“…I’ve set out to capture the Soul of This Human Race on film, in all its shades and from all four corners. So that we might see ourselves reflected in each other. So that we might see beyond all differences. So that we might come to remember that we belong to each other without condition and act accordingly.”

-Nic Askew

What is the relevance of belonging in pediatric critical care? Belonging is fundamental to being part of society. Not belonging precedes health inequities. The World Health Organization (WHO) description of social determinants (SDOH) of health starts with “…the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age and the wider set of forces and systems shaping the conditions of daily life. The SDH have an important influence on health inequities - the unfair and avoidable differences in health status seen within and between countries” (1).

Despite health inequalities being well reported, persistent and very eloquently contextualized by Marmot (2), the notion of SDOH has only recently come to the fore in clinical medicine. Hitherto, health outcomes and interventions have primarily been seen through the narrow lens of biology and genetics. Demographics have been set in a biological framework rather than in the wider context of SDOH and inequity. If the aim in pediatric critical care is to improve outcomes for all children, there will need to be a change in the mental model of clinicians, scientists, and health leaders.

What stands in the way of making equity a core component of our practice and research? We have made remarkable progress improving care, though even for these there is still work to do on optimizing ventilation, hemodynamic support, sedation/analgesia, and neuroprotection to name but a few core pediatric critical care areas. The systems we have chosen to improve might be considered our choice of picking the low hanging fruit. These efforts will remain insufficient if we don’t place equity central to our pursuits.

There is a choice to be made: continue to tolerate the status quo and accept an environment that limits children in their health or change our mental model and think beyond biology. This change in thinking is becoming apparent, albeit long overdue. The focus on SDOH in pediatric critical care is welcome, bearing in mind that social health disparities have been described for quite a while, for example, the work by David and Collins (3) in neonatology.

Recent studies include the following: Mitchell et al (4) purposefully focused on social determinants of health in pediatric critical care in the United States. Eighty-six studies were included in their review, approximately half of which had aimed to investigate disparities. The studies included, but not exclusively so, children with respiratory disease, sepsis, out-of-hospital cardiac arrest, traumatic brain injury, and oncological disorders. Overall, the authors concluded that racial, ethnic, and socioeconomic disparities exist in pediatric critical care in the United States. Outcomes included mortality, increased severity of illness on presentation, less parental satisfaction with quality of communication by healthcare staff, and less participation in clinical research. Although most studies originated from the United States and this review analyzed articles only from the United States, the authors noted that studies from several other geographical areas, including the United Kingdom, Switzerland, Sweden, Denmark, Turkey, and Australia, reported worse health outcomes for children from lower socioeconomic backgrounds or minoritized racial/ethnic groups.

Several other examples of recent studies on health disparities in severely ill children include those with hematological disorders (5), life-threatening asthma (6), and congenital heart disease (7,8).

It is against this backdrop that Menon et al (9) on behalf of the Pediatric Sepsis Definition Taskforce draws our attention to Reporting of Social Determinants of Health in Pediatric Sepsis Studies in this edition of Pediatric Critical Care Medicine. The authors’ stated aims were to identify WHO SDOH categories to “…facilitate the development of 1) an understanding of the association of SDOH with sepsis severity and outcomes, 2) meaningful comparison of study populations and extrapolation of results and 3) identification of potentially modifiable socioeconomic factors.”

The basis of their review was the 106 articles that they had studied in a previously published systematic review on criteria for pediatric sepsis. Studies originated from all continents (except Antarctica), with the largest contributing country of origin being the United States (19.8%, 21/106), followed by China (12.3%, 13/106), India (9.4%, 10/106), and Brazil (8.5%, 9/106). It is not surprising that, given the original aim to study the included articles, that is, criteria for pediatric sepsis, none of the reviewed articles had SDOH as the primary aim of the study. The authors state that nearly a fifth of articles (18/106) did not report on any variable definable as an SDOH, and 36.8% (39/106) only reported on gender/sex. Race/ethnicity was the most reported variable from high-income countries (38.3%, 18/47), with only an additional two studies from other countries reporting on race/ethnicity. Nutrition was the most reported category from upper middle income (37.1%, 13/35), lower middle income (60.9%, 14/23), and lower income (1) countries. None of the studies gave data on parental unemployment/job security or structural conflict.

The authors call for using a standardized terminology for social determinants of health (SDOH). They argue that this may enable determining their association with sepsis outcomes. Shared understanding is indeed key, and the setting of definitions will require an inclusive approach for these definitions to be meaningful.

