Martin Kaiser, editor: Rick Wood:
Ben Poston of the Journal Sentinel staff contributed to this report.
Lakisha Stinson and her daughter, Rashyia, who was born last month and is healthy, live in a Milwaukee neighborhood where the rate at which African-American babies die is worse than Botswana.
The child, Rashyia, born in December, is healthy. She coos, eyes closed. She touches her mother's cheek with her perfect hand.
Rashyia and her mother, Lakisha Stinson, live in a small attic apartment on Milwaukee's near north side.
Three modest rooms. The kitchen has just three chairs and a table that is missing its glass top. The living room has no furniture. The bedroom has a bed and a Pack 'n Play crib, a gift from Wheaton Franciscan-St. Joseph's Hospital, whose staff, nurses and doctors brought Rashyia through a high-risk pregnancy and into the world.
Rashyia and her mother live in a neighborhood where the rate at which African-American babies, such as Rashyia, die during their first year of life is worse than Botswana.
Public health experts have long considered the infant mortality rate to be an essential indicator of a community's well-being.
"It's like the canary in the mineshaft," said Geoffrey Swain, who is medical director of the Milwaukee Health Department and a scientist at the Center for Urban Population Health.
"The factors that drive the leading causes of infant mortality also drive the leading causes of death, illness and disability for all of us."
In Milwaukee, babies die during their first year of life at a rate greater than all but six of the nation's 53 largest cities.
In Milwaukee, babies die at rates associated with the Third World.
In Milwaukee, the infant mortality rate for all children, regardless of race, exceeds that of Uruguay, Bosnia or Kuwait.
Worldly comparisonsIn 1900, the infant mortality rate in the United States was about 100 deaths for every 1,000 live births, or 1 in 10.
By 1960, it had been knocked down to 26 deaths per 1,000 births.
By 2008, it was 6.6.
Sounds good. But compare the U.S. infant mortality rate with the rest of the world.
With the caveat that some countries count and report infant deaths in different ways, the U.S., for all its wealth and medical sophistication, does poorly.
In recent years, the U.S. infant mortality rate has been twice that of nations as diverse as Japan, Sweden, Portugal and the Czech Republic.
One federal ranking, based on 2010 estimates, puts the U.S. rank at 46th among 222 nations. That puts it behind Cuba, Hungary and South Korea.
Wisconsin's 2008 rate - 6.9 deaths per 1,000 births - falls in the middle of the other states.
Still, the number of infant deaths was staggering: 501 babies died in Wisconsin in 2008 - more than three times the number of homicides, more than twice the number of drunken-driving deaths.
The story of infant mortality in Wisconsin is the tale of two worlds divided, at least on the surface, by race.
In 2008, the infant mortality rate for whites was 5.9 per 1,000 births.
It was 13.8 for blacks.
That means that in Wisconsin, black infants die during their first year of life at more than twice the rate of white infants. It is worse than Romania.
It is among the worst in the nation.
It wasn't always this way.
From 1979 to 1981, Wisconsin's black infant mortality rate averaged third best in the nation. By 2003 to 2005, the three-year average dropped to the second worst.
In this discouraging trend, Swain finds reason for optimism.
"That's not ancient history," he said. "It's not some unchangeable situation. It changed recently. It can change again."
The Northern Manhattan Perinatal Partnership often is cited by public health experts as an example of what communities can do.
In 1990, when the partnership began, the infant mortality rate for New York City's central Harlem neighborhood was 27.7 per 1,000 births. In 2008, it was 6.1.
Using the New York approach as one of its models, the Wisconsin Partnership Program and the University of Wisconsin School of Medicine and Public Health are launching a $10 million program to improve birth outcomes in four of Wisconsin's most troubled cities: Beloit, Kenosha, Racine and Milwaukee.
The Milwaukee Lifecourse Initiative for Healthy Families is expected to complete its planning stage by July.
'Public health crisis'How bad is the situation in Milwaukee?
The city Health Department on Monday is to release the 2010 Fetal Infant Mortality Review Report, based on an examination of all 499 infant deaths that occurred in Milwaukee from 2005 to 2008.
In that time frame, for every 1,000 babies born, 11 died.
"We have a public health crisis," said Bevan K. Baker, Milwaukee's commissioner of health.
"We have moved beyond the tipping point."
The disparity between black and white infant deaths is even more disturbing.
The city's 2005-'08 white infant mortality rate was 6.4. The Hispanic rate was close: 7.4.
The city's black infant mortality rate during that period was 15.7, about 2.5 times the white rate.
These deaths are concentrated in a handful of ZIP codes, where poverty, joblessness and crime also are high.
The ZIP code with the highest rate was 53210 - which includes central city areas as well as parts of the Sherman Park and Enderis Park neighborhoods - with 19.5 deaths per 1,000.
That rate is worse than Colombia, Bulgaria and the Gaza Strip.
Health does not depend on health care alone.
Nor is it fully explained by genes or good habits.
Health care matters. So do the attributes we are born with. So do the decisions we make. Smoke or don't smoke. Eat this, not that.
But our health is also a product of the families that raise us, the communities that shape us, the times that we live in.
It is telling that two of the area's top hospitals for infant care are in the two ZIP codes with the highest infant mortality rates: St. Joseph's on the northern boundary of 53210 and Aurora Sinai Medical Center on the northern boundary of 53233.
"Infant mortality is a problem that is more than access to care," said Tina Mason, program director of Aurora Sinai's obstetrics and gynecology department and a former associate commissioner for New York City's Department of Public Health.
