DRIVERS OF OPPORTUNITY GAPS IN HEALTH AND HEALTH OUTCOMES

Theoretical and empirical work in the field of life-course epidemiology has consistently shown that prenatal and early-life conditions, including powerful social and structural factors, can affect children's physical health later in life (Kuh et al., 2003; Ben-Schlomo, Mishra, & Kuh, 2014). Gaps in opportunities related to health begin before birth and can have both short-term and lifelong consequences for well-being. These gaps are influenced by myriad factors, including access to health care and adequate nutrition, poverty, neighborhood safety, and environmental factors, and are exacerbated by racism, segregation, implicit and explicit bias, and stigma (Adler & Stewart, 2010).

Maternal Access to Adequate Prenatal Care

Related to access to health insurance is access to quality prenatal care, which in turn is linked to healthier birth outcomes and better health for the mother. Access to quality maternity care is a critical component of maternal health and positive birth outcomes, especially in light of the high rates of maternal mortality and severe maternal morbidity in the United States. Yet nearly 15% of women in the United States—ranging from a low of 5% of births in Rhode Island to nearly 25% in New Mexico—do not receive adequate prenatal care. The lack of quality prenatal care can be attributed to the lack of access to health care and health insurance coverage, as well as the limited availability of prenatal programs in an area or region of the country.

The percentage of Black women who do not receive adequate prenatal care (20.1%) is twice as high as the percentage for White women (9.9%; March of Dimes, 2022). This discrepancy is one of the drivers of the stark differences in birth outcomes between Black women and women of other races/ethnicities. Compared with their White and Hispanic counterparts, for example, the proportion of Black babies born preterm (Box 4-1) is 50% higher, and Black babies are more than twice as likely to be born at low birthweight.

BOX 4-1

The Effect of Preterm Birth on Opportunity Gaps.

Maternity care deserts are counties in which access to maternity health care services is limited or absent as a result of either lack of services or barriers to a woman's ability to access those services (March of Dimes, 2022). More than 2.2 million women of childbearing age live in maternity care deserts (1,095 counties), with no hospital or birth center offering obstetric care and no obstetric provider (March of Dimes, 2022). In 2017, almost 150,000 babies were born to women living in maternity care deserts, while an additional 4.8 million women of childbearing age lived in counties with limited access to maternity care (March of Dimes, 2022).

Congress recently reintroduced a sweeping package of 12 maternal health–related bills aimed at addressing racism and racial inequities that disproportionately affect pregnant and birthing people in the United States. The “Momnibus” aims to invest in training a cadre of perinatal health providers to improve upon and better address the significant disparities in maternal and infant health outcomes. For example, although midwives are widely recognized around the world as the primary source of maternal health care, they account for only 8% of U.S. birth workers (Scientific American Editors, 2019; Batstone, 2021). Midwives are health care professionals who may be part of the birth care team or stand alone in providing prenatal, delivery, and postpartum care. States that have policies to allow direct-entry midwives—credentialed midwives who are not registered nurses—and certified nurse midwives to practice may increase access to care, especially in underresourced areas (March of Dimes, 2022). Midwifery care, coordinated with care from a physician, can help reduce medical interventions that contribute to the risk of maternal mortality and morbidity in initial and subsequent pregnancies, lower costs, and potentially improve the health of mothers and babies (American College of Nurse-Midwives, 2021). The maternal care team may also include doulas, nonclinical professionals who support women emotionally and physically during the perinatal period, including birth and postpartum. Increased access to doula care can help improve birth outcomes and reduce the higher rates of maternal morbidity and mortality among women of color in the United States.

Troubling as well is that the rate of infant mortality among Black babies (10.8 per 100 births) is twice the national average (5.6 per 100 births; Ely & Driscoll, 2019). Black mothers are also more than twice as likely to die in childbirth or experience severe maternal morbidity, regardless of education level or socioeconomic status (Centers for Disease Control and Prevention [CDC], 2022). Adverse birth outcomes reflect the trauma resulting from discrimination and racism that many Black women have experienced across their life course, as well as their disproportionately lower access to financial security (Alhusen et al., 2016).

Where babies are born is also predictive of their birth outcomes; for example, babies born in Mississippi are nearly twice as likely to be born preterm and nearly three times as likely to die in the first year of life compared with those born in New Hampshire. Again, these differences in opportunities and outcomes are largely a result of state policy choices, such as those discussed previously with regard to Medicaid expansion. Those states that have declined to expand Medicaid are often the same states with weak safety net programs and consequently higher poverty rates, resulting in a combination of forces that exacerbate adverse birth outcomes for marginalized families.

Antiracism and Dismantling Race-based Medicine

As the discussion in the last chapter has demonstrated, racism, a system of advantage whereby opportunities and values are assigned on the basis of socially constructed categories of “race,” has been identified as a root cause of health and health care inequities (Jones, 2001). Racism operates on multiple levels—interpersonal, institutional, structural, and systemic—although it is perpetuated and reinforced at the structural level. Achieving health equity will therefore require addressing institutional, structural, and systemic racism in health care and public health, and race-based medicine is one area in which systemic racism manifests. It is also worth noting that, while pediatricians have often served as lead clinician in the pediatric medical home, a team-based approach to child health has emerged by which primary care is reconfigured to address access issues. This approach involves the incorporation of mental health in primary care and the medical home, along with an increased role for other health professionals, such as nurse practitioners, school nurses, nurse midwives, social workers, psychologists, doulas, and frontline staff.

