How is structural racism affecting atopic dermatitis in African American children?

By Kathryn Schwarzenberger, MD, November 1, 2020

In this month’s Clinical Applications column, Physician Editor Kathryn Schwarzenberger, MD, talks with Craig Burkhart, MD, MPH, MSBS, about his recent Pediatric Dermatology article "Structural racism and its influence on the severity of atopic dermatitis in African American children."

DermWorld: My thanks to you and your colleagues for your recently published insightful article looking at the influence of structural racism on the severity of atopic dermatitis in African American children. In case some of our readers are not familiar with the concept of structural racism, can you briefly define it and explain why you chose to study it?

Dr. Burkhart: A formal definition of structural racism is “the societal-level collective of institutional policies and practices that privilege the dominant racial group (i.e., white Americans in the United States context) over other racial and ethnic groups” (In Racism: Science and Tools for the Public Health Professional. 2019). Some things should be pointed out to fully understand what that means. One is that it doesn’t involve a character flaw or personal moral failing — it is a system of policies and practices collected in our customs, practices, and law. Another important thing to point out is that it doesn’t require an individual wrongdoer. Actually, inaction in the face of need can be evidence of structural racism. The “Racism Iceberg” is a helpful tool for understanding the concept of structural racism (Asian American Communities and Health: Context, Research, Policy and Action. San Francisco: Jossey Bass; 2009). Picture an iceberg floating in the water. On the top of the iceberg are the perceptible forms of overt racism such as hate crimes and explicit discrimination. Underwater are all the difficult-to-perceive forms of structural racism such as segregation, racial ideology, and institutional policies. These difficult-to-perceive forms of racism support overt racism.

In terms of our study, we actually didn’t set out looking for racism. Our study was designed to evaluate the effects of the community environment on atopic dermatitis. We defined the environment as both physical (overcrowding, pollution, traffic, and proximity to resources) and socioeconomic (residential segregation and social determinants of health). We were not specifically looking for an association between structural racism and atopic dermatitis severity, but the data were so convincing to us, that it became the theme of the paper.

DermWorld: How did you study this?

Dr. Burkhart: We performed a mixed methods study. After a pediatric dermatologist diagnosed atopic dermatitis and assigned a severity level, the patients’ parents filled out a survey assessing the effect of the community and home environments on atopic dermatitis. These surveys were geocoded with ZIP codes so we could learn about the counties that patients lived in. For 20 patients with moderate to severe eczema, we also did a home visit where we conducted in-depth interviews and home assessments using the CDC’s Healthy Housing Inspection Manual.

To establish an association of atopic dermatitis severity level with racism, we used a specific definition of racism: “A system of structuring opportunity and assigning value based on race that (1) unfairly disadvantages some individuals and communities; (2) unfairly advantages other individuals and communities; and (3) saps the strength of the whole society through the waste of human resources” (Phylon. 2003;50(1-2):7-22). Our hypothesis was that Black children and white children would be affected by measures of structural racism differently. Among Black children, increased segregation would be associated with worse atopic dermatitis (unfair disadvantage). Among white children, we hypothesized that increased segregation would be associated with milder atopic dermatitis (unfair advantage). Thus, we were looking for evidence that separating Black and white children was achieving the expected outcomes of racism.

DermWorld: What did you find, and were you surprised by any of the results?

Dr. Burkhart: We found that there was evidence for adverse effects associated with structural racism. Living in a county with high segregation was associated with worse atopic dermatitis for Black children, but not white children. In addition, there seemed to be a dose effect. The association between residential segregation and severe atopic dermatitis in Black children was stronger in more highly segregated communities and the association disappeared for Black children living in neighborhoods with low segregation. Among white children, segregation appeared to either have a benign or even beneficial effect on atopic dermatitis severity. This is consistent with a racist structure doing what it is supposed to do (i.e., improve the health and well-being of the dominant race at the expense of the non-dominant race).

My biggest surprises came from the home visits we made for the qualitative part of our study. Some of the homes we visited didn’t have functioning bathtubs, some depended on neighbors’ work schedules for transportation, some had washers and driers in the garage covered with grass and mulch from their lawn equipment, some families were having trouble affording moisturizers, and several had mildew and other signs of water damage throughout their bathrooms. I should emphasize that these observations were not race-dependent, but they show how a lot of our atopic dermatitis recommendations make no sense for many families. How can you do a bleach bath without a functioning bathtub? How good is a bleach bath if your bathroom is filled with mildew? Is a fragrance-free laundry detergent going to help if your washer and drier are already covered in grass and pollen? Should we emphasize moisturizers or topical steroids if families can only afford one of them? This says to me that we have to think beyond the individual patient to the home, community, and sociopolitical environments if we want to improve the health of all our patients.

