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The Road to Tolerance and Understanding

      In all parts of the world, an important discussion has begun in response to the discord and turbulence of the 2016 US Presidential campaign and some postelection actions [
      • Peeler K.
      Protecting the tired, the poor, the huddled masses.
      ]. The tensions and stressors that have generated a global wave of worry and uncertainty have created a need to ensure tolerance and understanding in our generation, in our children, and in future generations. We hope that an awareness of the need for enhanced tolerance and understanding of other people and other people's beliefs can help unite us and begin a journey of healing. We address this commentary to the entire child and adolescent health community. As pediatricians, we wish to discuss steps we can all take to be more welcoming, tolerant, and understanding of those who may see things differently from us. This includes fellow pediatricians and other pediatric health professionals whose opinions may not be the same as their colleagues but who share a common commitment to ensuring a bright future for all children and adolescents.
      We believe tolerance and understanding are intertwined in the path toward human progress. In all health care settings and in all policy discussions, both tolerance and understanding are essential. We define tolerance as the acceptance of another person, another viewpoint, or another behavior that is different from our own. Tolerance expands our ability to be open to new ideas, to people who have different viewpoints, or to people who are different from ourselves. Tolerance for those who are different from us or disagree with us allows us to recognize challenges in our own health care settings and to strive to improve upon those challenges. Understanding is the ability to walk in other people's shoes and to comprehend their needs, perspectives, and desires. Understanding also represents the ability to distinguish fact from fiction, science from fantasy, and to recognize the impact of our own actions. Understanding is the foundation for solutions. A journey toward tolerance and understanding often starts with inconvenient truths about ourselves, our clinics, our health care system, or our society, and moves forward with a strategy to implement challenging, often painful solutions. Tolerance and understanding are guideposts on the upward path toward improving the human condition, whereas intolerance and ignorance lead to a downward spiral of destruction and despair.
      We believe that the entire pediatric community, including our professional journals, has an obligation to ensure that we progress along the path to greater levels of tolerance and understanding. The 2016 US Presidential campaign and the postelection period have been notable for highly publicized discussions about intolerance and the misappropriation of facts to disparage, stigmatize, and ostracize segments of the population [
      • Murray M.
      Intimate choices, public threats - reproductive and LGBTQ rights under a Trump administration.
      ,

      Rosenbaum L. Resisting the suppression of science [published online ahead of print March 1, 2017]. N Engl J Med. 10.1056/NEJMp1702362.

      ]. Some of the first executive orders implemented by the Trump administration, such as efforts to exclude certain immigrant populations from entering the country and deport immigrants who have made a life in our country, have fueled a heated discussion about intolerance all around the world [
      • Jagsi R.
      From Muslim registries to radical health care reform-caring for patients in an era of political anxiety.
      ]. We believe that the global marches for women's rights and the demonstrations for the rights of other groups that took place in January 2017 should serve as a rallying cry for each person to return to the fundamental human goal of tolerance and understanding of others. Each of us, and each of our professional, educational, and social settings, has at some time had insufficient tolerance and understanding toward others. Religious leaders of all faiths, political leaders, artists, and people of all races, ethnic backgrounds, socioeconomic status, sexual orientations, languages, and nationalities have challenged us to join hands and walk together on the road to tolerance and understanding. At this time, we believe the pediatric community should not simply travel down this road but rather lead the way.
      How can pediatricians and all pediatric health care professionals lead the march toward tolerance and understanding? We believe that there are specific actions that every pediatric professional can take. First, we can transform our offices and clinics into safe havens and explicitly welcome families who are different, ostracized, or disrespected in modern society. What type of change can be implemented in the office setting? As a start, we can modify our signage and educational materials to welcome people from all cultures in a respectful, compassionate, and caring fashion. We can ensure that our office staff communicate with patients and families in a welcoming, open-minded way and do their best to interpret logistic challenges from the perspective of our patients. As clinicians, when we speak with patients and families, we must be sure to frame our conversations and our anticipatory guidance in a welcoming and open manner. We can listen. We can validate the worth and importance of children, adolescents, and parents with disabilities who may be mocked; of immigrants or patients of underrepresented racial and ethnic groups who too often suffer overt or unconscious prejudice; and of girls and young women who are too often disrespected and devalued. We can try to deepen our understanding of families who appear to devalue science, whether the concern is related to vaccines or other scientific advances, as well as families whose political or cultural beliefs differ from ours.
