POVERTY, ILLNESS, AND THE NEGRO CHILD

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SPECIAL ARTICLE

POVERTY,

ILLNESS,

AND

THE

NEGRO

CHILD

Max Seham, M.D.

From the Group Health Medical Center, St. Paul, Minnesota

(Received April 19, 1968; revision accepted for publication April 15, 1970.)

ADDRESS FOR REPRINTS: Group Health Medical Center, 2500 Como Avenue, St. Paul, Minnesota 55108.

I

N the midst of a rising prosperity

en-joyed by a majority of American

citi-zens, there are 39,000,000 of the nation’s

poor who belong to families with total an-nual incomes that fall below the recognized

subsistence level of $3,000 for a family of

four. Of these, six million are children

be-low the age of 6 years, and about nine mil-lion are between 6 and 17 years. As of 1966, more than a fifth of the nation’s youth, and

in some areas one-third, are growing up in dire poverty.

The children who, through no fault of

their own, are compelled to grow up under these circumstances are known to suffer

from the so-called “deprivation syndrome,”

a complex disorder which is often the

consequence of severe social pathology. It

interferes with normal growth and

develop-ment of the child in the physical, mental, and emotional spheres. It may result in

in-tellectual retardation, personality disorders,

social maladjustment, and even brain dam-age. Overwhelming evidence shows that

poverty accounts for higher rates of

mor-bidity and mortality among youth as well as

among other age groups.

Amid the affluence of modern life,

crum-bling tenements, inadequate sanitary facili-ties, malnutrition, and disease mark the spread of poverty. Public action has been inadequate in meeting even the most press-ing needs of families submerged in the

eco-nomic struggle. While poverty claims its

victims from among all racial groups, it has

undoubtedly wrought its greatest damage

upon the impoverished Negro child. No

case better illustrates the wreckage left by

poverty and discrimination than that

pre-sented before the Senate Committee on

La-bor and Public Welfare by Dr. Robert Coles of Harvard on June 15, 1967. De-scribing the condition of Negro youth in

Mississippi, he said:

I saw wide-spread malnutrition in Mississippi. I

saw it when I was examining children involved in

the Head Start program. One does not see the final

stages of malnutrition, the starvation that one sees

in countries of Asia or Africa; on the other hand

one sees a wide spectrum of diseases that are

dis-tinctly due to a poor and inadequate diet. I have

seen vitamin deficiencies of all sorts-poor muscle

tone and wasted muscles. Evidence of neurological

disease and repeated infections that plague all

parts of the body. Children with distended

abdo-mens and a whole range of diseases that would

probably shock the American public if they knew

that they existed amongst American children. Rare

vitamin deficiencies, more insidious diseases like

weight loss, muscle weakness, eye infections, loss

of vision, infections of the mouth and throat,

rick-ets and skin diseases of all kinds. Marked chronic

fatigue and bleeding of the mucous membranes

caused by lack of protein intake. The whole range

of psychological disorders like lethargy, despair

and exhaustion.1

MATERNAL MORTALITY

Among the most meaningful clues to the health status of a nation are the maternal and infant mortality rates. When I first

hung my shingle to practice medicine more than 60 years ago, the United States was

losing about 100 mothers for every 10,000

pregnancies. Today, the rate has decreased to only 2.5 for pregnancies in Caucasians,

but it still remains about 10 for Negroes,

about four times as high. Six percent of all

deliveries for Caucasians take place outside of hospitals, while 40% of Negro newborn in-fants are delivered in homes by “midwives of a granny type.” Pregnancy today holds 17 times less risk of death than it did in

1917, yet the risk is still four times as great

among the Negroes as the Caucasians

be-cause of illegitimacy, malnutrition, lack of prenatal care, and prematurity.

RATES FOR PREMATURITY

Authorities agree that the chief reason for

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States is the high incidence of immaturity and prematurity, which, with the accompa-flying low birth weight, predispose the

newborn infant to the respiratory distress syndrome within 24 hours after birth. The

mothers who have the greatest risk in

re-gard to low birth weight infants are the

teenagers, the unmarried, and those with

the poorest prenatal care. The Negro ranks the highest in all these aspects. Rates for

prematurity average 5.3% in the highest so-cioeconomic class of Negroes, as compared to 23.3% in the lowest. The percentage is highest among those with no prenatal care and lowest for those with private care. Moreover, among those who survive, 6% of

the Negro infants have congenital defects

in contrast to 2% among Caucasian infants.

