Rare inflammatory syndrome another example of pandemic’s disproportionate effect on racialized children

Uninvited and unwelcome, COVID-19 has pervaded all facets of our lives. For racialized and lower-income communities in Toronto, the virus has taken a disproportionate toll, one that extends to their youngest members.

We know that racialized Torontonians have COVID-19 infection rates markedly higher than that of the city’s white residents. While about half of Toronto’s population belongs to a racialized group, 77 per cent of COVID-19 cases have been among non-white residents. The curtain, we hope, has been permanently drawn back on the deep-rooted inequities – racism, poverty – behind these numbers. What the data do not convey is the pandemic’s disparate, growing and gravely worrying effect on racialized children and their families.

At the outset of the pandemic, pediatricians braced themselves with guarded optimism. Symptomatic COVID-19 infection was and continues to be less common and generally less severe in children. However, last spring, we began to hear from colleagues around the world about clusters of children presenting with a striking inflammatory syndrome in the weeks following an often-asymptomatic course of COVID-19 infection. Our pediatric patients were no longer exempt from the virus’ harmful effects. This phenomenon, commonly called Multisystem Inflammatory Syndrome in Children (MIS-C) in Canada, results from the immune system becoming overactive, causing uncontrolled inflammation throughout the body and, in some cases, affecting the heart and other organs. Although reminiscent of and likely intimately related to another ailment familiar to pediatricians – Kawasaki syndrome – MIS-C tends to affect slightly older children, seems to cause more severe inflammation, and more frequently requires admission to the intensive care unit. Thankfully, it remains rare and there have been no reported deaths in Canada.

Yet, the Centers for Disease Control and Prevention (CDC) in the United States is reporting a marked increase in the number of children with MIS-C since October as well as a greater proportion of patients requiring intensive care compared to the spring. At SickKids, we have cared for approximately 130 children with presumed MIS-C over the course of the pandemic. Only one in five of these patients have been white.

This disparity is not unique to Toronto. In New York City, although Black youth make up just over 20 per cent of the population, nearly 35 per cent of patients with MIS-C are Black. Across the United States, 69 per cent of reported cases are in Latino or Black young people while only about 20 per cent are in white children. Importantly, racial disparities in the incidence of Kawasaki syndrome, thought to reflect differing genetic risk, predate the pandemic with children of East Asian descent disproportionately affected. What we are seeing with MIS-C, however, more strikingly follows racialized socioeconomic lines.

The result, beyond the immediate concern for children’s health, is yet another wedge in the growing gap between rich and poor, a chasm increasingly defined by race in Toronto. A parent, perhaps an essential worker, is infected at the workplace and unwittingly brings COVID-19 home – a situation that is particularly concerning for multigenerational households. Fears of missing work and losing income, or even their jobs, may prompt them to continue working despite their illness. Weeks later, their symptoms resolved, the youngest child feels hot and starts to show signs of severe illness – a fever that won’t break, red eyes, cracked lips – prompting the family to seek care at the emergency department. In rare cases, the family may be faced with a prolonged hospital stay, maybe a few days in the intensive care unit. Perhaps the unexpected hospital trip and follow-up appointments lead to more missed work, lost income, and disruptions to childcare – additional stress on parents who may be concerned for the long-term health of their child.

Our failure to support our most vulnerable communities does not end with adults. Their children are now bearing the consequences of this inaction. As we continue to learn from COVID-19, we must advocate for policies such as robust income supports, paid sick-leave, and an extended freeze on residential evictions that could help save the lives of racialized adults and their children alike – both now and after the pandemic.

The comments section is closed.

  • Stephen Roedde says:

    I read this article with both interest and dismay. Clearly this serious illness needs investigation and analysis of epidemiological risk factors.

    Sadly, the title of this case-series suggests that this well-intentioned effort to understand an uncommon disease… leads with the race-card.

    Although mention is made to socioeconomic disparity and the myriad associated factors (crowded housing, parental employment in high risk environments) and the rest, as is typical these days, these critical factors are linked (in the title and recommendations), primarily to race.

    The Toronto COVID 19 data (https://www.toronto.ca/wp-content/uploads/2020/07/956b-SDOHandCOVID19_Summary_2020July1.pdf) suggests a striking socioeconomic association with 504/100,000 in the highest quintile as opposed to the lowest (162/1000,000).
    Does race add anything of value to this critical socioeconomic variable?

    This case-series makes no mention of other known predictors of serious SARS COV-2 disease (obesity, insulin resistance and metabolic syndrome). Do the authors have data on these pro-inflammatory factors, and if so, please present them?

    The cited article from NYC made no attempt to identify which factors best accounted for risk… they too went directly to race in their descriptive study. In fact they made no attempt to do so. Further, they acknowledge that missing data on race on non-hospitalized COVID 19 patients made proper analysis problematic… but of course the complete absence of actual evidence to support their position, they still moved on to attribute their observations to “structural racism”. (https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2773289). Typically, to these authors, differences in outcome are, by definition, proof of structural racism.

    Do the authors of this Healthy Debate article have evidence to support that race is anything but a surrogate for other known important risk-factors for SARS COV-2 infection?
    Did they attempt to analyze other pro-inflammatory metabolic factors?
    Have the authors made any attempt to do a statistical analysis that would allow any coherent interpretation of the role of confounding variables in their case-series data (https://dalspace.library.dal.ca/bitstream/handle/10222/53778/Ling-Shen-MSc-Stat-Aug-2014.pdf?sequence=3)?
    The final sentence is telling:
    “As we continue to learn from COVID-19, we must advocate for policies such as robust income supports, paid sick-leave, and an extended freeze on residential evictions that could help save the lives of racialized adults and their children alike – both now and after the pandemic.”

    This is the sort of totally unhelpful policy analysis that had led leaders in two California Counties to offer a version of “mincome” to poor families with children…. but specifically excluding poor white/Asian families. This does not help. (https://reason.com/2021/03/29/basic-income-programs-in-marin-county-and-oakland-exclude-white-people-is-that-legal/?itm_source=parsely-api).

    When those who should know better contribute to a narrative of society that is not supported by actual evidence, they, (perhaps unwittingly), contribute to divisive and unhelpful identity politics.

    I look forward to reading further on this critical topic, but hope that objectivity and proper scientific analysis provides clarity and useful data for policy-makers and clinicians.

  • Wallis Martin says:

    Alarming, comprehensive, comprehensible and direct. An authoritative appeal for essential, holistic and robust public policy informed by health policy. Hold your office-holders to account on this, please. WM


Raphaël Kraus


Dr. Raphaël Kraus, MDCM, FRCPC, is a pediatric rheumatologist and clinical research fellow within the Department of Pediatrics, The Hospital for Sick Children, University of Toronto.

Ronald Laxer


Dr. Ronald M. Laxer, MDCM, FRCPC, is a pediatric rheumatologist at The Hospital for Sick Children and professor within the Departments of Medicine and Pediatrics at the University of Toronto.

Rae Yeung


Dr. Rae Yeung, MD, PhD, FRCPC, is a pediatric rheumatologist at The Hospital for Sick Children and professor within the Departments of Pediatrics, Immunology and Medical Science at the University of Toronto. She is supported by the Hak-Ming and Deborah Chiu Chair in Paediatric Translational Research at the Hospital for Sick Children, University of Toronto.

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