      We should not underestimate the power of the pediatric community to heal through tolerance and understanding. It is enormously empowering for a female adolescent patient or a patient of color to hear her pediatrician say that she is talented, valued, and has the potential to make unique and important contributions to society. It is reassuring and validating for parents who are lesbian or gay or parents of children and youth who have special needs, or who are in foster care or are adopted, to hear that their pediatrician trusts, values, and supports their parenting efforts. It is uplifting for parents to be praised by their pediatric clinician because they are raising children, adolescents, and young adults to be kind and openhearted. It is liberating for adolescents who have been incarcerated or parents who have experienced drug addiction or mental health problems to hear that they can succeed and that their pediatric clinicians will support them. It is life-affirming for children and adolescents who are lesbian, gay, bisexual, transgender, or questioning to hear from their pediatric clinicians that they are free to be whomever they want to be [
      • Levine D.A.
      Committee on Adolescence
      Office-based care for lesbian, gay, bisexual, transgender, and questioning youth.
      ]. We should never underestimate our power to offer tolerance and understanding, as well as love, respect, and admiration within the sanctuaries of the examination room, our practices or clinics, and our academic health centers. Although many pediatric clinicians have strived to create such a safe haven for families within their practice or hospital, we must redouble our efforts in a purposeful manner.
      Pediatric educators can incorporate teachings related to tolerance and understanding into everyday educational sessions and not solely in special teaching lectures. We can expand our training around cultural humility [
      • Pletcher B.A.
      • Rimsza M.E.
      • Basco W.T.
      • et al.
      Committee on Pediatric Workforce
      Enhancing pediatric workforce diversity and providing culturally effective pediatric care: implications for practice, education, and policy making.
      ] and unconscious (implicit) bias [
      • Johnson T.J.
      • Winger D.G.
      • Hickey R.W.
      • et al.
      Comparison of physician implicit racial bias toward adults versus children.
      ], recognize and attempt to address contributors to poverty and social ills [
      • Dreyer B.
      • Chung P.J.
      • Szilagyi P.
      • Wong S.
      Child poverty in the United States today: introduction and executive summary.
      ], as well as engage, advocate, and actively participate in the communities we serve to reduce the detrimental effects of the social determinants of poor health and well-being. We can serve as role models of understanding and kindness in every patient encounter as well as every learning encounter with trainees. We can model the process of listening and attempting to understand others with whom we disagree. We can highlight the importance of training in diversity and inclusion in our curricula. Our continuity and subspecialty clinics can provide training in the social and emotional dimensions of our patients' lives and incorporate this training into the traditional training in the physical and physiologic dimensions of health and illness. We can develop and evaluate our curricula with the longitudinal themes of tolerance and understanding across the entire medical education continuum.
      Pediatric researchers who work with socially vulnerable populations should be supported and encouraged because this research is desperately needed. The new structure of the Clinical and Translational Science Awards involves a “Special Populations” component that must include children. While this requirement advances pediatric research, we need to ensure that such research includes children in vulnerable populations because they need and deserve our full attention and because of their disproportionate rates of adverse outcomes [
      • Chaudry A.
      • Wimer C.
      Poverty is not just an indicator: the relationship between income, poverty, and child well-being.
      ]. A promising area of health services and population research focuses on interventions that eliminate disparities by elevating the health and wellness of vulnerable groups such as the poor, underrepresented racial and ethnic groups, immigrants and refugees, youth involved with child welfare, incarcerated youth, lesbian, gay, bisexual, transgender, or questioning individuals, children from rural communities that lack access to high-quality health care, and many others. Institutions should value and reward researchers who focus on vulnerable populations and researchers from underrepresented groups. Tolerance and understanding can be embedded in the fabric of the research enterprise.
