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Research interests:
Studies the socioeconomically disadvantaged, particularly women and children.
So your research suggests that stress induced in those experiencing racism can actually cause health problems...
We're treading on very thin ice around here. We're treading on the ice of the effect of racism on health. I've been treading on that ice since before I came to Emory. I've been here seven years. I've been focusing most of my intellectual time on this for probably twelve years.
I got curious about this when the paradigm of poverty did not explain the excess infant mortality risk of African American babies. When I was at the CDC I was involved with the division of reproductive health. We put together all of the infant deaths to babies born in 1980 with their birth certificates. For the first time we were able to partially control for social status and look at what remained in racial effect.
The control that's available for the birth certificate is maternal education.
I hypothesized that when we had women of the same educational level, that the differences between African American and white infant mortality would be narrower than they are in general, because historical racism, which translates into African Americans being poorer, on average, than whites, is definitely related to infant mortality. And when you can control for that by looking at women of similar educational levels, then that should make that difference less, if not go away.
It did more or less go away in the lower educational levels. Under eight years of education there's not a whole lot of difference between African American and white babies. But among women with a college degree or more, there was a big difference, and it was a big difference than the overall average difference.
At a later point we were able to do a more refined analysis that included mother's age, the number of live births she'd had, whether she got prenatal care in the first trimester, father's education, and their marital status. We specifically looked at college-educated parents- couples in which both the father and the mother were college educated.
And this is what we found: that there is almost a two-fold excess risk of infant mortality for African American babies born to college-educated parents, and that when you control for all those factors, it doesn't reduce that risk very much- it goes down to 1.8, and there is still an 80% excess not accounted for by these factors. So it's got to be explained by something else.
Some people jumped to, 'Well, it's got to be genetic.' But the problem with that as an explanation is that there is far more genetic variability within African Americans then there is between African Americans and whites. African Americans have a lot of mixed heritage. Many African Americans have one or more white grandparents, parents, great-grandparents. So very few people are 100% from Africa, and even within those who are from Africa, east Africa is different from west Africa; north Africa is different from south Africa. So there is no genetic description. And there's no physionomic relation to genetic, except in very small ways.
But generally speaking, you cannot determine a person's genetic makeup by looking at them. So we then looked at other things like, 'What happens if you were born outside of this country and you immigrate.' What happens is that the infant outcome is similar when you control for education across race and ethnicity.
That suggests that there is something in this environment that, after the first generation, is toxic to African Americans. Then there are some studies from other health outcomes, like hypertension, that suggest that people's reaction to being discriminated against over a lifetime translates to poor health.
So we came up with an additional paradigm that says that reaction to chronic exposure to individual experiences with racism affects this. Then we came up against a blank wall, because nobody had been measuring this. Stress has been studied and measured with health for decades- you know, the type-A personality, etc. but these measures of stress did not include measures of feeling discriminated against, and they were not generally standardized on African American populations, and we needed to develop our own.
So I've been working with Dr. Fleeta-Mask Jackson and Dr. Mona Taylor Phillips from Spellman for a little over five years in attempting to understand the experiences of well-educated African Americans. We've been working primarily with graduates of Spellman college to understand how they perceive their experiences and how we can translate that into a measure, an instrument that we can use in this study.
We now have an instrument that we've been validity-testing. We're not to the point that I can say: 'This predicts poor pregnancy outcome.' We're probably two to four years away from that, and it's a long process. Of course, there's a lot of skepticism about this. Part of the skepticism is does stress affect pregnancy outcome at all, and then part of the skepticism is, even if stress does, is this a legitimate stressor, and if this stress is ubiquitous, why is it that only some women are affected?
One of the corollaries to this is that women aren't affected equally by what may be a more or less homogeneous exposure. They may perceive it differently. And even if they perceive it the same, some people are more reactive to a stressor than others. So there's stress reactivity built in there, too. It's an extraordinarily complicated paradigm that hopefully we'll simplify as we learn more about it.
But I think this is extraordinarily important. If we, as a majority population, are contributing to the ill-health of the minority in our country because of the way that we look at them or behave towards them, then our behavior needs to change. And we know that anyway, just from a moral and spiritual perspective. But if it also has a demonstrable health impact, then perhaps we'll pay more attention to this as a priority.
Moreover, it may be that we can learn from people who are exposed but who don't seem to have poor health outcomes as a result, what kinds of things they do to protect themselves from the noxious elements around them.
