Surviving through age 18 in Detroit

Karen Bouffard
The Detroit News

Like most new moms, 19-year-old Alaina Gonville loves her newborn son, Brandon, with all her heart.

But like so many babies born in Detroit, little Brandon has faced more than his share of challenges from the minute he entered the world five weeks early, on Oct. 28, at Harper University Hospital.

More babies, like Brandon, are born prematurely in Detroit than in any major city in the United States, a Detroit News investigation found.

Alaina Gonville kisses her 3-month-old Brandon at the Neonatal Intensive Care Unit at Hutzel Women's Hospital in Detroit. Brandon was born premature through an emergency C-section.

Prematurity, whose deadly side effects include brain hemorrhages, collapsed lungs and failing organs, is the leading killer of Detroit's babies. It's the major component of infant mortality — a catch-all term comprising all conditions that claim children before their first birthday.

Infant mortality is the No. 1 killer of Detroit children; violence is second. In 2011 alone, 130 of the 208 Detroit children who died that year had not yet marked their first birthday.

"It's infuriating, because we know we can change the trajectory of these numbers," said Kristen McDonald, vice president of program and policy for the Detroit-based Skillman Foundation.

The News found that Detroit has more babies born to moms who are under 20, like Gonville, and to single women, than in any other major American city. And often, those young women are not themselves in good health and otherwise ill-equipped to have babies.

Looking for answers

The challenges of caring for an infant are daunting in one of the nation's poorest, most violent cities. Detroit's infant mortality rate is the worst among big U.S. cities, and worse than some Third-World countries: 13.5 for every 1,000 live births in 2010, the most recent year for which comprehensive data are available.

Foundations, hospitals, social service and government agencies are attempting to tackle the problem through nurse visits, parenting programs and even special tests and treatment for physical conditions found more frequently among black Detroit women. The W.K. Kellogg Foundation alone invests $25 million annually in grants to projects that improve health and well-being in Detroit.

The cocktail of remedies can't come fast enough: 2,300 Detroit babies died before their first birthday between 2000 and 2011, the most recent year data are available from the Michigan Department of Community Health.

Factors include pervasive poverty, young and uninformed mothers, poor prenatal care and even race.

Detroit's infant mortality rate has changed little over more than a decade, despite efforts that have reduced infant deaths statewide.

"We know in Lansing and at the Department of Community Health that infant deaths and child deaths must remain the main focus of our programs," said Dr. Matt Davis, chief medical executive for Michigan and professor of pediatrics and internal medicine at the University of Michigan. "Infants have the most fragile health of any age of child (and) the families that have children are for a variety of reasons under a lot of economic stress.

"The reason that making progress on infant deaths is so challenging is that it is a powerful combination of fragile health and vulnerable economic situations. And so a successful strategy in public health and health care, to reduce infant mortality, needs to have strong medical approaches and strong social approaches."

Care, support key

Experts blame a confluence of health risks for Detroit's high infant mortality rate, including inadequate health care, information, support and know-how by young mothers.

Eighty percent of new Detroit mothers are unmarried, compared with 42 percent of all Michigan moms, which may mean they have less support — financial as well as emotional — than women with husbands. Also, the city has more teen moms than any other in America: 18 percent.

Teens who become mothers before graduating from high school are less likely to complete high school or go on to college, dooming them to a future of low-wage jobs.

And since a mother's education is proven to be one of the best indicators of how well a child will do in school, their children start out with the odds stacked against them.

Alaina's son, Brandon, was delivered by Caesarian section after 35 weeks of gestation, weighing 5 pounds, 8 ounces.

Babies born four, five or six weeks early are called "late preterm" to distinguish them from the very tiny preemies that are born at 32 weeks gestation or even earlier.

According to Dr. Roberto Romero, director of the Perinatal Research Branch of the National Institutes of Health, housed at the Detroit Medical Center, about 70 percent of preterm babies are "late preterm," and they face special health risks.

Dr. Roberto Romero, director of the Perinatology Research Branch of the National Institutes of Health at the Detroit Medical Center.

"There has been a perception that these babies generally do well because they are more mature," Romero said. "But recently it has been recognized that babies who are born late preterm have a greater risk of dying before the age of one, or having other complications such as cerebral palsy, (or) having respiratory difficulties. So a baby that is late preterm, between 34 and 36 weeks of gestation, even though he looks very similar to a term baby, those are not the same."

Brandon, suffering from a blood clot on his kidney, spent 67 days in the neonatal intensive care unit at Harper University Hospital. When Alaina took him home to her aunt's house on Jan. 2, he was plump and sassy.

"He's getting fat — he's 8 pounds, 11 ounces," Alaina said.

Her challenge will be to continue obtaining the social support and resources she needs to care for Brandon, and to maintain her own health.

"What we know in our neighborhoods is that we have a very high percentage of teenage moms," said Kristen McDonald, vice president of policy and programs with the Detroit-based Skillman Foundation, which has multiple projects aimed at improving safety and strengthening families in six Detroit neighborhoods.

"Many of them have had very little if no prenatal care and tend to be very, very isolated."

Doctor shortage

Exacerbating the situation: The city has a shortage of primary care physicians, and not all accept Medicaid. Pregnant women are challenged to find safe housing, healthy food and transportation.

Detroit's high concentration of African-Americans may also play a role in the city's infant mortality rate, because preterm births are more common in African-Americans for reasons not fully understood.

African-American babies also face greater risks of death in their first days of life, according to Romero.

"There is an ethnic disparity," Romero said. "If we look at the period from birth to 28 days, African-Americans have a mortality rate that's approximately double of Caucasians."

Resources available

Michigan is expanding by nearly 500,000 the number of state residents eligible for Medicaid. That expansion takes effect April 1 and could have significant impact on Detroit's infant mortality problem, said U-M's Dr. Davis. Gov. Rick Snyder also has made infant mortality a priority, and a state Infant Mortality Reduction Plan was developed in 2012.

According to Davis, women who are not pregnant or nursing are currently ineligible for Medicaid, and as a result, many low-income women enter pregnancy in poor health. Mothers are then kicked out of Medicaid coverage just weeks after delivering their babies, he said.

"They might not have had routine health care themselves, and may not be entering that pregnancy with optimal health or having appropriate care for health problems like high blood pressure or diabetes that place their babies at higher risk for health problems," Davis said. "The Healthy Michigan plan will likely provide coverage to many women and allow them to identify and get treatment for health problems before they get pregnant so they can get treatment and have healthier babies.

