The number of infants who die before their first birthday is much higher in the U.S. than in other countries. And for African Americans the rate is nearly twice as high as for white Americans. Even well-educated Black women have birth outcomes worse than white women who haven't finished high school. Why? We meet Kim Anderson, a successful Atlanta lawyer, executive and mother. When Kim was pregnant with her first child in 1990, she, like so many others, did her best to ensure a healthy baby: she ate right, exercised, abstained from alcohol and smoking and received good prenatal care. Yet two and a half months before her due date, she went into labor unexpectedly. Her newborn weighed less than three pounds. Kim and her husband were devastated. How could this have happened?
We know that in general health follows wealth: on average, the higher on the socioeconomic ladder you are, the lower your risk of cancer, heart disease, diabetes, infant death and preterm deliveries. For highly educated African American women like Kim, the advantages of income and status do make a difference for her health, but there's still something else at play: racism. Neonatologists James Collins and Richard David believe that African American women are at increased risk during pregnancy, not because of something innate to their biology, but because of the cumulative impact of racism they experience over their lifetime -- an impact that can outweigh even the benefits of higher social and class status. To demonstrate their theory, Drs. Collins and David showed that African immigrants to the U.S. and U.S.-born white women had similar birth outcomes, yet African American women tended to have babies that weighed significantly less. Moreover, they showed that the results changed over time: outcomes for the African-born group worsened within one generation and became comparable to the African American group. So how does racism get "under the skin" and affect pregnancy? Researchers like Michael Lu believe that chronic stress is the culprit: unequal treatment causes anxiety and the release of stress hormones, which over a lifetime of constant activation not only creates wear and tear on the body's organs and systems, but can trigger premature labor. As Dr. Camara Jones of the CDC points out, for most people of color, racism isn't an occasional problem but a subtle, everyday stressor that is added onto all the other stressors in a person's life. Anthropologist Fleda Jackson, sociologist Mona Phillips and epidemiologist Carol Hogue are working to help us measure and better understand racism's impact. Through focus groups and programs that provide family support, they and others are helping African American women find the resources they need to cope. Yet for all of us, the challenge remains to tackle the harmful conditions that surround and negatively impact African American women and babies in the first place -- so that everyone can have a good start for a healthy life.
Unnatural Causes is the acclaimed documentary series broadcast by PBS and now used by thousands of organizations around the country to tackle the root causes of our alarming socio-economic and racial inequities in health.
The four-hour series crisscrosses the nation uncovering startling new findings that suggest there is much more to our health than bad habits, health care, or unlucky genes. The social circumstances in which we are born, live, and work can actually get under our skin and disrupt our physiology as much as germs and viruses.
Extent of continuing physical, emotional, mental, and social ability to cope with one's environment. Good health is harder to define than bad health (which can be equated with presence of disease) because it must convey a more positive concept than mere absence of disease, and there is a variable area between health and disease. A person may be in good physical condition but have a cold or be mentally ill. Someone may appear healthy but have a serious condition (e.g., cancer) that is detectable only by physical examination or diagnostic tests or not even by these.
Science and art of preventing disease, prolonging life, and promoting health through organized community efforts. These include sanitation, control of contagious infections, hygiene education, early diagnosis and preventive treatment, and adequate living standards. It requires understanding not only of epidemiology, nutrition, and antiseptic practices but also of social science. Historical public health measures included quarantine of leprosy victims in the Middle Ages and efforts to improve sanitation following the 14th-century plague epidemics. Population increases in Europe brought with them increased awareness of infant deaths and a proliferation of hospitals. Britain's Public Health Act of 1848 established a special public health ministry. In the U.S., public health is studied and coordinated on a national level by the Centers for Disease Control and Prevention; internationally, the World Health Organization plays an equivalent role.