The causes of death for this population are related to the baby being immature- not anything that occurs after birth.
What kind of work did you do at the CDC?
I was at the CDC for ten years, and for the first six of that I was head of the pregnancy and infant health branch of the division of reproductive health. Then I was director of the division of reproductive health for four years. I was mainly doing research in this and related areas; supervising the training of EIS officers. EIS stands for Epidemic Intelligence Service- it's a two-year fellowship to teach people epidemiology on-the-job. It's a lot of public-health service, public-health data kind of work. The kind of thing that would be useful for public policy. I'm classically trained as an epidemiologist with a Ph.D. But my area of research has always been reproductive health; population concerns. My work at the CDC taught me policy analysis and translating research into policy.
Prior to being at the CDC I was in academia for ten years. I was at UNC for five and Arkansas for five. I was teaching epidemiology and doing research. The very first thing I researched was on the effect of induced abortion on pregnancy following abortion. Some of the other things I researched during that period of time were environmental exposure and pregnancy outcome. I also did a record-linkage study on sisters of teen mothers to see if teen pregnancy runs in families- and it does.
I set about to study that epidemiologicallly. I linked welfare records to medicaid records.
How did you get interested in science? What was your path from that point to the present day?
I was a junior in high school, and I was assigned to do a library research project on anything I wanted to. This was in the early 1960's. At that time there was a lot of news concerning the population explosion. So I did my research project on that. I got very concerned about what we're not doing about population growth. So I decided that that was an area that I should devote my life to. In college I was a sociology major, psychology minor, and I did a focused study in that area. After graduating from college, I was out of school for three years supporting my husband through graduate school. During that time I was a welfare worker, and it became clear to me that I should be in research and not in frontline work.
So I went to graduate school and discovered that the methodology of epidemiology was the proper methodology for me to pursue given what I wanted to do. I had not even heard the word epidemiology before I went to graduate school. It ended up that I had to transfer departments. I did a Master's and then a Ph.D. in Public Health. I minored in biostatistics. I felt that I needed the quantitative underpinnings to do research adequately.
I was very fortunate to get outside funding for my dissertation research. At the time there was a policy-research program sponsored by the Ford and Rockefeller foundation. They funded me to go to, of all places, Skopje, Macedonia to study women who had had an induced abortion for their first pregnancy in the 60's, and had had time to have a baby since, to see what the outcome for the pregnancy was. At that time Eastern Europe and Japan were the only two countries where abortion had been legal for a long enough time that I could do that kind of study. The results of that study were very influential, because it turned out that when you do an epidemiological study of this properly Šthat is, when you go back in the records to see who's had an abortion, rather than asking women, at the time that they deliver 'have you had an abortion?'- that there's no excess risk for pregnancy outcome.
Then I joined the faculty at UNC, which is where I got my degree, doing a variety of things, but including replicating this study in Singapore, and with much the same results. Then I served as a consultant on studies that other people were doing in the states, because abortion had been legal for long enough by then to do these kinds of studies. Which they cannot do now because records are no longer kept, in order to protect women who have had abortions. In the 70's there wasn't as much threat. The anti-abortion faction has made the study of abortion very difficult.
You might ask how I got from the population growth issue to studying the health outcomes of abortion. I was very influenced by my dissertation adviser, who was a population epidemiologist. He pointed out that the health theme in family planning was very important- he was a leader of that philosophy, the fact that people have to know that they're going to have healthy babies before they're going to be willing to control their fertility, and that women's health and the health of babies is all wrapped up in having the right number of kids born to that family.
I've done research in unintended pregnancies. I was on the Institute of Medicine committee that looked into unintended pregnancies and published the book, in 1995, on it, entitled The Best Intentions.
What should we be doing about teen pregnancy?
I'm just in the process of writing the paper in which I'm outlining a philosophy around family planning that says that for an undesired pregnancy to be a publich health issue, it has to be a health issue, and it has to be viewed by the public as a social, a public issue.
In the early 20th century Maragaret Senger, who was the grand dame of family planning, said that no woman should have to bear a child that she shouldn't have to bear. She went to jail for this several times, and every time she did the public got better-educated as to why this was a public problem, and that it was a health problem as well.
Gradually, the laws that sent her to jail were struck down by the supreme court, and public opinion moved in support of public programs to ensure that no woman had to have more children than she wanted. Then, with the development of modern contraceptives, that became even more possible.