Foundations, agencies and hospitals are providing support through programs like St. John Hospital and Medical Center's Infant Mortality Program, which matches pregnant women and new mothers to mentors who provide them with emotional support and education, and connect them with community resources. The WIN program (Women-Inspired Neighborhood Network), funded by the WK Kellogg Foundation, has trained six health workers to provide similar support to 1,500 pregnant and new moms in Detroit's Brightmoor, Osborn, and Chadsey-Condon neighborhoods.

Meanwhile, researchers at the Detroit Medical Center have made groundbreaking discoveries into the causes of premature delivery and are providing some Detroit moms with treatments that are prolonging their pregnancies.

"We know that if we concentrate medical care on mothers and young babies (this) can have very dramatic impact on infant mortality rates, and so there are some really important pieces of work that are happening but they are not done at a big enough scale," said McDonald, of the Skillman Foundation.

"We truly need to be very intentional about ... making sure that there is outreach to mothers so that they are not isolated, that there are services wrapped about them and their new babies to make sure that we're very intentionally going after them. It's infuriating, because we know we can change the trajectory of these numbers."

Sunsearae 'Lo Lo' Hall, mother of Kenis Green Jr., holds her son's ashes. Kenis was 12 when he was shot and killed on his front porch.

Children are dying in Detroit at a greater rate than in any U.S. city its size or larger, a Detroit News study shows.

Mostly, they die of conditions resulting from prematurity — the top killer of Detroit kids — and violence, which ranks second.

"This is a public health emergency in the city of Detroit," said Dr. Herman Gray, executive vice president of pediatric health services for the Detroit Medical Center and former president of DMC Children's Hospital of Michigan. "We are losing our future in really socially unacceptable ways."

All told, Detroit kids through age 18 died at a rate of 120 per 100,000 children in 2010, the most recent year for which complete data is available. Detroit was the only city whose death rate among children topped 100 per 100,000; Philadelphia, at 95.7, was a distant second.

Over six months, The News gathered and analyzed thousands of bits of data from state health departments across the country to rank and compare, for the first time, death rates for children 18 and younger by the major cities in which they live.

Kids in Detroit face greater-than-average health risks from the moment they are conceived, The News found. More die of common childhood illnesses and environmentally linked conditions such as flu and asthma than elsewhere.

In 2010, Detroit (population about 713,000) and Cleveland (population about 390,000) had the highest infant mortality rates of Big City America: 13.5 deaths for every 1,000 live births — higher than in Panama, Romania and Botswana. The measure includes deaths from all causes in a child's first 12 months, but most are the result of premature birth, which carries with it a host of potentially deadly conditions.

Violence, the second-biggest killer of Detroit kids, claimed 32 young lives in 2010.

"This is not just a police or criminal justice problem," Gray said. "This is a public health problem (that requires) a coordinated response from the public health agencies, the organized health infrastructure, from the philanthropic community, the educational system.

"Virtually everything that touches our children and youth in some way has to play a role. It really has to be a community effort to address this crisis for our kids."

Kristen McDonald, vice president of program and policy at The Skillman Foundation, which focuses on improving the futures of Detroit children, said "If kids aren't safe, nothing else matters."

"The homicide is horrific, but we actually have to get to this comprehensive place where children are just plain safe, not only safe from homicide but where they're safe from any sort of attack or any violence when they're trying to get to school or after-school programs."

Kenis Green was among last year's statistics.

Any dreams 12-year-old Kenis may have had of graduation, first dates or senior prom died Aug. 31, when he was gunned down on his front porch as his mother watched helplessly.

Sunsearae "Lo Lo" Hall, her two younger children and an extended family of grandparents, aunts, uncles and cousins are still struggling to cope with the loss. And avoiding becoming direct victims of crime doesn't mean Detroit kids, such as Kenis' siblings, will escape its impact: Experts say children who grow up in Detroit face a future of health risks associated with living in an atmosphere of trauma and chronic stress.

"Every time I see a car ride down the street, I still get nervous. I don't feel safe anywhere," said Hall, who keeps Kenis' ashes on the dresser next to her bed.

The deteriorating city impedes its residents' access to healthy food, medical care, safe housing, police protection and transportation, creating a perfect storm of conditions that threatens its children, according to Columbia University professor Dr. Irwin Redlener, co-founder with singer Paul Simon of New York City-based Children's Health Fund, which partners with Detroit's Henry Ford Health System to provide mobile health clinics for Detroit Public schoolchildren.

'Betrayed by leadership'

"You take a bad economy, cutbacks of services, cutbacks in police presence, corruption at the highest levels of government, and you have the impact of all that being an increasing malaise among the population," Redlener said.

"Communities feel abandoned and betrayed by leadership; you add that to a bad economy and people worrying about how they're going to pay their rent, and then cutbacks in the social programs create a very demoralizing environment where one is not surprised that there has been increased violence and homicidal fatalities."

The rates of infant mortality and child homicide worsened in Detroit during the Great Recession, according to state health data.

When the recession hit, Detroit already was wracked by pervasive poverty. Many of its neighborhoods had long been food deserts, where families with spotty access to transportation must travel miles for fresh food.

They also have few primary care physicians, and fewer still who accept government-provided Medicaid insurance. Families lucky enough to find a doctor often postpone visits or delay picking up prescriptions due to a lack of transportation.

"You have large (medical centers) but not as many doctors' offices as in the past," said Dr. Elliott Attisha, who runs one of Henry Ford Health System's mobile health clinics for Detroit students. "Many of the kids we see might have an assigned physician on their insurance card, but don't have a relationship with that physician.

"Also, a lot of these kids qualify for insurance, but many are not getting their yearly checkups, are behind on immunization; many have asthma and are not getting treatment for their chronic conditions."

About 20,000 Detroit children have asthma, and most cases are uncontrolled, Attisha said. An average of five children have died each year of asthma over the past decade, state records show, including nine in 2006 and eight in 2007.

Reasons for hope

As grim as the statistics appear, efforts are under way to improve the outlook for Detroit kids. Detroit Police Chief James Craig is targeting crime "hot spots" identified by neighborhood watch groups. Hospitals and private foundations are providing health clinics in Detroit Public Schools.