      But the pediatric community can do more. All pediatric health care professionals are highly respected by patients, families, and communities. We have taken important oaths to do no harm and to always attempt to do good. All clinicians want to do good for their patients and doing good 1 patient at a time is a vital strategy. Another equally important strategy is to mobilize, organize, and lead at a population level. Pediatricians can see themselves as collaborative servant-leaders because we can change health care organizations, including health systems and managed care organizations, by encouraging and helping them to understand the importance of focusing on vulnerable populations. We can influence our own health systems to be more welcoming and tolerant. We can influence community leaders and policymakers by using scientific truths and principles to educate them. We can become community leaders, state leaders, and even national leaders by speaking out for children, adolescents, young adults, and families and thereby advocate for the needs of all children and families [
      • Linton J.M.
      • Griffin M.
      • Shapiro A.J.
      Council on Community Pediatrics. Detention of immigrant children.
      ]. We must make it clear that “all children and families” includes immigrants and refugees, along with those who experience bullying, prejudice, and social inequities and yet who are an important part of the future of our country and our world. If the pediatric community does not lead the way toward tolerance and understanding of children, adolescents, and families, then who will?
      As editors, authors, and reviewers of the peer-reviewed scientific literature, we believe that pediatric journals can also contribute to advancing tolerance and understanding. Peer-reviewed journals are in the business of highlighting scientific findings and providing evidence to dispute fiction. Journals might consider special articles that summarize findings and dispel untruths about the health issues that affect underrepresented groups or mistreated or vulnerable subgroups of our population. As an example, many journals have published important articles and policies on the ravages of childhood poverty and interventions that can both prevent poverty and attenuate the impact of child poverty [
      • Dreyer B.
      • Chung P.J.
      • Szilagyi P.
      • Wong S.
      Child poverty in the United States today: introduction and executive summary.
      ,
      • Gitterman B.A.
      • Flanagan P.J.
      • Cotton W.H.
      • et al.
      Council on Community Pediatrics
      Poverty and child health in the United States.
      ]. We are proud that pediatric journals have been at the forefront of this effort. Articles on groups facing intolerance can be analogous to these articles on child poverty. As a second example, articles on groups facing intolerance or lack of understanding can be analogous to the published articles that provide scientific evidence about the value and safety of vaccinations [
      • Edwards K.M.
      • Hackell J.M.
      Committee on Infectious Diseases; The Committee on Practice and Ambulatory Medicine
      Countering vaccine hesitancy.
      ]. Professional journals should not be reluctant to publish controversial or politically charged articles if there is a need to inform the medical community and/or the population about facts and potential solutions that are based on strong scientific evidence. Journals should welcome controversial opinions and viewpoints in the spirit of tolerance and understanding and in appreciation of the importance of free speech. In addition, scientific journals can also make better use of print and online dissemination, especially social media, to translate complex concepts, findings, and potential solutions into language that connects with both the scientific community and the general public. By focusing on subgroups that face intolerance and by capitalizing on the respect and communication channels available to scientific journals, authors and editors can play an important part in this journey.
      Finally, the road to tolerance and understanding begins with a commitment to personal change. A mountain of evidence highlights the importance of unconscious or implicit bias in our everyday workplace, our everyday lives, and our everyday actions [
      • Zestcott C.A.
      • Blair I.V.
      • Stone J.
      Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review.
      ]. If nothing else, the tensions, anxiety, and recent protests should mobilize us to reflect on how we can propel ourselves, our children, our family members, our patients, our colleagues, our nation, and the global community to move more quickly on the upward-spiraling road of tolerance and understanding. What can each of us do today? Tomorrow? And the next day? The road to tolerance and understanding is long, difficult, and often indirect. But it is the right path, the path of justice, and the only road forward for our profession, our country, and our world. We hope you will join and lead us on this road as we advance with a deep commitment to tolerance and understanding for all.

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