History of Race in Medicine

The belief that Black and White individuals have fundamental biological differences was propagated by slaveholders to justify slavery and by scientists and physicians to justify unethical and inhumane medical research conducted on Black people (Cartwright, 1851, as cited in Guillory, 1968; Washington, 2006; Owens, 2017). Today, assumptions about athleticism associated with race/ethnicity are based in beliefs about racial genetics. Although biological conceptions of racial differences are not strongly associated with racist attitudes, they are associated with acceptance of racial inequities as endemic (Williams and Eberhardt, 2008).

The 1985 Report of the Secretary's Task Force on Black and Minority Health, commonly known as the Heckler Report, documented racial inequities in health. Unequal Treatment, a groundbreaking report of the Institute of Medicine (now known as the National Academy of Medicine), documented racial/ethnic disparities in the quality of care, demonstrating that for almost all diseases among hundreds reviewed, Black Americans received less effective care than their White counterparts even when such factors as insurance and socioeconomic status were matched (Institute of Medicine [IOM], 2003). Implicit bias in the form of unconscious racial stereotypes related to personal and cultural experiences and limited interracial or intercultural engagement is common among health care providers, mirroring the general population (Chapman, Kaatz, & Carnes, 2013; Ansell & McDonald, 2015). Implicit bias is thought to influence administrative decisions on insurance plans accepted, neighborhoods for establishing offices, and selection and inclusion of diverse students in medical education and training and among faculty (Ansell & McDonald, 2015).

Mounting evidence confirms that race is not a reliable proxy for genetic differences. Yet despite these advances in research, the use of race as a proxy for biological and genetic differences with clinical significance has remained embedded in medical practice, education, training, and research.

Diagnostic Algorithms

Diagnostic algorithms and practice guidelines that correct for a patient's race or ethnicity continue to be in common use in clinical medicine (Vyas, Eisenstein, & Jones, 2020), taught in medical education, and included in medical board examinations (Amutah et al., 2021). Race-adjusted clinical algorithms guide clinical decisions and operationalize racism in clinical medicine by directing attention and resources to White patients to the detriment of racial and ethnic minorities (Vyas, Eisenstein, & Jones, 2020). Many of these guidelines offer no rationale for the use of race/ethnicity (Vyas, Eisenstein, & Jones, 2020), or when investigated are found to be rooted in race- and class-based biases and assumptions (Braun, 2014).

Diagnostic algorithms that include race/ethnicity lower estimates of success for people of color, and their use to guide care can exacerbate inequities in health care and outcomes. The vaginal birth after cesarean (VBAC) algorithm, for example, predicts risk associated with a vaginal delivery among those who have had a previous cesarean section. The VBAC calculator was informed by a prior research study that identified variables correlated with VBAC success, including insurance type (Landon et al., 2005). It incorporates two race-based correction factors—one for African American women and another for Hispanic women—that subtract from the overall likelihood of successful VBAC, and these women are therefore assigned a lower chance of success (Vyas, Eisenstein, & Jones, 2020). While this algorithm incorporates race/ethnicity as a correction factor, it does not incorporate other factors, such as insurance type, that were correlated with VBAC success in the referenced study. In the United States, women of color have higher rates of cesarean section in comparison with their White counterparts, as well as three to four times higher rates of maternal mortality and morbidity.

Medical Education

Evidence suggests that medical students and trainees hold false beliefs about fundamental biological and genetic differences by race. The content of medical school curricula reinforces this misperception (Tsai et al., 2016), and this misrepresentation can propagate bias (see Table 4-1; Tsai et al., 2016; Nieblas-Bedolla et al., 2020; Amutah et al., 2021). This misrepresentation can take the form of race-based clinical guidelines; data that tend to associate minoritized populations with increased incidence of disease in the absence of context; association of disease with particular racial groups, which can lead to diagnostic bias; and presentation of racial/ethnic differences in disease burden without addressing the broader social context (Amutah et al., 2021). Race/ethnicity also appears routinely in question banks used to prepare for the United States Medical Licensing Examination (Ripp & Braun, 2017).

TABLE 4-1

Misrepresentation of Race in Preclinical Curricula.

Action Steps to Reform Medical Education

The portrayal and misuse of race in medical curricula has been explored, and revisions have been suggested (Amutah et al., 2021). Recommendations include (1) standardizing the language used to describe race/ethnicity; and (2) building relevant medical competencies, such as structural competency, which includes recognizing structures that shape clinical interactions and developing structural interventions (Metzl & Hansen, 2014; Stonington et al., 2018). Training in structural competency can help providers understand the structural and social forces, policies, and historical processes that affect health. More equitable and antiracist care practices could be supported if providers had a deeper understanding of structural and institutional racism and interpersonal discrimination and their impacts on health, clinical encounters, and conditions. To date, however, literature conceptualizing structural racism has not been adequately integrated into medical education, and the majority of empirical studies of racism have focused on interpersonal discrimination rather than structural racism (Bailey et al., 2017).