Gov. Rick Snyder has made infant mortality a priority, and posts updates on the statewide rate on Michigan's website along with other health and wellness measures. Furthermore, groundbreaking local research is discovering new ways to help reduce infant mortality.

McDonald, of the Skillman Foundation, says focusing on prenatal care and safety can save lives.

"It's really important to highlight the really significant reasons for hope that have happened," McDonald said. "I don't want to miss that, because when we have that kind of momentum it's really important that we all talk about it. We can make this better."

Big city health risks for kids

  • In 2010, the most recent year for which data were available, Detroit:
  • Tied with Cleveland for the highest infantmortality rate in the nation: 13.5 per 1,000 live births
  • Had more births to unmarried women than any major city in the U.S.: 80 percent
  • Tied with Cleveland for most preterm births among major U.S. cities: 18 percent
  • Had more births to women under 20 than any of the nation's largest cities: 17 percent
  • Had the most teens 16-19 not in school or working: 18 percent
  • Had the most kids who live in a home where no parenthas full-time, year-round employment: 62 percent
  • Had the most kids living in a homewhere no adult works: 23 percent
  • Had the most children living in extreme poverty in the nation: 32 percent

Sources: Kids Count Data Bank, the Annie E. Casey Foundation

Nearly 500 Detroit children have died in homicides since 2000 — an average of nearly three dozen a year.

Most were gun-related, and most were among children 14-18. Many youngsters just got in the way of a bullet intended for an adult, or for no one in particular.

Names on the sad, memorial roll call are etched into the hearts of those who loved these children:

Mariah Smith, 5, whose burned body was found in an abandoned house in 2011, the alleged victim of her aunt's 22-year-old boyfriend; 9-month-old Delric Waymon Miller, who died as he slept last February, when gunmen armed with an AK-47 sprayed his home with bullets; Robert Mosby Jr., 14, shot four times by an adult in a dispute over a bike; and Jamel Witcher, 4, who was playing at his grandfather's house this month when his 4-year-old cousin found a loaded shotgun in a closet and the weapon went off.

A Detroit News probe into what's killing Detroit children ages 18 and younger pinpointed violence — including abusive caretakers and gun play between kids — as the No. 2 cause, behind infant mortality.

The findings came from a six-month News investigation, during which thousands of bits of data from state health departments across the country were gathered and analyzed. The News found that the death rate from all forms of violence in 2010, the most recent year for which comparable data are available on other communities, is higher in Detroit than in any other major U.S. city: 15.7 per 100,000 children.

The number of child homicides increased in Detroit during the Great Recession, peaking at 45 in 2009. And while the number fell somewhat after that, there's no evidence that the deadly violence will evaporate any time soon.

Mertilla Jones holds the shoes of granddaughter Aiyana Stanley-Jones at a candlelight vigil in 2010.

It's a bitter reality for parents like Lyvonne Cargill, 42, whose 17-year-old son, Southeastern High School senior Je'Rean "Blake" Noble, was shot to death May 14, 2010, when he stopped at a party store on his way home from school. By all accounts, Je'Rean was an innocent — a good kid who was a member of the ROTC, who dreamed of becoming a Marine and then going to college to become an engineer.

"I'm 100 percent hurt," Cargill said Thursday outside the courtroom where two men are standing trial this week in her son's death. "My life is gone. When his life was stolen, it stole my heart."

In a bizarre twist, the encounter outside the party store ended up in two dead youngsters. Seven-year-old Aiyana Stanley-Jones was fatally shot two days later, when police entered the little girl's home in search of suspects in Je'Rean's murder. Officer Joseph Weekley's trial on involuntary manslaughter charges ended in June with a mistrial; a pretrial hearing on his new trial is scheduled for next week.

Guns 'very common'

Activists working to curb crime in the city say kids like Je'Rean fall victim to a culture of violence that is out of control, though they see glimmers of hope that change is underway.

Lynda White, an attorney with the Michigan Children's Law Center and executive director of Detroit's Ark NonViolence Program, said many Detroiters feel they must arm themselves — but often that leads to more violence. Ark provides anger-management and conflict-resolution training to Detroit Public schoolchildren starting in second grade, in an attempt to equip them with skills to resolve conflicts peacefully.

"They may have a gun for protection, but if there's a conflict that arises, they use it in a completely inappropriate way," White said.

"If you have a gun ... it emboldens you, so that if you started out having it for protection and you become mad and someone else threatens you, then you use it. And that is a big problem with the culture."

Twelve-year-old Kenis Green Jr. was on his front porch during a birthday party for his uncle on Aug. 31 when a gunman in a burgundy car sprayed the house with bullets. His mother, Sunsearae "Lo Lo" Green, says the bullets were intended for Kenis' uncle.

Kenis, an eighth-grader, just got in the way.

Hall said it was the third time in as many days that a neighbor living across the street had pulled out a gun. Alvin Conway, 33, was allegedly upset with Hall's brother, Willie Hall, over a perceived slight. He was slated for trial earlier this month, but it was postponed to allow time for psychiatric reports. Asked why nobody called police the first two times a gun was pulled out, Hall said "it's very common" for people to show their guns when there's a confrontation. "I see it all the time."

"A lot of people feel like 'They have one, so I might as well get one,' 'If that's the way they're gonna solve their problems then that's how I should solve it' — that's how people look at it," she said.

"They don't think like, 'Well, we can talk, or just leave it alone.' They think that they should use a gun to solve their problems."

Hall counts five family members who have been shot to death in Detroit in three years. About two weeks after Kenis' death, one of Hall's cousins, Robert Barnes, 44, was found shot to death on a Detroit street.

Children armed

Gun violence is so pervasive that some parents give guns to their children, White said.

"I work in the Wayne County Juvenile Court, and these children are obtaining guns from adults," White said. "They're obtaining guns illegally from people who are supposed to be responsible and people who are supposed to protect them. And if that person who has a huge influence in your life is giving you a gun, some of them tend to think it's OK to carry it. And they're being told, 'You need this for your protection, you live in Detroit.' "

White said nonprofits, churches, neighborhood organizations and school groups work with the Detroit Police Department to end violence in the city, but their efforts lack "cohesiveness."

"If we're not all working together, then nobody is, and these kids are falling through the loophole and they become adults who have no resources, no skills, no employment, and they do what they think they need to do to survive."

Family seeks healing

Before Je'Rean was killed, Cargill had a job at Target. She's given that up to cope with the emotional aftereffects on herself and her family.

