Today, many of us can take it for granted that our grandparents will live through our childhood—and that our children might get to meet them. Not that long ago, though, that wasn’t so common. Not just because our grandparents didn’t used to live that long, but because so many babies died before their first birthday. In most American communities, infant mortality is a thing of the past. But not in all of them. Dr. Abdul El-Sayed takes us to Detroit to dissect American life expectancy— to understand why it’s declining and why it may never have been as high as it should have been in the first place.

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ABDUL VO: It’s a pretty great time to be alive. Diseases that devastated millions of our predecessors –like smallpox or the plague–are either gone, or exceedingly rare. I took it for granted that my daughter would get to spend time with her great grandparents–she and they having lived long enough for that to be common these days. 

Life expectancy has skyrocketed over the past century. And given advancements in science and technology–that should keep going, right?

ARCHIVAL: For the last three years life expectancy is the United States has fallen 

ABDUL VO: Riiiight. 

This news should be alarming: life expectancy isn’t supposed to go down. Sure, at some point it can no longer go up — I don’t see us living past 110 any time soon – despite the best efforts of tech billionaires— but, overall, you expect to live longer than your parents, who expected to live longer than theirs, and so on and so forth. 

Our failure to address some of the issues we’ve talked about in this series–like loneliness, or opioids, or prescription drug inaccessibility–are starting to catch up with us. 

But there’s something else, too. Something hidden in these numbers. 

See, American life expectancy is nearly 79. That’s 6 years shorter than in Japan–the country with the longest life expectancy. And beyond asking why it’s going down, we should also be asking why it’s never been that high to begin with. 

People die at all sorts of ages. The younger the age at death, the bigger the impact on that number. So when babies die–it’s particularly brutal. And in America, that’s happening way more than it should. America ranks 56th in infant mortality worldwide — behind countries like Estonia, Slovakia–even Cuba. Today, we’re going to explore why. What does life expectancy look like on the other side of 79. 

This is America Dissected with Abdul El-Sayed. I’m your host. Stick around.

• SERIES TITLE AND THEME

ACT 1: WHAT THE HELL IS LIFE EXPECTANCY? 

ABDUL VO: Babies are vulnerable – if you’ve ever held one, you know this innately. But it also bears out in the science.

Galea_Sandro_edit: [00:16:52] Childhood is infancy. Infancy and childhood is the period where you have the highest risk of [00:28:11] mortality. 

ABDUL VO: That’s Dr. Sandro Galea — Dean of the School of Public Health at Boston University.

Galea_Sandro_edit: In Public Health, we are very concerned with infant mortality rate, one year mortality rate, and under-5 mortality rate. To the immortality of children. Once kids are over 5, the age period from 5 to 15 becomes a very safe period, because kids are robust. And in fact, it is the safest period and the lowest mortality throughout the lifespan 

[00:17:22] So the first five years are particularly vulnerable periods, both in childbirth all the way to infancy, neonatal period infancy, and early childhood. Once we get kids over five, it makes all the difference in the world for survival.

ABDUL VO: After the age of 5, our physiology–things like our immune system and brain function–are starting to work like they should. 

Before 5, it’s a different story. And in the time before public health especially–all kinds of infectious diseases or environmental dangers were right there to exploit those vulnerabilities.

Just one century ago, 32% — nearly 1 in 3 children — died before the age of 5. By 1950, thanks to public health improvements, things had gotten slightly better globally — 1 in 5.

Statistics tell one story – but the lived experience is something completely different. If you’ve been through it, you know. And if you haven’t, I want to take you back in time just one generation in my own family… 

VERITE: [5:22] MO: My mom made a lot of favorite food actually. She was an amazing cook. Her rice was just amazing. Perfect. 

ABDUL: It felt like eating a cloud.  

MO: yeah. That one thing I never really mastered as she did. 

ABDUL VO: That’s my father, Dr. Mohamed El-Sayed. Baba, to me. He grew up in a very different time, in a very different place–in 1950s Egypt. 

At the time, nearly 1 in 4 babies died in Egypt before the age of 1. My father’s family – with its 8 children – lived that statistic.

INTV – MOHAMED: [20:42] Badriyah was the first girl my mom had and she was very very very excited. She had her daughter that she always wanted. And when Badriyah was about, I think it was a year, less than a year, around a year old. 