NARRATOR: Several years ago, two physicians in Chicago set out to solve a mystery: whydo African American women have babies that are born too small, at twice the rate ofwhite American women? Richard David and James Collins are neonatologists --pediatricians who specialize in the care of infants who come into the world too earlyor dangerously underweight and often both. Like virtually everyone in their field,they were troubled by the striking racial differences in rates of premature and lowbirth-weight babies. What could account for the differences? JAMES COLLINS(Neonatologist, Childrens Memorial Hospital, Chicago): Originally I thought that thedisparity in premature delivery was really driven by socioeconomic differences betweenAfrican Americans and whites. Its well known that African Americans have a lower,collectively, socioeconomic status than whites; theyre less likely to receive collegeeducation than whites. So I thought once you corrected for that, that the gap would goaway. NARRATOR: But Collins and David discovered the gap didnt go away. COLLINS: Wewere very surprised to find that the gap actually widened as education andsocioeconomic status improved and then began to look at it from a bigger perspectiveand broader perspective, and really started to realize, well maybe its something aboutlifelong minority status which is the driving factor here. RICHARD DAVID(Neonatologist, Stroger Hospital of Cook County, Chicago): Theres something aboutgrowing up as a black female in the United States thats not good for your childbearinghealth. I dont know how else to summarize it. NARRATOR: So the two neonatologists beganto explore whether being a member of a particular minority group might affect pregnancyoutcomes, and they came up with a controversial hypothesis. Whats behind the low birthweight and premature birth for African American babies is the unequal treatment ofAfrican Americans in American society. In other words, racism is taking a heavy toll onAfrican-American children even before they leave their mothers wombs. Its an idea thatsslowly gaining acceptance. R. DAVID: Were in the midst of a paradigm shift. 15 yearsago, racism as a risk factor was almost never heard of in a scientific paper; whereasnow its much more a possibility. NARRATOR: The story of Kim Anderson, a successfulAtlanta executive and lawyer illustrates exactly what David and Collins are talkingabout. We know that a healthy lifestyle should lead to a healthy baby. Women who eatwell, exercise, get prenatal care, avoid alcohol and drugs, and cigarettes are morelikely to have a good pregnancy. But one of the best predictors for a healthy pregnancyoutcome is higher education. KIM ANDERSON: This is a picture of me, May 1984, when Igraduated from Columbia Law School. People would think Im living the American Dream: alawyer with two cars, two and a half kids, the dog, the porch, a good husband, greatfamily. Ive always been lucky to have good health. Always ate well. Exercised. Neversmoked. NARRATOR: So when we look at Kim Anderson a well-paid lawyer in good health --we would expect her newborn to be a healthy, full-term baby. It didnt turn out thatway. Back in 1990 when he was pregnant with her first child, Kim went into labor twoand a half months early. KIM ANDERSON: I just wanted to know at least that if she wasborn alive, that at least we had a fighting chance. I heard her cry, I said, Thank,God. But she was so small. I mean you could like, hold her in the palm of your hand.NARRATOR: Kims baby, Danielle, weighed only two pounds thirteen ounces when she wasborn. She joined the ranks of almost 300,000 low birth-weight infants born in the U.S.that year, about 1 out of every 14 babies, all of them at a high risk of dying beforetheir first birthday. KIM ANDERSON: I remember getting home and being in the bathroom,just, I fell apart. You know, cause its like I didnt get to take my baby home, youknow. I remember just sort of falling apart. NARRATOR: Preterm and low birth weight arethe leading reasons that the US claims the dubious distinction of having one of theworst infant survival rates in the industrialized world. We fall behind dozens ofcountries. Babies born in Slovenia, Cyprus, Malta and Croatia stand a better chance ofliving to the age of one than a baby born here. R. DAVID: It is kind of like the canaryin the mine; its the most sensitive of our health outcome indicators per population.NARRATOR: And infant mortality is not just a problem for African Americans. R. DAVID:White Americans, if they were a separate country, would still rank 23rd in the world.So outcomes are very bad. NARRATOR: As a country we pay an enormous price for our highrate of premature and low birth weight babies. Pre term birth is the second leadingcause of death for infants. If theyre lucky enough to survive, many face a lifetime oflearning and medical problems. Studies show that prematurity increases the risk forhypertension, diabetes and coronary artery disease. And the high cost of their medicalcare begins the moment theyre born. One months stay in a neonatal intensive care unitaverages $68,000 dollars. COLLINS: Neonatology is a lot of things. Inexpensive is notone of them. And we spend a disproportionately high amount of our income as a societytaking care of infants, a lot of whose problems probably could have been prevented