Early investments matter: Infant mortality, vulnerable children, and foster care

A few thought-provoking pieces I've read this week demonstrate the extent to which the US is failing to invest in our next generation. John Schmid of the Journal Sentinel points out that 44 other countries have lower infant mortality rates than the US (by UNICEF ranking), and we're tied for 45th place with Montenegro and Slovakia. Our overall national rate - 6.06 per 1,000 live births, according to the CIA World Factbook - conceals a great deal of variability by state and city, though. (See the Annie E. Casey Foundation's map for details on state-to-state differences.) Schmid zooms in on Milwaukee, where one baby under a year old dies for every 95 who lives (10.4 infant deaths per 1,000 live births, by my calculation). And then he zooms in further, to the Milwaukee zip code 53210, where "one baby dies for every 59 who make it" (16.7 per 1,000).

Schmid notes that complications from preterm birth are the leading cause of infant death in the US, and that the rate of preterm birth is much higher among black babies compared to white babies. Even among white babies, though, those born into poor census tracts have a much greater risk of dying before they're one year old. The article describes some of the aspects of poverty - particularly as experienced in zip code 53210 - that create such a hostile environment for infant survival.

Improving our shameful infant mortality rate should be a US priority. But we don't just want children to survive - we want them to thrive. And in this area, we're also failing some of the most vulnerable young members of our society.

In The New Republic, Jonathan Cohn describes research conducted with a unique study population: thousands of Romanian orphans who ended up institutions where they "received almost no meaningful human interaction." Charles Nelson was one of the investigators in the Bucharest Early Intervention Project, which involved comparing children who stayed in the orphanages with those who went to foster families. Cohn describes some of the findings:

Prior to the project, investigators had observed that the orphans had a high frequency of serious developmental problems, from diminished IQs to extreme difficulty forming emotional attachments. Meanwhile, imaging and other tests revealed that some of the orphans had reduced activity in their brains. The Bucharest project confirmed that these findings were more than random observations. It also uncovered a striking pattern: Orphans who went to foster homes before their second birthdays often recovered some of their abilities. Those who went to foster homes after that point rarely did.

This past May, a team led by Stacy Drury of Tulane reported a similar finding--with an intriguing twist. The researchers found that telomeres, which are protective caps that sit on the ends of chromosomes, were shorter in children who had spent more time in the Romanian orphanages. In theory, damage to the telomeres could change the timing of how some cells develop, including those in the brain--making the shorter telomeres a harbinger of future mental difficulties. It was the clearest signal yet that neglect of very young children does not merely stunt their emotional development. It changes the architecture of their brains.

Drury, Nelson, and their collaborators are still learning about the orphans. But one upshot of their work is already clear. Childhood adversity can damage the brain as surely as inhaling toxic substances or absorbing a blow to the head can. And after the age of two, much of that damage can be difficult to repair, even for children who go on to receive the nurturing they were denied in their early years. This is a revelation with profound implication--and not just for the Romanian orphans.

Cohn also points to other recent research suggesting that the first two years of life are especially crucial for preventing some of the "dysfunctions associated with childhood hardship." But, he points out, federal investments work out to just $4,000 per child for children up to age two, compared to nearly $11,000 for those of elementary-school age. And overall, per-person taxpayer spending on children is about half of per-person spending on the elderly. This, Cohn explains, is despite evidence suggesting that improving early-childhood experience in vulnerable populations could save us money on things like lost wages for serious mental health problems and incarcerating criminals, which cost the US $200 billion and $60 billion per year, respectively.

Cohn is considering all children who are abused and neglected, but I was particularly struck by the mention of foster children because I had just been reading about them. Sharon Astyk has been blogging about foster parenting at Casaubon's Book, most recently about the arrival of two-year-old M. into her family's welcoming home. She also linked to a wonderful article in the Washington Monthly by foster parent Benjamin J. Dueholm. His family currently includes Sophia, who arrived as an infant with a broken leg and more than a year later is "a vivacious chatterbox of a girl."

Foster parents provide crucial emotional attachment and security, but, as Dueholm chronicles, they also spend a lot of time and money assuring their foster children - who often have serious medical conditions - get the healthcare and nutrition they need. Foster children get WIC vouchers and Medicaid coverage, which help defray some of the costs, but WIC vouchers only cover a few basic food items, and it can be hard to find providers who'll accept Medicaid. Dueholm describes the partership between foster parents and the state as a fragile partnership that's threatened by calls for fiscal austerity:

It's a major bureaucratic process to remove a child from her home and family. The state insures the child, pays for daycare, investigates the claims of abuse, and retains legal custody, but it cannot actually put a baby to bed at night. And so, on the other side of this most intimate public-private partnership are usually people like us, left alone with a stranger's child and a garbage bag full of clothes and wondering what's going to happen next. And what happens next depends, to a stomach-churning degree, on the state's willingness and ability to keep up its half of the bargain.

So it was with an unusual sense of urgency and dread that our family watched the 2010 Republican wave and the austerity budgeting that has followed in ceaseless progression. When Paul Ryan's budget, approved by 235 Republicans in the House, proposed dramatic cuts to federal Medicaid spending, it was as if they were trying to make it even more hopeless for us to find a doctor to treat Sophia's health problems. When Scott Walker in Wisconsin sought to cut the workforce that administers foster care in his state, we went up to Madison to join the protests in solidarity, because we knew how helpless we would be if there were no caseworker on the other end of the phone to answer our own urgent pleas for help and guidance. And the threats have continued, as House Republicans repeatedly propose cutting trillions of dollars in domestic spending to reduce the debt while making room for sustained upper-income tax cuts. The way this hits home for us is simple. A foster parent joins hands with the state in order to take care of a dispossessed child. For the last year, the state has been trying to slip free of our grasp.

Over the long term, solving the problems of infant mortality and damaging early-childhood environments will involve reducing the disparities that leave so many families stressed and struggling. There are also plenty of short- and medium-term solutions, though, including better access to family planning and prenatal care, better support for foster parents, and better access to affordable, high-quality childcare. These things all cost money, but they're some of the most worthwhile investments we can make.