[21:14] I think I got whooping cough. And then Badriyah picked it up from me. But she was a baby.

ABDUL VO: My father – 3 years old at the time – had inadvertently given his baby sister whooping cough. Also called pertussis, whooping cough is a highly contagious bacterial infection of the throat. It suffocates kids. 

INTV – MOHAMED: [21:40] . And she was not doing very well. So my mom ended up taking her to the general hospital. She took her and went to the hospital and then came back without her and that was the most shocking thing in my life at this point. 

ABDUL VO: Before we had a vaccination for it, whooping cough killed millions of kids, like my aunt, Badriyah. Upper respiratory infections used to be one of the most common causes of death among children. The other common causes were gastro-intestinal infections: things like typhoid fever and cholera — which also came to visit my father’s family.

INTV – MOHAMED: [22:50] Jabbar. his name was Jabbar. He got a virus. And I remember that he could not keep anything inside him. 

[23:07 I remember him actually vomiting on the carpet that we had. And it looked kind of darkish yellow and gray and I was a little bit disgusted because I was a little bit older. 

INTV – ABDUL: [23:01] How old was he?      

INTV – MOHAMED:  He was also less than a year old.

[23:28]: I loved him a lot because we were connected. He was so so handsome boy actually. And then when he was not doing well, my mom took him to the hospital and my heart started beating. And again, she came back without him. 

[24:59] where… where he vomited and I was disgusted, I wanted to treasure that. I didn’t want anybody to clean it because that’s the last thing I had of my brother.

INTV – MOHAMED: [1:12:58] You see your mom suffer. And then you see the child go away after you have made a connection with. It really affects you tremendously and it leaves a stamp on your own life.

ABDUL VO: My dad never told me these stories before. It’s something he doesn’t talk about much. And I get it.

Even though these stories are devastating, hearing them gives me an appreciation of how far we’ve come. Today, globally – deaths to babies under the age of 1 is down to 29 deaths for every 1000 births– that’s 2.9%. Down from ten times that many a century ago. Pretty remarkable.

How did it happen? Public health! Remember John Snow, who we talked about at the top of this series? Everything that followed from the discovery of germs & infectious diseases, the development of sanitation systems, vaccines and antibiotics, and public health regulations — all of that has helped save babies’ lives and thus raised life expectancy across the world. Public health advancements protected them from exposure to the infectious agents that exploit still-developing immune systems–and protected them from all kinds of environmental hazards we don’t even think about today–like flying through a car windshield because they aren’t in carseats.

But my father’s story also reminds me that we still have a long way to go. Because there are still families – even in our own country – who suffer these tragedies far more often than they should. 

ARCHIVAL – recent reports of health disparities… like we saw in NYT article… 

ABDUL VO: We’ll explore these stories – and the inequality behind it all – after the break.

MID-ROLL BREAK

ACT TWO

ABDUL VO: This is The Vitals with Abdul El-Sayed. Today, we’re talking about the most vulnerable among us: babies. And what it says about a society whether they survive to age 1. In the US, infant mortality is deeply unequal. 

To me, that’s personal. 

INTV-EM: [13:24] Emmalee, what does a lion say? [Em roars.] What does a froggy say? [baby ribbits] What does a cow say? [baby moos] Oh, what does a horse say? [baby noise] What? [baby noise] No a horse says nayy. 

ABDUL VO: That’s Emmalee, my 18-month old baby girl. She loves her animal sounds and remembering what every different member of our family says to her. 

INTV-EM: [14:28] What does Baba say? Em: Habiba! SJ: Yeah! What does Mama say? Em: Love! SJ: Love, yeah, that’s kind of the same thing. I don’t know if you realize that. Em: adorable chaotic nonsense

ABDUL VO: I love my little girl. And I can’t imagine what my life would be without her. I take it for granted that she made it through infancy–we live in Ann Arbor, where the infant mortality rate is low.

Just 45 minutes away, in Detroit, where I was health commissioner? The infant mortality rate is more than three times as high: 14 deaths per 1000 live births.

MUSIC COMES IN

You’ve probably guessed it at this point in the series, but health disparities in this country leave infants of color at far higher risk. See, a lot of that progress we’ve made in the last 100 years, much of it has missed the poorest and most marginalized communities in America. 

