA et al.Racism, xenophobia, and discrimination: mapping pathways to health outcomes.Lancet. 2022; 400: 2109-2124Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar When this is combined with other inequalities, poorer experiences and outcomes are exacerbated—for example, minoritised children with a learning disability are likely to die at a younger age.3Chauhan U Umpleby K Roberts C et al.We deserve better: ethnic minorities with a learning disability and access to healthcare.https://www.nhsrho.org/wp-content/uploads/2023/05/Part-A-RHO-LD-Policy-Data-Review-Report.pdfDate: July, 2023Date accessed: January 11, 2024Google Scholar These intersectional inequities are not natural or the result of biology. Rather, racism is undermining children's right to equitable, fair, and good health. Health systems are the very institutions designed to keep us well; their primary purpose is to promote, restore, and maintain health. This objective is incompatible with racism. Racism and discrimination in health systems can deter people from seeking timely care, cause harm to patients, create inequity in the care minoritised people receive, and contribute to misdiagnosis and delayed treatment. In other words, racism diminishes every aspect of WHO's quality of care framework including availability, accessibility, acceptability, and quality of care, thus undermining the ability to promote health.2Selvarajah S Maioli SC Deivanayagam TA et al.Racism, xenophobia, and discrimination: mapping pathways to health outcomes.Lancet. 2022; 400: 2109-2124Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar Racism pervades the UK health system, and urgent action to combat it must be prioritised. In October, 2023, Race & Health and the Race Equality Foundation organised a hybrid roundtable discussion to support holistic action on racism and child health in the UK. This roundtable discussion focused on racism in the UK health system, with the aims of identifying key areas of exposure to racism in the UK health system for children, and the main barriers to uprooting racist structures and practices in the health system. The roundtable discussion highlighted that racism shapes children's experience of the health system and their pathways to accessing it. For example, under racist so-called hostile environment policies, migrant children have been excluded from free access to secondary health care and must pay up to 1·5 times the normal tariff for their treatment upfront for non–urgent care, restricting their access to essential services.4Department of Health & Social CareNHS cost recovery–overseas visitors. Guidance for NHS service providers on charging overseas visitors in England.https://assets.publishing.service.gov.uk/media/65d33bdf0f4eb1f5bba98141/nhs-cost-recovery-overseas-visitors-february2024.pdfDate: 2024Date accessed: April 10, 2024Google Scholar These policies are enforced by health-care institutions, embedding racism and carcerality into the delivery of care. Meanwhile, the racist construction of criminality within social and mental health services shapes Black children's pathways to accessing mental health care.5Deivanayagam TA Lasoye S Smith J Selvarajah S Policing is a threat to public health and human rights.BMJ Global Health. 2021; 6e004582Crossref Scopus (16) Google Scholar Compared with White children, Black children are more likely to be referred to mental health care through social services and the policing system, and these referrals are less likely to be voluntary,6Kapadia D Zhang J Salway S et al.Ethnic inequalities in healthcare: a rapid evidence review.https://www.nhsrho.org/wp-content/uploads/2023/05/RHO-Rapid-Review-Final-Report_.pdfDate: February, 2022Date accessed: December 15, 2023Google Scholar often contributing to a lack of trust in health-care systems. Expert participants in the roundtable discussion also noted that racism in the UK health system is present in the delivery of care, as shown by unequal care outcomes, lack of access to translators, and overt interpersonal racism. Children's experiences of racism in the UK health system are compounded by their families' and caregivers' experiences, exacerbating racism's health impacts on children. A flourishing health system that supports good health for all children must be free from racism. Combating racism within the health-care system requires a concerted effort and there are still many persistent barriers to overcome. Substantial barriers identified during the roundtable discussion included: lack of high-quality data, NHS workforce issues, and failures of leadership, resourcing, and accountability. We need better data to capture racism experienced by children in the UK health system, including higher quality and more complete quantitative data disaggregated by race, ethnicity, and other forms of categorisation.7Devakumar D Rajagopalan S Strong KL et al.Racism, xenophobia, and discrimination: data disaggregation is a complex but crucial step to improving child health.Lancet. 