ifthey had stayed in the womb until term. NURSE: Her current weight today, mom, is 2pounds, 6.3 ounces. MOM WITH PREMIE: Ok. NURSE: Ok? So shes gaining, she gained 15grams from yesterday. MOM WITH PREMIE: This is my first child, so I was like justamazed, yknow, and I was, I was a little shocked. I have never seen a child this smallbefore - never. It just took me away, but you see how she is now shes 2 pounds. So,miracles do happen. Everyday. NARRATOR: In the terminology of social scientists, KimAndersons family enjoys high socioeconomic status, which increases the odds for overallgood health. DAVID WILLIAMS (Sociologist, Harvard School of Public Health): Persons whoare higher in socioeconomic status, persons who have more income or more education orbetter jobs or more wealth, live longer, and have fewer health problems than those whoare lower in socioeconomic status. CAMARA PHYLLIS JONES (Medical Epidemiologist,Centers for Disease Control and Prevention): Education, for example, predicts infantmortality for both black women and white women. And the more educated you are, the lesslikely you are to have a low birth-weight baby, a preterm baby, or an infant death.NARRATOR: Women who are poorest and least educated are those whose babies are atgreatest risk in any racial group. But the babies of African American mothers withhigher education are still at greater risk than wed expect. Infant mortality amongwhite American women with a college degree or higher is about 4 deaths per thousandbirths. But among African American women with the same level of education, infantmortality is about 10 per thousand births almost three times higher. In fact, AfricanAmerican mothers with a college degree have worse birth outcomes than white motherswithout a high school education. MICHAEL LU (Obstetrician, David Geffen School ofMedicine, UCLA): Think about this. Were talking about African-American doctors,lawyers, and business executives. And they still have a higher infant mortality ratethan non-Hispanic white women who never went to high school in the first place. KIMANDERSON: As a mother youre thinking: I did all the right things. They told me to takevitamins; I took vitamins. They told me to walk. They told me to eat vegetables. Theytold me not to drink. I didnt do all that, and why is my kid sitting here with theseneedles and, you know, so you feel real helpless. You really feel helpless. NARRATOR:So Doctors Collins and David asked themselves if the answer could possibly be geneticits well known that prematurity can run in families. Is there something in the DNA ofAfrican American women that tends toward premature births regardless of education,prenatal care, or lifestyle? To answer the question, they created a study based on asimple assumption: R. DAVID: If there was such a thing as a prematurity gene, and itcame from Africa, then Africans should have more of it. NARRATOR: They comparednewborns among three groups: African American women, African immigrants to the U.S.,and U.S.-born white women. R. DAVID: It turns out that the Africans and the whites wereabout the same. The African Americans, on the other hand, had babies that weighedalmost eight or nine ounces less than the other two groups. NARRATOR: In other words,African immigrants to the U.S. and white women born in the U.S. had similar pregnancyoutcomes. So if there is any genetic pre-disposition for low birth weight babies, itsdoubtful that it falls along what we call racial lines. It turns out that when Africanwomen immigrate to the US, it takes only one generation before their daughters are atrisk of having premature babies at a significantly higher rate and with poorer birthoutcomes. R. DAVID: Has her heart rate been in that range? Over 180? NURSE: Noactually, its been about 160. COLLINS: So within one generation, women of Africandescent are doing poorly. This to us really suggests that something is driving thisthats related to the social milieu that African American women live in throughout theirentire life. NARRATOR: The news was once more hopeful. During the 1960s and 70s, withthe civil rights and antipoverty movements, the health of African Americans compared towhites improved overall. Government initiatives not only integrated hospitals, but alsoopened up education opportunities and better jobs and housing. The health ofAfrican-Americans began to catch up with that of whites. And infant mortality rates inthe African American community declined. CAMARA JONES: During my lifetime the gap hasclosed a bit, and I think its as a result of social policies. After the War on Povertyand the civil rights movement, we had social policies that were allowing people moreopportunity. NARRATOR: But in the 1980s, economic growth stagnated, and governmentbegan cutting back social programs. The impact on infant deaths was dramatic. The ratioof infant mortality among African Americans compared to whites began to climb. Andcontinues to climb today. But that doesnt explain the case of middle-class AfricanAmerican women like Kim Anderson. Why should highly educated women with good incomesstill have high rates of premature and low birth weight babies? Once again a study byCollins and David points to racism as a key factor. R. DAVID: Women who perceived thatthey had been treated unfairly on the basis of their race, whether it was looking forwork, in