It’s left infant mortality looking more like it does in far poorer countries. The average infant mortality rate in Detroit, like I said — 14 per 1000 births– is only slightly lower than it is in Egypt, at 15. 

And it gets worse, because in Detroit…

INTV – WELCH: [21:28] Cuba’s infant mortality rate is lower than ours like 4.3. Ours is 14. We have ZIP codes in the city where it stays as high as 22.

ABDUL VO: That voice belongs to someone who’s doing something about it.

INTV – WELCH: [02:45] Hi, my name is Leseliey Welch. I’m on faculty in Public Health at Wayne State University and a part of the development team for Birth Detroit.

ABDUL: And formerly Deputy Director at the Detroit health department and one of my favorite colleagues with whom I’ve ever worked.

WELCH: Thank you.

ABDUL VO: Leseliey was my first hire at the Health Department. She’s an expert in infant mortality.

Leseliey will share a whole lot more with us in a second – but first, some context — 

In the past–and even today–doctors and public health officials have tried to explain higher rates of Black infant mortality by looking at the characteristics of Black moms and babies themselves — like differences in the length of the cervix, or the measurements of the body. 

But those approaches haven’t worked–and they reaffirm the false and dangerous belief that racial disparities are about biological differences between people, rather than the racism they experience.

So leaders like Leseliey are taking a different tack. Centering the people beyond the numbers…

INTV – WELCH: [05:29] I was a volunteer doula before I was ever a mom. 

[06:02] And it was amazing. There’s just nothing like being present with a woman at that time, and being there when a baby’s born…

Centering the people we serve means bearing witness to their pain.

I have two girls. And unfortunately when you say the majority of Americans will never experience the funeral of a baby – I’ve also had that experience. I was with my brother-in-law and sister-in-law the day that my nephew was born in a local Detroit hospital. He was born too small and too soon. And he died the same day. And it was devastating for the whole family and certainly exceptionally devastating for them. And that was the first funeral for a baby I had been to. I’ve never seen a coffin that small….

INTV – WELCH: [8:23] From that moment forward, I saw every mom as my sister and every baby as not only my nephew, but every baby as my baby, right? And when you see communities that way, then you work harder. And you work differently.

ABDUL VO: When Leseliey and I worked at the Health Department we were confronted with this reality regularly… 

And also at that time I was working at the Detroit Health Department in Maternal Child Health and… we would actually get lists and demographic information on every baby that passed, and so a couple weeks later, a month or so later, I was looking at my nephew’s name on that list. 

So many of these deaths are preventable. So how do we prevent them? That’s the work that Leseliey’s about.

INTV – WELCH: [12:38] I think one of the things that is so important when we talk about infant mortality is the context of women’s lives, right? A lot of times we talked about it and we go right to care and we don’t look at whether or not mom had stable safe and affordable housing whether or not she had access to healthy food whether or not she had access to Quality child care for other children, and she had work that supported her and her family all of those things matter and in addition to.

ABDUL VO: The causes of infant mortality don’t start in the womb. 

They start outside of it. Direct racism is an important predictor of prematurity: one study of 277 women in Chicago found that Black women who delivered preterm were 2.5 times as likely to have experienced racial discrimination in the past year.  

Why does this happen? Well, Remember cortisol? That hormone that mediates the long term stress response we introduced when we talked about loneliness? Well, scientists have found that changes in cortisol levels during pregnancy may predict early delivery. And they’ve found systematic differences in cortisol levels among Black moms. In fact, one study found patterns of cortisol in Black women that are consistent with those suffering post-traumatic stress disorder. 

But it’s not just direct racism. Structural racism in our neighborhoods, our cities, and our states may matter even more. How we value black life in our laws and the distribution of our resources shapes access to housing, a living wage, the ability to breathe quality air and drink clean water — these factors affect the likelihood that a child is brought into the world healthy in the first place. 

One study of all babies born in 2010 looked at how levels of structural racism in a given state predicted the probability of infant mortality. Within each state, the researchers estimated the level of structural racism by tracking differences between Black and White residents in criminal justice measures, like incarceration and sentencing, and socioeconomic measures, like education, employment, and household income. They found that, even after controlling for the mother’s own socioeconomic characteristics, a Black infant born in a state with the highest level of structural racism was 25% more likely to die before the age of one.