Implicit Bias

Research has established that the majority of U.S. physicians and medical students have the kinds of implicit biases discussed above that privilege White patients (Haider et al., 2011), with significant proportions of medical students and trainees holding false beliefs about biological differences by race (Hoffman et al., 2016). As noted previously, implicit bias, stereotyping, and prejudice among health care professionals influence inequities in diagnosis, treatment, and care by race/ethnicity (Chapman, Katz, & Carnes, 2013; Hall et al., 2015; FitzGerald & Hurst, 2017), including among common pediatric diagnoses (Sabin & Greenwald, 2012). Medical students who hold such false beliefs were found to be more likely to rate pain lower and make less accurate treatment recommendations for Black versus White patients (Hoffman et al., 2016). Research has documented that Black patients, including children, not only are less likely to receive pain medication but also receive lower quantities and experience greater delays in administration even though they self-report similar levels of pain (Goyal et al., 2015; Singhal, Tien, & Hsia, 2016). Yet despite the disparities resulting from the inequities embodied in diagnostic algorithms and manifest in differential treatment, medical education and clinical practice have been slow to evolve to reflect race as a social construct rather than a biological category, and racism as a systemic factor in shaping social experiences that have biological consequences.

Efforts of Medical Associations and Other Organizations to Confront Systemic Racism

In recent years, medical associations, such as the American Medical Association (AMA), have acknowledged the role of racism in perpetuating health inequities and harms in communities that have historically been marginalized (O'Reilly, 2020; Madara, 2021; Tanne, 2021), and have adopted policies aimed at embedding racial justice and advancing equity in their work (Maybank et al., 2022). In 2021, the AMA adopted guidelines designed to confront systemic racism (American Medical Association, 2021).

The American Academy of Pediatrics (AAP) has recently taken steps to dismantle race-based medicine in clinical practice and medical education. To that end, it is examining and eliminating inaccurately applied “race corrections” or “race adjustment factors” that result in differential approaches to disease management and disparate clinical outcomes. The AAP recently retired clinical guidelines that linked race, as a biologic proxy, to urinary infections in children (Wright et al., 2022). Presently, the AAP is addressing the use of race in guidelines for newborn jaundice. In May 2022, it released a policy statement, “Eliminating Race-Based Medicine,” that calls for scrutiny and revision of the suite of clinical guidelines, algorithms, educational materials, textbooks, and literature used to guide clinical practice and for medical education (Wright et al., 2022). And some have called on other prominent health organizations, such as the National Institutes of Health, to examine ways of dismantling racism through research infrastructure (Bear et al., 2022).

Food Insecurity for Households with Children

Food insecurity is a pervasive problem in the United States, especially for households with children. The U.S. Department of Agriculture defines food insecurity as a lack of consistent access to enough food for an active and healthy life. In 2016, for example, 13 million (1 in 6) U.S. children were food insecure; 85% of counties with high child food insecurity were rural. Table 4-2 provides a sense of the problem of food insecurity in the United States (National Academies, 2019).

TABLE 4-2

Food Insecurity by Selected Household Characteristics.

Whereas nutritious foods are important sources of energy, fiber, protein, and key minerals and vitamins needed for healthy development, adequate food is more a measure of whether sufficient quantities of food are available for individuals and households over long periods of time in a sustained manner. Households often face a trade-off between (more costly) nutritious food and adequate quantities of food. Here again, disparities persist within the United States. Although evidence has shown the link between maternal and infant nutrition and children's health and developmental outcomes, access to affordable nutritious food is often more likely to be limited for low-income communities and communities of color (National Academies, 2019).

Safe and Healthy Environments

As discussed previously, young children exist within the contexts of their families and neighborhoods, including the places where they live, learn, and play, and these environments need to be safe and healthy if children are to achieve optimal physical health, growth, and development. Health-promoting neighborhoods provide the physical and social conditions and community resources—social, economic, environmental, and cultural—that enable young children to be healthy (CDC, 2009; National Academies, 2017). The Child Opportunity Index is a tool used to describe and quantify the neighborhood conditions experienced by U.S. children, ranking them from lowest to highest with regard to the opportunity they provide. Child Opportunity Scores rank all 72,000 neighborhoods in the United States from one to 100 according to this metric (Diversity Data Kids, 2019, Box 1-2). Child Opportunity Scores are also available for metro areas for use in assessing their level of opportunity overall and by race and ethnicity. The opportunity gap between very low- and very high-opportunity neighborhoods represents differences along important dimensions of neighborhood environment. Access to green space, for example, varies widely. In very low-opportunity neighborhoods, almost half of children (48%) lack access to parks and playgrounds, while in very high-opportunity neighborhoods, this is the case for fewer than a quarter of children (22%). As discussed previously, access to nature and to safe places to play is critical for children's health and well-being (Acevedo-Garcia et al., 2019).

