Truth, Reconciliation, and Transformation: Another Step Forward

In the aftermath of the murder of George Floyd, the American Academy of Pediatrics (AAP) Board of Directors published a policy statement entitled "Truth, Reconciliation and Transformation: Continuing on the Path to Equity."1 The statement acknowledged historical transgressions and discriminatory actions in consideration of African-American pediatricians Roland B. Scott and Alonso DeGrate Smith for AAP membership. These truths resulted in public apologies to the families of Drs. Scott and DeGrate Smith, and an organizational referendum to amend Article I of the AAP bylaws to explicitly declare anti-discrimination and reconcile the AAP to "embrace equity for all children and families, as well as for the pediatricians who care for them, as central to the mission of the Academy."2 Simultaneous to these governance actions, a pivotal viewpoint article, "The Case for Removing Race from the American Academy of Pediatrics Clinical Practice Guideline for Urinary Tract Infection in Infants and Young Children with Fever," was published and brought to the AAP Board's attention.3 "Urinary Tract Infection: Clinical Practice Guideline (CPG) for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months," which was originally published in 2011 and reaffirmed in 2016,4 was noted in the viewpoint to inappropriately position the social construct of race as a clinical characteristic and to subsequently use race assignment as a dichotomizing variable to direct the clinical course of care, i.e., whether or not to obtain a catheterized urine specimen. This algorithmic approach stood to discriminate based on race and to potentially contribute to outcome disparities disproportionately impacting young Black girls experiencing missed urinary tract infections. The authors of the viewpoint article definitively noted that "race-based or ethnicity-based assessments about biologic vulnerabilities to disease can reify disproven concepts, which, when positioned within clinical guidelines, may contribute to implicit bias and structural racism." The AAP Board responsively acknowledged the need for systematic transformation in the organization's development of equitable clinical guidance and retired the CPG.5,6 The challenge at the time, however, was that there was not a definitive corrective action plan or policy platform from which to move forward. Building upon recommendations published in a 2022 policy statement, "Eliminating Race-Based Medicine,"7 the last four years have seen evidence-informed interrogation and incremental progress toward achieving equity in the development of pediatric clinical guidance.8,9.