Nearly everyone agrees that the health care system in America is nearing a state of collapse. Patients and providers alike despair over spiraling costs, access and quality issues, and bureaucratic nightmares associated with insurance companies and government programmes like Medicaid, which provides coverage to the poor. The US spends almost twice per person on health care than any other nation - nearly $2 trillion a year. Yet life expectancy ranks 30th in the world and the country ranks 28th in its infant mortality rate, making it next to last among industrialized nations.
If you are an African American, this picture is even bleaker. A recent study pointed out that African American males living in New York's Harlem are less likely to reach age 65 than men in Bangladesh. African American babies are twice as likely to die as white infants and, in some urban areas, a black woman is more than three times more likely to die during pregnancy than her fair counterpart. Black women are also more likely to suffer from hypertension and diabetes. Overall, the anticipated lifespan for African Americans is six years shorter than for whites.
Conventional analysis of these disparities has largely focused on genetic make- up, lifestyles, and poor medical care. But these factors do not tell the whole story, says Dr Michael Lu, Associate Professor of Obstetrics and Gynecology at the University of California, Los Angeles. "You can't just look at snapshots during pregnancy. That won't explain what else is going on. And you can't reverse in nine months what has been occurring over the course of a life."
Now, new approaches to the problem of racial disparities in health outcomes, particularly in terms of maternal and child health, are offering a far broader, more complex and egalitarian view of the role that poverty, and racism, play in health inequities. Public health experts working in collaboration with social workers, medical professionals and policy and financial analysts are developing new paradigms for assessing socio-economic and race-based disparities in health.
Root causes of lifelong stress that can lead to poor health - income, housing, work, education and social status, along with a lack of power or control over one's life - are being factored into the equation as a way to better understand chronic disease, premature death and pregnancy outcomes. "Stress has a huge impact on women's health," says Lu. "If the body's ability to sustain stress is challenged, if there's no escaping from chronic stress, there can be hormonal changes that can create problems during pregnancy... We must improve women's health, especially for women of color, across the entire life course."
One of the key figures in this work is Dr Magda Peck, a professor of pediatrics and public health at the University of Nebraska. Peck is also the founding CEO and now Senior Advisor to CityMatCH, a national public health organization dedicated to improving the health and well-being of urban women, children and families. She strongly believes that currently "the social determinants of health and the fragility of the health care system make for the perfect storm".
In an effort to head off that storm, Peck and her colleagues are "connecting the dots" to look at what lies beneath the statistics. "You can look at infant mortality, a classic bellwether in epidemiology, or you can ask why women and children are not thriving."
Peck, who identifies herself as "an applied scientist" believes it is crucial to use data in such a way that it improves the public health community's understanding of myriad causes that can underlie stress and illness.
For many people who specialize in infant mortality and race disparities, this means looking at "preconception health" as well as what happens to infants between birth and one year. For example, if you explore fetal mortality, Peck points out, you find that the tiniest babies account for the greatest disparities. And there are much higher rates of small fetuses and babies among black women. "Looked at that way," Peck says, "you get a different picture. What happens prior to conception to put these babies at greater risk? It's not only about prenatal care because so much of the die has already been cast. In other words, what are the social determinants of health prior to pregnancy?"
Preconception care is defined by the Centers for Disease Control and Prevention (CDC) as a set of interventions that identify and modify biomedical, behavioral, and social risks to a woman's health and future pregnancies. It is a concept that takes a life course approach and that is helping to reframe public health initiatives as women's groups like the Black Women's Agenda and others join with medical professionals, policymakers and members of the financial community to re-energize the field of maternal and child health. Says Peck, "Women must demand it, politicians must do it, and insurance companies must pay for it!"
Clearly, it's a daunting task to "undo racism" and restructure the way public health is administered. Everything from organizational policies and attitudes to cultural competence training to new financing mechanisms must be considered. But, says Lu, "the one thing that public health heroes have shared historically is unwarranted optimism."
Encouragement has come from The Joint Center for Political and Economic Studies in Washington, DC, which has launched the 'Courage to Love: Infant Mortality Commission'. Its mandate is to find innovative approaches to addressing the problem of racial disparities in infant mortality by examining the socio-economic context in which black women live.
The Commission, funded by the W.K. Kellogg Foundation, in partnership with University of California/Los Angeles and University of Michigan's NIH Roadmap Disparities Center, has done significant research in areas like the impact of breastfeeding - African American women have the lowest rate of breastfeeding and the highest infant mortality rate - and maternal nutrition. They have also explored the historical framework of policies and practices currently in place to reduce infant mortality.
As a result, the Commission is calling for new approaches to prenatal care that encompass the cultural realities of stress, discrimination and the absence of social support among black women. Further, it is fostering efforts aimed at achieving greater empowerment, equity and social justice for black women, their families and communities. The role of the father is also being examined, as is America's welfare system.
"Clearly, race and poverty matter," says Peck. "But so do education, age and location. The real question is which women and babies are already doing well and why? How well can we do for every woman and child, regardless of race or economic status? It's a justice question. Shouldn't all women have what some others have? We need to redistribute our best outcomes. We must challenge communities to rise to that."