After reviewing some methodological considerations regarding the association between neighborhood and child health, this section looks at two specific aspects of neighborhoods thought to be linked most directly with young children's physical health: freedom from environmental contaminants and safety and freedom from violence.

Methodological Considerations

It is important to note that the evidence the committee presents on the association between neighborhoods and child health is complex, and the existing literature is fraught with methodological challenges and pitfalls. For example, associations between neighborhood characteristics and child health may vary based on individual-level characteristics, such as a child's race or immigration status, and effect estimates may be sensitive to the selection of covariates included in models (Paczkowski & Galea, 2010; Auchincloss et al., 2013; Meijer, Bloomfield, & Engholm, 2013; Blair et al., 2014). Given the correlation among different neighborhood factors—such as poverty, racial segregation, housing quality, and environmental contaminants—it is also difficult to separate out the effects of any single neighborhood factor. In addition, results vary widely depending on how a specific health outcome or neighborhood characteristic is measured, and many studies capture only limited subsets of neighborhood factors. As a result, it is difficult to identify specific interventions focused on altering specific neighborhood characteristics to target specific high-risk subgroups. Also, given that true randomized controlled trials are often unethical or infeasible in this realm, causal connections between neighborhood conditions and child health are challenging to validate (Oakes, 2004; Oakes et al., 2015; Glass & Bilal, 2016; Jeffries et al., 2019). For example, existing studies may suffer from selection bias by which unhealthy versus healthy families are more likely to live in disadvantaged neighborhoods.

A handful of studies have overcome some of these methodological limitations. For example, the Moving to Opportunity study randomized families to receive a voucher to move to a low-poverty neighborhood. Analyses of the Moving to Opportunity study have found that children who moved to low-poverty neighborhoods when they were younger were more likely to experience positive social outcomes (e.g., college attendance) later in life, while children who moved at older ages experienced worse outcomes (Chetty, Hendren, & Katz, 2016). The Moving to Opportunity study also showed that girls experienced improved mental health (e.g., decreased risk of major depression), while boys experienced worse outcomes (e.g., increased rates of posttraumatic stress disorder) (Kessler et al., 2014). Yet despite the strength of its randomized study design, the Moving to Opportunity study could not tease apart which aspects of the neighborhood environment mattered, or why this differed for children of different ages and genders. Moreover, the number of physical health conditions examined was limited, and the sample was relatively small (4,604 families, with 98% of households headed by women), restricted to only five U.S. cities, and enrolled in the mid-1990s. Therefore, it may be necessary to address this issue with a broader range of quasi-experimental and observational studies, which of course would have to be interpreted cautiously.

In recent years, an increasing number of quasi-experimental studies have leveraged natural experiments in which families are quasi-randomly assigned to neighborhoods of different levels of disadvantage so the effects of neighborhood characteristics on health can be examined. For example, several studies have found negative health effects of neighborhood disadvantage among refugees quasi-randomly assigned to more deprived neighborhoods in Denmark and Sweden (White et al., 2016; Hamad et al., 2020; Raphael et al., 2020), including increased mental health problems among children (Foverskov et al., 2022). Other studies have examined the effects of the built environment on cardiometabolic disease among older adults forcibly displaced and quasi-randomly assigned to neighborhoods in the wake of the 2011 Great East Japan Earthquake and Tsunami (Shiba et al., 2020). Unfortunately, few of these quasi-experimental studies have focused on child health, and the circumstances underlying the natural experiment, including those just cited, are often “unnatural,” hinging on quasi-random variation generated by natural disasters or policies that typically are not generalizable (Hamad, 2020). Nevertheless, quasi-experimental studies provide a balance between randomized studies (which are challenging and/or unethical to conduct and yet methodologically rigorous) and observational studies (which are easier to conduct but can suffer from confounding/endogeneity), and future research could identify natural experiments with which to focus on child health in the context of U.S. settings in particular.

Environmental Contaminants

Child well-being is affected by environmental determinants related to pollutants and contaminants in the water; the air; and other aspects of a young child's home, school, and play areas. Environmental contaminants have repeatedly been found to be associated with poor health throughout the life course, and the prenatal and early childhood periods represent particularly sensitive developmental windows in which individuals may be especially vulnerable to their effects. Young children may be exposed to thousands of potential contaminants, including through the air they breathe, the water they drink and use, the food they eat, and the consumer products with which they come into contact (Giudice, Woodruff, & Conry, 2017). While these substances may be present in the environment naturally, many are released through human-based processes such as manufacturing, fossil fuel use, and waste disposal (Di Renzo et al., 2015). This section looks at two specific subsets of contaminants—allergens and pollutants that cause asthma, and lead that affects neurological development and cognition—as well as evidence on environmental contaminants more generally.

Allergens/pollutants and asthma Asthma is the most common chronic lung disease in U.S. children (Zahran et al., 2018). It is a serious health condition characterized by inflammation of the lungs and chronic respiratory symptoms such as shortness of breath and coughing, especially with physical activity. Not only does asthma impair quality of life and increase health care utilization, but it also contributes to more than 10.5 million missed days of school annually among U.S. children.