She wanted to go to college to become a nurse, and was about to take a certified nurse assistant course so she could earn a good wage while working toward her nursing degree. Those plans were derailed.

Both families have sought counseling. Cargill and her 14-year-old son, Jamall — who was just 10 when his big brother was slain — have seen therapists, and both take medication to help them sleep at night.

Hall and her three remaining children moved in with Hall's mother, Chandra Holloway. Every week, Holloway takes DeChan, Jasmine, Kailyn and her other grandchildren to Open Arms, a support group for grieving children and families run by the St. John Providence Health System. Hall receives one-on-one therapy.

"The kids, they really like to go together," Hall says of the grief support group. "My mom has 17 grandchildren, so we took all of them."

Darnella Miller takes three buses and a taxi to get from her house on Detroit's west side to parenting classes on the east side. She goes every Wednesday, traveling hours each way, because she wants to get her children back.

Miller has made some mistakes, and she's suffered some misfortunes. And now she's trying to put her life together to make a better home for the baby who's on the way, and three children she's lost to foster care.

"I used to hang out with the wrong crowd. But as I've gotten older, the same people I was hanging around with, they're not willing to change. And I can't make them change, I can't force them, so if they want to continue smoking their lives away, drinking their lives away, that's on them," said Miller, 24, who's in school and works full time at a Taco Bell. "But I'm trying to get a better life. Not just for me, but for my children."

Paris Rutledge is Miller's mentor. A social worker assigned through St. John Providence Health System's Infant Mortality Program, Rutledge visits Miller regularly, connects her with necessities such as transportation, educates her on basics such as nutrition, and gives her emotional support. The program also provides the parenting classes Miller attends, and prenatal support groups.

During one home visit, the conversation included car safety seats, fire evacuation plans and breast feeding, plus Miller's need to find a primary care physician and a pediatrician before her daughter, to be named Miracle, is born in April. A nurse also visits.

"As your baby gets older, we will be doing screenings to be sure that your baby is developing appropriately," Rutledge told Miller. "We'll be doing screening every two months, and if you want, we'll provide you with a copy of the score sheet that lets you know how your baby is doing."

Rutledge, 53, has been working with women for 25 years. She began as a volunteer when Catholic nuns started the program.

A mother of three and a grandmother, Rutledge knows what's involved in raising a child. A good part of her visit with Miller focuses on the importance of social support.

"I've never met anybody that doesn't need somebody at some point," Rutledge told Miller. "It's not easy raising children, having children, and you do need support. You know, it has nothing to do with your love for your children, but everybody needs a break."

Since 1986, the Infant Mortality program has had more than 1,600 babies born and only five infant deaths with no maternal deaths, according to Karen Gray-Sheffield, director of community health for St. John Providence. The majority of participants are African-American women between 16 and 27 years old, and 98 percent are single mothers living at or below the poverty line.Many have poor nutrition, sought prenatal care late and have no one to support them. They often lack a regular and nearby physician. Some have a history of domestic violence or homelessness, or chronic diseases such as diabetes or high blood pressure.

Programs that provide one-on-one support to moms have been shown effective in reducing health risks to infants. The WIN program (Women-Inspired Neighborhood Network), funded by the WK Kellogg Foundation, has trained six health care workers to provide support for women in Detroit's Brightmoor, Osborn, and Chadsey-Condon neighborhoods. Of the first 155 babies born to program participants, there have been no infant deaths.

Miller, whose first child was born when she was 19, has been through this program before. She says she was prepared to care for her children, but they were taken away because she failed to protect them from their fathers — a mistake she vows not to repeat.

Her first two babies, a boy and a girl who will be 5 in February, were taken away by Child Protective Services after their father placed his boot atop the head of Miller's daughter during an argument and threatened to crush her. The father was sentenced to nine to 20 years for assault and kidnapping, and will be eligible for parole in 2019.

"Fortunately, CPS had stepped in and they took my children away ... cause at that time he had a gun, he had a knife, and I was fearing for my life and my children's lives and I was so scared of him I (didn't) know what to do," Miller recalled.

She met her third child's father two years later, and gave birth to a son. Again, an argument turned violent.

"And of course ... when the police found out I had an open CPS case they end up taking the third baby," Miller said.

In Detroit, nearly 14 percent of children live in families that have been referred to Child Protective Services for investigation of possible abuse or neglect. That compares with 9 percent of children statewide, according to state data provided by Kids Count in Michigan, part of a national project of the Annie E. Casey Foundation to track the well-being of children in the U.S.

Rutledge said a good number of the moms she mentors are working through personal issues that have affected their ability to care for their children. She speaks with Miller in a soft, reassuring voice, and takes her time.

"My goal is to try to restore the mom's faith in herself, the mom's ability to love herself," Rutledge said. "A lot of times ... we want to be loved, we want somebody, we want companionship, and I think sometimes we sacrifice a lot to have those relationships.

"A lot of our moms are from single-parent homes, don't have relationships with their fathers ... and a lot of times people unfortunately prey on other people. So my goal is, No. 1, to have a healthy baby, and Mom has to feel good about herself to be there for her children who need her."

Said Miller: "I have more confidence in myself to raise my children. I just want to raise my children by myself."

What's killing Detroit's kids

Here's the breakdown from 2010:
Infant mortality:

All causes: 146
Children over age 1

Heart disease: 3
Unintentional injuries: 25
Homicide: 29 (including three infants)
Congenital anomalies: 8
Cancer: 3
Asthma: 4
Car accidents: 14
Drowning: 3
Fires: 4
Poisoning: 1
Fall: 1
Pneumonia or influenza: 2
Accidental firearm: 1
Birth defects: 8
Unspecified other causes: 18
Source: Michigan Department of Community Health

Some Detroit parents struggle to understand doctors' instructions, read prescription labels or measure the correct dosage of medication for their children, because an estimated 47 percent of adults are functionally illiterate.

It's impossible to say how much of a health risk illiteracy poses for Detroit children. Though studies have linked illiteracy to infant mortality in Third World countries, few such studies have been undertaken in the United States, where people are expected to be able to read and write.

Those working with Detroit parents say poor reading skills make it harder for parents to raise healthy kids, support families or prepare children with skills needed to enter school ready to learn.

