Explaining the Country’s Infant Mortality Rate – Part 2
Infant mortality rates among the African American population are higher than those of the Caucasian population in this country. Part two of this infant mortality podcast addresses some theories that explain this disparity, including the issues of poverty, education and racism in the African American community. These stressors affect a woman’s overall health and as a result, the health of her baby before, during and after pregnancy. Listen in as Dr. Arthur James delves into these and other environmental factors that all contribute to very specific birth trends among this population. Dr. James also addresses how the genetics of this population are affected by environmental factors, and in turn, influence the infant mortality rate.
Dr. Rick McClead: Welcome to Children’s on Quality. This is your host, Dr. Rick McClead, Medical Director for Quality Improvement Services at Nationwide Children’s Hospital. A few months ago, I had the pleasure of interviewing one of our nation’s leading authorities on the problem of infant mortality in the United States, Dr. Arthur James.
Dr. James is an Associate Professor of Obstetrics and Gynecology at the Ohio State University College of Medicine and at Nationwide Children’s Hospital. He is co-director of both the Ohio Better Birth Outcomes project and the Ohio Department of Health’s Collaborative to Prevent Infant Mortality. He’s also the Director of the new Teen and Pregnant program or TAP at Nationwide Children’s Hospital.
Please join me for part 2 of my interview with Dr. James about the high rate of infant mortality in the United States.
When we speak about, I guess, basically busting certain people’s beliefs about why these disparities exist, specifically issues around socio-economic status, the difference between whites and blacks, genetic issues, education, address that for our audience.
Dr. Arthur James: OK. I don’t know that I really bust anybody’s bubbles, because I think most of those things that there is some contribution. But here is the perspective that I take – first of all, where the genetics issue is concerned, I don’t think that there’s any data, any current data that suggest to us that the belief that the black infant mortality rate is so significantly higher than the white infant mortality rate because blacks are genetically just predispositioned to have poor birth outcomes.
I don’t think that that argument holds any water. I don’t think that for several reasons – first off, if it was the case, just generally looking at the data in the United States, if that was the case, then how do we explain why blacks in Ohio in 2010 had an infant mortality rate of 15.5 while blacks in Northern Manhattan Perinatal project had an infant mortality rate of six; or why blacks in California for 2010 had an infant mortality rate of 8.5.
Are we suggesting that the black folks who live in Ohio are genetically inferior to black people who live in California or who live in New York City? Are we genetically more fragile? I don’t think that’s the case.
If we stay with the genetic issue for a while and look at a study done by Dr. Jim Collins out of Chicago who looked at comparing both birth cohorts over 15-year period of time for the entire State of Illinois, looking at the incidents of low birth weight, births for whites, for blacks who were born and raised here in the United States, as well as for African immigrants, so these would be women who were from Africa living in the State of Illinois and had babies.
During this period of time he looked specifically at low birth rate because we believe low birth weight to be a risk factor for infant mortality. The higher the incidents of being born with a low birth weight the higher the risk of infant mortality.
And what Dr. Collins’ study showed was that the birth weight distribution curves for white and for African women who had babies here in the United States that the birth weight distribution curves are more similar for those to than it was. For African-American women, the birth weight distribution curve was disfavorably shifted to the left, meaning there was a much higher incident of babies being born with low birth weight.
Dr. Rick McClead: So if you’re from Africa but you deliver here, you have an infant mortality rate that’s very similar to the Caucasian…
Dr. Arthur James: That’s absolutely correct.
Dr. Rick McClead: But if you’re African-American and lived here all your life and you give birth you have this two and a half times.
Dr. Arthur James: That’s correct. And Dr. Collins actually from that suggested to us that there was some other contributor that wasn’t genetic for sure and that there was some other contributor to why the disparity ratio was what it was. And he actually went as far as to suggest that one of the significant contributors and to that disparity ratio was actually racism.
Now subsequently, the Center for Disease Control published a study and said in essence, wait a minute, Dr. Collins, if you look at any immigrant group who comes to the United States and have babies, for those immigrants their infant mortality rates are good. We think that they’re good in part because it takes some level of financial independence for them, first of all, to move to the United States that there’s a higher incidence of therefore graduating from high school and going on and having a college degree that they’re a less teen births, so that there are things that we’ve selected out in terms of the immigrant group that comes here and that probably applies to the Africans who come here and have babies and that probably contributes to why for this that first generation why those babies born to Africans who deliver here in the United States have infant mortality rates and birth weight distribution curves more similar to whites.
