Social Determinants of health

Mamas on Bedrest: September is Infant Mortality Awareness Month!

September 8th, 2015
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Photo by Racha Tahani Lawler, Los Angeles, CA

Mamas,

Did you know that September is Infant Mortality Awareness Month?

Globally, The United States spends more on healthcare than any other country. Yet, it has worse birth outcomes than many other countries globally. Despite recent declines in infant mortality, the United States ranked 26th among the 29 Organization for Economic Co-operation and Development (OECD) countries in 2010, behind most European countries as well as Japan, Korea, Israel, Australia, and New Zealand (1). The U.S. infant mortality rate of 6.1 infant deaths per 1,000 live births was more than twice that for Japan and Finland (both 2.3), the countries with the lowest rates. Twenty-one of the 26 OECD countries studied had infant mortality rates below 5.0.

Overall in the United States, white infants die at a rate of 5-6/1000 births and Hispanic infants have a similar infant mortality rate. African American Infants die at a rate of approximately 11.4/1000 births. I’m here in Texas and our infant mortality rate for white and hispanic infants is 5.5/1000 births while it is 11.4/1000 for African American Infants. In Travis County (the Greater Austin Area where I live), African American Infants have an infant mortality rate of 11.5/1000 births, whereas white infants have an infant mortality rate of 3.7/1000 births and Hispanic infants 6/1000 births.(2) What is the cause of this disparity?

Researchers and public health officials have numerous speculations as to why the IMR for African American infants is so poor,

  • Delayed initiation of prenatal care among African American women
  • Lack of access to quality prenatal care
  • Lack of insurance
  • Poverty
  • Preterm labor/Prematurity
  • Low birth weight
  • Birth Defect
  • SIDS
  • Maternal health complications

However Dr. Michael Lu, an obstetrician and gynecologist at the David Geffen School of Medicine at UCLA and a professor in the Department of Community Health Sciences and the Center for Healthier Children, Families and Communities at UCLA School of Public Health has proposed other reasons for the birth outcome disparities. In his groundbreaking  research paper “Closing the Black-White Gap in Birth Outcomes: A Life-Course Approach (3) Dr Lu and his colleagues point to systemic racism in American culture as the underlying cause of the birth outcome disparities. Lu and his colleagues point out that racism passed down through generations, as well as repeated racial slights in the daily lives of African American women has created an allostatic load of stress on African American women that is affecting their overall health, but in particular, their reproductive health and causing the negative birth outcomes we see in African American women and infants. To address these social determinants of health, Lu and his colleagues propose a 12 point Life-Course approach to closing the racial gap in birth outcomes.

  1. Provide Inter-conception care for women with prior adverse pregnancy outcomes
  2. Increase access to preconception care for African American women
  3. Improve the quality of prenatal care for African American women
  4. Expand healthcare access over the life course for African American women
  5. Strengthen father involvement in African American families
  6. Enhance systems coordination and integration for family support services
  7. Create reproductive social capital in African American communities
  8. Invest in community building and urban renewal
  9. Close the education gap
  10. Reduce poverty among African American families
  11. Support working mothers and families
  12. Undo Racism

Lu and his colleagues have presented an approach that not only address issues surrounding pregnancy and childbearing, but also addresses the social issues affecting African American families and communities. Lu makes some very bold statements, ones that some people may be loathe to accept and even less likely to act upon. But as Lu says in his publication,

“We will not close the Black-White gap in birth outcomes without political will to do so. Political will is the ability to command resources to make things happen (i.e. implement the 12 points).”

As the saying goes, “Where there is a will, there is a way!” The question now becomes do we the American people have the will, the actual desire to close this gap?

 

References

MacDorman MF, Mathews TJ, Mohangoo AD, Zeitlin J. International comparisons of infant mortality and related factors: United States and Europe, 2010. National vital statistics reports; vol 63 no 5. Hyattsville, MD: National Center for Health Statistics. 2014.

Austin Travis County Health and Human Services Department. Infant Mortality Rate Causes of Death for Travis County, 2000-2011. Data Source, Center for Health Statistics, Texas Department of State Health Services. Texas Behavioral Risk Factor Surveillance System (BRFSS) 2011-2012

Lu, M.C., MD, MPH, Kotelchuck, M., PhD, MPH, Hogan, V., DrPH, Jones, L., MA, Wright, K., PhD, MPH, Halfon, N., MD, MPH. “Closing The Black-White Gap in Birth Outcomes: A Life-Course Approach” Ethnicity and Disease, Volume 20, Winter 2010.

Mamas on Bedrest: Your Baby’s Address Growing Up Helps Determine His Life Expectancy

May 26th, 2015

I just read a fascinating article about where you live and life expectancy.

