The specific biology of such mechanisms is still poorly understood, but sketches are being drawn, based mostly on animal research into neurochemical changes induced by fear and anxiety. One line of investigation has focused on cortisol, a steroid hormone that is elevated by danger or stress. It is one of multiple “chemical messengers” that affect brain function through receptors in nerve cells and elsewhere. Cortisol “helps to break down protein stores, liberating energy for use by the body,” Neurons explains, “suppresses the immune system, suppresses physical growth … and affects many aspects of brain functioning, including emotions and memory.”
There is some evidence that after extreme stress—or its chemical equivalent—cortisol remains high even when stress is removed. Monkeys and rodents that were flooded with prolonged doses of cortisol became more sensitive to stress and showed increased signs of fear and anxiety, which did not fully abate even when the threat was removed. Neglect soon after birth heightened their stress reactions. Nurturing, by contrast, dampened the anxiety and “shaped” their fear-stress system so in adulthood, the anxiety turned off quickly once the threat disappeared.12
One of the few studies done on humans found that “in a population of extremely deprived children in a Romanian orphanage, cortisol levels failed to turn off after a mild stress and were highly correlated with the children’s poor mental and motor performance and poor physical growth.”13Other research has shown that human infants in distress do not display greatly elevated stress hormones in the company of warm, responsive care-givers. “In contrast, insecure attachment relationships are associated with higher cortisol levels in potentially threatening situations.”14 This may be a biological component of the behavior seen among parents who suffered trauma, and who cannot modulate their reactions to stress.
Even without the biological mapping, the negative impact of stress on cognitive functioning has long been known. According to a summary of studies in the 1980s, “Children from highly stressed environments are at increased risk for a variety of developmental and behavioral problems, including poorer performance on developmental tests at eight months, lower IQ scores and impaired language development at four years.” Class is a factor: At school age, children from highly stressed families of low socio-economic status display “poorer emotional adjustment and increased school problems” than those from upper-income families who are also highly stressed.15
Causal connections are hard to trace, and IQ has been seen as more cause than effect by some researchers, most notably Richard J. Herrnstein and Charles Murray, whose 1994 volume, The Bell Curve: Intelligence and Class Structure in American Life, argues that intelligence is overwhelmingly inherited. In their view, people with lower IQs naturally do less well in life, gravitate to lower socio-economic levels, and tend to have lower-IQ chil-dren who repeat the pattern. Other researchers have found that twins raised apart, in different socio-economic settings, display similar abilities and personalities. But those studies have not been refined enough to document changes in families’ circumstances over time, or to pinpoint the family situations during critical periods of early childhood development, when the twins may have shared key experiences—as infants in the same household, for example, to be separated only at a later age.
The contrary view sees synergy between “nature and nurture,” the genetic and the environmental. It emphasizes the strong interplay between poverty, with all its disabling factors, and cognitive impairment. Whatever measure of intelligence is inherited—and a great deal is, no doubt—the genetic predispositions are believed to interact with an individual’s experience to enhance or diminish not only his biological health but also his intellectual success.
Such a dynamic has been observed in adopted children, many of whose IQs end up closer to those of their adoptive parents than to those of their biological parents. According to a 1999 study, children with low IQs of 60 to 86 before they were adopted at ages four to six increased their IQs dramatically. Most significantly, the increases varied with the socio-economic status (SES) of the adoptive families, as indicated by the father’s occupation. By ages eleven to eighteen, the children adopted by the highest-SES parents saw the largest growth in IQ, to a mean just under 100; those adopted by middle-SES parents had the next largest gain, to 93; and those who went into low-SES families had the least increase, to 85.16
In this analysis, biological disease becomes a model and a metaphor for intellectual and behavioral difficulty: Just as a complex of vulnerabilities contributes to the contraction of physical illness, so can poverty lead to cognitive and emotional deficits. Just as biological weaknesses inhibit recovery, so can socio-economic handicaps impede childhood development. In the last twenty years or so, the biological and the environmental, once viewed as parts of a dichotomy, have come to be seen as parts of a whole, as a complex array of “risk factors and protective factors” that include not only infections, nutrients, and chromosomes but also love, nurturing, and emotional safety. “Children who live in poverty,” Dr. Shonkoff said, “are particularly susceptible to the cumulative burdens of social stress and the greater biologic vulnerability related to a higher prevalence of such risk factors as perinatal complications and nutritional deficiencies.”
The risk and protective factors exist in both the child and the environment. “Within a child a risk factor could be some kind of chronic illness, an underlying brain problem, some kind of biological or constitutional difficulty. Or it could be an ornery temperament. An ornery temperament puts you at risk, because unless you’ve got a really well put-together, adaptive family, that could put you at risk of being abused—or being ignored. Some of it is hard biology, some could be personality style. Another risk factor could be a male child of a single mother who hates that son of a bitch who got her pregnant, and the kid reminds her exactly of that father. That’s another risk factor, as opposed to a protective factor, which is anything that increases the likelihood of a positive outcome. And they’re usually mirror images of each other. So protective factors in the kid are: good health; a nice, easygoing temperament; good looking; or that kid who reminds you exactly of somebody who’s near and dear to you.