Poor housing conditions can lead to increased risk of asthma in several ways. Research has found links between asthma and cockroaches, dust mites, dampness, and mold (IOM, 2000; Wu & Takaro, 2007; Rauh, Landrigan, & Claudio, 2008). Other work has found an association of higher density of housing code violations and worse public housing conditions with increased risk of health care utilization related to exacerbation of asthma (Beck et al., 2014; Kersten et al., 2014).

Lead Exposure to lead, even in small amounts, is associated with lower IQ and test scores, as well as increased incidence of impulsivity and attention-deficit/hyperactivity disorder (Needleman et al., 1979, 1990; Rauh, Landrigan, & Claudio, 2008; Leventhal & Newman, 2010; Muller, Sampson, & Winter, 2018). Such effects are thought to persist through to later in childhood and have been linked with high adolescent body mass index, impulsivity, anxiety, and depression, as well as lower earnings and criminal activity in adulthood (Kim & Williams, 2017; Winter & Sampson, 2017). Exposure to lead among pregnant mothers has been linked with adverse birth outcomes, possibly through transmission to the fetus (Taylor, Golding, & Emond, 2015). Consistent with prior research on disparities, Black children in these studies have more elevated blood lead levels (BLLs) relative to White children (Miranda et al., 2009). In one study, only one in four Black children had a BLL of 3 micrograms per deciliter (μg/dL) or less, compared with almost half of White children. In a study of BLL and third-grade test scores, non-Hispanic Black students had a mean BLL of 7.7 μg/dL—more than twice that of non-Hispanic White students (3.7 μg/dL; Evens et al., 2015; National Center for Healthy Housing, 2013). Box 4-2 provides an example of how policy changes related to lead exposure succeeded in improving academic performance in children and reducing community-level inequality in Massachusetts.

BOX 4-2

Policy Lessons: Lead Exposure and Academic Performance.

Other environmental contaminants Numerous other environmental contaminants have been linked to adverse health outcomes at birth and in early childhood. Chemicals from heavy metals and pesticides to carbon monoxide and ozone are thought to affect neurological development and contribute to endocrine disruption, with wide-ranging negative effects on asthma as well as on child growth and development, obesity, sexual anatomy, and kidney disorders (Cox et al., 1989; Kalter, 2003; Vandenbergh, 2004; Diamanti-Kandarakis et al., 2009; Nakamura et al., 2012; Manikkam et al., 2013; Di Renzo et al., 2015; Gore et al., 2015; Webb et al., 2016; Weidemann, Weaver, & Fadrowski, 2016; Giudice, Woodruff, & Conry, 2017). The effects of hundreds of contaminants remain untested. Therefore, these contaminants may have both immediate impacts on health and wellness and long-term effects on chronic disease, educational attainment and achievement, and mortality.

Opportunity gaps related to environmental contaminants As the evidence reported above demonstrates, children experience differing levels of exposure to environmental contaminants, such as lead and those that place them at risk of asthma. Exposures vary across an income and race gradient rooted in decades of discriminatory policies and programs. Children whose families have lower incomes and live in substandard housing are more likely to live in greater proximity to known sources of such contaminants, as are children from racial/ethnic minority and immigrant (particularly Latino) groups as a result of the chronic effects of structural racism (Oberg, Colianni, & King-Schultz, 2016; American College of Obstetricians and Gynecologists Committee on Obstetric Practice, 2021). Studies from the United States and other high-income countries also suggest that residence in urban versus rural areas affects the types and quantities of pollutants to which people are exposed (Northridge et al., 2003; Hendryx, Fedorko, & Halverson, 2010; Hulin, Caillaud, & Annesi-Maesano, 2010).

An example is particulate matter 2.5 micrometers or less in diameter (PM_2.5), which places children at higher risk of asthma. People living in poverty and people of color are exposed to significantly higher levels of PM_2.5 compared with White individuals (Mikati et al., 2018). Another study found that White individuals experience a “pollution advantage” more generally in that they have 17% less exposure to air pollution on average when the amount to which they are exposed is compared with the amount for which they are responsible; conversely, Black and Latino Americans experience 56% and 64% excess exposure, respectively, when the same comparison is made (National Academies, 2019; Tessum et al., 2019). These inequities persist even as exposure to pollution on average is declining as a result of increased regulation and a shift in population density away from polluted areas. The net result is large racial and socioeconomic disparities in the prevalence of asthma in the United States. Prevalence is highest among Black people (11.1% compared with 8.2% in the population overall), and Black individuals are more than three times more likely than White individuals to visit an emergency department for asthma care (Akinbami, Moorman, & Liu, 2011). And while child deaths from asthma are rare, they are roughly 10 times more likely for Black than for White children (Pate et al., 2021).

