On July 10, 2007, President George W. Bush, in a speech in a hotel in Cleveland, said: "I mean, people have access to health care in America. After all, you just go to an emergency room."
Although this is one of the silliest statements ever made about health care, it may reflect the views of many people who never think about problems of obtaining health care because they can afford it no matter what it costs.
A pregnant woman cannot go to an emergency room for ordinary prenatal care, which is essentially preventive medicine and not emergency medicine. In America, poor women are dependent on government-funded social-welfare programs for access to health care. Those programs are hardly state-of-the-art medicine. The consequence is a relationship between poverty and medical problems during pregnancy and delivery.
But in all ways, poverty is a condition that readily transforms into an inherited disease. The transformation is man-made and will occur in any society in which the condition of poverty means lack of adequate prenatal care during pregnancy and hazardous exposure to neurotoxins in the environment. In such societies, and America is a good example, poor people never receive as much health care as everyone else. It's poor people who live near waste dumps, not the middle and upper classes. Moreover, daily life among the poor is more stressful, fraught with family conflict and violence between parents who may suffer from chronic anxiety or depression, or whose psychiatric dysfunction may be exacerbated by various poverty-related circumstances. The effects of this stress on pregnant mothers and on their unborn fetuses are notable: significant correlations exist between these factors and low-birth-weight infants among mothers in poverty. Moreover, maternal anxiety, depression, and elevated cortisol in late gestation are associated with negative postnatal infant temperament.
The paradigm for the transformation is plain: low socioeconomic status (poverty) results in early age of pregnancy, poor prenatal care, and negative effects on fetal development (through exposure to maternal stress and distress, and to alcohol, tobacco, lead, and other environmental neurotoxins), which result in lower IQ and higher crime, which result in sustained poverty, which starts the cycle again.
Among academics, a debate continues about whether psychiatric disorders are caused by poverty (causation) or whether individuals with those disorders are socially and psychologically maladapted and therefore poor as a consequence (selection). It seems to me this debate is ridiculous, since given the fetal-impact-poverty cycle, both causation and selection must occur.
Anyone who thinks it's so easy to break out of the cycle of poverty needs to look closely at those living in poverty in the inner cities or in rural regions of the country such as Appalachia. Look at their living conditions, and then look for impacts on fetal development. A pregnant woman looking at you from the doorway of a shack in Chicago or Georgia or Texas is in a sisterhood with a pregnant woman looking at you from the doorway of a shack in West Virginia. The women may be black or brown or white, but it's a sisterhood. And their daughters and granddaughters will be in sisterhoods also. So it goes.
Poverty produces its own culture, its own environment, and in most industrialized countries, and countries that are now rapidly industrializing, the culture of poverty and its environment provide ripe ground for the dissemination of dangerous chemicals in air, water, and food--particularly neurotoxins.
In general, neurotoxins are for the most part community neurotoxins. The degree of exposure and the severity of their impact outcome depend as much on socioeconomic circumstance as on individual biology. Impacts of the prenatal environment on the developing brain create permanent changes in brain structure and brain chemistry, and these changes are reflected in postnatal behavior during childhood and throughout life.
But postnatal behavior is also shaped by postnatal environment and socioeconomic circumstances. Psychopathologies produced by fetal neurotoxins are influenced by social environment. Toxicity is not a physical property of a toxin--it's a variable dependent on many conditions, among them socioeconomic circumstance.
For example, many homes of urban families in poverty are infested by cockroaches. In New York City, among African-American and Dominican women in northern Manhattan and the South Bronx, 85 percent report that pest control measures are used in the home during pregnancy, mostly for cockroach control. All of these women (100 percent) have detectable levels of three different pesticides in their blood, and 30 percent of these women have detectable levels of 8 pesticides in their blood. Umbilical cord samples show that pesticides are readily transferred to the fetus. Prenatal exposure to pesticides is correlated with fetal growth restriction. In America, pesticide use among poor minority women is a continuing problem with cognitive consequences in children that are still hardly tabulated. How much of IQ depression among the offspring of such women is due to pesticide use in the home? We don't know--but it's certainly worth investigating.
In general, what is important is the degree and kind of social stress and the biological substrate that conditions the response of the individual to stress. It's common that children who are poor have higher levels of depression and antisocial behavior. This is not a problem unique to America. In Australia, for example, the more often families experience low income, the higher the rate of child behavior problems at age 5. Comparable correlations are found nearly everywhere. Prenatal impacts may be one cause. Another cause may be the child's postnatal experience of maternal depression produced by poverty. Due to social constraints, female children are more likely to remain in poverty than male children. Later, these female children become pregnant and the cycle of impacts begins again.