“On the environment side,” Dr. Shonkoff continued, “risk factors are poverty, economic distress, violence in the environment, lead in the air. So it can be psychological things like family stress. It can be more physical things like environmental toxins. Those are risk factors in the environment.… A single, inexperienced kind of a somewhat overwhelmed mother is a pretty potent risk factor. But a nurturing grandmother who lives in the same place can be a very powerful protective factor that buffers the kid against the risk factor of an inexperienced mother.… Protective factors in the environment are: an economically secure, stable family; at least one adult who’s madly in love with you, who’s totally devoted to you; a neighborhood that provides lots of supports for families with young kids.”
Dr. Shonkoff has noted that poor children are more susceptible than the affluent to various ailments, among them mild mental retardation. The evidence is indisputable: While severe retardation occurs at similar rates across all economic levels, studies show, mild retardation is increasingly prevalent as household income declines. The reasons are less obvious.
“When it comes to poverty and mental retardation, we don’t have all the mechanisms worked out,” he explained. “We don’t know what gene it’s on. We don’t know what the environmental triggers are.” But there are certainly environmental triggers, he believes. A genetic predisposition to a disease does not always produce the disease; that often requires an external assault. Because the poor have a higher incidence of mild retardation, he reasons, some elements of poverty must play a heavy role.
Among the known factors contributing to mental retardation are malnutrition; chromosomal abnormalities; infections before or after birth; fetal poisoning by lead, alcohol, cocaine, or tobacco; “dysfunctional infant-caregiver interaction;” and “poverty and family disorganization,” Dr. Shonkof
f said. Sexual abuse may be part of the equation as well. “We have overwhelming evidence from developmental and behavioral research that sexual abuse affects the brain” when the abuse has been chronic and extreme, he observed. “We know that those kids have severe emotional problems. If they have emotional problems, it means something happened to their brains, because that’s where all the emotional stuff is going on. It’s not your pancreas. Whatever’s going on in your behavior, your thinking, your feelings, it’s in your brain.”
The analysis may apply to Caroline Payne’s mildly retarded daughter, Amber, who was sexually abused. The trauma may have deprived the girl of the nurturing sense of safety that specialists see as influential on brain development, but it is not clear how, or whether, that affected her retardation. “Chronic abuse and maltreatment of all kinds, and particularly in a child who may be at risk for other reasons,” said Dr. Shonkoff, “are major determinants of the reason for the retardation. We know that the pile-up of all that stuff seriously compromises the development of competence.” And because mild retardation is more prevalent among children in poor, stressful environments, “we presume that the stress is an important factor.”
The cause of Amber’s brain damage was not thoroughly investigated by her doctors, so no firm link with her parents’ poverty could be established. Caroline’s diet was poor during pregnancy; with her meager wage and her husband out of work, the food budget was squeezed—though even in later years, she was mired in the junk-food-and-coffee habit. Caroline also smoked during pregnancy, and smoking has been linked to brain damage in unborn children. The old housing where she lived had old paint whose chips and dust could have laced the air with lead.
These intricate connections between poverty and health have momentous implications: Physicians cannot successfully treat certain disease without reducing risk factors far beyond medicine’s jurisdiction. They cannot always solve a child’s malnutrition unless they get the family food stamps and welfare checks. They cannot fully cope with a child’s asthma unless they improve the child’s housing. That’s why Dr. Barry Zuckerman hired attorneys to work on his staff at the Boston Medical Center’s pediatrics department. As he saw it, the lawyers “practice preventive medicine.”
Dr. Zuckerman is a tired-looking man with an inventive refusal to address only part of a problem. Some years ago, seeing children with poor reading skills crowding his clinic, he and his colleagues stocked the waiting room with used books from their own children’s shelves. Soon, however, the books began to disappear as kids stole them and took them home. When a colleague complained angrily that he wouldn’t contribute any more to the waiting room’s supply, Dr. Zuckerman had a happier reaction to the pilferage. “Well, maybe that’s good,” he remembered himself saying. “They’ll have them at home.” Then he made a little joke: “We should just give the books to the kids.” The joke became a nationwide program, Reach Out and Read, which has enlisted six hundred clinics across the country to give a book to every child who visits. “Actually,” Dr. Zuckerman declared, “we get bigger smiles—I swear to God—for books than for lollipops.”
In his own clinic, he confronts the effects of his patients’ poverty and Boston’s decaying slums. “I became frustrated prescribing antibiotics for kids with ear infections when they were being evicted from their house or the fuel had been shut off in the winter,” he said. “My only way of advocacy was to yell at people, and if you didn’t have the right telephone number, all you did was feel better yourself for yelling.”