"It's a societal problem."
Jackie Tillett, director of the Midwifery & Wellness Center, which is located at Sinai, said many of the women she sees are young, poor and uneducated.
"We follow people who are socially high-risk," she said. "You can't just take a pill for it."
The Center for Urban Population Health published a 2010 study focusing on health disparities among Milwaukee's socioeconomic groups.
The study ranked the socioeconomic status - measured by income and educational attainment - of people in Milwaukee's 29 ZIP codes, then sorted those ZIP codes into three groups: low, medium and high.
Problem areasThe bottom third - the group of ZIP codes with the most poverty and lowest college graduation rates - had the highest infant mortality rate.
It also had the highest premature death rate, chlamydia rate, HIV rate and teen birthrate.
It had the greatest percentage of low birth weights; preterm births; uninsured adults; people who hadn't seen a dentist in a year; births to mothers who received no prenatal care during their first trimester; smokers; pregnant smokers; obesity; violent assaults within the past year; single-parent households; and children who tested positive for lead poisoning.
The report emphasized that the sheer number of people living in the city's lowest tier and the depth of the health issues affecting them compromised the well-being of all Wisconsinites.
"Milwaukee's large population, poor health outcomes and large health disparities," the report says, "have a significant impact on the overall health of the state as well as on the economic vibrancy of the city and state."
Income and education fail to account for the racial disparity in Milwaukee's infant mortality rates.
Blacks across the socioeconomic spectrum have higher infant mortality rates than whites.
The infant mortality rate for a child born to a black woman in the highest tier is about the same as the rate for a child born to a white woman in the lowest tier.
The infant mortality rate for babies born to a black woman in the middle tier is three times the rate for babies born to white women in the same tier.
It is not clear why.
"I've been working on this for 20 years," Mason said, "and just when you think you've figured it out - whoosh! - it's gone."
A growing field of research suggests that the chronic stress of living in poverty or with barriers associated with low educational attainment increases the risk of the leading cause of infant mortality: preterm birth and low birth weight.
Research also shows that the experience of racial or ethnic discrimination deepens stress and further increases the risk of preterm or low birth weight.
A novel study published in 2006 vividly illustrates this theory.
Diane S. Lauderdale, a professor of epidemiology at the University of Chicago, wanted to know whether poor birth outcomes increased for women of Arab-origin after the terrorist attacks of Sept. 11, 2001.
Lauderdale looked at all California birth certificates for 2001, 2002 and 2003. She identified more than 15,000 mothers with Arabic last names.
Prior to 9-11, she discovered, women with Arabic last names had the same low birth weight rate as non-Hispanic white women.
But in the six months after 9-11, the chances of having a low birth weight child increased 34%.
The risk of bearing low birth weight babies, she found, did not increase for any other ethnic group.
There's a costComplications of prematurity, including low birth weight, accounted for more than half of all infant deaths in Milwaukee, according to the 2010 infant mortality report.
A preterm baby is a child born before 37 weeks' gestation. A low birth weight baby is a child who is born weighing less than 5.5 pounds.
Preterm and low birth weight babies, even when they survive, are subject to a host of medical complications, such as breathing problems, infections, neurological problems and unstable heart rhythms.
The report attempts to calculate the cost of preterm births.
Citing March of Dimes data, it estimates cost of a normal full-term delivery to be about $3,325, including prenatal care, hospitalization and drug costs.
Citing an Institute of Medicine report, it estimates the cost of a preterm birth to be $51,600.
It multiplies that figure by 4,851, the number of preterm babies born in Milwaukee from 2005 to 2008.
The cost: More than $250 million - about what the Milwaukee Public Schools system pays to run all its elementary and all its kindergarten through eighth-grade schools.
Lakisha Stinson would count the cost differently.
She would measure the bottomless anguish that followed the death of her first born, Kelviana. She would measure the years that followed that were lost to drinking, drugs, violence and jail.
There is a photo of Kelviana above the window in the bedroom where, on this cold January day, Stinson feeds Rashyia.
Stinson was 14 when she gave birth to Kelviana on July 28, 2003.
Kelviana was 14 weeks premature. She weighed less than 2 pounds.
She spent most of her life at St. Joseph's. The complications stemming from her preterm birth were legion: She suffered damage to her eyes and central nervous system, she bled into her brain, she was jaundiced, she had to be intubated and required a chest tube.
But she survived. By her 6-month checkup, her condition had stabilized and she seemed fine.
A young life lostOn April 15, 2004, while visiting her father's home, Kelviana spent the night in her grandparents' bed.
According to a medical examiner's report, the grandfather created a pile of pillows, blankets and dolls so she would not roll off the bed. The infant's grandmother, after taking a sleeping pill, joined her. Later, so did her grandfather, who had been drinking, according to the report.
The grandfather found Kelviana in the morning with her head over the side of the mattress, resting on the pile of blankets. He picked her up and put her to his shoulder. She vomited blood and sputum.
Kelviana was pronounced dead two minutes after arriving at St. Joseph's. The medical examiner ruled sudden infant death syndrome as her cause of death, with co-sleeping and prematurity as contributing causes.
Stinson, a child, buried her child in a toy-sized casket.
Less than 11 hours into this new year, Milwaukee recorded its first infant death. Malachi, 1 month and 9 days old, died sleeping beside his mother in an adult bed.
More babies will die in the year to come.
They will die of prematurity, sudden infant death syndrome, infection, homicide.
Too many of these deaths will have been preventable.