You Can’t Justify Inequality That Begins in the Womb.

Sadly, zip codes of birth do matter in the U.S. and they matter more than you think.

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By John Komlos

The Nobel Prize winning economist, James Heckman reasoned in a recent book, “Giving Kids a Fair Chance,” that, “the accident of birth is the greatest source of inequality in America today. Children born into disadvantage are, by the time they start kindergarten, already at risk of dropping out of school, teen pregnancy, crime, and a lifetime of low-wage work. This is bad for all those born into disadvantage and bad for American society.” To be sure, but “bad” is probably an understatement; disastrous would be more like it, at a time when 38 percent of African American children and youth live in poverty. One should add that the injustice of inequality actually precedes birth as its corrosive effects are at work already in the womb.

The womb is a miraculous tiny organ prior to pregnancy — not greater than a medium-size orange; its sole purpose is to nurture and protect the fetus until it is expelled into the world. Though small, its impact is gigantic: the nature of its environment during the short period between conception and birth has lifelong consequences on the fetus. For instance, babies born prior to the 37 weeks of gestation or weighing less than 5.5 pounds will be disadvantaged for the rest of their lives in just about everything including their lifetime earnings. Fetuses exposed to toxins or infections will be irreparably damaged. The elephant in the room that we’ve been ignoring for the most part is that inequality — the big social issue of our time — begins amazingly during those 37 weeks.

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Sadly, zip codes of birth do matter in the U.S. and they matter more than we think. If the fetus happens to find itself in a womb at 10104 (sandwiched between 5th Avenue and the Avenue of the Americas between W. 51st and 52nd Streets) with an average annual income of an unbelievable $2.9 million, it’ll surely enjoy the best nutrition imaginable: no toxins, no infections, certainly no shortage of micronutrients, and a stupendous team of doctors will make sure that it sees the light of day with optimal weight under optimal circumstances. Those in zip-code 10112 (near Rockefeller Center), who have to make do with $700,000 less, would not be bad either. However, should the fetus have somehow used an inaccurate GPS and landed in the Melrose-Morrisania neighborhood of the South Bronx — a small mix-up measured in miles — where in some housing projects half the households have less than $9,000 (no, not per month but per year) the fetus’ environment surely would be like on another continent.

The kind of inhumane deprivation that exists in the dysfunctional low-income crime-ridden environment that is colloquially called a slum and which the federal government refers euphemistically as “targeted census tracts,” leads to stress, anxiety, abuse, poor nutrition, infrequent doctor visits or no visits at all until the time of delivery, because of lack of money and lack of health insurance. Inadequate micronutrients, insufficient vitamin B or infections lead to all sorts of complications and suboptimal outcomes including birth defects, stillbirths, pre-term delivery and low birthweight followed by high infant mortality. The emotional stress that invariably accompanies such poverty all too often makes things much worse and all too often means that the fetus has to contend with toxins such as lead , alcohol, nicotine and heroin. In other words, in the targeted census tracts, just getting into the world as a healthy baby is a major challenge in and of itself.

The data are stark and unmistakable: in every single metric that matters to long run health or earning capacity, African American babies are disadvantaged by the time they take their very first breath in the world. For instance, blacks have a much higher rate of preterm births than whites 20 percent vs. 12 percent. Low birth weight (LBW) is also a major setback: it is 8 percent among whites but 16 percent among blacks, a whopping four times as high as in Sweden or Finland. LBW, defined as a weight of less than 5.5 pounds, has harmful effects forever and is also a main cause of infant mortality. No wonder that the mortality rate among African American infants is 2.2 times that of whites.

Given that the U.S. has the most unequal income distribution in the developed world it should not surprise us that its newborn health is also the worst in the developed world. The U.S. stillbirth rate is 17th in the world tied with Greece and Croatia (whose gross national income per capita is less than half of that of the U.S.) and is 50 percent higher than in Finland. Its infant mortality rate is 34th and is twice the rate of the Scandinavian countries and Japan and just below that of Cuba. African American infant mortality rate, at 12.2 per 1000, is higher than that of 60 countries in the world in a league with Russia, Serbia, Thailand and Sri Lanka. (Actually, those of Russia and Serbia are slightly better.) Surely, such rankings are not something to be proud of. In fact, the Washington Post refers to it as a “national embarrassment.”