Similarly, while more than half a million U.S. children aged 1–5 have BLLs above the reference range according to the most recent prevalence estimates (from 1999 to 2010), this risk is not distributed equally across all groups of children (Wheeler & Brown, 2013). Black children are more than twice as likely as their White peers to have a BLL above 5 µg (5.6% vs. 2.4%), and those who live in poverty or have Medicaid coverage are nearly eight times as likely to have elevated BLLs (Wheeler & Brown, 2013). Even after correcting for risk factors and other variables, such as housing, socioeconomic, status, and age, Black versus White children nationwide have BLLs 1.8 to 5.6 times higher within each risk factor subgroup (Yeter, Banks, & Aschner, 2020).

The primary reason for differential exposures to environmental contaminants is proximity to sources of pollutants, such as traffic and roadways, industrial facilities, power plants, and natural gas wells, that repeatedly have been associated with worse health outcomes for children, including adverse birth outcomes and asthma in particular (Ahmad et al., 2001; Hopenhayn et al., 2003; Tsai et al., 2004; Salam, Islam, & Gilliland, 2008; Clark et al., 2010; Pénard-Morand et al., 2010; Currie & Walker, 2011; Padula et al., 2012; Miranda et al., 2013; Ha et al., 2015; Woodward, Finch, & Morgan, 2015; Casey et al., 2016; Harris et al., 2016; Alexander & Currie, 2017; Fleisch et al., 2017). Proximity to sources of pollutants is in turn determined by other, more upstream risk factors, most notably family poverty, neighborhood poverty and disadvantage, and residential segregation driven by structural racism in housing policies, discussed in turn below.

Families that live in poverty are naturally less likely to be able to afford housing that is high quality (e.g., free of lead and asbestos) and located farther from sources of pollutants (Sandel et al., 2004; Rauh, Landrigan, & Claudio, 2008). Living in older housing also means that outdoor pollutants are more likely to enter the home (Houston et al., 2016). Thus lower-income neighborhoods are more likely to have higher levels of ambient air pollution, while at the same time they have fewer air quality monitoring resources (Stuart, Mudhasakul, & Sriwatanapongse, 2009; Houston et al., 2016).

Like family poverty, neighborhood poverty and disadvantage, experienced disproportionately by families of color, is associated with poor-quality housing and a higher risk of lead contamination (Baek et al., 2021). Although lead paint was banned in 1978, exposure remains high among children living in older homes (particularly in the Northeastern and Midwestern United States), where the paint can peel and be ingested, and among those living close to certain types of manufacturing sites (Rauh, Landrigan, & Claudio, 2008; Muller, Sampson, & Winter, 2018).

Residential segregation is a persistent feature of U.S. neighborhoods, driven by historical racist practices and policies such as redlining and discriminatory banking practices (National Academies, 2017). Although these policies are no longer entrenched in the legal system, their effects are persistent and demonstrated by the continued segregation of many U.S. neighborhoods. These patterns have contributed to the higher levels of poverty and disadvantage experienced by segregated Black neighborhoods because of their limited access to health-promoting resources, including those for children (Acevedo-Garcia et al., 2007, 2008), as well as their greater likelihood of being in proximity to potential pollutants and environmental hazards and of having poor-quality housing (National Academies, 2019).

Safe and Violence-free Environments

Children need environments in which to grow, develop, and thrive that are safe with respect to prevention of unintentional injuries, as well as exposure to violence—whether that exposure is primary (i.e., direct victimization by adults or peers) or secondary (i.e., witnessing violence in the home or community). Young children's exposure to violence in their home or neighborhood is likely to create additional obstacles to their long-term well-being.

Maltreatment Statistics reported for federal fiscal year 2019 document 656,000 victims of child abuse and neglect nationally, which equates to a national rate of 8.9 victims per 1,000 children in the population. The Centers for Disease Control and Prevention (CDC) estimates that in 2019, about 1 in 7 children were affected by maltreatment, and 1,840 of these children died as a result (Department of Health and Human Services, Administration for Children and Families, & Administration on Children, Youth and Families, Children's Bureau, 2021). The youngest children are the most vulnerable to maltreatment: nationally, more than one-quarter (28.1%) of victims are aged 0–2 years. Among school-based children, African American students, students who qualify for free/reduced-price lunch (i.e., those from families with low incomes), students living in relatively high-poverty areas, and students attending urban schools all have an elevated likelihood of being investigated by Child Protective Services for suspected child maltreatment (Jacob & Ryan, 2018). Maltreatment in early childhood is associated with significantly worse academic outcomes, even after controlling for school, neighborhood, race, and other key demographics (Jacob & Ryan, 2018). The total lifetime economic cost associated with child maltreatment in terms of worse outcomes, lower educational attainment, lower probability of employment, and high disability rates was estimated to be about $428 billion in 2015.

The Nurse-Family Partnership (NFP) is often cited as an effective intervention for preventing child abuse and neglect. This program provides nurse home visits to pregnant women with no previous live births, most of whom are: (1) low income, (2) unmarried, and (3) teenagers. The nurses visit the women once or twice per month during their pregnancy and the first two years of their children's lives (Arnold Ventures, 2020). Data on the outcomes of the program in Elmira, New York, and Memphis, Tennessee, show that it reduced verified incidences of abuse and reduced hospitalizations for injuries in young children. Treatment families reported statistically significant decreases in child abuse/neglect and domestic violence and improvements in home learning environments compared with control families.