And so Dr. Collins said, OK, so let’s look at the subsequent generation. Let’s look at the girls that these African women had who stay in the United States and then have a baby, let’s compare those babies to African-Americans and to whites.
Dr. Rick McClead: So this is will be the first generation of those, of the women who came here who delivered their daughters who were raised here in the United States, have a baby, that’s the population we’re talking about.
Dr. Arthur James: That’s right. And so when he looked at that group what he found was that the birth weight distribution curve for the daughters of the African women who had babies here in the United States was unfortunately much more similar to the birth weight distribution curve for African-Americans as it was for whites.
So whatever that protective factor was that initial generations who moved here enjoyed was essentially lost in one generation. Dr. Collins believes and many or the rest of us have jumped on that bandwagon that at least one of the significant contributors for that loss of protection was because of the experience of racism in this country.
But I want to go back to some of the other things that you mentioned because you talked about poverty, you mentioned socio-economic status, you talked about smoking.
Dr. Rick McClead: Education level.
Dr. Arthur James: Yeah. Education level. There are a lot of other things that contribute to the disparity, but they don’t contribute so much that they totally explain the disparity that exists. So the point that I’m trying to make here is that I think those other things also need to be addressed, that we need to be vigilant about trying to improve those circumstances.
But if we really want to eliminate the disparity in terms of black-white infant mortality then we have to address those things; we have to address what goes on clinically; we have to incorporate a social determinant of health perspective because if just try to improve infant mortality by only addressing, for example, poverty, which I think is a significant contributor, there are many of us who believe that poverty and racism are intricately intertwined with each making the other worse.
And in my opinion, racism is the venom in the bite of poverty. So that for groups who experience that in addition to being poor their outcomes are going to be much worse than we believe generally acceptable in this country.
Dr. Rick McClead: One of the things that you mentioned in your presentation at the Infant Mortality Awareness Conference that I thought was fascinating was this issue over the education that a graduate level educated black woman has an infant mortality rate that is higher than a white woman who didn’t graduate from high school.
Dr. Arthur James: That’s correct. That’s correct. And that’s been confirmed by a number of studies. It takes to a whole another level, much of which is more theoretical at this point, but it is believed and we take this from models that looked at the effect of stress on us physiologically, the effect of stress on us biologically and we believe that chronic ongoing stress has a detrimental effect overall on our health.
How does that occur? Dr. Michael Lewis is pretty infamous in his talk of asking us to imagine ourselves in a room where suddenly there’s a saber tooth tiger that jumps in and comes into the room. And for most of us our bodies automatically go into that fighter fight kind of response where our heart rates would significantly increase or depth of breathing and the rate at which we breathe would go up. Where we would look to flee we ran out of that room as quickly as we could.
But that kind of stuff happens automatically when we’re faced with significant stress, but then when we get to a place that we consider a safe haven without consciously asking our bodies to do it, our heart rate slows down, we begin to perspire less, our breathing rate slows down, our body goes into a recovery phase, if you will. We refer to these processes as allostasis.
Well the belief is that when we are chronically, day in, day out for all of our lives, challenged by stress that autoregulatory function and allostasis mechanism that I just described is altered, so that our body even in a “safe haven” doesn’t rev down, doesn’t slow down, doesn’t relax to the same extent that people who, for example, don’t experience chronic stress and don’t experience racism go-through.
And we think that the regulation of those cells that results in behaving as if we are in a chronic stress kind of environment is explained by this field that’s burgeoning right now that’s referred to as epigenetics that talks about the programming of our cells.
In that epigenetic sense, for those of us who are in situations where we experience racism everyday throughout our lives and the stress associated with that, that there’s a difference in the way our genes are programmed so that they’re revved up. Think about like the engine of a car that in a safe haven would be in a nice, slow, idle, not stressed at all versus in your garage a car where there’s somebody who has their foot all the way down on the gas pedal and so that engine is just accelerated at much higher speed than it ought to be for a car that’s parked in a garage.
Which of those engines is going to last longer? Which of those engines is going to have problems occur sooner? It’s going to be the engine that we’re gassing all the time, that we’re revving the engine at real high levels all the time. And there are many of us who believe that that’s the effect that racism has on us.
And the scary part about it is that while the Dr. Collins’ studies suggest to us that it only takes about one generation for us to lose that protective effect for our genes to be reprogrammed for us to begin physiologically and biologically experience some of the consequences of racism, what we don’t know yet is for those of us who had been in this country approaching 400 years we don’t know if we could flip a switch today and eliminate all racism that occurred in the United States.