In 1973, when the Supreme Court overturned all the abortion laws, the climate in this country, which had been moving steadily towards public support of public programs to reduce undesired pregnancies, was eroded. It has systematically been eroded since then, to the point that now when we think about undesired pregnancies, all we think about are teen pregnancies. We don't think about a woman who is 35 and married as a woman who has a pregnancy that she doesn't want as a public problem. Rather, 'that's her problem. What happened to her, that she got herself into that situation? Whatever it was- it's her problem.'
I think that we got to that place from well-intentioned people as well as people who are not so well-intentioned. The well-intentioned people said 'we want to continue putting the public's focus on the problem of undesired pregnancies.' And one of the ways to do this is to focus on the group that has the most to lose from unintended pregnancies. The Alan Guttmacher Institute, which is a public-policy instituted devoted to family-planning issues, published a booklet in the 1970's called 11 million teenagers focusing on the fact that when teenagers get pregnant, they don't generally want to be pregnant. It's a mistake and they recognize it- so what can we do to help them.
The National Institutes of Health then put virtually all the money they had to put into understanding the causes and consequences of undesired pregnancy onto understanding the causes and consequences of adolescent pregnancies. So we know a lot about teenage pregnancies, and all of this is from advocates of family planning.
The moralists became very well organized around abortion issues, as a result of the Roe v. Wade, Dobie-Bolton decision of 1973. What had been a minority and a not very vocal minority became very powerful, even though the proportion in the population did not change, the proportion of their influence changed dramatically. It is to their advantage to narrow the focus to teen pregnancies, because it is much easier to talk in moral fashion about teens who shouldn't be having sex, than it is to talk in moral fashion about adults- especially if the issue is a married couple having an undesired pregnancy.
So those two polar opposites have driven public discourse about undesired pregnancies for the last 25 years into a tremendously narrow point around teen pregnancy. I say it's to the moralists' advantage because they can then focus public funds towards abstinence programs, and the public thinks that's enough. But you can't tell a married couple "don't have sex." In fact the moralists are now focusing their attention on births out of wedlock in general, so they can tell unmarried people "don't have sex" regardless of their age. But that's not catching on very well in this country.
But there's no question from a health perspective that children who grew up in a single-parent family are at higher risk for poorer development, etc. The problem with that from the perspective of demagoguery is that you don't have to be unmarried to be unfortunate and have only one parent when you grow up. A lot of kids have one parent when they grow up, despite the fact that their parents were married when they were born.
And of course not every kid who grows up in a single-parent family suffers. But I'm talking about groups- and that's a group at risk. And a vast majority of those kids with single parents were born to a married couple to start out with. So what do we do? What we need to do, I think is broaden our understanding, and recapture the public's attention to what is a real public problem, although they're not recognizing it as a public problem. That is, there are a lot of undesired pregnancies that are occurring to people who have fewer resources then they should have to prevent those pregnancies from occurring. There are people who don't have health insurance, people whose health insurance doesn't cover every FDA-approved contraceptive.
Georgia actually took the lead last year and mandated that if an insurance company covers any contraceptive they have to cover all FDA-approved contraceptives. Of course that came as a result of Viagra. Thank god for Viagra!
But there still is not a recognition that it's a burden for women to have to have a co-payment every month for an oral contraceptive prescription. Insurance companies shouldn't require that. And in the countries that are way ahead of us in terms of preventing undesired pregnancies, the man has a much greater role in this than the man generally takes in this country. In the Netherlands the unintended pregnancy rate is almost ten-fold lower than in this country. They are taught from very early, in a K-12 program, boys and girls are brought up with age-appropriate education, leading up to what they call the double-dutch method, where the man uses a condom in any sexual relation. It doesn't matter if he's out with a prostitute or his wife. And the woman uses whatever effective method she prefers.
Statistically, these pregnancy-prevention techniques are independent. So when you have a use-effectiveness rate for the pill of 97%, 3% of women every year who are on the pill are going to get pregnant despite being on the pill. But if you combine that with the use of a condom, even though the use-effectiveness rate of a condom nowadays is around 80%, you reduce that 3% to less than 1%, to 0.6%, because only 20% of that 3% would get pregnant.
That message needs to get out. Some people on their own realize that if they really don't want to get pregnant they have to do this sort of thing. So these kinds of things need to be discussed openly and honestly, and federal programs need to address these- not to neglect the teens, but teens now I think are getting as much pregnancy-prevention as they can endure. It's having an impact- teen pregnancy rates are going down.