This reflects “bad medicine, bad econom-ics, and of course a low level of prenatal

care.”2 I have read, or heard it said, that in

some clinics, as recently as 1967, the long waits, the poor facilities, and the generally bad attitudes of the clinic personnel

frighten their clientele. Prenatal care is

actu-ally decreasing rather than increasing

among the poor-in our urban ghettoes-the

rate has steadily risen to the current level of

10% of live births, 7% for Caucasians and

16% for Negroes. Since 1960 there has been

an increase in the proportion of infants weighing less than 2,500 gm. If the present low weight trends continue, we can expect about a 10% increase in premature births

over 1964.

INFANT MORTALITY

The second most sensitive yardstick of

national health according to a number of public health authorities is the infant mor-tality rate. In a sense it is an index of what

our society is doing for our children

through the skills of our practicing physi-cians. Since 90% of all nonwhites are Ne-groes and the vital statistics are more accu-rate for this group, I have used the terms Negro and nonwhites interchangeably. Child or adult, male or female, the Negro in the United States is less healthy than the

Caucasian. The first inalienable right, life

itself, is cut short for every Negro child

born. A Caucasian newborn infant can ex-pect to survive about 68 years, but a Negro about 7 years less.

If we use Mississippi as an extreme exam-ple of the South, discrimination and pov-erty are responsible for the double standard of medical care. If the same care were available to Negroes in Mississippi and other southern states as in 4innesota and other northern states, Negro morbidity and

mortality rates among children could be sharply reduced. In 1964 of a total of 2,784

fetal deaths, the nonwhites, who

repre-sented 42% of the population, accounted for 57% of the deaths. Of the total number

of live births among Caucasians, 3% were attended by midwives, but 40% of the

Ne-groes were delivered by “granny midwives.”

There were 55 Negro physicians serving 42% of the population and 2,000 Caucasian

physicians to serve 58%. There was only

one Negro student enrolled in the

Missis-sippi Medical School.

The infant mortality rate in the United States has decreased considerably since

1930; but, as the wealthiest nation in the

world, we have no reason for pride or

com-placency because the 1965 overall rates are

20.9 for Caucasians and 40.2 for nonwhites.

Moreover, the discrepancy aniong the states is unnecessarily high. If all states had rates

as low as Utah (19.7), the lives of 23,000 who die before their first birthday would be spared. Marked differences also prevail in

different parts of the same city. Surveys of the infant mortality rates in large cities with populations more than 500,000 have revealed rates of approximately 16/1,000 in the higher socioeconomic classes in contrast to 27/ 1,000 in the lowest.

Why does the United States lag behind the Scandinavian countries, The Nether-lands, Switzerland, England, Wales,

Aus-tralia, and New Zealand in the infant

mor-tality rates? The best authorities do not

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infant mortality in the United States today was as low as currently reported in Sweden

(

14.2) and The Netherlands

(

14.8

),

there

would be an annual increment of 40,000 children in our population.”5 The U. S. Pub-lie Health Service predicts that, within 10

years if present trends continue, the infant

mortality in The Netherlands will be 9.4

and that of Sweden will be 10.7; but, in the United States it will remain about 22, the Caucasians 18.5 and the nonwhites 38.6. Clearly, poverty plays a major role in

caus-ing these higher rates our country.

PRESCHOOL CHILDREN

Even though Negro children survive the first 2 years, they have two strikes against them during the rest of their lives. Since the Head Start program began in 1964, the screening and the referrals have shown that Negro children have been left with many more undiagnosed and untreated defects than Caucasian children, chiefly because of lack of immunization against contagious diseases.6

SCHOOL-AGE CHILDREN

A few statistics from knowledgeable sources emphasize the urgent need for

fewer conferences and eloquent promises

and more congressional action in meeting the crisis so clearly demonstrated by the President’s Head Start program. To date,

Congress has paid little heed to former

President Johnson’s warning in his 1966

message to Congress on health, “Our public

health record for children gives us little cause for complacency. Our whole society pays a toll for the unhealthy and crippled children who go without medical care.”