an educational setting, or a variety of other settings, had more than two-foldincreased risk of very low birth weight infant. NARRATOR: So if racism is contributingto premature births among African American women how does it work? How might racismtake a physical toll on the human body over a lifetime? Increasingly researchers arelooking at chronic stress the stress caused by living day in and day out withdiscrimination. COLLINS: Recent data suggests that chronic stress associated with beinga minority, particularly being African American, for some biological reason, increasesthe risk of delivering a premature, low birth weight infant. TYAN PARKER DOMINGUEZ(Assistant Professor, USC School of Social Work): When you have a reaction to asituation in your life that makes you anxious or gets you stressed out, you not onlyhave a psychological or emotional reaction to that; you also have a body reaction.MICHAEL LU: And if that stress is chronic, constant, and you just cant escape it, overtime that chronic stress, the chronic activation of that response, creates wear andtear on your bodys organs and systems so that you create this overload on these systemsso that they dont work very well. NARRATOR: Researchers believe stress can affectpregnancy outcomes in several different ways. Stress hormones are part of the intricatechemistry of pregnancy under normal conditions. When those hormones reach a certainlevel they may help trigger labor. But what might happen if you went into pregnancyalready overloaded with stress hormones? DOMINGUEZ: Think about a woman who is pregnantwho is under a great deal of stress. Her body is going to start pumping out extrastress hormones. And so she may reach that tipping point for labor to begin sooner.NARRATOR: Stress can also constrict blood flow to the placenta, which could limit fetalgrowth and may lead to premature delivery. Chronic stress may also contribute toserious inflammation inside the uterus, which can trigger premature labor. Researchsuggests its not so much stress during pregnancy that may determine the health of amothers baby, but the cumulative experiences of the mother over the course of herentire life, regardless of race. Dr. Lu calls this hypothesis the life-courseperspective. LU: The life-course perspective posits that birth outcomes are the productof not simply the nine months of pregnancy, but really the entire life course of awoman. And the corollary for that is, disparity in birth outcomes is really theconsequences not only of differential exposures during pregnancy, but really thedifferential experiences across the life-course of women of color. NARRATOR: But isracism so dominant throughout the lives of African American women, that it can affectthe birth outcomes of their children? One recent study reports that the majority ofwhite Americans believe racial discrimination is a problem of the past. The evidenceindicates otherwise. For example, African Americans at all income levels are morelikely to be denied mortgages, pay more for automobiles, and receive fewer jobinterviews. DAVID WILLIAMS: It was a fairly dramatic study done in Milwaukee, Wisconsinwhere they sent black and white men, all with identical resumes to apply for 350entry-level jobs. What this study found was that a black male with a clean record, nocriminal record, was less likely to be offered a job than a white male with a felonyconviction. So it was a dramatic example of in the year 2004 of the persistence ofdiscrimination in American society. NARRATOR: This racial stress can have a life-longimpact on African American families and their health. RICHARD DAVID: Racism is asocietal level problem. Its institutionalized; its part of our educational system; itspart of our media; its part of our culture. Its one of the struts that reinforcesinequality in the society we live in. KIM ANDERSON: So nobody, when I walk in a store,nobody says, Oh, thats Kim Anderson, African- American, female lawyer, went toColumbia, they just see a black woman. I was in a store once, just walking around,thinking I was going to buy a pair of jeans. This clerks following me around. So Isaid, Why are you following me around? Im not going to steal anything. Leave me alone.Im not going to take something. When youre confronted with racism, that covert racism,your stomach just gets like so tight. You can feel it almost moving through your body;almost you can feel it going into your bloodstream. NANCY KRIEGER (SocialEpidemiologist, Harvard School of Public Health): There are very different kinds ofquote, unquote stressors in the world. You can have a bad day and somebody else canhave a bad day. They can cut you out of a parking space. Its an occasion, but its notpremised on the idea of second-class citizenship. Its not something that is a repeatedand reactivated insult that occurs. LU: So if were serious about improving birthoutcomes and reducing disparities, weve got to start taking care of woman beforepregnancy and not just talking about that one visit three months pre-conceptionally; Imtalking about when shes a baby inside her mothers womb, an infant, and then a child, anadolescent and really taking care of women and families across their life course.NARRATOR: So how do we actually identify and measure the kind of subtle, everydayracism that follows black women throughout their lives? Camara