It seems self-evident that psychiatric disorders have social consequences for the individual. One consequence is truncated education. But the degree and nature of the social consequences of psychiatric disorders vary with socioeconomic status: poor children with psychiatric disorders are not subject to the same constraints and consequences as children with psychiatric disorders in middle or upper class families. Poor children are in a different world. Children, both male and female, born into poverty in Northern Ireland, for example, are at a special risk of developmental delays in motor functions and reading ability. Such children are constrained by their deficits to be poor as adults and have their poverty affect the fetal development of their offspring. Thus the cycle begins again in the next generation.
The culture of poverty encourages alcohol and tobacco use during pregnancy to relieve the stress of daily life. Both alcohol and tobacco use during pregnancy are a consequence of the interplay between psychological and social forces. The correlations are clear: women who use tobacco are twice as likely to have a psychiatric disorder than non-users, and women who use tobacco during pregnancy are even more likely to have a psychiatric disorder. In the general American population, among pregnant women, 22 percent use cigarettes and 12 percent meet the criteria for nicotine dependence. Among pregnant women with cigarette use, 45 percent meet criteria for at least one mental disorder, and among those with nicotine dependence, 57 percent meet criteria for at least one other mental disorder. Given the impact of tobacco use during pregnancy on fetal development, these are the statistics of a troubled society. Too many women either don't know about the dangers or they do know and they don't care.
Alcohol and tobacco use by women in poverty is not unique to America but endemic throughout the Western world. In Germany, for example, tobacco and alcohol use is more prevalent in lower socio-economic groups and particularly high among the unemployed and among people living alone. In Germany, people in poverty spend up to 20 percent of their income on tobacco.
Tobacco and alcohol use are also correlated with heavy caffeine use (more than three caffeinated drinks a day) among pregnant women before and during pregnancy. Older women are more likely to smoke and ingest caffeine or drink alcohol and ingest caffeine during pregnancy. Caucasian women are more likely to continue smoking during pregnancy, while African-American women are more likely to continue drinking during pregnancy.
Poverty increases the prevalence of infection by reducing immunological defenses. Maternal and fetal infection during pregnancy is common among groups in poverty. The combination of poor maternal nutrition and maternal infections during pregnancy are especially powerful impacts on the development of the fetus. These are consequences of social conditions, a direct connection between society and fetal damage.
Adolescent pregnancy is common in groups in poverty, and we need to ask how this affects the fetal environment. What we know is that adolescents who get pregnant are more likely to start smoking early, to abuse alcohol and other drugs, to have low interest in academic performance, to be children in single-parent families, and to be poor. Adolescent pregnancies are prone to complications such as anemia, hypertension, sexually transmitted diseases, and premature delivery. The consequences of the whole package of risk factors are fetuses impacted by growth restriction and infection and exposure to various neurotoxins.
It seems to me that dealing with the problem of adolescent pregnancy by communicating with pregnant teenagers about the importance of prenatal care is equivalent to offering an aspirin to bring a fever down. We do need to educate teenage girls about the crucial need for prenatal care, but such education does not attack the causes of teenage pregnancy. In America, teenage pregnancy is a cultural phenomenon associated with poverty, familial chaos, and hopelessness. If there's a public desire to reduce teenage pregnancy, is there enough public focus on getting people out of poverty? We are a dismal people if poverty is considered merely collateral damage in a free-market economy.
The poverty connection is paramount and extends across most American ethnic groups in poverty. But the culture of poverty in America may have a special character. For example, low-income Hispanic teenage girls who are more acculturated into American culture have a greater likelihood of drinking alcohol in and around the time of pregnancy than less acculturated Hispanic girls. What are the social forces that produce these consequences? In southern California, 30 percent of white non-Hispanic, black non-Hispanic and English-speaking Hispanic women drink during pregnancy compared with only 16 percent of Spanish-speaking Hispanic women. We have little chance of reducing the prevalence of fetal alcohol impacts until we understand the social dynamics of alcohol use during pregnancy.
I have no ideological fixes to recommend. Ideology is a lazy method of dealing with complex social problems. It's a method that allows us to do hardly more than fool ourselves. The impact of culture on fetal development can produce cycles of poverty, cycles of misery, the shackling of large numbers of people by the chains of circumstance. More than 150 years ago, Charles Darwin gave us a single sentence to clarify the issue: "If the misery of the poor be caused not by the laws of nature, but by our institutions, great is our sin."
This is the last essay in this series. Previous articles in the series are available from my Huffington Post page at http://www.huffingtonpost.com/dan-agin/
[Parts of the above text are adapted from the new book More Than Genes: What Science Can Tell Us About Toxic Chemicals, Development, and the Risk to Our Children. Author: Dan Agin. Oxford University Press, 2009.]