Following on from these articles, as researchers and clinicians, what might we do next? It might be that the next steps are to stop tolerating and explicitly acknowledge the current unjust differential in outcomes based in social circumstance, followed by reflection. As researchers and clinicians in pediatric critical care, we will first need to reflect on our intent when considering health disparities, and only after that reflection can we take informed action.

Challenging and changing the status quo will take effort and motivation. We will need to ask ourselves uncomfortable questions. Where may we ourselves have been complicit in maintaining the status quo? (Full disclosure: I have published papers with a narrow genetic framework) Which stories do we tell each other? Which mental models may no longer hold true? Are we prepared to ask ourselves difficult questions? That is, are we really committed to put in the hard graft of change?

Several colleagues are leading by example and sharing different models of thinking and practice beyond awareness. In adult medicine, some algorithms incorporated “race” in clinical risk assessment without robust underpinning and thus potentially perpetuated or even amplified race-based health inequities (10). How we frame, formulate, and carry out research and with whom is paramount in not perpetuating current inequities. The editors of the New England Journal of Medicine clearly stated which steps were required for the research population to appropriately reflect the population in clinical practice. In addition, they described what was in their sphere of influence to change and implement. The New England Journal of Medicine now requires authors to provide evidence of representativeness of their study group (11).

Pediatric critical care recently featured articles highlighting that population needs do not necessarily translate to appropriately placed or offered pediatric critical care provision. Not only do the consequences of racism, poverty, or distance to a PICU need to be taken into account (12,13), there is also a requirement to actively dismantle the unjust organizational structures, which prevent children achieving as best a health outcome as possible. Antiracism is one such approach (14).

Transformation is required if equity is to be a core component of pediatric critical care. This transformation will need to be ubiquitous, at individual, institutional, and structural levels (15). This work is not for the fainthearted, but we should be well up for the challenge. We’re good at teaming, we take pride in well-led units, and we’re used to difficult decision-making with bravery, kindness, love, and resolve. Inherently, we all belong and always have done. Let’s make it so that we see us in our patients and their families.

1. World Health Organization: WHO Social Determinants of Health. Available at: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1. Accessed January 7, 2023 2. Marmot M: Social justice, epidemiology and health inequalities. Eur J Epidemiol 2017; 32:537–546 3. David RJ, Collins JW Jr: Differing birth weight among infants of U.S.-born blacks, African-born blacks, and U.S.-born whites. N Engl J Med 1997; 337:1209–1214 4. Mitchell HK, Reddy A, Perry MA, et al.: Racial, ethnic, and socioeconomic disparities in paediatric critical care in the USA. Lancet Child Adolesc Health 2021; 5:739–750 5. Gore L, Keating AK: Eliminating disparities improves outcomes. Blood 2021; 137:439–441 6. Grunwell JR, Opolka C, Mason C, et al.: Geospatial analysis of social determinants of health identifies neighborhood hot spots associated with pediatric intensive care use for life-threatening asthma. J Allergy Clin Immunol Pract 2022; 10:981–91 7. Best KE, Vieira R, Glinianaia SV, et al.: Socio-economic inequalities in mortality in children with congenital heart disease: A systematic review and meta-analysis. Paediatr Perinat Epidemiol 2019; 33:291–309 8. Tran R, Forman R, Mossialos E, et al.: Social determinants of disparities in mortality outcomes in congenital heart disease: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:829902 9. Menon K, Source LR, Argent A, et al.; Pediatric Sepsis Definition Taskforce: Reporting of Social Determinants of Health in Pediatric Sepsis Studies. Pediatr Crit Care Med 2023; 24:301–310 10. Vyas DA, Eisenstein LG, Jones DS: Hidden in plain sight - reconsidering the use of race correction in clinical algorithms. N Engl J Med 2020; 383:874–882 11. Rubin E: Striving for diversity in research studies. N Engl J Med 2021; 385:1429–1430 12. Brown LE, Franca UL, McManus ML: Socioeconomic disadvantage and distance to pediatric critical care. Pediatr Crit Care Med 2021; 22:1033–1041 13. McKee MN, Palama BK, Hall M, et al.: Racial and ethnic differences in inpatient palliative care for pediatric stem cell transplant patients. Pediatr Crit Care Med 2022; 23:417–424 14. Zurca AD, Suttle ML, October TW: An antiracism approach to conducting, reporting, and evaluating pediatric critical care research. Pediatr Crit Care Med 2022; 23:129–132 15. Parsons A, Unaka NI, Stewart C, et al.: Seven practices for pursuing equity through learning health systems: Notes from the field. Learn Health Syst 2021; 5:e10279