We don’t know how long it would take for those of us who had been adversely affected by racism to physiologically recover so that whatever those effects are of racism that have a detrimental effect on our health it would totally be reversed.
There’s also one other piece that I’d like to address here because I heard this at the Neonatology Conference and I’ve also heard this at other times when I’ve given this talk that there are a lot of people who feel like despite any and everything that I’ve said, despite what much of the evidence suggest to us, that in fact the reason for the disparity in infant mortality has entirely to do with people’s behaviors.
It’s not the fault of racism, for example, that people don’t graduate from high school and go on to college and graduate from college. I think there’s some debate there about what influence racism has on those things. But where the behavior piece is concerned, Sir Michael Marmot out of England, who’s probably the godfather of this whole social determinants of health approach to improving our general health situation, but many, many, many, many others have also suggested to us that the behaviors that we may want to modify that contribute to poor health outcomes are in fact shaped and influenced by our environment.
And so African that takes a social determinants of health perspective looks to alter the environment away than more favorably influences our choices. So that if you live in an under-resourced community where for example there is a much, much, much higher density, for example, liquor stores, stores that sell cigarettes than there are in communities that are significantly better resourced.
And those under-resourced communities have much higher incidents of crime. There’s a much higher incidents as we said earlier of unemployment, school failure, etc., that if we change the milieu, if we change the circumstances in those communities, we believe that we would also change many other behaviors that we think are more detrimental to our health and that those things would contribute significantly toward improving the infant mortality.
Well, Dr. James, is there any evidence of that? I would then go back to the Northern Manhattan Perinatal project, where in fact that project remembers sits in in this part of the Harlem’s children’s zone, where in the Harlem children zone there was this general effort to improve the quality of life for a certain geographic area within Harlem.
And within that geographic area of the Harlem children zone there was even a smaller area carved out where coupled with the efforts that were taking place in the Harlem children zone there’s been this concerted effort to try to improve birth outcomes. And it’s there that we’ve enjoyed this 85% improvement in the cohort that’s 85% African-American.
And that project has been so impressive that nationally there is an effort going on now that’s called “Better Baby Zones”. It is in essence, attempting to emulate that effort.
Dr. Rick McClead: To duplicate that project.
Dr. Arthur James: Right. Right.
Dr. Rick McClead: What it’s going to take to set up these baby zones all over the country so that we can, I mean probably we need to focus on major urban areas around that country, but what has to happen to make something like that come about?
Dr. Arthur James: Well personally, I think that the biggest obstacle right now is creating the will to do it. The will within communities to accept and understand that this is something that we can do, that it’s achievable, that we need to get away from being stuck in this mode where these disparities are concerned that they’re just fixed, that they’re just the way things are and that there’s nothing that we can do to improve them.
Once we create the community will then I think all the rest follows in terms of the amount of funds that it’s going to take, the commitment of different groups and organizations. The other piece that I think is going to require a substantial paradigm shift for us is to really begin to accept that there are the significant, non-clinical, non-medical things like employment, like the quality of our lives and the communities that we live in, that have huge, huge impact on our health.
And as long as we take the approach that for those of us who practice medicine have just stayed with in terms of the medical model, we won’t get to those other things. One of the tough parts for those of us who practice clinical medicine to appreciate and understand about this is that we can’t do it by ourselves.
We have to go out and engage the rest of the community in this process. So we need to get politicians, the business community, the public school system, private school system, parks and recreation, police and law enforcement. There is no segment of our community that doesn’t have a role to play in terms of improving the social determinants of health.
And the wisdom in that approach is that while my interest for right now is improving infant mortality and trying to actually eliminate the racial disparity that occurs in infant mortality. The wisdom in the social determinants of health approach is that I believe that approach is not only going to help to accomplish the improvements that I’d like to see in terms of infant mortality, but it also will help in terms of decreasing the poverty rate, improving school performance, decreasing the dropout rate, improving college attendance rates, improving the quality of life in general for people in this country so that a lot of the other things that we also have concerns about will also be substantially improved.
And by the way, we improve the quality of life, the longevity of life, we decrease the disparity and heart attack rates and strokes and hypertension, diabetes and a of other things that we also are plagued by in this country.
Dr. Rick McClead: Well that’s all the time we have for this edition of Children’s on Quality. Children’s on Quality is produced by Kelly Nightingale. Our theme music, Fleeing Moments, was composed and performed by Ryan McClead. Next time on Children’s on Quality, we will be discussing the problem of what to do with those unused prescription drugs.
Until then, this is your host, Dr. Rick McClead wishing you the very best of good health.