Yo u might think that a landlord who gets yelled at by a pediatrician would feel moved to act. Not so, in the clinic’s experience. But when the call comes from a lawyer, that’s another story. “We had a child here with asthma, was on steroids, could not even go to school,” Dr. Zuckerman said. A nurse was dispatched to the apartment. “The mother did what she could in terms of dusting and taking down some curtains, but there was wall-to-wall carpeting, and the house was damp ’cause there was a leak. Our doctor didn’t get anywhere, but our lawyer had two conversations with the landlord, and after the second one, the landlord fixed the leak, took up the wall-to-wall carpeting. Four or five weeks later, the child was off steroids, back at school.” In other words, “instead of using that money for a doctor, I’m using it for a lawyer,” he said, “ ’cause I’m real serious about taking care of patients. In this setting, I need a lawyer to take care of them.… The sad truth is, it’s my fastest-growing division. I started with one, I have three now, and I have a bunch of law students.” Needless to say, medical insurance doesn’t cover the cost: Most funding comes from foundation grants and other private contributions.
Poor housing is an incubator of physical ailment. Old paint applied before lead was outlawed in 1978 flakes into dust that enters the lungs and poisons the child. Exposed wiring causes injuries. Balky furnaces lead residents to light stove burners or use freestanding kerosene heaters, which cause fires. Overcrowding leads to fights and stress—and “stress is recognized as a trigger” of asthma, said Dr. Megan Sandel, a pediatrics fellow at the Boston University School of Medicine, who has studied the links between housing and health. Poor ventilation and dangerous streets combine to trap children inside apartments with unhealthy air.
Asthma now strikes 9 percent of American children in all socio-economic groups, 12 to 15 percent of black children in the inner cities,17 and higher percentages in certain impoverished neighborhoods. For youngsters with a genetic predisposition, “there are lots of allergic triggers in the home,” Dr. Sandel said. Exposure to such antigens as mold, dust mites, or the powdery shedding of cockroach skin can activate bodily defenses in the extreme. “You breathe in this antigen, your lungs are irritated, and that irritation causes two things,” Dr. Sandel explained. “One, it causes, literally, contraction of the muscles in the lungs themselves. And it causes swelling. Just like if you touched poison ivy, your skin develops some swelling and itching and stuff, you have a similar thing develop in your lungs.” This asthmatic condition, which impairs breathing, can usually be controlled by medication administered with an inhaler, but it still results in hospitalizations and numerous days of missed school.
Many parents of asthmatic children are unaware of the triggers because doctors don’t bother to tell them. That was the experience of the Baltazars, a struggling family of Mexican farmworkers in Ivanhoe, North Carolina. Although cockroaches infested their small frame house, the specialist who treated the father, Agustin, and two of their children for asthma never asked about housing, never mentioned roaches as a factor. He once called to invite them to a conference on asthma, said Agustin, “and they would give me some kind of machine, an apparatus for my asthma. But I couldn’t go. You had to pay $15 to get into it.”
Most doctors don’t explore problems that they can’t address, but that overly narrow focus has been discarded at the Boston Medical Center. There, knowing that lawyers and social workers are available, pediatricians and emergency room staff ask the larger questions. “I’ve received zillions of referrals of kids who live in poor housing conditions,” said Jean Zotter, one of the attorneys in the pediatrics department. “A kid will show up with an asthma attack, and they’ll start asking about the housing, and it turns out there’s mold growing on the wall. They’ve refused to let kids go home. They’ve wanted to keep them there and advocated with the health insurer to keep them there because sending them home would be exposing them to the things that would make them sick again.” Insurers won’t pay for hospitalization if they know it’s because of the housing.
A lawyer’s phone call can usually get the Housing Authority to move tenants from moldy apartments into other public housing units, Zotter said, and private landlords often respond to a firm nudge as well. But sometimes it takes more muscle: a demanding letter, a city inspector, a threat of legal action, or even a lawsuit. That’s what happened in the case of a nine-month-old boy with pulmonary stenosis, which restricted blood flow to his lungs. He had surgery but then remained danger
ously ill in a house whose furnace was blowing toxic fumes and black dust into the air. The landlord, who lived modestly in the same neighborhood, “refused to even look at the furnace,” Zotter said.
She used Boston’s strong tenant protection laws and called for an inspector, who cited the owner for many violations. A hearing was held, the landlord failed to appear, he was given fourteen days to replace or repair the hot-air furnace, and he did nothing. Zotter then went to court, where the owner claimed that he could fix the furnace himself. Over her objection, the judge gave him two weeks to do so, after which she went back into court, and got a different judge, who ordered the landlord to replace the furnace. He finally complied, “but that whole process took a month and a half,” she said, “and in the meantime the nine-month-old baby was in and out of the hospital.” Five months later, the boy died from an infection he could probably have fought had his immune system not been so compromised. Although Zotter considered suing the landlord for damages, a clear connection between the furnace and the death would have been hard to prove. The mother, devastated and angry, moved out.
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