A new report concludes 600,000 children have died in the United States for no reason over a 50-year period. Thousands more will die this year, and next year, and the year after that. 600,000 is a lot of people. it’s more than the population of Tulsa, Oklahoma. Or Oakland, California. Or Minneapolis, Minnesota. Or Omaha, Miami, Atlanta, and Milwaukee.
An entire city of children has been lost.
This is the real “death tax.” It’s a tax on poverty, a tax on race, a tax on political powerlessness. And it’s paid with the lives of the innocent.
These deaths should have led every news broadcast and been a banner headline in every newspaper in the country. They would have been, if terrorists had killed these kids. After all, we changed our way of life after 3,000 people died on 9/11. But after the deaths of 600,000 children, nothing’s changed at all.
The report, published in the journal Health Affairs, compared child mortality in the United States with that of 19 other comparably developed nations. Here’s what the authors found:
A child born in the U.S. is 76 percent more likely to die before reaching adulthood than a child born elsewhere in the developed world.
“From 2001 to 2010 the risk of death in the U.S. was 76 percent greater for infants and 57 percent greater for children ages 1–19.”
“During this decade, children ages 15–19 were eighty-two times more likely to die from gun homicide in the U.S.. Over the fifty-year study period, the lagging U.S. performance amounted to over 600,000 excess deaths.”
The leading cause of infant death was extreme immaturity, which was three times higher for American infants, followed by sudden infant death syndrome (SIDS).
For children aged 15 to 19, motor vehicle accidents were the leading cause of death. Significantly, these accidents were twice as likely to result in death in the U.S. The second-leading cause of death was gunfire. American teens were 82 times more likely to die by gun than their peers in the comparison countries.
“There is not a single category for which the (comparison countries) had higher mortality rates than the U.S. over the last three decades of our analysis.”
The United States spends more on health care than the other countries, but has worse outcomes.
Although it spent more on health care, the U.S. “spent significantly less of its gross domestic product per capital on child health and welfare programs, compared to other wealthy nations.” These programs also affect child health.
A Moral Failure
The U.S., say the report’s authors, is “the most dangerous of wealthy nations for a child to be born into.”
As the Los Angeles Times notes, “The study authors said their findings support the conclusions of the Institute of Medicine, which blamed a fragmented health system, poverty, a weak social safety net and other factors for ‘poor health outcomes’ in the U.S.”
The authors reached the following conclusions:
“The care of children is a basic moral responsibility of our society. The U.S. outspends every other nation on health care per capital for children, yet outcomes remain poor.”
“All U.S. policy makers, pediatric health professionals, child health advocates, and families should be troubled by these findings.”
They also warn that Donald Trump’s proposed budget cuts will make the situation even worse. And, as of this writing, Republicans in Congress have not renewed funding for the children’s health insurance program known as CHIP. Parents are already being warned that their children’s coverage could lapse as soon as next month if Congress doesn’t act.
The Health Affairs report is new, but we’ve known about the systemic injustices in our healthcare system for a long time. African-American infant mortality rates are 2.2 times higher than those of non-Hispanic whites. They were 3.2 times more likely to die from complications due to low birthweight, and experienced more than twice the rate of Sudden Infant Death Syndrome (SIDS).
Racial disparities are even more pronounced when they are combined with geographic differences. The infant mortality rate in Mississippi is the highest in the country. At 9.4 deaths per thousand, that state is closer to Costa Rica, Botswana, and Sri Lanka than it is to the overall United States.
A 2015 study found that infants born Washington D.C.’s poorest neighborhood were ten times more likely to die than its richest infants. That neighborhood, Ward 8, was 93.5 percent black at the time. It also found that the nation’s capital has a higher infant mortality rate than any other capital in the developed world.
Another recent infant mortality report found something else significant: The white, non-Hispanic infant mortality rate ranged from a low of 2.52 deaths per 1,000 in the Washington, DC to a high of 7.04 in Arkansas. That difference is, of itself, an injustice.
The mortality rate for black infants ranged from a low of 8.27 per 1,000 in Massachusetts to a high of 14.28 in Wisconsin. That means a black infant born in Wisconsin faces the same likelihood of death as an infant born in the West Bank of Palestine. She or he is more likely to die than an infant born in Colombia, or Jamaica, or Venezuela, or Tunisia.