The national health survey revealed in 1962 that 55% of all children under 6 years of age and 69% of those between 6 and 16 years had not had a regular examination by a physician in the year prior to the survey. Almost all children need some dental care by the time they reach school age, but half

of those examined between 5 and 14 years of age had made no visits to the dentist. This was true for 70% of the nonwhite population. The incidence of heart

dis-ease, orthopedic handicaps, hearing and speech disorders, and mental retardation

was found to be much higher among the

nonwhites. Once again, it seems clear that

poverty plays a major role in causing these higher rates in our country.

MENTAL RETARDATION AND EMOTIONAL DISORDERS

Emotional problems and behavior

disor-ders are among the most common and the least recognized and treated. Pediatricians who are in the most strategic positions to recognize and deal with these conditions are either too busy or are untrained to

ac-cept the challenge. The extent of psychiat-sic illness is impossible to estimate accu-rately, but it is logical to assume that it is much more common among the disadvan-taged and minority groups.

Although 3% is the nationally quoted fig-ure for the incidence of mental illness, this cannot be the same for all segments of the

population. The prevalence of inferior school work by Negroes was revealed by recent psychological studies in Harlem schools. Eighth grade pupils were found to have a mean I.Q. of 87.7, as compared to a mean of 100 for all New York City eighth graders. Another study of 1,800 Negro

ele-mentary school children in five southern

states yielded a mean I.Q. of 80.7, which is considered borderline retarded. These fig-ures are substantiated by evidence of draft rejections. Of all 18 year olds examined for military service in 1965, the rejection rate

for Negroes was 87.1% and only 39% for

Caucasians.

Authorities no longer believe that the dif-ference between the I.Q.’s among the drop-outs and lower achievement nonwhite pupils are racially determined. The more

important factors are probably the lack of

accessibility and availability of health

ser-vices, the poor schools, and the lack of

envi-ronmental stimulation and cultural

depri-vation. Whether the parents are responsible

for not making the health services available to their children or whether they cannot

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for private care-it is the responsibility of social workers and other school personnel to bring the necessary medical care to the children, as is being done now by the Head Start programs.

The conclusion that the contrast between the Caucasians and the Negroes is due to

environmental circumstances, rather than

innate biological characteristics, is

sup-ported by observations of Leon Eisenberg.T In the summer of 1965, 500, 5-year-old Negro children were enrolled in the Balti-more Head Start program. Half of them came from families with annual incomes of about $500. The result indicated that, under proper management, intelligence quotients

could be raised in about 10 weeks and be-havior disturbances could be reduced. The mean I.Q.’s rose from 86 to 95, while the

I.Q.’s of control children remained about the same. It was concluded that the I.Q. as used by psychologists is not a true

predic-tive measure of inherent capacity and intel-ligence, but rather a measure of the perfor-mance of the child at the particular time of testing.

Almost no Negro families have the

re-sources to obtain private psychiatric care.

Public outpatient facilities are so limited that vast numbers of children requiring help are never diagnosed or treated.

In a country as rich as ours, there are too

many undernourished children, whether

from lack of food or the wrong kinds of food. There are too many crippled children be it from birth injury, accidents, or ne-glect. There are too many who are hard of hearing and too many who are partially

blind and could be helped through hearing and sight conservation. Too few schools

have any child guidance programs for the thousands of children who are maladjusted, insecure, and potential delinquents. This situation is tragic, not only in the rural

ar-eas of our country but also for the urban

poor and minority groups. As long as we do not give greater priority to the application of our technical knowledge, I believe we must

admit that our present school health

pro-grams are neither efficient nor effective.

PROJECT HEAD START

But, all is not as dark as I seem to have

painted it. Congress has finally awakened from its apathy and indifference and is be-ginning to recognize the urgent health

needs of about 11 million deprived youth.