INTV – ABDUL [35:19] if we were serious about solving all the challenges that we women like your sister-in-law face in the lead-up and the postscript to their labor, what would we be doing? And how would we be approaching it?

INTV – WELCH: That is such a huge, huge question and it brings to mind for me two things. One is that what we know about, particularly black women, in our experience of infant mortality, maternal mortality, is that education and income are not protective for us, right? And so my sister-in-law and brother-in-law were professional people and you know with quote unquote good income and so forth, but those things were not protective, right?

ABDUL VO: Many studies have shown that racial disparities in infant health persist among infants born to college educated moms, too. 

INTV – WELCH: And so I think a broad scale effort would do two things. It would, one – really seek to address racial equity – because we have research and data to say, it gets into our bodies, right? It stresses us, it isolates us from each other, and we know it’s directly related to our experience. Right? So some literally large-scale effort to address not only interpersonal racism, but structural racism. And then addressing income inequity, too – like really addressing that – to address the larger number of families for whom economic stability would make all the difference.

ABDUL VO: To solve the problem of black infant mortality we have to tackle structural racism. We need to break down decades of racial inequity…. That’s a big job. 

But in the meantime, there are other solutions to pursue on a smaller, community-level scale — changes that could still have a big impact even as we do the serious work of rooting out racism.

In our time at the Health Department together, Leseliey and I learned that first-hand.

INTV – WELCH: [10:14] And sister friends was started to have regular women in the community support other women in the community during pregnancy during the birth of a baby and postpartum at least up to one year, right? And so when you’re with a woman in that time and through that time what you began to form is more of an extended family relationship and these are volunteers.

ABDUL VO: The program pairs pregnant moms with peer-mentors–sisterfriends–who support them through their pregnancy, meeting regularly, accompanying them to prenatal care, and connecting them with programs that provide services through pregnancy.

INTV WELCH: To you know, share it with you and to have support around I’m starting it in Detroit because what was learned over the almost 30 years, I think women have been having sister friends. In other areas of the country is that when moms have sister friends not only do they have a better experience of pregnancy and birth and postpartum, but.

Their babies are born more term, right? So less likely to be born too early. Also less likely to be born too small; moms are more likely to breastfeed successfully– all of the things that we care about and babies are more likely to live to that first birthday. 

ABDUL VO: Other community-level solutions involve rethinking how and where women give birth.

INTV – WELCH: [22:07] We know 80% of women can give birth with midwives, but we don’t do that thing. We know that in countries where midwives that are primary provider of care. Their outcomes are better, but we don’t do that thing

ABDUL VO: Midwives are trained health professionals who help women during labor, delivery, and after the birth of their babies, and can often deliver babies in situations where both mom and baby are healthy. Midwives may be particularly important to providing patient-centered care in communities like Detroit, where Black moms often feel like their worries are ignored or dismissed. 

I remember going on my first ride-along with Mildred, the incredible woman who led our infant mortality response team at the Detroit Health Department to check in on a woman who had lost her baby who was born premature. The young mom recounted her story–about how she felt like the staff at the local hospital never took her worries seriously.

This dismissal of Black moms is all too common, and as Leseliey mentioned earlier, it cuts across socioeconomic lines. Case in point: Serena Williams and the birth of her baby girl in 2018. Having suffered a pulmonary embolism–a potentially deadly blood clot that goes to the lungs–in the past, she knew what she was feeling when she started getting short of breath after her labor. But hospital employees dismissed it, until a CT showed that, in fact, she was having what she thought she was having–and was promptly treated.

Leseliey’s organization, Birth Detroit, is building a birthing center to tackle this problem. 

And when all else fails, sometimes you’ve got to think outside the box–or maybe inside the box. 

ABDUL: [34:33] Remember when we tried to launch the baby box project?

WELCH: (laughing) Yes!

ABDUL VO: A baby box is exactly what it sounds like: literally a cardboard box that a baby would sleep in for the first three months. Why? Well, one of the leading causes of infant mortality is unsafe sleep – the fact that babies who co-sleep with parents are far more likely to die. Unfortunately, babies don’t have very good neck control – and so if a parent were to roll over, it’s not like that baby can really move and get out of the way, and sometimes those babies end up suffocating under the weight of their caretaker. Baby boxes stop that from happening. Because, well, you can’t really sleep in a box with a baby.

