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CHILDREN'S HUMAN RIGHTS PROGRAM
Global Child Survival: A Human Rights Priority
V. Case Study: United States of America

Executive Summary

While the crisis of avoidable child mortality in non-industrialized countries is well recognized, the magnitude of the problem in the United States can not be overlooked. The United States has seen dramatic improvements in child survival in the past century. Important strides in living conditions, public health, and medicine have largely eliminated many health threats posed by a vast array of deadly but preventable childhood diseases. Nonetheless, today the United States lags far behind many other countries in infant survival. As one of the wealthiest nations in the world, and one that allocates extraordinary resources to health care, the United States carries the disrepute of an infant mortality rate that is worse than all other industrialized countries. The crux of the U.S. infant survival situation now lies in the racial and socioeconomic differentials in health and well-being. The comparatively high level of U.S. infant mortality is due, in large part, to gross disparities in death rates between different groups within the country. Despite continuing improvements in the health of children overall, racial minority and socioeconomically disadvantaged children still fare considerably worse than others.

High child mortality is not only a tragedy in its own right, it is also a negative reflection of the state of health and well-being of the country. The implications of high and disparate infant mortality rates in the United States are even more alarming when demographic trends are considered. The percentage of children in population groups with disproportionately high mortality is increasing. First, the percentage of children who are black continues to rise, although not as quickly as Hispanic and Asian populations. Second, the proportion of children in poverty is growing. The U.S. child poverty rate has risen to nearly 22 percent of all U.S. children, and is now the highest in the industrialized world. The increase in the percentage of children in poverty has occurred among white, black, Hispanic, Asian, and Native American children. As the United States faces an increasing proportion of its child population born into vulnerable circumstances, the hope for a healthy society is threatened.

The United States must address the racial and socioeconomic disparities in infant and child death rates. Black and poor infants should have the same opportunity for survival as does the population at large. Effective strategies need to integrate the socioeconomic with the biological and behavioral approaches. The United States has seen dramatic changes in public benefits in health care and social welfare since the 1980s. While the U.S. strategies for reducing infant mortality have had mixed success in the last two decades, "reforms" in the social and health delivery systems, if not carefully scrutinized, may undermine the significant gains so far, and increase the risk of further deterioration in infant and child health differentials between people in different socioeconomic classes. Reduction in socioeconomic supports for vulnerable infants and children would likely worsen the disparities in child health and survival.

Healthy People 2000 is a national initiative that sets specific objectives for achieving health for all U.S. residents. While major improvements in health among U.S. residents were achieved during the 1980s, Healthy People 2000 places emphasis on reducing the persistent health disparities between those who bear the disproportionate burdens of illness and death and the population at large. The country’s gross disparities in infant mortality are associated with racial and ethnic background, as well as the gender and socioeconomic status of various population groups. Progress to date has been mixed, with some improvement for all groups and a deterioration in the health condition of some disadvantaged groups. The status of black infants as compared to whites is an apt illustration. Use of prenatal care has improved for both blacks and whites, but remains significantly higher for whites. The incidence of low birth weight remains stable for whites and has worsened for blacks. The disparity in black and white infant deaths rates is growing. It now appears unlikely that the main objectives in reducing racial disparities in U.S. infant health can be achieved by the target year.

The widening disparity gap in infant mortality, and in socioeconomic status, of various population groups in the United States points to a general failure on the part of the U.S. government to live up to international standards to protect and provide for all of its infants. The United States has not ratified the U.N. Convention on the Rights of the Child. The U.S. Senate Foreign Relations Committee has continued to take an obstructionist stance with the treaty ratification process. Nonetheless, the United States has ratified the Convention on the Elimination of Racial Discrimination and the International Covenant on Civil and Political Rights, which require the government to take steps to protect its children against racial disparities in child survival and development.

Findings of the U.S. case study

• The United States has seen dramatic improvements in child survival in the past century. Nonetheless, the country has an infant mortality rate that is worse than 20 other industrialized countries, while the death rate among U.S. black infants is even higher than those of developing countries such as Costa Rica, Cuba, and Sri Lanka.

• Eight in ten deaths to children under age five in the United States occur in the first year of life. There is more information available about infant deaths than deaths to children aged 1 through 4 years because U.S. data collection, reporting, and research focuses on the infancy period. Significant discrepancies exist in the collection of data useful for understanding and preventing the underlying causes of disparities in infant mortality. Vital records of births and deaths are the primary data sources for understanding patterns of U.S. infant mortality, but information about the household income status of infants at the time of their birth or death has never been collected on vital records in the United States.

