These pieces originally appeared as a weekly column entitled “Lessons” in The New York Times between 1999 and 2003.
[THIS ARTICLE FIRST APPEARED IN THE NEW YORK TIMES ON FEBRUARY 6, 2002]
Linking Infant Mortality to Schooling and Stress
At a Martin Luther King’s Birthday speech in Harlem, New York’s mayor, Michael R. Bloomberg, repeated a pledge to make education his priority, saying that if schools improved, “a lot of what Dr. King wanted to accomplish in our society will take care of itself.”
It was a bold, if commonplace, claim, yet policy makers rarely examine their theory that school improvement alone can drive progress in health care, housing and income inequality.
If the idea is true, then the mayor and others (President Bush, for example) are smart to focus on schools. But if it is false, it is dangerous to ignore social and economic problems in the hope that, with better schools, the problems will take care of themselves.
Three days after the mayor’s speech, the Centers for Disease Control and Prevention reported on racial disparities in health. Blacks’ infant mortality, for example, is more than twice that of whites (14 deaths per 1,000 live births for blacks; 6 per 1,000 for whites). The rate of low- birth-weight babies for blacks is also twice the rate for whites (13.2 percent versus 6.6 percent) and barely changed in the 1990’s.
Low birth weight for so many black children itself impedes improved education. Children born with below-normal weight get lower average I.Q. and achievement test scores, have more frequent learning disabilities and attention disorders, are more often asthmatic (with more school absences) and are less likely to graduate from high school. Higher academic standards alone cannot undo the physiological hurdles.
Mayor Bloomberg’s theory could be correct if better schooling led women to take more steps to prevent difficult pregnancies. Until recently, most health professionals believed that inadequate prenatal care was the most important cause of low birth weight and infant mortality. If so, black women who were better educated and more aware of the need for prenatal care would have healthier births.
But it now seems that education cannot explain much about the racial gap in the outcome of pregnancies. The infant mortality rate experienced by black women who are college graduates is higher than that for white women who are high school dropouts. This is not because of racially linked genetic differences – the babies of black women born in the United States die at a higher rate than than those of black immigrant women in similar economic circumstances.
The idea that education about prenatal care would eliminate disparities is also a doubtful one because virtually every state now provides Medicaid to low-income pregnant women, with no consequent drop in the incidence of low birth weight or infant mortality for blacks.
Although the poor use medical care less than the middle class, sometimes because of less flexible work schedules or because poor women are less informed about their health benefits, education about prenatal care is now sufficiently widespread that the number of black women without care in the first trimester of pregnancy has declined significantly. Even so, the infant mortality rate experienced by black middle-class women is much higher than for poor white women.
In examining the causes of problem pregnancies, medical researchers increasingly study lifetime stress, not only stress during pregnancy. Dr. Michael C. Lu, an obstetrician-gynecologist and community health specialist at the University of California at Los Angeles, puts it this way: “You can’t cram all the good things into nine months of pregnancy. You’ve got to start early, when the mother is still a fetus, and an infant, and a child, and an adolescent.”
Many experts now conclude that stress causes release of hormones that weaken the uterus, leading to premature delivery or mortality. The hormone changes can occur over a lifetime, not only in pregnancy. They may build up from fear of violence, from worries about paying for food or housing, from job insecurity or from having to stand for long periods at work. One study found that problem pregnancies were more frequent among black women who reported more experiences with racial discrimination in employment or housing.
If pregnancy crises are exacerbated by all the socioeconomic conditions that make life more difficult for black women, better education alone – even education about health – cannot undo these stresses. And because women who themselves were born prematurely are more likely to have problem pregnancies, even an approach that involved schools as well as economic programs could take more than a generation.
Mayor Bloomberg’s passion to give minority children better schools is admirable. But to create the society of Dr. King’s dreams, school improvement must link to a broader strategy for improving the social and economic circumstances of black communities. Expecting other problems to take care of themselves only assures failure on all fronts.