Under Title 2 of the Economics

Opportu-nity Act of 1964, 560,000 children between

the ages of 2 and 5 years were initially en-rolled in a nationwide program of screen-ing, detection, and correction of physical

defects and mental disorders. Now in its

fifth year, the Federal Government has ap-propriated many millions of dollars for

about two million children in centers all over the country. The program still has a long way to go, but it has already brought diagnostic, curative, and preventive health services to more than 100,000 children who

had been neglected by their local

communi-ties. The cycle of poverty has been cracked

by attacking the educational gaps; by im-proving the child’s all around performance; by finding and correcting all physical,

den-tal and emotional disorders; and by

insur-ing the child’s future health through

ade-quate immunization.

Data collected from Head Start centers

confirm the need for these projects. In one

large urban center it was found that 34% of the children had not seen a physician in 2

years. Only one in four had ever seen a

dentist. More than 14% were not born in a

hospital. About one-half had never been

im-munized against diphtheria, pertussis,

teta-nus, poliomyelitis, and smallpox. Only 12

had received measles vaccine or a tubercu-lin test. In addition to Project Head Start, one of the first neighborhood health centers

(

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)

to measure the need for health care in the poverty income areas, (2) to provide health care through comprehensive health centers, and ( 3 ) to prove that community action in the training of auxiliary health

workers can be used as a springboard to

general social improvement. The project at

present is limited to low income families

living in a district housing area. Previously,

there had been no physicians or dentists in

this area. It provides complete

comprehen-sive, preventive, and curative care 24 hours

a day ( especially for infants and children), prenatal maternal care, and care for the

el-derly. The center is staffed by members of the faculty of Tufts University School of Medicine and by a staff recruited from the community.

“Basic to the program,” says its director Dr. H. Jack Geiger, “is the premise that health services should be comprehensive and coordinated, not fragmented, and that these services be made available to the

community where the people are, rather than wait for people to come to often mac-cessible hospitals.” Says Dr. Geiger, “Health and poverty are very much related in our nothern cities, in the rural south, in Appalachia, indeed in the United States as a

whole. The poorest people are the sickest

people. Ill health makes poor people poorer and poverty helps cause illness. Without in-tervention, the poor get sicker and the sick get poorer.”8

Another one of the 60 similar projects in the largest urban slums was a community-sponsored program to care for all medically indigent children in a geographic area

within the purview of the Brooklyn Jewish

Hospital. For this purpose a grant expected to total $7,000,000 by 1971 was made to this hospital. A special feature of this plan was to reach out into the community and liter-ally draw in children who were not only in

need of medical care but also of psychiatric diagnosis and treatment. Dr. Charles

Pryles, the director, states, “We have got to see if people can be made first to want and then to demand medical service-if this ex-periment is successful, a much larger

num-ber of medically indigent children who need but whose parents have not sought

medical care will be rescued from much crippling disease.”9

Another seriously impoverishd area for which the Office of Economic Opportunity has proposed family comprehensive service is the Watts district of Los Angeles, Califor-nia. Watts is virtually all Negro, with an in-flux of about 1,000 per month. One half of the population is under 20 years of age. The

program has been running for about 4

years. The health services are part of a full program of education, medical and

psychi-atric care, and all necessary social services.

In a recent survey of the children who live in Watts, it was found that 51.3% of 1,135 children had one or more referable condi-tions. At the time of the screening, 73% were not under any physician’s care. Before the plan was put into effect, attempts to se-cure treatment for 80% of these children were met with very little success.1#{176}

I should like to mention the Head Start

program in Minneapolis, in which I have participated for over a year. Under the aus-pices of the Board of Education, the Min-neapolis Board of Health provided the

personnel to screen, immunize, and give

cor-rective therapy (through Title 5) for 997

preschool children in 21 schools. Of these, 813 children received some type of health

screening. One or more health problems

were found in 63.7%. Dental problems led in frequency, followed by defects of ears, eyes, nutrition, and heart. Of 804 children, preventable defects were found in 202

(

24.8%). Visual defects were found in 45 (5.6%) of 797 children, and hearing

de-fects were found in 76 (9.5%). No

posi-tive tuberculin tests were found. Before the Head Start clinics, polio immunizations had been given to 15%, smallpox vaccina-tion had been given to 69%, and

immuniza-tion against measles had been given to

67%. After Head Start, immunizations

in-creased to : DPT, 86%; polio, 63%;

small-pox, 76%; and measles, 79%. As of January 1, 1968, of 5.8 children having a total of 770