DermWorld: Your study was limited to a relatively confined region of the country. Is it safe to generalize these results to the entire country, or do you think things might be different elsewhere? Can local resources mitigate such issues, or is this something that needs to be addressed on the national level?

Dr. Burkhart: Sampling is a limitation of this study. All patients were recruited from one academic referral center in the southeast. So, it is possible that the results may not be generalizable to the entire country. However, a major strength of the study is that we did see effects of structural racism in our clinics and the results are consistent with studies in so many other diseases. The size of the association with structural racism and mechanisms by which it operates may vary by region of the country, but I would be surprised if the negative effects of structural racism on skin disease were not seen in other areas of the country — the skin would be a very unique organ and atopic dermatitis a very unique disease if similar results are not found in the rest of the United States.

In terms of addressing structural racism, racism (and all the “-isms” for that matter) is a national issue that affects all levels of community. I think most people would agree that the recent news of police brutality and differences in COVID-19 outcomes have revealed that the racist policies and practices that have produced poor outcomes for Black Americans in so many areas have never been adequately addressed and their effects are still being propagated. As this has been going on for a very long time, the fight against Black and white health inequities is likely going to be a long process involving leadership at national, state, local, family, and individual levels.

DermWorld: I was going to ask if there are other diseases or health conditions that you feel are likely impacted similarly by structural racism, but it may be easier for me to ask: Do you think that there are any conditions that are spared from this influence? Do you think this issue impacts children more than adults?

Dr. Burkhart: To answer this question, one has to understand that race is a social and political concept — not biologic or cultural as many believe. Race, as it is labeled in dermatology and epidemiology studies, may have some level of association with genetics, socioeconomic status, and behavior, but its strongest association is with the experience of racism (Am J Epidem. 2001; 154(4):299-304). Pre-Civil War physicians used to blame poor health among slaves on biologic inferiority instead of conditions related to servitude (Virtual Mentor. 2014;16:472-8). Today, half of white medical students and residents hold false beliefs about biologic differences between Black and white people (Proc Natl Acad Sci. 2016;113:4296-301).

“We should never accept a biology-based hypothesis for Black and white differences in health outcomes without clear data supporting the statement. We also shouldn’t hide health inequities.”

─ Craig Burkhart, MD, MPH, MSBS

For example, they believe that Black people’s skin is thicker than white’s or that Black people’s blood coagulates faster. In contrast, I would say that in every disease where there is a race-associated difference in health outcomes, racism should be evaluated. We should never accept a biology-based hypothesis for Black and white differences in health outcomes without clear data supporting the statement. We also shouldn’t hide health inequities. So many studies in dermatology report race-related findings without comment on them or, just as bad, use statistics to adjust for race as if it is just a confounder.

DermWorld: What can we do as individuals to help? Any thoughts on steps the AAD might consider taking at this point to improve the care of all our patients?

Dr. Burkhart: If we really want to tackle racism, I would say the “Health in All Policies” framework is the best tool we have that can be applied to us as individuals and the AAD (Rudolph L, C. J.-M. American Public Health Association and Public Health Institute). Basically, in our practices, businesses, and institutions, we need to prioritize recognizing and addressing racism and the toll it takes on the health and well-being of Black and other minority groups (both patients and our colleagues). Then we need to include equity considerations in all our own business and government decision-making processes. Finally, we have to engage community members and advocates across sectors (business, housing, religious, etc.) to collaborate on health equity. The problem is huge, so solving it will take collaboration.

Areas the AAD might focus on include: (1) explicitly acknowledging and apologizing for racist policies and acts we have committed in the past as an Academy and as individual dermatologists; (2) reaffirming our commitment to justice and equity and actively developing and evaluating policies and processes to ensure that racism is not systemically embedded in our Academy; (3) explicitly communicating our views against racism and clearly creating a safe and welcoming community for all; (4) develop and evaluate interventions that address stresses affecting our minority providers, residents, and medical students; (5) and improve and evaluate training for providers to be able to discuss and address racism and intervene when they identify affected patients or colleagues (J Adolesc Health. 63(2018): 257-261).

As individuals, we have to be willing to be uncomfortable. It is very uncomfortable and is taking a lot of humility for me to write an article about racism as a white male in America and it is likely that I made several mistakes. However, all of us need to be able to acknowledge racism and be willing to make mistakes in order to discuss race, learn about racism, and start to be part of the healing process.

Craig Burkhart, MD, MPH, MSBS, from Burkhart Pediatric & Adolescent Dermatology in Cary, North Carolina, serves as adjunct professor at the University of North Carolina at Chapel Hill. His paper appeared in Pediatric Dermatology. Dr. Burkhart has no relevant financial or commercial conflicts of interest to disclose.

Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DermWorld.

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