Phyllis Jones is afamily physician and epidemiologist at the Centers for Disease Control. She was oneamong of the first to investigate the connection between racism and health. One studylooking at chronic diseases in over 100,000 women, posed a critical question to get abetter understanding of how women internalize their racial experience. JONES: How oftendo you think about your race? For white women, fifty percent saying that they neverthink about their race. For black women, almost fifty percent think about their raceonce a day or more frequently, with twenty-one percent thinking about their raceconstantly. Thats an eternity of experience apart. CAROL HOGUE (Epidemiologist, EmoryUniversity): Recently there has been a coming together around the hypothesis thatstress really does make a difference. And that racism is a particular kind of stressor.Its like an addon to the other stressors of ones life: losing a job, losing a spouse,etc. The question is, how do you address this? You have to measure it. FOCUS GROUPWOMAN #1: You know, there have been times where Ive called on the phone and been likeI cant do this today yall. Somebody, you know, come help, come NARRATOR: Finding waysto identify and measure racism is a challenging task. Psychologist Fleda Jackson,sociologist Mona Phillips and epidemiologist Carol Hogue have attempted to measure theimpact of racism on middle-class African American women. Its a first step inunderstanding how ordinary, daily encounters with racism can affect women throughouttheir life course. FLEDA JACKSON (Psychologist, Emory University): To collect the datawe decided we first needed to hear from African-American women about what were thestressors in their lives. And so we started with focus groups. HOGUE: And over a periodof about 15 years, we evolved this measure, which is gendered. Its only just forAfrican-American women. FOCUS GROUP WOMAN #1: I think constantly having to internalizethe racism that we experience every day. Its like, to me, where do you escape to? Mydaughter shes real open and friendly, and so, you know, shell run up to the whitechildren and say, Can I play with you? And then they dont even answer; they just lookat her and run away. Its heartbreaking for me to see that. JACKSON: If you have to takechildren outside of your neighborhood for the best educational opportunities; if youhave concerns that they will be racially profiled; if there are concerns about theopportunities that they will have, all of that represents serious kinds of stressesthat are experienced by African-American women on a constant basis. JONES: Its likegunning the engine of a car, without ever letting up. Just wearing it out, wearing itout without rest. And I think that the stresses of everyday racism are doing that.FOCUS GROUP WOMAN #2: You have a doctor that comes in that doesnt really pay attentionto what it is youre saying, that invalidates what it is youre saying. FOCUS GROUP WOMAN#3: No matter how many times I made it to the final interview, or how many programscome out of my research, its just not enough. And I think its unfortunate, but it doessomething to me internally. Ive taken jobs, I mean, getting paid way less than thepeople that I know dont have as much education. I dont know what kind of resume towrite at this point. So, you know, Im scared to give people a resume. NARRATOR: Can weprotect African American womens bodies from the wear and tear of racism? One program,The Family Health and Birth Center in Washington, DC provides family support,employment and financial counseling-- and prenatal care. The result: preterm birthswere reduced by a third and low birth weight deliveries cut in half. NARRATOR: In KimAndersons case its impossible to pinpoint one cause for Danielles premature birththestress of racism, genetic predisposition, or other factors. But researchers work withaverages, not individuals. And with thousands of examples the evidence pointing to theimpact of racism and stress on pregnancy outcomes is becoming hard to ignore. KIMANDERSON: Danielle was discharged, even though she was so small, you know four pounds,but she just pulled through. She could have had sight problems; she could have hadlearning disabilities. Shes a great student. She doesnt have problems with health. Itcould have been so different. It could have been so different. MICHAEL LU: What kind ofnation do we want? I have two daughters, and the question is: What kind of nation do wewant them to-to grow up in? This nation was founded on the self-evident truth that allmen and women are created equal, and yet 230 years later, that truth still not quite soself-evident. Right you aint created equal if you cant get a equal start. KIMANDERSON: Sometimes I do worry what would happen if my daughter delivered a preemie. Imlooking at a second-generation preemie who says she wants to be a cardiologist andneonatologist, which to me is stress on top of stress, and as a African American woman,(laugh) who now wears dreads. So, so all those things that are going to be on herheart, on her mind, in her life. You dont want her have to worry about what to do witha preemie. Just dont want her to have to go through that and experience that, andwonder what the outcome would be. And I hope, I pray, that if it happens, her outcomewill be as blessed and successful as ours has been with her.