Infant Morbidity in Harlem: A Status Report

41 Presentation INFANT MORBIDITY IN HARLEM: A STATUS REPORT DAVID BATEMAN, M.D. Assistant Clinical Professor of Pediatrics College of Physicians and Surgeons Columbia University; Chief Newborn Service Harlem Hospital 506 Lenox Avenue New York, New York 10037 Harlem's cultural, symbolic, and historical importance does not appear to have conferred any special health benefit to its residents. Over the past half-dozen years, a wave of calamities—the pervasive use of crack cocaine, epidemics of AIDS and syphilis, and increasing poverty, homelessness, and violence—have swamped the community like a crushing plague. No age group has been exempt from these insults, but the community's infants and children have seemed particularly vulnerable. There is little rhetorical excess to the claim that Harlem is losing an entire generation of its children. Unfortunately, the situation is nearly as grim for the children of New York City's less famous but equally impoverished neighborhoods: Jamaica, Ft. Greene, Red Hook, Bedford, Morrisania, and Mott Haven.1 The social disintegration that has followed in the wake of these calamities has only added to their force. Over the last six years, measures of risk for poor outcome of pregnancy and poor infant health have worsened throughout New York City. Increasingly mothers have had late or inadequate prenatal care, are uninsured, have given birth out of wedlock, have untreated syphilis, and use illicitdrugs.1 AmongNewYorkCityneighborhoods,theCentralHarlemhealth district ranks at or near the bottom for these measures of health outcome. In 1987, the New York City Department of Health surveyed mothers using a composite of three risk factors associated with poor outcome of pregnancy Journal of Health Care for the Poor and Underserved, Vol. 2, No. 1, Summer 1991 42 Infant Morbidity in Harlem (maternal age under 20 years, no prenatal care in first six months of pregnancy, out-of-wedlock birth). Less than half of New York City mothers had no risk factors. In Central Harlem, only 11 percent of mothers had no risk factors, the worst rate among all health districts in New York City.1 After nearly a century of improvement, the infant mortality rate of New York City (and of Harlem, which is often twice that of the city as a whole) has risen during each of the past three years. The major cause of increasing infant mortality is the higher birth rates of low- and very low-birthweight infants. In New York City, such infants are bom at rates approximately 50 percent higher than in the nation as a whole; in Harlem, low- and very low-birthweight babies are now being bom at rates nearly twice those of New York City as a whole and three times those of the United States. Low birthweight is probably also the most important correlate of infant morbidity and infant health care utilization.2"1 The discussions that follow amount to a clinical progress report on how the infants and children of Harlem have endured the past half-dozen years. They are also an index of the strengths and failures of health care and social policy. Arguably, few neighborhoods have such a compelling need for improved health care and social services, yet an impenetrable curtain of poverty sometimes seems to frustrate all efforts to intervene. The cocaine epidemic Harlem has traditionally had a high rate of maternal substance abuse. During the 1970s, four to five percent of mothers delivering at Harlem Hospital either used illicit drugs (mainly heroin or phencyclidine) or were enrolled in methadone treatment. Fewer than one percent used cocaine. By 1984, a cheap, smokable, intensely habituating form of free-base cocaine called crack became widely available in New York City and by 1985, thousands of women had delivered infants who were exposed to cocaine in utero. At Harlem Hospital, nearly 15 percent of the 3,000 infants bom in 1986 were identified as having been exposed to cocaine during gestation, a four-fold increase in the number of drugexposed infants bom in 1984. The rate of cocaine exposure increased to 17 percent of births in 1988 but has decreased slightly during the past year.5 Infants adversely affected by maternal drug use must be reported to the New York State Child Welfare Administration...