Something else is striking about these race-based statistics: The country’s worst white infant mortality rate is better than its best black rate. That is apartheid, and it is a moral crime.
Racial and Economic Barriers
A 2011 study compared World Health Organization data from the U.S. and 19 countries and found that the U.S. had the worst child mortality rates. Using a UNICEF standard of measurement, it concluded that “the USA health care system appears the least efficient and effective in ‘meeting the needs of its children’.”
Meeting the needs of our children: why can’t we do it?
Many parents can’t afford adequate healthcare for either expectant mothers or children. Many of the same parents also face barriers of entrenched racism. A news brief from the University of California, San Francisco offers the striking anecdote of “an ER physician who had lost a document and was searching frantically for it in the garbage bins behind … San Francisco General Hospital and Trauma Center. What he found instead in the mountain of rubbish were crumpled prescription slips that patients had tossed in hospital trash cans throughout the week.”
They had been tossed, not because parents didn't care, but because they couldn't afford to pay for the medications their children needed.
The brief goes on to describe physicians’ efforts to provide care in the face of poverty, including “the nurse trying to help a mom living in a single-room-occupancy hotel find refrigeration for her son’s antibiotic before an infection ruptures his second eardrum.”
A 2017 survey conducted by NPR, the Robert Wood Johnson Foundation, and the Harvard School of Public Health found that 22 percent of African Americans reported that they avoided needed medical care because of fear of discrimination, and more than half did not go to the doctor when they needed care because of cost.
A similar survey of Hispanic Americans found that 17 percent avoiding medical care out of fear of discrimination, while 58 percent reported that they did not seek medical care because of the cost.
Insurance matters, too. A 2002 report from the Institute of Medicine (U.S.) Committee on the Consequences of Uninsurance concluded that “Uninsured women receive fewer prenatal care services than their insured counterparts and report greater difficulty in obtaining the care that they believe they need.”
That report also found, unsurprisingly, that “Health insurance status affects the care received by women giving birth and their newborns. Uninsured women and their newborns receive, on average, less prenatal care and fewer expensive perinatal services.”
It concluded, “Uninsured newborns are more likely to have adverse outcomes, including low birth weight and death, than are insured newborns.”
Poverty itself makes people sick.
Environmental problems plague lower-income communities and communities of color. Jasmine Bell listed five of the environmental injustices faced by communities of color, including higher exposure to air pollution; greater proximity to landfills, toxic waste sites, and industrial facilities; higher rates of lead poisoning; water contamination; and greater vulnerability to the effects of climate change.
Each of these factors can directly affect the health of children. An in-depth report in Scientific American, “Pollution, Poverty and People of Color: Children at Risk,” detailed the harmful health effects of environmental pollution and chronic stress. The complex relationship between poverty and health was explored further in a journal article entitled “Epigenetics and Understanding the Impact of Social Determinants of Health.”
Low-income housing can make you sick, too. A report for the Philadelphia Department of Health outlined the harmful impact of inadequate housing on children’s health. Housing can cause or exacerbate asthma, lead poisoning, and physical injury, and can inflict emotional harm on both parents and children.
Childhood obesity is singled out in the Health Affairs study. It’s worse among poor children, and its effects are more severe. Other factors affecting child health include nutrition for both mothers and children.
Inequality: Economic, Medical, and Political
The 2018 World Inequality Report (by Alvarado, Chancel, Piketty, Saez, and Zucman) found that “the divergence in inequality levels has been particularly extreme between Western Europe and the United States, which had similar levels of inequality in 1980 but today are in radically different situations.”
Today, according to a related paper, the top percent earn more than 20 percent of the nation’s income, up from 10 percent in the 1970s. The share going to the bottom 50 percent of earners fell from 20 percent of national income to 12 percent.
Why do we spend more on health care than other countries, and get less in return? There are many answers to that question. One of them is inequality of care. Some people can afford all the medical treatment they need. Others, even those with health insurance, may struggle to get needed care. Others have no way of affording it. And our system permits financial exploitation by pharmaceutical companies and other for-profit players, leaving less money for actual care.