2023; 401: 1321-1323Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar These data must be complemented by qualitative data that capture patients' experiences of discrimination in their own voices. Vast ethnic inequalities in leadership representation in the NHS and failure to combat inequity within the NHS workforce8NHS ConfederationChairs and non-executives in the NHS: the need for diverse leadership.https://www.nhsconfed.org/system/files/media/Chairs-and-non-executives-NHS-diverse-leadership.pdfDate accessed: December 15, 2023Google Scholar also present a major stumbling block in the fight for health equity. To combat racism and white supremacy in the UK health system, increased accountability amongst health professionals for dismantling structural racism is essential. Additionally, resources must be allocated to combating racism and better understanding the health-care needs of racialised children.9Müller M Growing up in crisis.https://www.urbanhealthcouncil.com/reports-playbooks/growing-up-in-crisisDate: July, 2022Date accessed: December 15, 2023Google Scholar Despite the barriers and the state of crisis in the NHS, the experts convened for this roundtable discussion stressed that action is needed now to protect children's rights, beginning with the actions outlined below (panel). Change cannot wait for a convenient time, perfect data, or an abundance of political will to facilitate change and increase accountability. There are enough resources to be able to provide the right health care for all children; we simply have to prioritise them.9Müller M Growing up in crisis.https://www.urbanhealthcouncil.com/reports-playbooks/growing-up-in-crisisDate: July, 2022Date accessed: December 15, 2023Google ScholarPanelActions needed now•Adopt a human rights-based approach that upholds children's rights to the highest attainable standard of health without discrimination and abolish policies that undermine these rights for minoritised children•Incorporate anti-racist health and research practice into the health system's functioning and commissioning, including by increasing engagement during decision making, and co-creation of processes, policies, and procedures with minoritised communities to foster greater trust•Integrate anti-racist training within health-care curricula to ensure that the next generation of health workers have the information and skills to recognise and combat racism in the health system•Embed professional accountability to uphold anti-racist principles and practice into the health system, including by embedding anti-racism within the annual appraisal process as a professional requirement•Ensure that data and evidence collected and valued by the health system incorporate the voices and inputs of communities, delivering epistemic justice•End structural discrimination in institutions and systems that shape children's interactions with the health system, including social care systems, and separate policing and prison systems from health care•Uphold equality, diversity, and inclusion commitments and funding and allocate funding to dismantle racism and white supremacy in the UK health system•Co-create anti-racist and anti-oppressive services with minoritised communities, providing a viable alternative to oppressive systems and structures •Adopt a human rights-based approach that upholds children's rights to the highest attainable standard of health without discrimination and abolish policies that undermine these rights for minoritised children•Incorporate anti-racist health and research practice into the health system's functioning and commissioning, including by increasing engagement during decision making, and co-creation of processes, policies, and procedures with minoritised communities to foster greater trust•Integrate anti-racist training within health-care curricula to ensure that the next generation of health workers have the information and skills to recognise and combat racism in the health system•Embed professional accountability to uphold anti-racist principles and practice into the health system, including by embedding anti-racism within the annual appraisal process as a professional requirement•Ensure that data and evidence collected and valued by the health system incorporate the voices and inputs of communities, delivering epistemic justice•End structural discrimination in institutions and systems that shape children's interactions with the health system, including social care systems, and separate policing and prison systems from health care•Uphold equality, diversity, and inclusion commitments and funding and allocate funding to dismantle racism and white supremacy in the UK health system•Co-create anti-racist and anti-oppressive services with minoritised communities, providing a viable alternative to oppressive systems and structures DD is the Director of Race & Health, within the UCL Institute for Global Health. All other authors declare no competing interests. We acknowledge and thank the following individuals for their participation in this roundtable discussion: Omowunmi Akindolie, Gunjit Bandesha, Andy Bell, Pamela Das, Rachel Ibikunle, Ayesha Kadir, Samia Latif, Esther Lau, Catherine Mbema, Ashlee Teakle, Jennifer Yip, strategist (anonymous), public health professional (anonymous), public health professional (anonymous), policy and advocacy professional (anonymous), public health professional (anonymous). The opinions expressed in this Correspondence are solely those of the authors and do not necessarily represent the official positions of the roundtable participants' affiliations. We thank the University College London Institute for Global Health for hosting the roundtable discussed in this Correspondence. This funding source had no role in the design, writing, delivery, or publication of the roundtable discussion referred to.