Health Disparities: Breastfeeding's Role in Closing the Gap

Abstract

One of my favorite poems is by the late Tupac Shakur. The poem is entitled A Rose that Grew from Concrete:

Did you hear about the rose that grew from a crack in the concrete?

Proving nature's law is wrong it learned to walk without having feet.

Funny it seems but by keeping its dreams it learned to breathe fresh air.

Long live the rose that grew from concrete when no one else ever cared.

This poem epitomizes the sentiment that not all young people in America are being grown or developed in the same fertile soil. Tupac—coming from a difficult background—understood that we are asking a lot of children to grow up and be beautiful roses when they are being raised in the concrete environments of poor inner-city communities, with high crime rates, poor schools, and limited access to healthy foods, to name a few of the obstacles faced, with the extra challenge of being, in many cases, ethnic minorities. I use this poem a lot in Pasadena, CA, where I am the Director of the Public Health Department and the Health Officer. In Pasadena—with all the attention that the Rose Parade and the Rose Bowl gets—this poem reminds us that we must fight to give every child the best chance to grow up and flourish.

Disparity City

When we look at a map of the train system for Washington, DC, there are interesting geographical disparities. In his book The Status Syndrome,¹ Sir Michael Marmott reports that those who live in the southeast section of Washington, DC, will live shorter lives. Interesting how in the wealthiest country in the world its capitol city has some of the roughest neighborhoods anywhere, and one of them is near the Capitol Heights station.

On the flip side of the coin is the Shady Grove station in Maryland—one of the nicer areas in which one could hope to live. As you leave the Capitol Heights station and travel by train to the Shady Grove station, life expectancy increases by approximately a year and a half for each mile traveled. In fact, the book reports that the typical suburbanite will live on average 20 years longer than the typical city dweller near the Capitol Heights station. Staggering!

Race and Health Disparities

African Americans bear a disproportionate share of disease morbidity, mortality, disability, and injury.² Data from 2005 indicate that African American men live on average 6.2 years less than white men and 7.8 years less than the national average of 77.8 years. Otten et al.³ reported death rates per 100,000 for people 35–54 years of age 2.3 times higher for African Americans than whites. After adjusting for six well-established risk factors (smoking, systolic blood pressure, cholesterol, body mass index, alcohol intake, and diabetes mellitus), the gap decreases from 2.3 to 1.9 times; add family income, and the gap decreased to 1.4 times. This leaves about one-third of the difference unexplained. Controlling for poverty leaves an excess of 38,000 deaths per year or 1.1 million years of life lost among African Americans in the United States.⁴ Anecdotally, being rich and African American does not prevent an early death.

It's not just African Americans who have key health disparities. Mexican Americans suffer disproportionately from diabetes. Puerto Ricans suffer disproportionately from asthma, human immunodeficiency virus/acquired immune deficiency syndrome, and infant mortality.

Infant and Maternal Mortality

When we look at the disparities in infant mortality rates, we see that African American, Native American, and Puerto Rican infants have higher than the national average rates of infant mortality.⁵ African American babies have almost double the national average. This also holds true in the area of maternal mortality. We have seen in California a significant increase in the maternal mortality rates, and within that increase maternal mortality rates for African American women are significantly higher—as much as three times higher.

This is problematic because these two indicators, infant mortality and maternal mortality, work like the canary in the coal mine. It tells us of bigger problems in the healthcare system. The United States ranks low compared with other developed nations on these two indicators. If you then pull African American or Native Americans out and looked at them as their own separate nations, it would be safer for these women to be delivering and having babies in many countries we consider to be "Third World." Looking further down the timeline of health outcomes, away from maternal and infant outcomes to childhood obesity, we see disparities again. Latinos and African Americans have higher rates of obesity than the national average, Asian Americans, or white Americans. This, of course, increases the future risk for many chronic disease conditions in those overweight and obese children.

Breastfeeding and Health Outcomes

For African American women, these disparities parallel another disparity: the decreased rates of exclusive breastfeeding found in African American women. We know that breastfeeding is important in getting babies off to the best start in life. When the data point to the fact that certain groups will have worse health outcomes in areas where breastfeeding is protective, then there needs to be a greater call to action to support and promote breastfeeding in those communities. Yes, if we really want to decrease health disparities in this country, we should start with disparities in breastfeeding rates.

Breastfeeding has been shown to increase intellect and cognitive function as well as being protective against obesity later in life. There are also all the benefits of a baby who needs to visit the health provider's office less in the first 2 years of life because of lower rates of upper respiratory infections and otitis media.

Policy Advocacy

Yet, little has been done to protect the most vulnerable families from the effects of being overmarketed to by formula companies. These companies clearly do not have the best interest of the mother or the child at heart, but rather the interest of the shareholder. The promotion of exclusive breastfeeding—and the protection of even the poorest, most marginalized woman's right to give her child the nourishment that is not only best but the standard—is then not just an issue of health and the reduction of health disparities, but also an issue of social justice.

In order to level the playing field, policies that support and promote breastfeeding are critical. A great example of how changing policy can encourage breastfeeding is the results we have seen around the country, and definitely in southern California, of the improved breastfeeding rates that have come as a result of the change in the food package policy at the Special Supplemental Nutrition Program for Women, Infants and Children. Federal policies around breastfeeding have also been improved by the Affordable Care Act requiring coverage for breastfeeding support. Of course, as hospitals change their own internal policies and go Baby-Friendly, we see improved exclusive breastfeeding rates at discharge from the hospital. In the future, we can only hope that the Joint Commission on the Accreditation of Healthcare Organizations eventually mandates some of the key elements of Baby-Friendly hospitals.

We need to work harder to change environments and systems more than we do to change an individual's behaviors. And yes, we still need to work hard to change behaviors.

Yes, there are roses that grow out of the hard concrete of poverty and poor environments, but we cannot simply keep asking the roses to grow from concrete. We must also turn the concrete into fertile soil. Breastfeeding makes for a great fertilizer in the soil of our society.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Marmot

. Status Syndrome: How Social Standing Affects Our Health and Longevity. London: Bloomsbury Publishing, 2004.

Kung

, Hoyert

, Xu

et al. Deaths: Final Data for 2005National Vital Statistics Reports, Vol. 56, No. 10National Center for Health Statistics: Hyattsville, MD, 2008.

Otten

Jr , Teutsch

, Williamson

et al. The effect of known risk factors on the excess mortality of black adults in the United States. JAMA, 1990; 263:845–850.

Franks

, Muennig

, Lubetkin

et al. The burden of disease associated with being African-American in the United States and the contribution of socio-economic status. Soc Sci Med, 2006; 62:2469–2478.

Mathews

, MacDorman

. Infant Mortality Statistics from the 2007 Period Linked Birth/Infant Death Data SetNational Vital Statistics Reports, Vol. 59, No. 6National Center for Health Statistics: Hyattsville, MD, 2011.