Posted on April 13, 2021 at 10:48 AM
by Stephanie Preston, MD
In the health professions, we have all been taught that some of the most common, chronic, and debilitating diseases in the United States – hypertension, diabetes, heart disease, and most cancers – disproportionately affect Black Americans. As resident surgeons, dogma holds that umbilical hernias are more prevalent in Black children, but without any discussion about underlying drivers. There is no evidence to support that this disparity is related to biologic or genetic differences. However, a recently published study continues to state that umbilical hernias are 8-9x more prevalent among Black children in the United States, and that “degree of African ancestry” is a contributing factor. Examining the references supporting this assertion reveals a major problem: the evidence is 70-80 years old. More recently published data examines umbilical hernia prevalence in Nigeria, not the United States.
Dr. E. Perry Crump, a Black physician at Meharry Medical College in Nashville, Tennessee published one of the most-cited papers about umbilical hernia in Black children in 1952. Dr. Crump evaluated ~1300 Black infants and children and found a prevalence of 26.6%, compared to the 3% prevalence described in white children at the time. This study was published prior to the court ruling on Brown vs. Board of Education and the end of Jim Crow legislation, which legally relegated Black Americans to second class citizenship. Dr. Crump cites several other investigators who proposed malnutrition as a potential mechanism for the increased prevalence of umbilical hernia in Black children. Given the association of malnutrition and vitamin deficiencies with a variety of connective tissue disorders and syndromes, it is not a big logical leap to infer that malnutrition might lead to weakness at the umbilical ring and higher rates of hernia formation. This association would mean umbilical hernias were preventable with public health nutrition interventions. Surely, I thought, there must be more recent investigations into this potential association.
My search did not yield a single study done in the United States examining this association. However, several Nigerian investigators corroborated Dr. Crump’s initial findings that umbilical hernia was much more common among African children compared to Caucasian children. Only five months after Dr. Clump’s study, Dr. D.L. Jelliffe published “The Origin, Fate, and Significance” of umbilical hernia in 1,300 Nigerian children and adults. He found a staggering 97% prevalence of umbilical hernia among neonates of low-income parents. This figure steadily decreased with age until to 46% in children aged 10-15 years. In adults, he finds a difference according to socioeconomic status, with 14% prevalence in high-income adults versus 27% in low-income adults. Prior to the conclusion of his study, the author surveyed American authorities on the subject, who confirmed the high rate of umbilical hernia in Black American children, but asserted that “no correlation could be made with poverty or malnutrition.” Despite his own observations about the association between class and umbilical hernias, Dr. Jelliffe concludes his manuscript by reiterating that “no evidence can be found that the condition is related to antenatal or postnatal malnutrition or to associated disease.”
It wasn’t for two more decades, ten years after the end of European colonization of Africa in 1960, that Nigerian physicians published on the association between umbilical hernia, poverty, and malnutrition. In 1971, Dr. S.O. Oduntan evaluated prevalence of umbilical hernia among school-aged children in various groups according to class. The highest prevalence was observed among non-school going children (42.6%) and rural primary school children (39.2%), followed by urban school children (27.3%), and children of members of the “elite” class like (8.6%). While the author does not provide statistical analysis that the school groups did not differ at baseline according to age, they discuss this known correlation and admits that while the decreased rate of hernia in secondary school children (15.6%) might be due in part to decreased prevalence with increasing age, this does not explain the difference between elite children and the other groups.
Dr. Ebomoyi further delved into the potential etiology of umbilical hernia in Nigerian children by investigating nutritional status. In the Hausa ethnic group, the overall prevalence of umbilical hernia was only 2.8% among well-nourished children compared to 25% in those with mild or moderate malnutrition, though this difference was not statistically significant. There was a significant difference in umbilical hernia according to parental occupation, a marker of class. These findings have been replicated recently in 2004 by Dr. Uba, who found a strikingly low prevalence of umbilical hernia among Nigerian children applying to private school at just 1.3%.
All of the aforementioned studies agree that umbilical hernia is almost always a benign condition, and only rarely results in complications like perforation or strangulation. In the United States, many umbilical hernias undergo spontaneous closure by 4-5 years of age. In fact, current guidelines recommend observation until at least 4-5 years of age prior to pursuing surgical intervention. According to the recently published study in JAMA Pediatrics, Black children are also more likely to receive treatment which deviates from the standard of care – undergoing hernia repair at an early age (<3 years old), which is associated with more complications. In other words, Black children in the U.S. may be undergoing procedures that are entirely unnecessary at rates higher than white children. Unsurprisingly, other factors like public insurance and lower income were also associated with early umbilical hernia repair, reinforcing the importance of incorporating classism and other forms of structural disadvantage into discussions on health disparities.
This analysis drives home the point that when confronted with racial disparities in healthcare, the literature has tended toward conclusions that perpetuate scientific racism and naturalized inferiority – asserting that Black people are somehow biologically inferior to white people without sufficient evidence. We have all been conditioned to think it is normal that Black people have almost ten-fold the rate of disease compared to white people without examining the obvious structural factors at play, like concentrated poverty. While national child advocacy organizations like the Children’s Defense Fund publish on the worsening childhood poverty and food insecurity that disproportionately affects children of color, there is a conspicuous absence of studies in the American medical literature examining this phenomenon and its sequelae. While it our responsibility as allies to understand and undo the effects of systemic racism, this also underscores the importance of representation in medicine, as Nigerian investigators are solely responsible for evaluating the association between race, class, nutrition, and umbilical hernia in children.
We need to completely overhaul the way the U.S. medical system views race, racism, and white supremacy. As so many have said before – racism – not race, is almost always the risk factor associated with disease. The Nigerian papers came to logical conclusions as a result of their investigations: that investing in social programs, better nutrition in schools, and addressing wealth and income inequality would likely improve the rates of umbilical hernia in children.
In a field like academic medicine that rewards publications, it is no mistake that so few exist in this area. Those in power have little interest in examining structural inequality and changing the status quo. White supremacy ensures we do not ask the questions because it does not want to know the answers – that systemic racism is a modifiable risk factor best addressed with policy and financial investment.