Beyond “Red Man Syndrome”: An Argument for Health Equity Among American Indians
Sitting in the lecture hall, the first year medical student, a first generation American Indian graduate, was shocked and dismayed to learn of the antimicrobial agents and their side effects, as the professor described “the syndrome. the red man ”(RMS). The student was relieved when other students in the course discussed the racial insensitivity of the term and cited recent articles calling for the language to be removed. However, that feeling of isolation and damage was already inflicted. Unfortunately, this experience is not uncommon. Minority medical trainees are subjected to micro-attacks and prejudices on a daily basis.1 As a medical community, we need to do better.
Konold et al present a good example of using a fast cycling quality improvement methodology to purge the obsolete and race-insensitive term RMS from the medical record.2 They describe how the documentation of 274 pediatric patients diagnosed with RMS within their hospital was successfully removed from the records.2 In addition, the success of this intervention is supported by the reduction in the use of this language 3 months after the intervention, with only 29 of the 65 cases of allergies to vancomycin listed citing RMS. It is important to note that the rate of use revealed a statistically significant difference before and after the intervention (P <.001>2 This approach is being used to replace a more medically descriptive and correct terminology, “vancomycin flushing reaction” or “vancomycin infusion reaction”, as recently recommended by the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society.3–5
Konold et al’s Quality Improvement Project serves as a simple, disseminable action that other hospitals can emulate.2 They describe how others can use electronic medical records to address the racial injustice of terminology with continuing education to continue to make positive changes toward equality in the hospital setting.2 An important element of the quality improvement project was buy-in from hospital management and accountability, which are vital priorities in the fight against systemic racism.
Further support for this change can be bolstered by similar position statements from the American Academy of Pediatrics and the American College of Physicians, and it is hoped that such direction will be forthcoming. Beyond these actions, the rectification of this terminology in medical education is paramount to ensure that this formulation is eliminated from the vocabulary of healthcare providers of future generations and with respect for Native American (AI) and native patients. from Alaska (AN). Konold et al recognize the lack of an educational component as a limitation of their study, but allude to the proactivity of trainees in making this amendment of their own accord, possibly indicating the possibility of embracing this change in the years future.1 As this movement gains momentum, clinicians and trainees are expected to similarly prevent further trauma associated with the use of this and other insensitive terms.
However, it is important to recognize that although RMS has been erased from medical records, historical and current health inequalities have not been erased. AI and AN human health curricula are sorely lacking in the current American medical education system. Along with education on the removal of RMS, it is imperative to emphasize a patient-centered and culturally competent approach to the health of individuals with both historical and force-based AI and AN perspective to transform human health. care for these groups for years to come. Understanding the historical trauma, cultural practices, and modern health inequalities for AI and AN children in the region served by each hospital is important, given the diversity of tribes across the United States. Additionally, the hospital experience for many families is stressful and intimidating, but for some of our patients of color it can be traumatic. Current research has found, even in the field of pediatrics, that there are implicit biases, leading to worse health outcomes for children of color.6–8 It is imperative that the hospital be made a safer and more welcoming environment for patients and families of color. Using culturally appropriate and trauma-informed care modalities will help create such an environment.
The language shift away from RMS is one of many recent advancements in the management of AI and AN children. The most important of these is the recent publication of a policy statement from the American Academy of Pediatrics, “Caring for American Indian and Alaska Native Children and Adolescents.”9 In it, the authors describe the many health inequalities facing this vulnerable population and offer clinical and advocacy recommendations to proactively address the social, biological, and environmental determinants of health in a culturally aware manner.9 AI and AN children have a mortality rate between 1 and 4 years which is 3 times that of the general population, with accidents accounting for 52% of all deaths and homicides 8%.ten Native American children are also more likely to be obese or overweight, with 39% of this demographic having a BMI above the 85th percentile.ten Additionally, 79% of AI and AN preschoolers had dental caries.ten Native American children also have an increased prevalence of mental health disorders, with a significantly higher risk of substance use compared to white children.ten Additionally, over 25% of AI and AN households live in poverty and have the highest rate of child abuse of any other ethnic group in the United States.ten
All of these disparities are linked to the social determinants of health and structural racism. The AI and AN populations have struggled for centuries to maintain an ethnic identity and a physical location to develop their families and culture. The struggle for land rights persists to this day, from massive migrations in the 19th century to the claim for sovereignty and respect at the heart of the struggle against the Dakota Access and Keystone XL pipelines. In addition, the ethnocide propagated by settler colonialism and manifested in the boarding school system and the erasure of the history of AI and AN in public education continue to contribute to the erasure of a distinct and proud identity of AI and AN in the United States.
In addition to providing recommendations for the management of AI and AN children, it is essential to improve the representation of the AI and AN populations among healthcare professionals. Recent evidence suggests that the number of AI and AN applicants and people enrolled in medical school has increased, although the graduation rate does not reflect this change.11 The recent opening of the Oklahoma State University Health Sciences Center in the Cherokee Nation represents a critical opportunity to train AI and AN physicians and others in Native American health as as the first tribal-affiliated medical school in the United States. Other pathway programs, such as the Wy’east Post-Baccalaureate Pathway through the Northwest Native American Center of Excellence at Oregon Health & Science University, strive to increase the number of AI providers and AN by targeting AI and AN interns about to register. The shift from RMS to a more physiological term is also extremely important for learners to feel heard and supported in this historically monocultural profession.
The move away from RMS is a small but significant step towards health equity for both RN and AN populations. The movement toward using the vancomycin flushing reaction follows the lead of granulomatosis with polyangiitis and reactive arthritis by replacing the racist terms and eponymous conditions named for human rights violators. These advances alleviate the burden of stress and trauma associated with hospitalization by reducing the unintentional microaggressions associated with such terms.
We encourage all facilities to replace RMS with a vancomycin flushing reaction, vancomycin infusion reaction, or other physiologically descriptive term. However, this is only a small first step. Healthcare systems also need to explore ways to improve care for AI and AN communities, and educational institutions need to develop recruitment and retention strategies to increase AI and AI representation. the NA within the health profession.
We acknowledge and thank the original custodians of the lands on which our centers occupy and are built: the Multnomah, Kathlamet, Clackamas, Tumwater and Watlala bands of the Chinooks and Tualatin Kalapuya, Molalla, Wasco and the many indigenous nations of the Willamette Valley and the plateau. from the Columbia River of Oregon, as well as the Matinecock, Manhasset, Lenape, Montaukett, Unkechaug, Shinnecock, Mericoke, Massapequa, Nisequaq, Secatague, Setauket, Patchoag, Corchaug and the many original inhabitants of Queens and Long Island, New York.
FINANCIAL DISCLOSURE: The authors have indicated that they have no relevant financial relationships to disclose for this article.
FUNDING: No external funding.
POTENTIAL CONFLICTS OF INTEREST: The authors have indicated that they have no potential conflicts of interest to disclose.
BACKING PAPER: A companion to this article can be found online at www.hosppeds.org/cgi/doi/10.1542/hpeds.2021-005993
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