"It's all part of the same story of the uphill battle that Detroit families have to climb," said Kristen McDonald, vice president of program and policy with The Skillman Foundation. "Parents who have low literacy levels are struggling to find work, and their low literacy levels make it more difficult for them to connect to critical systems like health care and human services.

"Imagine being a 17-year-old mom with a new baby without being able to read a pamphlet on safe sleep or the literature from Le Leche League about breast feeding. (Literacy and health) are absolutely connected."

Wayne State University professor Daphne Ntiri, who is director of the WSU Literacy Outreach project and the Detroit Literacy Coalition, published a scholarly article on health illiteracy and the need for nurses and other medical professionals to be aware that not all of their patients can read.

According to Ntiri, research has shown that patients with poor literacy skills often wait until they are very sick before seeking medical care, are less likely to participate in health promotion or disease prevention activities and have little knowledge of their health conditions or illnesses.

"This behavior contributes to increased health care costs," Ntiri said, adding that such patients often have trouble managing conditions like diabetes.

"Illiteracy impacts everything," said Karen Gray-Sheffield, director of St. John Providence Community Health. "People who have low literacy skills are going to be hindered in employability and receiving information, whether it's from a doctor or someone else."

St. John Providence writes materials for its Infant Mortality Program and other services, such as prenatal classes and parenting classes, at a fourth- to sixth-grade reading level. It also screens clients for illiteracy, and refers moms to literacy classes or GED programs.

"The problem we have encountered is that individuals will come to us thinking they can complete their GED within a few months, but they may still be at a seventh-grade level as far as the assessment," Sheffield said.

"We know that if we're going to really change the cycle of poverty education is extremely important, because people who have not gained the education necessary to complete job applications and function in a way to get good jobs are going to remain in poverty, and do not have the skill sets to educate their children."

Jala Jackson is always looking over her shoulder — even more since her father, Marcel Jackson, was fatally shot while on duty as a security officer on June 20, 2012.

Safety officers at Renaissance High School tell the 16-year-old and other students to walk in groups because there are so many robberies in the neighborhood. When she got her driver's license, Jala's mother warned her to keep an eye on her side mirror at red lights, in case a carjacker creeps up.

"We have this neighborhood park and sometimes I go there with my friends," Jala said. "We usually play around, but there's a lot of bad people on the block. You just never know if something bad happens there."

Living in unsafe or poor neighborhoods can be stressful for children — stress that for some children is compounded by trauma. A growing body of research shows kids who grow up under constant stress face future health risks, including higher rates of obesity, heart disease, high blood pressure and diabetes.

Many families in Detroit must cope with the slaying of a family member. Marcel Jackson was killed while working as a security guard, leaving behind, from left, Tarik, 13; wife Hollie holding Aaliyah, 2; Jala, 16; Najidah, 18; Tamia, 13; and Gwendolyn, 7.

Hollie Jackson, 40, takes her six children to the family grieving program at Greater Grace Temple. On Monday nights, Jala; her sister Najidah, 18; twins Tamia and Tarik, 13; and Gwendolyn, 7, participate in group activities and can speak to counselors and other kids who have lost a loved one. Baby Aaliyah, 2, colors and sings.

Najidah also participated in Open Arms, a program run by St. John Providence Health System that provides group grief support and counseling for children in Detroit Public Schools. Open Arms runs a group for families once a week at Connor Creek Community Center, and one night Najidah brought her whole family.

"Each night, I dream about my dad," Gwendolyn said. "It seems like I'm in heaven, and I say, 'Where am I?' And then an angel appears and says, 'You're in heaven.' And then I said, 'How'd I get in heaven?' And he said 'Jesus took you here.' "

Aaliyah Jackson hugs her sister, Gwendolyn, who wears a T-shirt in memory of their father, Marcel, who was shot and killed in 2012.

Hollie was a homemaker and Marcel, 38, supplemented income from his full-time job as a security guard at Walgreens by working security for Detroit nightclubs. Marcel Jackson was a key member of the crime-fighting Detroit 300 community group. He was gunned down outside Pandemonium Night Club, allegedly by a patron who was angry about being ejected.

"Moving out of Detroit was one of our goals. We seen how crime was really getting bad, and we said 'It's time to go,' " Hollie said. "It just didn't happen fast enough. Right now, I just kind of feel stuck with him not being here. I have to start over again."

Dr. Charles Nelson, professor of pediatrics and neuroscience at Harvard Medical School and an expert on the effects of toxic stress on children, said exposure to early adversity can lead to long-term impacts on their brain and biological development, and their health. The earlier such adversity is removed from a child's life, the greater the likelihood of recovery.

"(The effect) depends on things like the age of the child, the resources available to the family, if it's a single event or sort of a constellation of chronic stress," Nelson said. "The more stressful experiences you have growing up, the worse the outcome. So it's not any single bad thing, it's the accumulation of multiple bad things.

"Take a child born two months prematurely into a single-parent household that doesn't have a lot of resources. Mom might have a substance abuse problem, then there's neighborhood violence. All those things sort of conspire to pull the rug out from underneath the kids."

A growing body of research has shown that stress can become so toxic that it affects even the body's cells. Cells contain chromosomes, twisted threads that embed all genetic information. Tacked onto the end of each chromosome is a repetitive sequence of DNA called a telomere, which gets shorter each time a cell replicates.

Studies have linked chronic stress with the shortening of telomeres. And, in turn, shortened telomeres are associated with the onset of heart disease, diabetes, stroke and other age-related diseases.

Racial disparity also may be a factor. A University of Maryland study released this month found that African-American men who reported experiencing racism, and who had the strongest bias toward their own racial group, had telomeres that were biologically 1.4 to 2.8 years older than those of black men who reported the lowest levels of discrimination and least racial bias.

According to Nelson, kids who grow up with chronic stress are more prone to depression and anxiety, and have increased risk of Post Traumatic Stress Disorder. Severe stress and trauma also can harm learningand memory.

Nelson said early intervention is the key to minimizing the long-term impacts of chronic stress or trauma on children's health. One example of an effective program, he said, is the Nurse Family Partnership. Nurses meet regularly with new moms to offer advice and support. Parenting education and programs that provide cash assistance to families with young children are also known to reduce the negative impacts of stress on children, Nelson said.

Najidah participated with other kids in an Open Arms grieving support group held during the school day at Old Redford Preparatory High School, the Detroit charter school she attends.