However, the benign neglect of extensive maternal deprivation in one of the wealthiest countries in the world is more than embarrassing: the society pays for it dearly. The Nobel Prize winning economist Amartya Sen has been pointing out that the mother’s role as life-givers is uniquely important: “maternal deprivation in terms of nutrition and healthcare rebounds on the society as a whole in the form of ill-health of their offspring.” The rebound is in terms of lives: maternal mortality is high in the U.S., 1 in 1800 pregnancies, which is somewhat higher than in countries such as Romania, Turkey, Ukraine and about 6-7 times as high as in Western Europe where mothers have free medical care. How inefficient! Or take the case of premature babies: 12 out of 100 babies born in 2010 were premature (an increase of 30 percent since 1981). The first year of medical costs for a preterm baby is some $32,000 — ten times as much as for normal term infants — for a total cost of not less than $26 billion a year. In other words, neglecting the uterine environment during pregnancy has immense immediate financial consequences as well.

There are immense additional costs such as the increased costs of the criminal justice system. Being the country with the highest incarceration rate in the developed world costs the U.S, according to one estimate, some $1 trillion annually. The cost to society of a single murder is about $9 million; so the 12,000 murders a year cost about $100 billion alone. The legal cost of executing someone like Clayton Lockett in Oklahoma for murder and rape is easily twice as much as seeking life imprisonment.

Clayton, born in a stereotypical slum, belongs in this essay precisely because his mother was a drug addict and hence his life was botched from the very moment of its inception. Society’s benign neglect meant that he was abandoned to his fate with miserable consequences and not only for him but also for his victims. The point is that society paid for it dearly. It would have been immensely smarter and cheaper to follow Heckman’s and Sen’s advice and not turn a blind eye to his miserable fate.

Although it is obvious, we should nonetheless stress that the fetus has no agency; it did not choose the womb in which it finds itself. Yet it will soon enter the world and have to bear the consequences and responsibility of its experience in the womb. The tremendous variation in its fate depending on the zip code of its conception cannot be considered “just.” Luck ought not be the basis of justice, as the political philosopher John Rawls taught us. Yet, society has a tremendous stake in the fate of that fetus, because the future of the country depends on the fate of such fetuses.

In the more humane societies of Western Europe the fetus that became Clayton would have had a significantly better shot at a normal life. Why? Because in these countries the community affirms that it has a major stake — both financial and moral — in the outcome of the pregnancy. Therefore, maternal protection is the law of the land and is strictly enforced. Maternity leave in U.S. is 84 days, the lowest in the developed world. In Sweden it is 240 days; in Norway it is 315 days. In Germany, expectant mothers cannot be laid off from the very beginning of the pregnancy until four months after the birth; moreover she is not allowed to work with toxic substances and she is not allowed to work overtime. The expenses are born by the taxpayers, i.e., the community but they also reap the rewards.

In addition, and most importantly, during the pregnancy the mother has the right and the obligation to visit a doctor free of charge on a regular basis. The results of all relevant medical information and all examinations are recorded in her maternity passport (in Germany since 1961) and she is expected to keep it with her at all times in case complications arise if she is not at home. If parents decide to take some time off after the birth they receive subsidy from the state that adds up to about $5 billion per annum. Moreover, the family receives a subsidy of $200 monthly for every child independently of income. In other words, the community takes an intensive interest in the well-being of the fetus and there is help for the family throughout the pregnancy and beyond. Instead of a “pro-life” political rhetoric, politicians actually do something for a “pro dignified life.”

Benign neglect is a no-win strategy. Pay later is inefficient, an immense waste of human and financial resources. At a time when some parents can afford to spend over a quarter million dollars on their children’s playhouses, it seems like we should be able to scrape enough money together to help avoid the nightmare of dysfunctional maternity. Warren Buffett said as much recently: “The American Dream has been very real for millions and millions of people over the years but there has been an American Nightmare that accompanied that, where people who equally tried to get educated and worked hard and had good habits and found themselves living a life that’s been on the edge throughout their entire lives and the same for their children; and America can do better than that.” What better opportunity to start “doing better than that” and break the vicious cycle of poverty and inequality than during that miraculous nine months in the womb that separates conception from birth.

Originally published here.

2016 September 19

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