Scientists looked at poor urban areas of Detroit Michigan and found that residents there had accelerated aging as noted by shortening of the Telomeres of their DNA strands. Telomeres are the tips of DNA that protect the strands from injury, disease and premature death. They are similar to the plastic tips on shoelaces. People living in depressed urban areas of Detroit were noted to have shortened telomeres which predispose them to chronic disease and premature death. The new study found that low-income residents of Detroit, regardless of race, have significantly shorter telomeres than the national average.

“There are effects of living in high-poverty, racially segregated neighborhoods — the life experiences people have, the physical exposures, a whole range of things — that are just not good for your health,”

noted lead researcher Dr.Arline Geronimus, a visiting scholar at the Stanford Center for Advanced Study, as she spoke with the Huffington Post. The co-author is Dr. Elizabeth Blackburn, a leading researcher who  helped to discover telomeres, an achievement that won her the Nobel Prize in physiology in 2009. 

But there is more interesting data to this article. Rates of accelerated aging were varied amongst ethnic groups and not in a predictable fashion. 

“White Detroit residents who were lower-middle-class had the longest telomeres in the study. But the shortest telomeres belonged to poor whites. Black residents had about the same telomere lengths regardless of whether they were poor or lower-middle-class. And poor Mexicans actually had longer telomeres than Mexicans with higher incomes.”

This is completely counter intuitive. One would think that higher income would confer longer telomeres and hence better health. But because this was not the case, the researchers looked at other possible answers. What they found is that health outcomes are not based solely on race, education or economic status as is often assumed. Other factors such as perceived discrimination and having a supportive community are also factors determining health outcomes. For example, Geraniums and her colleagues found that Mexican immigrants actually fare better than lower middle class Mexican Americans because despite their poverty, they live in fairly insulated communities where there is shared language, share tradition and shared culture. Although they may face discrimination outside the community, when they return home, they are once again validated so the discrimination is not as impactful. But for African Americans, lower middle class or poor, perceived discrimination is not offset by the community support. Job and income instability, family and social networks and segregation seem to account for the lack of differentiation between lower middle class and poor African American. And amongst whites, those of lower middle class status were most likely to separate out of these neighborhoods while poor whites were not able to move out of poverty and seemed to suffer greater stigma and shortest telomere length as a result.

So what does this mean for Mamas on Bedrest?

It means that where your child grows up and under what social circumstances will have a significant impact on his or her lifespan. In this country we are so used to quantifying things by race, educational status and economics. What this research shows is that the factors playing into our health are far more complex than we expected. Issues such as community engagement and interaction, discrimination and cultural norms have more influence on health and longevity than previously imagined. So while we may all agree that we want our children to be raised in nice homes in “good, safe neighborhoods”, we have to take other factors into consideration. The social determinants of health-issues such as racism, classism, discrimination, isolation, cultural norms and social support just to name a few- show that,

“So much of what makes people either well-being or not is not coming from within themselves, it’s coming from their circumstances. It makes me think much more about social justice and the bigger issues that go beyond individuals,” said Dr. Blackburn.

Not everyone who lives in a depressed area is able to move, and according to this study, it may not be in their best interest to do so. What this article says to me is that we have to include social and cultural norms in addition to race, education and economics when considering what is truly impacting someone’s health. We have to consider discrimination and its impact on health. We have to consider that for some groups, like Mexican immigrants in this case, the close knitted communities are actually protective of health, and rather than people working tirelessly to flee these depressed areas, perhaps it is in the best interest of the larger society to invest in these neighborhoods; fix the schools, stores and other structures and help the communities that are doing well to do even better because they have the support and services they need.

Every baby born in the United States should be able to grow up in a safe home, in a safe community in and be able to live to the age of “normal” life expectancy. We as a culture and society knowingly cannot allow poverty and depressed areas to persist, knowing that it is essentially causing chronic disease and premature death.  We have a moral obligation to at least try to help meet the needs of our fellow citizens to give them an equal shot at a long and full life. As Dr. Blackburn noted,

“When something’s really hard to assess, the easy thing is to dismiss it. They say it’s soft science, it’s not really hard-based science.”

Telomere data is providing a new way to quantitatively analyze some of these complex topics. Whether they have experienced severely negative experiences in childhood, and so on, their telomeres are substantiating their feelings and experiences. With this knowledge, we all have the moral obligation to make changes so that all children can reach their full life expectancy and their full individual potential.

What is your take on this ground-breaking research? Share your thoughts in the comments section below.

References

The Huffington Post: Scientists Find Alarming Deterioration in the DNA of the Urban Poor

Arline T. Geronimus, Jay A. Pearson,Erin Linnenbringer, Amy J. Schulz, Angela G. Reyes, Elissa S. Epel, Jue Lin, and Elizabeth H. Blackburn, “Race-Ethnicity, Poverty, Urban Stressors, and Telomere Length in a Detroit Community-based Sample” Journal of Health and Social Behavior 1–26. © American Sociological Association 2015 DOI: 10.1177/0022146515582100 jhsb.sagepub.com