"We help (children) to communicate in ways that they can't verbalize," said Karen Gray-Sheffield, director of St. John Providence Community Health. "Through activities, play therapy, we can help them learn more about their feelings, remember their loved ones in a positive way.

"Younger children don't always understand the permanence of death, so they feel the person is going to come back. We can't help them cognitively grow up too fast, but we can explain the cycle of life, how trees and leaves die, things that might not be totally connected to the human aspect of it. Flowers grow, flowers also die."

Nearly one-third of all pregnancies in the city of Detroit end in abortion, a statistic public health officials blame on rising poverty and dwindling access to affordable contraception.

Of an estimated 18,360 pregnancies among Detroit residents in 2012, the most recent year for which data are available, 5,693 ended in abortion, or 31 percent.

During that same year, an estimated 160,219 pregnancies were reported in Michigan, with 22,699 abortions.

That translates into a Detroit abortion rate — the number of abortions by population, including women who weren't pregnant that year — of 37.9 per 1,000 women aged 15-44. That's up from 27.5 per 1,000 women in 2001.

It's a staggering three times greater than Michigan's statewide rate, which declined from 12.6 abortions per 1,000 women during child-bearing years, to 11 per 1,000, over the same period.

While the abortion rate has been climbing in Detroit, it's been declining in Michigan and across the U.S. "We're seeing a picture that looks more like some Third-World country than someplace in the United States," said Dr. Susan Schooley, chairwoman of the Department of Family Medicine at Henry Ford Hospital.

National studies show a direct correlation between abortion and poverty. Legal abortion is considered a medically safe procedure with few complications. But problems that often underlie abortion, such as poverty and poor access to health care, are public health issues that need to be addressed if the rate is to be reduced, experts said.

Funding for family planning and contraceptives has decreased significantly in Michigan in recent years, from more than $5 million in 2006 to $692,300 in 2013, according to the state Department of Community Health. The number of clients receiving free family-planning assistance decreased by about 80,000 between 2006 and 2013.

"Both routine primary care and family planning-specific primary care are not available in Detroit," Schooley said. "To the extent that a significant proportion of those (pregnancies) are unplanned, it leads to all these decision-making options of which abortion is one lousy choice."

It's another public health challenge for Detroit, which is the most dangerous city in America to be a child, according to a Detroit News study. Published in January, the study found that the death rate for children 18 and younger is higher in Detroit than in any U.S. city its size or larger. The highest number of deaths occur in the first year, most related to premature birth. Homicide is the second greatest cause of child deaths in the city.

"It made me sad," said Penelope Allen, now 21, of an abortion she underwent at age 15. "I was still in school and I had to do what I had to do. I was a kid. People make mistakes."

A foster child since the age of 4, Allen ran away from a group home at 15, and became pregnant. She returned to foster care until aging out of the system at 19. She now has a daughter, Patience, who's almost 2.

"I'm doing better — I have a car, I have a job," Allen said of her life today. "My daughter, it was her, she helped me get my life on track."

The U.S. abortion rate in 2011, the latest year for which national data is available, was 17 per 1,000 women. That's the lowest since the U.S. Supreme Court made abortion legal in all 50 states through it's 1976 Roe Vs. Wade decision, according to a February study by the Washington, D.C.-based Guttmacher Institute, a pro-choice think tank.

Health professionals expect the Affordable Care Act to reduce abortions by providing greater access to birth control for low-income women, either through expanded Medicaid or low-cost health insurance.

Dr. Jay Berman, chief of gynecology at DMC Hutzel Hospital and division chief for gynecology at Wayne State University Medical School, said health reform will reduce cost barriers that have kept women, including many who have health insurance, from using long-acting reversible contraceptives — such as injections, intra-uterine devices (IUDs) and subdermal implants. These kinds ofcontraceptives, however, can be the most expensive option.

"Ultimately the (Affordable Care Act) is going to have an impact on the abortion rates," Berman said. "We're also promoting long-term reversible contraception, the implants in the woman's arm, shots and IUDs, which are very suitable for a lot of these patients. There are three, five and 10-year IUDs that are available."

Berman noted that legal abortion is a safe procedure. He said the general consensus among physicians is that abortions — even multiple abortions — do not lead to premature birth or other complications with future pregnancies.

"We certainly would like to reduce that number," Berman said. "There's physical stress, but there is psychological stress as well. (Unplanned pregnancy) has an effect on plans for education, for work. Women don't take these choices very lightly. It certainly has an emotional and psychological (effect)."

Abortion rate peaked in '08

It's impossible to compare Detroit's abortion rate to that of other cities, because mandatory reporting of abortions is not required in all states, as it is in Michigan. But abortion rates tend to be higher in poor urban centers such as Detroit, experts said. The city's abortion rate peaked in 2008, coinciding with the worst year of the recession and increasing cutbacks in social safety net programs. Infant mortality and child homicides peaked the same year, according to a Detroit News study.

"We do have an association nationally with higher rates of abortion among low-income women; the rate drops off as women have higher incomes," said Marianne Udow-Phillips, director of the University of Michigan's Center for Healthcare Research and Transformation.

Udow-Phillips noted a 2008 study by the Guttmacher Institute, in which researchers found that 42 percent of 9,493 women who had abortions had incomes at 100 percent of the federal poverty level or below. In Detroit, 42 percent of women have incomes below the poverty line, compared with 17.3 percent statewide.

"Why are abortions not reducing in Detroit when they are statewide? It could be evidence that women aren't getting contraception when they need it," said Udow-Phillips when asked if the high number of abortions in Detroit is a concern.

Loretta Davis, president and CEO of Detroit's Institute for Population Health, which administers health services for the city of Detroit including family planning programs, said the increasing abortion rate represents a "public health failure."

"Somehow, we need to be able to get to these women and girls and reach them in such a way that they are able to make a healthy decision around their sexuality and choose a method of birth control that will work for them," Davis said.

Abortion debate continues

The debate over abortion and contraception has become so contentious that several individuals and institutions declined to comment for this story. Among them were Michigan State University and the University of Michigan, which both have medical schools. The state Department of Community Health declined to comment on the issue, as did Detroit's Department of Health and Wellness Promotion.

Daniela Scholl, spokeswoman for St. John Providence Health System, sent a statement saying "St. John Providence Health System operates in accordance with the Ethical and Religious Directives for Catholic Health Care Services and therefore does not promote or condone contraceptive practices."