INTV – WELCH: [48:01] A baby box is actually, I think, Finnish, right, in concept, and it is a box actually that the government gives to expectant parents. And it is a box that is large enough for baby to sleep in and it also includes, I think, everything a baby would need – at least in that country – everything a baby would need for a certain number of months of the baby’s life. And it is kind of a welcome to parenthood, welcome baby package.

ABDUL VO: Finland — the country behind the baby box — has one of the lowest infant mortality rates in the world. In part that’s because Finland has created creative community-driven solutions like the baby box. In Detroit, unfortunately, our plan was stymied by politicians who worried about the legal exposure.

Of course, the three solutions we talked about–sisterfriends, patient-oriented birthing centers staffed by midwives, or baby boxes–are just a few of the solutions we can implement to help Black moms and their babies. 

In the end, the deeper solution *is* all about what Leseliey spoke to earlier: creating more economic stability, rooting out structural racism. And that is going to involve big government solutions– luckily, that’s what public health is all about.

LESELIEY: That is – that’s our job in public health. What we’re left with right now in public health – the reason we would see an overall improvement and we would see disparity persist is because – we are not at the limitations of our science, we are at the limitations of what we believe about one another. We are at the limitations of what we are willing to let go of or give up or do differently to improve lives. And so we got a lot of work to do in that area.

MUSIC IN

ABDUL VO: Right now, life expectancy IS falling in the US. As we’ve talked about, it’s a complicated calculation – and some of what we’re seeing now is due in large part to things we’ve talked about in earlier episodes: increases in opioid overdoses and suicide. 

But even as we work on solving these problems, let’s not forget something: American life expectancy was never as high as it should have been. And that’s because babies–usually black babies–are dying before they even have a shot at life. And it’s been that way for a long, long time–an epidemic baked into the fabric of our society. So as we turn our attention to addressing our falling life expectancy, let’s make sure to address this, too. 

Before we go– the next and final two episodes on this show are gonna be a little different — we’re gonna turn our attention to the thing that’s been conspicuously absent from most of our discussions: healthcare. Oh yeah, we’re gonna get into it.

But first, I want to say a few words about what the core of this series has always been about: the work of public health. Because while healthcare is important, I hope we’ve shown you, it’s not everything. Public health is so much deeper. 

It’s also quiet. At its best, public health operates in the background– humbly, competently keeping us healthy. We don’t watch scientists in their labs creating the vaccinations or antibiotics of tomorrow. We don’t see sanitation laws or water purification systems or air quality regulations happening. But without them, our lives would be so much the worse. And because public health doesn’t usually speak for itself, we need to speak for it.

When we hear people deride science and scientists or demonize government like they’re some great evil, let’s not forget that without them, so many of the basic dignities we take for granted might not be possible. Our lives literally depend on them. 

When your elected representatives want to cut public health support. When you hear your friends talking about why they’re worried about vaccinating their kids. Speak up. We need public health–not just to continue to solve the problems of today–but to take on the problems of tomorrow. 

Now, to healthcare. Next time, on the XYZ.

If you’d like to support Leseliey’s quest to build a birth center in Detroit, visit www.birthdetroit.com.

America Dissected is a production of Crooked Media. Our producers are Austin Fisher, Cary Junior II, and Katie Long. Andrea B. Scott is our story editor. Our sound designer is Daniel Ramirez. Production support from Alison Falzetta (Fall-ZET-ta), Elisa (AY-lisa) Gutierrez, Kara (CARE-ah) Hart, Daniel Porcerelli (PORE-sir-el-ee), and Tara Terpstra. Fact-checking by Dr. Nicole Aiello (aye-YELL-low). The theme song is by Taka Yasuzawa (TAAK-ah Yaas-oo-ZAH-wah) and Alex Sugiura (SOO-ghee-er-ah). Our executive producers are Sarah Geismer (GUISE-mer) and Mukta Mohan (MO-haan). Special thanks to Jon Favreau, Jon Lovett, Tanya Somanader (SOW-men-ay-der) and Tommy Vietor. And I’m your host Dr Abdul El-Sayed. Thanks for listening.