The UN Special Rapporteur for Extreme Poverty and Human Rights, Phillip Alston, recently visited the United States. In an eloquent and comprehensive statement at the end of that visit, Alston noted the erosion of democracy in the U.S. and said:
“My visit coincides with a dramatic change of direction in U.S. policies relating to inequality and extreme poverty… The dramatic cuts in welfare, foreshadowed by the President and Speaker Ryan, and already beginning to be implemented by the administration, will essentially shred crucial dimensions of a safety net that is already full of holes.”
To be clear, the problems with U.S. child mortality began well before the 1980s, when inequality began to soar. But inequality makes the problem worse, and the growing political power of the wealthy makes it more difficult to find solutions. Healthcare remains inaccessible to millions of Americans, with that number about to increase dramatically. 40 million Americans are still impoverished, including more than one child in five.
Antipoverty programs reduced the national poverty rate from 26 percent in 1967 to 15 percent in 2015 but, as the Center for Budget Policies and Priorities has documented, that figure would return to its 1967 levels if those programs were eliminated.
That’s why authors of the Health Affairs report are so concerned about Trump’s budget and its impact on child mortality in this country. It’s why we should all be concerned about the Republicans’ refusal to renew the CHIP program, at least so far.
Sure, House Speaker Paul Ryan talks a good game about this critical program. But, as Dylan Matthews points out, he’s had more than enough time to protect it. Worse, Ryan’s lifelong ideology of stripping the poor of even minimal government support stands in opposition to programs like CHIP – and his ideology is shared by many members of his party.
The Republicans may pass some version of it eventually, if only out of fear of the political consequences. But for now, unfortunately, they’re holding it – and the 9 million American children who depend on it – hostage, as part of their budget gamesmanship.
We’re willing to keep tens of millions of Americans in perpetual poverty, and to sacrifice the children of poor and working Americans, to perpetuate a system that gives us growing inequality and the loss of political and economic power. Why are we so indifferent to these children?
In part, it’s a problem of white indifference. Contrary to popular white assumptions, 31 percent of poor children are white, and 24 percent are black. 36 percent are Hispanic, and 1 percent are indigenous. But most white people probably don’t know that. Their racial stereotypes allow them to assume that the poor are “other.” For some, that results in a lack of empathy.
Nevertheless, people of color are hardest hit by poverty. Although they are not the largest group of the poor, they are disproportionately affected because they are minorities. Overall, only 14 percent of white toddlers and infants in this country is poor. By contrast, 42 percent of all black children in this group are poor. So are one-third of all Hispanic children, and 37 percent of Native American children.
But most white people don’t know that, and many don’t care.
Sexism and Child Health
Sexism is also a major source of the problem. Child health depends heavily on a mother’s health, both during pregnancy and afterwards. Our culture, political and otherwise, has been notoriously indifferent – if not downright hostile – to the health needs of American women.
The needs of working women are also a subject of political neglect. Wage theft, unplanned shift changes, low wages, hostile work environments, lack of family leave: all these factors make life hard for working mothers to provide for their children, give them a healthy environment, and get them the medical care they need.
Even the subject of children’s health itself is often treated as a “women’s issue,” as if men don’t care about their kids. In our sick political life, it’s not helpful when something is labeled a “women’s issue.”
Then there’s greed. In our oligarchical political system, neither child health nor income inequality can be addressed without mildly inconveniencing the very wealthy.
Democratic politicians aren’t talking enough about this issue, either. That’s partially because they need donors, too. And they, like others, follow the media’s lead more than they guide it.
Perhaps they, and the well-intentioned voters who support them, could spend less time mocking the personal qualities of Republicans they don’t like and more time talking about the deaths of American children.
Breaking the Circle
The child mortality study begins in 1961. The youngest child to die needlessly that year would be 56 years old today, and the oldest would in her seventies. Many of them would have had children, and grandchildren, of their own. Theirs are the faces we don’t see, the voices we don’t hear. Their thoughts and ideas and deeds, which might have enriched our lives in so many ways, will never be expressed.
Poverty and inequality not the only cause of child death, of course. But they are leading factors. The policies being pursued today will lead to more poor people, and fewer services to care for their children’s health and well-being.
We can’t address poverty or inadequate health care without addressing inequality. And we can’t do that without paying more attention to the deaths of America’s children.
If terrorists had taken their lives, we’d hear about it night and day. But these children were killed instead by bigotry, political cynicism, and greed. Politicians and the press will keep looking the other way, and the deaths will continue.
Unless the public demands that they stop.