Bill Albert, chief program officer for the non-partisan National Campaign to Prevent Teen and Unplanned Pregnancy, said the tenor of conversation has changed since 1970, when the Title X Family Planning program was signed into law by President Richard Nixon.

"What has been striking has been the ... conflation of contraception with abortion," Albert said. "State and national policy makers, some of them, use these words interchangeably."

According to Albert, some of the most successful public campaigns to reduce unplanned pregnancies combine messages about abstinence with education on contraception.

Detroit Public Schools spokeswoman Jennifer Mrozowski said the district has an abstinence-based sexuality curriculum that is "age, sequentially and developmentally appropriate for all students grades K-12 including special education."

But Davis, of the Institute for Population Health, said sex-education can't be left to schools. She called for a cool-headed community discussion of the issues surrounding contraception and abortion.

"We really have to come together as a community and look at it from the science of it all," Davis said. "We need highly effective and safe birth control for these people who are not ready to become parents."

Michigan abortions

In 2012, the most recent year for data from the Michigan Department of Community Health:

86.3 percent of abortions were at 12 weeks gestation or fewer

13.5 percent of the women were younger than 20; the greatest proportion, 35.8 percent, were aged 20-24

89.4 percent of women who had abortions were unmarried

58 percent had at least one child already

25.3 percent had one or more previous abortions

Self-pay was the source of payment for 95.4 percent of abortions reported

Source: Michigan Department of Community Health

Detroit women are dying from pregnancy-related causes at a rate three times greater than for the nation.

Experts blame the same combination of medical conditions and social toxins that kills Detroit babies at a frequency that is the worst of America’s big cities, and even some Third World countries.

Data from the state Department of Community Health show at least six Detroit moms died yearly, on average, as a direct result of pregnancy or childbirth from 2008-11 — a total of 26 maternal deaths in that period. That translates to a maternal death rate of 58.7 per 100,000 babies — higher than in Libya, Uruguay or Vietnam.

While it’s widely assumed that death in pregnancy or childbirth is an anachronism in a highly developed country, the national and local rates are actually creeping upward.

Americans “don’t think women are dying (from pregnancy) in the U.S., let alone that the rate is going up,” said Dr. Priya Agrawal, executive director of Merck for Mothers, a 10-year, $500 million initiative launched by drug-maker Merck in the United States in 2011 to reduce maternal mortality.

“It’s always surprising to me that we focus on the infant and forget about the mother.”

Experts attribute increased maternal death rates to uncontrolled chronic health conditions, which are more common in African-Americans, and to poverty that deprives low-income women of health insurance and access to health care. Detroit fits squarely within those perimeters: 83 percent of residents are black, and Detroit has more people living under the poverty line — 42 percent — than any major city in America,according to an analysis of U.S. Census data by the Annie E. Casey Foundation.

“Clearly, this is one of those examples where there is a glaring health care disparity,” said Dr. Gregory L. Goyert, division head for maternal fetal medicine at Henry Ford Health System.

“... it always comes down to African-American women having a three to four times greater risk of maternal mortality than Caucasian women. When you have a population with large numbers of African-American women, you are going to have a higher rate of maternal mortality.”

Health conditions that factor into maternal deaths include obesity, diabetes and high blood pressure. Untreated, they can lead to excessive bleeding, blood clots, strokes and other deadly complications.

These ailments also can result in preterm delivery — the No. 1 killer of babies in Detroit, which has the highest infant mortality rate among major U.S. cities, according to a special report published by The Detroit News in January. The News also disclosed that children 18 and younger die at a higher rate in Detroit than elsewhere in the U.S. — most often the victims of illnesses and conditions of infancy, and secondly by violence.

“(The maternal death data) speaks to the need for people to be healthy before conception,” said Wayne State University Associate Dean Dr. Sonia Hassan, a leading researcher on preterm delivery.

Noted Vernice Anthony, director of Detroit’s Department of Health and Wellness Promotion: “The risk factors that can impact preterm birth (are the) same risk factors that can increase the risk for maternal death.”

Health act may impact rates

Health care professionals are hopeful that maternal and infant death rates will decline as more women gain health care options through the federal Affordable Care Act or expanded Medicaid, and become more educated about their bodies.

Kanitra Patterson, 27, almost became a statistic, but is learning from her first pregnancy to take better care of herself. She developed pregnancy-induced cardiomyopathy — weakening of the heart muscle — about 24 hours before the birth of her son, Robert, six years ago. Patterson was admitted to DMC Hutzel Women’s Hospital for dangerously high blood pressure when suddenly, she couldn’t breathe. Doctors placed Patterson on oxygen and induced labor, and she and her baby survived.

Patterson is again at risk of the potentially fatal heart condition, now that she’s pregnant with her second child, daughter Kahlia, due Aug. 7. Patterson is watching her diet more carefully this time to control her blood pressure.

“It’s prayer, and I’m laying off the salt,” Patterson said. “When I was pregnant with my son, I was hard-headed. I learned my lesson and listened.

“I went (for prenatal care) a little earlier. And I’m up to the doctor’s office every two weeks since I was five months pregnant.”

Cheryl Larry-Osman,a labor and delivery nurse with Detroit’s Henry Ford Health System, said she once had two laboring patients nearly die in a single day. She recently testified at a congressional briefing in support of the proposed Maternal Health and Accountability Act, which would provide federal funding to assist states in preventing pregnancy-related deaths and reducing racial disparities in maternal health care.

One of the patients, an African-American woman in her mid-30s, stopped breathing in the recovery room.

“She didn’t look OK, her eyes were open … but not really focusing. She didn’t have a pulse so we started CPR on her,” the nurse recalled.

“She survived, the baby survived, but it could have gone easily in another direction.”

Deaths on rise nationally

Statistics paint a sobering picture for the nation, state and city.

The national rate increased from 7.2 pregnancy-related deaths per 100,000 live births in 1987 — the first year the Centers for Disease Control and Prevention analyzed data — to 17.8 in 2009, the most recent year for which CDC data are available.

In a worldwide study of maternal mortality, published in May in the medical journal The Lancet, the U.S. maternal mortality rate ranked 60th in the world, among 188 countries; Iceland had the lowest death rate.

While statistics are incomplete, the frequency of maternal deaths within the U.S. states varies widely.