Injuries Injuries are a leading cause of death among children in the United States, and data on these deaths reveal prominent racial disparities (CDC, 2021). According to a CDC report based on data from 2000–2009, American Indian/Alaska Native children had the highest death rate from injuries at 30.4 per 100,000 in 2000 and 23.8 per 100,000 in 2009—nearly double the rates among Black children (16.2 and 12.8, respectively), the population with the next-highest rate in 2009 (Gilchrist, Ballesteros, & Parker, 2012). There is also a more than sixfold gap between the lowest and highest rates across states (from 4.0 per 100,000 in Massachusetts to 25.1 per 100,000 in Mississippi).

The impact of injury and injury severity on academic outcomes can be substantial. Following an injury, a young person's ability to learn and concentrate can be interrupted, future learning can be affected, and injuries resulting in physical disability have been shown to negatively influence cognitive skills (Ewing-Cobbs et al., 2006; Vu, Babikian, & Asarnow, 2011; Fulton et al., 2012; Kingery et al., 2017; Prasad, Swank, & Ewing-Cobbs, 2017; Treble-Barna et al., 2017). Aside from problems with cognitive performance, seriously injured young people may also experience psychological and physical health problems that can adversely affect their academic performance (Foster et al., 2019a,b). Results of one large population-based study (involving more than 150,000 injured children) suggest that while some young people may fully recover after their injury, others may experience ongoing adverse effects on their school-based academic performance. Overall, injured young people demonstrate poorer performance on school assessments, with increasing injury severity having a greater negative impact. In addition, one study found that injured young people had almost twice the risk of not completing high school compared with their uninjured matched peers (Mitchell et al., 2021).

Exposure to violence Exposure to violence is disturbingly prevalent among U.S. children. Data from the National Survey of Children's Exposure to Violence (2013–2014) show that 37.3% of children had experienced physical assault in the past year; 51.4% had experienced physical assault in their lifetime; and 24.5% and 38.3% had witnessed violence in the past year and in their lifetime, respectively (Finkelhor et al., 2015). Black children have the highest exposure to violence in their communities—9.5% among children aged 5–12, compared with 6.9% for White and 5.7% for Hispanic children (Ullmann, Weeks, & Madans, 2021). Boys are at higher risk than girls.

Opportunity gaps related to safety and exposure to violence Several factors may explain the above disparities in young children's exposure to violence; they include individual, family, and place-based risk factors. On an individual level, babies under 1 year old experience higher rates of injuries and maltreatment (CDC, 2014, 2021). Children with disabilities also are at increased risk, having more than three times greater odds of being victims of violence compared with their peers without disabilities (Jones et al., 2012). In these latter cases, it is likely that increased family conflict and parenting challenges contribute to the greater risk.

At the family level, poverty and structural racism lead to higher levels of chronic stress that may contribute to greater family tensions, which in turn have been found to be associated with increased levels of child maltreatment and violence (Jewkes, 2002; Foster, Brooks-Gunn, & Martin, 2007; Stith et al., 2009). Families living in poverty and parents with limited educational attainment may also be less able to acquire health-promoting resources that can protect against injuries, such as the ability to afford or properly install car seats or to perform adequate childproofing in the home. Similarly, as noted earlier, poverty and structural racism may affect the ability to afford high-quality housing, which is more likely to have appropriate safety measures in place (Reading, Haynes, & Shesnassa, 2005).

Place-based characteristics also contribute to potentially unsafe environments. In addition to the issues with housing quality mentioned above, disadvantaged neighborhoods tend to be the recipients of poor urban planning, with roadways and traffic patterns contributing to traffic injuries (Morency et al., 2012). As noted previously, the distribution of health-promoting community characteristics is racially and socially patterned as a result of historical segregation, placing low-income children and children of color at high risk of exposure to such hazards. The geographic disparities across states discussed above also suggest that aspects of the social and physical environments may play a role, including exposure to place-based hazards (e.g., vehicle-miles traveled, exposure to water settings, urban versus rural environment) and differences in public policy (e.g., gun legislation; Ullmann, Weeks, & Madans, 2021). Additional research is needed to clarify what aspects of disadvantaged neighborhoods are most important to address in this regard (Newgard et al., 2011).

Finally, police brutality, especially in segregated Black, Latino, and Indigenous communities, is a significant driver of health problems in these populations. Beyond police-inflicted violence, these community tensions can also worsen mental health problems among residents, as well as affect downstream outcomes relevant to child health, such as prenatal outcomes among Black women (Alang et al., 2017).