But the rate of conceptions that are unwanted are not going down- because those occur in adult women.
What do you currently teach?
I currently teach two courses- I teach a course called Translating Epidemiology into Women's Health Policy and a course called Reproductive Health Program Management.
What's the philosophy behind your teaching?
Actually, I was fortunate to be one of the students in the inaugural class of the Teaching Portfolio seminar. So I was able to look at what my teaching philosophy is. It boils down to- I'm teaching adults. I only teach graduate students. These adults are responsible for their own learning. What I need to do is provide tools that they can use for the rest of their life. Then those tools should be something they can modify and adapt over time. I impart information- but information in this area gets stale in a hurry. So if I don't use the information as illustration as to how you gain further information after you graduate, what they learn in that kind of class is obsolete within a few years.
What was your Ph.D. in?
In epidemiology and biostatistics.
What can a person do with a degree in public health?
The mph is a generalist degree, but it's obtained in a department. So if you get an mph degree and you are enrolled in epidemiology, then your career afterwards is different than if they got it in the division of health education. If that person takes a test and gets certified as a health educator, then they will serve as a health educator either doing personal health education, or serving as a staff health educator for an HMO or something like that.
With an epidemiology mph, a person might serve on the staff evaluating programs, developing surveillance systems to track the effectiveness of programs, serving in many capacities on ongoing research projects, as directors and analysts. They tend not to be the project PI with a master's degrees- for that, often you have to have some kind of doctorate, or it could be an M.D. with an M.P.H. Generally speaking, a person who thinks up a study and gets money for it and does it is someone with a doctorate.
Most people who are in epidemiology are in some kind of research. The other departments in the school are Health Policy and Management, International Health, Environmental and Occupational Health, and Biostatistics. Graduates in each of those programs will have a different array of job opportunities open to them.
So why do you say, "Thank God for Viagra?"
For years people have been trying to get coverage of all contraceptives that are approved by the FDA, and that has gone virtually nowhere. When Viagra was introduced, insurance companies started covering it almost immediately.
Congress was called to task for the fact that they were supporting Viagra, and they had never required that Federal insurance programs cover contraceptives. Olympia Snow, a congresswoman from Maine, and another congresswoman, effectively lobbied their cohorts to require that any insurance company that insures federal employees, had to cover contraceptives. So, "if you're going to do this for men, why are you not doing it for women."
The moralists were exposed with this. The Best Intentions Institute of Medicine study pointed out that if you're opposed to abortion, the moral perspective would be that you would be in favor of family planning, because the vast majority of women who obtain abortions, have unintended pregnancies. So if you want to cut down on abortion- cut down on the need to make that decision. If she's not pregnant, she's not going to have an abortion.
The problem is that the anti-abortion faction is really anti family-planning. They will not go with that argument. Surgeon General Koop could. But there are many people in that group who can't cope with it- the Roman Catholic Church, which is a big funder of many of those groups opposed to abortion, can't do that. They can't say, "OK, you're right, if we want to be opposed to abortion we need to be in favor of family planning,"- because they're not in favor of family planning.
They have been able to finesse this, but the rhetoric got very vitriolic around the subject of contraceptives. So the far, far right started calling contraceptives 'baby pesticide.' And you wouldn't want to fund a baby pesticide would you? Then it was like the Emperor has no clothes... they started arguing that oral contraceptives and IUDs were baby pesticide. Then Olympia and the others started saying- well, what is the definition of a pregnancy? It's an implanted ovum- 'so maybe you think this is a baby pesticide, but you're the only person who thinks that. Moreover, the FDA has approved this.'
This was an interesting, and I think critical watershed, for the balance of power around this extraordinarily sensitive topic. Anything that has to do with sex gets to be very controversial.
I got into this field in the early 60's, and for the first decade I thought I was on the side of the angels. Public opinion was getting better towards women- and the need to recognized that pregnancies don't just come and they could be and should be planned. Things were going beautifully, and then the next 25 years, they deteriorated, and I'd say only in the last year and a half did we hit bottom and start up again.
There are lots of reasons for this- some of them having to do with backlash towards women and feminism in general. I have to remember that we have had the vote for less than a century. When my parents were born, women did not have the vote. In the brief time that I've had a career, in the brief history of personhood, it may not be too surprising that when you have such rapid change, there will be a backlash.
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