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Tue October 9, 2012
Infant mortality, part 2: The most disturbing disparity
In part two of our State of Opportunity documentary on infant mortality and disparities, we ask the question: Why are black babies two and a half times more likely to die before they turn one than white babies?
Two of the leading causes of infant mortality are babies that are born too soon or too small, and a disproportionate amount of those babies are African American.
Growing up in a toxic soup
Dr. Carolynn Rowland is the Maternal Infant Health Director for the Detroit Department of Health and Wellness Promotion. She says the story of infant mortality disparities doesn't begin in the NICU, where a lot of preterm and low birthweight babies end up. No, she says, the story of racial disparities in infant death begins much earlier.
“Growing up a woman of color in this society is toxic," says Rowland. "It’s toxic to you, to your physical health, to your mental health and therefore that impacts your reproductive capacity."
Rowland’s toxic soup metaphor - part racism, part poverty, part inequity - isn't some fringe idea. The data show moms with little or no income; moms who live in troubled neighborhoods; moms who don't finish high school; and moms who receive inadequate prenatal care are more likely to lose a child.
But there's also a growing body of research that implicates racism in the black and white infant mortality disparity.
So what, exactly, are the social determinants of health?
One African American woman who's made it a personal and professional quest to figure out why these disparities in infant mortality exist is Dr. Renee Branch Canady. She's the director of the Ingham County Health Department, and before that was a research professor at Michigan State University.
Canady has three grown boys, but she lost her first born son, Mark Howard, when he was just six months old; Canady had preeclampsia, and her son was born premature. Since then, she's focused much of her research on race and health disparities.
"Even when we controlled for economic status, there was still this unexplained difference in the pregnancy outcomes of women of color versus white women," says Canady. "And so with that you begin to say: What is distinct in the lives of African American women?"
Canady and many other public health workers believe something called the "social determinants of health" play a role in the disparity. Canady describes the social determinants of health as "those economic, social and contextual factors that influence a woman’s ability to have a healthy pregnancy or to engage in healthy behaviors needed to have a favorable pregnancy outcome."
In other words, where you live, work, and play all contributes to your chances of delivering a healthy baby. Canady says all those factors play a role in the kinds of decisions women are able to make. And often, she says, women "don't have the ability to respond [to choices] because of a number of social barriers in their lives." Canady believes one of the biggest barriers women of color face is what she calls "interpersonal racism," and the chronic stress that goes along with that discrimination.
The effect of all that stress has a name. It's called "weathering."
"Weathering" the storm of chronic stress
Arline Geronimus coined the "weathering hypothesis" term back in the 1980s. Geronimus, a professor at the School of Public Health at the University of Michigan, claims that women of color experience chronic stress related to being black and how they are treated. These stressors rapidly age the women so much that by the time they are in prime childbearing years they are at risk for poor birth outcomes.
“Chronic stress means you’re endlessly flooded with stress hormones, they don’t go back to normal levels and they do damage to your heart, to your blood pressure, to your weight,” says Geronimus.
And she says it's not just African American women in poor neighborhoods who feel the effects of weathering. Rich and middle class African American women experience it, too.
"They’re still dealing with stressors related to the contingencies of being black and how they’re treated. They’re dealing with being tokens," says Geronimus. "They're dealing with having been raised one way and then being part of a kind of institution that has unwritten rules that you didn’t get the memo to" but everyone else did.
But not everyone buys into the "weathering hypothesis" and the role racism plays in health disparities.
A lot more work to be done
Amitabh Chandra, a Harvard health economist, believes the claim that racism is responsible for infant complications is premature.
“I think we need to do a lot more work to understand how racism affects early onset of aging,” says Chandra. "What we have is a hypothesis with a lot of intriguing evidence around it, but I don't think we have evidence that rises to the level of having firmly determined that this is why we see what we do."
To Chandra, factors that can be empirically measured such as education, neighborhoods, and behaviors are important in studying health disparities.
Doak Bloss agrees with Chandra that a lot more work needs to be done, but that's where the similarities end. Bloss believes racism is at the heart of health disparities, and he thinks more needs to be done at the health provider level in order to make a difference.
Bloss runs Health Equity Workshops for the Ingham County Health Department, where he teaches public health workers to treat everyone equally - regardless of age, gender or race. These four-day workshops are mandatory for everyone who works in the county’s health department.
In Bloss’ mind, these workshops are having a slow but effective effect on the health department.
“I would say it’s a 20 year effort to change the culture in the way we want,” says Bloss.