Gun violence is now the leading cause of death for all children and teens aged 1–19 (Figure 4-1). According to the CDC, nearly two-thirds of the 4,368 U.S. children up to age 19 who were killed by guns in 2020 were homicide victims (CDC, 2020). In that year, by comparison, motor vehicle crashes, formerly the leading cause of death for children aged 1 and above, killed nearly 4,000 children. While mass shootings garner the attention of the public and policy makers, routine gunfire kills more children each week than died in the Columbine, Sandy Hook, and Parkland massacres combined. Here, too, there are stark racial disparities. Black children and teens are four times more likely than their White peers to die from gun violence. U.S. mortality rates among children due to gun violence are the highest across high-income countries and are thought to be due to this country's having the least restrictive gun policies, higher rates of gun ownership, and types of guns available to the public. Differences in state-level gun control policies are also associated with differences in firearm-related morbidity and mortality among children (Rudolph et al., 2015; Raifman et al., 2020).

FIGURE 4-1

Leading causes of death among children and adolescents in the United States, 1999–2020. SOURCE: Goldstick, Cunningham, & Carter, 2022.

The consequences of gun violence are pervasive, affecting entire communities in addition to families and children. More than 25% of children witnessed an act of violence in their home, school, or community during 2009, and more than 5% witnessed a shooting. Beyond gun regulation, then, it is essential to address the impact on those who have been injured and traumatized by such violence (Finkelhor et al., 2009; Children's Defense Fund, 2022; Collins and Swoveland, 2022; Goldstick, Cunningham, & Carter, 2022).

While the majority of children who experience injuries or are exposed to violence recover, they often suffer short- and long-term consequences (Schneeberg et al., 2016). Long-term consequences may include impacts on their physical health (e.g., physical disability, asthma, blood pressure), mental health (e.g., posttraumatic stress disorder, sleep disorders), and cognitive health (e.g., cognitive performance, attention disorders). Some of these effects are direct consequences of the injury or violence itself, while others are due to missing school during recovery, and still others are mediated by the impact of stress on dysregulation of biological pathways involving the hypothalamic-pituitary-adrenal axis and autonomous nervous system (Brunton, 2013; Provençal & Binder, 2015; Theall et al., 2017; McGowan and Matthews, 2018; van den Bergh, Dahnke, & Mennes, 2018). Moreover, children exposed to one incident of violence are more likely to be exposed again, including to other forms of violence (Finkelhor, Ormrod, & Turner, 2007; Finkelhor et al., 2009, 2015).

ADDRESSING OPPORTUNITY GAPS IN PHYSICAL HEALTH AND HEALTH CARE

Opportunity gaps in the physical health and health care of young children can be addressed through efforts focused on poverty reduction, access to pediatric and family health care, antiracism and dismantling of race-based medicine, screening for social influences on health, alternative models for delivering health care, and safe and violence-free environments.

CONCLUSIONS

Healthy birth, medical care, nutrition, and safe and healthy environments are key determinants in ensuring that children have optimal physical health. In all of these cases, however, notable disparities exist by race/ethnicity, income, rural versus urban residence, and immigration status.

In the prenatal period, adverse outcomes experienced by children and birthing people are often due to preventable pregnancy and birth complications, inadequate access to health insurance, and suboptimal prenatal care. These outcomes can have lifelong consequences for children's health and well-being. Early life, including the in utero and even preconception periods, includes critical points during which exposures can influence the trajectory of physical health. Gaps in opportunities intertwine and build on each other over the life course and across generations. Economic insecurity, for example, drives adverse birth outcomes, which then become determinants of later-life challenges that can impact educational experiences.

Proper nutrition plays a large role in physical development, and young children are the most vulnerable to nutrition deficits given the important developmental changes that occur during the first years of life. Existing programs and tax credit policies play an important role for the poorest children, and recent extensions to these programs may help reduce child hunger and poor nutrition. Children also need safe environments in which to grow, develop, and thrive. They need to have stable and secure housing. Their homes and places of play and schooling need to be free from contaminants (e.g., lead) and allergens (e.g., mold), and from exposure to violence and unsafe conditions.

As noted in other chapters of this report, access to high-quality care and programs that can aid in meeting the above needs can vary significantly from state to state. Programs administered at the state level, such as Medicaid, have differing criteria for eligibility that limit access in ways that affect both parents and children. Lack of access to adequate health care in the early years reduces opportunities to screen for, identify, and intervene on a number of health and developmental concerns. Failure to provide these opportunities early in life can lead to worse outcomes or exacerbate health issues that are cause for concern. Children of color and those from lower-income households are more likely to experience these opportunity gaps. The COVID-19 pandemic and related policies, such as school closures, exacerbated these disparities, because of both the disproportionate burden of disease experienced by low-income communities and people of color and the further limitations placed on access to key material and psychosocial resources among marginalized groups.

Stable access to quality health care is essential for child health and development. For young children, health care involves communication and relationships between clinical systems and caregivers. It is important to understand, however, that the broader social and political context impacts engagement with the health care system for families. Critical to a child's optimal physical health and development are equitable access to a stable medical home, one that provides health promotion and preventive care and is patient and family centered, and a social context that supports child, caregiver, and family well-being. Also essential to the development and well-being of children in their early years is having healthy and well-cared-for parents. The absence of these conditions lays the foundation for opportunity gaps in physical and cognitive well-being in the early years that can persist into adolescence and adulthood.

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