• Gross disparities in infant and child mortality rates persist among different groups in the country. Poor children and black children are the most vulnerable. Black children under five years of age die at twice the rate of whites. Of the 32,000 infant deaths in 1994, almost one third were black, even though black infants represented only 16 percent of all babies born alive that year. The risk of death is higher for black infants than whites for all leading causes of infant death except congenital anomalies. The mortality rate among infants from poor families is 60 percent higher than for infants above the poverty level. The poverty rate among black children is more than three times that among white children. These disparities are growing in terms of both race and poverty.

• Child mortality rates in the United States are linked to biological, behavioral, social, and economic factors including maternal health, socioeconomic conditions, public health practices, and access to quality health care and social services. The disparities in these factors among population groups generally parallel the disparities in the death rates.

• In its failure to address socioeconomic and racial disparities in mortality rates and underlying causes of death, the United States has failed to live up to international standards to protect equally all of its infants—no matter their race or economic status—and to provide conditions adequate for survival and healthy development.

Recommendations

• Ratify the Convention on the Rights of the Child; the International Covenant of Economic, Social, and Cultural Rights; and the Convention on the Elimination of All Forms of Discrimination Against Women.

• Ensure implementation and compliance with all human rights obligations under treaties and instruments to which the U.S. is a party.

• Promote and protect children’s rights, in particular rights related to child health and survival, through adequate programs and funding.

• Achieve further reductions in the disparity in infant mortality (and morbidity from poor birth outcomes). Such reductions require changes in social and economic barriers to healthy pregnancy and birth outcome. Both the public and private sectors should increase their investment in health care coverage, child care, education and training.

• Ensure that the changes in public benefits and health care delivery do not further threaten child health and survival. Several examples include:

·         changes in eligibility for Medicaid on pregnant women;

·         food stamp allocations and the effects on pregnant women and children;

·         change in prenatal care services for immigrants;

·         changes in supplemental security income eligibility on infants and children with disabilities;

·         federal funding for Maternal and Child Health State Block Grants Program; and,

·         transition from welfare to work.

• Implement strategies that minimize the risks of unintentional injuries and violence toward children. Child-welfare and law-enforcement agencies should collaborate to help protect children who are not adequately protected by their own families. When child abuse and neglect occurs, existing services to deal with this maltreatment need to respond more quickly. Prevention of child abuse and neglect should focus on the millions of high-risk families who are living below poverty or are plagued by domestic violence and substance abuse, the major risk factors for child maltreatment.

• Develop an organized public education and advocacy program to heighten awareness of the need to improve maternal and infant health, directed toward the general public, women of childbearing age, families, teachers, and employers.

• Adopt an integrated policy on children’s health and well-being in both the federal and state governments, addressing not only the medical needs of all expectant mothers and newborns, but also investing in broad-based preventive (or promotive) approaches. An integrated policy on infant and child health should include:

·         redistribution of health care and social services toward children;

·         paid parental leave;

·         subsidized child care;

·         expansion of earned income tax credit;

·         guaranteed access to social and health care for all pregnant women and infants; and,

·         health insurance for all uninsured children.

• Strengthen coordination between state and federal programs and social and health services for women and their children. A comprehensive service delivery system is needed, offering perinatal clinical services and linkages between community-based health care and social services.

·         Centralize and coordinate maternal and child care services to make available "one-stop" visits.

·         Refer and coordinate services to assure a healthy pregnancy and a safe, supportive environment for the infant. Referrals from medical/health to social or community-based services should be made, especially in times of crisis when families may have the most difficulty following through.

·         Link mechanisms for referral, tracking, and follow-up of clients among health and social service organizations that provide:

> health services specific to preconception, prenatal, perinatal, postpartum, and pediatric care;

> social services specific to housing, employment, mental health, substance abuse, poverty, and child care.

• Increase funding at the state and federal level for monitoring, data collection, and research on the status of children’s health and well-being:

·         demonstration projects aimed at reducing the racial and socioeconomic disparities in mortality (and morbidity) among infants and children;

·         Infant Mortality Reviews;

·         monitoring of health status of racial, ethnic, and socioeconomic subgroups of the population; and,

·         interdisciplinary research in the following areas:

> etiology of major causes of infant death (and morbidity) including preterm birth, low birth weight, congenital anomalies, etc., with an emphasis on what factors are responsible for the racial/ethnic disparities in cause-specific infant mortality;

> availability and potential development of prenatal care systems, with emphasis on how specific prenatal care services that are or could be provided during the course of a pregnancy may reduce infant mortality; and,

> the role of socioeconomic, environmental and lifestyle factors, along with genetic and physiological factors.

• Cultural competency in health and social service provisions should be strengthened, particularly in such areas as provider-client communications and medical practices.

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