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been completed or is still being given for

550 deviations. Follow-up is incomplete for

15 medical and 107 dental problems

be-cause these children have moved away

from the community or their parents have refused the services offered. In no instance

was this due to lack of resources or

finances.h1

One of the most surprising and

encourag-ing developments of Project Head Start is that many teachers, ministers, social

work-ers, and nurses have volunteered their

ser-vices. It can be truly said that the Head

Start program has blazed a trail in showing

communities that there are large reservoirs of talented people ready and able to con-tribute their efforts without pay. If a Head

Start program could be made effective in

each community, there is no question but

that there would be a marked reduction in

morbidity and mortality and crippling

se-quelae of disease.

It is, of course, too early to make a final evaluation of the lasting and practical

ben-efits of this revolutionary experiment in the

delivery of health services to the poorest and the most neglected children. Data are being carefully collected and analyzed by social experts. The main problems to be overcome today are congressional inertia, wasteful planning, community apathy, and, I must admit, complacency and indifference

of the entire medical profession. These facts give the lie to the criticism that Head Start is a mountain which is giving forth a

mouse.

IF NOT NOW, WHEN?

The test of a democracy can be found in

the sacrifices society is willing to make for

its most precious resources, its children. If

we are to return to the 11 million or more American children who are suffering from the “deprivation syndrome,” their

inalien-able rights to total health, what is urgently

needed now are not more conferences for more basic researches but rather a frontal attack on poverty and its associated evils. Our privileged children have access to the

best medical care in the world, but the poor

“kids” get only crumbs of what technology

has to offer. We have the know-how to

save, protect, and conserve all our children.

\\That we lack are public concern, a Con-gress that will respond to the call of social

justice, and a new leadership of the medical

profession that will stop fighting the 30-year

cold war with the Government.

Poverty, whatever definition you want to accept, is the major barrier to the best

mcd-ical care for millions of our poor people, black or white. But poverty is not a simple matter of having little or no money. It

means also low educational standards, poor

housing, and poor nutrition. The poor, and

especially the Negro and other nonwhite minorities, have been trapped in a relent-less cycle of poverty for many years. One

half of the Negro population in this wealthy

country has annual incomes below poverty

levels, and in southern states the

percent-age is even higher. Negro children get only fragmented medical care. They go to one clinic if sick, to another which may be in another part of the city to be immunized, and they may have to go to still another for

a specialty problem. Is it any wonder that

many of the parents become discouraged and do not follow through the necessary

steps to give their children the care they

need?

In view of these established facts, why do we tolerate this continuous waste of our

greatest national asset? Why do these

obvi-ous and necessary changes in health service

take so long in being effected. In an age

which prides itself in having mastered the

technology of medicine, why does our

soci-ology lag so far behind? We know what

should be done and how to do it. If not

no\v, when?

REFERENCES

1. Coles, R. : Testimony before Senator Clark’s

Committee on Labor and Public Welfare:

Children in Mississippi. Washington, D. C.,

June 15, 1967.

2. Stitt, P. G. : Pediatrics, poverty and poor

health. A look at some pertinent

consider-ations. Clin. Pediat., 5:713, 1966.

3. Yerby, A. S. : The disadvantaged and health

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311

4. Wegman, M. E.: Annual summary of vital

sta-tistics-1966. PEDIATRICS, 40: 1035, 1967.

5. Humphrey, H. H. : War on Poverty. New York:

McGraw-Hill, 1964.

6. Comely, P. B., and Bigman, S. K. : Extent of

selected immunizations among a low income

urban population. J. Nat. Med. Ass., 55:213, 1963.

7. Eisenberg, L. : Social Class and Individual

De-velopment. National Institute of Mental

Health Publication No. 51 :73, 1966.

8. Geiger, H. J.: Personal communication.

9. Pryles, C. V.: Personal communication.

10. Roemer, M. I. : Health resources and services

in Watts. Hosp. Top., 44:28, 1966.

11. Hartman, E. E., and Olson, A.: Health

pro-gram for Minneapolis Project Headstart

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1970;46;305

Pediatrics

Max Seham