Michigan ranks eighth highest in all maternal deaths, largely due to the high number of deaths in a few regions, including Detroit and Genesee County, which like the Motor City is a black-majority community with stubborn poverty. Among African-American women in that category, Michigan ranks fourth worst.

The District of Columbia has the highest rate in the nation, and Massachusetts has the lowest. Other states with higher rates than Michigan are Idaho, Arkansas, Oklahoma, Wyoming, Mississippi and Montana.

Officials admit that reliable statistics by which maternal death rates can be compared among cities and states are difficult to come by, because there are no national reporting standards.

Michigan is among 41 states with a question or checkbox on death certificates related to pregnancy status. As states add such a checkbox, their maternal mortality rates increase due to better reporting.

There also is no uniform reporting requirement among Michigan’s 83 counties. To circumvent that lack of data, the Michigan Maternal Mortality Surveillance System — a collaboration of the state health department, Michigan State Medical Society and medical schools — matches death records of women with birth records, and reviews deaths of women who died while pregnant or within one year of termination of pregnancy, irrespective of cause.

Six-year-old Micheal Washington has asthma, like more than 20,000 other Detroit kids.

His family lives in a brick bungalow built in 1924. As in many older houses, it's prone to mold, dust and other allergens that can make him wheezy and short of breath.

A Detroit News analysis of Michigan Department of Community Health data found an average of five children die annually of asthma in the city, including nine in 2006 and eight in 2007.

But promising projects are underway to combat childhood asthma in Detroit, such as home visits by asthma educators like Elizabeth Milton, who teaches preventive measures to Micheal's mom, Cassandra Debrowsky, while providing the moral support often needed by parents who care for kids with chronic diseases.

"I'm trying to get her past the fear that her child could die," Milton said. "Every hospitalization for asthma is preventable."

The 2014 Asthma Capitals study by the Asthma and Allergy Foundation of America ranked Detroit the 10th worst city in the nation for asthma sufferers, both children and adults. The study looked at 100 cities and graded them on 13 asthma risk factors, including air pollution, poverty rates and visits to emergency departments.

"No child should die from asthma, unless it's the very rare child who has really severe asthma," said Dr. Herman Gray, vice president for children's health services at the Detroit Medical Center.

"It boils down to accessing the appropriate level of care and using it as you should, both in terms of making your home as safe as you can and meeting with your pediatrician."

Most Detroit children with asthma receive little or no treatment, according to Dr. Elliott Attisha, who runs a mobile health clinic that cares for children at schools in Detroit. Asthma, an inflammation of the small and large airways that transport oxygen to the lungs, causes tightening of the chest, coughing, wheezing and shortness of breath, and can kill — a risk that increases when proper medication isn't available or used.

Twelve-year-old Samuel Maldonato saw Attisha for a checkup during one of the mobile clinic's recent weekly visits to Dixon Elementary School.

"Today I was in gym playing basketball, and all of a sudden I couldn't breathe well," Samuel said.

"I was breathing like heee-aaa, heee-aaa," he said, demonstrating how hard it was to draw air into his lungs.

Like many kids Attisha sees, Samuel has some medication for his asthma, but not the complete list of medicines required to keep his asthma under control.

Rise nationwide in asthma

"For many of these kids, they're not getting adequately managed because transportation is an issue," Attisha said inside the 38-foot motor home. It's retrofitted as a full pediatric office on wheels, with a laboratory, refrigerator, exam rooms and an office. It stops at Cody High School and Thirkell Elementary-Middle School on other weekdays during the school year.

"(Samuel) doesn't have his day controller and he's out of his Albuterol — that's the rescue medication," Attisha said. "He was never given a controller because he hasn't been in to see his doctor."

In the past decade, there has been an increase in Michigan and nationwide of children having asthma sometime in their lifetime, according to the Centers for Disease Control and Prevention. The proportion of asthmatic children nationwide has slowly risen during the last 10 years of data available, while the percentage of Michigan children has spiked upward in bursts during the same period.

Asthma is triggered by pet dander, dust mites, cockroach feces, car exhaust and other pollutants. Stress and genetics also may play a role.

Asthma is more common in urban areas, where there's often more air pollution, and where families often live in older homes filled with allergens like mold and dust mites.

Detroit's asthma problem is exacerbated by extreme poverty, difficulty in using public transportation to visit doctors and a shortage of primary care physicians. Poverty is a known risk factor for the disease, and Detroit has the lowest median family income among 50 cities ranked in the Annie E. Casey Foundation's annual Kids Count report — $19,800 a year compared with the national average of $60,700.

School nurses keep watch

Two mobile health clinics, including Attisha's, are among projects underway to improve the health of Detroit kids. The clinics are part of the Children's Health Project of Detroit, a partnership between Henry Ford Health System and the New York City-based Children's Health Fund. Molina Healthcare and the Michigan Department of Community Health also contribute. A second unit was added last year with help from the W.K. Kellogg Foundation.

Three Henry Ford Health System nurses work in Detroit Public Schools with funding from the Michigan Department of Community Health. They are Attisha's eyes and ears inside the schools, monitoring how kids are doing and sending them to the clinic if needed.

St. John Providence Health System runs nine school-based clinics in Detroit Public Schools, each staffed by a nurse, a medical assistant and a mental health professional.

On a recent Tuesday, 11-year-old Sommer Jenkins stopped by Attisha's clinic to pick up a bag of three medications she needs to control her asthma. The bag contained an instruction sheet showing photos of her medications alongside suns, moons, smiley faces and frowny faces — to indicate if the medicine should be taken in the morning or at night, when she's feeling good or not so well.

"I have to take two inhalers and my nose spray," the Dixon sixth-grader said.

Milton, the asthma educator, visits families in their homes, where she teaches parents how to eliminate asthma triggers and manage their child's disease. She is a certified asthma educator with Better Life Learning, a Detroit-based financial and health services organization that provides case management services for people on Medicaid health care program for low-income earners.

Debrowsky said learning about the disease, including when and how little Micheal should use his rescue inhaler, has helped her feel confident in caring for her son.

"(Milton) tells me if anything happens I am prepared, I have the inhaler," she said. "I wish they would have started (Milton's home visits) a little sooner. They should start it as soon as somebody is diagnosed." 
This story is part of a collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. The “Surviving through 18 in Detroit” series was made possible through the National Health Journalism Fellowship, a program of the University of Southern California’s Annenberg School of Journalism.