Unequal at birth

Recent events in Baltimore, Ferguson, and other places have highlighted the explosive potential of discrimination and inequality. Much attention has been paid to police practices, the long-term effect of joblessness, and the trauma of the criminal justice system incarcerating large numbers of African-Americans. This focus on the present is understandable. It is also insufficient. There is a need to understand and address the huge disadvantages, and indeed disabilities, imposed on future generations by pre-natal conditions.

As James Heckman, a Nobel Prize-winning economist, has noted, “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.” Disastrous is more like it. The injustice of inequality actually precedes birth as its corrosive effects are at work already in the womb. With around 22% of African American families and 38% of children and youth living in poverty, the implications are profound.

Insights into the implications are found through combining an understanding of biology and economics—the focus of emerging field of economics and human biology. Thanks to the work of David Barker we now know that human capital formation begins in the womb. The nature of the fetus’ environment during the short period between conception and birth has lifelong consequences on it, including birth defects and chronic conditions such as coronary heart disease, stroke, type II diabetes, and hypertension. 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—their height, cognitive abilities, educational attainment, employment, and their lifetime earnings. Those exposed to toxins or infections in the womb will be irreparably damaged. While we talk about equality of opportunity and equality of outcomes, the elephant in the room that we’ve been ignoring for the most part is that inequality–the disrupting social issue of our time–begins amazingly during those 37 weeks.

Here is where economics comes in—both economic conditions and economic methods. The environment of a fetus in midtown Manhattan, where the annual income is $2.9 million, is coddled: absolutely no toxins or 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. A few miles away, the fetus in the Melrose-Morrisania neighborhood of the South Bronx, where in some housing projects half the households have less than $9,000, the fetus faces a very different environment.

And the environment matters greatly. There are numerous of well-known negative effects if a fetus experiences stress, anxiety, abuse, poor nutrition, infrequent doctor’s 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 as it leads to drug use or alcohol abuse.

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. Blacks have a much higher rate of preterm births than whites (20% vs. 12%). Low birth weight (LBW) is also a major setback (it is 8% among whites but 16% among blacks). Low birth weight, defined as a weight of less than 5.5 pounds, has harmful effects that last forever, such as stunted educational achievement and lower lifetime earnings, and is also a main cause of infant mortality. No wonder that the mortality rate among African American infants is more than twice that of whites and 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.) The Washington Post refers to it as a “national embarrassment.”

It is also very costly in terms of lives. Maternal mortality is high in the United States: 1 in 1800 pregnancies, which is about 6-7 times as high as in Western Europe where mothers have free medical care. 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.

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.

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 provide optimal maternal environment. Warren Buffett said recently that the American Dream “has been an American Nightmare” for many families and we “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.